^n '^fc-iaif.r'i.. -• ■*■■ - C'Ai'SirV'.C.^.r."^! :.^c;:;:.t;uiia]iuxu!.: NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service OPINIONS OF THE PRESS ov WATSON'S PRACTICE OF PHYSIC. The Publishers have great pleasure in submitting the following letter from Professor Chapman, as well as a few of the notices of the medical press, with which this work has been honoured. Philadelphia, September 'Ulth, 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 Medicine 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,"—American 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 remember 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 Orleans Me- dical 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 for such a purpose, all must admit; but their sphere of usefulness may extend much beyond this. We are satisfied, indeed, that no physician, well read and observant as he may be, can rise from their perusal without having added largely 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 of condensation. Here is brought 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 young, 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 skilful practitioners may be deduced from the doctrines contained in this book, but we hesitate 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. * * * * We would advise no one to set himself down in practice, unprovided with a copy."—British and Foreign Medical Review. * NOTICES OF WATSON'S PRACTICE. "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.' Bat 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, orfalse 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, fyc. " The style is correct and pleasing, and the matter worth the attention of ail practitioners, young and old."—Western Lancet. " We.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 schools, 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 different. " Lastly, we are well pleased to observe that a strong vein of common sense, as well as good taste, 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 at^&nJJesh <$f the profession to the elegant volume recently published by Lea & Blancherd-4the lechrres delivered at King's College, London, by Dr. Watson—we do not suppose any p.n£ at all conve/sant with the'medical literature of the day to be unacquainted with its gene- ral ^"acter-v- i Dr- W> !<*eli^ep«d' tMssir'Bow celebrated lectures during the medical session of 1836-7. They have been revised by the -author, and those who now study these erudite produc- tions will have them divested of any objectionable matter that might have formerly crept in through inadvertence". TfieM are ninety lectures, fully written, embracing the whole domain 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 impressed at once with the strength and depth of the lecturer's views; he gains on our admiration in proportion to the extent ot 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 Me- dical and Surgical Journal. LECTURES ON THE 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 HOSPITAL ; AND FORMERLY FELLOW OF ST. JOHN'S COLLEGE, CAMBRIDGE. SECOND AMERICAN, FROM THE SECOND LONDON EDITION. REVISED, WITH ADDITIONS, / BY D. FRANCIS CONDIE, M.D., SECRETARY OF THE COLLEGE OF PHYSICIANS ; AUTHOR OF A TREATISE ON DISEASES OF CHILDREN, &C &C. PHILADELPHIA: LEA AND BLANCHARD. 1S45. WIB Entered according to the Act of Congress, in the year 1845, by LEA AND BLANCHARD, In the Clerk's Office of the District Court for the Eastern District of Penn- sylvania. • *".J\,/ *'£ * \ 2 ?, '..•'■. i K> l\ 1 '* ->l PHILADELPHIA: T. K. & P. G. COLLINS, PRINTERS. 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 given by the Author will be found somewhat defective, while he has omitted 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 preparing the present edition, has mainly directed his atten- tion. In the notes he has added to Dr. Watson's lectures on diarrhoea and dysentery, he has endeavoured to fill up the very brief sketch pre- sented in the text, of the chronic forms of those diseases; he has attempted, also, to supply, in part, 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 in- duced to append to the present edition, the Editor has succeeded in adding in some slight degree to their value, he will be amply repaid for his labour. Philadelphia, September, 1845. , AUTHORS ADVERTISEMENT TO THE SECOND EDITION. The unexpected 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 have been corrected, but in substance, as well as in form, the Lectures are nearly the same as before. ADVERTISEMENT TO THE FIRST EDITION. The following Lectures were put together, with unavoidable haste, during the Medical Session of 1836-37, in which they were first deli- vered. They were repeated, with slight variations, for four successive years; the Author always meditating, but never finding time to accom- plish, 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 publi- cation, the Author took no pains to note authorities 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 familiar 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 lessons 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. CONTE NTS. LECTURE I. PAGE Introductory, - - - - - . . . - -17 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 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, ---..---..34 LECTURE IV. Morbid alterations of the Fluids, especially of the Blood. Changes in its quantity and distribution. General and Local Plethora. Poverty of Blood. Active Congestion— its Phenomena—state of the Vessels, as seen by the Microscope. Mechanical Conges- tion. Passive Congestion. Relations of these forms of Congestion to Inflammations— to Hemorrhages—to Dropsies, ---.-...40 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, - - 50 LECTURE VI. Causes of Disease: distinction between predisposing and exciting causes. Enumeration of causes, as connected with the Atmosphere—Food and Drink—Poisons—Exercise— Sleep—M«ntal and Moral Conditions—Hereditary Tendencies—Malformations. Tem- perature. Effects of Heat and of Cold, -------59 LECTURE VII. 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 applied. Modifying influence of certain states of the Mind—of Sleep—of Habit. Means of protection. Influence of the different Seasons. Impurity of the Air. Hereditary tendencies to Disease, - 70 LECTURE VIII. 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, - - - < - 81 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- vessels and of the Blood in a part inflamed, - - - " #" - 94 LECTURE X. Inflammation, continued. Buffy Coat of the Blood. Terminations or Events of Inflamma- tion. Resolution—Delitescence—Metastasis. Effusion of Serum. Effusion of Coagulable Lymph, or Fibrin. Organization of this Lymph. Suppuration. Ulceration, - 105 10 CONTENTS. LECTURE XI. Mortification, as an event of Inflammation. Inflammatory Fever. Hectic Fever. Typhoid Fever. Modification of Inflammation by differences of Tissue; Areolar Tissue; sub- stance of Glands and Solid Viscera; Serous Membranes; Synovial Membranes; Tegu- mentary Membranes—Skin—Mucous Membranes; Muscular Tissue; Arteries; Veins; substance of the Brain, - - - - - - - " -115 LECTURE XII. Varieties of Inflammation: Acute and Chronic; Latent; Specific. Scrofulous Inflammation. Tubercles. Relative frequency of Scrofulous Disease in different Organs. Signs of the Strumous Diathesis, ___------ 127 LECTURE XIII. Cancer; its Species or Varieties. Scirrhus; Encephaloid Cancer; Colloid Cancer. Its mode of Growth ahd Dissemination. Habitudes of the several Varieties. Treatment of Inflammation. Antiphlogistic Regimen. Blood-letting. - 138 LECTURE XIV. Treatment of Inflammation, continued. Recapitulation. Bleeding. Purgatives. Mercury. Antimony. Digitalis. Colchicum. Opium. Local" Remedies. External Cold. External Warmth. Counter-Irritation. - - 152 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. 162 LECTURE XXII. Symptoms of Cerebral Diseases. Inflammation of the Dura Mater and Arachnoid from of thTiiXter ^ DiS6aSe °f thG B°neS °f the Ear' and °f thG N°Se' Inflammat'°n 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, LECTURE XXIV. ^ofteniZT6118' Ct°nClUAdKd; treTatment.[^l- Chronic Inflammation of the Brain. Softening, Suppuration^ Abscess, Induration, Tumours in the Brain, - . . • LECTURE XXV. HyMnril0pl7A0!thf Bcain; Atr°Phv- Acute Hydrocephalus; Premonitory signs • Different Modes of Attack; Stages of the Disease; Anatomical Characters; Causes, ' - ! 171 LECTURE XVI. Dropsy: its General Pathology. Passive Dropsy; Cardiac and Renal. Active, Acute, or Febrile Dropsy. Prognosis; and General Principles of Treatment in Dropsies, LECTURE XVII. Diseases of the Eye. Catarrhal Ophthalmia. Purulent Ophthalmia of Adults, - - 184 LECTURE XVIII. Purulent Ophthalmia, continued. Gonorrhoeal Ophthalmia. Purulent Ophthalmia of Infants. Strumous Ophthalmia, -----..._ 194 LECTURE XIX. Strumous Ophthalmia, continued. Recapitulation. Treatment of Strumous Ophthalmia. General Remarks on Conjunctival Inflammations. Iritis: its Symptoms and Treatment. Causes of Iritis, ------._._ 209 LECTURE XX. Iritis concluded. Rheumatic Ophthalmia. Amaurosis, - 219 LECTURE XXI. Diseases of the Brain and Nervous System. Difficulties of the subject. Short Review of some points in the Physiology of the Brain and Nerves. Peculiarity of the Cerebral Circulation. Pressure, 226 235 246 254 266 CONTENTS. 11 PAGE 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, -.--.._ 277 LECTURE XXVII. 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, - ...... 288 LECTURE XXVIII. 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, - - 302 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, - 312 LECTURE XXX. Apoplexy continued. Relations between the Symptoms and the Appearances found in the brain after death. Exciting Causes. Prognosis. Treatment, - - - - 324 LECTURE XXXI. Spinal Hemorrhage. Paraplegia. Facial Palsy and Facial Anaesthesia; their Symptoms, Prognosis, and Treatment. Other Forms of Local Paralysis, and Local Anaesthesia, - 338 LECTURE XXXII. Tetanus. Its Symptoms and Varieties. Causes. Diagnosis. Pathology. Treatment: Opium; Blood-letting; the Warm Bath ; the Cold Bath, - - - - 351 LECTURE XXXIII. 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, - _._-_■ 362 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 the Disorder. Treatment. Preventive Measures, ....... 375 LECTURE XXXV. Epilepsy. Its Symptoms and varieties; duration and recurrence of the paroxysms; periods of life at which they commence ; warnings. Effects of the paroxysms, immediate and ultimate. Pathology. Anatomical characters, ------ 387 LECTURE XXXVI. Epilepsy continued. Recapitulation. Exciting causes. Simulated epilepsy. Diagnosis., Prognosis. Treatment: during the fit; during the intervals ; during the warnings,, - 396 LECTURE XXXVII. Chorea. Symptoms; Pathology; Complications; Causes; Treatment. Chronic Chorean. Other Nervous Disorders to which the same name has been applied, - - - 408 LECTURE XXXVni. 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], - 420 LECTURE XXXIX. Catalepsy. Ecstacy. Neuralgia; Tic Douloureux; Sciatica; Hemicrania, - - 433 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 effects upon the human body; influence of soils in evolving it, - ~ ^45 22 CONTENTS. PAGE LECTURE XLI. , 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, ----- 458 LECTURE XLII. Treatment of Intermittent Fever; during the paroxysm ; during the intermissions. Prophy- laxis, ----------- 468 LECTURE XLIII. Epistaxis. Bronehocele ; Cretinism; their Phenomena and probable Causes. Medical and Surgical Treatment of Bronehocele, - - - - - - - 478 LECTURE XLIV. Cynanche Parotidaea. Spontaneous Salivation. Aphthae; pathology of [note]. Cynanche Tonsillaris, - - -'- - - - - - -491 LECTURE XLV. Acute Laryngitis. Symptoms. Treatment; Blood-letting. Tracheotomy, Mercury,Anti- mony. Anatomical Characters of the Disease. Causes. Secondary Laryngitis. (Edema of the Glottis. Chronic affections of the Larynx, ----- 504 LECTURE XLVI. Cynanche Trachealis: Symptoms; Pathology; Prognosis; Treatment. Tracheotomy [note]. Child-erowing, or Spurious Croup, ------- 515 LECTURE XLVII. Diseases of the Thorax. General observations. Dyspnrea. Cough. Methods of exploring the physical conditions of the Chest, by the senses of sight, touch and hearing, - 528 LECTURE XLVIII. 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 Infarction of a large Bronchus, -------- 540 LECTURE XLIX. Influenza. Symptoms and progress. Conjectures as to its Cause. Treatment. Hav Asthma. Chronic Bronchitis. Its varieties. Morbid Anatomy of these affections, - 551 LECTURE L. Hooping-cough ; symptoms; duration; complications ; pathology; treatment. Pneumonia • its stages and morbid anatomy ; auscultatory signs, - . _ ^"e_umoma • LECTURE LI P~^?1S^^nU^^^0?laS2Sr5 P™^y^w~,conBh,,«pecU>r.ti«m: Con»e LECTURE LIL Pleurisy. Its anatomical characters; false membranes; liquid effusion; effects of the,P pCiy, T and_C°ntef 0f th.e Chest: a*<* «_Pon ^healthy sounds. Symptoms of LECTURE LIII. Pleurisy continued. Recapitulation of symptoms; of diagnostic signs Causes of P1P„ nsy. Pneumothorax; Us condition, and signs. Treatment of pL,tU,1 Z °f PIeu" Paracentesis Thoracis. Typhoid Pneumonia [note], .ent ™ P1™nsy. Empyema. LECTURE LIV. LECTURE LV. 565 577 599 617 CONTENTS. 13 PAGE physema; its anatomical characters, symptoms, cause, and cure. (Edema of the Lungs. Phthisis Pulmonalis, -.-.-----628 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, dys- pnoea, pain, hectic fever, diarrhoea, wasting, oedema, aphthae, - - - - 639 LECTURE LVII. 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, ---------651 LECTURE LVIII. Melanosis of the Lung; true, and spurious. Accidental intrusion of solid substances into the air-passages, ---------- 662 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, ----------- 670 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, ---------- 683 LECTURE LXI. Pericarditis; its frequent connection with Acute Articular Rheumatism. Rheumatic Car- ditis. Anatomical characters of acute inflammation of the Pericardium; of the Endo- cardium. General symptoms. Auscultatory signs. Relations of Carditis with Rheumatic Fever,...........694 LECTURE LXII. Treatment of Acute Pericarditis and Endocarditis: blood-letting; mercury; blisters. Chro- nic and partial inflammation of the Pericardium. Disease of the Aorta. Thoracic Aneurisms; their various situations and symptoms ; plan of treatment, - - 710 LECTURE LXIII. Diseases of the Veins. Phlebitis; adhesive and suppurative; consecutive scattered Ab- scesses. Treatment of Inflammation of Veins. Effects of the gradual obstruction of large Venous Trunks, --------- 720 LECTURE LXIV. Asthma: its nature; complications; exciting causes; and treatment. Diseases of the (Esophagus; Inflammation of Infants [note]; Stricture; Spasm: Dilatation, - - 729 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 symp- toms ; and causes. Puerperal Peritonitis. Peritonitis from Perforation, - - 741 LECTURE LXVI. Treatment of Acute Peritonitis ; Bleeding, Mercury, Opium. Chronic Peritonitis; Granular Peritoneum. Ascites; Ovarian Dropsy; Diagnosis of these diseases. Other forms of Abdominal Dropsy, --------- 750 LECTURE LXVII. Pathology of Chronic Ascites; of Ovarian Dropsy. Treatment of these two disorders. Internal remedies: Extirpation of the ovarian sac; Paracentesis Abdominis, - - 759 LECTURE LXVIII. Acute Gastritis; symptoms; anatomical characters ; treatment. Acute Gastritis of Infants [note]. Chronic Inflammation of the Stomach ; thickening of the Mucous Membrane ; Ulceration: symptoms and treatment of the disorder. Cancer of the Stomach, - 768 14 CONTENTS. LECTURE LXIX. Hemorrhage from the Stomach: sometimes from a large vessel, usually by exhalation. Idiopathic Haematemesis. Vicarious Haematemesis. Haematemesis from gastric disease or injury: from disease and other organs. Melaena. Haematemesis from a morbid state of the blood. General phenomena of Haematemesis. Diagnosis. Treatment. - 781 LECTURE LXX. Dyspepsia. Physiology of Digestion. Symptoms of Dyspepsia. Treatment and Preven- tion, Dietetic and Medicinal, -------- 790 of the Affection, - LECTURE LXXIX. Anasarca; its consideration resumed. Distinction of Chronic General Drnnov ;„♦„ n a- and Renal. Characters and signs of each of these varietiesHiStaS* lnt°_Cardia° LECTURE LXXX. LECTURE LXXXI. ^^Zt8111'' Sympt°mS5 VarietieS5 treatm6nt- Chronic ^eumatism; phenomena; Gout: description of a paroxysm ; progress of the disease; general state of A, i,„hi, ■ gouty persons; causes of the disease"; diagnosis between S^d^J^^^ ™ LECTURE LXXXII. Pathology of Gout. Prognosis. Prejudices respecting the disease Tr^tm^. a ■ the paroxysms; during the intervals. Cutaneous diseases, - ^ ent [ dunnj> LECTURE LXXXIII. 800 LECTURE LXXI. Enteritis : its symptoms; causes; treatment. Mechanjcal occlusion of the Intestinal Tube. Colic. Colica Pictonum ; its symptoms, complications, treatment, and prevention, LECTURE LXXII. Diarrhoea. Chronic Diarrhoea [note]. Sporadic Cholera. Epidemic Cholera, - . 815 LECTURE LXXIII. Dysentery: Morbid Anatomy [note]; Chronic [note]. Diarrhoea Adiposa. Intestinal Con- cretions. Worms, - - - - - . __ . 829 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, - - - - - 844 LECTURE LXXV. Diseases of the Liver. Acute Inflammation. Abscess of the Liver. Causes and Treat- ment of Acute Hepatitis. Chronic Hepatitis. Jaundice. Its symptoms, causes, species, and pathology [note], - - . _ ... - - 857 LECTURE LXXVI. 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." Different kinds of Gravel. Diseased states of the Urine. Description and Remedies of the Lithic, Phosphatic, and Oxalic Diatheses, - 870 LECTURE LXXVII. Suppression of Urine Diabetes: Qualities of the Urine; symptoms; anatomical appear- ances ; general pathology of the disease; treatment. Diuresis, - . PP , LECTURE LXXVIII. ^SalXlo^ What * imP°rts- Anatomical of thelffeSn g - 5' S^toms to which this r*nal disease gives rise. Nature 882 894 904 914 924 936 944 CONTENTS. 15 PAGE LECTURE LXXXIV. Continued Fever, continued. Phenomena of the second week; Delirium, an Eruption, Diarrhoea: 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, --------..-957 LECTURE LXXXV. Varieties of Continued Fever. Its causes, exciting and predisposing. Prophylaxis, - 966 LECTURE LXXXVI. 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, --------- 977 LECTURE LXXXVII. Small-pox, continued. Inoculation. Vaccination. Their comparative advantages. Treat- ment of Small-pox, ......... 999 LECTURE LXXXVIII. Chicken-pox. Measles. Scarlet Fever, ---.... 1013 LECTURE LXXXIX. The Plague. Erysipelas. Erythema Nodosum. Urticaria. Prurigo. Scabies, - - 1026 LECTURE XC. Herpes; Eczema; Pompholix; Lepra; Psoriasis; Impetigo; Boils; Carbuncle; Purpura; Scurvy. Conclusion of the Course, ------- 1037 Index, ........... 1051 LECTURES ON THE PRINCIPLES AND PRACTICE OE 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 ("or obtaining his pur- pose; and whether he is qualified, by the possession of the requisite preliminary information, for pursuing 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 college, 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 gene- ral 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 particularly the human body; its construction and qualities; its actions audits sufferings ; its derangements ; its decay. In this study, which affects the mind with a strong feeling of curiosity, not unmixed 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 endow- ments, the working and the uses of its several parts. This amount of knowledge was indispensable to your further progress. But it forms a portion only of what you assemble here to learn : or rather it is the necessary 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 contemplated its fullness of exquisite contrivance, its endless examples of means adjusted to ends; its prospective expedients against future needs, its compensations for inevitable disadvantages, its direct provisions for happiness and enjoyment,—without receiving the profoundest conviction of the being and the attributes of its Maker. It is upon human anatomy that Paley, in his unrivaled argument for Natural Theology, " takes his stand ;" and sixteen centuries before 2 18 INTRODUCTORY LECTURE. him, Galen had felt that, in writing his anatomical 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 investigation 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. Hitherto you have been told of structure and of function. Henceforward our theme must be of health and of disease. Of health, that we may 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 implies freedom from pain and sickness; 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 signify any fixed and immutabte 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 day, 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 him- self, or by others ; or some unsafe, though hidden condition, of which he may be quite unconscious : 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 applied 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 whether 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 p.fter death, and the most careful scrutiny fails to discover in it any faultiness of texture, there may still be ground for suspecting that some material change, too subtle for detection by our senses, may have been wrought in its finer and more delicate organization. I shall take care to point out to you, as we go alono-, 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 from 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 of diseases,) if we include all their differences in kind and in degree, is scarcely calculable; and the first thing requisite towards investigating INTRODUCTORY LECTURE. 19 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 dis- eases might be framed. 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 for the mechanical circulation of the blood ; there is an appa- ratus expressly designed for the repeated exposure of the blood to the air; a system for regulating the movements and the feelings of the body ; another for receiving, preparing, and appropriating its nourishment; another for the elaboration of matters that are useful or essential to its functions; another for carrying off its impurities, 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, whatever 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 —diseases 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 affect all these systems in common, or simultaneously, and comparatively few that are strictly confined 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 speaking 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 framing 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 nature of particular diseases, it will be requi- site to give some general account of the different ways 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 will be proper to take a general view of symptoms, and of their ascertained relations with the several forms of altered structure: for doubtless you are aware that, although diseases are not constituted by symptoms, they are, in the living body, disclosed by symp- toms. 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 sen- sible 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 illus- trative 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 truth, the great object of our art is to prevent or postpone the disclosure of the others. The 20 INTRODUCTORY LECTURE. 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 from which the symptoms 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 be expedient to premise something, in a general 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 differ- ent 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 texture 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 inflammation. 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 familiar to us—which we can see and handle; those which we witness when the disorder is seated in or near the sur- face, 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, paren- chymatous, muscular, 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 of inflammation, and of morbid conditions generally, by the influence of certain diatheses, 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 list of particular maladies. There are certain facts and reasonings common to all inflammations, to all hemorrhages, to all dropsies. By combining these "generalities" into one comprehensive statement, we help the memory, avoid needless repetitions, and find room for the exposition of prin- ciples. Diseases themselves, in the mass, are sometimes distinguished accordino- as they are local, or general. Taking these epithets in their popular sense, we should sav that local diseases are those which occupy a definite portion only of the body ; o-eneral 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 only 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 callino- 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 Inflam- mation of a small portion of the frame may give rise to much secondary or symp- tomatic fever; but here also we properly speak of the disease as beino- local- the secondary general disorder resulting from the local and primary, following it in point of time, and subsiding upon its cessation. INTRODUCTORY LECTURE. 21 But there are still other forms of disease which show themselves, not like inflammation now in this and now in that part, but in many or most parts of the body at the same lime. I will take the complaint called purpura, characterized by the universal appearance of purple spots, as an example of what I mean. It is in truth a hemorrhage affecting many or all the tissues of the body simulta- neously. 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 all, of those which have been thus reputed general, are, in fact, reducible to the class of local diseases. The fluids are as much parts of the body as the solids ; 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 themselves wherever there is blood circulating—that is, throughout the whole system. 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 nerv- ous 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. Whether 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 filling 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, maybe 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 outline of general pathology, with an especial reference to those morbid conditions which fall lo 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 under- stand 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 arti- ficial 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 individualized, or presented under a definite shape. And here, I repeat, I shall chiefly pursue an anatomical order, as being comprehensive and inartificial, 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. 22 INTRODUCTORY LECTURE. 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 peculiar 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 affections 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 respira- tion 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 in- terruption of those functions. Still there would remain certain diseases, which would not necessarily find a place in 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 pro- pose to adopt may appear chargeable. I had rather not be cramped and hampered by attempting what abler heads than mine have failed to achieve, and what, in truth, 1 believe, 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 information 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 speak when upon the subject of inflammation; This, then, is a sketch of the method I propose to follow. In the earlier lec- tures, with the general pathology, I shall endeavour to lay down principles. To these principles I shall continually refer, as occasions offer, both in those prefa- tory remarks with which I purpose to introduce the diseases belonging to the several great systems 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 combine the advantage of repetition, which was the peculiar advan- tage of two short courses in a season, with that of greater completeness, which forms the recommendation of a single extended course. The same great advan- tage of repetition—or I should rather say of recapitulation—will be further aimed at in the stated examinations 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 the principles of medicine are meant those general truths and doctrines which have been ascertained and established, slowly, indeed, and irreo-nlarly, but still with considerable precision, by the continued observation of attentive minds throughout the entire progress of medicine as a science. These principles I pro- fess 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. It is the science that I shall here endeavour to unfold. Skill and facility in turning that science to useful purposes I am unable to impart. INTRODUCTORY LECTURE. 23 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, how- ever, 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 exer- cise is wanted; and that it requires skill in observing as well as skill in acting. You will find what, perhaps, previously to positive trial, you might not suspect, that the senses—the eye, the ear, the touch—however sharp or delicate they may naturally be, require a special course of training and education before their evi- dence can be trusted in the investigation of disease. I do not know that these views are capable of being rendered plainer by illustration; for you must have observed a similar distinction between the science and the art in 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 the beautiful science of astronomy—may acquire the power of working upon paper its sublimest and most abstruse pro- blems—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 move- ments of a single star. But place such a person night after night in an observa- tory—let him notice and imitate the proceedings of some one already skilled in examining the phenomena of the heavens—and he will soon acquire the requisite tact and facility himself. 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 tho- roughly or safely learn to practice 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 de- scriptive 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 furnished his mind with 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 travelers will reap the greatest harvest of enjoyment and of profitable knowledge from his journey. Not less striking is the difference, 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 preconceived 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 marvel- ously ignorant, and the science of medicine would stand still, or cease to be. " II 24 INTRODUCTORY LECTURE. 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 different times ; and not less so by the outward resemblance of disorders essentially unlike. 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 Medicine, or, as it is sometimes worded, the Nature and Treatment of Diseases, is first to fix upon some order in which to treat of the various subjects comprised in his 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 have already told you that if I can distribute and connect the multifarious forms of disease 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 arrange- ment 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 things 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 accidental: 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 dis- puted 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 colligit, et utitur, ut faciunt empirici; aranea ex se fila educit, neque a particularibus materiam petit, ita faciunt medic speculativi ac mere sophistici; apis denique caeteris se melius gerit. Haec indigesti e floribus mella colligit! deinde in viscerum cellulis concocta maturat, iisdem tamdiu insudat, donee ad integram perfectionem perduxerit." I may venture to paraphrase it thus:— The lecturer must not be the ant, collecting all things indiscriminately from all quarters, 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 INTRODUCTORY LECTURE. 25 in the recesses of his brain, and submitting it 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 matters of mere speculative curiosity or intellectual amusement—to be taken up to-day and dismissed perhaps with unconcern to-morrow—but they involve questions 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 life you will con- fidently and constantly 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 examin- ing the principles to be derived from those facts, which I propose to employ for your instruction and guidance. But amid all the responsibilities, gentlemen, both of teacher and of learner, the profession which you and I have chosen, or which circumstances have prescribed to us, is a noble profession, and worthy the devotion of a lifetime. If you fit yourselves 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. Affording ample scope and exercise for the intellect, it is con- versant with objects that tend to elevate the thoughts, to chastise the feelings, 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 that singularly interesting thought, excites increasing wonder and admiration the more closely we investigate its marvelous 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 beware 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 enmi- ties, of political strife, of sectarian dissensions. Disease and pain the sole condi- tions of its ministry, it is disquieted by no misgivings concerning the justice and honesty of its client's cause; but dispenses its peculiar 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;" reading continually to our own hearts and understandings the most impressive lessons, the most solemn warnings. It is ours to know in how many instances, forming 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, 26 PATHOLOGY. our opportunity precarious, and our time, even when longest, very short, if mea- sured 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 redeemetli 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. Jitrophy—its causes and consequents. Changes inform. Alterations in consistence. Induration—its various kinds. I propose to devote several lectures, in the commencement of the course, to pathology, as it relates to medicine. 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 col- lected ; 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 con- ditions 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 contem- plates particular diseases. An acquaintance with general pathology prepares us for, and conducts us to, that which is special; and when I say that the earlier lectures of the course will be given to a consideration of the leading facts and doctrines of pathology, 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 living frame are liable: and I speak chiefly of sensible changes ; leaving unnoticed for the present those conditions which are perceptible only through the microscope. to 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 parts may be altered in bulk; inform; in consistence; in their ALTERATIONS OF SOLIDS. 27 intimate texture, i. e., in the qualities and arrangement of their component parti- cles ; 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 with 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 constant 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 addition 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 other, and by a beautiful law of compensation, the sound organ, without any alteration of its peculiar fabric, enlarges. The same is observed to be the case with 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 commodity 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, 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 uni- versal. It 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 magni- tude. Hypertrophy of this unmixed -kind—unattended by any change of texture-— (and it is to this that the term should as much as possible be restricted)—is be- lieved to depend upon more active nutrition of the part (vrttp fpo$*i). More ma- terials 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 instance), by tying its principal nutri- ent artery. The magnitude of the bronehocele diminishes. It is curious that no 28 HYPERTROPHY. 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 intes- tinal 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- pre- served specimens of 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-bladder, when the exit of the bile has been chroni- cally 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 processes 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 dan- ger 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 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 swal- lowing. 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 bronehocele; in certain forms of enlarged prolate- in the thymus gland not unfrequently. Of a state of the brain which fs 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- HYPERTROPHY. 29 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 atrophied. There are parts of the heart wpon 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 hypertrophy of the female breast con- sists, 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 throughout the body, pro- ducing 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 suddenly to grow fat; and in about fifteen months, without any other dis- coverable malady, she gradually enlarged into a corpulent unwieldy monster. At length her legs and thighs became cedematous as well as fat, her lips blue, her 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 be- lieve, to fat collected upon the heart, oppressing its movements, and at last stop- ping them altogether. In 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 hyper- trophy to your notice among the alterations to which parts are liable in bulk. But it is not always so. There may be hypertrophy of an organ without enlargement—in at least three different ways:— 1st. In hollow organs, where the additional substance is deposited centrically, 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 space, and preserving the same absolute dimensions as before, but becoming more full of component particles, 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 par- ticles 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 manner. An inch of the middle part of the fibula of a quadruped was cut out. 30 HYPERTROPHY. 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 hemor- rhage from the stomach, 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 passage of blood from the liver was greatly impeded. Under these circumstances the liver became so large as nearly to reach the crest of the ilium. Suddenly the aneurism burst, the pressure was taken from the cava, the hepatic veins were allowed to empty themselves, and before the body was opened for inspection, the liver 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 converse proposition be as generally true—whether hypertrophy of a part always denotes increased activity in its function—is much less certain. If that were ascertained, 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 thryreo'id gland, for example), by investigating the circumstances under which they become sub- ject 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 in- creased energy in the known functions of that member. A few isolated facts, bearing upon some points connected with this inquiry, have been made out. In the first place, certain localities appear to be influential in the production of certain forms of hypertrophy. Thus bronehocele is very frequent among the inhabitants of certain districts; especially in close or marshy valleys at the feet of high moun- tains. 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 that 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 sty, and give him as much food as he is willing to eat, and you ensure his rapid pinguescence. If you cannot so certainly attain the same result by similar means huhe human animal, it is chiefly, I believe, because moral causes, and especially mental anxiety, will effectually counteract those means. A healthy man, with a quiet mind, usino- habitually a full nutritious diet, and leading a sedentary life, will fatten, I appre°- * Mr. Stanley's Lectures, Coll. Surg. ATROPHY. 31 hend, as unfailingly 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 disposi- tion 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 com- position, 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 imme- diately contiguous to it may sustain damage from its pressure ; or the functions of distant parts connected with it by dependency of office may be disordered ; or all these consequences 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 alteration 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 import- ant part in altering the bodily organs, both in health 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 pur- pose only. Upon the cessation of their especial function they dwindle, or disap- pear. 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 peculiar to the fcetal 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 work, remodeling 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 functions of the ovaries expire, these organs shrink, through atrophy. It is so with the testes of old men. Indeed, atrophy, to a pertain 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 fcetal 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 monstrosity. 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 hyper- trophy, 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 was previously announced; the develop- ment of a part is proportioned to the activity of its function. In most cases, I 32 ATROPHY. believe, the atrophy will be found to resolve itself into a deficient supply of healthy arterial blood. Building 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 sup- pose) 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 inaction which it produces, in causing the atrophy of a paralyzed limb—it still 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 circula- tion, 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 testicle withers when the sper- matic 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 furnished by the establishment of a collateral circulation. Chronic inflam- mation 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 nutrient fluid is diminished, or its quality impaired—produce a greater or less degree of general 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 propor- tions 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, exter- nally sound in appearance, have had their specific gravity so greatly reduced by internal atrophy, that 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 necessary accompaniment. Why it happens in one case, and not in another— whether the adipose hypertrophy is ever the cause of the atrophy associated with it, or the atrophy the cause of the hypertrophy:—these are questions which, in the present state of the science of medicine, do not admit of any positive solution. J r It is scarcely necessary to observe that the changes of bulk which we have been considering, imply often, though not always, changes of form also. You will have one or two of the chambers of the heart greatly 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 con- sidered as accidents of disease than among its important elements: and I nass on to other alterations. > ' INDURATION. 33 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 induration 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 patholo- gists, who first noticed this condition as an element of disease, call it ramollisse- ment. You are already aware—those of you who have attended the lectures of the professors 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 like 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 them;—of bile, for example, in the gall-bladder; of urine, in its receptacle; of gases in the stomach and intestines ; 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 neces- sary that you should be aware of its occurrence, and of its nature. I say of it? nature, because this is not always understood. In the induration arising from the last circumstance 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 sometimes been erroneously ascribed to some other morbid condi- tion. 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 cf simple oedema 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 proportion as the effusion is recent, and has taken place rapidly. Again, induration may accompany, and be a consequence of, simple hypertro- phy. 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 expression of its fluid, and the compression 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 we can restore, to a certain extent at least, its bulk and spongy feel, by forcibly inflating 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 parts, in the little spaces left between their component tissues, of fluid or solid matters which are not found there in the healthy state. Bony or earthy particles are sometimes laid down, and the part thus changed is said to be ossified. There are few parts of the body in which this kind of induration docs 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 obliterate 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. I 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 3 34 SOFTENING. lost; it resembles liver in its compactness 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 pulmo- nary 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 vesicles of one or more of its lobules ; the lobules thus gorged with blood become even harder and firmer than when hepa- tized ; 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 concrete and harden iviihin their proper vessels, and so lead to another form of induration. Thus the blood, under certain circumstances, coagulates in the living 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 consequences 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 calculi 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 yet to notice another source of unnatural induration, in the deposition or growth of irregular masses of matter within the body, differing remarkably from any of the solids or fluids that enter into its healthy composition. These unnatu- ral formations vary considerably in their nature and appearance, and in their con- sistence, at different periods. Sometimes they exist in distinct and separate masses, and whether hard or soft in themselves, cause induration by their pressure upon surrounding 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 malignant, 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; Us causes and varieties. Transformations of Tissue; Changes of 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 to be sensibly altered by disease. We considered the changes to which the solid parts are subject in bulk and form; and that alteration of their consistence which constitutes hardeninff or induration. 6 The opposite condition to this is softening, diminished consistence, a less degree ol cohesion of parts and tissues than is natural. This also is a state of which it is important that you should comprehend the SOFTENING. 35 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 any 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 occurrence, 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 exceed- ingly common, 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 sometimes, 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 lined 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 sub- stance of the heart, for example. Here the muscular fibre may itself have under- gone a change of consistence; or the muscle may simply appear to be softened, in consequence 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 lining 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 mollities ossium, 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 constituents; atrophy of that particular tissue. Indeed, softening is often a con- comitant or a result of atrophy. The accidental products to which I adverted when speaking of induration— especially some of the varieties of cancer—are sometimes remarkably soft, resem- bling 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 gene- ral cause of softening is inflammation. Every part, I believe, that is inflamed, undergoes, in the first instance, a diminution of its consistence. This appears to be almost the necessary consequence of stagnation of the blood, the effusion of serosity, and the suspension of healthy nutrition. These are circumstances to which I shall recur. I cannot avoid alluding occasionally to things with which you are supposed to be as yet but little acquainted, and which will engage our particular attention as the course advances. It would be a great mistake, however, to suppose that all softening results from previous inflammation. Doubtless it often proceeds directly and simply from deficiency of nutrition, and is then closely allied, as I said before, to atrophy. 36 TRANSFORMATIONS OF TISSUE. 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 arterial blood, and ceases to be properly renovated : hence a loosen- ing of its texture, a separation of its component particles, an approach to the fluid state. I shall, of course, hereafter endeavour to point out to you more particu- larly the means we possess of distinguishing these two forms of cerebral soften- ing; 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 chil- dren, 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. Magendie kept animals upon food unsuitable to them, containing no azote, and incapable of supplying sufficient nourishment; and one curious con- sequence 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 its 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 whole, 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 insufficient sustenance, or from altered qualities of the blood—may ulti- mately, (like atrophy) be resolved into suspended or defective nutrition. Furthermore, as there is a hardness of parts resulting from repletion and dis- tension, so there is a softness rather than a softening, from their emptiness and flaccidity : as of the breast immediately after the child has sucked ; of the abdo- men'soon after delivery ; of the integuments in those who, having been fat, have wasted, either from disease or from advancing age; and so on. On former occasions, I thought it right to lay before you the views of M. Andral (which 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 tmnatural 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 two 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 chants of this kind, and those changes which occur during the growth and progressive TRANSFORMATIONS OF TISSUE. 37 development of the human body, does not in reality obtain. More recent and more exact microscopical researches have shown that the several tissues do not commence 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 conversion 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 unreduced, it assumes by degrees the characters, toge- ther with the uses, of those tissues which naturally inclose the joint, and is con- verted 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 nearly 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 lime, 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 unfrequently met with in very fat persons—you will 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 mentioned 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 liver affords another instance of this morbid accumulation. The altered liver is of a light tawny colour, of diminished specific gravity, 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. By boiling it you may obtain a concrete oil, which has all the characters of fat. The change is wrought by an enormous augmenta- tion in quantity of the fat which is a natural constituent of the texture of the liver, and which thus comes to predominate immeasurably 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 that the "foie gras''' procured from certain birds, is an article of great luxury among epicures. 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, their eyes are put out, but this I should imagine to be a useless and super- fluous 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 effect. At the same time the birds are sedulously crammed with food. Under this discipline their livers acquire the requisite size, and greasiness, and the true flavour. An ingenious theory has been constructed, in reference to the modus operandi of this process. The excessive supply of nutriment tends, no doubt, of itself, as 38 TRANSFORMATIONS OF TISSUE. it always does, to the production of fat; the constrained state of inaction inter- feres probably with the right and healthful formation of blood, a matter in which the liver is believed to be a good deal concerned; then we know, by experience, that the privation of light has the effect of blanching animals as well as vege- tables, and thus further interferes with the due renovation of the blood. In this way, the transformation 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 consumption ; 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 allow- ance 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 incon- venience of a club-foot, a large bursa was distinctly to be felt on that part of the instep which 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 con- siderable 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 there- fore 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 abolished. On the other hand, the mucous membranes, under peculiar circumstances, approximate to the skin in their physical aspect and qualities. 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 neighbouring parts—that is to say, when it is placed under the same condi- tions 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 medicatrix naturae. 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 adaptation. To a certain extent it is a self-mending machine. Surely this is an admirable provision, and clearly indicative both of wise con- trivance and of beneficent design. The intimate texture of parts may be further altered—not simply by some modification or reconstruction of the ordinary tissues, but—by an absolute dis- appearance 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 after- wards pass into the solid state, or it is a consequence of the Growth of solids LESIONS OF NUTRITION. 39 which do not belong to the healthy body. In this sketch of general pathology 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 the head of lesions of nutrition, as the French pathologists speak. That is to say, they commence, and have their primitive seat, in that process and place where the blood, having reached the capillary system of vessels, performs its special pur- poses. It is in or through the capillaries that the fluids and solids accomplish their vital union. Each solid receives from the blood, and assimilates with its proper substance, material 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 of nutrition. The few changes already spoken of, and not included among the lesions of nutrition, 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, by 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 ren- dered 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 life 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 parts. 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- bon presented a remarkable example. He had an immense scrotal hernia; so 40 CHANGES IN THE BLOOD. large it was, that it hung down very nearly as low as his knees. After his death it was found that almost the whole of the omentum, and the greater part of the colon, had descended into the scrotum, and had dragged the stomach after them ; so that its pyloric orifice lay close to the abdominal ring. Akin to 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; just as one portion of the finger of a glove is sometimes pulled into the remaining part, by the withdrawal of one's hand. The container? portion of intestine is liable to be nipped and strangulated by the containing1 portion—and all the peril of hernia results, with much less chance of relief by art. This state of things is called intussusception. 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 dan- ger. Inversion of the uterus is another example. Thus much, then, of the changes to which the solid parts of the body are sub- ject, 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 theories of medicine might vary and fluctuate, the humoral pathology, till a com- paratively recent period, ran through almost all of them. At length, the absurdity of the hypotheses, and still more the dangerous practice, which this doctrine generated, 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 conditions 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. The old extra- vagances 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 humoralism, should ever have found advocates. LECTURE 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 Microsome Mechanical Congestion. Passive Congestion. Relations of these forms of Congestion to Inflammations—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 IN THE BLOOD. 41 changes which are apt to take place in its fluid constituents. I reminded you that, respecting the whole of this subject, pathologists had passed from one extreme of opinion to another; that, for a very long period, the humoral patho- logy 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 misconception should have so long maintained its ground. If we consider the definite relation subsisting between the solids and the fluids of the body, and the unceasing agencies which they 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 constantly at work in decompounding it by the various secretions—we cannot avoid perceiving that distinctions of the kind I have mentioned, founded upon mere differences of consistence, are futile. Flesh and blood are almost con- vertible terms: their composition, the chemists tell us, is identically the same. To use the strong expression of Bordeu, Le sang est de la chair coulante. You may be certain that no notable alteration 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 propor- tionate modification of its solids. 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 which 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 aliment, 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 away, may, and often do, directly alter and contaminate the blood, and act as poisons upon the system: matters, for instance, 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 harm- less while merely transitory, and in minute quantity, become noxious when retained and accumulated in the blood, in consequence of faulty 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 health, is continually purified by the kidneys; and bile, which is naturally separated therefrom by the liver; and carbonic acid, which it is the office of the lungs to excrete—will furnish topics of interesting inquiry hereafter. The fluids that leave the blood may be considered under a threefold division. 1. Those which are directly expended 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 42 PLETHORA. in too scanty quantity, or of imperfect quality, or not at all: and all, or any, 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 disorders of the parts or functions connected with each shall be dis- cussed. 3. Those which are separated from the blood merely to be excreted, as the urine, certain 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 of 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 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 is 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 composition, 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, inter- fering 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, the 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 quantity. It may exist in too great abundance throughout the body; and it may exist in too great abundance in certain parts only of the body. These states have been recognized for ages. Sometimes they are called respectively general and partial plethora: sometimes general and local congestions of blood ; people speak also of irregular determinations 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 thino-; and their frequent recurrence in medical works, is, of itself, suflicient 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 prepared 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. Inflam- mation, 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 GENERAL PLETHORA. 43 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 fullness of the cutaneous blood-vessels. The phenomenon of blushing, the red cheek of anger, the heightened colour of the skin under brisk exercise, are familiar 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, insensibility, and some- times death itself, when the congestion affects the cerebral blood-vessels; and attacks of difficult breathing when the capillaries of the pulmonary tissue are concerned ; and even these attacks, for aught that I know, may end fatally. It often 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 surface, as in the extremities, are visibly paler: and there are, at the same time, corresponding and palpable differences of temperature. Perhaps it may not be so obvious that the whole quantity of blood, throughout the body, is sometimes in excess. That in the adult state, when the growth or increase of the body has been completed, blood may be made in greater abundance, and more rich in the mate- rials 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 occa- sion 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 libe- ral expenditure of it through the skin, and by means of the other organs of secretion, which would occur under more active habits. Persons thus circum- stanced are apt to grow, fat; the adipsoe tissue seeming, in these cases, to form a kind of safety valve for the diversion of the superfluous blood. Such persons have turgid and florid cheeks, red lips, red mucous membranes, and (not uncom- monly) 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 hypertrophy 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 expect them to be, and as many writers state them to be, peculiarly prone to suffer inflammatory complaints. There is a general fullness of the vascular system, but no irregularity, 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 portion 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. Oligemia is the cacophonous but more 44 ANAEMIA. exact name assigned to it by Gendrin; but 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 fre- quently lose a certain quantity 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 suffer repeated hemorrhages from the uterus. When the drain has been long-continued, these persons become very pale; 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 will have a small clot floating in an abundance of serum, and that small clot will be of a light rosy colour; showing a great diminution in the proportion of fibrin ; and a still greater deficiency of the red particles. The 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 conjunction with the obvious curative measures comprised in arresting the habitual loss of the vital fluid, and in affording sufficient nutriment to the system,—the preparations of iron, and the respiration of pure air, have signal efficacy in renewing the red 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 conges- tion—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 proportion of its nutritive materials, have been considerably dimi- nished by disease, or by hemorrhage. This remarkable tendency, under 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 functions 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, disturb their action, and derange the balance of the circulation. That the capil- lary blood-vessels may be filled to excess, or completely emptied, by causes ope- rating 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 difference, are often determined through the agency of the same ner- vous system. And persons endowed with 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 in 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-ves- sels ; there is, evidently, more than the usual quantity of blood attracted to ihe part, or detained in the part—a degree'of redness, which soon subsides if the cause of it be withdrawn in time. LOCAL PLETHORA. 45 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 inten- sity, and the phenomena of inflammation begin to manifest themselves. I said we can produce local congestion when we please upon the surface of the body; but there can be no doubt that a similar state may be produced by analogous causes, in internal parts. Look at this representation of the stomach of a dog [one of Dr. PoupeWs 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. Andral, whose nomenclature has come much into fashion of late years, calls it sthenic, or active hyperasmia. 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 are wrought, when the process advances a stage beyond mere local ple- thora. What has been observed, by the aid of the microscope, with respect to the blood-vessels, I will endeavour to describe to you. I take the account I am about to give you chiefly from Kaltenbrunner, a Ger- man pathologist, who has recently investigated the subject experimentally, and whose observations are believed to have been most carefully and skilfully con- ducted, and their results no less faithfully narrated. His observations were made upon the circulation as it appeared in trie 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 op- portunities 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 consider 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 spec- tacle, 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 vvith great velocity along tubes which divide and subdivide into smaller and smaller branches, each branch (speaking generally) going off at an obtuse angle : these are plainly arteries. Then, in an- other part of the field of view, you see the blood moving in the contrary direction, more slowly, 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 particulars—that they interlace and anastomose in all parts, in a very irregular manner, and at all angles, and that they retain every- where 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 46 ACTIVE CONGESTION. forming the meshes of a net, except that the interstices are irregular in size and shape. These are the true capillaries, intermediate between the arteries and the veins, and perfectly distinct in character from each, but communicating and con- tinuous with both. If now you press upon the animal's leg, so as to obstruct the circulation a lit- tle, 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 globules 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 three times as great as usual; the velocity of the blood is accelerated ; the dis- tended sides of the vessels 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 inter- rupted. The globules, passing with great rapidity through all the vessels, retain the characters of arterial globules even when they arrive at the veins ; they pre- sent a bright colour, 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 slightly tumid, and assumes a brighter tint than common. All these phenomena begin from a circumscribed spot, of which the circumfer- ence 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 incu- bation; 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 slight, 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, when it has not been so slight, the congestion terminates by an evident crisis, which Kaltenbrunner thus describes:—The blood, receding 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. I he moment of exhalation is very transient; but it is repeated often, and in dif- ferent spots, until the congestion has disappeared. It is evidently critical, for the congestion is relieved and extinguished in proportion as the exhalation is repeated. 1 shall follow these consequences of active and continued local congestion no further at present; but merely remind you again that the changes fhave last mentioned 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 textures of animals, we rea- sonably infer to take place, under analogous circumstances, in those parts of the body winch 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. »c^»uu "* One obvious mode of remedying this congestion is the mechanical abstraction PASSIVE CONGESTION. 47 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 con- stitution may be such, that the disposition to local plethora would be increased by the loss of 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 irregularly 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 successful. 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 single limb, when the principal venous trunk belonging to that limb is compressed, or otherwise diminished in size ; and when no collateral and compensatory channels for the returning 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, con- gestion 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 t>f gravity alone is sufficient to produce venous congestion, and consequently congestion of the capillaries, in parts of the body in which, under ordinary cir- cumstances, 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 time, we see the unequivocal signs of such congestion in the tumid condi- tion 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 venae cavae, 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 mechani- cal obstacle in the veins. To this form of congestion the term passive is applied. Andral denominates it passive or asthenic hyperaemia. 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 posi- tion of the limb will perhaps diminish the livid redness, or may even sometimes entirely remove it. But the'depending position ought not to cause it, and would 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 elasti- 48 PASSIVE CONGESTION. city ; they easily dilate under the pressure of the blood, which, being thus retarded, accumulates in the part. The employment of friction, or some stimulating appli- cation, will often remove this congestion. 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 hyperaemia, 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 indolent 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 circulation, and unloading the congested capillaries. Observe, again, what not unfrequently happens in regard to the eye; a little organ, indeed, but one that supplies us with more striking lessons in pathology and therapeutics than any other portion of the body. You know that the con- junctiva and sclerotica, through which, while healthy, 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 substance to the surface of the organ will increase the existing redness, multiply the number of visible vessels, and aggravate the complaint. These are cases of active congestion, dependent upon irritation that is still sub- sisting. But it is equally well known to practical men that the blood-vessels of the eye are liable to congestion of a very different kind. They are seen to be distended, somewhat tortuous, almost varicose, 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 elasticity, 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 con- gestion, 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 to similar conditions of passive congestion. Take those exceedingly vas- cular organs, the lungs, through which the whole of the blood circulating in the living body has to pass. The lungs, as might be expected, are very liable to congestion and engorgement of their capillary vessels. Oft-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 preva- lent here in the spring of 1831, and again in the early part of 1837. Among the most constant and striking characters of the disease were the symptoms of pulmo- nary catarrh ; and it was remarkable how long, in some persons, these symptoms persisted. After the pulse had regained its natural frequency of beat, and when all fever had ceased, the patient would continue 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 conjec- ture that this disappointing obstinacy of some of the symptoms might depend upon a lingering but passive congestion of the pulmonary mucous membrane PASSIVE CONGESTION. 49 And the nature of the juvantia showed the correctness of this conjecture. 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 anatomist. You must take care not to confound a knowledge of pathology, in th*e proper sense of that word, with a knowledge of morbid anatomy. Pathology comprehends 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 living body, and the laws which govern those processes. There is one important law ascertained in respect to both active and passive congestion ; viz., that it is apt to recur; that those parts are most likely to suffer it (or inflammation, which implies itj that have suffered it before. We may often turn our knowledge of this general fact to good account, in what is termed the prophylaxis 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 suffice 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 lungs (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 debility. This state of the capillaries is called by Lerminier the " engorgement of position;" and by Laennec, " the pneumonia of the dying." It neither proceeds from irritation, nor has it the essential characters of inflammation ; although it is apt to be con- sidered an evidence of inflammation 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—Inflammations, 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, before 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 irf which the physical con- ditions 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 alterations of structure, or interruptions of function, are incompatible with the further continuance of life, and put a stop to the working of the whole machine, is an inquiry of no less interest, though of a somewhat different kind. 4 50 CONDITIONS OF LIFE. LECTURE V. Different modes of dying. Pathology of Sudden Death. Death by Ansemia ; 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 Phe- nomena, 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. 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 con- sidering, 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 entan- gled; 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 into the several processes and modes of dying—the steps, or ways, by which the vital functions of the body are extinguished. A very little 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 life, and apparent health perhaps, to the condition of a corpse, is made in a moment: in another the process of dissolution is slow and tedious, and we scarcely know the precise instant in which the solemn change is completed. One man retains pos- session of his intellect up to his latest breath: another lies unconscious, and insensible to all outward impressions, for hours or days before the struggle is over. We seek to ascertain 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 dis- eases, I shall constantly refer to the facts and reasonings which I am now about to lay before you. / In pursuing this inquiry, we need not go into any deep physiological disquisi- tion respecting the conditions that are essential to life. It is sufficient for our purpose to remark that life is inseparably connected with the continued circulation of the blood. So long as the circulation goes on, life, organic life at least, remains. When the blood no longer circulates, life is presently extinct: and our investigation of the different 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 carrying on and maintaining this essential function. First, there is an extensive hydraulic apparatus distributed throughout the frame, and consisting of the heart and other blood-vessels. Next, there is a large pneumatic machine, forming a considerable part of the whole body, and composed of the luno-s, and the case in which they are lodged. Lastly, the power by which this machine is to be worked PATHOLOGY OF SUDDEN DEATH. 51 and regulated is vested in the nervous system. Each of these systems must con- tinue in action, or the circulation will stop, and life will come to an end. The functions they 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 sur 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 perceive. 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 them to contract. If this, the proper stimulus to the internal surfaces of the heart, be withheld, or much deficient, it will soon cease to beat. There are plainly, there- fore, 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 requisite ; first, circumfused air to enter and depart at short intervals ; and, se- condly, 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 condition 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 depend- ent upon any constant nervous influence conveyed to it. The circulation goes on in an acephalous fffitus; it may be kept up, by maintaining artificial respiration, in a decapitated 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 nutriment—it has been clearly ascertained that very sudden and extensive injurv 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 affecting the heart, bring the motions of respiration to a pause: and there are certain states of the brain and nerves which act directly on the heart and arrest its play. 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 simplest forms. We must examine the cases in which the vital func- tions are, each in their turn, suddenly stopped, by some known cause, operating upon this or that vital organ. We must take advantage of the experiment (if I may so call it) which is performed before our eyes whenever a healthy man is cut off at once by external violence, or by poison, acting directly upon a par- ticular organ or system of organs. The inquiry might be assisted, and, indeed, it has been mainly carried on, by experiments made upon living animals of a 52 DEATH BY ASTHENIA. 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 predominant 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 called, 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 want of power to contract upon its contents ; but it is found empty, or nearly so, and contracted. Secondly : this conclusion is confirmed by the reverse experiment: by the effect, I mean, of the transfusion of blood. It is a fact well ascertained, 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 living animal of the same species. Now it is quite clear that this intro- duction 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 counte- nance and lips, cold sweats, dimness of vision, dilated pupils, vertigo, a slow weak irregular pulse, and speedy insensibility. With these symptoms are fre- quently conjoined nausea, and even vomiting, restlessness and tossing of the limbs, transient delirium: the 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 here- after described, may also prove fatal in the same manner. This, then, is one form of death beginning at the heart. Another form, the converse of this, but spoken of also as death beginning at the heart, is that in which there is no deficiency of the proper stimulus to3the 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, ap- plied to some part or other of the body, speedily extinguish life: 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 an- tiar, that the heart was not empty, but full, there being purple blood in its rkht, DEATH BY INANITION. 53 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 anaemia, the suspension of the func- tions 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. Syn- cope is sooner produced by venesection when the person bled is silting up than when he is recumbent: 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 pri- marily 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 perito- neum, in what is called malignant cholera, and in cases of extensive mortification. Akin to this form of dying is that in which the living powers are slowly ex- hausted by lingering and wasting disorders, as in many cases of phthisis, in dia- betes, 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, to be ascribed lo 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 starvation, 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, as well as of the muscles generally, is weakened; and from these combined causes its movements at length cease. Ac- cordingly 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 oesophagus, prohibiting the introduction of food; of the stomach, preventing its retention; of the digestive organs gene- rally, hindering its assimilation, are fatal in this manner. We have yet to consider how death is produced by the suspension of the respiratory function—in other words, by a want of the due arterialization of the blood. There are two perfectly 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 obstacle to its entrance. 54 DEATH BY APNtEA. 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 asphyxia. The second is conveniently termed death by coma. 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 very 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 therefore 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 con- sidering, namely, death beginning at the heart. And you will presently see that it is peculiarly 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 established by custom, to allow of its being restored to its proper mean- ing without much confusion. But, at any rate, I can and shall avoid its use, and adopt in preference the generic term apncea (privation of breath) as justly expres- sive 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 stoppage of the mouth and nostrils {smothering):—by submersion of the same inlets in some liquid (drowning); 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 without, as by the bowstring (strangulation; both these varieties are included in the term throttling):—by forcible pressure made at once upon the chest and abdomen, preventing 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 situation was perceived just in time to save his life;" 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 by the poisonous influence of strychnine, all the respiratory muscles being fixed in rigid spasm :—by para- lysis of the same muscles, from injury or disease of the spinal cord above the origin of the nerves that give off 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 both 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 pleurae become filled with liquid of any kind. Whenever the privation of air is sudden and complete, the following external phenomena 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 unpleasant, of vertigo, and then by loss of consciousness, and convulsions: at length all effort ceases, a few irregular twichings or tremors 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 life are over; there is no asphyxia (properly so called) till the very last. DEATH BY APNCEA. 55 During this process, which does not occupy more than two or three minutes, the face at first becomes flushed and turgid, then livid 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 symp- toms, have been carefully studied, and accurately, though slowly and lately ascer- tained. 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 insensi- bility 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 alto- gether ; the lungs remaining full, the right chambers of the heart distended, and therefore less capable of contracting. Meanwhile 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; andthis side of the heart is comparatively empty. In this state, even after the heart has ceased to beat, but not long after, if the cause 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 undergoes 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 begins, in the lungs. When the carcass of an animal, that has thus perished of apncea, is immedi- ately 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 cavae, 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 impedi- ment to the further transit of blood through them; and that death resulted from obstructibn of the circulation in the lungs. He was partly right; but he erred in supposing that the stream of blood was arrested absolutely, and at once, and by a a mechanical obstacle. Apnoea, vvith all its peculiar phenomena, occurs, when atmospheric air is excluded, although the lungs continue to play ; as in persons who breathe azote or hydrogen gas. It was clearly shownljy Dr. Goodwyn, in his Essay upon the Connection of Life with 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 contraction 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 ligature upon the trachea of a living 56 DEATH BY APNCEA. 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 flow, and the afflux of this dark blood upon the brain was marked by convulsions and insensibility. Bichat con- ceived, therefore, the erroneous belief that the blood underwent 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 system, 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 empti- ness 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 consequence 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 sup- port, 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 sup- plied with no blood at all. Doubtless, in death by apncea, the movements of the heart are weakened, partly in consequence 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 difficulty 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 conclusions are founded, I must refer you to his work on Asphyxia. Sudden death by apnoea 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 uncommon consequence of accidents, in which the upper cervical vertebrae are broken or displaced. I have seen several instances of death rapidly 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 apncea is plainly discernible, sometimes for a long while before their fatal termination 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 that are auxiliary to the respiration ; we perceive by the dusky and loaded countenance, the livid lips, and ears, and eyelids, that the blood is but imperfectly arterialized. The diminished capability of such blood to support the functions of the brain is made evident by ihe 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 appear- ances are even more constantly visible in the dead body, when apncea has been gradually produced, than after sudden suffocation ; simply, I believe, because ihey are more permanent. After sudden death, however caused, the blood seldom coagulates; and the venous tumescence consequent upon rapid apnoea, although great at first, has time to subside and disappear before the body is examined. In protracted cases, death does not lake place purely in the way of apnoaa; the DEATH BY APNCEA. 57 heart is weakened, and the nervous influence impaired by the continued circula- tion of imperfectly arterialized blood; but the symptoms belonging to apncea are plainly 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 additional cause of suffocation. The same phenomenon is observed when the par vagum is divided on both sides. Death by apncea in disease is extremely common. It maybe produced by any thing which narrows the chink of the glottis ; by warts that sometimes grow there, by (edema 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 membranes 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 proceed 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 apncea; more commonly it tends to death by asthenia. Diseases of the pleurae attended with effusion, and causing pressure upon the lungs; diseases of the heart and great thoracic blood-vessels, affecting the quantity of blood in those organs; even certain abdominal maladies, accompanied by swelling, and thrusting the diaphragm upwards—terminate by the same mode of dissolution. Death by coma, although common enough, and of much importance to be understood, 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 profound ; the sensibility to outward impressions is destroyed, some- times 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 continue; 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 perhaps imperfectly, the reflex power of the medulla oblongata, which 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 apncea. You will observe that the extinction of organic life takes place in exactly the same manner in both cases: tjje difference between the two forms of dying being this—that in death by apncea, 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 the 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 of their operation. The essential anatomical characters of death by coma, and of death by apncea, are therefore the same. Death occurring in the way of coma has this peculiar kind of interest belonging to it, that it may sometimes be effectually 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 58 APPLICATION OF PRINCIPLES. respiration artificially in animals labouring under the influence of narcotic poisons, the heart might be kept in action until the stupefying but transitory effect ot the poison upon the brain had gone off. This idea he soon brought to the test ot 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 be 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 diminu- tion 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 effort to breathe. At the end of another hour the animal, for the first time, showed some signs of sensibility when roused, and made spontaneous 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 experi- ment 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 substance 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 affections of the brain, both acute and chronic. These will form subjects for our 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 the venous blood through the arteries. In one of these, the first step is the sudden shutting out of air from the lungs ; the blood which arrives in 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 functions 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. CAUSE OF DISEASE. 59 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 fulfilling 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 bear- ings 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 illus- trate 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, life is extinguished in the way of suffocation or apncea: and occasionally fever seems to terminate fatally in the way of syncope, especially when the stress of the dis- order has fallen upon the bowels, when there has been continued diarrhoea, and ulceration 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 treat- ment, 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 recommended by other physicians, because it does not appear to accord with the results of our own observation. LECTURE VI. Causes of Disease: distinction 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 of 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 inflamma- tion of the lungs; or softening of the brain. When we do not, we call the com- plaint 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. 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 lec- tures, except perhaps in a quotation, again. 60 CAUSE OF DISEASE. 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 inter- vene 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 (quae 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 diseases are much more frequent among persons known to have been exposed to the agency of the presumed causes than among persons who aTe not known to have been so exposed. The evidence at first is presumptive only. But the more uniform their conjunction, and the more rare their disjunction, the more confidently do we assign to the two consecutive events the relation of cause and effect. By this kind of observation a number of exciting causes of disease have been clearly established to be such. But recollect, certain circumstances being present, such and such diseases do often, not always, follow. Some persons are more liable to be affected by the operation 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 circumstances,.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 catarrh, 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, therefore, the exciting cause alone that in all cases determines the disease. Something—nay much, or all—will frequently depend upon the condition of the body at the time when the exciting cause is applied; and this con- dition of the body, which we call predisposition, will depend upon circumstances then or previously in operation; and these circumstances are, in our language, predisposing causes. Do not confound, as many seem to do, the predisposition with the circumstances creating it. The predisposition is a certain state of the body—the predisposing cause is 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 lo the exciting cause of the particular disease. It is sometimes difficult, or impossible, to say of a given cause whether it ought to be 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- position 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 climate, 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 off, notwithstanding the presence and application of its exciting cause, when its predisposing causes are ascertained and can be prevented. In proportion as 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 fortifying the system, we walk with comparative security amid surrounding pestilence. CAUSE OF DISEASE. 61 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 frequent) is, that the causes have not hitherto been discovered. Now the ascertained causes of disease are many and various. Whatever mi- nisters to life, health, or enjoyment, may become the medium, under changing circumstances, 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 when it consists of certain sub- stances, or certain admixtures of substances ; so that there really was much truth, as well as some humour, in the startling motto to Mr. Accum's book on adulter- ations—" 77/ere is death in the pot." Our passions and emotions also, nay, even some of our better impulses, when strained or perverted, tend to our physical destruction. The seeds of our decay are within as well as around us. Let us enumerate, however, a lilile more particularly, the various known sources of disease, with the view of making, afterwards, a few practical comments upon some of them. 1 shall piss over, in this enumeration, nearly all chemical and mechanical injuries ; 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 conditions ; differences of pressure, as measured by the barometer ; a de- ficiency 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 ol the fore- going heads are also prolific sources of disease. Another 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 be- comes of a bright red colour ; the swelling increases. In the immediate place of the injury the swelling 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 thermome- ter, it will be found to exceed the temperature of the neighbouring surface. The part is inflamed. This is what is called phlegmonous inflammation. <&xsyiiovri is a Greek word, and inflammatio is a Latin word, and they both mean the same thing, viz., a burning, or a flame. Phlegmonous 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 leaches that, philosophically speaking, there is actual and excessive combustion going on in that part. If the inflammation reach a certain degree of intensity, other signs of dis- order present themselves at a distance from the injured spot. The patient usu- ally 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, wiih 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, gels 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 inflammatory fever. This is an indirect symptom of inflammation, manifesting itself through the medium of the system at large. Various names have been given to this general derangement of the vascular and nervous systems: constitutional disturbance—sympathetic fever—symptomatic fever. It matters little what term is used, provided that we affix always the same meaning to it: but inasmuch as the word fever, in this and in other languages, is taken to express a specific disease, it would perhaps be better to employ the term pyrexia, as Cullen and others have done, to denote that secondary febrile slate which grows out of, or is associated with, primary local inflammation. Now what is the end of ibis remarkable state of things ? Why, 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 ihe bit of glass, then it will often happen that the phenomena just described will gra- dually recede and disappear; the pain will abate, the redness fade, the swelling diminish, the heat decline, the pyrexia cease; until ihe part at length regains its usual sensations and its natural appearance. When inflammation subsides in this way it is said to be resolved, to terminate by resolution; and this is its most favourable and desirable mode of terminating, whenever inflammation occurs as a morbid process. But in many instances the inflammation does not thus subside. The irritant PAIN. 97 cause still 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 have not succeeded. The symptoms already described continue, and are aggravated in degree: at length the swelling begins to assume a more projecting and pointed form, and ihe skin in its centre to look white; the central part of the swelling, formerly so hard, becomes softer—the pain is of a throbbing kind: a pulsative sensation, keeping lime wiih the beats of the heart, is experi- enced 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 generally 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, ihe character of the general febrile excitement undergoes a change. Slight but frequent shiverings, or feelings 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 peculiar and offensive odour. This is mortification. When the injury 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 starlings of the tendons of the voluntary muscles; his pulse is weak and very frequent; his tongue be- comes 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 without 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 living parts, and leaves a breach of surface. The separation is effected by a vital process which is denominated ulceration; but which I 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 pecu- liar appearance known by the name of the buffy coat, i. e., on the surface of the coagulum, 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 inflam- mation 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 differentlv felt, ceteris paribus, by different persons, according to their natural susceptibilities. It varies from the slightest degree of sensibility to the utmost agony and torment. Parts which, when sound, are endowed with little or no capacity of sensation (as tendons, ligaments, cartilage, bone), become often exquisitely sensible under inflammation. The organs of sense are variously affected in ihis respect. Thus the specific sensibilities of the mouth and nose are blunted by inflammation—ihose of the eye and ear are often rendered pain- full v acute. There are great diversities also in the kinds of pain. Sometimes it ' 7 98 INFLAMMATION. is of a dull aching character, 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 feeling in inflammation of the serous membranes, 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 mucous membranes and in the parenchymatous textures of organs. Very often the 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 pais. 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 common earache. It is upon this principle, I believe, that the differences in regard to pain, which occur in different structures under inflammation, are partly to be explained. Speaking generally, there is more pain felt in external inflammations, and in the inflamma- tion of investing membranes, than in inflammation of the substance of the vis- cera, 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 sen- sation. 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 tex- ture, and often attached to the subjacent parts in loose folds, and they allow of an accumulation of blood within them without becoming much stretched, or very tense. The investing serous and fibrous membranes are more tightly applied, and much less capable of yielding: and their inflammation is usually attended wiih severe pain. The pain that belongs to inflammation sometimes precedes any other apparent 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 inflamma- lion, the state 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 ques- tion 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 affected part—intentionally by the medical man-or accidentally, 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 aa-rravation ot 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. 1 hus pain of the abdomen may result from colic, or spasm—from a distension of die intestines by air, and a stretching of the textures and nerves belon*inion, which grows turbid and whitish, and at length distinctly assumes a puriform character. But in much the greater number of ram-s the for- mation of pus is preceded by the effuHon of coagulable lvn.ph, with or without ULCERATION. 113 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 little beyond the adhesive stage. This was the opinion of John Hunter, who was the first to teach us any thing worth 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 himself 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 inflammation." 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 one 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 pre'erence to the adhesive is remarkably seen in various other cases. In simple pleurisy—from exposure to cold—we seldom have any liquids effused, except coagulable lynph and serous fluid. But if the inflammation has been caused by a punctured wound from without, or by laceration of the pulmonary 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 results—pus is formed. So also in pneumonia: at first the inflamed lung is rendered solid by the effusion of coagulable lymph into the air cells ; but if the inflammation persists, the next thing that happens is what is called by Laennec gray hepatization—a puriform infiltration takes the place of the lymph. The same principle is exemplified in the case of the urethra ; inflammation of ihe free surface of its mucous membrane leads rapidly to the for- mation of pus; inflammation of its attached surface occasions the pouring out of lymph, which produces stricture. And in general I think it may be said of sur- faces that are open to the air, of tegumentary 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 super- seded by a puriform discharge. We have every-day examples of this, in inflam- mation of the conjunctiva, of the bronchi, and of the bladder. Perhaps it is in this principle that we may find an explanation of the fact that whereas in the inflammation of areolar tissue, of glandular organs, and of the parenchyma of the viscera generally, the pus which forms is collected into an abscess; circumscribed 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 will of course come under our consideration again. There is, however, manifestly a close connection in many cases between the effusion 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 belonging to the inflammation usually abates, or ceases, except when ihe pus is imprisoned so as to keep up the pre-existing tension. Certain remarkable constitutional phenomena 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 tegumentary 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 gonorrhoea. 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 8 114 INFLAMMATION. no fixed relation to the intensity of the inflammation by which it has been pre- ceded or accompanied. A fifth event of inflammation is ulceration. You may remember my telling you that Kaltenbrunner observed the progress of absorption in the inflamed tis- sues 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 absorption 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 absorp- tion. 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 maybe 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 increas- ing 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 sur- rounding 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 ulcera- tion. The 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; and great differences are observable between the different tissues, in respect to the facility with which they severally ulcerate. Ulceration is most common in the tegumentary membranes. It is frequently met with, also, in the inner coats of ihe 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 important pathological bearings. But I may not stop to consider these at present: they will be particularly noticed as the course proceeds. When I state that ulceration 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 atten- tion 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 Outlines of Pathology. 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 granulations 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 suppuration; 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 ex- tends 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 MORTIFICATION. 115 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 callous or indolent: and when the granulations 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 of 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 capa- ble 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 textures which have been destroyed. I explained to you, in a former lecture, that inflammation may lead to a wast- ing of parts, although there is no suppuration or ulceration. The testis some- times withers as a consequence of inflammation : interstitial absorption takes place. Atrophy, in short. LECTURE XI. Mortification, as an *vent 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— Mucous Membranes ; Muscular Tissue ; Arteries ; Veins ; substance of the Brain. 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 inflammation; 2dly, serous effusion; 3dly, the pouring out of coagulable lymph, constituting the adhesive form or stage of inflammation; 4lhly, the formation of pus, or suppuration; and 5thly, ulceration. The pathology of these several events, so far as it is understood, and the change of symptoms to which they may respectively lead, 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 in- flammation that requires to be noticed : viz., gangrene, sphacelus, mortification. 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, pur- plish, 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 faecal matters which had rested upon them. What I 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 the living parts ; and nature proceeds to amputate the portion which has lost its vitality. The process by which this is effected is extremely interest- 116 INFLAMMATION. ing. Adhesive inflammation constructs a barrier of lymph.against any further advance of the mortification; 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. Meanwhile very interesting changes occur in the part that . lives, the large vessels are plugged up, to a certain distance, by the coagulation " of the blood contained in them ; the coagulation of the blood following its stagna- tion. They are further sealed up, and the smaller vessels also are closed, by coagulable lymph. Were it not for these changes, fatal hemorrhage would fol- low the separation of the dead part. Now this is just what a surgeon rudely imi- tates when he amputates a limb; 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 repair 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. It seldom affects the other mucous systems—those which belong to the air-passages and the urinary organs. It occurs sometimes—but not very often—in 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 superficial; necrosis when the entire shaft of a long bone dies. In these cases 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. Now mortification is no certain or constant event of inflammation. It depends, more or less, upon various causes and conditions. Sometimes, upon the mere intensity of the inflammation, as in 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 gonorrhaeal ophthalmia is another example to the same purpose. 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 in- flamed. In persons who are debilitated 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 dropsical patients, with feeble and impeded circulation, we find that a blister on the extremities, where the circulation is the most feeble, will sometimes cause mortiflcation; while it might be applied to the chest without any risk of that event. Probably, in each of these instances, the unhealthy condition of the blood con- duces to the sloughing, process. Inflammation of the stomach and intestines ia marked by a strong disposition to run into gangrene—and this again is consistent with 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 beincr produced by cation. [The affection of the throat in cynanche maligna is not, strictly speaking mortifi- Th^i JL \ sh1own,b7I?t;elo<.nneau and others, to be a true pellicular inflammation. rin«d 5,^? TnM' y t \ C faU,CCS arel_p^ered>either in Pan or entirely, becoming Kr wSrh ' aSSrC * t&Tk °r a,n!P!1 black aPPearance> and exhale an intolerabl! foetor—which circumstances have caused them to be mistaken for sloughs—but when they become detached the mucous membrane is found to be perfectly entire, and wiAoutw appearance of softening; the peculiar odour of gangrene, also, is absent.-C ] * INFLAMMATION. H7 other causes, as well as by inflammation. The death of frost-bitten parts is per- haps scarcely an exception—the phenomena of mortification occur in them after the reapplication of a certain degree of heat—suflicient, 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 mortification. 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—the gangrena senilis; which, by the way, is not always dry In the majority, however, of these cases, the gangrenous part, not being preter- naturally loaded with fluid, does not so rapidly putrefy; but remains dry and shrinks up. 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. Pro- bably 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 col- lateral 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 exter- nal injuries. There is also a very curious form of chronic and dry gangrene, produced by the continued use 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 coresponding disturbances of the system at large. These were touched upon (barely mentioned, however) in that rough and general outline which I attempted to sketch in the outset, of the various phenomena of inflam- mation ; and to which I have since referred as a type. They require, for many reasons, to be 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, what changes it has undergone. You may perceive that the opposite lips of a wound have adhered : 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 actual death of the part. The mere exercise of your exter- nal senses apprises you, not merely that there is inflammation, but also whether it is of the adhesive kind; or has reached the degree of suppuration ; or has pro- duced 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. Sometimes 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 declare 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, some- 118 INFLAMMATION. times, as sure indications afforded us by direct symptoms, cognizable by the sense of hearing or of touch, of the state of internal organs, as we could have ll they were exposed to our view. To these direct symptoms I am not now about to refer; thev 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 symp- toms that denote the existence of inflammatory fever are debility and chilliness, 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, languor, thirst, loss of appetite, a furred or white tongue. Among these leading symptoms, the chilliness, often amounting to shivering, has this particular importance attached to it, that it marks the date of the febrile disturbance. And it is worth observing, that rigors more commonly attend the commencement of spontaneous inflammation than of inflammation caused by exter- nal 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 inflammation: 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 irritated, 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 increase 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 hand, 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 inflammation. The circulation in the web of the opposite 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 contain an unusually large proportion of fibrin; and it has acquired the unnatural quality whereby, when withdrawn from the body, and allowed to coagu- late, it exhibits 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 exanthemata, afford instances of exception; the fever sets in before any mani- festation 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 in- flammatory ; such as inflammation of the lungs, and cynanche tonsillaris. There are other cases in which the local symptoms and the general febrile disturbance appear to burst forth simultaneously: 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 that common com- INFLAMMATORY FEVER. H9 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 commonly 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 times 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 abdominal organs; and particularly by inflammation involving their peritoneal covering. This lowering influence (which is analogous to that of certain me- chanical 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 peculiar 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 habils 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 febri(e 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 move- ments 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. 6. The relative duration of the inflammatory fever is subject to some variety. It may persist for a little while, for a few days, even, after all the local signs of inflammation have disappeared: this happens chiefly in persons of an irritable habit. We watch such cases narrowly, not without some apprehensions of a relapse. On the other hand, a rapid abatement of the febrile symptoms some- times 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, that event is frequently marked by the supervention of peculiar symptoms; and the character of the fever undergoes, for the most part, 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 neces- sary while any prospect rejnained of the resolution 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 blood from the part, or from the system ; and applies perhaps warmth and moisture, by means of a linseed 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 continuance 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 circum- stance 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 120 INFLAMMATION. connected wilh suppuration. They usher in, as I presume you know, most forms of fever, appearing at the very outset of the disease. They recur, at regu- lar intervals, in intermittent fevers. Slight causes will, sometimes, produce them. They often follow the introduction of a bougie into the urethra. But when they occur after symptoms of internal inflammation have been for some time present, they denote, in most cases, the production of pus in the part or 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 circumstances 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 suppuration is commonly marked) are an abiding frequency of pulse; alternations of chilliness with heat and flushing, followed by perspiration; a gradual wasting of the body; and progressive debility. I shall hereafter have to speak of a very different kind of disease, in which, however, there is a succession of symptoms resembling more or less closely the series that characterizes hectic; I mean remittent fever; the succession of symp- toms 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." Cullen has described 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 distintly 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. Sometimes, however, there are two or three fits in a day. The paroxysms are shorter, and less regular, tljan those of intermittent or of 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 ihe 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 some- times happen." Hectic fever is one of the fearful accompaniments, and sometimes the most strongly marked symptom, of pulmonary consumption: and where the existence of that complaint is suspected, yet a matter of doubt, we look for indications of hectic fever with the greatest anxiety and dread. With relation to hectic fever, considered as an indirect symptom that suppura- tion 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 inflam- matory fever that attends the earlier stages of inflammation. The pulse loses much or all of its hardness and strength, but it remains per- manently more frequent than the pulse of health : the appetite returns in great measure | the thirst abates; the tongue, instead of being covered wiih a white fur HECTIC FEVER. 121 becomes clean and moist and towards the end is sometimes unnaturally red, or speckled with aphthae : 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 incur- vated into an adunque form ; and the sclerotic coat of the eye, as seen through the conjunctiva, becomes of a pearly 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 or other of the body is so frequent, that it has been deemed, by persons of great ex- perience 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 evidently, or when he*had not ground to suppose there was, a permanent purulency or ulceration in some external 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 belief. Considerable 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 ope- ration. Facts like these prove, I think, that heetic 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 sympa- thetic hectic fever is a teased action of the system, endeavouring to throw oft" what annoys it; the cause of irritation being removed, it ceases forthwith. And there is another conclusive circumstance to be mentioned. Notwithstand- ing 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 any- where. We often see hectic, or a general state of the system not to be distin- guished 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 soften- ing and suppuration of a single tubercle. I call to mind one instance in particular of this. The hectic was distinctly marked, and continued long. The patient died, at last, comatose, after two attacks of convulsion. 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 122 INFLAMMATION. 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 I spoken of it rather at large. Whenever I mention hectic fever in the further 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 mortification as an event of inflam- mation. 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, cold- ness 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 faeces and of urine. I must, however, now inform you that these typhoid symptoms are no constant or necessary con- comitants of mortification. The natural mode of death, under gangrene, is death by asthenia. But the typhoid state involves the nervous functions, and tends to death by coma. Whenever, therefore, typhoid symptoms supervene upon in- flammation 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 previously to the mortification, and have even helped to produce it, as when inflammation 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 super- vention of internal mortification, is the sudden cessation of pain : giving hope to the patient and his friends that the danger is over; but not deceiving the experi- enced physician. So much, then, for the local and constitutional events of inflammation, con- sidered generally. It remains for me to make some observations upon the modifications of inflam- mation, 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, therefore, 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 sloughin* 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 inflammation of the cellular membrane. I his diffused form of inflammation frequently follows the introduction of animal poisons into the system; and accompanies the inflammation of veins and of absorbent vessels. It is this disease which is so often fatal to members of our prolession, when it results from wounds or punctures received in opening dead SYNOVIAL MEMBRANES. 123 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, suf- fers changes analogous to those observed in the areolar tissue: probably because areolar tissue enters largely into their composition. Acute inflammation of the liver, when it 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 liver, 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 liable to be rendered permanently thick and hard 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 unfr>quent result of slow inflammation ; producing that particular change in the liver which the French pathologists denominate cirrhose; 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 ; by hardness of the pulse; and by buffy blood; by its tendency to spread; by the effusion of serous fluid, and of coagulable lymph ; and sometimes, when the inflammation is very violent, or air gets admitted to the inflamed surface, by the effusion of pus. Speaking generally, however, it is adhesive inflammation which we most expect in this tissue. False membranes, consisting of organized lymph, belong to it: and the agglutination of contiguous surfaces. Sometimes the lymph, instead of being deposited in flakes or layers, appears in ihe form of numerous small granules: this is a phenomenon frequently observable in inflam- mation 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 com- mon in the pericardium. 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 motion of the pericardium over the heart is going on. Ulceration of a serous membrane is very uncommon. I mean ulceration commencing in that tissue ; for these membranes are frequently perforated by ulcers which approach them on their attached side, and which begin in other tissues, especially the mucous. Neither does mortification 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 effect in the omentum frequently ; in the peritoneal covering 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 inflammation 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 agglutination of their synovial surfaces; but, generally, by means of granu- lations 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 causeis evident from the circumstance that the same acute inflammation, the same general affection of the system, and equal danger, often result from the careful incision made into a joint by the surgeon, for the 124 INFLAMMATION. purpose of removing loose portions of cartilage. I have now at the hospital an out-patient who has, among other ills, a large cartilage floating about in fluid in one of his knee-joints: but I believe that Mr. Arnott, 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 employ- ment, and until other methods of relief have failed. Suppuration of the joints is also one of the occasional consequences of phlebitis. Inflammation of the syno- vial membrane speedily leads to a serous effusion 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 affects the tegumentary membranes. Considering the skin as one membrane, and neglecting its subdivisions into epidermis, 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 reso- lution ; the only consequence of the inflammation being the separation of the cuticle in small branny fragments; in one word, desquamation. We call the superficial inflammation, 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 cantharides—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 characterized 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 constitutional diseases, of which the cutaneous affection forms merely a part. Inflammations of the internal tegumentary membranes—of the three internal surfaces that communicate with the air, and are clothed with mucous membrane —are very interesting to the physician : and the first thing which strikes our atten- tion 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 membranes 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 necessarily 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 membrane 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 (but 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 formation of adventitious membranes under 'inflam- mation. Casts of the smaller branches of the air-tubes have, in rare instances, been repeatedly coughed up in large quantity ; constituting what have been very inaptly called bronchial polypi. The membranous 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 lon may, in certain cases, be preferable tlTiTntl • th%m"St be,flve" ,n rater qUanti1^ Some Practitioners believe o onortTon"l dT f^ p,U ^ ™^ 3CtS S00ner' and a»swers better, than a proportional dose of either, given alone. emTn^n.lvl'M administering me™^ s° ™ to affect the syst'em at large, is bird!niyharhPPn,n mT T^ °f 3CUle Phle^o"ous inflammation .after bleeding 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 bleedina renders the body more readily susceptible of the influence0 of mercury; andI he lod 10 Vbe t C n'em7 C°meS ^i"?. u°f the Salutar^ effect of the ^ action of ciuld'accomphlh sln^ aCC°mpllSh * **^ ^ what ^r of them airencv oTZT' * kmW ^ different Pers™s ad™< 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 iner and useless ^ »s most grievously disappointing to watch a patient labouring under inflamnmion MERCURY. * 157 which is likely 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 histoty 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 prescribed 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 sleep- ing 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 trouble- some or distressing extent, it has supervened 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 (/or 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 plan to adopt in such cases : but I never could get much 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 ffood effect, that of correcting the foetor. 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 emergencies, 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 knew 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 inflammation: apply eight or ten leeches beneath the edge of the jaw bones, and wrap a soft 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 of your patient for the great comfort this measure has afforded him. Pure tannin, moist- ened and smeared upon the spongy gums, is remarkably efficacious in rendering 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 158 •* INFLAMMATION. 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 Hospital; 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 fashionable 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 situation, 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 physician 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. It is of great ser- vice in many cases of chronic inflammation; and I may repeat here the observa- tion 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 mer- cury 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 tender- ness 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 scrofu- lous persons are not exempt from attacks of common inflammation ; and in some such cases the possible aggravation of their general ill health, by mercury, is not to be put in competition 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, was 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. Antimony 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 weakness. Antimony, so far as my 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 signallv beneficial. You will see a patient labouring for breath, unable perhaps to lie 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 affection; and upon listening at his chest you hear that peculiar wheezing sound which we call sibilus, in every part of his lungs. I shall have to describe this sound, and its 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 ANTIMONY. 159 forcible, his face grows pale, and he can breathe again. The nausea is not a plea- sant 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 mem- brane, 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 perhaps 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 remedy as mercury, when serous membranes are inflamed. The French and Italian physicians place much reliance upon antimony for the cure of inflammation ; and they seem to know little or nothing of the remarkable agency of mercury upon that disease. For my own part I do notksee 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 particular 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 shall all come at last to freshly dissolved tartar emetic. The antimonial pow- der is of very 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 circumstance, that although vomiting and purging are apt to be produced by the first two or three doses, they usually cease when the same quantity is per- severed with. Tolerance of the remedy is established. But although these un- pleasant 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 symp- toms return, you repeat the medicine. It sometimes acts violently upon the bowels, and then it is necessary to add a few drops of laudanum to each dose.* Digitalis is another powerful medicine, from which, as a remedy for active inflammation, much was 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 mo- derate doses of digitalis, its peculiar effect upon the pulse comes on at very un- certain periods, and may be postponed until it is too late to be of any service. If, on the other hand, you give it in such quantity as speedily to affect the heart's action (which is what we want in acute and serous inflammation), then you are never secure against what may be 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 ihe 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 inflam- mation, in very large, and I should say startling doses, with the very best effects —doses which range from half a drachm to half an ounce, and even six drachms* • [The remarks of Dr. Watson upon the remedial effects of tartar emetic in inflam- matory 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 con- siderable 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] 160 INFLAMMATION. of the officinal tincture. I confess to you that I should be very unwilling 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. Colchicum is a drug which is often prescribed in inflammation. It is a most valuable remedy in certain specific forms of inflammation. But for repressing common phlegmonous inflammation we have much more certain and better reme- dies. For this purpose colchicum is, I believe, a very unimportant medicine. I have formerly been asked, by students attending here—and therefore I anti- cipate the question now—respecting the utility of opium as a remedy in inflam- mation. 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 different cases. Yet there are a few general observations which I may make now on this subject. The administration of a full dose o.f 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 ab- straction of blood is calculated to produce; or to augment, if it finds 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 con- stitutions 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 physician, 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 medicine, that they never woke again. As a general rule I should say that you must be very careful how you venture upon opium in in- flammatory diseases that tend to produce death by coma, or apncea. If there be any unnatural duskiness of the face, if ever so slight 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 imperfect arterialization of the blood, as I hope you all know now, either results from, or conduces to, a state of coma. On the other hand, it is, cseteris paribus, in cases where the tendency is to- wards 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 in- flamed 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 peri- tonitis-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; TOPICAL REMEDIES. 161 urine from rupture of the bladder; and so on. If there be any hope in such cases, it is to be found in the continued exhibition of opium in considerable doses. But upon all these points I shall go more into detail when we come to consider indi- vidual 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 cra- nium. It is really wonderful what a sedative and soothing effect 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 plea- sant 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 applications to the chest, and to the belly, in active inflammation of parts situated within those cavities, have been praised by some practitioners ; but I be- lieve are very seldom employed. T have no personal experience either of their utility, 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 accumulating it in internal parts, would be likely 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 warmth 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 which 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 pro- mote resolution. We have an illustration of the beneficial agency of cold appli- cations for this purpose in the treatment of recent burns and scalds, particularly when the injury is superficial, and the skin has not been destroyed. Probably there is scarcely any one present who has not experienced the relief 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 was thereby wholly prevented. I have known this expedient fail, however. A nurse in the Middle- sex Hospital fell as she was carrying 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 water; but after a while was obliged to desist; the cold immersion bringing on severe rigors. In erysipelas I am persuaded that warm fomentations not only afford more com- fort, but are more effectual and safer than cold lotions. Independently of their occasional influence in promoting resolution, warm ap- plications—warm soft poultices, for instance—are often used with the view of forwarding suppuration. Hence this rule. Whenever resolution of the inflam- mation 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 11 162 HEMORRHAGE. resolution, with less hazard of retarding or rendering untoward the process of sup- puration, in case resolution does not take place. Counter-irritation, by means of blisters, sinapisms, irritating ointments, setons, 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 inflamma- tory 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, there- fore, 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, blisters 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. Vica- rious 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 endeavour- ing 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 termination ; 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, which conduct respectively to the consideration of he- morrhage and of dropsy. These branches are shorter than that along which we were last traveling; but they are not uninviting; they will open to us, if I mis- take 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 sur- gery : and it will receive at the hands of my colleague all the attention which its great importance, as a surgical accident, demands. But we, also, as physicians, have much to do with hemorrhage ; 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. 6 J In surgical or traumatic hemorrhage 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 usually 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 instances out of ten, if there be any rupture at all, it is rupture of nume- rous capillaries only: but even of this there is often no evidence BY EXHALATION. 163 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, mucus from the inner surface of the bowels, and serum or synovia from the 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 naturally ask what proof we have of its truth. The proof is simple, and, I think, conclusive. We 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 or bowels, that the death which ensued could be sufficiently accounted 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 mem- brane appears, here and there, of a red colour, and, as it were, charged with blood. Sometimes it is pale and transparent, while the vascular net-work visible immedi- ately beneath it is gorged and turgid. Sometimes the whole is colourless; the same net-work of vessels having been completely emptied by the previous hemor- rhage; and sometimes, again (and this is very illustrative of the mode by which the blood has issued), vast numbers of small dark-coloured masses, like grains of fine sand, can be made to start from the surface of the membrane by slight pres- sure. 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 wit- nessed. There are well-authenticated instances on record of cutaneous hemor- rhage ; 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 guttatim 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 unbroken membrane, I should not lay much stress upon it for any other purpose. It is not exactly a case in point. The process of men- struation cannot be looked upon as a 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, which, 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 membranes 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 exhala- tion. It is a convenient word, and will spare circumlocution. What the vessels or outlets 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 concerning which we have no positive knowledge. We know, indeed, 164 HEMORRHAGE. that such channels must exist, though we cannot demonstrate or see them ; and we know that while every part of the body is in a state of health and integrity, they do not allow the blood, as such, to pass through them. I am aware that my learned colleague Dr. Todd objects to this doctrine of hemorrhage without rupture, even of capillary vessels : arguing that, if the red corpuscles of the blood, which measure from ^qVo to snWthof an i"cn m diameter, could pass through lateral pores in those vessels, such pores must be large enough to become 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 existentibus eadem est ratio, I shall venture to adhere to the term exhala- tion. 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 exhalation. Exhalation is the rule—other modes of hemorrhage furnish the occasional excep- tion. I must exclude, however, from this general statement one very important hemorrhage. 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, can- not properly 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 lives, 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 exciting 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 disposi- tion 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 peculiar 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. Gall, founded upon this 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 declining 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 that which affects youno- 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 pre- IDIOPATHIC. 165 ludes, proceeding from the same part, continuing for the same space of time, and furnishing always about the same quantity of blood. Its accidental interruption is almost uniformly the cause or the conseqiience of some derangement of the health: and when it becomes excessive, it becomes, like too profuse menstrua- tion, a disease. It forms a very curious part of the general history of hemorrhages that they are not unfrequently vicarious, or supplemental, sometimes of each other, but more often of the monthly discharge from the uterus. Females are liable to per- verted menstruation (so to call it) through other channels than the natural one: and here again the analogy between the catamenia and habitual hemorrhage comes into view. The hemorrhages which belong to the constitution are apt to wander in their seat. As bleeding from the lungs, stomach, rectum, or skin, sometimes follows upon the suspension 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 hemorrhois. 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 revulsion: a doctrine to which I 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 state 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 de- nominated idiopathic: inasmuch as they are apt to arise without any perceptible connection 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 hypothesis derives its chief support from the occasional efficacy of astringent substances (either applied 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 qualities; as, for example, in certain cases of purpura and sea-scurvy. And hemorrhages of this kind are often cured by measures calculated to repair ihe blood ; to restore it to its natural condition by improvement in diet; or by food of a peculiar kind, as the juice of lemons. Whatever may be the true explanation of the differences in question, there can 166 HEMORRHAGE. ■■•;<*, be no doubt that they exist, and are often strongly pronounced in cases of hemor- rhage, which, 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 dis- tinctive characters of active and passive hemorrhage, as they are broadly and decidedly visible, in well-marked cases. 'Active 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 heat, strong mental emotion, violent exercise, or bodily efforts. More frequently, perhaps, no exciting cause is apparent. It is some- times ushered in by a set of symptoms expressive of what has been called the molimen hemorrhagicum. The patient experiences a general feeling of indispo- sition, 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 heat and tingling, sometimes a slight degree of turgescence and redness, and a visible fullness of the larger veins, indi- cate the afflux of 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 circulation in them. And to this state of things there often succeeds a general increase of heat, with a frequent, full, and bounding 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 conse- quently akin to inflammation. Perhaps it may be more true that in some of these cases we actually have the initial stage of inflammation, of which the hemorrhage proves the natural cure: strangling it in its birth; applying that remedy, in the very moment when it is most effective, 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 evacua- tions, or the depressing passions. It is not, in general, announced by any pre- cursory symptoms, 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 debility 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 effusion; frequently, indeed, passive hemorrhage resists the means opposed to it, the more, in proportion as it has continued longer, 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 uncommon 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 symptomatic; that is, they result from some previous disease, either in the organ USUAL SYMPTOMS. 167 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 symptomatic 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 hemorrhage is the consequence and the relief of active congestion, provoked by the irritation of tubercles ; rather than the result of a mechanical obstruction of the circulation. Again, we have hemorrhage into and from the lungs, as a consequence of such 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 distension, 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 precisely 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 exhala- tion, depending upon previous disease, not of the organ itself from which the blood proceeds, but of another organ intimately connected with the former. When I say that hemorrhage into and from the lungs may result from such disease of the heart as implies an impediment to the circulation, you must not suppose that the lungs are the only channel through which the mechanical con- gestion 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 the 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 sometimes 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 examined 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 extravasated, and adhering to the surface of the membrane: there had been, in short, unequivocal hemorrhage. There are several things, worthy of notice, in respect to hemorrhage by exha- lation, 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, haemoptysis, haematemesis, melsena, hsemorrhois, haematuria, menorrhagia, are names descrip- tive 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 you 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 168 HEMORRHAGE. subjacent to them, are supplied with a capillary 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 surfaces. They are liable to occur, but much more rarely, from serous mem- branes. In the majority of cases, however, in which blood is found effused into any of the serous sacs, it has either been an event of inflammation, or the blood has been poured out from an accidental opening in some considerable vessel. Cutaneous hemorrhage is also very rare; probably because the cuticle opposes a barrier to the exit of the 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 1 mentioned before, in which blood has transpired, in a sort of dew, from the external 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 life, 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 hemor- rhage from the fauces may be the result of ulceration there, which has penetrated the coats of a vein or artery : haemoptysis is occasionally produced by the lacera- tion of a blood-vessel during the softening and expulsion of tubercles. Haemate- mesis sometimes 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 corrod- ing 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 kidneys 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 hemorrhage 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 he- morrhage is caused by the giving way of a diseased artery in the brain. How, in all 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, and 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 implies, according to the'part from which it.proceeds, and the circumstances under which the blood is poured out. It some- times happens that death ensues from the mere loss of blood : either at once, by one profuse 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 dan- TREATMENT. 169 ger 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 liable 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, de- monstrate the 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 outright, 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 of blood, when none had passed either by vomiting or by stool. And when the blood does make its appearance outwardly, it is sometimes not easy to determine whether 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 hema- turia, proceeds from the kidneys, or the bladder, or the urethra. 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 sur- face: 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, I 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, spring- ing 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 ex- terior 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 hemor- rhage—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 extent, 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 then depend—and probably in all cases they chiefly depend—upon the actual abstrac- tion of the blood from the circulation. The management of individual cases of hemorrhage must be mainly regulated by 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 I 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 pro- ceed (as they mostly do) from parts of which the structure is not likely to be 170 HEMORRHAGE. spoiled, nor ihe 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 appli- cable. Epistaxis 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 metas- tasis takes place for 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 ple- thoric persons; and when they are urged and kept up, as they frequently are, by intemperate 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 who would rather continue to have them, than to submit to any change in their mode of life, 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 to exist there is danger of a cessation of the piles, and of the supervention of serious or fatal affections of other parts, and especially of the head. Apoplexy, or cerebral he- morrhage, has frequently been known to follow hard upon the suspension of constitutional hemorrhois. The patient should be admonished also that the dis- charge 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 observance of them. It is in the inter- vals 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 stanching 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 DROPSY. 171 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 effected 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 hemorrhage; 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 cold in constringing the smaller vessels is not confined to the part vvith which it is in contact; it will stop hemor- rhage by the sympathetic shrinking which it produces in distant parts. Epistaxis, for example, has often been arrested by the sudden apposition of cold water to the neck, back, or genital organs. The 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 illustra- tion in the suppression of the catamenia by cold and wet accidentally applied to the feet. There is a long catalogue of medicinal substances which are esteemed to pos- sess 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 emi- nently 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 hemorrhages, seem to owe their astringent and styptic properties to the gallic acid which enters into their composition. Such are the rhatany root, uva ursi, bistort, tormentil, the pomegranate, kino, catechu, the several prepara- tions of gall nuts, and the nostrum called Ruspini's 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 indications for administering which, I may return to, when I have to speak of individual hemorrhages. LECTURE XVI. Dropsy: its General Pathology. Passive Dropsy; Cardiac and Renal. Active, Acute, or Febrile Dropsy. Prognosis ; and General Principles of Treatment in Dropsies. There remains now only one subject, of the pathology of which it will be convenient 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. 172 DROPSY. 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 inflammation ; 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 with 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 would be more philosophical 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 disease 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 func- tions, and even extinguishing life. The removal of the dropsy (although its original cause, of which it was a symptom, may remain behind, untouched, to be again productive of effusion under circumstances favourable to its operation)—the removal of the dropsy 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 little 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 investigation 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 sometimes 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 pleurae, of the areolar texture of the lungs, or of the submucous areolar tissue of the glottis, any of which may cause death by apncea; of the pericardium, producing death by syncope. I men- tion 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 hydrothorax, or hydropericar- dium. If the cavity of the peritoneum be the seat of the effusion, we call the complaint ascites. When the areolar tissue of a part becomes infiltered with serous fluid, the part is said to be osdematous ; and anasarca is the name given to the more or less general accumulation of serum into the areolar tissue throughout DROPSY. 173 the body, and especially to visible subcutaneous oedema 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 enumerate them. Now what reasonable account can be given of these remarkable conditions? How is it that the hollows and interstices of the living 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 augmented, the absorption remaining the same; or the absorption has been dimi- nished, the exhalation continuing the same; or else the exhalation has been increased, while at the same time the absorption was either lessened or not pro- portionally 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 dropsies do actually arise, in each and all of these ways. It will best suit my purpose to speak first of those dropsies which are occa- sioned 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 lymphatic absorbents, than they are really entitled to. You will find that pathologists, even in modem 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 absorbents 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 treatment: 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 absorbents, 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 per- sons 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 must be confessed that our knowledge respecting the mechanism of absorp- tion 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 probably 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 lym- phatics is to take up and carry into the blood those old and effete portions of the solid constituents of the body, 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. 174 DROPSY. If this be so, the difficulty just now mentioned vanishes. Of the two sets of absorbing 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 imbibi- tion and transudation, through the coats of those vessels ; that when the veins are distended 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 surrounding serous fluid passes readily into them, or, in common lan- guage, is absorbed. The venous absorption is explicable therefore upon the principles of endosmose and exosmose, as laid down by Dutrochet; or I would rather say, according to the more general and more simple laws of heterogeneous attraction, as explained by Professor Daniell. 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 consist- ence—will vary with the varying distension of the vessel. When the vessel is moderately full, the exterior fluid passes uninterruptedly inwards, and is conveyed away by the internal current. When, on the other hand, the vessel is kept much distended by its contents, the contained fluid, or its thinner part, passes continu- ally outwards; and there is an intermediate degree of distension, at which the pressure is just sufficient to prevent the transit of fluid in either direction. Ma- gendie found, accordingly, in a well-conducted and conclusive series of experi- ments, that by regulating the conditions of comparative emptiness or fullness of the circulating system, he could accelerate; or retard, or suspend altogether, the operation of a poison dissolved 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 repletion 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 dis- tended 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 me- chanical obstruction to the venous circulation. We can produce it whenever we will. Our countryman Dr. Lower, 170 years ago, tied the jugular vein of a living dog. When a few hours had elapsed, he observed that all the parts be- yond the ligature, reckoning from the heart, were much swollen : and upon dis- secting 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 dis- covered 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 haec ad ascitis et anasarcas causas investigandas con- ducant, aliis judicandum relinquo." He even explains the extravasation of the PASSIVE DROPSY. 175 thinner or serous part of the blood as taking place by infiltration, " velut 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. Tra- vers was obliged to tie the femoral vein ; the areolar tissue of the limb was speed- ily infiltrated 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 soon after childbirth, although it is not peculiar to them, nor to the female sex. The foot, leg, and thigh, become enormously cedematous. The essence of this disorder is inflammation of the femoral vein ; blocking up that vessel near the groin, and retarding or precluding the return of the venous blood from the limb. One arm often swells in the same way, and front 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, anasarca of the lower extremities, which dis- appears as soon as the pressure is removed by the delivery of the woman. The flow of blood through the vena portae is frequently hindered, by disease in the liver, or by other causes; and serous liquid accumulates in the peritoneum, con- stituting ascites. A French physician, M. Tonnelle, narrates several cases in which serosity was found in the cavity of the arachnoid, in conjunction with ob- literation 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 blood is 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 ven- tricle enlarged in capacity, the opening between them unnaturally wide, and the tricuspid valve unequal to its office of closing 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 pri- mary ; 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 ultimately depend, therefore, upon some bar to the circulation, placed even at the mouth of the aorta. Obstacles situated anywhere in the circuit formed 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 retrogade 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 diseases 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 asso- ciated. 176 DROPSY. As if to furnish the experimentum 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 curiously 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 pre- posterously 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 prin- cipal 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, vvith 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 had 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: imperfectly, indeed, at first; but, at length, as the supplemental chan- nels become more numerous and free, the supply of blood to the limb 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 arte- rial. Now I am not aware of any instance in which it has been shown that the principal vein was obliterated, and yet there neither was, nor had been, any oedema of the limb. The recorded cases have been met with in dissecting rooms, and the previous history of the subject has been unknown or unregistered. Mr. Kiernan has told me that he once examined the body of a woman who had ex- cited 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 dropsical, and the cause of the huge varix was sought for with great interest after her death. The inferior cava was obliterated. Here the compensating result was obvious 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 invalid, until some authentic instance shall be brought forward of the obliteration of a large venous trunk, without a corre- sponding 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, pos- sible enough, that the obstruction of a large vein may be effected gradually, by the slow encroachment, for instance, of a growing tumour; and the collateral cir- culation 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 obliteration of veins, and independent of any discoverable organic disease in the PASSIVE DROPSY. 177 heart or anywhere else. We see this every day, in weak chlorotic girls, with bloodless cheeks, and pale lips. 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 have been an organic change: in fapt 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 vvith 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 chambers ; and that so an occasional but tem- porary 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 loedentia. 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 recovers 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 re- ceives 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 recover ; they are cured. I should apply a similar expla- nation to some other forms of dropsy. Andral describes a certain cachectic dispo- sition of the body as being a cause of dropsy ; persons may be bled into a dropsy, or starved or weakened into a dropsy. These are genuine instances of dropsy from debility, which is what the ancients conceived all dropsies to proceed from. It maybe that the thin and watery quality of the blood induced by frequent bleed- ings, by insufficient nourishment, by certain poisons, or by other causes, may facilitate its passage through the coats of the veins. But admitting this as a con- current cause, I am disposed to the belief that all passive dropsies occurring under the circumstances just adverted to, and without any apparent organic disease or change, are mainly to be 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; and we call them, accordingly, cardiac dropsies. But another class, perhaps as numerous, are connected in a remarkable manner with certain diseased conditions of the kidneys; 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 dropsical swellings, adverted to in the commencement of this lecture: namely, excessive exhalation of serous liquid. Dropsy so caused comes on sud- denly and tumultuously, and is spoken of as being acute or active. It borders closely upon inflammation, and sometimes can scarcely be discriminated from inflammation vvith serous effusion. The condition of the capillary circulation is supposed to be intermediate between that in which the ordinary amount of secre- tion is maintained, and that in which inflammatory effusion 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 12 178 DROPSY. occasioned by violent exercise; to the plentiful flow of tears caused by any irrita- tion 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 inflammation. 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 constitute 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 exter- nal cold and moisture: 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 perspi- ration is suddenly checked ; and in the course of a few hours he becomes univer- sally anasarcous. Again, a patient recovering from scarlet fever ventures out into a cold atmosphere, while the process of desquamation 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 excre- tion 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 deranging 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 com- pensated 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 toothers. The reciprocal but inverse accommodation of function that subsists between the skin and the kidneys affords the strongest and the most familiar example. In the warm weather of summer, when the perspira- tion is abundant, the urine is proportionally concentrated and scanty. On the other hand, during winter, when the cutaneous transpiration is checked 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 vvith 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 detained 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 disappear- ance of a watery collection from another part. It is no uncommon thinf to see the swollen unwieldy legs and thighs of an anasarcous patient quickly unload themselves, and resume their natural bulk and symmetry. His friends con^ratu- ACTIVE DROPSY. 179 late 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 water 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 liquid, 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 serious 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 them- selves 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, we can seldom tell. We often find it difficult 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 readily deposit a part of it: but also that when they are in the opposite condition of comparative emptiness, when they contain less blood than is natural, they are equally ready to replenish themselves by ab- sorbing fluids from any source to which they can find access. In the case of the man who was cured of his hydrocele upon the occurrence of profuse watery dis- charges from the stomach and bowels, it seems clear 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 follows, it appears proba- ble that the absorption is the first of the changes, and the effusion the second: and had this effusion 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 pre- ternaturally empty, they readily drink up watery fluid wherever they come in contact with it. 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 pro- positions. The application 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 evidence of inflammatory action. The two facts which it chiefly con- cerns us to remark are 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 180 DROPSY. 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. Diarrhosa, for example, is more common, under the supposed circum- stances, 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, between 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 obvious 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 small 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 ana- sarca usually increases or decreases, as the quantity of urine diminishes or aug- ments. 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 in 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 amount 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 cir- culation is disturbed and tumultuous; in the other, it remains tranquil. It is probable that in the more acute forms, the serum transudes through the coats of the arteries, or of the capillary vessels next adjacent to the arteries^ In the com- pletely chronic and cardiac forms, there is a defect of absorption by the veins. Active dropsies are sometimes spoken of as belonging to the left side of the heart; passive dropsies to the right. But there are intermediate degrees, in which the full veins are not only unable to admit any addition of aqueous liquid, 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, DROPSY. 181 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 anasarca, 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 perfect, 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 effu- sion, 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 earlier 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 oedema 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 simi- larly bags : and in these cases we commonly may hear the crepitation of pulmo- nary oedema 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 liquid could seek a passage. So some- times, it is stopped at a lower point of its descent by tight garters, and the thighs swell earlier than the insteps. It is not at all uncommon to see persons who, in the daytime 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 obstruction to a large vein in the neighbourhood of the shoulder caused oedema there, and the 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. Caeteris 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 subjacent to mucous membranes. In the examination of a drop- sical corpse, the mucous coat of the intestines may sometimes be seen to be ele- vated by the water collected beneath it. It then looks like jelly, and the valvulae conniventes, which are flat and thin in their ordinary state, become round and convex. Dropsy of the submucous tissue of the air-passages is frequently a cause of death. Many persons seem disposed to ascribe these anasarcous swellings, especially when they make their appearance suddenly, to inflammation; and much is said about the frequency of inflammatory dropsy. But the facts we have just been 182 DROPSY. considering sufficiently refute this theory. If the serous liquid be the product of inflammation, 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 quar- ters under the influence of gravity. The term inflammatory dropsy may not, perhaps, be indefensible 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 coagulable lymph, which are distinctly events or pro- ducts of inflammation, with other collections of serum which resemble the former in that respect only, but differ entirely from them in every 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 epithet febrile would not be inappropriate. There may be some few cases in which it is impossible to deter- mine whether the effusion be inflammatory in its origin or not. If the serum be turbid, if we can discover in it the smallest admixture of pus, or of flakes of lymph, or if the disease has been marked by the ordinary signs of internal inflam- mation, 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 inflam- matory. 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 general 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 oftener admit of complete recovery, than the passive or chronic. Local dropsies are to be regarded with 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 complicated 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 difference in this respect is immense between the tunica vaginalis, and the pericardium; between the areolar tissue of a limb, and that which lies beneath the mucous membrane of the glottis. It remains that I should offer 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 dis- eased 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 advan- tageous in several ways. It helps to relieve the congestion, akin to inflammation, upon which 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 effectual 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 circulating fluid, and thus enfeebles the patient more than would the indirect measures, to be mentioned presently, for evacuating the collected liquid. Perhaps, by rendering the blood more watery, venesection may indi- TREATMENT. 183 rectly favour the transuding of its serum 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 augment 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 producing a flux. By what surface or channel this artificial drain shall be attempted, is often a matter of great 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 lining of the alimentary canal: in others, by the external skin. The circumstances by which our choice must be determined will come under review hereafter. Passive dropsies are much more difficult of cure than active, and will often baffle our best directed efforts. You are not, however, to regard those passive dropsies which depend upon the obliteration of a large vein as necessarily incura- ble ; for if a collateral venous circulation be accomplished, the dropsy will per- manently disappear. 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 allevi- ate 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 suffering of the patient, as well as much of his dan- ger. Now, when we cannot get rid of the water by bleeding, or by internal reme- dies 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 operation. Paracentesis is the scientific, and lapping the vulgar name, for this proceeding. 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 acupunc- ture 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 membrane 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 rules 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. 184 DISEASES OF THE EYE. LECTURE XVII. Diseases of the Eye. Catarrhal Ophthalmia. Purulent Ophthalmia of Adults. Having brought my observations on general pathology to a close, I next pro- ceed 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 shall 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 men- tioned before one advantage, as it seems to me, of bringing together, in juxta- position, all the diseased conditions to which the same part, or the same neigh- bourhood, of the body is liable—namely, the facility thus afforded of comparing the phenomena by which they are characterized, and of discriminating one dis- order 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 the 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 surgeon 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 infernal 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 you 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 meet 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 ani- mal tissues. We find in it bone, cellular and adipose substance, and blood-ves- sels ; mucous, fibrous, and serous membranes ; the conjunctiva exemplifying the first; the sclerotica, the sheath of the optic nerve, and the lining of the orbit, the second ; the surfaces containing the aqueous humour, the' third: muscular, ner- vous and glandular parts ; common integument and hairs. Besides these, it con- tains 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. In- flammation, for example, is often confined to one of the tunics of the eye, external or internal; and when it affects more, it is usually in consequence of the exten- sion of the inflammatory process, from some one texture in which it took its rise. You will not expect me to 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 CATARRHAL OPHTHALMIA. 185 under your notice ; and I shall select those concerning which the physician is most frequently consulted ; which every one, whatever branch of the profession he may follow, ought to be competent to treat; and, more particularly, which are calculated to elucidate other diseases, and, above all, other internal diseases, that are usually assigned to the care of the physician. 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 con- sidered the mucous membrane of the eye. Like other mucous membranes, it forms a surface communicating with the external air. Some of these affections are very 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 variations, 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 mem- brane 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 un- learned, 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 sud- denness (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, lines the eye- lids, and covers about a third part of the globe of the eye anteriorly. The inflam- mation, in catarrhal ophthalmia, is confined to the conjunctiva and the meibomian follicles. Its leading symptoms are redness of the surface of the eye ; some pain and uneasiness there; an increased discharge from the affected membrane and the follicles : and a sticking together of the eyelashes and lids. The redness is worth notice, both in respect to its tint, an'd to the arrangement of the vessels in which it appears. It is superficial, and of a bright scarlet colour; and usually irregular, or diffused 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 extrava- sated 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 appear- 186 DISEASES OF THE EYE. ance 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 bright 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 arranged regularly, after the manner of radii in a circle. They lie in the sclerotic, round the cornea, like what is called by painters a glory, or like a halo, or zone surrounding the central cornea ; and they cannot be made to shift their place by any dragging of the lids. These are very important distinc- tions. 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 uni- versally 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 mem- brane, 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 out- set 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 complains rather of a sensation of stiffness 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 resemblance of this feeling, 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 inequality and roughness of the surface, consequent upon the irregular distension of the vessels of the inflamed membrane; irritating the organ mechani- cally, just as a piece of dust would irritate it. Now in this respect, again, there is a marked 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 it 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 even- ing till after midnight, abating towards morning, and ceasing in a great measure during the day, to be again renewed in the evening. I am speaking now particu- larly of inflammation of the sclerotica produced by the same causes as give rise to catarrhal ophthalmia; 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 cha- racters 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, which it glues together at night. Sometimes, 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 swelling of the conjunctiva. If there be any, it results CATARRHAL OPHTHALMIA. 187 from an effusion 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 effusion often goes to a very great extent in purulent ophthalmia, or in violent inflammation of the external mem- branes, as I shall show you by and by. So much, then, fox the symptoms and causes of catarrhal ophthalmia. It is necessary that you should be familiarly acquainted with them; not so much because the complaint is very serious in its nature, but because it is common; because you are sure to be again and again consulted about it, and because it is of great importance to distinguish it from other forms of ophthalmia, in order to adopt the proper treatment. 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 perma- nent 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 moisture 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 with calomel followed by a black dose. If the system at large sympathize with the local disease, it may become neces- sary to take blood from the arm, or to apply leeches; but neither of these mea- sures is requisite, except the inflammation is unusually severe, or the disease has been neglected 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 immer- sion of the feet in warm water, at bed-time; and saline draughts containing two or three drachms of the liquor ammonix 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 exten- sive scale, at the Glasgow Eye Infirmary, that " general remedies in this disease are inferior to local ones; that violent general remedies are worse than useless ; and that a local stimulant treatment may almost entirely be relied 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 par- ticularly applicable. In disorders which manifest a strong natural tendency to terminate in recovery, it is only 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 applica- tion, viz., a solution of the nitrate of silver in distilled water, in the proportion of four grains to the ounce. A large drop of this solution is to be applied to the 188 DISEASES OF THE EYE. 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 sensation, 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 inflam- mation 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 application, for five or six hours perhaps; and when the symptoms return, they are again 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 sometimes alarmed other practitioners by proposing to drop upon the surface of an eye highly vascular, affected with a feeling as if broken pieces of glass were rolling under the eyelids, and evidently secreting puri- form matter, a solution of lunar caustic; and that he has been not a little 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 collyria or eye-washes, 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 by 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 of its symptoms, in the danger which it implies to the sense of vision, and in its exciting causes. It takes its name from the profuse discharge of pus, or of altered mucus which 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, go- norrhoea! ophthalmia ; and 3, purulent ophthalmia of newly-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 inflamed 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 through- out. A copious discharge of thick, yellow, puriform matter is speedily established ; this flows 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 mio-ht 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 PURULENT OPHTHALMIA. 189 singular phenomenon. The conjunctiva is raised to some distance from the sub- jacent sclerotica by the effusion 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 palpebrae, producing great external 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, some- times marked here and there with patches of extravasated blood. The appearance is called chemosis: not ecchymosis, as the similarity of the sound has led some erroneously to suppose, but chemosis. Exxvpuiots, from sx^«o, signifies an effu- sion, and by common consent among medical writers, an effusion of blood. Xj^sttftj, the root of which is z^pa, 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 inflammation, 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 laminae 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 mem- brane. The conjunctiva that lines the lids 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 friction 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 haziness 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 tex- tures of the organ. The pain then presents those characters which I mentioned before as belonging to certain inflammations of the sclerotica : i, e., it is pulsative ; and sometimes sharp and lancinating, sometimes dull and aching ; and it is inter- mittent, 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 circumorbital 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 scald- ing 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 generally 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 190 DISEASES OF THE EYE- scarcely disturbed at all. But the constitution begins 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 ia 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 different cases. Children manifest more constitutional disturbance when labouring under purulent ophthal- mia 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 climates : in 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 Ralph Abercromby. In this way it got the name of the Egyptian ophthalmia. It naturally excited very great attention at that time, and it does not appear to have been accurately 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 will find these statements in a paper in the third volume of the Transac- tions of a Society for the improvement of Medical and Chirurgical 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 blindness 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 vvith each other. And one of the first questions that naturally arises in one's mind is, whether it is capable of being propagated from one person to another by contagion. Much difference of opinion has existed on this sub- ject. For 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 important 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 Military Asylum, while syringing the eye of a boy who had much purulent discharge, found that a considerable quantity of the matter had spurted into her own right eye. This was at four o'clock in the afternoon. She felt little or no smarting at the time ; but towards nine o'clock PURULENT OPHTHALMIA. 191 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 complained 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, except that the matter spurted into her left 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 precau- tion, 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, the lids were swelled, and upon moving the eye- ball she had a sensation as if some sand were lodged beneath them. In the course of the same day purulent fluid 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. A third nurse in the same institution did not come off so well. She was sponging, with warm water, the eyes of a boy suffering severely from purulent ophthalmia: and she inadvertently applied the sponge she was using to her right eye. This happened at eight o'clock in the morning. She mentioned the cir- cumstance to the other nurses, but she took no means to prevent infection. Be- tween three and four o'clock of the afternoon of the same day, itching of the right eye 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 accidentally applied. But a similar application has been made intentionally and by the way "of experi- ment, and with the same results. Dr. Guillie, of Paris, introduced the puriform secretion furnished 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 introduction 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 puriform matter. Here we have not one case (which might be considered as an accidental 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 effluvia 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 192 DISEASES OF THE EYE. 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 circum- stance has been uniformly observed: that it first broke out in soldiers who had come from Egypt, or had communicated with regiments which had been in Egypt. In all cases its origin could be traced to the introduction 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 favour- able 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 towels: 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 conclusion. Rust, a German author, mentions this striking fact in corroboration of what I have just been saying. The disease broke out in the town of Mayence. This place was garrisoned by Prussian and Aus- trian 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 ophthalmia, 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 sufficient in themselves to account for it. That the inhabitants of that country never dream of its being caused by con- tagion. Assalini, who saw the complaint raging in the French army, professes bis belief that it did not arise or spread by contagion. He remarks that the atmo- spheric conditions which are known to occasion catarrhal affections, are very fre- quent and powerful in Egypt: the days are very hot, the nights chilly, and attended with heavy dews; and men's eyes are perpetually 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 slightest 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 com- mon soldiers, therefore, more frequently than the officers. Other circumstances adduced by the disbelievers or sceptics, in respect to con- tagion, are that many who have intercourse vvith 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 dis- seminated, as theysay it ought to be, supposing it to be communicable from one person to another; that, in fact, this dispersion, the disbanding of troops, for in- stance, and sending them to their friends and families all over die country, is the surest way of stopping the disorder. Again, many ineffectual attempts have been made to inoculate the eyes of ani- mals vvith 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, PURULENT OPHTHALMIA. 193 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 per- sons 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 instances 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 acknowledged on all hands to be contagious, and to have no other source at present, however they might have originated at first, but contagion : the small- pox, for example. I think there is some reason for believing, from the facts which 1 have been relating, that purulent ophthalmia, like the small-pox, is capable of being communicated from one person to another, not only by positive contact, but by transmission of the specific poison somehow for a short distance through the air. But many persons exposed to the contagion of small-pox escape it alto- gether : 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 with the dis- ease prevents instead of favouring its dissemination, that circumstance is really no argument at all against our belief in its contagious nature. We shall see here- after, 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 effective, 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 dis- tinctly 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 I have been speaking of as purulent ophthalmia, or Egyptian ophthalmia, the author calls it contagious ophthalmia ; he holds that the inflammation of the conjunctiva, whether in the mild or the more severe form, may and often does originate from common atmospheric influences ; 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 opera- tion 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 194 DISEASES OF THE EYE. minds respecting it. At present I will only remark, that there is nothing absurd, nor unlikely in the supposition, lhat 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 susceptibility 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 propa- gated. At any rate I would desire to impress upon you the expedience and propriety of acting, whatever your doubls 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 practitioners 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 unjustly: 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 that we are now concerned with, you will do well to act as though it were certainly contagious; whether you meet with it 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 employing 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 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. Gonorrhoeal Ophthalmia. Purulent Oph- 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 purulent 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 which 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 propaaated from person to person, through the medium of the air, without the necessity for any substantial application of the morbid secretion 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 cleanliness, and use the same towels and utensils • that it GONORRHEAL OPHTHALMIA. 195 has been propagated again and again by the direct application of the morbid secre- tion ; and that its progress is checked by measures that provide against such acci- dental application, 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 disper- sion of the sick in this way is the most effectual 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 contagious. 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 inflam- mation ; and that having so originated, it acquires contagious properties, which develop themselves only under circumstances that favour the propagation of most of the contagious complaints. I shall next advert to purulent ophthalmia as it is observed to occur, in the adult, in connection with gonorrhoea. If we look to the mere phenomena pre- sented by the inflamed eye, we find nothing to distinguish the gonorrhoeal from the Egyptian ophthalmia. Taking the average of a large number of cases, the gonorrhoeal is the severer form of the two, and runs the more rapid course. It is said, also, that the inflammation usually commences on the lids in the Egyptian variety, while it attacks the whole conjunctiva at once in the gonor&hceal. But comparing individual instances, these mere differences, and slight differences, too, in degree and situation, will not help our diagnosis. 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 atmospheric causes of that disease, and at a time when purulent ophthalmia is not prevailing as an epidemic, and if this patient have a clap, we may conclude that we have to deal with a case of gonorrhoeal ophthalmia; and this conclusion will be further 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 ophthalmia almost always appears in both eyes together, but not in the same degree; and Eble (another German author) states that ihe contagious ophthalmia has not confined itself to one eye in any instance. These round assertions require, however, 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, gonorrhoeal ophthalmia mostly, but by no means always, is limited to one eye. In Mr. Lawrence's instructive book On the Venereal Diseases of the Eye, he mentions fourteen cases of gonorrhoeal ophthal- mia. In nine of these, one eye only was inflamed. It is always a matter of some interest to make out whether the disease has or has not any connection with gonorrhoea; even though we may gain nothing, in respect to the treatment, by the distinction. Purulent ophthalmia has been said to be connected with gonorrhoea in three several ways; 1st, by direct contact of the gonorrhoeal 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 3d, 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 medical as well as of other philosophers. Some who believe that the disease is 196 DISEASES OF THE EYE. communicable 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 prudence," conveyed the matter of gonorrhoea from his urethra to his eyes, vvith impunity. 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 taken 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 inoculation of 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 inoculation of the conjunctiva with matter from the ure- thra 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 per- sons 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. Lawrence alludes to several similar cases. He details an instance also, in which partial sloughing of one cornea occurred; the disease having been caused by the patient's wiping his eyes vvith a towel soiled with the gonorrhoeal discharge from his own urethra. But one of the neatest and most conclusive ex- amples of the production of the disease 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 discharging a large quantity of purulent fluid ; the lower lid 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 discharge from his penis, flung a drop of it fairly into his left eye. Violent inflammation immediately set in, was confined to the eye that was thus inoculated, and produced the results I have mentioned: the gonorrhoea going on just as before. Numerous authentic cases have been recorded of gonorrhoeal ophthalmia pro- duced 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 dress- ing-room of her son, who had gonorrhoea, and washed her face with a towel which he had recently been making use of. Purulent ophthalmia quickly super- vened, and destroyed 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 in- flammation soon arose, and the sight of one eye was lost. Several cases of puru- lent ophthalmia have been observed in laundresses, who had been employed in washing linen foul with the discharge of gonorrhoea. Mr. Lawrence seems to be of opinion that purulent ophthalmia is not a very frequent consequence of the application of the urethral discharge to the eve 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 with it, and how inattentive to cleanliness the lower classes are, we cannot help GONORRHEAL OPHTHALMIA. 197 concluding that the gonorrhoeal discharge must be often applied to the eyes of the same individual; yet gonorrhoeal ophthalmia is comparatively rare." Dr. Mackenzie, 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 conjunctiva, 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- rhoeal 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 sub- ject. In the majority of cases of gonorrhoeal ophthalmia, we are unable to trace any application 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 German 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 gonorrhoeal discharge from the urethra." Mr. Lawrence never knew the urethral discharge stop upon the coming on of the ophthalmia; it has generally diminished, but in some instances has continued as copious as before. He seems to regard the occurrence of the oph- thalmia 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 oph- thalmia 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 problema- tical. The eye is well known to suffer, as well as other organs, in the secondary forms of 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 wiih gonorrhoea, where 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 df this alleged form of purulent ophthalmia. Whether it exists or not is of very little consequence in regard to the main ques- tion ; namely, what is the proper mode of treating the purulent ophthalmia of adults ? 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- rhoeal 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 submitted 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 part 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. 198 DISEASES OF THE EYE. It is also a matter of experience, that general bleeding has more influence over the inflammation of serous and fibrous membranes than over that of the mucous tissues. Accordingly, though bleeding has been even lavishly employed in puru- lent ophthalmia, it has too often disappointed 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 inflammations. " 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 paleness ; the pain is gone, the eye is opened without difficulty, and the full influx of light 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 violence 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 par- ticular.; 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 internal 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 expedients 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 nocturnal paroxysms ; for this symptom denotes that the inflammation has descended deeper than the conjunctiva. The bleeding should be performed in the way I formerly spoke of as being required in serous inflammation : the pa- tient should be bled from the arm 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 many times to a smaller amount. The bleeding ad deliquium 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 ad- vantage; round the eye and not upon 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 of undiluted liquor plumbi acetatis; and Mr. Briggs, in his translation of a work of Scarpa on the eye, advised the introduction 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 severest forms, by stimulant and astringent 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 prac- tice. Now Mr. Guthrie treats purulent ophthalmia on the same principle, but wilh 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 PURULENT OPHTHALMIA. 199 a local disease of a peculiar character; and, acting upon the aphorism of John Hunter (an aphorism, however, which requires some qualification) that two dis- eases or actions cannot go on in a part at ihe same time, he proposes to set up in the inflamed conjunctiva a new action, which shall supersede the original disease, and create another that is more manageable. In this point of view Mr. Guthrie's ratio medendi 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. Guthrie's plan tried, but, from all that I have heard of it, I believe it to be a valu- able discovery. A priori, we should expect that the caustic application would add to the existing mischief and destroy all chance of saving the inflamed eye. But it is not so. Even Mr. Lawrence, who was, I have reason to think, formerly very sceptical on this point, appears to be so no longer. In his treatise On the Venereal Diseases of the Eye, he uses this cautious language :—" Destructive or injurious consequences have so frequently resulted under the usual management of this disease"—he is speaking of gonorrhoeal ophthalmia—" that I should cer- tainly 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 most 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, reduced to an impalpable powder, vvith 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 by 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 not 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 fomen- tations may be employed 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 sticking together. The next morning the discharge is again to be removed, and the ointment to be reapplied; 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, wilh 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 ophthal- mia 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 disease, under the treatment ordinarily adopted before his ointment was devised, I will say also that were I so unfortunate as to be attacked with 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. 200 DISEASES OF THE EYE. Some persons, and Mr. Guthrie among the rest, recommend the exhibition of mercury, so as to affect the gums. Now I believe that mercury is quite useless in this complaint; and'if useless, mischievous. The disease is too rapid to be overtaken by the mercury, and if you could obtain the specific influence of that mineral in time, i. e., before any of the destructive effects of the inflammation were accomplished, 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 has seen both the ordinary purulent, and gonorrhoeal 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 irritation; a disadvantage not compensated by the quantity of blood discharged from the divided vessels. Dr. Mackenzie recom- mends it, stating that the incisions will bleed copiously, and greatly allay the symptoms. Who shall decide in this puzzling 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 scarifica- tion 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 conjunctiva 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 be- lieve, that 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 that 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 placed, in gonorrhoeal ophthalmia, upon any attempts to reproduce the urethral discharge; indeed, in most cases it is not suspended. 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 gonorrhoeal 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 easily 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 oph- thalmia in the adult: you are sure to be consulted about the purulent eye of infants, the ophthalmia 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 con- cealed 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 slouched 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, PURULENT OPHTHALMIA. 201 although it may commence later. It is confined, at first, to that part of the mem- brane which lines 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 eye- ball, the eyelids swell, sometimes enormously : and an astonishingly copious dis- charge 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 sepa- rated 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 conse- quences 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 trans- parent 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 contagion. We might, perhaps, expect this from the analogy of the severe inflammation 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 con- finement, with some kind of vaginal discharge—leucorrhoea, or gonorrhoea; 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 regu- larly 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 illustration of this fact, which fell under his observation at the Eye 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 in each eye of the old man, the greater part of the cornea remained opaque, and adherent to the iris. However, the disease certainly occurs in the infants of mothers who seem to be healthy, and who deny that they have any unnatural discharge. It may pro- bably be brought on, sometimes, by bad management on the part of the nurse: by exposure soon after birth to draughts of cold air, or to the injurious influence of a hot and bright fire ; or by the introduction of soap into the eye in the primary ablutions, or of gin, wherewith the lower classes, in some absurd persuasion of its strengthening virtues, are wont to bathe the unlucky infant's head. The dis- order is observed to be most common in damp and cold weather; in low crowded places; and among the children of the poor.* One striking difference between the disease as it exists in adults and in newly- born children I have already adverted to; viz., its rapid and often uncontrollable progress in the former; and the facility 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 the lids sufficiently to obtain a glimpse of the cornea, and perceive that it is still brilliant and uninjured, you may confidently tell the [* The remarks of Dr. Watson on the causes of purulent ophthalmia in children, present a 'brief summary of all that is positively known in relation to the subject—for further details, bearing more especially upon the question of the production of the disease in the infant by a morbid vaginal discharge existing in the mother at the period of its birth, and the circumstances generally, under which the affection most frequently presents itself, the reader is referred to the Editor's Treatise on the Diseases of Children. We have not met with a single fact, during a long and somewhat extensive practice, in proof of the com- munication of the purulent ophthalmia of infants by contagion.—C] 202 DISEASES OF THE EYE. anxious mother that, with due care on her part, her child's eye is safe. If the cornea has lost its transparency, it is still wjthin 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 conclude both rich and poor under this phrase) that if they are not forewarned of the clanger, they are very apt to attri- bute 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 satis- factory view of the cornea without using a degree 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 occasioned 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 dissolving 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 unin- jured 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 of 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 considerable period, the advantage of watching Mr. Lawrence's patients under that treatment; and the result of it was so entirely and uniformly satisfac- tory, that I should never think of employing any other. If 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 uses, I fancy, his caustic ointment; but I am sure that the simple and less severe plan I have been describing is quite sufficient. There is just one more disease belonging to the conjunctiva, that I wish to bring before you; and then I shall have done with the morbid affections of this external membrane of the eye. It has received several names: sometimes it is culled pustular ophthalmia, from the appearance of little pustules upon the surface of the organ. Dr. Mackenzie, who looks upon it as an eruptive disease, affecting the conjunctiva not so much as a mucous membrane, but rather as a continuation of the skin, names it phlyctenular ophthalmia. It has also acquired the title of scrofulous or strumous ophthalmia, from its continual occurrence in children of a scrofulous habit, and its very 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 eyes in young persons, nine will be of this kind. I §hall 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. Although a disease of children, it is not a disease of infants at the breast. It is most prevalent from the time of weaning to about the age of eight. I mentioned to you, in a previous lecture, the remarkable 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 STRUMOUS OPHTHALMIA. 203 have to deal with purulent 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 con- junctiva ; and specks which are the result 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 altogether 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 other 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 between the sclerotica and the cornea, or near that line. Sometimes, however, you may see one or two near the centre of the cornea. They are smaller in size when they 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; more "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 become 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 leu- coma,) which, according to its size and its exact place, will interfere more or less vvith the patient's vision. The intolerance of light is a very prominent symptom of this disease, and sometimes it really is the only symptom that manifests itself. It is curious that this inability to endure a bright light bears no regular or definite proportion to the intensity of the other symptoms. It is not that the eye is painful when pro- tected from the light; but that the access of the ordinary light of day occasions extreme suffering; the eyelids being spasmodically closed and the orbicular muscle in such strong, and apparently involuntary action, as effectually to resist all at- tempts 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 with- out 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 light 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 204 DISEASES OF THE EYE. sympathetic, and need not of itself excite any fears about the vision. Towards dusk, indeed, in the twilight, the child can generally 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 lachryma- tion, even when there is but little visible redness, by the distribution of the lachry- mal nerve; which, after supplying the lachrymal gland, goes to the conjunctiva, and to the orbicularis 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 evi- dences also of scrofulous disease. Swelling and redness of the alae 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 severity with some of these other local scrofulous complaints ; get- ting better as they get worse, and vice versa. LECTURE XIX. Strumous Ophthalmia, continued. Recapitulation. Treatment of Strumous Ophthalmia. General Remarks on Conjunctival Inflammations. Iritis : its Symptoms 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 relieving strumous or phlyctenular ophthalmia. 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 eigdit, are extremely liable. It may occur considerably later. Sometimes it is the first and only token of the exist- ence 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 pro- ceeding from one or more fasciculi of superficial vessels, which advance from the circumference of the visible part of the eye towards the cornea, where they usually stop : sometimes, however, they pass a little 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 phlyctenae are situate towards the central part of the cornea. Secondly, with this partial vascularity and these pim- ples, 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 cha- racteristic 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 sometimes covering the cheek like a mask, porrigo larvalis. I may add to this summary of what was stated in the last lecture, that some- times 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 thick, 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 STRUMOUS OPHTHALMIA. 205 patchy and vascular. The appearance presented by the eye under these circum- stances 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 we cannot get rid of; and whenever the exciting causes, of scrofulous diseases come into action, this form of scrofula is very prone to declare itself, at the period of life which I have already mentioned. More good is to be done by 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 confectio sennae, or castor oil. The recovery will be greatly promoted, also, by those measures which are found to benefit the general health in such constitutions ; warm clothing, frequent ablution of the body, 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 that it acted like a charm, " abating, commonly, in a few days, the excessive intolerance of light and profuse epiphora; promoting the absorption of phlyctenulae, and has- tening 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. Mac- kenzie'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 seldom requisite, except when there are more redness and pain than common, and the tongue becomes white, and the skin hot. Certainly you must not take the intolerance of light as a fit indication for the use of leeches. Abstraction of blood rather aggravates that symptom; apparently by increasing the irritability of the retina. Warm fomentations are generally very comfortable to the patient's feelings. When the general disorder of the system has been somewhat rectified, local stimulants and astringents are of great service. Thevinum opii and the solution of lunar caustic are the best. These are often tedious cases, and therefore it is necessary that you should be aware of one great objection to the long-continued employment of the nitrate of silver wash, which objection has been pointed out by Dr. Mackenzie. 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 be preferred in slow cases, and in cases where frequent re- lapses happen. The good effects of either of those preparations are very striking; they diminish the irritability of the eye, and promote the healing of the ulcers. The red precipitate ointment, and the citrine ointment of the Pharmacopoeia, diluted, are also found beneficial. 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 206 DISEASES OF THE EYE. seen chronic strumous ophthalmia, of seven years' duration, quickly and effectu- ally 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 which had been made above twelve months, I found the immediate consequence to be a relapse of stru- mous 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 insert- ing 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 crusta 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 fourounces 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 disfiguring and disgusting scab, which they naturally enough felt apprehen- sive 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 opportunity 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 inflammation, 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 maybe 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 inflam- mation sometimes 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 contrary, that they readily pour forth pus. This tendency to the formation of pus I formerly showed you to be commonly observable, when- ever 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 conjunctiva of the eye, or the internal lining 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 disorder that originates in common and accidental causes may become capable of propagating 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 con- stitutional disturbance ; an illustration of the fact that the inflammation 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 IRITIS. 207 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 irrita- tion, in altering 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 wilh 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. Whether the phlyctenae, 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 com- pletely 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 inter- nal—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 inflam- mation: and, small as it is, the inflammation seems to be entirely confined to it, or to the surfaces immediately before and behind it. No doubt, with inflamma- tion 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 what is the actual condition of the choroid and retina; but we have this proof, either that they do not always participate 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 in- flammation. 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 mucous surfaces of the body ; but this serous cavity, constituting the anterior chambers of the eye, is the only serous cavity into which we have the privilege of looking, and of noting what is going on, when the membrane that forms its boundary is inflamed ; and this it is that makes iritis, to me, one of the most interesting of all diseases. There is no single part of the body from which you can derive so much instruction con- cerning some of the minuter processes of inflammation, and concerning the power of certain medicines over those processes, as you may by watching a few exam- ples 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 effusion 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 lo. 208 DISEASES OF THE EYE. 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 1 had to convince a surgeon of some pre- tensions, that he did not know this disease when he saw it. And English sur- geons 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 enu- merate 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 depo- sition of coagulable lymph. All these changes are apparent and conspicuous. Scientific writers term them objective symptoms. Then there are also the sub- jective 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 lines stop 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 gra- dually shaded off; the posterior portion of the sclerotic being generally pale. As the disease advances, and in violent cases, the more superficial conjunctival ves- sels 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 colour 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 be effused into the texture of this coloured part, it deepens, and at the same time alters, its tint. A gray or blue eye is thus rendered yellowish 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 natural to the iris. But besides a variation of colour, the peculiar bril- liancy of the surface is spoiled. It becomes dull and tarnished, as it were, and the fibrous arrangement, which is usually so evident, is confused or gone. The change commences at the inner or pupillary margin of the iris, and extends gra- dually towards the outer or ciliary edge. This is a symptom which you can scarcely overlook. It is rendered 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 striking and more important, in so far as the functions of the organ are concerned. The lymph becomes visible upon the surface of the iris. Its precise appearance varies considerably in different cases. Sometimes it presents little spots like freckles, or specks of rust: or a thin stratum of the same colour is de- posited. Sometimes it exhibits the appearance of drops, or (as they have impro- perly 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 magnitude 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 nearest to the pupil, to the annulus minor; while its IRITIS. 209 ciliary portion, or annulus major, is dull and clouded. Sometimes, when the inflammation is very violent, or the disease has been neglected, actual suppuration takes place. A reddish-yellow prominence 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 appearance 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 blunl: 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 crystalline 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 light; gra- dually 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 only, 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 inflammation 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 state of the aqueous humour. Acute iritis is attended with pain and intolerance of light. To the latter cir- cumstance is probably owing the contraction of the pupil during the progress of the inflammation : and then the lymph fixes the pupil in that state 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, how- ever, in regard to the pain. Sometimes it is constant and severe, but still more aggravated in nocturnal paroxysms. Sometimes, even when the quantity of mis- chief 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, the pulse is full and hard, and the tongue white, and the sleep is broken. If the progress of the inflammation be not checked, it extends itself beyond its original seat. It creeps from the pupillary margin to the ciliary ; 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 delicate texture of the retina is spoiled for ever. I have thus described the phenomena of iritis generally: and I will next con- 14 210 DISEASES OF THE EYE. sider, in the same manner, the treatment which it requires. It will afterwards be necessary 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 with 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 inflamma- tion 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 dwell- ing at any length upon the mode in which it should be employed, or the indica- tions for its adoption. I shall content myself vvith saying that the intensity of the local symptoms, especially of the pain,—and the degree in which the general symptoms, the fever, and the hardness of pulse, are present,—offer the best mea- sure, both of the necessity for bleeding, and of 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 purga- tives 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 inflam- mation 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 inflammatory 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 mercury 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 foetor of 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, vvith 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 effect is desirable, inunction of the mercurial ointment should be added. And in IRITIS. 211 some cases mercurial frictions alone may be sufficient, and the most expedient. Or the hydrargyrum cum creta, in five or ten grain doses. You may have bled your patient freely, and purged him well, and yet, on look- ing into his eye, you perceive the mischief to be still going on, and the deposition of lymph increasing. But the instant that his gums and breath acknowledge the specific 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 integrity, and beauty, and usefulness. I speak now of favourable cases. The changes for the better that I have been describing are sometimes rapidly accomplished, sometimes slowly. If the disorder has been long neglected, irreparable damage may have been done; the effused 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 of belladonna. 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 crystalline lens; and if it has recently contracted such adhesions, we may, while the lymph 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 effect 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 oocasions, and was witnessed by Ray himself. Other vegetables have the same properly: henbane, for example, stramonium, and the cherry laurel. And there are others which have it not, although we might have expected that thev would possess it, from the analogy they bear to the former in other respects. It has been ascertained that neither hemlock, 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 around the eye, upon the lids, and brow, and forehead. It is washed off 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 eyelids. 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. Rei- singer procured atropine and hyoscyamine, 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 212 DISEASES OF THE EYE. a small drop of the solution into the eyes of several dogs and cats. No irritation whatever of the eye was produced in any instance, but the pupil was so much widened by the application, that in an hour's time only 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 applied 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 shutting 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 hyoscyamine in a drachm of distilled water, and inserted a drop of the solution into the eye of an old lady of seventy- 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 dilatation 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 probability, adopt hyoscyamine or atropine, for artificially dilating the pupil, instead of the preparations now in use. Till that time arrives, you had better smear the surrounding skin vvith 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 facility 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, one 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 edge of the iris with the surface of the lens; and these are stretched, and not unfrequently 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 effused 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 ? IRITIS. 213 Why we have, in iritis, an illustration of what I have more than once men- tioned before, viz., that the rapidity of a disease will require a corresponding haste in the use of its remedy. In acute and violent cases, the mouth should be made decidedly sore, as quickly as possible; and when that has been done, the further administration of the mercury may be suspended. " Full salivation," says Mr. Lawrence, " quickly produced, cuts short recent disease, as if by a charm." In cases of longer standing, or of slower progress, we must be slower in the introduction of the remedy: it will be 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. When 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 mer- cury upon the gums has been achieved, yon 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 off. And you will be inclined to believe, 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 inflammation. 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 frag- ments of the lens) disappear, i. e., are absorbed, just as rapidly as the lymph in iritis, although 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 lymph on the iris ; and he says that the lymph was immediately absorbed, as soon as the inflammation ceased; and that he never saw it disappear 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 ihe 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 vvith two grains of finely pow- dered 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 dis- eased 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 treat- ment that I have been sketching out should be actively prosecuted. But inflammation of the iris sometimes arises slowly and insidiously, without vascularity 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 themselves with 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 influ- ence must be gradually brought about; and it is not so certainly productive of 214 DISEASES OF THE EYE. benefit as when it is employed in acute iritis:—probably because the chronic inflammation has involved the posterior tunics also. But most frequently iritis is met with in combination with syphilitic, or with rheumatic 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 second- ary symptoms of syphilis; and accordingly it is commonly associated with other secondary symptoms; with syphilitic eruptions, nodes, pains in the limbs, and ulceration of the throat. 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 distress- ing, so as entirely to prevent sleep until it takes its departure in the morning. We cannot, I believe, distinguish syphilitic 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, arthritic 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 age, 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 seldom affects 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 inflammation was first distinctly recognized. But you must not fall into the error of supposing 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 all men of experience are agreed. " Its influence (says Mr. Lawrence) is not confined 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, inflammation 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 immo- bility of the pupil; closure of the pupil by lymph; adhesion of the uvea to the membrane of the crystalline lens. All these we can see and ascertain for our- selves. We can ascertain also the presence of fever, which attends the acute forms of the disease. And we learn from the testimony of our patient that his RHEUMATIC OPHTHALMIA. 215 sight is impaired; that the influx of light into the eye hurts 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 foetor of the breath : and these effects are to be sought for rapidly or gradually, according as the inflammation of the iris is recent and acute, or moderate and chronic. The object of this remedy is to arrest the effusion of coagulable lymph: to put a stop to the adhesive inflammation. 3. The application 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 prevent the adhesion of the iris to the parts in its neighbourhood; to detach it from the 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 obviate 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 off by the knife in making the section of the cornea, without any injurious result. When iritis is excited by mechanical violence, it is acute. 2dly. A chronic form of iritis is sometimes brought on by excessive employ- ment of the eye, in looking at minute or bright objects. 3dly. The most common species of iritis is that which arises in connection with syphilitic disease. It is one of the early secondary symptoms of syphilis. It is marked by the co-existence of other secondary consequences of the introduc- tion into 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 dis- placed 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 distinguished. Mercury is perpetually exhibited for the cure of syphilis ; and people who have been treated for syphilis are very liable to iritis. This seems to be the only foundation for the opinion in question. When we come to appeal to facts, 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 offered to the patient in such a case: " Take thou some new infection to thine eye, And the rank poison of the old will die." Mr. Lawrence has seen no instance of iritis, of whatever kind, in which there . has 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 quantities of mercury for other diseases, as for affections of the liver in India, are particularly subject to inflammation of the iris. On the other hand, iritis has come on, in hundreds of cases, in connection with syphilis, though not a particle of mercury had been swallowed by the patients. Lastly, there is a peculiar form or variety of iritis, called the arthritic or rheu- matic. This affection is characterized by the following general features. It occurs in persons who are subject to gout or to 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 216 DISEASES OF THE EYE. 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 ; but adhesions readily form under it, and lymph is effused: and in each successive attack fresh effusion takes place: the pupil becomes more and more contracted ; and it may be filled up, at last, by an opaque plug of lymph. Some patients, however, will sutler ten or a dozen recurrences of the disease, and recover almost completely, and enjoy perfect vision in the intervals before the sight becomes much impaired. Some of the local appearances, are more or less characteristic of this variety of iritis. It is seldomer attended than the syphilitic variety by a deposition of lymph 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 syphilitic iritis. The adhesions 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 not 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 rheuma- tic 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. What is called rheumatic ophthalmia, then, is inflammation affecting the fibrous coat of the eye, the sclerotica. We know that the fibrous tissues through- out the body are frequently the seat of rheumatic inflammation. Some persons are more liable lo rheumatism than others—are more readily affected by its ex- ternal exciting causes, which are vicissitudes of temperature, and exposure to cold and wet. In such persons there seems a tendency to take on inflammatory action in all the structures of the same kind ; and most particularly in the fibrous mem- branes, and tendons, that 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 rheumatism seldom leads to any permanent alteration of structure; seldom, at least, when the ophthalmia is confined, as it often is, to the sclerotica alone. Perhaps 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. I will take a well-marked example, related by Mr. Lawrence. He was sent for to see a gentleman who was suffering from what is commonly called rheumatic gout: swelling, some redness, and severe pain of one foot and knee, and one hand ; aching of the back ; and great constitutional excitement. He got well under the treatment adopted. After a short interval, upon 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, I examined more attentively. On bringing him towards the window, he obviously RHEUMATIC OPHTHALMIA. 217 felt the light troublesome; he drew down the eyebrows, and half closed the lids, 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 inflammation. 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 per- fect ; 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 occupations, and of his tastes, which were literary, prevented him from giving his eye the necessary repose; and the condition of the sclerotica just described lasted for three or four months;" so that Mr. Lawrence was apprehen- sive that seme serious mischief would ensue to the organ. The affection re- mained confined, however, to its original seat, evincing only that obstinate cha- racter which belongs to disorders of such structures; and at last it disappeared completely, 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 improve 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: col- chicum, I mean; bark; sarsaparilla; the iodide of potassium. In these abiding or frequently recurring 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 easily 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, with that affection of the sclerotic which I have heen describing, there is combined a moderate degree of inflammation of the conjunctiva, this complex disorder receives a compound denomination; it is called catarrho-rheumatic ophthalmia. Dr. Mackenzie states it as the result of his experience, that arthritic iritis sel- dom occurs in connection with the earlier appearance of gout, while the patients still retain strong powers of digestion, and have the means of indulging ther appe- tites ; 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 be- yond the age of fifty, very frequently in tobacco-smokers, and whisky-drinkers, who.have often suffered rheumatic affections, who are teased by headaches, acid- ity of stomach, bad gums and teeth, and lowness of spirits : in persons, that is, whose health has been impaired and broken by intemperate habits. I believe you will find this to be a very correct statement; although arthritic iritis may also 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 mercury, 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 con- ducted on the principles already laid down, and adapted to circumstances. If there be any 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 digestive organs right, and to correct the bad habits of the patient: give small doses of mercury (such as five grains of Plummer's pill) three or four times a week; ex- cite counter-irritation by blisters, or by the tartar-emetic ointment. After the use 218 • DISEASES OF THE EYE. 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, ex- tremely 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 Dublin : not as being a better remedy 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 exhibition 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 removed, and effused lymph was absorbed, and vision restored, under the use of this medicine. It is necessary to its beneficial action that the bowels should not be confined. In other instances of the same disease, Mr. Car- michael was not so successful. Mr. Guthrie, who has also tried this remedy, reports of it that " in some cases it succeeded admirably, in others it has been of little service, and in some unequal 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 particularly 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 between 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 described. When vision is impaired or destroyed in consequence of any of the complaints 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 refraction 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 with 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 amaurosis. The term is derived from the Greek word auavpo$, 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 6ome 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 amau- rosis. 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 deter- mining 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 endea- vour to give you such a sketch of it as you may fill up and complete by future observation and reading for yourselves. It will be something to learn the direc- tion and objects of our inquiries into what is yet unknown in the pathology of this affection, AMAUROSIS. 219 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 commence- ment at the base of the brain to its termination in the retina; or it may be confined to the retina itself. . . , There is reason to believe that the functions of the retina may be impaired or suspended, by deviations from the natural quantity of blood sent to it; by disturb- ances of its circulation. Various degrees of amaurosis are common among per- sons 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 light: so as habitually to fatigue the eye. Engravers, printers, watch- makers, tailors and milliners, mathematical instrument makers, persons who gain their bread 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 stimulus leads to a chronic disorder, which, increasing in in- tensity, may terminate in total blindness. We call these cases of amaurosis, bM they may be justly considered to be instances of chronic inflammation 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 remove it, we are warranted in regard- ing the essence of the disease to be retinitis. The same condition, apparently, may be suddenly produced by the transient operation of some more powerful cause of congestion : such as intense light. I will illustrate this form of amau- rosis—amaurosis, that is, dependent upon congestion, which, perhaps, amounts to inflammation, sometimes slowly established, and sometimes very suddenly— by the narration of a few cases. I may as well premise, however, that the treat- ment which promises most, or I should rather say, which has performed most, in this form and kind of amaurosis, is very nearly the same (excepting 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 fact a 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. Purga- tives, 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 became blind. He had corrected the press, and was otherwise engaged in read- ing, 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 lime the amaurosis was so complete that he could not distinguish one object from another, 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 ulti- mately recovered his vision. The next instance that I shall cite is recorded, in these words, by Mr. Law- 220 DISEASES OF THE EYE. rence. " A young woman, of florid complexion and full habit, came to the London Ophthalmic 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 her strength by free living. The pupil was slightly dilated ; the iris motionless. A faint and scarcely perceptible pink tint was observed in the scle- rotica 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. I considered the case to be pure retinitis ; and to afford a favourable opportunity for showing whether the affection 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 full bleeding from the arm, free purging, low diet, repose of the organ, and general rest. At me end of two days the sight was worse: cupping and a blister were now ordered; but there was no improvement at the end of two days more. I now determined on trying 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. Full salivation, which took place in about a week from the first appli- cation of this patient at the infirmary, suspended all the symptoms ; the sight immediately improved, and was soon completely restored." A soldier, unacquainted with the proper method of observing an eclipse of the sun, employed for 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 was 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 ihe head continuing, he came under the care of Barron 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 afier 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 Memoires de Chirurgie.) In the year 1832, 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 said afterwards that the lightning appeared to enter his eye wilh a scorching sensation. During the night vision was quite lost. The next morning there was no redness, 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 calo- mel, 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 enough, 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 usina her legs: when she attempted to stand they separated, and she sank down. She had not perfect 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. Sensibility in the legs and thighs was 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, AMAUROSIS. 221 but complained immediately that the lightning had hurt her eyes. They presented no visible injury 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 tremble, 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 S tonic plan of treatment, and in ten days she could walk, dragging her left leg a little after her. In ten days more she was dis- missed 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 con- dition 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 exist. 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 tem- porary defect of sight may be produced by a diminished circulation through the retina, as in approaching syncope 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 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 lid, 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 pro- tracted a secretion (which may be considered a sort of hemorrhage), is sometimes noticed in nurses. Mr. Lawrence describes the case of a young mother of slender make, who suckled her first child, which was strong, and took 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 was completely insensible. She could not discern the situation of the window, nor see a lighted candle held close to her. Alter weaning the child, and using generous diet, she got perfectly well. Some counter-irritation was employed in this instance, but I question whether it had any thing to do with the recovery. Such cases are not uncommon, 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 dis- ease of debility, and requires tonic and stimulant remedies ; bark, and high feed- ing, and strychnia, and electricity. "Our eyes are weak," say they, "and we require strengthening medicines." You must perceive from what has already 222 DISEASES OF THE EYE. been said, how necessary it is to discriminate in such cases: to look closely into all the circumstances under which the disease has occurred. When amaurosis is the result 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 remedial measures. We cannot say, indeed, in many instances, where the cause of defect lies :tand 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 volun- tary 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 recog- nize his disease. He comes into a room with an air of uncertainty in his move- ments ; 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 har- mony of movement and expression 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 crystaline lens or its capsule, i. e., in consequence of cataract. They, on the contrary, while they cannot 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 pupil is larger than ordinary. When the blindness is total, the commonest con- dition 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 light 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 confined to one eye, this may happen. You examine the diseased eve, and you find that the pupil enlarges, or contracts, as you diminish or increase the light. 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 lively, but its independent movements were lost. But some- times the independent movement is unaffected: nay, the motions of both irides may be perfect, although both eyes are completely amaurotic. I may state, bv the way, that ceteris 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 eve alone was amaurotic, I found the independent motion of the iris of that eye unimpaired. We know that in the healthy condition of the parts, the brightness of the liaht 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 experi- ments 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 that 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 pa.r unaffected: 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 thhd pair of AMAUROSIS. 223 nerves, and so continue to govern the motions of the pupil. In conformity with these views, M. Andral relates cases in which amaurosis connected wilh 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.* 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 London, has a young son, who on two or three occasions has caused him great uneasiness, 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, apparently 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 relates a very singular instance of dental irritation giving rise to amau- rosis. 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 con- tinued 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 alteration. 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 im- proved, 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. Galen- zowski 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 I am certain that I have seen this myself. An unmarried lady, of a very nervous and suscep- tible 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 vvith Mr. Travers, who took an unfavourable view of the case, and thought the chance of recovery was very slender. I had one reason * [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 have met with many cases of this kind, and they are repeatedly referred to, more especially by the German writers on the disease. Children confined in ill-venti- lated 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 treatment, and such remedies as are adapted to restore the regular func- tions 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 werecompelled to the performance of tasks beyond their powers. Complete bjindness, we have known suddenly to occur in consequence of the presence of indigestible food in the stomach, and to be as quickly removed upon its expulsion. For fur- ther information on this subject, the reader is referred to the chapter on amaurosis by Dr. Taylor, in the 2d volume of Tweedie's Library, Philadelphia edition, page 515, and to the very able paper of Dr. Jacob on Ihe same subject in the Cyclopaedia of Practical Medicine, Philadelphia edition, vol. i. page 78.—C] 224 DISEASES OF THE EYE. 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 unable 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 few weeks the sight returned, she knew not how ; and she has since lost it a second time, and a second time regained it. Certain poisons will produce temporary amaurosis ; and the suppression of certain natural evacuations, as of the perspiration, of the menstrual fluid, and of the bleeding from piles, and the repulsion of certain eruptions, have been charged, by authors, with producing the same complaint. In those cases in which amaurosis creeps on slowly and insidiously, as it is apt to do from various causes: and more particularly when it depends upon a low and chronic inflammation, engrafted upon habitual congestion of the vessels of the internal tunics of the eye; its approach is marked by sundry curious affections of the vusion. The eye feels full or stiff, and sometimes there is pain of the head in its neighbourhood; 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 dull and murky, but in the dark it often appears shining, reddish and fiery: the flame of a candle is seen surrounded with a halo of prismatic colours. That amaurosis of this kind is often really dependent upon local congestion we are taught by the loedentia, by the circumstances that aggravate it: thus straining of any kind, which augments for the time the fullness of the vessels about the head, will make the mist appear more dense : the same effect may be produced by tying the neckcloth tight; or even by stooping. Boerhaave relates the case of a man who, whenever he was intoxicated, laboured under complete amaurosis : it came on by degrees, increas- ing according to the quantity of wine he drank; and after the drunkenness went off, his vision returned. Surely these phenomena are very illustrative of the way in which nervous disorders may arise, or be made worse, from mere local ple- thora, 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 car- riage, which happened to pass the window, seemed to him as small as a wheel- barrow, and the horses no bigger than*dogs. More commonly ocular spectra become visible: that is, parts of the retina lose their power, or perhaps are eclipsed by turgid vessels: the patient sees flies in the air, muscse volitantes, particles of soot, blacks, as we, who live in London, call them, which always float before his eyes, and seem to follow their motions ; and which are especially plain and troublesome when he is looking upon a white surface. They multiply in number till the whole becomes dark. Do not, however, suppose that the appearance of these muscae volitantes, even when they are permanent, necessarily implies the approach of amaurosis. I should be sorry if it were so, for I see two of them every morning, when my eyes are directed towards a white basin, while I am 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 appearance, 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 di- rected 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 AMAUROSIS. 225 itself is concerned in the production 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, preparations 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 expe- dients. 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 sometimes to do this for the retina, as well as for the nerves supplying voluntary muscles. 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. Strychnia has, of late years, been used for the cure of amaurosis. I shall hereafter 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 stimulating the exhausted or atonic nerve into action. With respect to this remedy also I may say—first endeavour to ascertain that it is not likely 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 distress, that he was obliged to discontinue its use. It is not given, in these cases, by the mouth, but applied locally, and Mr. Middle- more 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 sprinkles the strychnia, finely powdered, upon the raw part, and covers it with linen smeared with the unguentum cetacei. He repeats this every twenty-four hours, cautiously increasing the dose till the vision improves, or some sensible evidence of the 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 we 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 simultaneous agency of some specific poison upon the system, as that of syphilis; or by the presence of constitutional tendencies to disease, such as are observable in gouty and rheumatic people. And we have seen that the functions 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 inflammation of its texture, chronic or acute: and even, in some mysterious, or hitherto unexplained manner, by mere irritation of a distant part; by worms, for example, in the alimentary canal; by poisonous substances introduced into the stomach; and by what, in our ignorance, we denominate the 226 DISEASES OF THE BRAIN 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 Review of some points in the Physiology of the Brain and Nerves. Peculi- arity of the Cerebral Circulation. Pressure. Having considered some of the most important disorders of the eye, because thev afforded me the means of illustrating many of the doctrines and principles, which I had previously endeavoured to lay before you, of 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 interesting, 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 dis- eases as they affect different parts of the body from the head downwards in suc- cession, I shall speak of the diseases of the spinal cord, and of the nervous system generally, in connection with those 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 system, is surrounded with peculiar difficulties : 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 nervous 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 conse- quently, though such adaptation doubtless exists, we are not able to trace the reason or the manner of its interruption. We find in the lungs an apparatus of tubes and cells fitted for the 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 with any obstruction of those tubes, or any obvious im- pediment to the play of those muscles, we perceive at once how and why the function of respiration is deranged. But no alterations that become visible, after death, m the brain or spinal marrow, afford us any explanation of the interruption of their proper functions; which are, in three 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 distended lateral ventricle with the exer- cise of the will. The morbid anatomy does not in any degree elucidate the dis- order, 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 ag- gregate. 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 matter which composes it, and say, here resides the influence that governs this or that particular function. 3. Again, the brain and cranio-spinal axis are so encased by their bony cover- AND NERVOUS SYSTEM. 227 ings, that, in the living body, we are unable to ascertain their physical conditions by means 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 func- tions 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 fre- quently 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 functions 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 diffi- cult 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 communion with the world around us ; the stage upon which all the phenomena of animal life are transacted: the instrument of the mind? And with all its difficulties, there is also a good deal in the pathology of the brain and nerves that is fairly made out and well understood; and we are at pre- sent 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 un- attainable. With mere speculative questions, that have no practical bearing, I shall meddle as 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 ; and some strong probabilities which almost amount to certainties. Without first ex- pounding my creed upon these matters, it would be impossible for me to explain, as it would be for you 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 masses of nervous matter, called the nervous centres; and of nerves therewith connected. 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 degree 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 228 DISEASES OF THE BRAIN 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 animals 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 believing 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 complicated form, in man: and after him, in those of the inferior animals which show the largest share of reason. 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 in the spinal cord. The muscles furnish the instruments of motion. Now there is a certain class of muscles which contract without our willing their contraction: and generally without our being conscious that they are contracting. Such are the heart, the muscular fibres of the alimentary canal, and of the blad- der. 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 considered and called voluntary muscles. There is still another distinct set of muscles, of which the habitual action is involuntary, yet which submit also to the interposing control of the will. You will call to mind at once the nuscles of respiration, which act while we are asleep, or otherwise unconscious; and the sphincters, which regulate the entrances and outlets of the body. Here, I say, the habit is involuntary, but the occasional action is prompted and governed by volition. But sometimes the involuntary action rebels against the willed action, and overcomes it. The muscle contracts in spite of the will. Nay, those muscles which, ordinarily, move only in obedience to volition, do sometimes, under the influence of strong emotion, or of disease, contract inde- pendently of any effort of the will, and even in opposition to, and defiance of, the voluntary power. Under certain circumstances the limbs move with much briskness and force in decapitated animals, in which sensation and volition are extinct. Some physiolo- gists 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 affirming 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 voluntary motion, and quite dead as to sensation, do yet, under certain conditions, AND NERVOUS SYSTEM. 229 contract and move when the integuments are pinched; the rational patient not feeling the pinch, and not being conscious of the movements. Whence does the impulse that leads to motion in these cases proceed—how is the motive power awakened ? 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 great 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 dis- orders, until the publication, in 1832 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 Miiller of Berlin. I must recommend you to study the works of these authors; and I may 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. Carpen- ter's two works, Principles of General and Comparative Physiology, and Prin- ciples of Human Physiology: and a very able paper on the Pathology of the Spinal Cord, by Dr. William Budd, in the 22d volume of the Medico-Chirurgi- cal Transactions. If, on the other hand, you wish to see how nearly the idea, which has been so happily simplified into an intelligible principle by Dr. Hall, was reached by earlier 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 condition 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 ihe brain, may send down an influence, which travels with electrical rapidity to the spinal cord: whence, the requisite change having been instantly produced, the motive influence passes, with propor- tional 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, whether 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, by an influence carried to the cord, not from the brain, but from the extremities 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 ihe reflex function of the spinal cord. The apparatus subservient to this function is named by him the excito-motory sys- tem ; the nerves which carry the impression to the cord are incident or excitor nerves; those which convey the motive impulse from the cord, reflex or motor nerves. Dr. Carpenter's terms (which I like better, except for their similarity in sound) are afferent and efferent nerves. 230 DISEASES OF THE BRAIN Mr. Grainger believes that physiology indicates, and anatomy can exhibit,four sets of fibres belonging to the nerves and the nervous centres. Sensiferous, and volition nerves, connected with the gray substance of the cerebrum, and subordi- nate to the exercise of feeling and of the will; and 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 efferent fibres be the same, while the afferent fibres are different; 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 the 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 orifices 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 mainte- nance of what is called their tone, their natural tension and firmness : in disease, as we shall hereafter see, it sometimes acts upon them vvith 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 insurmounta- ble. One or two of them, however, appear to call for a more attentive considera- tion. 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 are 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 tothose functions. There may be only one such undiscovered disturbing cause, variable in degree in different cases ; or (what is more probable) there may be several such conditions differing in kind. A blow or fall, which jars the brain ; a sudden mental emo- tion; an electric shock ; a teaspoonful of prussic acid; any one of these causes may destroy 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 the 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 that such conditions may be furnished by the varving state of the cere- bral circulation. In point of fact, we know of some changes in the circulation hrough the brain which have the effect, invariably, first of modifying, and at length, if they are continued, 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 AND NERVOUS SYSTEM. 231 But whatever may be the nature of the unknown, and perhaps fugitive, physi- cal conditions of the nervous centres, thus capable of disturbing or abolishing their functions, it is useful to keep in our minds a disiinct 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 inconsistencies to which I before adverted. The same symptoms, I repeat, have been found to accompany physical lesions of the 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 symptoms. 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 presumed cause of morbid phenomena, is a variation in the relative quantity of blood contained respectively in the arteries and veins that lie within the eranium. 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 these 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 limes, 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, how- ever, without 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 of bone. Its surface 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 mate- rially increased, unless something is displaced or compressed to make room for the addition; nor materially diminished, without the entrance of something to supply the place of the blood subtracted. Dr. Kellie noticed that while, in animals bled to death, the other organs 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 scull, by means of the trephining instrument, taking 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 fawcetat its lower orifice, but no beer will run out 232 DISEASES OF THE BRAIN 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 you bore a small hole vvith 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 con- verse experiment. He desired to ascertain whether, under circumstances calcu- lated 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 quan- tity of blood escaped; marking plainly enough the congestion of the vessels exterior to the cranium, but there was no such congestion observable within. " The sinuses contained blood, but in no extraordinary quantity ; the larger vessels on the sur- face and between 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 atten- tion to the condition 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 execution, the eyes were blood-shotten, and the lips and countenance turgid and livid. 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 extravasated. But when the bone had been sawn through, and the skull-cap removed, the large veins of the brain did not 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 was of very natural texture and appearance, and not more than commonly full of blood." Among the propositions deduced by Dr. Kellie from his observations and ex- periments were the following:— 1. That in the brains of animals that have 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 stran- gled. ^ 3. That the quantity of blood in the cerebral vessels is not affected by gravita- tion : 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 experi- ments 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 reducing 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 vessels of the head. " The contrast between the two brains in point of vascularity, both on the surface and in 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." He next investigated the effect of posture upon the condition of the intercranial AND NERVOUS SYSTEM. 233 "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) by the hind legs. They were left suspended for twenty-four hours; and before they were taken down for examination, a light ligature 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 eyeballs, &c, were pallid and flaccid ; the muscles of the scalp and bones of .the cranium were also remarkably exsanguine. Upon opening the cranium, the membranes and substance of the brain were pallid, the sinuses and other vessels were exsanguine—anaemic 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 prominent, the longitudinal and lateral sinuses were gorged with dark blood, and there was straining of the tissues, if not extravasation 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 congestion of the cerebral vessels after death by hanging. It is the subsidence of the fluid 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 delineated by M. Breschet." Moreover, the manner in which the corpse is generally examined, proves an additional 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 erro- neous assumption. Dr. Burrows thinks that the anatomical structure of the human cranium 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 equilibrium of pressure on the parts within and without the cranium, very serious consequences would arise at the various foramina of the skull." We fall back, therefore, upon another principle, whereby some of the difficulty and obscureness which attend certain affections of the brain and nerves may be explained. I mean the principle of varying pressure upon the nervous substance, 234 DISEASES OF THE BRAIN. 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 ence- phalon sustains pressure from 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 protudes a little; and it again subsides with the succeed- ing diastole. This shows that the tension of the arteries, produced by every con- traction 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 thorax in breathing; rising with every act of expiration, and sinking with every act of inspiration. 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 pressure on the parts within the head. In further proof of this, if any were needed, I may again refer to Dr. Kellie's experi- ments. 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 lo 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," discharging itself by the nerves, at brief intervals, " when the tension of the elec- tricity 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 dis- ease itself be permanent. For example, we see continually persons who are epileptic: that is, they have fits of convulsion and stupor now and then, and appear perfectly well in the intervals. After the death of such patients we some- times 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 suffi- cient explanation of the preceding disease ; but we are always pressed with this SYMPTOMS OF CEREBRAL DISEASES. 235 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 many 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 compressing 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 numerous train of distressing symptoms, which too well marked the existence of enlargement 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 and reappeared 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 by 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 debility advanced he be- came 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. (Aber- crombie.) An old clergyman, who is sometimes my patient, is troubled by two grievances : deafness 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 pre- sent, with having pointed out the main grounds upon which the theory rests. The difficulties that attend it, and the considerations which diminish the force of those difficulties, will 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 with various forms of disturbance to which these same cerebral functions are liable. Let us pass them shortly in review. 236 DISEASES OF THE BRAIN. 1. The faculty of sensation may be morbidly keen, or morbidly obtuse ; 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 pre- ternaturally acute. Tenderness ascribed to different parts, their natural sensations being heightened into pain ; a general state of irritability ; intolerance of light, 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 anaesthesia; dullness of hearing, deafness; dimness of sight, blindness; failure, or absolute extinction of the senses of taste and of smell. Perverted sensations, sensations unnatural in kind, are very numerous. To mention a few: giddiness ; nausea ; ringing in the ears; ocular spectra; ill smells in the nostrils; false tastes on the palate ; itching; and sundry uneasy feelings, many of which are indescribable. Various kinds of pain belong to this class ; spirits violently high; causeless depression, anxiety, and dread. 2. Innumerable degrees and varieties of disturbance of the faculty of thought are met with. Delirium in all its shades; dullness and confusion of intellect; sundry defects of memory ; incapacity of judgment; and every degree of stupor up to complete 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 debility; palsy. Now, as I stated before, there is, and there can be, no physical 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 disturb- ances of function just enumerated, in every case in which more or fewer of them appear ; and when you are told that these symptoms are apt to present themselves in almost every conceivable order and combination, and, moreover, that many of them may be sympathetic of diseases of other parts than the brain, you will scarcely need to be further informed, that the language they speak is often very hard to construe ; that we frequently fail to reach and discover, by these outward 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 barren of certainties in these matters. Hints, sketches, approximations, 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 partial. 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 is composed of blood-vessels held together by a web of 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 implicating also the surface of the convolutions with which it has so close a relation, and so intimate a vascular connection. Again, with respect to the membranes themselves, the dura mater may be inflamed while the pia inater remains unaffected. I believe also that the arach- noid may suffer inflammation, and leave the subjacent pia mater untouched. DURA MATER AND ARACHNOID. 237 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. Can we separate and distinguish these several inflammations by assigning to each its proper external phenomena? Seldom; scarcely ever. Doubtless each has its peculiar symptoms; and if inflammation were often strictly limited to the one membrane 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 circu- lation of blood through it, then we might expect greater uniformity, and might hope by careful and repeated observation to seize upon the desired distinctions. But this simplicity is not exhibited by the inflammatory affections of the parts within the cranium. Inflammation commencing in one membrane is apt to spread readily and rapidly to the rest, and to the cerebral substance; and the complication of diseased conditions coexisting within the skull at the same time, throws confusion over the whole subject. This uncertainty of exact diagnosis is however of the less consequence, inasmuch 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 general 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 de- scribed many years ago, by Mr. Pott. A man receives a blow on the head; the blow stuns him perhaps 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, delirium, convulsions, or coma. Meanwhile the part which was struck becomes puffy, tumid, and somewhat tender; 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 removed, 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 car- ried 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 distance, 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, was frequent, but it was said to be so during health. His intellect was clear, and he had no head symptoms; 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. 238 DISEASES OF THE BRAIN. 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 also had lost its vitality. Some pus lay upon it. No relief followed the operation. On the 10th 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 sloughy. Over the whole of the anterior and lateral surface of the left hemi- sphere there lay, upon the arachnoid, a thick coating of coagulable lymph, smeared with pus: this extended down the posterior partof the hemisphere also,nearly toils 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 detected. 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 para- lytic 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 diffused 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 delirium had been manifested : there had been no convulsions, nor was there any other morbid appearance wilhin 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 necessarily extending to the pia mater; just as inflammation may overspread the pleura, or the pericardium, without touching the lung or heart which those serous membranes respectively clothe. Here no sensible traces of inflammation were discovered deeper than the free surface of the arachnoid; and there had been no disturbance, till 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 con- ceive 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 derangement 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 affec- tion. 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 bier as a crown-piece and at that spot was ulcerated. But there was also found an adven- titious 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 winch intermit; and so regular sometimes are the intermissions, that the practitioner may be tempted to believe that he has got an aguish patient, and to administer bark. J he intellectual faculties, especially at the outset of the disease, are but little affected ; which ,s just what we might expect. The dura mater and he arachnoid lying apart from the sensorium, their inflammation can have no other man an indirect influence upon its functions. nrimlrv1^ inAammation of,.the dlira «»ter * very uncommon as an idiopathic or Kin hY r1"' 7 V6ry fre<*uenl|y meet wit» *t as a secondary affection ; and then there are few diseases more surely fatal or less within the reach of remedies. DURA MATER AND ARACHNOID. 239 It is as a consequence of what is called otitis, that physicians are chiefly accus- tomed 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 Ihe 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 be- comes dull and drowsy; slight delirium, perhaps, occurs; and by degrees he sinks into stupor. In some instances no pus issues externally. More commonly symptoms of the same kind supervene upon a chronic discharge of purulent mat- ter from the ear. It is scarcely possible to sketch an accurate general picture of this insidious but most dangerous complaint. Next to seeing and watching actual cases of it, the best way of becoming acquainted with its phenomena is by attend- ing 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 ac- count 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 abscess 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 coma. 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 sus- pended. A foetid discharge 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 hemisphere was covered with a layer of coagulable lymph and pus. The ves- sels 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 crum- bling; and contained foetid pus." In this case, you will observe, there was no symptom to mark the extensive mischief 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 lia- ble 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 forehead, 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 coma, the pulse having been always under 90. A 240 DISEASES OF THE BRAIN. considerable quantity of colourless fluid was 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 thick- ened 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 sup- puration in the cerebellum; the parts lying between the abscess and the dura mater escaping. This last, and somewhat singular circumstance, might have been owing, (so at least I conjecture,) to the extension of the inflammation from the suppurating 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 otorrhoea, have fallen under my own observation; one of them in private practice, the other in the hos- pital. 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 puru- lent 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 perspiration, occurred very regularly for two or three days in succession; suggesting the suspicion that his complaint might be ague : but then pain and swell- ing of some of the joints came on, and were, at first, considered rheumatic. How- ever, 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 considerable quantity of foul, grumous, dark-coloured matter let out. After about a fortnight 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 arti- cular cartilages were gone, and matter had burrowed extensively among the sur- rounding muscles. The knee and ankle joints of the same limb were in a similar state. It is curious that the destructive 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 pene- trated from the ear to the dura mater, I entertain no doubt: in all probability 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 Hospital, 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 relaxed. A puriform discharge came from his right ear He had been suddenly seized, a week before, with sharp pain in that ear, which asted 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 rheu- matism (as he supposed it to be) commenced in the foot. When this part was DURA MATER AND ARACHNOID. 241 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 shoulder was punctured, and three ounces of pus, mixed vvith blood, came out. After this incision the rigors ceased; but the abscesses continued open, and the discharge 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, and a rapid and feeble pulse. The diarrhoea continued, more or less, throughout. "For some time before his death, which happened about the middle of the month of December, the left leg and thigh had been much enlarged by oedema. 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 mem- branes, and of its veins, was not noted. The right shoulder-joint was extensively diseased ; the cartilages were 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 impli- cated also in the abscess which 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 fro in ^ 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, purulent matter could be made to ooze by gentle pressure. The mastoid cells of the right temporal bone were filled with pus, and there was a slit-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 disorganization 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 seve- ral distant parts, and, in the last case, the actual femoral phlebitis: these circum- stances form a chain of presumptive evidence, amounting, in my judgment, to moral certainty, that the fatal mischief, in each case, found entrance through " the porches of the ear;" and that the dura mater underwent inflammation. The same evidence is scarcely less affirmative of the complication of cerebral phle- bitis. Perhaps the veins of the diploe, which in the cranial bones are of con- siderable magnitude, were involved in the inflammatory mischief; perhaps the large sinuses of the brain. The close vicinity of the lateral sinus lo the diseased bone, and its formation by a duplicature 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 1836, 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" Phlebitis of the cerebral sinuses as a result of purulent otorrhcea." He refers to several other instances of the same kind recorded by different authors. This combination of disease is doubtless more common than had been heretofore sup- 16 * 242 DISEASES OF THE BRAIN. posed : and the important pathological considerations connected with it will pro- bably receive further illustration, now that the attention of the profession has been called to the subject by Dr. Bruce's paper. Dr. Griffin has published, in the Dublin 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 trifling: 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 offensive brownish pus sprang out vvith great force. This gave much relief. The bone was carious over a space as big as a shilling. After about ten days, the pain 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 delirium: his face was flushed, and his pulse hard; and he died within a few hours after the accession of these last symptoms. The most remarkable features in this case were the similarity of the fits of shivering 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 treatment 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 inflammation of the dura mater; and to put you upon your guard against over- looking 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 lighted 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 merabrana tympani is perforated: the little bones of the ear come away: more or less deafness ensues ; and from time to time, or habi- tually 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 inflamma- tion 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 inflammation in the ear that remedies are most likely to be efficient in preventing this catastrophe. 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.* If symptoms of acute inflam- mation within the head supervene, the complaint requires more vigorous treatment, which I shall describe when I have spoken of inflammation of the other mem- branes of the brain. After what has been said, it is unnecessary to point out to you that the prognosis in these cases is very unfavourable. 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: a'nd the follow- ing would seem to be an instance of recovery when the source of the mischief * [The frequency with which inflammation of the dura mater supervenes upon otitis, especially 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 ihe termination is very generally fatal.—C] PIA MATER. 243 was situated m 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 can- not be sure in such a case that the matter came from the brain ; but the symptoms 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 symp- toms that are known to result from cerebral pressure. Cases are recorded of analogous disease communicated from the carious aethmoid 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 in- flammation spreading inwards from the socket of the eye; but I make no doubt that each may occasionally happen. Tht^e three, then—idiopathic inflammation of the dura mater—very rare ; in- flammation of the dura mater by extension of disease from the aethmoid 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 : consti- tute those forms of inflammation of the outermost tunic of the brain, which the physician may be called upon to treat. The inflammation is not always—nay, perhaps it is seldom, if ever—restricted to that tunic ; but it begins there; and the essence of the disease is inflammation of the dura mater. Acute arachnitis—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 opposite portion of the same membrane spread over the surface of the brain. So, likewise, 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 arachnoid ; but include under that term inflamma- tion 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, yon 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-like 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 inflammation 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. 244 DISEASES OF THE BRAIN. 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 charac. ter 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, L 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 arachnoid does not go. In fact, considering the arachnoid as the serous mem- brane of the brain, we should expect that, when inflamed, it would present the events or products of inflammation on its free surfaee; and we sometimes find them there; but this is very rare; and for my own part, I look upon those effu- sions which lie beneath the arachnoid, between it and the pia mater, as being furnished exclusively by the vessels 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-eontinued paroxysm of general convul- sions. Some'imes this is the first thing noticed. Sometimes it comes on altera few days of discomfort, slight headache, and vomiting. The convulsions recur, and 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 pre- sumed 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 they invest the upper surface of the cerebral hemi- spheres. 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 menin- gitis of any kind. He relates them as instances " of a very dangerous modifica- tion of the disease, which shows only increased vascularity." I venture with great humility 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 ft> 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 delirium 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 violent 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 immediately 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 thedura 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 PIA MATER. 245 as a wafer, and in some places dipped down between the convolutions. A con- siderable quantity of it extended over the surface of the cerebellum also. A child iwo 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 convolutions were most strikingly marked by a bright line of vivid redness, produced by the inflamed membrane. There was no effusion 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 excessively 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 ihe symptoms had been very obscure. The child in whom the disease occurred was convalescent 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 mem- brane may exist, and prove fatal, without giving rise to any violent symptoms at all. I must trouble you with one more history, because it affords another example of what I have mentioned as being rare; viz., the effusion of the products of inflammatory action upon the outer surface of the arachnoid,—marking therefore very distinctly the inflammation of that membrane. It was evidently combined, however, vvith 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 occasioned 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 vvith pus was found covering the surface 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 the 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 arach- noid 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 246 DISEASES OF THE BRAIN. sometimes spoken of as phrenitis, or as brain-fever? Why these are instances of acute inflammation of the whole contents of the cranium ; of the brain and its membranes; of the encephalon in short; and, therefore, the disease has, not im- properly, 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 in which the disease may commence. Period of Collapse. Treatment. Delirium 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 ra- pidly to all ihe rest. As the contents of the cranium are called, collectively, the encephalon, so the disorder which I am about to consider has been named enceph- alitis, 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 be- lieve this to have arisen from the circumstance that the effects of the inflammation, which become visible after death, are often 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 cere- bral pulp may escape the notice of a hasty or inexpert observer: and those changes of colour, which sometimes denote increased vascularity of the same part, may very easily be passed over without attracting much attention. Phrenitis, 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 different 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 appea*which are comprised under the term collapse. Sometimes these two sets of symptoms, instead of following 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 constriction across the forehead ; throbbing of the temporal arteries , flushing of the face; injection of the eyes, which have a wild and brilliant look ; contraction of the pupils ; preternatural sensibility to external impressions, amounting fre- quently 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 com- mence 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 im- ENCEPHALITIS. 247 mediately 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 these 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 dis- tended, 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 con- tinued, bile is to be expected in the matters brought up : the action of the duode- num, as well as that of the stomach, is inverted; and the bile passes in ihe 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 meningitis. This symptom, according to Andral, is a much more certain sign of cerebral 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 encephalitis, may depend upon the part in which the in- flammation begins; and that it is soon propagated from that part to the whole of the organ. I should suppose that when nausea and vomiting are the earliest symp- toms, the inflammation has taken its point of departure in the cerebral pulp; in the substance of the brain; and that when the attack comes on vvith a sudden fit of convulsion, the inflammation has commenced in the pia mater or arachnoid. This is consonant with what we know of inflammation of those parts when they are separately affected. 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, simul- taneously. I say I offer these as conjectures of my own : what it is of import- ance 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, lhat cannot be brought within even this gene- ral rule. They begin in some irregular or obscure manner, or with some unusual phenomenon. Andral states that he has seen a few striking instances of inflam- mation of the brain, of which the first 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 man- ner in which the disease 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 climate. 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 248 DISEASES OF THE BRAIN. 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 fol- lowing 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 bad squinting and double vision, and a very obstinate state of bowels, and his pulse was 60. 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 genera] was found highly vascular, and a very considerable extent of it was in a state of softening mixed with suppuration. The ventricles were distended vvith fluid, and the membranes in many places were much thickened. One very curious circumstance (affording perhaps some expla- nation 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 bv 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 delirious, 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 painfully acute, but dull, or perverted ; strabismus and double vision are not uncommon; and the pupil from being contracted to the size of a pin's head, becomes first oscillating, then widely dilated, and ultimately motion- less. The patient is not shaken, at this period, vvith 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 coun- tenance 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 hours; or the patient 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 membrane and the arachnoid; softening of the cerebral substance, with pus infiltered into the softened parts; or great vascularity, shown by a pink or purplish mottling 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 delicate organ- ization 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 rigidly observed; the patient should be kept as much as possibfe 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 by cupping or leeches from ENCEPHALITIS. 249 the back of the neck, or the temples, or the mastoid processes; and these deple- tory measures must be repeated according to the violence or continuance of the symptoms which first demanded them. The application of cold to the head is a remedy of great importance in this dis- ease. The head must be first shaved, and the mere removal of the hair is some- times followed 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 sup- posing, 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 flex- ible 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, with the reduction of the external heat of the head, there is also an evident miti- gation of the violent symptoms; the agitation 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. Aber- crombie tells us that he has seen a strong man, submitted to ihe operation of this cold douche, " thrown in a very few minutes into a state approaching to asphyxia, who immediately before had been in the highest state of maniacal excitement, with morbid increase of strength, defeating every attempt of four or five men to restrain him." Of the effect of this measure in a somewhat different 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 child, 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, and completely insensible ; her face flushed and turgid. She was raised into a sitting posture, and, a basin being held under her chin, a stream of cold water was directed against the crown of her head. In a few minutes, or rather seconds, she 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 pa- tient'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 understand me to advise that it should supersede the use of copious blood-letting: it 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; but 250 DISEASES OF THE BRAIN. we must not, in this disease, combine it with opium, to prevent its passing off by the bowels. 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 satis- factory 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 medicine 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 pro- duce its specific influence upon the gums, a great change for the better will often be perceived. 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 you 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 pa- tient's head symptoms, 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 effused serum, or lymph : when this order of symptoms make their appearance, I believe the time fordoing much good by active bleeding has gone by. If, however, blood-letting has not yet been employed, 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, had violent headache and vomiting, with great obstinacy ol the bowels; and these symptoms 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 salivation, had been employed with- out 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." (Abercrombie.) 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 convalescent. °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 violent 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 frequency, as being a very eommon circumstance and sign, in inflammatory affections of "the brain.l " At first it was found impossible to bleed him, on account of the violence of the con- vulsions ; but about seven in the morning a full bleeding was obtained, after which ENCEPHALITIS. 251 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 purgatives 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 application of cold to the head—we have much encouragement to put them into combined operation in these very serious cases, especially when we have the opportunity of using them at an early period. Should 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 and 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 busi- ness. 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 itself, 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 blistering 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, neces- sarily, hopeless conditions. These symptoms do not always proceed from fatal disorganization of the brain, but sometimes (there is reason to believe) from simple exhaustion of the nervous power. And this is a point of critical importance. Patients apparently moribund are occasionally saved by the judicious administra- tion of stimulants 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 result 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 conditions, 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 debility and tremors, coldness of the extremities, a want of power to respond to external impressions; these are alarming, but not abso- 252 DISEASES OF THE BRAIN. lutely desperate symptoms, especially 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 vvith blistering the head, of internal stimuli; and no other plan affords even a gleam of hope. There is jusi one caution that I wish to mention before I leave the subject of acute encephalitis; and it applies to all cases of coma and insensibility, and espe- cially 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 and prominence there, pro- duced by the distended bladder. I shall revert to this matter more particularly at some future time; and I content 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 inliammaiions which are chronic, or partial. These forms of disease are more common, in adults, than acute and general encephalitis. 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 per- suaded, 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 consideration of which we have just been occupied. The mistake is the more serious, because the remedies that I have been recom- mending 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 op- portunity 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 patho- logists. 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, fidgeting with his hands, affected often with tremors of the limbs, having a rapid pulse, and bathed in sweat. Now it is very natural that a person not on his guard should look upon these symptoms as indicating 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 delirium you will generally find to be, not a fierce or mischievous delirium, but a busy delirium : he does whatever you desire him to do, but he does it in a hurried manner, vvith 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 blun- dering 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 very 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 DELIRIUM TREMENS. 253 rambling: 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 stimu- lus. 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 theh, as the delirium came on, he has been freely bled; and that he has been none the better, but commonly 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 describe, and especially when there has been obstinate watchfulness, and the tongue is moist, and the skin is sweating, you may be pretty certain that your patient is affected, not with inflammation of the brain, but with delirium 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 indication 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 de- scription. In the year 1831 I was requested, by a most respectable practitioner in this town, to ^isit 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 who, 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 little, and talking much and incoherently. He was particularly anxious that his legs 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, espe- cially of late, drinking a good deal; and somewhat anxious about his affairs: he was a builder. His former history 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 laud- anum 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 laudanum, 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 that neighbourhood. I found a large strong man between 30 and 40 years of age. He had been without 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 vvith 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 ihe 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. 254 DELIRIUM TREMENS. These are the broad outlines of delirium 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. Delirium Tremens, concluded. Chronic Inflammation of the Brain. Soften- ing, Suppuration, Abscess, Induration, Tumours in the Brain. I drew a rude outline, yesterday, of that singular and interesting malady usu- ally 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 cer- tainly 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 delirium tremens ; and the drug, by the timely and careful adminis- tration of which we can often promise a speedy cure in delirium tremens, is one which we must carefully 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 ebriositalis: 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 tremefaciens i and you would hardly suppose it, but there has been a sort of contention for the honour of thus mending the nomenclature of this dis- ease. But they who object to delirium tremens appear to see no harm in deli- rium 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 trem- bles ; 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 delirium tremens: and, therefore, if it be only to 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 eager and fidgety employment of them. To these are added other symp- toms which, though they are not so calculated to strike a looker-on, are of not less importance, inasmuch as they help to establish the diagnosis. The tongue is moist and creamy; the pulse, though frequent, is soft; the skin is perspiring, and most commonly the patient is drenched in sweat. The sweat is usually de- scribed 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, i> not always the case, and therefore this point cannot be relied upon as a distinguishing DELIRIUM TREMENS. 255 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; describes, in an agitated manner, his feelings, puts out his tongue, and does what- ever you bid him : but immediately afterwards he is wandering from the scene around him to some other that exists-only in his imagination. Generally his thoughts appear to be distressful and anxious ; he is giving orders that relate to his business to persons 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 vvith 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 will 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 symptoms such as I described just now, you hear a his tory of this kind, you may be satisfied that the disease is not inflammation of the brain, but delirium tremens. I believe 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 opportunities of noticing such cases. But the disease is not confined to drunkards, although it is so commonly con- nected with that pitiable vice, as to have been called mania e potu. You meet with it occasionally in men who have overstrained 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 accus- tomed 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 en- tangled himself in some of the speculations 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 apo- plexy : 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 consequence of the treatment and regimen to which the patients are subjected, rather than of the surgical or medical com- plaint. 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 cessation of the accus- tomed spur, that the continually recurring stimulus has been regarded as the pre- disposing, 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. We had a porter (an old soldier he had been) at the Middlesex Hospital, who was of great use to us as a subject to practise upon, and to show to the pupils. I never saw him so drunk as to.be unable to perform his duty : 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 256 DELIRIUM TREMENS. 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 .that 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 ex- haustion 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 some- what greater than for males. On the men's side of the house cases of delirium tremens are very frequent: whereas 1 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 you. On the other hand, Dr. Roots thinks he has seen quite as many instances of delirium tremens attacking females as males. The result of M. Rayer's observation is more in accordance wilh 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 peculiar 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 Greenwich. 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, ac- cording as bleeding or narcotics were adopted. It is the same disease which Dr. Abercrombie speaks of as " a dangerous modification of meningitis, which shows only 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 treatment. Of late years many essays and papers on the same malady have appeared 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 1 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 tangible, you lose yourself in mere hypothesis. But we see a number of striking phenomena in this and in many other forms of disease, for which phe- nomena 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 Chinese name it would have been all the same. From certain symptoms we infer irritation ; 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 irritation are established vvith ahy thing like the certainty which belongs to the ascertained laws of gravity: but we pursue the investigation of these laws in the same way in the one case as in the other: and it is quite idle to object to an arbitrary term, like irritation, because it is meant to represent something which makes itself known to us only by its effects. Now I apprehend that we are borne out, by authentic facts, in believing that certain changes in the blood-vessels will lead to irritation, and at length to inflam- mation, of a part. But there are other sources of irritation ; and irritation in its turn will lead to changes in the blood-vessels. In the one case we bring back 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- DELIRIUM TREMENS. 257 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 sanguiferous 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 yon 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 delirium 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 presently sleep, or become composed, if you 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 exhaus- tion goes along with and augments the nervous irritability. This I have continu- ally experienced 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 state of the digestive functions. If you learn that, notwithstanding the intem- perate 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 will frequently be necessary: and it is well to ascertain, in such cases, what the stimu- lus has been, whether spirits, or beer, or wipe, 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 circumstances must be cautiously withdrawn. 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 discommending them. I know persons who in treating these cases combine calo- mel 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 fol- lowed 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 per- sons : and if it comes to affect the mouth, you inflict upon your patient a super- fluous discomfort; 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 258 DELIRIUM TREMENS. 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 con- sider 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 vaeant corner in one of our own. Of the combina- tion of opium and antimony, which has been much praised by good and compe- tent 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-waistcoat: but this is a most unfortunate 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 eseape 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 difficulty 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 suffi- cient 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 exceedingly difficult to treat; and which require opiates on the one hand, and moderate depletion on the other. When the indications are uncertain, or equivo- cal, we must carefully weigh the different symptoms, and we must cautiously try the remedies. The circumstances that most distinguish the one form of the dis- ease from the other are to be found in the pulse ; which is hard and resisting in the earlier stages of inflammation 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; which 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 whether it has the buffy coat: and note the condition of the patient afterwards. In mixed or ambiguous eases 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 delirium 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 some- times thought that the recovery has been accelerated by the application of a blister 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 appear- ance whatever in the brain or its membranes. In other cases there is serous liquid collected in the interstices of the pia mater, or in the cerebral ventricles; and I have on several occasions seen the arachnoid thicker and less transparent DELIRIUM TREMENS. 259 than is natural, and sprinkled over vvith 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 inflammation in various parts and tissues of the body : in the blood-vessels, in the liver, in the kidneys, and in the arach- noid. We need not be surprised at finding that membrane thickened and partially opaque in the victims of delirium tremens; since they are chiefly men who have run a ldhg course of intemperance. I believe that disease to bear the same rela- tion, 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 per- sons 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 likely 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 animals 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 dis- order. 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.vvonderfully clever man. It is unfortunate that we are obliged to set off, against this advantage, a cor- responding danger, when the disease ends ill, of being blamed without our deserv- ing 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 ac- count. The man was about forty years old. He had been attacked some days 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 delirious, 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, with 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 hack- ney-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 for dissipation he had for some time been an habitual hard drinker; that he had frequent dealings with the coachmen to the various families which he fur- 260 DELIRIUM TREMENS. uished vvith horses ; and that he was obliged to drink something with each of them ; so that every day he had many glasses of spirits, and a good deal of porter. She told me, also, that his mind had been anxious and uneasy; that the business was a large and harassing 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 cha- racter 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 swallow 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 watchfulness. 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 appren- tice 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 con- sulted his books, and then came back again vvith 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 had offered lo 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 pa- tient 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 cannot be sure of that) if the opium had been persisted with, the case might have terminated 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 stertorously, 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 vvith whom I had first seen the patient—a very sen- sible man—was much concerned at this issue of the case, and observed to me thai doubtless our patient had been poisoned by the three grains of opium. I was able, however, to relieve his mind from this notion: and I have mentioned the case chiefly for the sake of guarding you against similar misgivings, under simi- lar 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 plaee 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 coining on of the comatose symptoms. Dr. Christison, in his elaborate and valuable work on Toxicology, states it as the result of exten- sive 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 postponed much beyond the hour, except, occasionally, when the person taking it was intoxicated at the time. In one re- markable 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 recom- mending 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 opiate, in smaller doses perhaps, had been steadily continued. DELIRIUM TREMENS. 261 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 Doctor, like Belinda's Betty-, is " praised for labours not his own."* 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 1 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 symptoms with the same morbid conditions, and of the same [* The account given by the author, of the character, phenomena, causes, and treat- ment of delirium tremens, is, upon the whole, so very judicious, that it would scarcely appear to demand any other comment, than one of general approval. But as there exists a very decided difference of opinion among American practitioners in regard to the proper management of 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 ex- tensive employment for a series of years, have been adduced, by their respective advocates, in evidence of the superior efficacy of each. One practitioner cures all or nearly all his cases by repeated emetics, another, by the free exhibition of alcoholic drinks, and a third, by opiates in free doses, continued at short intervals, until sleep is procured—while a fourth considers that 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 the stomach in the commencement of the attack, and some gentle cathartic to keep 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 ma- jority of cases, when judiciously and cautiously managed, the most promptly and effectually remove the symptoms of the disease. That the opiate practice has been abused, we are perfectly aware. Under the supposition that opium 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 may be ef- fected 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 cer- tainly and promptly arrested is opium admini.stered 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 confirm the 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 con- vinced from ample experience. In the practice of our preceptor as well as in our own, which has extended now beyond a quarter of a century, we have had sufficient oppor- tunities 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 complica- tion of the temulent delirium 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 down drunkard, it or the stimulant practice, is the only one upon which any dependance 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 we were disappointed in its effects. On the subject of the proper treatment of delirium tremens, 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] 262 DISEASES OF THE BRAIN. 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 present; 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 appa- rent irregularity. Doubtless there is some constant and uniform connection of cause and effect between the altered physical states of the brain and the altered manifestation of its functions: but we have not yet been successful in our search after those settled relations; or we have but partial and imperfect glimpses of them. One very remarkable condition of the brain has been several times mentioned in 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 toge- ther 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 co- herent, 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 soflened parts are thus easily distinguishable from those which 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 sec- tion through a part thus diseased, a portion of the softened brain adheres to the knife, and is removed by it, and a depression 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: you 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 soft- ened part: it is often caused, also, if I may say so, by its starvation ; by the dimi- nished supply of arterial blood, in consequence of diseased blood-vessels. Can we distinguish these two forms of softening from each other by their physical characters ? Why, sometimes, we can : and sometimes, it must be con- fessed, 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 convolu- tions, 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. RAMOLLISSEMENT. 263 If there be pus mixed with the softened brain, we know that there has been preceding inflammation. Again, if we find the arteries impervious, we conclude that the softening has not been inflammatory. Dr. Carswell states that the obli- terated 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 we 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 redness may be the result of inflammatory congestion; but cerebral hemorrhage may occasion softening; and, on the other hand, softening may give rise to cere- bral hemorrhage. This may be said, however; that the redness is seldom con- siderable 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 occupies 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 ihe softened part, we may regard the softening as the consequence of inflammation. And we adopt the same belief, vvith 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 peculiar to the advanced periods of life; whereas inflammatory softening may occur at any age; in child- ren, 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, vvith 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 relaxation ; the contracted limb has become utterly palsied. I believe that this is a valuable diagnostic symptom of softening, and especially of inflammatory softening—when it occurs. But it is often wanting. I wish 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 dis- tinguished 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 disturb- ance, but which terminate favourably. I will give you the general result of his experience in this matter as being untinctured with any wish lo reduce his facts into conformity with a preconceived opinion, or hasty generalization. He states that "the cases which terminate by ramollissement seem in general to be charac- terized 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 ihe very time of death." In another instance " there was no convulsion at all, but a sudden attack of palsy, exactly resembling the ordinary 264 DISEASES OF THE BRAIN. attack of hemiplegia from other causes." In two cases he found " ramollissement of very limited extent, in connection wilh symptoms of long standing, both cases being at last rapidly fatal by a sudden attack of convulsion." In other cases " there was extensive destruction of the cerebral substance, without either para- lysis 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 cavity, surrounded by cerebral matter in a healthy or in a hardened state. Now in suppuration occurring in the brain, there is the same puzzling diversity of symptoms as in cases of simple softening. Still, in the main, there seems an approach to the same order of symptoms; convulsions in the earlier period constituting the most prominent feature 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 con- tinued about half an hour: paralysis of the right arm followed the attack of convul- sion. 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 13th 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 again 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 head- ache, 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, vvith a rolling movement of the eyes ; the arm was in constant and violent motion. She was sensible and complained 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 60 ; 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 23d, was left in a state of permanent palsy. Hitherto no other parts of the body had been affected by the convulsion; hut on the 24th it attacked the right thigh and le£, 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 little 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 fetid 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 hemisphere, very near the surface; and the other immediately behind it. In the posterior part of the right hemisphere there was a small abscess containing about half an ounce of pus. There was no serous effusion 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 reasonable 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 INDURATION. 265 of permanent paralysis denotes the period of softening or suppuration, of complete disorganization, 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; comes 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, and contains but little blood, but is, on the contrary, distinguished by its pearly whiteness. That these changes are the result of slow inflammatory action is the more probable, because 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 partial induration 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 remit, and are again aggravated by paroxysms. These cases are the more interesting, because they offer 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 tumours, which also give rise to a great diversity of symp- toms. There are fibrous tumours which grow rather around the nervous matter than within it, and are 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. Scrofulous tubercles are also not uncommon: these are embedded in the nervous substance, and assume a round form, for the reason I formerly men- tioned, 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 children than in adults; and they are more commonly met vvith in the cerebral hemispheres than in any other part of the brain, occupy- ing 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 egg; and they are sometimes even bigger than that. The substance of the brain immediately surrounding these tubercles may be unchanged, in which case it is probable that the tubercles themselves give rise to no particular symp- toms, 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 softening, or suppuration; and then the ordinary consequences of these changes declare themselves outwardly. Cancerous tumours occur also in the substance of the brain. They usually occupy 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 neces- sary that you should be aware, for you may expect to meet with them frequently in practice. And it is right also that you should be aware that they do not dis- close 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, sometimes, from 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 symptoms which denote disease of the brain are caused hy 266 DISEASES OF THE BRAIN. scrofulous or cancerous tumours there situated; but from the symptoms them- selves, we can only learn that there is some morbid condition of the brain. I attended, recently, vvith Dr. Latham, a youth, whose symptoms led us to believe that he had tubercular disease of the peritoneum ; a very formidable com- plaint, which I shall more particularly describe hereafter* We thought it probable, also, although there were no physical signs of pulmonary disease, that his lungs contained 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 symptoms whatever indicative of organic disease within 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 few days afterwards with great violence, and he died. It was as we had conjectured. The perito- neum was found studded with innumerable miliary tubercles: there were a few crude tubercles, of some size, around 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 disease, simply by the evidence which had satis- fied us that scrofulous tubercles existed in other parts of the body.* 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 likely, 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 Characters; 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 children. 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 * [For a more full account of the present state of our knowledge in regard to tubercles ot the bram, see the Editor's Treatise on Diseases of Children, page 572.—C] HYPERTROPHY. 267 when she was somewhat recovered, she told us, for the first time, that she was subject to such attacks. The convulsions recurred on the same day, and she be- came 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 flat- tened, so that the little furrows between them were nearly effaced; 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 say that we should find some cause of strong pressure in the central part of the brain ; effusion 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 this examination, the state of the blood-vessels 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, fori had never seen nor heard of anything 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 pro- perly (as it seems to me) considered them as the result of hypertrophy of the brain. There is a very good memoir upon the subject, by M. Dance, published in the fifth volume of Breschet's Repertoire d'Anatomie: and Andral gives an account of the disease in his Pathology. It appears that Morgagni had not over- looked 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 with hydrocephalus, he had been surprised at finding a very small quantity only of fluid in the ventri- cles, 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 little red blood ; and sec- tions of it are seen to be unusually dry and pale. In several of the cases of hypertrophy of the brain recorded by authors, the patients had suffered epileptic fits, or rather paroxysms of convulsion ; and in some of them the convulsions terminated in paralysis. Andral states that the intel- lectual 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 un- due and disproportionate development of that organ may, and does happen, without giving rise to any morbid phenomena at ail. 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 considerably thicker, and more compact and heavy, than is usual; 268 DISEASES OF THE BRAIN. but the capacity of the cavity had not undergone a proportional augmentation: nay it might, for any thing 1 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 pro- bable 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 lo be aware that the brain, and its case, may be extravagantly developed without there being any disease, or any symptoms of disease. M. Scoutetten gives an instance of this which he observed in a child five 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 lines 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 mea- sure, 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 little 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 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 startings 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 abscence 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 fonta- nelle 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 arach- noid 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 different 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.* 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 * [For some further facts in relation to Hypertrophy of the Brain, the reader is referred to the Editor's Treatise on Diseases of Children, page 336.—C] ACUTE HYDROCEPHALUS. 269 cerebral 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 fmial state. In the other the change appears to take place in consequence of dis- ease, either in the membranes of the brain, or perhaps in its arteries; though the effect of disease in the 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 corpora 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 out by a large collection of fluid in the interior cavities of the brain, constituting the disease called chronic hydrocephalus. I have 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 peculiar or characteristic symptoms is what I have not discovered. I shall content myself, on this subject, with showing you Cruveilhier's repre- sentation 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 engrav- ing 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 cerebellum 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. In long- standing cases of this description you must 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 acute hydrocephalus has been given. By that term I desire to signify inflammation 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. 270 DISEASES OF THE BRAIN. 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 denominate 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 cause, 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 vvith 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 you will not *be surprised to learn that acute hydrocephalus furnishes a great variety of symptoms; and many variations in the mode of their coming on, and in their combination, 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, describe 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 are by no means always followed by acute hydrocephalus ; nor is acute hydrocephalus 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 capricious : he sometimes appears to dislike his food, and sometimes devours it voraciously : his tongue is foul, his breath offensive, his belly enlarges, and some- times 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-smelling, slimy, 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 de- jected ; his customary spirit and activity are gone; he gets fretful and irritable, and is manifestly uneasy ; and sometimes he shows a little unsteadiness and tot- tering 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, give warning also of the approaching malady. Now when this sort of alteration is observed in a child who has any hereditary title to scrofula, or bears the marks of the strumous diathesis, or is even a preco- cious and particularly clever child, and still more if he present any other indica- tion of strumous disease, there will be much reason to apprehend that mischief is brewing within his head. I advert to these tokens of scrofula, because the in- flammation, 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 as it occurs in an organ of very delicate structure, and one which is essential to life, its progress is more rapid, and it is more neces- sary 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, there- fore, 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 ACUTE HYDROCEPHALUS. 271 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 practical importance. Whether the disturbances of the nutritive functions cause the brain disease, or merely indi- cate it, they are equally valuable in directing our attention to the head. In these little patients any source of irritation seems to act as an exciting cause: surgical operations, which are sometimes necessary at that tender age—falls or injuries of any kind—painful dentition. There are, at least, three several ways in which this disease may make its attacks; and with these it is proper that you should be acquainted. In the first place, it may come on gradually; after such symptoms as have already been spoken of as being premonitory. Probably this is the way in which it most 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 in 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 children 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 posture, 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 ten 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, vvith 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 manner, is very like an attack of continued fever. You may find these varie- ties 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 com- plaints of the head and belly, alternating with stupor, or rather lowness, and un- willingness 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 vomiting 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 symp- toms, 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 certain 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 272 DISEASES OF THE BRAIN. other malady: presently after the disappearance of an eruption from the scalp; during the decline of scarlet fever, small-pox, hooping-cough, or any inflammatory or febrile complaint; and even after painful dentition. In these cases ihe 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 remembered, have divided the symptoms into groups, and considered each group as characteristic 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 almost 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 Edin- burgh Medical Essays), 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 ihe ground of his division. He makes three stages of it therefore; the first, in which the pulse is frequent; the second, in which it is slow and irregular; and the third, 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 German 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 vvith, makes four stages, according to what he believes to be the condition of the brain in each. First, he has the period of turgescence, which corresponds with that period in which the premonitory symptoms occur; secondly, the period of inflammation; thirdly, the period of effusion; 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. Whytl, by the state of the circulation, but by ihe state of the nervous system. Thus he calls the first the period of increased sensibility, when every stimulus produces an impres- sion 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 wiih him is that of palsy and convulsions, in which there is squinting, 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 first symptoms. The pulse is sometimes remarkably slow at the outset.; sometimes frequent through the whole, disease; and sometimes perfectly natural. I do not make these statements to magnify the difficulty of distinguishing the disease; for the diagnosis is really not so difficult as it has sometimes been repre- sented ; but to show you that you must not trust to any succession of symptoms, still less 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 fre- quently, " 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 an- noyed by light and by noise; the pupils are contracted most commonly during this stage; the child is unwillinar 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 vomiting, a total loss of appetite, a white tongue, offen- sive breath, costive bowels, unnatural stools, green often, or black, like tar, scanty ACUTE HYDROCEPHALUS. 273 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 excre- tion 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 inflammatory 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 lo 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, which 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 acute hydrocephalus corresponds, in its general features, with the period of collapse in encephalitis. The pulse becomes irregu- lar, 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 diminu- tion of sensibility, and general heaviness and stupor; the,pupils dilate, the light is no longer troublesome, 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 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 irri- tate the child—who lies on his back, vvith the eyes half closed, in a state of drow- siness or stupor, which is occasionally 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; para- lysis ; sometimes hemiplegia. The urine and stools are passed unconsciously. Sometimes the child, with feeble and tremulous hands, is incessantly picking his lips, or boring his fingers into his ears or nostrils. Tnis 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 con- tinually ; waves its hands in the air, or one hand, the other frequently being pal- sied ; sometimes there is paralysis of one side, and convulsive 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 pro- ducts 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 274 DISEASES OF THE BRAIN. place, yet the inflammation going on. And we may understand how the whole collection of symptoms may vary and fluctuate, and assume an uncertain charac- ter, according as the inflammatory process has ceased, or is still in progress; according as it exists alone, or is mingled with the further source of cerebral dis- turbance 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 pre- sence by appropriate signs in proportion to their place and extent, and their vari- ous kinds and combinations. What are these events ? In other words, what are the morbid appearances presented 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 com- monly 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 vvith in the strongly marked cases. When portions of the cerebral mass are removed by slicing 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 warrant any conclusion in respect to the state of the brain before death. We find these red spots numerous in many cases, where there had been no cerebral affection manifested during life ; and they are not always to be seen when we are certain that there was inflammation.* 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. Golis describes an instance of this kind, in which, he says, the fluid could be expressed from the cerebral substance as from a sponge.t But the most common and characteristic change is softening of the central parts of the brain, tvith an effusion of serous fluid into the ventricles. Generally the effused 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 effused is uncertain; speaking generally, it varies from two to six ounces.J But the effused fluid is not always clear and limpid ; sometimes it is turbid, * [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 exudation, or with numerous white flocculi, which become very apparent when the mem- nS?n, ,wmei m ^ IUS °ft? easi'y sePa™ted from the cerebral substance. The plexus choroides is very often injected, and thickened; sometimes, however, it is pale and tnlt^t Sil I'"'* W,"h TS h^datifo™ c?sts; this 'alter appearance has, also, been found in the cellular texture of the pituitary gland— C] „nt S tT, CaSCS 1^ Substanf of the brain has been found of a firmer consistence than IS *??£ VT&1\ef T hyPertr°P^d. A case is related by Golis, in which, upon Z r™Si™ Th' i r am exPanded> so that it could not again be replaced within Ihe skulL-6.] convoIutIons are ^nietimes flattened, apparently from pressure against ,-< LEr"y Casfsihhe arTunt of efflls,e * fluid is very trifling; in some scarcely a trace or fn the f n7 T ^uT ma>'takeFlac* « the arachno°id or sub-arachnoid tissues, ralW mlt 21/iT,"? *' ^ *?"* 3t the Same time' The greates< a">°™t is gene^ ally met with in the ateral ventricle-occasionally the quantity is so great as to enlarge free^SS, W "'I6 6Vate 'n6 1°™*' I??tare the SePtUm lucidum> and thus establish a ™vT^H & "? SetTn aU thC ™nutnC,6S- The cellular ^sue of the choroid plexus aS h£ r? Tth STm'- ^hen l,he Serous effusion in the bnun is consider- able, it is olten found also in the spinal canal__C] ACUTE HYDROCEPHALUS. 275 like whey, or even puriform, with flocculent shreds floating in it. These have been considered 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 neighbourhood ; for the septum lucidum, the fornix, and other parts form- ing the walls of the ventricles, are very commonly found soft, and pulpy, or en- tirely 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 figure, or falls asunder when the most gentle attempt is made to raise it. Dr. Abercrombie holds not only that this softness is the result of inflammation, which I think cannot reasonably be doubted, but that the inflam- mation of these central white parts 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 condition 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 relates two striking examples of this kind ; one of them was as follows.—A woman became affected vvith violent pain in her head, shooting from temple to temple. She was extremely restless, tossing from one side of the bed to the other; her eyes were slightly suffused, and impatient of the light; pupils contracted; the pulse 60, soft and rather weak. She was repeatedly bled, both generally and topically, and used purgatives, cold applications to the head, blistering, &c. For three days she was much relieved by these measures ; the violent pain was removed, and she complained of pain only when she moved her head. She was quite sensible, but oppressed, and inclined to lie without being disturbed. At the end of four days her speech be- came 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. Not unfrequently scrofulous tubercles are discovered in the substance of the brain; and it is probable that these would have been more frequently met vvith, if they had always been carefully looked for. They consist almost universally of a cheesy kind of matter, like that of large tubercles in the lungs.* 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 intestines. 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 * [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 matter, following it between the con- volutions ; occasionally, however, they occur in distinct patches of an inch or more in extent. They are commonly hard, semi-transparent, and of a grayish or yellowish colour. They are met with, also, imbedded in the gray matter of the brain, and are here 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, yellowish tint. The plexus choroides is, also, often covered with tubercles. They are very commonly met with, likewise, on the serous membranes of the thorax and abdomen, in the lungs, and occasionally in the substance of the liver. In twenty-seven out 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 tubercular 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] 276 DISEASES OF THE BRAIN. those which are observed in the voluntary muscles. The intussnscepted portions are easily pulled out, and show no marks of inflammation. There have been endless discussions respecting the true pathology of acute hydrocephalus, and it may be proper that I should offer you a few remarks upon this point, before I proceed to the treatment of the disease. 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 fans et origo mali— lies in the stomach, or bowels, or liver; and that the brain affection is secondary, and caused by sympathy with these distant parts: and this opinion they fortify by referring 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 faulty 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 inade- quate plan of treatment. The grand predisposing cause of acute hydrocephalus is certainly 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 affords 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 lo have strumous disease set up in various organs at once, or perhaps in succession ; 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 explanation of the cause of jaundice or of dysentery, when the liver or the colon was known to be diseased. I do not mean to assert that the morbid conditions of the brain and of the abdo- men 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 conse- quence of head affections, affords familiar evidence of the influence which cerebral disorders may exercise upon the abdominal functions. Conversely, any disease in other parts of the body may react injuriously upon the brain, and may some- times be regarded as an exciting cause of disease in that organ. The period of life is also a strong predisposing circumstance ; acute hydroce- phalus 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 insufficient nutriment, exposure to cold, inadequate clothing, impure air—may be regarded as a 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 en. It some- times supervenes upon the drying up or repression of eruptions, as tinea capitis, ACUTE HYDROCEPHALUS. 277 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 begin 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 manage- ment. Violent heating exercise has sometimes, apparently, kindled the cerebral inflammation. Among the exciting causes we may place all physical injuries which jar and stun the brain; blows on the head, falls from a height, although the head may not be the part struck ; 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 pregnancy may lead to the occur- rence of acute hydrocephalus in the child ; and he brings forward this curious fact in support of his opinion:—A large proportion of the children 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. Acute Hydrocephalus, continued. Prognosis and Mortality of 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 hydrocephalus, 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 early; 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 precursory 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, without its being possible for us to refute the assertion, that not all of the disorders 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 symptoms 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 decision on the part of the medical man ; and we are bound to act, in some instances, upon very slight indications; as when, for example, we perceive what we think 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 tell for 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. But this notion is refuted by plain and well- 278 DISEASES OF THE BRAIN. 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 violent, 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 disease is more likely to be amenable to 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 early 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 pro- ceeds 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 establish 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 in- crease 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 apparent 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 contract briskly under a strong light. The prognosis is especially bad when acute hydrocephalus supervenes upon other 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 we are warranted in the expectation of sometimes carrying our patient through this most perilous malady, I 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 recovered. He had seen upon the whole, forty-one instances of recovery from acute hydrocephalus. Dr. Mills, who has also written on the disease, has narrated twenty-eight cases, all of which died but seven ; and Mr. Bricheteau 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 rnostly those in which antiphlogistic measures were adopted early. 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 life, and the presence of the stru- mous 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, ACUTE HYDROCEPHALUS. 279 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 loss of blood, even to fainting, once or twice: but that their vital powers were apt to sink 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 pro- cesses, 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 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 efflux of blood must be stopped if syncope 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 suffi- cient one ; should produce some decided and manifest impression. 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 malady. You must afterwards go on with the leeches to the head, or you must withhold them, ac- cording 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 diminution of the fever, the previous strength and condition of the child, and so forfh. And let me once more admonish you that, as you have to deal, in general, vvith 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 inju- rious 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 bleed- ing has sometimes 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 alimentary 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 off the stress from the cerebral arteries. The best forms of purgative medicine to be used for these purposes with children, consist of calomel and jalap, or calomel and scammony ; and if these do not act freely, senna and salts must be given in aid of them. I have already made you acquainted vvith Dr. Abercrom- bie'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 temporary 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 abstraction of blood, that it prepares the way for the more effectual operation of aperients and of mercury. A large clyster will often be of service, both in settling 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 medicine by which he sometimes succeeded in quieting the 280 DISEASES OF THE BRAIN. irritable stomach, and procuring evacuations ; he would give a drachm or two of magnesia, saturated vvith lemon juice, every two or three hours. You may some- times get calomel and scammony, 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 follow- ing 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 140 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 350 grains of calomel (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 from 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, until the inefficacy 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 much 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 evaporation), upon the child's head, taking care to renew it frequently, 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 hope- less, retrieved by letting water fall in a small succession of drops upon the scalp, an,d continuing 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 disease. Knowing how powerful an influence it has in controlling inflammatory action, and that the inflammation in acute hydrocephalus often leaves behind it traces showing that it was of the adhesive kind, I should not omit giving mercury; but (as I 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 evi- dence respecting the efficacy of mercury carried to salivation in acute hydroce- phalus 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 termination. 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 life, 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 considered 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 ACUTE HYDROCEPHALUS. 281 of opium upon young children in general, and in the early period of head affec- tions in particular. The calomel should be given steadily, in equal doses, at equal intervals. Green evacuations from the bowels, resembling wet tea-leaves or chopped spinach, usually follow its continued administration; and this appear- ance (like the rising of the gums in adults) is generally regarded as a proof that the influence of the mineral is felt by the system, and that it is doing all the good 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 depletion, and the regulated exhibition of mercury in small quanti- ties, afford, generally, a better chance of success than the large bleedings, and the full and frequent doses of calomel, which have sometimes been recommended. Of blisters I may repeat the substance of what I stated when we were consider- ing encephalitis. I should 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 of the malady, I believe blisters are often of good service. They may be applied 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 unguentum cantharidis, or the ceratum sabinae. 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 extremely beneficial: two or three grains of Dover's powder furnish a very eligible form of opiate in such cases. I do not feel called upon to say any thing, in addition to what I stated in a former lecture, about other remedies that have been proposed in acute hydroce- phalus; 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 believe 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 purpose than trying now this and now the other remedy, because it is new, or because some persons tell you they have been wonderfully success- ful vvith it.* 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 which show decided marks of the scrofu- lous diathesis, the earliest attention should be paid to any deviation from the healthy condition of any of the functions. Weaned children in such families should be kept upon a nourishing but light and unstimulating diet; consisting of well-dressed vegetables, 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 * [When the disease has reached the paralytic stage, its fatal termination is usually sup- posed to be inevitable; but Dr. Christie, of Scotland, and Dr. Woniger, of Hamburg, have each recently 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 teaspoonful every four hours, at the same time that a weak ointment of the binio- dide of mercury was rubbed upon the child's scalp. Dr. Woniger gave a solution of one drachm of iodide of potassium, 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 commenced with, but in Dr. Woniger's case, not until after the end of seventy-two hours. In both the recovery is said to have been complete and permanent.—C] 282 DISEASES OF THE BRAIN. 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 be freely exposed to mild and dry air; and in winter great care should be taken to have them sufficiently clothed. During the hazardous period of dentition, the state of the teeth and gums must be sedulously attended to. There is good reason for 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 that organ. 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 in 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 rela- tion 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 directed against it. Encephalitis, whether it occur in the child or in the adult, has its spurious double. As, in morals, every virtue has its cor- responding 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 difference of character that lurks beneath external similarity of feature. It is a most curious, but unquestionable fact, that anaemia of the brain, a diminution of its natural supply of red blood, and ex- haustion of the nervous power, will produce symptoms very much resembling those which result from the diametrically opposite condition. To excess of pres- sure 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 by 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 uterine hemorrhage and so on—what do we see ? Why the patients may have nervous delirium, become convulsed, and then insensible, vvith 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 murderous in the other. It is the same with the functions of other parts: we have palpitation of the heart when that organ is insufficiently supplied with blood ; palpitation when it is over-loaded ; dyspnoea, 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. Aber- crombie, and the late Dr. Gooch—each of these three physicians appears to have discriminated for 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 SPURIOUS HYDROCEPHALUS. 283 their names. Dr. Gooch's Essay is entitled—"Of some Symptoms in Children erroneously attributed to Congestion of the Brain." His description of the dis- order 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 debilitatingcauses. The physician finds the child lying on its nurse's lap, unable or unwilling to raise its head; half asleep; one moment opening its 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 remarks 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, 'he bowels had been already disturbed by purgatives; the symptoms had invariably been attributed to congestion of the brain; and the remedies employed had been leeches and cold lotions to the head, and purgatives—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 befoi 3 them, the pupils unmoved on the approach of light, the breathing irregular and suspirious, the voice husky. These symptoms are sometimes preceded by irri- tability, 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/oic/ 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, vvith or without a relaxed condition of the bowels* The diarrhoea is often produced by improper food, and frequently succeeds wean- ing: or it results from the ill-timed administration of purgative medicine. The exhaustion from loss of blood generally follows the application of leeches, for some previous complaint—or for this very complaint 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 immediately, 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 unwillingness 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 weaned 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 (i. 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 neighbouring square, which had been treated vvith 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 off, 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 aromatic spirit of ammonia in a small draught every four hours. When we met me 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 284 DISEASES OF THE BRAIN. 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 intervals, 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 picture of the mor- bid 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 mixed 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 ambigu- ous, your judgment concerning the true nature of the case will be much aided by tracing the manner in which they came on, and the causes to which they seem to be attributable. In very young children—in respect to whom the question is most likely to arise—you may often determine between congestion 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 state of the unclosed fontanelle. If the symptoms proceed from plethora, or inflammation, or an approach to inflammation, 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 acute hydrocephalus, which is an inflammation. I have next to speak of chronic hydrocephalus, 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 yield to the increasing pressure, and the size of the head is aug- mented in various degrees; at the same time the cerebral functions are more or less deranged. This dropsy of the cranial cavity often commences before the period of intra-uterine life is completed, and the head of the foetus becomes so large, that it cannot pass vvith safety into the world. Accordingly, many of these infants perish at the moment when their separate existence commences ;—nascen- tes moriuntur. 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 the 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 dis- proportionate to the growth of the other parts of the body ; and enlarging, it be- comes misshapen also. The intervention of the membranous partitions' called fontanelles and open sutures, between the ununited bones, allows the centrifugal pressure of the gradually accumulating water to modify the shape of the head. These membranous interspaces are unnaturally wide, and more numerous than in healthy children. Nevertheless the process of ossification goes on, but the bones are extremely thin. We see little islands of bone in seas (as it were) of mem- brane. 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 CHRONIC HYDROCEPHALUS. 285 closed up, its surface exhibiting an unusual number of joinings ; there are many ossa triquetra. 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 slant- ing 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 flat- tened 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 thence grow no faster than usual, perhaps not even so fast; and the disproportion that results gives an odd and peculiar 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 is broad, and the outline of the features tapers towards the chin. The visage is triangular. This great disproportion of size between the head and the face is diagnostic of the disease, and would serve to distinguish the skull of a hydrocephalic child from that of a giant. Heartless parents sometimes make a wretched profit of the deformity. A penny show of that kind existed very re- cently in the immediate vicinity of this College. When, after death, 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 accumulated 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 cavity which should contain the nervous pulp is filled up by a thin pellucid fluid. From some unknown cause, operating during the period of intra-uterine life, the pro- gressive formation of the brain has been arrested. Marks of imperfect develop- ment 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 perhaps, is pinched up into a conical peak, and has con- siderable thickness. They are obviously hopeless cases. To the physiologist they are subjects of much interest; for the practical physician they have none! But in the majority of instances, when the infants survive their birth, the liquid is contained in the central cavities or ventricles of the brain, which are expanded into one. The convolutions are unfolded, and the cerebral matter is spread out into a hollow 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, however, is more apparent than real; the two conditions are sub- stantially 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 introduced within it; while in the other case the seams, or commissures (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 up- wards, and seem to constitute the summit of the cerebrum. This was the state of the parts within the immense skull from which the largest of the casts before 286 DISEASES OF THE BRAIN. you was taken. It belonged to a man named Cardinal, who died in Guy's Hos- pital, in 1825, and of whom Dr. Bright has given a very interesting 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 un- wieldy head is too much for the muscles of his neck to sustain without fatigue; or even, when they are unassisted, to sustain at all. He walks gently and care- fully, like a person balancing a heavy load upon his head ; or he holds and partly carries his head 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 effects 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 defective 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 in- fancy. Still, a few survive, bearing their complaint to the adult period, and even to old age; and in some of these individuals who, vvith excessively large heads, have yet numbered many years of existence, the intellect and the senses, if not entire and perfect, have been sufficiently 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 of a hydrocephalic girl, six years old, whose head measured two feet four inches in circumference. She is described by him as being " as lively and sensible as most of her age," and as " having a strong memory." Dr. Bright'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 appeared 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 years 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 di- gestion good. Dr. Bright states that his mental .faculties 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 vvith 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 go on so well, when the machinery through which the mental powers are manifested— the instrument whereon and whereby the immaterial principle mysteriously ope- rates—is so palpably and greatly deranged ? How comes it that life, and espe- cially 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 CHRONIC HYDROCEPHALUS. 287 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 has 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 the one hand, nor, on the other, induces coma, or convulsions, or idiocy, by its compression. Most commonly, however, the mental and voluntary functions are maimed or perverted; 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 subject in the last lecture, that the head may be extravagantly large without dropsy of the brain and without disease. We have just seen that, while the brain itself is gradually unfolded, or its hemispheres are parted and turned aside, by the liquid accumulating within the cranium, the functions of the organ may 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 symptoms arise, or the defects that have previously shown themselves are aggravated. Hence that period of life becomes a perilous period, at which the skull, by the closure of its fontanelles and sutures, loses its capability of further expansion. In some rare cases, the closed sutures re-open under the augmenting pressure, and a respite is thus obtained. Dr. Baillie has recorded an instance in which this happened 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 ao-e. The sutures of his skull separated again after having been united; and it was re- marked that the teeth in the jagged edges, whereby the bones interlock with each other, were much fewer than is usual. If this be always so when the sutures give way, it will serve to facilitate our understanding how such a separation can take place. The skull may, however, go on expanding, although the sutures are per- manently closed; there still being left intervals between the several points of ossi- fication, which intervals are covered by membrane only. The beautiful preparation on the table, showing this remarkable state of the cranium, I have borrowed for your inspection from Dr. Sweatman'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 circumstance, and the symptoms it is apt mechanically to produce, form the only differences between the disorder as it affects the child and the adult. In both cases disturbance of the cerebral functions arises, and at length convulsions or coma closes the scene. In both, a dropsical state of the ventricles of the brain constitutes, often, the 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, forgetful, 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. Baillie 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 «ide of the body; and for eleven months before his death had lost the recollection of his own language, vvith the exception of four or five words, which he employed, with different intonations, to express his vari- ous wants. The celebrated Dean of St. Patrick's afforded another instance of the same 288 DISEASES OF THE BRAIN. disease, attended with a similar interruption of the power of discoursing. The case, as related in Sir Walter 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 favour? " 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 phy- sicians that 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 1745, in a state of silence, with few and slight exceptions ; and died in the 78th year of his age. Golis 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 phy- sician at Vienna, likewise died in the decline of life, having suffered 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 number of recoveries to forbid our despairing in any case, and to make it incumbent upon us to employ carefully all those measures which have occasion- ally brought the disease to a favourable termination. Golis even affirms, that of the cases which began after birth, and which he saw and treated early, he was fortunate enough to save the majority. LECTURE XXVII. Treatment of Chronic Hydrocephalus ; Internal Remedies: Mechanical Expedi- ents ; Bandages, Tapping. Symptoms of Spinal Disease. Inflammatory conditions of the Spinal Marrow. The cure of chronic hydrocephalus may be attempted by internal remedies, or by external mechanical expedients, or by both. The internal remedies by which most good appears to have been effected, 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 quanti- ties 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 woolen cap. Infants 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 fallowed 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, wilh the former reme- dies : 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 CHRONIC HYDROCEPHALUS. 289 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 considerable 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 adminis- tering mercury successful. I will give you them nearly in his own words. In the year 1817, he had under his care a lad, named Scott, labouring under chronic hydrocephalus. He had been ill two or three years, was nearly blind, had very little use of his lower extremities, and could not walk across the room without support. He suffered violent pains in 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 blue pill, drastic purgatives, and ordi- nary diuretics, tried in combination and succession, gave him temporary relief; but no permanent benefit was obtained. Dr. Gower then suggested a plan which he had himself found successful in such cases, and which had first been used by Dr. Carmichael Smith, who had recorded ten cases of recovery under its adop- tion. Dr. Gower's plan was to rub down ten grains of crude mercury with about a scruple of manna, and five grains of 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 the fresh squills, making the whole into the consistence proper for pills with liquorice powder. The patient took this dose three times a day, for nearly three weeks, without any ptyalism being produced. Its effects were great pros- tration of strength, and loss of flesh, with gradual relief of all the boy's sufferings. 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 ordered an ounce and a half of Griffith's mixture thrice daily; and soon regained his health and strength, and 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 years old, and afflicted in nearly the same manner as Scott, except that the pain in his head was more acute, and caused violent screaming: relief had been repeatedly given for a time, by cupping. The physician in attendance was un- willing to try the plan, when it was proposed to him, but said that he would give what was equivalent—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 effects of the mercury having subsided, and the patient then suf- fering 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 conse- quence. It acted, as before, without producing ptyalism, but with a great reduc- tion 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 what maybe 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 opportunity 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 formulae. 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 Edinburgh 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 19 290 DISEASES OF THE BRAIN. 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 stales of the encephalon, very dissimilar in their essential character, yet having some symptoms 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 whereby these inverse conditions, requiring contrary remedies, may be discriminated. Bandaging the head is one of these two expedients; puncturing 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 con- taining 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 increase of pressure is hurtful. The middle point of safety it may be hard to hit. 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 the safety of these patients. If the skull did not expand as the water gathered, morbid symptoms would ensue. Great nicety must therefore be requi- site in the use of this remedy. While the head is palpably enlarging, compres- sion by means of plasters 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 support. 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 applies strips of adhesive plaster, about three-quarters of an inch wide, completely round the heads from before backwards: 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 stra- bismus, 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 compression alone may be equal to the cure. To such cases, Dr. Anion's air-press would seem, from the facility with which its equable compress- ing force may be regulated, to be especially adapted. drachms, and half an ounce of suet. Dr. Hannay remarks, that the application of this liniment, three or four times a day, is followed in about thirty-six hours, by a papular and vesicular eruption; and he is of the opinion, that as chronic hydrocephalus often succeeds to the suppression of eruptions on the scalp, the use of this counter-irritant will 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] CHRONIC HYDROCEPHALUS. 291 But in children who are not of this pale and feeble habit, and in whom ossifi- cation of the skull goes on, the period when the walls cease to yield is the period of danger. The water continuing to accumulate, inordinate pressure begins to lake 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 quantity of 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 effectual, of emptying the distended cavity, has therefore been earnestly sought after; and the second mechanical expedient of which I have spoken offers a very sure method of attain- ing this object. He must have been a bold physician 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 Uas received particular attention in this country of late years: and though tapping the brain in chronic hydrocephalus has been denounced as useless and cruel by some high continental authorities, 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 safety, for the operation itself is attended with the present risk of accelerating the patient's death. Other means, however, failing, 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, whose life, without it, could scarcely be long continued, or capable of enjoyment: 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 lo be looked at. Of the three, the second is, in my judgment, incomparably the worst; and if the case were my own, if I had to decide the painful 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 sup- pose ; provided that the operation be skilfully and cautiously performed, and only a moderate quantity of water drawn off at a time. That even a very rough ope- ration is not necessarily fatal we learn from a singular case related by Mr. Great- wood. A child, fifteen months old, afflicted vvith chronic hydrocephalus, fell down, and struck the back part of its head against a nail, which penetrated the skull. Above three pints of water gradually 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 suc- cess it has had. There is an account of the performance of this operation by Lecat, in the Phi- losophical 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 cranium. 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 inte- resting 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 a couching needle. Upwards of three ounces were on that occasion evacuated ; and it was estimated that about the same quantity dribbled away afterwards. The child thereupon became very 292 DISEASES OF THE BRAIN. weak, but was presently revived by some cordial medicine. About six weeks afterwards, the liquid having collected again, an opening was made with a bis- toury, and eight ounces were removed ; and nine days after that, twelve ounces more, without any bad consequences. The head diminished in size, the patient got apparently well, and the case was published as a successful one. Unfortu- nately, 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 affected with strabismus, and a perpetual rolling of the eyes. The usual routine measures, compression among the rest, had been employed without any success. By four operations performed at intervals of about ten days, the size of the head was con- siderably 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 dimensions of the head were less, by four inches in circum- ference, 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 chil- dren for this complaint, and in ten of the nineteen cases the children survived. He introduces a small trocar through the coronal suture below the anterior fonta- nelle, 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 puncturing. 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 total quantity of water removed was fifty-seven or fifty- eight ounces by five successive tappings. This expedient, therefore, though doubtless hazardous, is really a valuable one. The rules relating to its performance may be briefly 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 ; rpendicularly to the surface, at the edge of the anterior fontanelle ; so as to be as much as possible out of the way of the longitudinal 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 weak, 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. Gentle com- pression should be carefully made to compensate, in some degree at least, the pressure that has been removed vvith the fluid. Should the infant become pale and faint, it must be placed in the horizontal posture; and a few drops of sal volatile, or of brandy, mixed with water, may be given. Sometimes slight inflam- matory 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 subdue 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 that 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 per- CHRONIC HYDROCEPHALUS. 293 pendicular 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 pre- sently became deadly pale and faint. A verdict of infanticide by misadventure 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 wish to have it repeated ; 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 downwards ; 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 disappeared. Three ounces more were taken away the next day. For two days thereafter all the symptoms appeared to be mitigated; but the skull was flaccid ; yielding, 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, before midnight, 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 nie to draw any comparison between the merits of com- pression and of paracentesis, as substantive remedies. They are opposite mea- sures, 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 employed in the same case, in succession, according to its varying circumstances. If the walls of the head be tight and firm, the trocar should precede the bandage ; if lax and movable, compression should be cau- tiously tried, and followed, if need be, by the puncture.* I have now done vvith the inflammatory affections of thebrain: in conjunction with which I have also considered some other morbid conditions, that are either connected with inflammation of the contents of the cranium, or resemble it in some of their phenomena. Thus, T have spoken of delirium tremens, which is apt to be mistaken for inflammation of the brain : of softening 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 some- times is the sequel, sometimes the precursor, of acute hydrocephalus ; and has other points of analogy with that disease, the encephalitis of children.! * [Dr. Whitney relates, in the Edinburgh Med. and Surg. Journal, an instance of the successful puncture of the brain in a case of chronic hydrocephalus. By the first opera- tion, 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 ihe child appears to have been complete. Two cases are related by Pro- fessor Wutzer, and Dr. Butcher, in the Austrian Medical Journal, in which the puncture of the brain was unsuccessfully employed. In the first, a child seven months old, death occurred in six days after the first operation; in the second case, of a child sixteen months old, the operation was repeated, after an interval of four weeks, and seven weeks after the second puncture, the child died in convulsions.—C] f [Meningitis encephalica.—Under this name, Dr. Brockman has recently described a 294 DISEASES OF THE BRAIN 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 inte- resting ; 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 difficulties with which I showed you in a former lecture that the entire subject of the diseases 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 expense of 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 peculiar form of cerebral disease incidental to childhood, 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 frequently as an idio- pathic affection. ft is sometimes associated with general disease of the braini at others, it is uncompli- cated. Notwithstanding, in its earlier stages, it is unattended by any serious symptoms, it is an affection fully as dangerous as cerebral meningitis. The first stage, or that of simple hypersemia, 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 intole- rance 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 the occiput is augmented ; the head becomes retracted, as in the ordinary cases of acute hydrocephalus; and convulsive twitchings of the limbs occur, similar to the effects of light electric shocks, which recur every few 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 condition of the pupil; the peculiar air of stupidity that character- izes hydrocephalic patients is wanting. Two pathognomonic symptoms, however, indicate the occurrence of the stage of effusion. One of these is deafness; the other difficult arti- culation, and difficulty in moving the tongue—both of which occur at the same time, pro- bably 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, the 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 ij! often preceded by various singular nervous phenomena—as sudden pauses in the respi- ration, or equally sudden syncope. In some cases, however, the paralysis does not follow, but the anomalous symptoms subside, and the patients gradually recover; until, indeed, the paralytic stage is fully established, the recovery of the patient is still possible. In the uncomplicated cases of the disease, upon examination after death, the cerebrum in general, presents an extremely pallid and anasmic condition, in striking contrast with the cerebellum, the vessels of which are turgid with blood, while its substance, also, is often in a state of marked hypersemia. The hyperEemia increases in intensity towards the central portions of the encephalon; and the membranes covering the pons varolii and medulla oblongata are found in a most decided state of inflammation; the portion of in- flamed membrane is perfectly isolated, and not more, usually, than a square inch in extent —the membrane of the cerebellum being entirely free from any indications of inflamma- tion. 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 effusion 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. Brockman, in its first two stages, is depletion, by leeches to the posterior part of the head, cold applications to the scalp, and the free admi- nistration of calomel, which latter may be continued during the stage of effusion. Here, however, 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 maybe required. According to his experience, powerful counter-irritants, as a large blister, or the actual cautery, prove, aJso, sometimes beneficial.—C] AND SPINAL CORD. 295 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 voluntary motion ensues in all those parts of the body 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 vary 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 intercos- tal muscles and the diaphragm have at all times the main share in carrying on the mechanical actions of respiration; and probably they execute the whole action in every case of ordinary breathing. Now the intercostal muscles are furnished with motor nerves from the spinal cord, all along the dorsal vertebra?; 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 independently of the will. The pneumogastric and trifacial nerves, with respect to them, are excito-motory nerves, and call into play a reflex power which is transmitted from the medulla 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 as though the access of air to the lungs had been suddenly prevented by a ligature drawn tightly round his wind- Pipe- Again, when a segment of the cord, however small, is disorganized in its cer- vical 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 fall; 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 feeling 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 com- munication with the brain, the excito-motory 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 296 DISEASES OF THE controlling influence of the sensorium is withdrawn. All of you have probably seen the, limbs 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 mani- festations 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 vertebral column. He was totally deprived of the power of moving his lower extremities. 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 appa- ratus 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 knowledge 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 cord 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. 5. Under the sagacious researches of Dr. Marshall Hall, the physiology, and with it the whole pathology, of the spinal cord is undergoing, at this very time, a complete reformation. I know of no modern discovery so fruitful of important practical consequences, or so likely to improve our remedial management of ner- vous disorders, as the singularly interesting truths which he is even now engaged in demonstrating and enforcing. I do not profess to teach you this new physi- ology. I touch only, as I pass along, upon some of its cardinal points, to which I may have occasion to refer in future. We are considering how the signs of spinal disease may vary according to the particular location of that disease; and I would have you remark, here, that inasmuch as all the acts of ingestion and ex- pulsion, all the inlets and outlets of the body, are governed by the spinal marrow, with its corresponding apparatus of incident and motor nerves—it is to be ex- pected 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 likely to disturb the natural functions of the lower orifices—the rectum and anus, the bladder and urethra, the os uteri—which are chiefly outlets. 6. 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 func- tions ; the anterior roots being composed of motor fibrils, the posterior of sensi- ferous. 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 per- haps, 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, through- * This very interesting case has since been published, in detail, with several others resembling it, in the 22d volume of the Medico-Chirurgkal Transactions. SPINAL CORD. 297 out their entire extent; 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 por- tion of the cord, in its whole length, from the pons to its lower end, was of a dark-brown colour, and extremely soft and tenacious. The anterior half, in its entire length, exhibited its natural whiteness and firm consistence. The roots of the spinal nerves were unaltered. 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 mag- num. In this manner a cavity is produced betwixt the membrane and the inner surface of the spinal canal (external, i. e., 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 immediately covering the cord), communicates freely vvith the cavity of the cranium ; so that fluid may pass easily from one to the other, according to the position of the body." I shall pursue the same order, in speaking of the inflammatory affections of the spinal cord, as I followed in respect to the analogous conditions of the ence- phalon. And, first, let us inquire what 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 com- mon. Usually, when we have meningitis of the cord, we have the same disease also within the cranium; usually, also, with meningitis of the cord, we have more or less inflammation of the nervous matter composing it. The commonest symptoms of inflammation of the meninges of the cord (for I do not pretend to speak of the several membranes separately), appear to be pains, often intense, ex- tending along the spine, and stretching into the limbs, 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, back, and abdomen, as if those parts were girt by a tight string: feelings of suffocation: retention of urine: obstinate constipation: and with these symptoms, rigors 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. 298 DISEASES OF THE 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 occasional 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, vvith pain of the forehead and occiput, disturbed sleep, and loss of ap- petite, 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 abdomen, and had much pain and difficulty in passing his urine. About the end of the second week in April his sufferings 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 16th, he went to take a warm bath, walking down three stairs, and into an adjoining street, with little assistance. His speech afterwards became some- what affected : there were convulsive twitches of his face, and difficulty of swal- lowing. Some transient squinting also was observed. The pulse was now very frequent. On the 18th, while sitting in a chair, he suddenly threw his head back- wards vvith great violence, fell immediately into a stale of coma, in which 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 the most healthy state. Some gelatinous deposit was found under the medulla 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 sub- stance 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 Olli- vier's Treatise on the Spinal Marrow. The prominent symptom was generally pain, referred to some part of the spine, and increased by motion; and what is curious, 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 softening of the cord itself. Constantly there was increased sensibility; a circumstance which Ollivier thinks calculated to distinguish inflammation of the membranes from inflammation of the substance of the cord; the latter being usually attended vvith diminished sensibility. In the case that I have quoted from Dr. Abercrombie, the intense pain underwent no remission or abatement. In one of Ollivier's examples, there was at the commencement of the disease, a striking intermittence of the pain; it came on with intense severity at ten at night, and lasted till three in ihe 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 wagoner sitting on the shafts of his cart, was thrown off by a sudden jerk, and SPINAL CORD. 299 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 followed 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 vertebrae, 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 pres- sure it occasioned. 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 cerebral matter. Softening—induration—suppura- tion. I need not, therefore, again describe the physical characters of these altera- tions. The symptoms which flow from inflammation of the nervous pulp of which th<3 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 impli- cated. 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 the 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 arrangement of symptoms as the following. Convulsive affections 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, involun- tary stools: and with respect to the voluntary muscles corresponding to these parts of the spinal marrow, convulsions, or palsy; or palsy succeeding to con- vulsions. I must again have recourse to examples, to put you, more fully than any attempted abstract picture could put you, in possession of such forms of inflam- mation of the cord as you may expect to meet vvith in practice. A man, fifty-six years old, was exposed to severe cold, while traveling on the outside of a coach. After this he was attacked with pain in the right arm and leg, most severe about the shoulder, but affecting the whole side, and he had also con- siderable headache. He soon perceived some loss of power in the affected limbs ; and the progress of this was very curious. It began at the upper part of the arm, and extended downwards so gradually, that he was able to write 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 commencement 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 left arm became paralytic, rather suddenly ; but it was not so completely motionless 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 300 DISEASES OF THE got feebler and rapid : he then fell into a state of stupor, muttering incoherently, but answering questions distinctly when he was roused. He lost his speech a few hours before death. For the last eight or ten days there had been considerable sloughing of the sacrum. The brain was found to be healthy throughout. Much bloody fluid was dis- charged from the spinal canal into the cavity of the cranium before the spine was laid open. On displaying the spinal 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. (Abercrombie.) 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 mem- branes : we find also, that stiffness and spasm of the muscles marked the menin- gitis ; palsy, the inflammation of the substance of the spinal cord. In neither of them were the intellectual functions disturbed till towards the last. I believe that the characters now pointed out belong to these forms of disease respectively. I shall take, from the same store-house, one more case, in which both the membranes and the cord were simultaneously inflamed; and which, therefore, was analogous to encephalitis. And I quote it the rather because it possesses one or two points 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, accompanied 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 shil- ling, 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 seated among the lower dorsal vertebrae, and extended downwards in the course of the ureter, with a frequent 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 were perfect palsy of both thighs and legs, without loss of feeling, retention of urine, and involuntary stools. He had still some pain in the lower part of the dorsal region. He died at length, on the 14th 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 anaesthesia. 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 whole 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 anterior 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 >vhich the power to move the limbs is transmitted, while their sensations are car- ried 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, but they ought not to discourage you. That time, and our advancing SPINAL CORD. 301 science, will at length explain and reconcile them, I cannot doubt. Meanwhile they teach a lesson which many practitioners much need—viz., that it is unphilo- sophical 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 shall 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 displaced. 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 vertebral canal, independently of external injury; simply be- cause 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. Bartholomew's Hospital; and I will state very briefly the particulars of one, as an exemplar. In the year 1820, 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 showed, however, no trace of injury. When picked up, he was found to be powerless, 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 phrenic and intercostal nerves. . He suffered pain about the middle part of the neck behind. He went on exceedingly well for four or five days, and then the nurse very fool- ishly acceded to his request to be turned on his side, which caused his death in a very few 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 portion of the spinal column. Among other remedial measures, the sur- geon 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 convenient 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 cer- vical vertebrae were dislocated from each other without any fracture: a thing which has sometimes been pronounced impossible. The articular processes were fairly separated; and the vertebrae 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 enlargement 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; 302 DISEASES OF THE BRAIN. 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 overflows 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 paralysis 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 quality, under this state of palsy. The urine becomes thick, ropy, and alkaline, and exhales a very offensive ainmoniacal smell; and the inner surface of the bladder is found, after death, to be thickened, red, and covered with adhesive mucus—in a state of chronic inflammation, in short. LECTURE XXVIII. Inflammatory and Structural Diseases of the Spinal Cord, continued. Treat- ment. Apoplexy. 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 sys- tem. 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 that portion, from centre to circumference, will be likely 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, extin- guishes life by stopping the actions of respiration. A similar interruption in the cervical part of the cord, above the origin of the intercostals, but below the origin of the phrenic nerves, destroys life as certainly, but not so rapidly, nor in exactly the same manner. We find the lungs loaded with frothy serous fluid in such 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 vertebra? 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 fhe 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 posterior columns alone will be likely to alter or abolish the faculty of sensa- tion in the corresponding parts : to cause pain, tingling, numbness or complete anaesthesia. But I have mentioned certain facts which contravene this opinion. Suspend your judgment 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 affecting the lateral half only of APOPLEXY. 303 the cord will be likely to derange both the sensibility and the power of movement, in the corresponding parts 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 membranes of the spine is most apt to declare itself by pain, increased 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 anaesthesia. 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 diffused and mixed vvith 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 recommended in inflammation of the brain and its membranes. When the inflammation is acute, we must take blood freely; from the arm, or by cup- ping-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. Per- fect rest in the horizontal posture 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 especially 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 I 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 with the skin, to the great increase of his suffering, and of his danger. Indeed, take what pains we may, there is generally 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 distri- buted 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 the 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 paraly- sis, without fever or what is called reaction ; and that the locality, and extent, and effects of the paralysis, 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 affections: and especially to cerebral hemor- rhage, and spinal hemorrhage. When a person falls down suddenly, and lies without sense or motion, except 304 DISEASES OF THE BRAIN. 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 unna- tural 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 men- tioned already in these lectures : 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 respira- tion ; while the functions of organic life, and especially of the circulation, con- tinue 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 medulla oblongata, the involuntary 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 of a narcotic poison ? If you were summoned to a person in the state I have been describing, how could you tell whether he was affected with apoplexy, or labour- ing 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 discri- minate the one from the other. In each case there is profound coma; but the cause of the 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 of 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 smelt the smell of gin in his mouth; and thereupon very pro- perly 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, however, 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 afterwards the patient began to recover his senses. It turned out that he had partaken more APOPLEXY. ' 305 liberally 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 liking to introduce 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 ser- vant came to open the door, his master tumbled senseless on the floor. I need not point out to you the ridicule which the physician would have brought upon himself, and the damage he might have inflicted upon his patient, had he busily applied, 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 occurrence 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 undergo some great alteration. It is still more probable (to my mind) that a temporary stress upon the cerebral blood-vessels (produced by a de- termination of blood towards the head, through the arteries, or by a detention of blood in the obstructed veins) may really exercise pressure enough to cause tran- sient coma. But these are mere conjectures. In the second place, the apoplectic coma may terminate, more or less quickly, in death. And on examining the brain, we may find a large quantity of extrava- sated 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 unfrequently, 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 less crippled in body, and more or less maimed in intellect. In these cases, when at length we have an opportunity of examining the brain, we almosj 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. Occasionally, instead of a clot of blood, we meet vvith circumscribed softening of the brain. The attack of apoplexy does not always occur in the same manner: and Dr. 20 306 DISEASES OF THE BRAIN. Abercrombie has pointed out three several ways in which it is apt to come on. I 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 someof 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 uncertain. 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 paralytic of one side, and with some imperfection of speech, or of one or more of the senses. And this paralysis and imperfection may dis- appear in a few days, or gradually subside, or remain for life. In the second form of the attack, the coma is not the earliest symptom. The disease 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 state 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 to 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 intances, 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 very beginning some loss of sense or motion, it goes off again in a very few minutes, or perhaps in a few seconds: the prominent symp- tom, at the commencement, is sudden and violent pain in the head, with faintness, sickness, and often vvith vomiting. The pain continues, and is sometimes con- fined 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 posses- sion of his intellect. At length he recovers his natural temperature, his counte- nance improves, and the pulse becomes stronger and steadier: then his face gets flushed, he feels oppressed, answers questions 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 inspec- tion," says Dr. Abercrombie, " we find none of those varieties and ambiguities, which^occur in the apoplectic cases, but uniform and extensive extravasation of blood." [I should state that he calls the first class of cases apoplectic cases, the • APOPLEXY. 307 coma being present from the first: and the second class, which we are now con- sidering, 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 circulation 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. Abercrombie'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 apo- plexy. Dr. Abercrombie conjectures 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 the 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 sen- sible, listens to and comprehends your questions, and answers them as well as he is able, either by 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 some- what 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 apoplectic 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 apo- plectic 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 inflam- mation and its consequences. In a vast majority of cases, I repeat, this sudden hemiplegia marks 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 dis- 308 DISEASES OF THE BRAIN. tinction, 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 interest 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 Us assault. I will next say something of the persons who are most liable, caeteris 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 impend- ing. 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 approach- ino- 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 pre- cede and herald the attack of apoplexy. The classes of persons in whom, caeteris paribus, attacks of apoplexy are especially 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 shape 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, i. 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 come of an apoplectic stock are themselves more than ordinarily liable to apoplexy. 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. Caeteris paribus, corpulent 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 appearances presented after death by apoplexy. The disease begins to be com- mon after 50 : but it does sometimes occur even in young children. I am speak- ing 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 ex- amined by Rochoux (who has written a very good treatise on this affection), two only happened between the ages of 20 and 30 ; eight between 30 and 40; seven between 40 and 50 ; ten between 50 and 60 ; 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 little further : it appears that of the sixty-three cases 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 and 80. And from this fact Rochoux has drawn, I conceive, an erroneous conclusion ; and I mention it that, in case his treatise falls in your APOPLEXY. 309 way, you 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 depended 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 vvith apoplexy between 70 and 80 than between 60 and 70. All these three kinds of predisposition are beyond our power. We cannot ex- terminate the hereditary tendency; nor remodel the plan upon which the body is constructed ; 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 ex- ercise more or less control. One of these I referred to just now—the kidney disease discovered by Dr. Bright. Disease of the cerebral blood-vessels is a very common and a very pregnant circumstance of predisposition. I shall revert to this when I describe more par- ticularly the anatomical characters of cerebral hemorrhage. Diseases of the chest influence very materially and injuriously the circulation in the head. Without going into detail respecting complaints vvith which lam obliged to suppose that you are as yet unacquainted, I may state, by anticipation, that impediments to the free transmission of blood through the heart and lungs constitute the mode in which thoracic disorders predispose to apoplexy. The plethora capitis produced by such impediments is frequently visible in the turgid and livid features, and in the distended jugular veins. The cessation of habitual discharges, of the catamenia, of bleeding piles ; the drying up of old sores ; the healing of long established issues and setons ; all have an unquestionable tendency, by causing or augmenting plethora, to generate a predisposition to apoplexy. And large observation of the habits of those who fall victims to this terrible malady, leaves no room for doubling that intemperance often paves the way for its invasion. The continued abuse of ardent spirits, in particular, lays the founda- tion 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 apo- plexy : 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 apoplectic attack. Vertigo itself, even without headache, is a very common precursor or warning 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 310 DISEASES OF THE BRAIN. seconds or minutes, is another of these warning symptoms. The late Dr. Gre- gory, of Edinburgh, 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 striking case of the kind on record. Dr. Ferguson expe- rienced 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 delivering 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; atone time corpulent and very ruddy, and, though by no means intemperate, he lived fully. I say he did not attend to these admo- nitions ; 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 ninety-three; up- wards of thirty years after his first attack. Sir Walter Scott describes him as having been, " long after his eightieth year, one of 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 peculiarity 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 philoso- pher which could be seen in modern days." This anecdote, which I have made use of as a wrapper for some medical in- struction, 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 apoplexy. Double vision is one form in which such limited palsy is apt to show itself. It is evidently connected vvith 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. Gregory was acquainted with a sportsman who one day, when out shooting, disputed vvith 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 inarticu- late mode of speaking. The rapidity of the movements of the tongue requisite for distinct utterance is so great, that the slightest weakness of any one of its muscles is rendered obvious. We see this in one very common 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. "Clipping the King's English" 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 affected by ine- briation in different persons ; the same sets being always the first affected 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 APOPLEXY. 311 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 them- selves, 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 solitary muscle, as of the levator palpebrae. 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. Sometimes, on the contrary, the patient stares at you, frightfully, wiih one eye, which he cannot shut. The numbness also assumes various characters, according to its place and de- gree. One patient will tell you that he feels as if one of his limbs was muffled in flannel; another, 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 pre- cursory 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 of thought. Thus one very deplorable warning is the loss of memory. All persons find, as they grow older, that they do not retain so tenaciously in their recollection things which have recently occurred, as things which happened when they were young. This partly depends upon the degree of attention which we pay to dif- ferent circumstances. 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 something more than this. It is sometimes partial, and extends to certain sets of things only. For example, some persons entirely forget certain words, while they recollect others perfectly. Common words are often thus for- gotten, while unusual or remarkable words are remembered ; or a wrong word is chosen. One word is used for another that sounds something like it. Thus one of my patients, meaning to accuse a certain individual of perjury, always called it purging: and many other words he changed after the same fashion. But in truth ihe modifications of a partial loss of memory that have been known to pre- cede apoplexy are both odd and endless: some people forget their own names, or the names of their children. Dr. Gregory, who had paid particular attention to these precursory symptoms, and who had a large practice for a great number of years to furnish them, used to mention a case of this kind. After some efforts his patient could recall to his recollection what his Christian 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. Gre- gory, and partook of a hearty breakfast, having forgotten that he had breakfasted before he came out. On the same day he attended, vvith Dr. Gregory, 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 vvith all the kindness of an old acquaintance at first meeting; saying lie was happy to have fallen 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 312 DISEASES OF THE BRAIN. 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 sentence, 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 ac- counted 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 palient 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 slip, stair by stair, from the top to the bottom. Yet vvith 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 your 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. Hemiplegia. Affection of Involuntary Muscles. Anatomical Characters. Situation of the Clot of Blood. Disease of the Cere- bral Blood- Vessels. We were engaged vvith 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 altoniti and siderati, as if ihey 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 faint- ness ; the coma supervening usually in no long time. The third form is ushered m by sudden hemiplegia 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 primarily apoplectic; and paralytic cases: and so as you bear in mind what these terms really imply, they appear unobjectionable. I next po.nted out the classes of persons in whom an attack of apoplexy is chiefly to be apprehended: those, namely, in whose families that disease has been known o be common : those who have large heads, thick necks, red faces, square shoulders, and a short stature ; although persons of quite the opposite con- have passed the middle period of life, and are advancing towards old a column on each side are connected with it by two fasciculi 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 sensation 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 fasciculi 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 vvith 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 sensation, and the other to motion. And such is found to be the case ; and the arrangement here is really 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 observation; 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 un- touched, would destroy, not only the general sensibility of the "face on that side, but also the power of contracting these particular muscles. And this was tho- roughly 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 perfect: while in the woman Church there were default of sensibility, and paralysis of the temporal and masseter muscles: but the move- ments of the superficial muscles were unimpeded. Total interruption of the function of the portio dura will paralyze these super- ficial muscles of ihe face: and such interruption maybe 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 346 FACIAL PALSY. it. And it is of great importance to observe that the morbid condition which causes the interruption 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 immo- bility 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 sug- gested 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 only. When the 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 lies 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, unattended 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 comparative harmlessness of character, had been observed and described some years previously : 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 Trans- actions 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 apo- plectic 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. fSir 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 scal- pel, 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 vvith the same kind of para- lysis, which seemed, in him, to have been occasioned by a mere shock or jar. He was a coachman, and one day, when he was off his box, his horses started away, and he ran to their heads to stop them, but was thrown down in the at- tempt, 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 circumstance 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 ex- ercising the affected muscles; but he still was unable to bring the right eyelids FACIAL PALSY. 347 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-p;itient. Moreover he got drunk; and he soon presented him- self again vvith 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 ihe worst consequences of facial palsy. Fortunately it is only an occasional consequence: and it will occur or not, according to the quan- tity 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 the temporal bone. As this tumour gradually subsided, the palsy disappeared. In each of Dr. Powell's three cases the affection was apparently caused by expo- sure 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 he was returning in the cabin of a steamboat, 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 traveling 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 ap- peared 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 complaint, and cases thus arising are more obedient to treatment than most others. Probably some of you saw a female patient who came under my care in the hospital in May last (1838), in whom 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 than it might and ought to be, if the palsy were really the harbinger of apoplexy. At the same time you should not be ignorant that a similar limita- tion of paralysis to the particular muscles supplied by the portio dura is sometimes (though 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 subject of it was a personal friend of mine.—I was summoned to his house in the autumn of 1829, 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, 348 FACIAL PALSY. there were other symptoms present which indicated that the interruption of the functions of the portio dura was connected vvith some morbid condition within the cranium: nausea and vomiting, twitching 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 engage- ment, 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 believe, of an emetic. But he had another attack of the same kind in the subsequent May: the same severe pain over the right brow, with great drowsiness and confusion of mind. He could not recollect the first line of the iEneid. He wished a friend to look at the signatures of some letters that had arrived : and though he knew the root, he could not tell how the word he wished to use was formed ; whether it was signition, or signation, 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, blistering, purgatives, and small doses of calomel continued 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 mis- sion so ably that after his return the government appointed him to one of far greater importance 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 you vvith 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 ihe muscles supplied by the portio dura on the right side ; and of no others. There were symptoms enough, however, to show that some serious michief was going on within the skull. He suffered intense headache, more on the left than the "right side ; was dizzy and staggering; and could not get to the ward without being Ted. 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 s°pit 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 paralysis 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 portions of the seventh nerve; and therefore indicates the probability of an internal cause. LOCAL ANAESTHESIA. 349 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 limes, 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 satisfactory explanation of the deafness and of the facial palsy which had been noticed during his lifetime. 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 por- tion 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 to palsy of these parts hold true also in respect to their loss of sensibility. The anaesthesia may or may not portend danger 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 hospilal with the sensibility 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 affection 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 appropriate remedies will readily suggest themselves. When, for example, it has come on after exposure to a current of cold air, or after a blow, or any cir- cumstance likely to give rise to inflammation, you must treat the case as you would treat inflammation ; bearing always in mind that a small amount of disor- ganization, a little thickening or induration of the parts around the nerve, may render the deformity and the inconvenience 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 precau- tion, lest any effusion of lymph should cause abiding 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 treat- ment just described must be pursued with greater diligence, and with such modi- fications as the nature of the case may require. If there be evidence of chronic disease in 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 tympaui, 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 anaesthesia, 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 350 REMARKABLE CASES. any suspicion arises that they may be connected wilh cerebral disease. Some- times they evidently have no such conneciion. In the month of November, 1834, a coachman became my patient in the hospital, with incomplete paralysis affecting some of the muscles of ihe 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 continued 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—treatment 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 days the sensation and the power of the limb were almost restored. Mr. Swan 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 anaesthesia, showing that the 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 (solo speak) of the necessity that exists for its perpetual and vigilant operation. Con- tinued volition is essential to the continuance of the muscular tension. Thus Dr. Yelloly describes a woman who had no power of feeling in her hand and fingers, although the power of moving them, and of grasping any objects, was entire. This woman found that she could carry glasses or plates in that hand 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 sensi- bility 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 anaesthesia, which pre- ceded an attack of apoplexy. The patient lost, from time to time, all sensation in certain isolated parts of ihe 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 Sciences Medicales for January, 1828,) 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 this sensible spot, his wife and children were enabled to inter- change ideas with him. He died at length, and his body was not examined. I shall finish what I 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 fidelity. A servant girl, about 20 years old, sprained her back in lifting some heavy article of furniture. She felt no great inconvenience at the time; but some little while after, weakness of the legs came on, and gradually increased lo 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 TETANUS. 351 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 con- trived 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 cedematous. In ihe same manner, if her head fell forward upon the thorax, it remained in that position until raised by an attendant. Her mind was entire. She died after four days' illness with symptoms of low typhus fever. You may suppose that Dr. Abercrombie looked vvith the greatest interest for the cause of these most remarka- ble symptoms. " I examined the body vvith the utmost care, (says he,) along with Dr. Pitcairn, who had heen in the habit of seeing her for several years; 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- motory 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 dis- turbance 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 these diseases we do, to be sure, sometimes meet vvith morbid appear- ances in the brain or the spinal marrow: but none that are constant, or uniform. LECTURE XXXII. Tetanus. lis 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 atten- tion, 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 convulsion, 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 morbidly heightened, as in the preternatural strength of a madman ; nor lowered, as in palsy; but) perverted: performed in an irregular and unnatural manner. There are two sorts of spasm. One of these is marked by a long-continued contraction of the affected muscles, not rapidly alternating with relaxation : the relaxation 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 repeatedly, 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 undergoing 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. 352 TETANUS. With regard to spasmodic diseases generally, I may say that some of them constitute 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 vvith 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 characteristic. Its name is derived from ttlva, to stretch. In respect to all those diseases concerning the exact pathology of which we are ignorant, and which we identify by the group of symptoms they present, rather than by any organic changes of structure in any part of the body, the most con- venient 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 when it is fully formed. But it is of much importance to be aware of the marks of its approach, and of its earliest symptoms ; in respect of 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, vvith trismus or locked jaw ; 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 distressing part of the disorder, an acute pain at the lower part of the sternum, piercing through 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 implicated. 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 will 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 affected to the time when the disease is relieved, or the patient dies, they con- tinue in a state of contraction, and are swelled and hard in their centres. The jaw, for instance, can never be completely opened; and the muscles of the abdo- men 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 remis- sion of the spasm been observed. The exacerbations usually begin by an increase of the pain felt 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 swallowing, or speaking. As the disease advances, these parox- ysms 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 speedily 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 TETANUS. 353 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 con- sequence of this abatement. However, a similar phenomenon occurs in at least another of these spasmodic diseases, as we shall see hereafter. Mr. Mayo 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 were soft and yielding, and had not the least tension. The boy was awakened, and at ihe 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 roused, 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 opistho- tonos, 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 ihe patient is rolled together like a ball. This is called emprosthotonos. In the only example of emprosthotonos which I ever saw, these two conditions alter- nated 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 oppo- site posture was assumed, 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 the 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 these varieties occur, and may be looked for; but in all: of them—trismus, opisthotonos, emprosthotonos, or pleurosthotonos—it is the same disease : and the prognosis 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 rigidi, the eyeball motionless and staring, (he 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 risus sardonicus. The tongue is apt to get between the teeth, and to be severely bitten. All the contractions are attended wilh 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 lhat the same sensation which you then felt in the calf, involves nearly all the volun- tary 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 mus- cular contractions was a sort of tingling, of rather a pleasurable kind. So violent are the contractions sometimes, that the teeth have been broken by ihem. 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. Latht-.m 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 23 354 TETANUS. derangement of the other 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 this 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 apncea; 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 chiefly, it occurs from asthenia: ihe 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 sufficient 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 eases of tetanus may be traced to one of two causes : which are, exposure to cold, especially to sudden alternations of temperature, and bodily 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 coun- try, and I believe in every other, the traumatic variety of the disease is much more common than the spontaneous. But in what manner soever it may origi- nate, 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 apredis- posing cause only; the exciting cause, in addition to the wound in the traumatic species, being the application of cold (particularly, according to Hennen, of cold air in motion) after the 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 cymplaint;; which did not spare even those who under- went immediate amputation.. Idiopathic tetanus is .extremely rare in this country. Dr. Gregory, of Edin* burgh, 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 exposure to cold, is narrated in the Edinburgh Medical and Surgi- cal 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 fol- low 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 Transactions) 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 compli' cated." Sometimes, however, 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 com- TETANUS. 355 mencement 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 whiplash under the eye, although the skin was not broken; from cut- ting 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 frequently than others concerned in the pathogeny of tetanus. The disorder more often supervenes upon injuries of the extremities, than pf 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 con- stitute the ball of the thumb, are very apt to be followed by tetanic spasm. Some have supposed that the disease has some special connection vvith injuries of tendi- nous parts ; but there 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 injury. Professor Robinson, of Edinburgh, was once at table, when a negro servant lace- rated his thumb by the fracture of a china dish. He was seized with convulsions almost instantly, 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 genera], the 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. Ali- son) we have no information whatever." The longer, however, that the disease delays its assault in these traumatic cases, after the reception of the local injury, the milder, in general, does 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 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 these cases, sometimes dies on the second, and generally before the fifth day. If he lives lo 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 com- mences 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. 356 TETANUS. 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 con- founded with it, except, perhaps, that extraordinary disease, hysteria, which some- times 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 tetanus. 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 unlikely to be made an instrument of suicide, or of murder. It is neces- sary, therefore, that you should be acquainted with the effects of this poison, which constitutes the active principle of the nux vomica, the fiiba S" Ignatii, and the upas ticute. Dr. Christison has excellently well described these effects as they are observable in brutes: and I have once, by accident, had an opportunity of wit- nessing 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 vvith it upon animals, tells us that the creature "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 animal 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 intimately mixed wilh 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 person 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 suddenly seized with tetanic spasms; his legs were separated widely from each other, and rigidly extended : and his head and trunk bent back- wards. 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 wilh the pain at the coming on of these spasms. Any attempt at move- ment, even the touching 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 I 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 quantity 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 TETANUS. 357 diminishing rather than increasing. He was perspiring profusely. It is stated by Dr. Christison that if the spams do not come on within two hours after the poison was swallowed, the patient is safe. It was more than two hours since this patient had taken the strychnia. I gave him a full dose of purgative medicine, which acted as an emetic j 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 commenced. 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 circu- lation: 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 on 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 wilh 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. Christi- son has suggested that the cases of fatal poisoning by strychnia 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, ibis 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 after- wards from the irritant effects 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 while he was perspiring; and whether he has recently received any bodily hurt. By a careful investigation of all the circum- stances, we shall generally be enabled to decide the true nature of the case; but it is clearly necessary that our eyes should be open to the possibility of a oase 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 con- ceive, than that of those nervous diseases in general which produce violent symp- toms, 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 irri- tation of the spinal cord, or of its afferent nerves; and that the brain is not in- volved 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 inflammation of the spinal marrow : and some of them have sought to remedy it by enormous blood-leltings ; 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 afong the course of the spine, 358 TETANUS. and to the epigastrium. But this doctrine 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. Num- berless 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 verte- bral canal. 1 say we must content ourselves vvith referring the phenomena of the disease to irritation, direct or indirect, of the spinal cord; or its nervous appen- dages ; 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 spasmo- dic contraction of the limbs. 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 some- times 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 limbs contract spasmodically; those on the side to which that nerve belongs become rigid, and those on the other side also. That property of the cord comes into play which I have so often mentioned : 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 pro- perty 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. Marshall Hall I have been afforded ihe opportunity of witnessing, in the headless turtle, the phenomena 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, irrilation is set up at the free extremity, or some- where in the course, of incident nerves ; along these nerves an influence is con- ducted to the cranio-spinal axis, in which a process or change takes place, where- by 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 were withdrawn. 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 com- municated, in both directions, throughout its entire course: the whole of this centre of the excito-motory system, responding 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 distinguishing epithets to tetanus, according to the supposed source and locality of the irritation. When the irritating cause operates TETANUS. 359 directly upon the spinal cord itself, he calls the disease centric 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 tetanic spasm. We then refer 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 appplied 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 compress a nerve, with a pair of forceps, in a decapitated turtle. That experi- ment shows us that very slight irritation may be enough to produce the spasmodic action; and we find that slight injuries, as well as severe, will bring on the dis- ease, 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 vvith 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 proceed 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 super- venes 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 fre- quently 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 these 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 cause ; 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 dark. 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 often 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 loo near the root, so rigid all over with tetanus, alternating with convulsions, that their bodies would project in a right line with their hind legs, when one held them out horizontally by the hind feet." Dr. Mason Good tell us that parrots also are 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- logy of this disease, when we lay down the following propositions: that it is essentially a disorder of the excito-motory apparatus; that it results from irrita- tion of a peculiar kind, affecting that part of the nervous system ; that the irri- tating cause may be centric,—within the spinal canal itself; and that il 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. 360 TETANUS. At one time it was supposed that the physical cause of the disease was de- tected, 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 met wilh when there has been no tetanus. If, therefore, there he any connection 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 im- portance becomes daily more apparent, ami by which his name will be endur- ingly connected with the physiology of the nervous system, receive a strong confirmation from the phenomena of tetanus. They furnish a key to many problems which had previously perplexed the pathologist; and they do this simply by distinguishing the proper functions of the two distinct nervous centres; ihe 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, tnt, tpapati, ortaauoi iftiytvo/xuvoi, Oamaifiov, tetanus supervening on a wound, is mortal: and the aphorism holds true, with very few exceptions, in ihe present day. Almost all the acute and severe traumatic cases are fatal. Hennen declares that he never saw a case of " acute symptomatic 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 Hippocrates' aphorisms is dxoaot vrco tt-taaiov axtaxovtai tx tsoaapoiv ^tfpjjotv aito7a.wta.t, they who are seized vvith tetanus, die within four. days: but he adds, rtv Se tav-tac huxfyvyuxsiv vyistt ywovtcu', if they get over this period they recover. And to this we 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, there 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 spasmodic disorders it is of unquestionable service. Very large 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 fortifies the nervous system against the peculiar influence of narcotic substances. We need not, therefore, be surprised that opium, administered in enormous quantities, in this painful disease, has had but little effect. 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 pre- sent, 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-Chi- rurgical Transactions, in which an ounce of solid opium was taken, in divided doses, every day, for twenty-two 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. Aber- nethy say that he had found enough undissolved pills of opium in the stomach after death, to poison a dozen healthy persons. 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 morphia. And with the internal ad- TETANUS. 361 ministration 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 ihe introduction of medicine and of nourishment; but I hope you will never be guilty of such clumsy barbarity as this. Food, and phy- sic, 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 teelh, where there is always an aperture that will admit a lube sufficiently large. After all, in respect to the cures that have been ascribed to the opiate treat- ment, 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 cir- cumstance makes it a question whether they were cures at all: whether they were not simply recoveries. Dr. William Budd (in the paper already referred to) challenges the propriety, on physiological 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 function 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 con- siders "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 ihe 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 inferior animals, to what we suppose would happen in man. The failure, however, of opium in the severer forms of the malady, and its equivocal utility in any, taken together vvith 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 bleed- ing, when adopted, should be early, 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 to a stand-still, it may refuse to begin again. In a complaint which depends so much on irritation, and so often on manifest irritation of external parts, we look naturally to the warm bath for help. And it has been fairly tried: and some persons have found it useful; and others have found it useless, doing neither good nor harm: and some have condemned it as actually 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 lifeless." Sir James M'Grigor says that, during the campaign of Spain, 362 TETANUS. " the warm bath gave only momentary relief; and the cold bath was worse than usbIoss. However the application of cold water to the surface has, in many recorded instances, been of at least temporary benefit and comfort: and, m the West Indies, where the disease is common, the cold effusion still continues, I believe, to be the 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 ani- mals. 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 tetanus, I find the following statement. " The effect of cold in dimi- nishing 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 w°ere he himself the subject of tetanus, he would desire to have the cold affusion tried. If you are willing 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 employ- ing cold as a remedy in tetanus seems well worthy of trial. It would have the advantage 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. Wine; Mercury; Purgatives; Digitalis; Tobacco; Musk; Prussic Acid; Belladonna; Carbonate of Iron; Oil of Turpentine; Strychnia; Surgical Expedients; General Rules. Hydro- phobia. 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 ; or eccentric, situated out of the spinal canal, applied to some part of one or more of its afferent nerves directly, and thus influencing indirectly the cord itself, and through it the reflex motor nerves : and that a certain ill-understood state of the system is necessary, a certain aptitude to take on the disease, before the ex- citing cause can be efficient; and that one circumstance which has been ascer- tained to tend to the production of such an aptitude, is a long-continued high temperature of the 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 TETANUS. 363 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 idiopathic 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 reco- vered ; and that the recoveries had been almost exclusively among those patients in whom the disease appeared 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 essen- tially a disease of debility, and looking probably at its common tendency to dealh 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 vvith what has been already stated of opium, that how much wine soever may be swallowed by the patient, nothing like 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 110 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 vvith 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, mentioned in ihe last lecture. Tetanus has some- times, however, commenced while the patient was 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, against 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 consequence of the opium that is given, I am not sure. When they do act, very unnatural motions are frequently produced. Mr. Abernethy tells us of a hospital patient of his who recovered under the use of purgatives ; they were loner 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 nurses, in other cases, have reported the stools to be more like 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- 364 TETANUS. 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 look 210 grains of scammony, 89 of gamboge, 80 of calomel, an ounce and four scruples of jalap, and 2£ 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, 280 grains; scammony, 260; 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 7s drachms ; infusion of senna, 10| 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 encouragement to you to prescribe such doses. It is certainly proper and necessary to clear out the bowels, and to endeavour to correct unhealthy secretions; 5'et 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 ; bolh, 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 ihe muscles which belongs to syncope. But if we consider that the influence of these sub- stances 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 disposi- tion observable in tetanus towards death by asthenia, we shall scarcely be prepared to expect any good, but the contrary, from digitalis, or tobacco; especially in the latter periods, when, so far from obviating the tendency to death, they would seem to co-operate vvith 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'Crigor mentions a case in which it caused a relaxation of the spasms; but the man died afterwards, appa- rently from the effects of the remedy. And this 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 al 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, Fonr- nier-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 tinner else that he had tried. Prussic acid and belladonna are said, by Dr. Eiliotson, to have been freely pie- 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 em- ployed not without success : the carbonate of iron. Reflecting, he'tells us, upon the good effect of this medicine in another complaint which has some points of TETANUS. 365 analogy with tetanus, viz., chorea, of which I shall soon speak, and considering how miserably 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 the 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 which the remedy was administered was this. The carbonate was made into an electuary by mixing it vvith twice its weight of treacle.- The elect- uary 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 contu- sion of the thumb. Dr. Elliotson says that he never saw a case, which 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-four hours of the time when the remedy was first prescribed. To produce its effects upon the system (Dr. Elliotson observes, very truly), iron must be given/or a few days: nay, he holds that months sometimes 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 by 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 vvith an equal quantity of castor oil. The one oil dissolves or becomes incorporated in the other. Strychnia has been suggested as a remedy for severe tetanus; not in infinitesi- mal doses, as Hahnemann would, I suppose, prescribe it, but in sufficient quantity to produce a sensible effect. The principle upon which this has been recom- mended is the same vvith that on which the nitrate of silver ointment is applied to the inflamed conjunctiva in purulent ophthalmia. We know that strychnia acts upon the spinal 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 justi- fiable, I conceive, to give the strychnia, in ihe hope that it might occasion a mor- bid action which would supercede 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 corporc vili; upon one of the lower animals. This, were it successful, would be a cure, according to the Hahnemannic doctrine— similia similibus curantur—a doctrine much older, however, than Hahnemann. But the opposite maxim, contraria contrariis, has been suggested. Mr. Morgan proposes to give such poisons as are known 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. Sevvell himself, I give you Mr. Mayo's account of it. " A horse, suffering from a severe attack of tetanus and lockrd-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 the wourali poison. In ten minutes 366 TETANUS. apparent death was produced. Artificial respiration was immediately commenced, and kept up about four hours, when reanimation look place. The animal rose up, apparently perfectly recovered, and eagerly partook of corn and hay. He was unluckily too abundantly supplied vvith 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 recurrence of tetanic symptoms." I had fancied that the death had resulted from some injurious effect upon the lungs, pro- duced 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 little to say concerning what may be called the surgical treatment of traumatic tetanus. It was a natural thing, the source of the irritation being sup- posed 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. Elliotson says he has searched scores of books, and found only one case in which the limb and the disease were lopped away together. However, Mr. Blizard Curling, in his Essay on Tetanus, 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 believe 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 ampu- tate 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 ihe division 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 was 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. Wihout loss of time, the posterior tibial nerve was divided. The limb was previously cold, and, as the patient said, dead, and he had little power of moving it. He could not articulate dis- tinctly, on account of the closed state of his jaws. The nerve was cut through by one stroke of the scalpel: and "immediately (says Dr. Murray) he opened his mouth with an exclamation; and on looking at his countenance I was asto- nished at the 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 stiff- ness of the jaws and neck remained for a day or two; but he soon recovered. Dr. Murray refers 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 condition 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 vvith HYDROPHOBIA. 367 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 im- portance to protect the patient against these sources of trouble, so sure to aggra- vate his sufferings, 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 circumstances 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 trau- matic cases, the nerve, in my judgment, should be promptly divided. And in all cases, there being no special indications to the contrary, I should be more in- clined 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 implies, 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 has been called " the ninth-day disease." Another of its names in the British settlements there, is "the jaw-fall 4" from the circumstance that shortly before death ihe 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 Ja- maica used to die of this disorder. Some persons refer it to the irritation pro- duced 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-verrtilated lying-in hospitals. Pure air must, therefore, be desirable as an adjuvant. Tetanic symptoms sometimes occur (but I should think very rarely) in ague. Or paroxysms of tetanus return at regular intervals, and terminate by profuse perspiration: the patient being well during the intermissions. When such phe- nomena arise, the treatment proper in severe forms of ague must be adopted: what that treatment 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 enemata of oil of tur- pentine, 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 appalling; 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. This 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 368 HYDROPHOBIA. 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. Afier another interval the man is -dead. Before we advert to the many very interesting points of inquiry which arise out of the con- templation of this malady, let us 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 animal 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,/or the most part, between six weeks and eighteen months, and which has been called the period of incubation—the following symptoms begin to be noticeable. The patient experiences pain, or some uneasy or unnatural sensa- tion, in the situation of the bite. If it has healed up, Ihe 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 arresh, 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 constitutional symptoms begin : he is hurried and irritable ; speaks of pain and stiffness, perhaps, about his neck and throat: unexpectedly he finds himself unable to swallow fluids, and every attempt to do so brings on a paroxysm of choking and sobbing, of a very dis- tressful 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. Bartholo- mew'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 pa- tient 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 Thursday his hand had become painful, and swelled a little. On Friday the pain extended 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 spasm 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 medical attendant that he could not take his draughts, because of the spasm in his throat. That gentleman (Mr. Maedonald), concealing his own suspicions as to the true nature of the disease, said, "Oh, you don't like the taste of vour physic! drink some water." But he declared he had the same difficulty"With w:ater. The next day he came to the hospital. When there, water was brought and HYDROPHOBIA. 369 placed before him in ahasin, 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 ihe supposed cause of his illness; 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 appear- ance, well; lyin 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 lips 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, espe- cially when the latter part is uneasy, (as it clearly is in mad dogs,) this Aict, of the production of the disease by a scratch, if thoroughly made out, would not prove that the disease can be introduced into the system in any other way than by means of the slaver. LECTURE XXXIV. Hydrophobia, concluded. Various Questions considered respecting the Disease as it appears in the Human Subject, and respecting Rabies in the Dog. Pa- thology 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 statements made upon credible authority, that the same group and succession of symptoms 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 sponta- neously engendered in their bodies. I would make the same remark vvith 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 ihe 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 animal. Mr. Youatt affirms, that the saliva of the badger, of the horse, and of ihe 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 I feel much less certain about these latter animals. Respecting the dog, the fox, the wolf, 376 HYDROPHOBIA. 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, labouring under hydrophobia, is capable of inoculating another human being with the same complaint? Mr. Youatt says yes: that the disease has undoubtedly been so produced. 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 vvith certain precautions : so as not to suffer their saliva to come in contact vvith any sore or abraded surface; nor, if it can be avoided, with any mucous surface. On the other hand, all carefulness of that kind will be unneces- sary, if the disease cannot be propagated by the human saliva. Certainly many experimenters have tried in vain to inoculate dogs wilh the spittle of a hydrophobic man ; but there is one authentic experiment on record, which makes it too proba- ble that the disease, though it may not be communica/erf often, or easily, is yet communicate. 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, 1813, vvith 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 malady, among dogs, during the whole summer. Now this is a very striking fact, yet it ought not to be considered conclusive : for it is possible that the dog might have gone 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 point: never- theless, we have enough in this one experiment to make us use all necessary caution when engaged in attending upon a hydrophobic palient. I just touched upon the question, whether the saliva of a rabid dog could pro- duce the disease if it fell upon the sound skin ? The first of the two cases which I related as having been witnessed by myself, 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 lo 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 door that was rabid, were attacked with rabies seven or eight days afterwards. Mr. Oilman, of High- gate, in a little pamphlet 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 claws— the claws of a cat, for example—we are not to set it down as a sure thing that the disease 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 pulling their paws to their mouths when they feel uneasy there, we may readily understand how the poisonous saliva may be introduced by a mere scratch with the creature's nails. Mr. Youatt believes that the saliva 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 disease explodes? Or does it remain imprisoned in the wound, or in the HYDROPHOBIA. 377 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 might 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 lhat the recrudescent pains seem always to follow the course of the nerves, and do certainly never in- flame 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 numerous 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 examined 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. Aber- nethy's lectures, another striking case, still more to the point. " A very intelligent boy had been bitten by a dog in the finger: he was brought into St. Bartholo- mew's Hospital. Caustic had been liberally used, affecting the sinewy parts, and producing a terrible sore: yet the boy was recovering himself, and the sore was healing'. One day as Mr. Abernethy was going round the hospital, he saw and spoke to the boy, who said he thought himself getting well, but that he had that day an odd sensation 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 poul- tice, and recommended the boy to take some medicine. Early the next morning Mr. Abernethy visited the ward, pretending he had some other patient there 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 was very unwell, and had not slept all night. Mr. Abernethy felt his pulse, told him he was a little feverish, as might be expected, and asked him if he were not thirsty, 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 it 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 ihe 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 this done even at that period, the mo- ment 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 say that the facts now referred to, show with any certainty that the poison remains in the place where it was first deposited, until the phenomena of recrudescence take place: but they afford some presumption in favour of that notion ; and in such a disease as hydrophobia, we are bound to act upon the very lowest presumption that affords a chance for our patient's life. The poison may be absorbed into the general sys- tem al the period of recrudescence, although no affection of the absorbing vessels or glands should be manifest: through the veins, namely. Considering the matter philosophically, we might be inclined to suppose that the poison was silently maturing its force in the general system during the period of incubation, just as the poisons of small-pox and of measles are presumed to do. But looking at it practically, I should recommend, under the circumstances already stated, the excision of the cicatrix. 5. Another important question is this. Is a man who has been bitten by a mad dop;, 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 means. 378 HYDROPHOBIA. But few, upon the whole, of those who are so bitten, become affected wiih hydrophobia. It is curious thatdifferent species of animals appear to be 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 inocu- lated wiih 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 in- stance in which, of twenty-one persons bitten, one alone fell a victim to hydro- phobia. Dr. Hamilton estimates the proportion to be one in twenty-five. But I fear ihese computations are much too low. In 1780, a mad dog, in ihe neigh- bourhood 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 fol- lowing 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, twenly-three persons were bitten and fourteen perished. Four died out of eleven that were bitten near Dijon : and eighteen of twenty-four bitten near Ro- chslle. At Bar-sur-Ornain, nineteen were bitten, of whom twelve died of hydro- phobia within two months. Here we have one hundred and fourteen persons bitlen by rabid wolves, and among them no less than sixty-seven victims ; con- siderably more than one-half. There is no doubt, however, that ihe 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, appa- rently, 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 bilten 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. If it be made through clothes, and especially through thick woolen garments, or through leather, the saliva 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 different places by the same dog; viz., in ihe 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 re- crudescence 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 wilh 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 preven- tion. 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: ihey 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 with- out undergoing a painful operation, leads many to neglect the only sure mode of obtaining safety. HYDROPHOBIA. 379 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. 1 should strongly recommend you not lo act upon this opinion : but to use ihe same precautions, in dissecting a rabid animal, as you would use if you were persuaded that the disease might be communicated wiih equal certainly before and after the death of the animal. 6. A still more anxious inquiry next arises. Whoever has been bitten by a rabid or a suspected animal, must be considered, and will generally consider him- self as being in more or less danger of hydrophobia. This dread is not entirely removed, even by the adoption of ihe 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 majo- rity of instances, indeed, the disorder has broken out within two months from the infliction of the bite. But ihe 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 ihe poison and the eruption of the consequent malady. Nay, in one instance, three years are said to have elapsed, and in another the enormous period of twelve years. lu these cases one cannot help supposing that some unsuspected re-inocu- lation, some fresh application of the peculiar virus, must have taken place. If not, then we must conclude that the poison really lies imprisoned in the part; and only becomes destructive when, under certain obscure conditions, and at indefi- nite periods, il 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 Filzwilliam'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 quarreling; at last, therefore, he shut that dog up by himself, and then there was no further disturbance. On the third day afterwards, the quarrelsome hound be- came unequivocally rabid; and on the filth 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, 83, 155, and 183 days. There are some considerations respecting this disease which relate both to the biter and the bitten ; the canine and the human being. And there are some which 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 may be pro- duced by a healthy, 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 in- clined 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 Mr. Youatt describe cases in which there had been no symptoms of rabies ob- served in the dog 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 sur- veillance, 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 uncertainty, which might otherwise have haunted him for months or years. If the dog dies mad, the injured person will be no worse off than if ihe animal had been killed in ihe 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 380 HYDROPHOBIA. imputation of madness. A poor wretch of a dog is perhaps ill, or weary, or cross, or he may have been worried already by mischievous boys: the cry of mad dog is raised; and then he can expect no mercy. There are gross errors prevalent vvith regard to the signs of madness in the dog. If a dog be seen in a fit in the street, s°ome person charitably offers a conjecture that 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 existence of epilepsy is a clear proof that there is no rabies. Again, it is a very 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 Iruth 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, vvith, "perhaps, an occasional exception in the horse, drink with ease, and wilh increased avidity. This erroneous impression is not confined to the vulgar. In the case which I have more than once alluded to, and which is mentioned 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 consequence 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, weary 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 earnest licking of some part, on which a scar may generally 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, straw, even dung : and frequently he will lap his own urine, and devour his own excre- ment. Then the animal becomes irascible ; flies fiercely at strangers ; is impa- tient of correction ; seizes the whip or stick ; quarrels with his own companions; eagerly hunts and worries the cats ; demolishes his bed ; and if chained up, makes violent efforts to escape, tearing his kennel to pieces vvith 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 diligently and perseveringly seek his enemy. Accord- ing 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 extir- pated. This opinion is founded of course upon the belief that rabies never origi- nates 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 Jamaica, after that island had enjoyed an immunity from the disease for at least fifty years pre- viously ; and Dr. Heineken states that curs of the most wretched description HYDROPHOBIA. 381 abound in the island of Madeira; that they are afflicted with almost every dis- ease, 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 counte- nance is remarkably changed ; the eyes glisten, and there is slight strabismus. • Twitchings 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 succeeded by insatiable thirst: the dog is incessantly drinking, or attempt- ing to drink : he plunges his muzzle into the water. When the flow of saliva has ceased he appears to be annoyed by some viscid matter in his fauces ; and in the most eager and extraordinary manner he works vvith 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 wiih 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 affected in a less degree. The dog is able to use it in the act of lapping: 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 paralysis often attacks the loins and extremities also. The animal staggers about, and frequently falls. Previously to this he is in almost incessant action. Mr. Youatt fancies that the dog is sub- ject lo what we call spectral illusions. He says he starts up and gazes eagerly at some real or imaginary object. He appears to be tracing the path of some- thing 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 his 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 lone, and generally terminating with this characteristic howl. Respiration is always affected : often the breathing is very laborious ; and ihe inspiration is attended with a very singular grating, choking noise. On the fourth, fifth, or sixth day of the disease, he dies : occasionally in slight convulsions : but oftener without a struggle. Mr. Youatt gives a detailed account of the appearances met with after death in 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 per- fectly 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 says, upon careful inquiry, that the dog has vomited much hair, hay, straw, or the like. In 1837, a few days after the case of hydrophobia occurred in the Middlesex Hospital, I saw the carcass of a dog, that had died rabid, examined by Mr. Ain- slie at his and Mr. Youatt's Infirmary. The most remarkable morbid appearances were in the stomach, which contained some bits of straw and stick, and a con- siderable 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 extravasated beneath, and partly incorporated with, the mucous membrane. I believe that Mr. Youatt's opinion, already mentioned, of the cause of rabies in dogs, and in all creatures—viz., that it always results from the introduction of a specific virus into ihe system—I believe this opinion is not commonly enter- tained. 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 382 HYDROPHOBIA. the weather. It is thought by many to be particularly likely to occur in the dog- days ; 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 lhat period, for muzzling dogs, and so on: very good and proper advice, but, if those who have noted the statistics of the disease may be depended upon, it would be as appropriate at one period of the year 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, who 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 MM. Dupuytren, Breschet, and Magendie, have caused both dogs and cats to perish with hunger and thirst, without producing 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 sailed 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 animals 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 inocula- tion has been effected. 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 ihe excito-motory apparatus; the true spinal marrow, vvith its appendages of afferent and efferent nerves. Nay, I should go further, and say that it is the upper part of this apparatus, of which the functions are primarily and chiefly deranged : that the poison acts mainly upon the nervous arcs which pertain to the throat, suid with which the eighth pair of nerves in particular is connected. There is nothing sin- gular in this localization 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 ihey simply illustrate, when they do happen, the facility vvith which any morbid state of the spinal cord may propagate its influence in either direction. Whether, in hy- drophobia, the essential change be centric or eccentric, cannot be determined with any thing like certainty: but it seems to me to be most probable that the sensi- bility of the afferent nerves of the fauces, of the skin, and of the air-passages, is altered or morbidly exalted; whence, upon the application of the exciting stimu- lus, the peculiar sighing dyspnoea, 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-motory 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 I0.10.1 Oavatos. The physician that cures is death. There can be no ground therefore for the recom- mendation of any especial drug, or form of medicine, nor even for any general plan of treatment, after the peculiar symptoms of the disease have once set in. Of course those powerful remedial agencies that are in common use among HYDROPHOBIA. 383 medical 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, strych- nia, cantharides, the nitrous oxide gas: and no end of less gigantic remedies ; such as alkalies, and especially ammonia, carbonate of iron, electricity and gal- vanism, tobacco-juice and the guaco (which was introduced into this country a few years ago with high encomiums 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 time or another, have been vaunted as success- ful remedies, veratrum sabadilla, and ticunas 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 in- jection 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 corresponding 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 iwo 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 lime, by applying ice to the cervical portion of ihe spine, and to ihe 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 tracheotomy, the hydrocyanic acid. Now I should be sorry 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 dis- ease. The mode of death offers no encouragement to its use. There may be spasm of the glottis, but I doubt it. At any rate the patients do not die of suffo- cation. The death is not death by apncea, 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 a bed a whole night long, inspiring with such difficulty that, if I had not been aware of his having, scores of limes, been as bad before, I should not have thought he 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 differ from great authori- ties on practical points, but I see no hope of cure, nor even of sufficient benefit to counterbalance the inconvenience and hazard of the operation from the perform- ance of 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 lo the lungs through the larynx; but in hydrophobia there is no such permanent obsta- cle to surmount. Though your patient in laryngitis should be at ihe 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 amendment is the prelude of 384 HYDROPHOBIA. 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 drank a large 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. Farthermore 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 relief. 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 any confidence: and even here we are met wiih 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 prevented 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, vvith 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 fre- quent 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, all 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 causlic ; and the caustic he uses is the nitrate of silver. But I advise you to trust to nothing but the knife, if ihe 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-ke'lle; 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 vvith 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 should 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, 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 together 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 HYDROPHOBIA. 385 may even be filled with quicksilver, to see if a globule will escape. The effi- cient performance of the excision does not depend upon the extent, but upon the accuracy, of the operation." Mr. Abernethy 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 would 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, ihe 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 after they had ap- peared ; 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 tingling, 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 escharotic 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 complete cauterization, cannot be effected; but I should think it quite useless as auxiliary to those expedients, and only likely to keep up, or to produce, a hurt- ful irritability of the system. I should perhaps have mentioned before, a theory, and a plan of preventive treatment, which made a great figure in all the journals, foreign and domestic, a few years ago. It was pretended by a Russian physician, Dr. Marochetti, that some time between the third and the ninth day after a person has been inoculated wiih the hydrophobic poison, by the bite of a rabid dog, small pustules appear on or about the fraenum 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 pre- tended 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 vvith a red hot iron; and afterwards 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 system ; 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 hydrophobia; nor in English mad dogs. The truth seems to be that the mucous follicles of the mouth, gene- rally, and those at the base of the tongue, and those beneath the tongue, in par- ticular, are commonly enlarged and exaggerated in the dog, and in the human animal, labouring under the disease; and these enlarged and altered follicles were 25 386 HYDROPHOBIA. regarded by the Russian physician 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 vvith the hope of checking the disease, so a great number of medicines and measures have been praised as preventives. Some people have great faith 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—whether they believe in them or not is another matter—sell them at no cheap rate to those who, having been bilten 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 ingredi- ents the most insignificant and worthless, or of poisons of which the inefficacy had already been ascertained. The celebrated pulvis antilyssus, which was intro- duced 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 Tonquin medi- cine was composed of cinnabar and musk : and the Tanjore pills were a combina- tion of mercury and arsenic. Even now scarce a year elapses but some corre- spondent of the newspapers, whose philanthropy is more conspicuous than his judgment or his knowledge, recommends a new and infallible preventive. I confess to you that I have not the slightest faith in any one of them; but as I have a great respect for Mr. Youatt, and as he is not quite 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 pro- phylactic 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 effect. He tried the alisma plantago, the boasted efficacy of which had been strictly inquired into by the magistracy of Toula, and the receipt purchased by the Russian government at an immense price. But he had no success vvith it. He then put the belladonna to the test, beginning with two grains, and increasing the dose to a scruple twice every day, and con- tinuing this for six weeks: and he says he is confident that he saved several dogs; but he lost almost as many. They all became debilitated 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 preventive of rabies : and upon trial of it, he soon was brought to'regard it as really valuable: and (not to tire you vvith a detail of his proceedings in the interim) he at length combined it with belladonna: " and the result" (I here quote his own language) " 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, I 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 Scutel- laria and belladonna were given: the third, a fox-hound bitch, was abandoned to her fate. On the 29th day after the inoculation she became rabid." The others, at the time this was written, i. e., some months afterwards, were living and well. He afterwards took the same two dogs, and a third. He moistened two pieces EPILEPSY. 387 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 mouth of the same rabid dog twenty four hours after its death, was inserted in the poll of the second of the old dogs. This dog and the new one were suf- fered to take their 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 must be tried; and I would prefer those which are thus sanctioned by Mr. Youatt's good opinion to any others. And with respect to the established disease, I think that if I were the unhappy subject of it, 1 should wish to be put into a hot air bath, and thoroughly sweated, and to take opiates * not so much in the hope of recovering as with a view to the euthanasia. But with all respect to those gentlemen 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 idtimate. 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 stales 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 definite and constant to allow of our giving them distinctive names, and making them separate objects of inquiry. At the same time, 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 ; qualis debet esse sororum." Occasionally the features are so nearly alike, that we find it somewhat puzzling to determine with which of the sisters we are conversing; but usually there is some mark or other by which the individual may be identified. Of these essentially nervous diseases, there are several in which the most prominent 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 disorders belonging to this head :—of tetanus, namely, in which the mus- cles of voluntary motion present the most striking changes, being affected with tonic spasm ; while ihe sensibility undergoes no other alteration than what is a conse- quence of that spasm, pain I mean in the muscles themselves; and the intellectual functions continue undisturbed :—and of hydrophobia, in which the natural sensi- bility suffers much, and the mental functions some derangement; yet still the characteristic features 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 388 EPILEPSY. attended wilh the same urgent and immediate peril to life. Yet it is, upon the whole, productive 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 painful 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 conscious- ness, with clonic spasm ; recurring at intervals. It is impossible to frame a perfect definition of epilepsy: nay, so various are its forms, so numerous its modifications, that no general description 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 to 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 palient 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 expected by himself or by those around him, in the middle of a sentence, or of a gesture, the change takes place; and the miserable sufferer is stretched foaming, struggling, and insensible upon the earth. This fearful suddenness is expressed in the name of the disease, IrtO.q^iu, 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 was seized with epilepsy 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 comitialis. Morbus 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 themselves. In this country ils common designation is the falling sickness: or, more vaguely, fits. The cry which is frequently, though by no means always, uttered, is generally a piercing and terrifying scream. Women have often been thrown into hysterics upon hearing it. It is said to have caused pregnant females to miscarry. Even the lower animals appear to be sometimes starlled 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 commencement, 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, some- times 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 issues 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 EPILEPSY. 389 the patient with great force, or bruising themselves against surrounding objects, or inflicting hard knocks upon the friends and neighbours who have hastened to the patient's assistance. It frequently happens that the urine and excrement are expelled during the violence of the spasm : and seminal emission sometimes takes place. The spasmodic contraction of the muscles is occasionally so powerful as to dislocate the bones to which they are attached: ihe joints of the jaw, and of the shoulder, have been thus put out; and the teeth are sometimes fractured. When the convulsive paroxysm is over, the patient falls into a deep sleep. You might imagine that he slept from exhaustion, like a man worn 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 de- grees, 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 volun- tary motion is not likely to occur without some derangement or modification of the functions of the circulation. The breathing is irregular, gasping, or arrested. The heart palpitates violently against the ribs during the paroxysm ; the pulse becomes frequent 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 fore- head are visibly distended. 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 slight and transient, or even no convulsion at all; no tur- gescence of the face; no foaming at the mouth ; no cry ; but a sudden suspen- sion of consciousness, a short period of insensibility, a fixed gaze, a totter per- haps, a look of confusion ; 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, vvith this temporary abeyance of the mental functions, there is some slight 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. Some- times 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 dis- tinguished by that appellation from the epileptic fit. Of affections 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 recurrences of the epileptic vertigo, and at length will become affected with violent epileptic 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 character 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 perecive, 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 390 EPILEPSY. still more difficult to offer a strict definition of the disease. Cullen defines it to be " musculorum convulsio, cum sopore." Dr. Copland furnishes a larger and more comprehensive definition : " Sudden loss of sensation and consciousness, with spasmodic contraction of the voluntary muscles, quickly passing into violent convulsive distortions, attended and followed by sopor, recurring in paroxysms often more or less regular." 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 inter- ruption of consciousness; there may be no subsequent coma or sopor; there may be no recurrence 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 connected with the paroxysms. In the first place they vary considerably in duration. Sometimes, as I have already stated, 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, vvith indistinct intervals of comatose exhaustion. In the long-continued fits, or in the protracted succession 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: sometimes every day or every night: and not very unfrequently they take place many times in the twenty-four hours. This extreme frequency of repetition be- longs principally 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 irregular. The time of life at which the fits commence, and the circumstances attending their commencement, are deserving of notice. They not uncommonly 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 teething, and sometimes upon manifest disorder of stomach and bowels—these fits are not distinguishable in their phenomena from genuine epilepsy ; and we must reckon them as instances of epilepsy. It has been remarked by some one, that if you can trace the early history of an adult epileptic, you will almost always find that he or she suffered infantile convulsions.* 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 perspicu- ous), the most common periods are about the age of seven or eight years, proba- bly 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 be- tween 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 epilepsy is apt to begin. It is a reasonable piece of theory, and serves to lie the * [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 ihe disease to commence immediately subsequent to puberty or even late in life. In ihe majority of these latter cases the disease appeared to be the result of a life of intem- perance.—C] EPILEPSY. 391 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 evolu- tion 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 irri- tation. Then follows the trying period of teething. In a few years the second dentition occurs. In a few years later, all the great changes connected with the age of puberty. 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 on the vigorous frame, acquire power from its relative weak- ness." 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 the 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 lo the night. Some 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 remedies. Sometimes each paroxysm arrives unannounced and unexpected; sometimes distinct warnings of its approach are given. The latter is less frequent than the former. Georget affirms that 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 con- siderable 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 man- ner, 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 appe- tite becomes voracious; a great flow of urine takes place ; he smells an ill smell, is aware of a strange taste, hears extraordinary noises, or sees spectral illusions ; not mere specks floating before him—muscae volitantes—but distinct 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 little 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, 392 EPILEPSY. or lividity : difficult articulation ; vomiting. Of twenty-one epileptics treated in ihe hospital at Wilna, by Joseph Frank, vomiting announced the paroxysm in seven. Some of the uneasy feelings are apt to come on and continue even for s-everal days previously to the attack ; restlessness in particular, disturbed sleep, distressful 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 indescribable. 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 the trickling of water, lo 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 finger, or toe, or from some spot on the trunk,—and runs along the skin towards the head : occasionally 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 sensations are blended. In some instances, spasms of the muscles of the part whence the aura proceeds are 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 sometimes 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 he 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 com- menced 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. Seymour 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 within 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 atlack 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; some- times as affording us the opportunity of staving 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 mo- ment. 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 mo- ments ; some appear to recover consciousness, and then falUnto a deep and prolonged slumber; but many do not regain their consciousness at all upon the cessation of the convulsions, remaining in a state of profound stupor, from which, however, they can generally be roused for a time. This state of coma (for it is .EPILEPSY. 393 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 lime : not unfrequently there is a degree of partial paralysis, which also usually soon goes off, though it occasionally is per- manent ; 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 discom- fort of some kind. Ii 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 ihe fact by finding themselves wet or dirty ; by the injuries they have received during the convulsions ; by the soreness of ihe bitten tongue; by the bruises of their limbs ; or by the confused or painful sen- sations, which they subsequently experience, and which they have learned to associate with the conviction that a fit has happened, by having been informed on previous occasions, when they felt the same sensations, that they had suffered a paroxysm of insensibility 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 their repetition. Doubdess 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 ordi- nary observer, 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 the 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 confirmed imbecility or insanity. It is this tendency which renders epilepsy so sad and 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 mal, the violent 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 dis- puted, 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 whenever the disease comes on, if it repeats itself frequently, it is much more often than not followed by impair- ment of the mind, or by some apoplectic or paralytic affection, which implies and accompanies ihe mental change. You will sometimes hear the cases of Julius Cajsar, of Mahomet, 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 however, 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 epilepsy ; and that he had Wo attacks while en- gaged 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 394 EPILEPSY. 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. Sensa- tion, 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 irregular 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 illustration 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 yet intimately connected wiih, and dependent upon, each other, a thousand familiar facts assure us: and there are good reasons for believing that the change, whatever it is, which is the im- mediate precursor and cause of the epileptic fit, may sometimes oiiginate 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 of epilepsy. It is true that the spinal cord is concerned when- ever there is convulsion; but it is concerned in every voluntary movement also, through the instrumentality of the brain itself; and it may be, and often is, irregularly influenced by a disordered and unnatural state of the brain. Tetanus may fairly be regarded as a 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 volition remains, although the morbid condition of the cord renders it inef- fectual. In epilepsy, these cerebral functions are always implicated. There is always a loss of consciousness : and in the epileptic vertigo, the petit mal, there is frequently a suspension of consciousness only, without any compulsion at all. The brain, therefore, we must consider to be essentially concerned in this disorder. What the precise stale 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 natural quantity 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 exa- mining the condition of the nervous system. Often you will find nothing at all which can throw any light upon the occurrence of ihe 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 scrofu- lous tubercle, a spiculum of bone projecting from the skull. Have you then detected the cause of the disease ? 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 paroxysms; the derange'ment itself, if* indeed, it was of such a nature as to be cognizable by our senses, has gone, with the symptoms; the tubercle 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 in persons who have been subject to epilepsy, uncomplicated as yet with any permanent disorder of the intellect, or of the faculty of voluntary motion, and who have died in the fit, constant alterations are observable within the head; viz., a EPILEPSY. 395 strong injection of the vessels of the encephalon. The membranes, the brain, and the cerebellum, are gorged, he asserts, with livid blood. But he goes on to say thai this is to be ascribed to the mode of death : that we see the same appear- ances in persons who have died by hanging, or any form of apnoea; that they are not peculiar to epilepsy, and do not explain the attack, but only point out ihe 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 (grant- ing 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 sud- denly 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 symptoms of the paroxysm begin to subside and disappear. So that we cannot, I think, look upon the congestion as the cause of the convulsive symp- toms. Let us go a step further, and inquire into the state of the encephalon in those persons who, having suffered epilepsy, had, before death arrived, been affected with some permanent impairment of ihe 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 wiih in the brain in such cases are the fol- lowing. 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 the 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 irregular on its surface, marbled or of a rosy colour in its substance, and sometimes altered in consistence. And in many cases the membranes are found to be adherent in some parts to the convolutions vvith which they lie 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 inflammation of the brain and its membranes. They are the consequences (I imagine) of repeated paroxysms of epilepsy ; they are the very same as are fre- quently met with in cases of insanity complicated with paralysis, and they eluci- date, 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 depend. 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 ihe 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 ihe morbid appearances that are sometimes only visible in the nerv- ous centres themselves, there are others, which it is of great importance to attend to, situated in other parts of the body, and at a distance from those centres: dis- eased slates of the liver; biliary concretion; granular kidneys; renal calculi; stones in the bladder; worms in the alimentary canal; diseases pf the uterus; and of various other parts. And these morbid conditions have often, no doubt, an 396 EPILEPSY. intimate connection 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 them- selves, 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 lo express it. Cerebral and occasional; primary and secondary; idiopathic and sympathetic; centric 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 situated in the brain ; eccen- tric, i. e., in respect to the true spinal marrow. But I apply 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 collateral branches of the ancestors. This is just what takes place in other hereditary maladies. You may often notice also that other forms of nervous dis- order prevail in the same families. MM. Bouchet and Casauvielh found that among 110 instances of epilepsy, 31 were hereditary. Of 321 persons afflicted vvith epileptic insanity, and seen by Esquirol, 105 were descended from insane or epileptic parents. Again, a tendency to epilepsy is very often found to go along with an unnatural form of the head, which is pinched up like a sugar-loaf; or misshapen and un- symmetrical, one-half being unlike the other; or oddly configurated in some way or other. Epilepsy is no uncommon attendant of chronic hydrocephalus. And thirdly, the scrofulous diathesis is a strong predisposing cause of epilepsy. Dr. Cheyue even holds that epilepsy is as certain a manifestation of the strumous disposition, as-tubercular consumption, or psoas abscess. Now of the two pre- disposing 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 head, are both very likely to descend from parents to their progeny. Whether the sex has any influence in determining a predisposition to epilepsy, is a question that remains to be settled. Foville thinks it is most common in females ; Dr. Elliotson 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 to determine the point. We want numerical statements on a large scale. At the close of the year 1813 there were 162 male epileptics in the Bicetre; 289 female cases in the Salpetriere. Jos. Frank observed lint of 75 patients, 40 were females. LECTURE XXXVI. Epilepsy, continued. Recapitulation. Exciting causes. Simulated epilepsy- Diagnosis. Prognosis. Treatment: during the fit; 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 EPILEPSY. 397 attacks are characterized by a sudden cry, immediate loss of consciousness, general and violent convulsions, and subsequent coma or heavy sleep. The very slight attacks consist in a momentary abeyance of the mental faculties, sometimes with and sometimes without slight and partial convulsion. The extreme forms of epilepsy we judge to differ only in degree, inasmuch as they both attack the same persons at different times ; or the one form conducts to the other. Between llicse the gradations are innumerable. We call the extremes the epileptic fit, and the epileptic vertigo; the French name them the grand mal and the petit mal. 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 about 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, especially in the outset and the decline of the disease; usually when the patient is between asleep and awake; i. e., at the commencement or the ter- mination of his slumber. In the majority, perhaps, of cases, the fit is unexpected, and preceded by no warning. But in other instances there is some alteration perceptible by the patient himself, or by his friends, giving notiee of its approach ; some change in the temper, feelings, 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 paralysis; delirium; inarticulate speech. There is seldom any appreciable per- manent 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 imbecility of mind, to complete fatuity; and with this there is often associated some paralysis or muscular debility. 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 muscular 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 encephalon, or in the spinal cord, of persons who have suffered epilepsy uncom- plicated with any permanent mental or paralytic affection ; tubercles, for example, or bony growths 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 vvith permanent alienation of mind, or vvith some degree of paralysis, evidence of chronic inflammation of the brain and its membranes is generally discovered. This has been the consequence of ihe repetition of the paroxysms. This explains the frequent connection of fatuity and palsy vvith epilepsy of long standing. The diseased condition which excites the paroxysms may be situatad in the 398 EPILEPSY. 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 consi- derable 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 likely to be propagated from parents to children. But the predisposition is found to be hereditary, even when the shape and structure of the body is, to all appear- ance, quite perfect and natural; and when no outward indication of the strumous diathesis is perceptible.* At the very close of ihe 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 pre- disposing cause of any, not congenital, is masturbation—a vice which it is painful and difficult even to allude to in ihis 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 convic- tion that they had thus brought upon themselves epileptic paroxysms 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 fact alone would be enough, I conceive, to forbid our ascribing the paroxysms exclusively to an affection of the spinal cord. Bodily pain ; manifest and great 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 inscrutable. 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 wiih the uterus: and when long periods have intervened we may usually trace each distant parox- ysm to the repetition 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 irri- * [The following statistics are presented by M. Leuret, in an interesting paper on Epilepsy in the Archives Generates 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 twenty-fourth 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 was it ascertained that the disease existed in one or other parent, and in bat'eight was it found that one of the parents had died of any disease of the brain, namely, three of insanity, two of apoplexy, one of paralysis, one of suicide, 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 presume* cause of the first attack of epilepsy was ascribed to terror; in twelve to onanism; in six to drunkenness; in two to anger; in two to distress; in two to falls; in one to Ubertinage, Sfc. Thirty of the patients had an attack very regularly once a fortnight; 17 suffered attacks once a month; 13 once a week; 9 every three or four days; 4 almost every day; 2 every day; 1 every two months; 3 every three months; and 24 at very irregular 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 occurred in the day; in 8, they occurred during the day only; in 8, 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] EPILEPSY. 399 talion being seated in some part at a distance from the nervous masses in the stomach, or intestines, or uterus.* Now I would suggest the expediency of ob- serving what muscles or sets of muscles are first affected by the spasm in such cases, and in what part the warning aura (if there be any) arises: because by accurately noting these particulars, 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. Among the exciting causes of epileptic fits are also enumerated—and I believe, 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 on convulsions and a state of insensibility exactly like certain forms of epi- lepsy. Persons 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 affected wilh convulsions before they expire. There is vet another very singular occasional cause of epilepsy that deserves to 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 suf- fered such attacks, often fall into one upon seeing another so affected ; 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 ihe 11 lb 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 suffered fre- quent and exceedingly 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 visiled the parties. In a fortnight from his first visit he also was seized with similarly violent attacks. Dr. Hardy quotes the following short case, also, from Baglivi:—"Vidimus, anno 1690, in Dalmatia juvenum gravissimis correptum convulsionibus, propterea quod inspexerat solummodo alium juvenem dum epilepsia humi contorquebatur."t Dr. Cullen, who, 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 to the mere force of imitation, which is often so strong, in health as well as in disease : and he decides in favour of the force of imitation. In fact there are many other signs equally horrifying with that of a person in convul- sions ; 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 some of them, especially in hysteria, its influence is more remarkably seen than in epilepsy : I shall iherefore have to recur to it again. There is one very curi- ous fact, however, which relates to epilepsy in particular. You are aware that * [M. Lamothe relates, in the Journ. de Med. de Bourdeaux, a case in which the epilepsy 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 intro- duced.- He at first experienced only a slight diminution of hearing; afterwards suppura- tion 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 proba- ble existence of a foreign body in the ear, made an examination, and detecting it, by proper means, succeeded 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.] | [M. Meyer has recently given an account of a number of the pupils in a female school that were attacked with epilepsy, in consequence of seeing one of their number under the influence of the disease. Most of the subjects were approaching the period of puberty whilst they were all of a highly excitable temperament.—C] 400 EPILEPSY. this disease is often feigned, by impostors. Now I believe it is ascertained, be- yond the possibility of doubt, that fits and actions which were at first, in these pretenders, strictly voluntary, have at length become involuntary and uncontrol- lable, 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 epi- lepsy. First, how are we to distinguish the feigned disease from the true? Se- condly, are there any other real diseases which may be mistaken for epilepsy, or for which epilepsy may be mistaken ? In the number of feigned diseases epilepsy is one of the most common. Sol- diers and sailors pretend to have epileptic fits, in the hope of obtaining their dis- charge 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 live tolerably well, and quite idly. It is easy enough, they think, to throw their legs and arms abou', and to grin ; and many of them get up a capital show of foaming at tbe mouth, by placing a bit of soap between the gums and cheek. The means of delecting these vagabonds are of some importance to us all; and it is more particularly neces- sary that they should 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 pretenders 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, by cross- examination. A cheat will seldom be consistent in the account which he gives of his fits; as to whether they are regular or irregular; and as lo the times and places in which he has suffered 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 walk. True epileptics almost always select retired places to take exercise in ; especially if they have any warning or expectation of the approach of a paroxysm. You will find also that the impostor is not attacked al 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 tumbling down. True epileptics are often seriously hurt by their falls; feigned ones gene- rally come off without much bodily damage. However, if the fits are alleged to be frequent, and if also they are regular, 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 muscular 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 ihe second place a real epilectic 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, vvith the eyeball visibly rolling and distorted. In feigned epilepsy the actor almost always prefers to shut his eyes completely. Sometimes, if he be closely watched, and no suspicion is expressed, he .will be seen to open his eyes occasionally, to ascertain the effect of his exhibition upon the bystanders. In real epilepsy, too, the pupils are often considerably 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 light. The pulse, in true epilepsy, is not only frequent but often irre- gular also ; a circumstance which never can be imitated. The skin of an epilep- tic, 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 is scarcely possible for him to deceive us. Again, an impos- tor will not bite his tongue, as epileptics often do; nor very willingly void (like them) his excrements and urine during the fit; indeed, it would not be very easy EPILEPSY. 401 for him to do so, and at the same lime to carry on the necessary pretence of con- vulsions. Besides, epileptics, during a fit, are quite insensible to external im- pressions ; 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 believe is more fashionable among beadles and police constables, when they have to administer to such patients), the pressing your thumb-nail violently under that of the supposed impostor. This causes exquisite 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 pretender, 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 supposed to be shamming, was laid upon the upper one, while his paroxysm was on him ; and the fear of falling from such a height soon stopped the convulsions. Mr. Hutch- inson 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 sneez- ing, 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 effects, 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 remark- ably 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 im- postor, and yet not calculated, like the one last mentioned, to injure a real sufferer : which is to propose gravely, in his hearing, to pour boiling water upon his legs, and then to proceed actually to pour cold water upon them. Of the real diseases which are apt to be confounded with 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 discrimi- nation is generally to be made. In the first place the total suspension of con- sciousness, 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 com- mon 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 countenance, and probably congest the brain with venous blood. In hysteria the respiration, 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 sano-uineous apoplexy, and even overwhelming emotions of the mind. The reten- tion of urea in the iinpurified blood, occurring in connection vvith 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 26 402 EPILEPSY. 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. Caeteris 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 palient; 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 epileptic physiognomy has become established. The prog- nosis 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. e., 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 irf 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 teeth- ing, for example: and besides this, it is stated by many practical writers that even repeated and habitual attacks of epilepsy in children often go off as ihe 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. Elliotson mentions a case in which a girl had epilepsy prior to the first period of menstruation: then the fits stopped; and she remained free from them until in advanced life the catamenia ceased to recur; and then the epi- lepsy returned. In all those cases 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. " The eccentric epilepsy (says Dr. Hall) is to be viewed as curable, however difficidt of cure." And how- ever 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 cure under any treatment, yet there are few which may not be relieved by treatment, so far as regards the frequency or the violence of the fits, or both. The treatment of epilepsy 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 cannot 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 * [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] EPILEPSY. 403 expedient cleverly. If the head be visibly congested, and hot, cold wet cloths may be applied to it with propriety ; 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 moulh: 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 paroxysms ; but after reading that letter, I desired the nurses to treat all my patients who might be 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 con- vulsions. Probably it is more calculated to relieve an hysterical than an epileptic fit. In the epileptic fits of children 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 respect- ing 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 fit, 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 cupping, 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 abstraction 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 effect of excessive blood-letting upon the system at large, is manifest, sometimes, for 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 predisposition 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 pre- disposition which we cannot get rid 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 difficult, 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 continuance 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 direc- tion, or towards emptiness and asthenia in the other. The first of these unnatural states may be redressed by regimen 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 plethora, 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 vvith epilepsy, although it may not be very apparent in some few 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 fits. It is owing, perhaps, to a neglect of these two somewhat opposite conditions 404 EPILEPSY. 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 tempera- ment ; when he has a hard pulse, or any degree of feverishness ; when the disorder has supervened 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 regi- men. When former paroxysms 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 superficial 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 effect of this remedy is the occurrence 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 disease, 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 permanent discoloration of the skin, a frightful lead-colour. There is a footman in a house 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 penciled over with plumbago. A barrister, a friend of my own, had a narrow escape from a similar misfortune: in fact his skin has acquired a just perceptible tinge of gray. Now if the remedy were sure to cure the disease, I am not certain that every one would accept of a cure 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 unamiable 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 gre;it 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 you wish to try it, or if you have a palient 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. EPILEPSY. 405 And it is worth observing that in the larger doses this drug proves purgative. It is possible that its good effect, 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 arseni- calis 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, how- ever, 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 corroborating the nervous system. The most renowned of them are valerian, assafetida, wormwood, the misletoe of the oak, the cardamine pratensis, rue, the sedum acre, indigo ; narcotic vegetable preparations, stramonium, bella- donna, hemlock, lettuce ; animal substances, musk, castor, ox-gall; and the num- ber might be many times multiplied: and this long array of drugs, all of which have been known, or supposed, to accomplish a cure, affords, in truth, one of the strongest evidences of the intractability of the disease under any plan of treat- ment. 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, and 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 by 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 should rise early, and take regular exercise in the open air; keeping his head cool, and his extremities warm. He should avoid all mental 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 striv- ing 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 they 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 less engrossing objects of attention. No minute rules can be laid down on these points, but, keeping the general indication in view, it will seldom be difficult to follow 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 ex- clude 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 all 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- litic affection of the bones of the skull; 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 pre- mise, however, 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 suspected; the influence of that remedy being carefully watched. It will 406 EPILEPSY. 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 result 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 dis- charging for seme time, by means of issue peas. The formation of the issue is said to be not so painful as one might suppose. Dr. Quain, in his edition of Martinet's Pathology, relates ihe following case: " Some years ago I saw a boy who was epileptic from infancy, and who, in one of his usual fits, fell over a cliff by the sea-side, and received a very severe lace- rated wound of the scalp, which healed slowly and wilh 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; slight 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 liver, by sueh 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 lies 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 dis- order. Foville states that he has seen excellent effects from it. It is highly spoken of by Dr. Percival, in the Dublin Hospital Reports. It is not to be given in large doses, but 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. Occa- sionally turpentine has done good in virtue of its anthelmintic properties. I know that a physician of my acquaintance cured a case of epilepsy in this way, some- what to his own surprise. Without having in his mind any notion of worms, he thought it might be well to purge his patient, who had laboured under epilepsy for some time, with the oleum terebinthinae. 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 EPILEPSY. 407 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 ex- cellently 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 in- telligible to the patient—may be enough, sometimes, to make a practitioner's for- tune. 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 turpentine 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, by 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 awakening 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 ligature 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 paroxysm may sometimes be prevented by dashing cold water on the face, or by exciting the nostrils 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 warning (which consists chiefly in giddi- ness) is generally so short that he has not time to have recourse to his preventive before he falls down. It is a question whether the fit may not be obviated by a strong mental effort in some cases. I make no doubt that it may, especially in the 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 advert generally to those precautions which every one who is subject to epilepsy ought to observe, and which il is the business of his medical adviser to enforce, both upon the patient himself, and upon his friends.. His bed should be large; or if not large, it should be enclosed wilh 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 tem- perature is 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 populous town, in which the multiplicity and distraction of objects are apt lo produce, even in a healthy person who is not accustomed to them, a degree of vertigo and confusion. Dr. Cheyne advises that when the 408 CHOREA. patient's circumstances will admit of his having a constant attendant with him, the lalter should be provided with some diffusible stimulus; a potion, for example, composed of camphor mixture and Esther, by swallowing which the impending paroxysm may sometimes be repelled. LECTURE XXXVII. Chorea. 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 com- plaints which we have recently been considering; but it is a very unpleasant disorder to suffer, and it has several points of analogy vvith 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 rigid spasm, while the mind was clear and free; volition was unaffected, but the muscles which should have obeyed the effort of the will, were seized upon by some stronger overruling power. In epilepsy, with convulsive spasm, there was suspension of the mental functions: a temporary interruption of conscious- ness, 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 volition. 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 lo gesticulate and grimace like a Merry Andrew. Moreover, these apparently absurd movements do not occur in paroxysms, but continue throughout the day, sometimes for weeks together; 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 vvith fever. 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. Without 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 wilh slight twiches of a few muscles in the face, or in one of the extremities; and by degrees the spasmodic 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 attempts to do so before she can accomplish it; and then the longue 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. CHOREA. 409 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 endeavours 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 palient, 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 some- times 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 physi- cian, 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 palient 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 sometimes 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, 53 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 have 204 cases, of which there were 144 females and 60 males ; the propor- tion is 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 120 cases, of which 87 were females, and 33 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 410 CHOREA. 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.* When the disease is strongly marked, or lasts long, there is usually some imbecility 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 gene- rally 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 duration 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 Middlesex Hospital, Dr. Hawkins, had a fatal case. He found great vas- cularity of the uterus, earthy concretions in the pancreas, omentum, and mesen- tery, and tubercles in the lungs. But these conditions had no connection pro- bably with the chorea. In an instance that proved fatal under Dr. Bright's observation, there was considerable disease in the uterus and its appendages. I am afraid that we shall seek in vain injhe 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- operate 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 phenomena of chorea. And it is most certain that the irregular movements by which chorea is characterized can neither be considered as the effects of imper- fect paralysis, as some have stated, 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 agreement 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 denominated 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 encephalon which presides over the locomotive func- tions ; and there are altered states of that portion, which lead to a loss of the due association of muscular contractions. That portion is the cerebellum. Such is their theory; and it is a very plausible and pleasant, but withal an unsatisfying theory. The disorder really belongs, I apprehend, to the excito-motory depart- * [According to Mr. W. H. Bell—{Diet, des Etudes Medicates) DufossfS (ibid.), and Rufz (.Archives Generates de Mid., iv. 339)—the subjects of chorea have chiefly light hair.—C.J CHOREA. 411 ment of the nervous system. From some infirm or unnatural state, either of the cord or of the incident nerves that convey impressions to it, its reflex function is called into irregular play, and voluntary muscles contract independently of voli- tion. Sometimes, at the same instant, the patient wills certain definite move- ments through the instrumentality of the very same muscles. But the authority of the will is impaired, and the automatic motions are proportionally 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. Cho- rea is a complaint that is seldom attended with any bodily pain. I have in seve- ral 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 will find that in all respects, excepting the nervousness, and the irregular move- ments, 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 sto- mach and bowels, either before or during the complaint; a capricious appetite, costiveness, a tumid abdomen, offensive breath, a foul tongue. Chorea is sometimes complicated with other disorders, and above all with hys- teria : 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 vvith acute rheumatism and rheumatic pericar- ditis ; 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 experience 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 like those of chorea in a few instances of rheumatic car- ditis. Very lately a boy, affected with chorea, became my patient in the hospital. We soon detected a slrong 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 Transactions, there is a paper by Dr. Bright, detailing "cases of spasmodic disease, accompanying affections 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 ques- tion, 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 sys- tem may act as an exciting cause of chorea. Strong mental emotion, or a sudden mental shock, is very likely to bring it on in those of a movable constitution who are predisposed to it. Of its ascertained or alleged exciting causes, fright is beyond all 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 or bowels, by improper diet, by accumulated feces, or by worms; and it is found to be connected, in not a few cases, with difficult and painful men-* 412 CHOREA. struation. It frequently 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 was com- plete. This Dr. M. Hall 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.* 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 havino1 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.t I had occasion, in the last lecture, to. remark, that when avast number of differ- ent 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 intractable 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 whom 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 administer bitters, aromatics, and antispasmodics, with the 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 liberty of referring you to books (to Dr. Copeland's Dictionary, for example) for further information on that subject, and content myself with telling you what modes of treatment I have been in the habit of employing, vvith very satisfactory results. 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, * [We have not found the disease to be much influenced by the season of the year or condition of the atmosphere. Duges, Rufz, Spangenberg, and "Blache state that it occurs most frequently in summer. According to the statements of Rochoux, Chervin, and Dansle it is a rare affection in the southern hemisphere. It is nol a very frequent disease in Philadelphia.—C] $ [Chorea, like epilepsy, may be excited by imitation (Andral); the fact is, however, denied by Rufz and Blache.—C] CHOREA. 413 if you have at your 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 purgative 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 rate one full 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 olher 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. Elliotson,. 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 intestines, 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 day, make no impression 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 frequent 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 olher 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 to 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 carbonate 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 extremi- ties, and sunk into a typhoid state; and I really was afraid that I should lose her. But she recovered from this condition, which I could not 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. The oil of turpentine also is certainly a valuable medicine in this disease ; whether there be worms at ihe 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 ihe 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 414 CHOREA. 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 generous. 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 impulsps to action. The stillness of the muscles during sleep is in accordance with this belief.* There is an affection (it scarcely deserves to be spoken of as a disease) which is sometimes 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 per- sons, 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 rather awkward tricks than spasms: a repeated shake of the head, or knitting of the eyebrows, or corruga- tion of the integuments 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 evolutions 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 that exertion was extremely painful, and was followed by languor and much discomfort. In some instances I 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 time, as an out-patient at the hospital, a girl about seventeen 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 familiar 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, like 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 importance. I 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 modifications of the nervous affection which I have been noticing. In fact that term was originally applied, and much more suitably, to another set of symptoms of a most singular kind, concerning the real occurrence of which we might well be sceptical, if we * [ For further observations on the treatment of chorea the reader is referred to the Editor's Treatise on Diseases of Children, page 399 et seq.—C] CHOREA. 415 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 his- tories to which I allude. They relate to an affection characterized 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 volition that, in these cases, is morbid and perverse. You might fancy the patient to be possessed and coerced by an evil spirit, like the Saijitonfo^aj/ot of the Gospel history. Some of the subjects of these extraordinary affections, impelled by a strange unintelligible necessity, execute measured and regular movements with surprising energy, rapidity, and perseverance. When music is performed in their hearing, the movements 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; realizing the fable of Orpheus, and giving origin (it may be presumed) to those romantic legends met with in the literature of most ages and countries, of universal, involuntary, and unceasing saltation, at the sound of a magic pipe. To these feats the term chorea is apposite enough. Indeed I have seen it some- where suggested that the phrase chorea Sancti Viti is but a vulgar corruption of chorea Sancti 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 Ihis holy person to have been a cer- tain 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 cir- cumvolve 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 narries attests the reality of the disorder. You will find one of these singular cases related by Mr. Kinder Wood in the seventh volume of the Medico-Chirurgical Transactions. The patient was a young married woman. After having suffered severe pain in one side of her face, she began to be troubled vvith 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 extended 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, regu- lated by 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 continued dancing till he was out of breath. A drum and a 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 watched; and by always rolling the drum as soon as ihey threatened to begin, the chain of association which seemed to 416 CHOREA. constitute the disease was at length broken. The bowels were in an unnatural state during the complaint; and the menstrual discharge appeared on the evening of the day on which it ceased. One might conceive that the conduct here de- scribed 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 affairs 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 dwelling upon her mind, which at times becoming more pressing, irresistibly compelled her to commence the involutary motions." In a lad}', whom Dr. Abercrombie saw, the following symptoms, among others, occurred :—After she had been ill vvith 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 difficult 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 swallow produced spasms, resembling those of tetanus. At olher times, after lying for a long while quiet, she would in an in- stant 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 fling herself into bed, or would leap, 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 motion 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, vvith 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. Sul- phate 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 start of the whole body vvith 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 re- mained 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 fea- ture 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 paroxysms which were repeated many times a day, and was attended with inordi- nate 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 CHOREA. 417 the same thing in a hospital patient. Dr. Crawford met with an instance of in- voluntary rotation of the head, without pain, but. attended vvith 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 of " rotatio or chorea." The motions are said to have been furious and alarming: they were executed vvith 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 sometimes 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-Chi- rurgical 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 pro- pensity to twirl round on her feet, like 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 returned, 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 herself across the bed, and turning over like a roller, more rapidly from one end of it to the other. At first the fits of this kind lasted two hours; but they gradually ex- tended 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 olher; 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 little 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 vvith 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 diarrhoea 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 Physiologie, the two following singular forms of disease are referred to. A man, after some other symptoms of cerebral disorder, was seized with an irresistible inclination to move forwards, stopping only when exhausted. 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 neces- sity. In the attacks of a nervous disease she was irresistibly propelled backwards, and vvith 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 you 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 ihey were not attested by unimpeachable au- 27 418 CHOREA. 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 nowa- 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 whom the menstrual function is suspended or irregularly performed. Some per- sons 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 medical Newton will arise, and reduce all these apparently complicated 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 physiology do throw a little glimmering of illumination into these dark corners of pathology. 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 phenome- non occurred upon the division of the cms 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 drunkenness 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 locomotive 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 result upon various species of animals'—dogs, cats, hedge- hogs, 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 disorganized the corpora striata. It has further been ascertained, by the same experimenter 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 receded for more than a month, and even flew backwards. A section of the medulla oblongata, > CHOREA. 419 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 endowed with energies which tend to cause motion in various directions; that in the healthy state these balance each other, and that a preponderating impulse can be 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 phe- nomena. 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 forward, and makes an exertion to repel the imaginary force; or to be moving backward, or turning round in one direction, and endeavours to correct this by moving the corresponding muscles. Whatever may be the true explana- tion, the 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 the category 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 link 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 slate:has been com- municated 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 prose- cuted 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 Account of Scotland, under the head of the " Conversions of Cambuslang;" and in one of the early volumes of the Edin- burgh Medical and Surgical Journal. Dr. Robertson has described, in an inau- gural dissertation De Chorsed Sancti Vili, 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 wilful, 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 were horse- ponded, by way of example. With respect to the solitary instances of perverted 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. 420 PARALYSIS AGITANS. LECTURE XXXVIII. 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; Pre- vention. In the last lecture I spoke of chorea, and of some singular forms of disorder that have sometimes been included under the same appellation; and I shall begin the present vvith 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 palsy —paralysis agitans. Allusions to this form of disease are to be found in many of the older systematic 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:—"In- voluntary tremulous motion, with lessened muscular power, in parts not in action, and even when supported: vvith a propensity to bend the trunk forwards, and to pass from a walking to a running pace: the senses and intellects being uninjured." The latter symptoms constitute 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 forwards. 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. Parkinsonls notice was first called to the disease during his professional attendance upon a,person affected 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 imperceptible that the patient cannot recolleet precisely when it began. A sense of weakness, 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 deli- cate manipulation—in writing, for example; and he is obliged to walk with circumspection and care: his legs are not raised to that height, nor wilh that promptitude which the will directs ; so that much attention is necessary to pre- vent frequent falls. Then, as the malady proceeds, the propensity to lean forwards becomes more strong—the palient 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 irresistibly 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 falling forwards by the pres- sure of his hands against the fore part of the patient's shoulders : his powers of MERCURIAL TREMOR. 421 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 rheumatism, 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 Anatomic 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 of decay. Dr. Elliotson indeed says that he succeeded in one instance (of which, however, 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 patient 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 fumes 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 limbs 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 support he must have fallen down. His arms were agitated with similar involuntary movements. His tongue was tremulous, and he spoke in a hurried, abrupt, interrupted, staccato manner, not natural to him. He had no fever. His pulse was 66, and soft; his skin natural; his bowels costive. He complained of slight nausea. At the end of six weeks he went out well, or with very slight remaining weakness of his knees, and a little occasional tremor upon unusual exertion. In June, 1839, 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 absorption of that metal when raised into vapour by heat, and inhaled in breathing. It is accordingly very common among water- 422 MERCURIAL TREMOR. gilders. Water-gilding is the gilding of metals, and of silver in particular, by means of fire. It is called water-gilding, I believe to distinguish it from other kinds of gilding, called gilding in oil. The 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 off, and the gold alone is left adher- ing. 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 quicksilver 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 Medico-Chirurgical Transactions, 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 Colique Metallique. 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 increasing, till 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 manual operations, are interfered with; he becomes unable to convey food to his mouth, 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, delirium, loss of consciousness. 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 intes- tines. 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 dura- tion 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 wjth 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, aug- mented by the shock of the shower-bath: and always became excessive in thun- dery 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 without 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 atmo- sphere, and in administering tonics. Conium has been recommended by Mr. M'Whinnie. Quina 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 instructed to avoid, as much as possible, inhaling the poisonous fumes, to ventilate the room tho- roughly, and to pay great attention to cleanliness. I believe the furnaces may be HYSTERIA. 423 so built that the metallic vapour shall not reach the operator. If he cannot avoid being involved in it, perhaps some sort of respirator might afford protection.* 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 I have to say, so as to present the disorder to your notice in the most intelligible manner. 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 first attempt to describe to you the phenomena which are peculiar to hys- teria ; 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 hysterical constitutions, and to some other points connected with this extraordinary complaint. I need not tell you that the hysterical paroxysm is almost exclusively confined to women.t' It occurs under a great variety of forms, but they may all be reduced, for convenience of description, to two. The first of these has a general resem- blance to an epileptic fit. The trunk and limbs of the patient are agitated with strong convulsive movements ; she struggles violently, like 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 power- ful are these muscular contortions that it often is all that three or four strong persons can do to restrain a slight girl, and prevent her from injuring herself or others. The head is generally thrown backwards, and the throat projects; the face is flushed; the eyelids 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 liberty, 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 breathing 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 starting at the slightest * [A very peculiar form of convulsive disease has recently been described. It is charac- terized by repeated bobbings of the head forward, at first slight and occasional, but becom- ing, 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 bob- bings 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 attack occurring whether the patient was sitting or lying. During the attack, the child retained 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 one and six years—death did not occur in either; in the female and one of the boys the disease appears to have ceased. Of this strange form of convulsions, the pathology is still a subject for future investiga- tion; and until that is ascertained, its treatment must be tentative and experimental.—C] f [We have repeatedly seen all the phenomena characteristic of hysteria in the male subject. The fact of their occurrence in males is also stated by Sydenham, Louyr Vil- lermay, Georget, Ferriar, Frotten, Conolly and others. See also the admissions of Dr. Wat- son towards the close of his remarks on the pathology of the disease.—C] 424 HYSTERIA. noise or the gentlest touch; or sometimes she remains motionless during the remissions, with a fixed eye; till all at once the convulsive movements are re- newed: 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 suddenly sinks down insensible, and without convulsions: with slow and inter- rupted 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 nervous system ; and. indicate great derangement in the 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, frequently 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 repeated; the abdomen becomes distended vvith wind, loud rumblings and sudden eructations take place ; there is much palpitation of the heart, the patient is sad and sorrowful, and prone to shed tears. After the paroxysms, these patients commonly void a large quantity of limpid, pale urine, looking almost like water; and this is sometimes expelled during the fit. Such is a brief, and, I am aware, incomplete account of the hysterical paroxysm. It sets forth, however, in outline, the two principal varieties of the attack: and you are to observe that the last, the quieter form, is often the prelude to the con- vulsive ; but it not seldom also occurs alone, and then is as indicative of hysteria, as the petit mal, 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 pf great importance to be able to render the diagnosis 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 distressing, 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 yourselves 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 pronounce 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 exclusively to the sensorium : it is characterized by vertigo, and by a suspension (however 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^ there is an entire loss of consciousness. The patient, on emerging from the paroxysm, recollects nothing of what has been going on during 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 pa- tient 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. HYSTERIA. 425 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 ourselves. We 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 advan- tage of her apparent unconsciousness, and pretend to believe in it, and speak of certain modes of treatment which she will not much approve of, but the very men- tion 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 breath- ing: 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 respi- ration is deep, sighing, mixed vvith cries, and sobs, and often with laughter. But, perhaps, the convulsive motions differ most in the face. The epileptic expression is usually frightful: the eyelids 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 thai 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 lips, and the convulsions are more pronounced on the one side of the 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 out- set of the epileptic paroxysm the respiration, I believe, is thus suspended. 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 condi- tion of the brain and nerves ; but it does not follow that the disease originates in lhat altered condition. We know that the uterus or the ovaries cannot of them- selves determine the muscles to contract; but if they be in an unhealthy state they may act upon the muscles through the medium of the nervous system : and such 1 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 wiih diseased conditions of the uterus and ovaries—amenorr}icea, dysmenorrhoea, menorrhagia, even disorganization—with- out any of these nervous symploms. True ; and we cannot always fathom the mystery of this. But one thing is certain, that there exists in some persons a 426 HYSTERIA. 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 sys- tem. Sueh diseases occur in certain individuals only ; and in these individuals there pre-exists a peculiar condition of the nervous system, "for which," says Dr. Alison, " we have no more precise or definite expression than nervous irrita- bility, or mobility; a condition which is more common in women and children than in men ; and more common 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 habitu- ally excessive or altered as in leucorrhcea, or suddenly suppressed, or more gradually obstructed in the different forms of amenorrhcea, than in others. In this condition of mobility, both sensations and emotions are intensely felt; and their agency on the body is stronger and more lasting than usual; continued vol- untary efforts of mind, and steady or sustained exertions of the voluntary muscles are difficult, or impossible; the muscular motions are usually rapid and irregular, and the ' animus, nee sponte, varius et mutabilis.' " 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 life. 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 capri- cious ; they will devour wax candles, wafers, chalk, sealing wax, slate pencil, and such trash. And, what is very curious and characteristic, although they often abstain almost 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 peculiar constitution there is one other very remarkable 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 disordered state of action and suffering more or less resembling that which inflam- mation 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 patient for the time; but we shall leave her more prone to the nervous affection than before, and permanently damaged by our mischievous activity.* I say that almost every kind of serious disease may be mimicked by what we must call hysteria. And your skill will sometimes be severely tasked to deter- mine 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 peritoneum. You will find a patient complaining of acute pain of the abdo- men, 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 ute- rine functions, you will do well, before you bleed her to syncope, and cover her * [On the subject of the pathology of hysteria the reader is referred to the very judicious paper of Dr. ConoUy in the 2d vol. of the Cyclopasdia of Practical Medicine, Philadelphia edition, 562 et seq.—C] HYSTERIA. 427 abdomen with leeches, to ask yourselves whether all this suffering may not be simply nervous. 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 assafetida enema to be thrown into the rectum; and in a few 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 hypo- chondria are probably the most common. They are oftener complained of in the left hypochondrium than in the right. These things are much more generally understood 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 leeehes, and blisters, and blue pill, for supposed chronic inflammation of the liver or spleen, or still more actively depleted for 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 be 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, without any of the other symp- toms which commonly mark the real disease, its sudden disappearance, 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 com- mon. Aphonia, for example: the voice being lost on a sudden, and returning as suddenly. Mock laryngitis. I remember being asked by Sir Charles Bell some years ago to see a young woman in the Middlesex Hospital under his care. She had recently arrived, and was breathing with the stridulous noise peculiar to inflammation of the larynx. She had twice before, in the country, had tracheotomy performed 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 were spasmodic and hys- terical ; and she recovered under the remedies which do good in hysteria. Ina- bility to swallow, dysphagia, is another of the hysterical vagaries relating to the parts about the throat. Dr. Bright has a very instructive case of that kind. A patient was sent to Guy's Hospital for stricture of the oesophagus. 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 oesophagus by means of a probang; and no sooner was the instrument introduced, than the patient went into an hysterical fit, which was fol- lowed immediately by hysteria in several females in the same ward. The complaint turned out to be nothing but an hysteric constriction, 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 infi- nitely worse by applying 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 peculiar kind of cough which you ought to be acquainted with. It is loud, harsh, dry, more like 428 HYSTERIA. a bark than aeough. Sometimes it is incessant, sometimes it occurs in paroxysms which, I verily believe, are more annoying to hear than to suffer. Hysterical affections 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 would 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 hys- terical 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 haematemesis. 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 pot- fuls 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 men- strual 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 vvith a present of some game, and told me that she had got married to a hair-dresser, and was quite 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 diligently the source of the bleeding, and puzzles him- self to determine whether the case be one of haematemesis or of haemoptysis. Nine times out of ten it is neither the one nor the other. The blood comes from the mouth or the fauces. 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 limb, 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 little 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 mto 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 sup- posed to labour under diseases of the joints, labour under hysteria, 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 hysteria, 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 horseback. HYSTERIA. 429 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 is at once reversed. Potest quia posse videtur. Mr. Corfe, the present apothecary to the Middlesex Hospital, has no little trouble with patients of this kind; but he generally succeeds in making 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 influ- ence prevails. A lady told me not very long ago that an acquaintance of hers, a member of a family of distinction, had been lying I know not how long on her back; that position having been prescribed to her by some medical man for a pre- sumed 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 lived chiefly upon chickens ; and the number of chickens she devoured was incredible. She lived at some 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 at- tempt to do so would kill her. He was resolute, however, 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 deter- mination, would probably have failed. Dr. Bright has a good example of a some- what 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 ifito a paroxysm of agitation, and of excru- ciating 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 dis- ease; 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 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 tranquilizing 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 at- tempted to get her shifted gently from the bed to the sofa, but it was impossible; the paroxysm almost overcame 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, three mornings before, under a deep religious impression, she had completely recovered all 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 religious 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 in- fluence enough with her to make her believe that if on a certain day she prayed for recovery vvith a strong faith, her prayer would be successful, she would reco- ver 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 sensa- 430 HYSTERIA. tion 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 disgusting. 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 feelings. Sometimes, no doubt, the difficulty is real; but it is oftener feigned or exaggerated. I have again and again known it 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 obliged 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 decep- tive appearances displayed in the bodily functions and feelings find their counterpart in the mental. 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, before a theatre-full of students ; and then the imposture was detected. Sometimes they simulate suppression of urine, and after swallow- ing what they have passed, vomit it up again, to induce the belief that the secre- tion has taken place through the new and unnatural channel. It is impossible, I say, not to pity the unhappy victims of this wretched dis- order, when their morbid propensities drive them to such acts as these. I men- tion 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 men- tioned, viz., a pain occupying some one point in the head; the patient speaks of it as, a sensation like that which would be caused by driving a nail into the part; and the affection has therefore been called the clavus hystericus. It is often situated just above one eyebrow; and it sometimes comes on every day, at the same hour. Now in these cases it imitates very closely the hemicrania, which con- stitutes no uncommon form of an intermittent, and is called, accordingly, the brow ague. The distinction between the two—whether the affection, I mean, be hys- terical or aguish—is not of any great consequence : but in many of the previous examples of hysterical pain mimicking organic or inflammatory disease, the diag- nosis 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'lf 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 sub- ject to fits 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 tender- ness is not limited to the part complained of. Suppose it is the abdomen, the HYSTERIA. 431 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; and if various organs appear to be attacked in succession. Between 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 investiga- tion of the case, you still doubt, it will be right either to pause, or to treat it upon the most tmfavourable supposition. The consequences of suffering active inflam- mation to go on unchecked would be far worse than the temporary and slight and remediable injury to the system which might result from once applying the reme- dies 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 hys- teric complaints a careful object of your future study. I have hitherto spoken of hysteria as if it were exclusively a malady of females. Etymologically to apply that term 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 Jess than a dozen medical men for advice; and in that batch I happened to have my turn. He had some of the symptoms 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 mova- ble state of the nervous system, and the same symptoms referable to that sys- tem, may exist in both sexes. In females, in nine cases out of ten or in a much larger proportion, the exciting cause of the hysteria is connected with the sexual functions; 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 uterine sympathies. At the same time it is quite true that the " uterus is not the only organ of which the irritation may so affect the nervous system as to produce hysteria." As in epilepsy, so also in hysteria, the treatment to be adopted regards, first, the paroxysm itself; secondly, the condition of the patient during the absence of the paroxysm. One object, during the paroxysm, is to prevent the patient from injuring her- self, 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, you may sometimes shorten the attack by administering a couple of ounces of the mistura assafetida; or half a drachm of ether, with fifteen or twenty minims of laudanum, in camphor julep ; or a draught containing a drachm of the ammo- niated tincture of valerian. When the patient cannot or will not swallow, 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 432 HYSTERIA. half a pint of water, by means of the yolk of an egg; or the turpentine injec- tion, made in the same manner, and containing half an ounce of turpentine; or the same quantity of ice-cold water thrown into the rectum, or applied to the pudenda, will often bring the fit to a speedy termination. Indeed I believe there is more virtue in cold water, in hysterical diseases, than in any other single remedy. In the paroxysm 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 commonly a costive, sometimes an obstinate, and always an unnatural, state of the bowels. In those long paroxysms—if they may be so called—in which some other dis- ease is simulated by hysteria, the cold affusion is a most valuable resource : espe- cially 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' appli- cation of the cold douche. Mr. Corfe, as I stated before, takes much pains wilh 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. Presently the limb begins to tremble, the tight state of the muscles is evidently on the point of yielding, 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 effect, and by degrees the habit is broken, and the patient set free. It requires some determination to put this expedient in practice. The patient looks upon you as a monster of cruelty : 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 com- mon 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" appli- cation of water to the face; or the immersion of ihe whole 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 extre- mities, 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 imperfect, 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 per- formed. 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 proceeded to pour pitchers of 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 propaga- ble 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 dia- thesis, 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 CATALEPSY. 433 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 wonder- fully in check: and on the other hand, great sympathy vvith such patients has a striking effect in encouraging the paroxysms. These facts show that the symp- toms are, to a certain degree, under the patient's control. The fits are not wholly wilful; neither are they wholly unconquerable. 1 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 disor- dered functions of the uterine system. Now much the same plan of treatment is applicable 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 sub- ject of epilepsy, and other nervous spasmodic ailments. The following points must be kept in view. The regulation of the bowels, which are mostly slug- gish, 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 horse- back ; 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 life to which they are subjected for the sake of filling them with fashionable accom- plishments. I cannot close this subject, and this lecture, better than by quoting Sir Benjamin 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 instructions in respect to local hysterical affections. "You can render (he says) 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 ordinary system of educa- tion tends to engender ihe disposition to these diseases among their female chil- dren. If you would go further, so as lo make them understand in what their error consists, what they ought to do, and what they ought to leave undone, you need only point out the difference 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 carriage. Then, for the most part, the latter spend much more of their time in actual study than the former. The mind is over edu- cated at the expense of the physical structure: and after all vvith little advantage to the mind itself: for who can doubt 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 moral faculties; or that, other things being the same, this is more easily accomplished in those whose animal functions are preserved in a healthy state, than it is in others." LECTUR-E XXXIX. Catalepsy. Ecstasy. Neuralgia: Tic Douloureux; Sciatica; Hemicrania. There are yet some strange forms of nervous disorder which require to be mentioned; but upon which I do not intend to dwell. Catalepsy is one of these* 434 CATALEPSY. and what is called ecstasy another. These affections are very rare as well as very wonderful: 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 occurrence 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 hysteria in being seldom attended vvith 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 I said upon the treatment and prevention of hysteria, in yesterday's lecture. I shall content myself, therefore, with a short description of these two 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 vet 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. We have had the same muscles shaken with clonic convulsions; both vvith and without coexistent disorder of the intellectual functions. .But here we have a new phenomenon: the mental faculties are in abeyance, and the sensibility is abolished, and so also is the function of voluntary motion; but the limbs are not tied down by spasm ; nor agitated by successive contraction and relaxation of their muscles; nor yet left, like portions of dead matter, passively obedient to the laws of gravity: they assume any posture, however absurd, however (to all appearance) inconvenient and fatiguing, and that posture they retain, until some new force from without is applied 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 inanimate 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. These singular attacks occur in paroxysms; and they have been known to alternate 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 opportunity of doing so of which I did not avail myself. Dr. Gooch has described a case of it, as he witnessed the disease in a patient who suffered puer- peral mania. She had long been subject to the common forms of hysteria. This is illustrative of what I have often stated respecting the consanguinity of these nervous disorders. It had become necessary to confine this patient in a straight waistcoat; she was attended by Dr. Gooch and Dr. Sutherland. I will quote Dr. Gooch's account of the cataleptic slate ; for it is authentic and modern. He says, " A few days after our first visit we were summoned to observe a remarkable change in her symptoms: the attendants said she was dying, or in a trance. She was lying in bed, motionless, and apparently senseless. It had been said that the pupils were dilated, and motionless, 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 movements of the nostrils, no appearance of respi- ration, 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." ECSTASY. 435 " The trunk of the body was now lifted, so as to form rather an obtuse angle wilh the limbs (a most uncomfortable posture), and there left with nothing to support it; there she continued sitting while we were asking questions and con- versing; so that many minutes must have passed. One arm was now raised, then the other; and where they were left, ihere they remained. It was now a curious sight to see her, sitting up in bed, her eyes open, staring lifelessly, 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 endea- voured to rouse her by calling 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 ; wilh 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 inca- pable 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 day mare. From her time of life, her habits, and some other points in ihe his- tory of the disease, 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 exter- nal 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 voluntary 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 ixarao^ 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 sometimes it runs into ordinary 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 ihen 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, enigmatical questions ; describe exactly their own internal organic diseases; and even foretell future events. Credat Judaeus Appella, Non eoo! I take for granted that they who were in the habit of speaking, a few yearsVnee. in some of our places of worship, in what they called unknown tongues, were either gross impostors, who deserved to be publicly whipped, or persons labouring under this disease, and wanting physic. Dr. Copland mentions a curious fact in connection vvith (his subject. He says that many of the Italian Improvisatori 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 the management of these diseases, to what I have already said in reference* to the whole class to which they belong. Leaving these nervous disorders, in which the function of voluntary motion is so curiously modified ; and in which there sometimes is no alteration of the intel- lectual 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 436 NEURALGIA. which the nervous system is still the part principally interested, but in which the deviation from the natural slate is manifested chiefly in the function of sensation; the powers of thought and of voluntary motion, being scarcely affected, or not affected at all. Complaints, I mean, in which the sensibility is perverted, and augmented ; cases of nervous 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 like; 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 by no inflam- mation, no detectable change of structure in the painful 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 particu- lar 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 confined 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 distance 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 affected 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 production 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 limb upwards, however, an aneurism of the femoral artery, as big as an orange, was discovered in the thigh. This the patient thought nothing of; his only con- cern was the pain in his knee. Sir E. Home 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 after 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 must 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-Chirurgical Transactions. A sailor was wounded by a musket-ball in the arm. The wound healed ; but the patient remained affected with agonizing pain, beginning in the extremities of the thumb and fingers, except the little finger, and extending up the fore-arm. His. sufferings were so great that he willingly submitted to have the limb amputated : and the operation gave him com- plete and immediate relief. When 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. NEURALGIA. 437 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 of irritation in the trunk of the nerve, from which the part in question is supplied with nervous fibrils. But the source of irritation may be further back than this : it may depend upon a diseased state 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 it were, along the branch which is not, directly, the subject of the irritation. Thus filaments of the phrenic nerve penetrate the diaphragm and communicate with the ganglia that lie around the cacliac artery ; other filaments are distributed to some of the muscles about the shoulder; and in this way has been explained the well-known fact, that disease or irritation of the liver is very apt to be accompanied wilh pain in the shoulder. Thus also we have pain in the glans penis, from irritation of the bladder, produced by a stone there; pain 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 irritation of the urethra. There are many pains also, plainly enough connected vvith irritation of distant parts, although no other 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. Wollaston 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 digesting 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 followed 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, indicated the existence of an unusual quantity of acid in the sto- mach. To relieve the hitter 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." The lesson that we learn from all these facts is this: than 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 parts supplied by other 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 * adequate cause, either in any diseased structure, or in any morbid action of the blood-vessels, there are certain general facts observable which I will mention before I 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 438 NEURALGIA.' next of all, probably, in the abdomen. In the head, or face, the branches of the fifth pair of nerves are very frequently the seat of neuralgia; and to such pain, in that situation, the name of tic douloureux is generally given. The painful affec- tion called hemicrania 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 certain nerves; but this is not, I think, very com- mon. 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 ihe 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 disordered ; and by their frequently abating under tonic remedies, or what are called specifics, 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 lo 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 stemo-cleido-mastoideus, drags the chin round, and the head awry. Persons affected vvith that sort of deformity when awake, have their necks flexible enough, I believe, while they are sleeping. I mentioned just now one character of these neuralgic pains, viz , the total absence in most cases, when they occupy the surface, of'■heat, redness, swelling, or tenderness ; and I said in most cases, because there are unquestionably excep- tions to this. After these pains have been long-continued and intense, they may give 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 became swollen, from an effusion of serum into the cellular texture, and so exquisitely 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 con- siderably swelled." The attacks of neuralgia may recur at intervals of a few seconds only ; or they may take place daily, or every other day : or they may be separated by much longer intervals, regular or irregular. Sometimes there is continual pain, but it is wonderfully exalted and aggravated by fits. It is described as being sharp, sudden, twinging, like an electric shock in its momentarv duration. Sometimes it is attended by a feeling of constriction and cramp, although no muscular con- traction 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. Whenever a patient tells me he has spasms here or there, I am obliged to request that he will explain himself further. I want to know how he construes spasm; TIC DOULOUREUX. 439 and nine times out of ten I find that he intends a sudden and sharpish, and gene- rally a transitory attack 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 such or such a part, it is impossible to tell what he means, unless that term is explained by the con- text. Pray avoid this inexactness. The most common of these neuralgic pains, as I have said, is that which has been called, Xav tZox*}v, tic douloureux, 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 neighbourhood. Sometimes two, sometimes all of them, are impli- cated. 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 endurable ; 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 super- ciliary hole ; and it involves the parts adjacent, upon which the fibrils of the nerve are distributed ; the forehead, the brow, the upper lid, sometimes the eyeball itself. The eye is usually closed during the paroxysm, and the skin of the fore- head on that side corrugated. The neighbouring arteries throb, and a copious gush of tears takes place. In some instances the eye becomes blood-shottm 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 mid- dle branch of the nerve, it is sometimes quite sudden in its accession, ami some- times 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 the 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 referrible 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 symphysis 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 spasmodic 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 move- ments 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 fre- quently gives relief, and causes a sense of numbness to take the place of the pre- vious agony. This cruel malady occurs most commonly in persons who exhibit, in other respects, 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 440 TIC DOULOUREUX. when that disorder is corrected. Sometimes it is clearly connected with a dispo- sition to rheumatic affections ; coming on in persons who suffer rheumatism in other parts, and even 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 may 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, perhaps, for that reason, to be affecled by vicis- situdes of temperature ; but in many of these cases the disease seems to be pro- duced by the malaria, which is prevalent 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 exostosis, in the neighbourhood of the painful spot. The late Dr. Pemberton afforded a well-known^example of this. He was seized vvith tic douloureux in the very zenith of his reputation, and when he was in the fullest practice of his profession in this town. It com- pletely ruined him : compelled him to give up business. He ultimately died of apoplexy. When his head was examined after death, the os frontis was found to be unusually thick, and on the falciform process of the dura mater, at 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 several 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, asitdepends upon different causes and different persons, 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 example of it that comes before us, must be to investigate all ihe particulars of the case. We must not be satisfied with learning 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 origin of the disease is plain, and the remedy obvious. We must endeavour to make out whatever 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 plethora. Mr. John Scott gives the case of a gentleman who suffered severely from it for some time ; at length he had an attack 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 treat- ment so strongly recommended by Mr. Hutchinson, viz., by givino- the carbonate of iron. This remedy has been put largely to the test, since Mr. Hutchinson wrote in commendation 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 admin- istering 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 carbonate of iron proves beneficial by its me- chanical operation on the internal surface of the intestines: but I should rather ascribe its good effect to the well-known property 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 stale of the digestive organs should be attended to. Mr. Abernethy used to relate, in his lectures, many instances of tic which he had been successful in curing by TIC DOULOUREUX. 441 measures which were solely directed to the improvement of the stomach and bowels. He had a notion, that in patients who suffer under this disorder, 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 commonly find indications of a faulty state of both these systems. " The two," he used 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, ihe unhealthy 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 colocynth ; 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 olher cases have been since reported, both by Sir Charles and by others, in which the same prescription 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 ; col- chicum ; 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 unredressed, 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 com- munication, 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 miffht have been expected. In Dr. Pemberton's case the several branches of the fifth 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 per- form castration with the view of remedying that pain in the testicle which is apt to be produced by the passage of a calculus throngh the ureter. Nevertheless there are cases, in which the division of the nerve, or some other surgical opera- tion, 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 vvith 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 thus effected. And if this cannot be done, or if the nerve itself be altered in structure, either from disease or injury, (I am referring now to neuralgia in general, and not merely to that in 442 TIC DOULOUREUX. which the facial branches of the fifth pair of nerves are implicated,) under those circumstances it will become.a very proper subject of deliberation 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 men- tions 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 whose finger had been amputated for very acute neuralgic pain which she had suffered in it; 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 paroxysms. Of this I may mention one remarkable example, which fell in part under my own observa- tion : although I had nothing to do with the treatment. I was asked, a few years ago, by a friend, to go vvith him to call upon a relation of his, who laboured, he said, under tic douloureux : 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 delicate, 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 prac- titioner who had desired that she might eat mutton-chops three or four times 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 steadily 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 prac- titioner, Mr. Pennington, was called in. He acted, like 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, however, 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 sliQuld refrain altogether from taking food or drink by the mouth. Nourishing injections, composed of beef lea wilh 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. Penning- ton 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 any thing, without the slightest inconvenience. I 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 TIC DOULOUREUX. 443 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. I allude to aconitine : the active principle of the monkshood. The property belonging to this plant, of benumbing sensation, has long been known. Sir Benjamin Brodie found many years ago that after chewing its leaves, a remarkable numbness of ihe 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 it, as a benumber of pain, is highly encouraging. It has been of singular benefit to a surgeon who formerly lived in Charterhouse Square, and whose case is well known, I 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 doloureux, 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 the 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 under- stand, that the application 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 application 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. Mor- son'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 times a day over my patient's face, and the attacks presently dimi- nished 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. It 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 tem- perature 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 allay- ed the pain for a time it would be highly valuable. But, judging from the in- stances 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 gen- uine 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 em- ployed 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, vvith the professed object of introducing to general notice a spe- cies 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 oint- ment, but without benefit. It consists of the iodide of mercury, mixed with lard * This gentleman is since dead. 444 SCIATICA—HEMICRANIA. in the proportion 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.* There is a kind of face-ache, which cannot properly be reckoned as a species of 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 principally, 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 ex- tracted, 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 speedily cured by the muriate of ammonia;— a medicine that we seldom give internally here, although it is so much used in Germany. And I have again and again availed myself of this-hint, and been much thanked by my patients for the good I did them vvith 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 recently 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 lo 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 hemicrania. I have very little to say, in this place, of either of these. Sciatica, or pain radiating from the sciatic notch, and following the course of the sciatic nerve, is sometimes an inflammatory complaint, and yields to the remedies of inflammation—bleeding and blistering: 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, affecting 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 the 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 little 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 affecting 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 * [In several cases of neuralgia, of different parts of the body, which, for a number of years, had resisted a variety of plans of treatment, we have seen almost immediate relief, and in a few, a permanent removal of the disease result from acupuncturation. In other cases, however, no benefit has resulted from the operation.—C.J INTERMITTENT FEVER. 445 occurs in connection vvith hysteria; sometimes it plagues women who have suckled their infants too long; sometimes it acknowledges 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 anaemia, 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 cases out of ten in which it occurs. But steel or bark, being milder and safer drugs, are, caeteris paribus, to be preferred. I say this disorder often acknowledges the same cause as ague; namely, the miasm of marshes, or malaria: and as that cause, mysterious as it is in some respects, exerts apparently its primary or chief influence upon the nervous system, and as ague has no definite seat in the human body, if it be not in the nervous system, 1 shall not find a more convenient place in these lectures for the consi- deration of ague 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 Intermittent Fever. LECTURE XL. Intermittent Fever. Phenomena of an Ague Fit. Species and varieties of Inlermitlents. Predisposing causes. Exciting cause. Malaria: known only by its effects; places which it chiefly infests ; conditions of its produc- tion; its effects upon the human body ; influence 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 symptoms. Before we can inquire successfully into its history, it is neces- sary that we have the group of symptoms which identify it set fairly before us. I must first, therefore, 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 symp- toms occurs, and then the patient reverts to a state of health : but this alternation commonly 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 repetitions 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 stretch himself; and he soon feels chilly, particularly in the back along the course of the spine; the blood deserts the superficial capillaries ; he grows pale, his features shrink, and his skin is rendered dry and rough, drawn up into little prominences, such as may at any time be produced by exposure to external cold, and presenting an appearance somewhat like the skin of a plucked goose : hence it is called goose's skin, and in Latin cutis anserina. Presently the slight and 446 INTERMITTENT FEVER. fleeting sensation of cold, first felt creeping along the back, becomes more decided and more general; the patient feels 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 slightly from the constricted state of the integuments of the scalp ; his face, lips, ears, and nails turn blue ; rings which before 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 generally he voids but little, 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 ordi- nary condition and bulk. But the reaction does not stop here ; it goes beyond the healthy line. The face becomes red and turgid ; the general surface hoi and pungent and dry; the temples throb; a new kind of head-ache is induced; the pulse 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 symp- toms 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 debility. The paleness of the surface, and constriction of the skin, and collapse of the fea- tures, 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. Horripilalio is the learned term for this state of the surface. The coldness of the skin is another conse- quence 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 shiverings of the patient. The necessary accumulation of the blood in the larger and internal vessels offers a reasonable explanation 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 ihey 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 supposed cause, and also that the supposed cause and INTERMITTENT FEVER. 447 the effect are not proportioned to each other, we cannot but conclude that the sup- posed 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 forcible 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 in- creased by exercise: the extreme vessels receive a larger supply 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 deserv- ing of mention. Thus it is said that this circumstance should not have been introduced iato the definition, because it is not necessarily or universally 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 trifling. 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 the body; but the truth is, that no satisfactory explanation of it has ever been given, and we must be con- tent, for ihe present at least, to receive it as an ultimate fact; and, doubtless, a very strange and interesting fact. For distinguishing some equally curious varieties of these successions and alternations 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 paroxysm and the commence- ment of the next is called an intermission; while the period that intervenes be- tween the beginning 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 inter- missions are perfect and complete, the patient resuming the appearance and sen- sations of health, the disorder is an intermittent fever. When the intermissions are imperfect, the patient remaining ill and feverish and uncomfortable in a less degree than during the paroxysm, then the complaint is said to be a remittent fever. But, confining ourselves for the present to intermittents, it is another curious property 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 circumstance 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 qfher 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 alter- nate days ought to be styled secundan. But nosologists have chosen to reckon the day on which the preceding fit happens as the first: and then the day on which the fit next to it will happen, 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 intermittent fever. It follows, of course, from what I have been stating, that in the quotidian 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 paroxysms of the quotidian ague begin in the morning; those of the tertian, at 448 INTERMITTENT FEVER. noon ; those of the quartan, in the afternoon. These are the rules. 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 day, before they take their final departure. This is called postponing: and when they occur earlier than their stated hour, the paroxysms are said to anticipate. Now a postponing quotidian may be deferred till noon. But when the disease is pursuing its regular undisturbed course, the rule is such as I have mentioned. The three principal types differ from each other, not only in their respective intervals, and in the periods of the day at which the paroxysms severally com- mence, 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 intermission is nearly the same. The tertian paroxysm commonly begins at noon, and is finished the same evening; its average duration maybe 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 the 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- 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 observed (and that is very rarely) they are merely irregular quartans, postpon- ing perhaps 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, Pliny, the naturalist, informs us that a certain Improvisatori was in the habit of having a paroxysm once a year, and that exactly on his birlh-day ; yet he died at a good old age. There are, however, some curious modifications of the three principal types; or ralher of two of them, the tertian and the quartan. For instance, a paroxysm may occur daily, and yet ihe ague not be of the quotidian type, but of ihe 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 differences 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 Tues- day 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 variations. The form I have last mentioned, in which two dissimilar paroxysms occur every other day, is called tertiana duplicata, while the other form, in which there is a lit 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 INTERMITTENT FEVER. 449 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 like the third, and so on. This is the quartana duplex. But two fits may happen in one day—say on Monday ; none on Tues- day or Wednesday ; 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 counter- part 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 complica- tions still, vvith 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 likely to practice abroad. Some physicians have used the words double tertian, and so on, in the literal sense, and have supposed that two or more distinct agues coexisted. This savours a good deal of the error that I formerly warned you against, of looking upon dis- eases as separate entities, and not merely as modes of being and of acting differ- ent from those which are proper to the state of health. The vulgar always re- gard disorders in this light. A coachman by whose side I sat while traveling from Broadstairs to Margate, 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 ad- ministered to his suffering parent a glass of brandy : whereupon " he threw the agy off his stomach ; and it looked for all the world like a lump of jelly." That was the only occasion on which he had ever " seen the agy." Besides these varieties in type, some other deviations from the normal and regu- lar paroxysms require to be noticed. Sometimes ihe 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 shakes, 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 com- plaint 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 experi- ences frequent and irregular chills, is languid and uneasy, and depressed. This state is commonly known among the inhabitants of our fenny and aguish districts as the dumb ague, or the 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 invasion, 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 of 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 symp- toms which constitute the fits. Occasionally each paroxysm is attended by vio- lent delirium : this is most common, I believe, in the hot stage. This symptom has been known to be almost constant throughout an epidemic. Sometimes the 29 450 INTERMITTENT FEVER. patient is eonvulsed in the paroxysm; or syncope comes on; or tetanic rigidity; or petechia? take 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. I shall presently have a good deal to say upon the one grand—I may say sole—excitinc 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 determining 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 maybe protracted 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 other 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, caeteris paribus, the more severe and dangerous. The quotidian is most common in the spring; the quartan in the autumn; and the tertian is frequently met with both as a vernal and as an autumnal ague. You will bear in mind that in all this I am stating the prevailing rules ; which are liable to numerous exceptions. * Ague is one of those disorders of which (as of common inflammation) all per- sons, at all periods of their existence, seem to be susceptible, when submitted to the influence of the specific exciting cause. Individuals of all ages, from sucking infants to persons of four score, are liable to it, but they are not equally subject to it. It is less likely (caeteris 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 eurious 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 ob- noxious to many forms of disease ; for we trace the consequences of such disease, in visible changes of structure, immediately after birth. Pulmonary tubercles constitute one malady to which the foetus in utero is liable: hydrocephalus is another: acute inflammation of the peritoneum a third. And there can be no doubt that various specific poisons influence, occasionally, the included being, even although they may have no sensible effect upon the parent. The foetus 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 pregnancy; and the infant in the womb must have caught the disease, for I was assured that he hooped the very day he eame into the world. The sins of the parent are thus visited often upon the child, when, before its first breath is drawn, its frame is contaminated t 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, which 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 INTERMITTENT FEVER. 451 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 fre- quently seen in men than in women. Among the circumstances which predispose to ague, debility has a powerful influence. 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, without becoming affected by it, while strong and in good health; and have fallen ill of intermittent fever upon being weakened by exertion and fatigue. When I have told you that debility, any how produced, constitutes 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 disease; 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 com- plaint 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 mak- ing that statement I refer to its 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 be- lieve, 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 effects of predisposing circumstances in respect to ague. 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 insisted, much against the will of the surgeon of the regiment, on resuming his duties before his strength was completely re- stored ; and the consequence was that he was immediately attacked by a remittent fever of such violence, that his life was for some time despaired of. But this was not all. The remittent disease assumed by degrees 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 appearance his health was re-estab- lished, 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 slight causes were sufficient to reproduce 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 cir- cumstance, the east wind, is a common re-exciting cause in such cases ; exposure 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 somewhat 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 convenient 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 atmosphere. 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 452 INTERMITTENT FEVER. health, as I formerly took occasion to show you : but it does not generate fever: neither continued fever, nor intermittent.* 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 malaria. 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 practice 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 difference and controversy amongst medical men: not a few of whom confound the severe continued fevers which spring from the malaria, and which are never contagious, vvith the severe continued fevers usually called typhous, which are unquestionably communicable from person to person. The effluvia which thus form the sole exciting cause of intermittent and remit- tent fevers proceed from the surface of the earth, and are, probably, gaseous, or aeriform : at any rate they are involved in the atmosphere. But they are imper- ceptible 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 unequivocal 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 1695, f)e noxiis paludum effluviis. This is the great original work upon the subject. To the production of this deleterious agent, a certain degree of temperature seems necessary. It does not appear to exist within 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 Fahren- heit's thermometer. The nearer we approach the equator, the more abundant, virulent, and pernicious does the poison become, wherever it is evolved at all — In this climate it gives rise to intermittents, and principally to tertians. As we go south, in Spain, and along the shores of the Mediterranean, the remittent be- comes the predominant form ; and (what is very instructive) remittents there con- tracted often improve into intermittents 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 continued 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, snowing 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 overflowed. Many of * [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] INTERMITTENT FEVER. 453 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 Sydenham's time they were very frequent, and very fatal in- deed, in this metropolis. James I. and Oliver Cromwell both died of ague con- tracted in London. At present (as I said before) we seldom meet vvith them.— Except in the year 1827,1 have never, since I have been in practice, known ague to be at all common here. This comparative 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 Maremna, which stretches for about thirty leagues along the shores of the Mediterranean, and which in some places is ten or twelve leagues broad, is ren- dered dangerous, and almost uninhabitable, by the vast quantity of malaria annu- ally evolved from its soil. In America large districts are, for the same reason, prolific of disease. The late Bishop Heber, in his Narrative of a Journey through the Upper Provinces of India, 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 only, but every thing which has the breath of life, instinctively deserts them from the beginning of April to October. The tigers go up to the hills ; the antelopes and wild hogs make incursions into the cultivated p]ain ; 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 solitude. 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. It is in the extreme heat, and imme- diately after the rains have ceased, in May, the latter end of August, and the early part of September, that it is most deadly. In October the animals return. By the latter end of that month the wood-cutters 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." Persons 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 result of the unfortunate expedition to Walcheren. Sir Gilbert Blane has given an account of the ravages it there committed among our troops. You may see his paper, to which I shall presently again refer, in the third volume of the Medico-Chirurgical Transactions. Not only a certain degree of heat, and a certain quantity of moisture, but the presence 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 pestilential agent; but in vain. A more likely way 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 principle eludes the test of the most delicate chemical agents. Where there 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 454 INTERMITTENT FEVER. matters was somehow or other requisite to the formation of the poison that exists so commonly in swampy situations. This belief has descended, almost unques- tioned, from the time of Lancisi; and it obtains almost universal acceptance, I fancy, among physicians of the present day. Yet very strong facts have been adduced to show that the decomposition of vegetable substances is only an acci- dental, though a frequent, accompaniment 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 without the production of malaria. The rotting cabbage-leaves of Covent Garden, and those which taint the air of the streets from the neglected dust-holes of Lon- don, 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 quanti- ties upon some very healthy parts of our sea-coast. But the converse facts are the most remarkable and conclusive. I have stated that marshes are not neces- sary to produce malaria; but Dr. William Ferguson—a physician who has had, and who has well used, very sufficient 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 dissemi- nated by medical men, I will mention a few of the most striking of the facts detailed by Dr. Ferguson. 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 en- camped 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 pre- cisely similar. Sir Gilbert Blane describes it as consisting " of a fine white eand, 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 suf- fered in that island from the endemic fever, to a degree which Dr. Ferguson speaks of as "being almost unprecedented in the annals of warfare." In the year 1809, 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 vvith violent remitting fever before they could move from the bivouack the next morning. "Till then (says Dr. Ferguson) it had always been believed amongst us that vegetable putrefaction (the humid decay of vegetables) was essen- tial to the production of pestiferous miasmata; but in the instance of the half-dried ravine before us, from the stony bed of which (as soil never could lie for the tor- rents) the very existence even of vegetation was impossible ; it proved as pestife- rous 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 pools in the courses that had formerly been rivers. The troops there "suffered from remittent fevers of such destructive 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; INTERMITTENT FEVER. 455 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 worth 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 unhealthy region. On the one side is a bare hilly country; the foundation 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 pestiferous. Moreover, in and near Lisbon there are numerous gardens, where they keep water, during the three months' absolute drought of the summer season, in stone reservoirs. These reservoirs, containing water in the most con- centrated state of foulness and putridity, are placed close to the houses and sleep- ing 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 ignorant 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 fSot been seen for months, and where water, being absorbed into the sand as soon as it fell, was never known to be putrid, he would run the greatest risk of being seized with remittent fever." Now these facts, and facts like these, seem to prove that the malaria, and the product 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 capable of absorbing moisture, and 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 of animal matter is sometimes spoken of as an element in the formation of the malarious poison. But the evidence I have just set before you refutes this supposition as completely as it excludes the alleged necessity of vege- table decay. I hope 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 proceed from parts of 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 had previously been very danger- ous, 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 con- 456 INTERMITTENT FEVER. tract 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 differences observable in regard to these fevers at different elevations, and in dif- ferent 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 continued. The following instructive facts are stated by Dr. Ferguson. In 1816, 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 was 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 expire within less than thirty hours after being carried up to his barracks, vvith a yellow skin, and having had black vomiting. Those in the barracks on Monk's Hill, ivho did not come down, the superior officers, the women, children, and drummers, had no fever of any kind. Seven- teen 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 con- tinued fever, resembling, and I believe identical vvith, yellow fever: at the eleva- tion 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 intervening hills; the Italians 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 oecur; that is to say, after the heats of summer : and the hotter and drier the pre- ceding summer, the more frequent and fatal are the autumnal fevers. The Pontine marshes lie to the southward of Rome; and Horace, you know, says or sings, Frustra per autumnos nocentem Corporibus metuemus austrum. The effects of these morbific effluvia upon the human bpdy vary much under different circumstances. Where they are most concentrated and deadly, their operation 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 incu- bation. 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 Wal- cheren 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 MALARIA. 457 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 acci- dental ; 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 which 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 pestilential plains of Estremadura the superstitious natives, unable or unwilling to account for a disease of a type so uncommon, among the soldiers, from any unwholesomeness 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 re- commended 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 Wal- cheren, in order that the men might be habituated or seasoned to the air, (accli- mates,) 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 mortality 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 travelers as being puny, sallow, and sickly; feeble in body and spiritless in mind ; as having yellow faces, swelled bellies, and wasted limbs; as being subject to dropsies and fluxes; phlegmatic, melancholy, and short-lived. One remarkable exception is mentioned by Dr. Ferguson. From some pecu- liarity 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 concen- trated, prove to him congenial. He delights in them, for there he enjoys life and health, as much as his 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 tQ 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 458 INTERMITTENT FEVER. in which the peat-moss abounds, are completely free from these fevers. Dr. Bisset affirms that the exhalations from black peat-moss do not occasion intermit- tents, " at least in high moors under a clear sharp air." Now in the climate of Virginia, this counteracting 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, like 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. Ague, continued. Speculations respecting its periodicity. Habits and proper- ties 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 dimi- nished by the increase of cultivation and of population. Ultimate effects of the poison on the body. Ague formerly thought salutary. Prognosis. Pro- priety 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 delineated ; 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 intermittent fever, which may all be briefly included under the head of circum- stances that tend to debilitate the body: the strongest predisposing cause of all being 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 circumstances 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 substances 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 lec- tures, 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 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 sur- face with water, and a subsequent drying of that surface under a certain degree of heat, constitute the sole or main conditions of the generation of the poison. We found that the effects of the malaria are modified by the temperature of the place: that in low and hot situations it may 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 inter- mittent type: that the period of incubation—the period which intervenes between exposure to the malaria and the invasion of the fever—is extremely variable in duration: that the poisonous effluvia affect strangers more certainly and more severely than natives of the place: that persons may become in some sort sea- soned to the malarious districts: but that, wilh the exception of the negroes in INTERMITTENT FEVER. 459 the West Indies, the inhabitants of places much infested with the peculiar mias- mata, are feeble, and sickly, and shortlived. There was one point which I briefly adverted to, and dismissed perhaps too unceremoniously: 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 phe- nomenon 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 hypothetical, or totally insufficient and illogical. Willis ascribed the intermission to a periodic development of the fermentable matter in the blood. But if any such development took place (of which we have no evidence) we should be no nearer the mark: the question would still recur, why the development oT this matter should happen periodically: and the same remarks apply to various other so-called explanations 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 offers a very singular conjecture upon the subject: he attributes the periodic phenomena to the modification 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 oscillation of posture are not subject to intermittent fevers ; but this is said not to be a fact. Rodet and Char- pentier 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 occurrence of con- tinued 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 emanations (which he conceives to proceed from putre- fying vegetable 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 coldness of the atmosphere at that time; and coming in contact with the surface of the body, vvith the mucous membrane of the air passages, and perhaps also vvith that of the digestive organs, and being absorbed by those sur- faces, it occasions the phenomena which constitute an ague fit. The influence of the miasmata being intermittent, 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 460 INTERMITTENT FEVER. out; which accounts for the spontaneous 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 exposed to the miasmata. His theory fails altogether also to account for the different types of intermittent fever. The differences of type are indeed opposed to the theory. After all it is most probable that Cullen had discovered apart 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 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 revo- lution 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 quar- tans 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 exacerbations and remissions are generally to be observed—all this marks the power of diurnal revolution. A most interesting experiment, as it appears to me, performed by M. Brachet upon himself, shows in a strong light the influence of acquired habit in continuing certain unnatural states of the system when once they have been originated: the experiment connects itself also with the peculiar phenomena of intermittent fever. Towards the end of the month of October, in the year 1822, M. Brachet took a eold bath, at midnight, for seven nights in succession, in the river Saone. On the first occasion 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 time became affected with considerable 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 fitappeared in due order and succession ! As, however, this artificial 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 regu- larity. 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 heat by placing himself before a large fire, and from that time the febrile phenomena 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 in continuing 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. In 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 quartans. Indeed in quotidians themselves there is much difficulty in applying the explanation, for though by anticipating, or postponing, they may come on at different hours of the day, yet their usual and natural paroxysms occur, not in the evening, but in the morning, when, on the principle of diurnal habit, there should be the least tendency to exacerbation of febrile action.* * I would beg to refer the reader to Dr. Holland's interesting chapter (in his Medical Notes and Reflections, published since these lectures were delivered) " On Morbid Actions oflntermittent kind."—T. W. MALARIA. 461 In yesterday's lecture, I pointed out the favourite habitats, if I may so speak, of the malarious poison. I have still a few observations to make respecting its ascertained 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. In 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 copiously evolved, or whether it be merely condensed and concentrated by the diminished temperature, or whether the body be at that time more susceptible of its influence, it certainly is most active and pernicious during the hours of dark- ness. 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 praesertim indormientes magis quam vigi- lantes laedantur ?" 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 many or all of them seized with the fever. Take one instance as a sample of many. It is recorded by Dr. Lind. In 1766 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 ships 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 night on shore;" while the rest of the ship's company, " who, after spend- ing 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 Yellow 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 I yesterday mentioned—are permitted to sleep for two hours about noon. They do so at that time without danger: but when the dews of evenlncr 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 summer 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 travelers who, in consequence of their having crossed these fens during the night, have been at- tacked with 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 a 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 hazardous to leave the house early. Secondly, the malaria loves the ground. It tends downwards. Whether this results from its specific gravity; or from its adhering to the moisture suspended in the lower strata of the atmosphere; or from some peculiar attraction for the earth's surface; I cannot tell you. There is reason to suppose that the poison combines somehow, or becomes entangled, with fog: and fogs usually brood and settle, at 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 462 INTERMITTENT FEVER. all malarious seasons and countries," says Dr. Ferguson, " the inhabitants of ground floors are uniformly affected in a greater proportion than those of the upper stories. According to official returns during the last sickly season at Bar- badoes, 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 contained 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 ap- peared 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 Bar- badoes, 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 uni- formly in favour of the proposition that the poison is most prevalent and destructive near the surface of the earth, and does not rise high into the atmosphere. To specify the sanatary 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; lo which, perhaps, it may cling. The following passage relative to this subject occurs in Bishop's Heber's Journal. " From Cheeta Talao our road lay through a deep and close forest, in the lowerparts 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 pestiferous, 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 sur- face of the ground to another, it is very important to attend to in all places; and especially 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 excep- tions 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 penin- sula 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 pyra- midal 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 establishments of the garrison were originally placed ; the whole space within the peninsula being the driest, the cleanest, and the healthiest sur- face conceivable. It was speedily found that the barracks in the valley were very MALARIA. 463 unhealthy; and to remedy this fault, advantage was taken of a recess or platform near the top of the inner hill, to construct 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 hun- dred 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 at- tacked with tertian ague. So also Humboldt informs us that the town of Cariaco is afflicted with intermittents by the north-west wind conveying across it the mi- asmatic emanations of the Laguna of Campona. And as the wind may thus transport the malaria to a distance, and thereby ren- der a spot unhealthy which naturally would not be so: so also it is often of ser- vice 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 climates, especially where trade-winds prevail, w^ould 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 islands. Fourthly, it is a singular, but well-ascertained fact, that the miasmata lose their noxious properties by passing over even a small surface of water. Probably they are absorbed by it. And this is another proof of their tendency down- wards. 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 ende- mic; but also the guard-ships which were stationed in the narrow channel be- tween this island (Walcheren) and 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 Brabrnt; especially in reference to four bat- talions which had remained for some time in Zealand : and he says, " But Com- modore 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 esti- mate of the space through which the poisonous effluvia can be carried upon land, by the wind. Although the distance to which they are capable of being so con- veyed, without losing their morbific power, has never been precisely defined, there can be no doubt that it is considerable. In Italy, according to Dr. Maccul- 464 INTERMITTENT FEVER. loch, the poisonous exhalations of the lake Agnano have been ascertained to reach as far as the convent of Camaldoli, situated on a high hill three miles distant. 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 dangerous, in malarious places, to go under large thick trees, a*id 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 belt of trees be interposed. New Amsterdam, in Berbice, lies 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 maybe turned, was known to Lancisi. He describes the vast increase of agues and remittent fevers in Rome during the summer of 1695, 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, between 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 unfor- tunately built in the vicinity of marshes, might sometimes be rendered safe and salubrious 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 effects, of the malaria are pre- vented, 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. Conversely, in regions which have been suffered to fall out of cultivation, intermittent and remit- tent fevers multiply. The more thoroughly any country is cultivated, the more fully, in general, is it peopled also: and in many places the prevalence of these fevers has been observed to diminish and increase with the increase and diminu- tion of the population. Caeteris 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 productive of malaria, is depopulated, the more evident does the power of the poison become. The Italians date the introduction of the malaria into the Ma- remna, from the great plague in the sixteenth century, since which period the inhabitants of that district have never been sufficiently numerous to counteract the bad air which increases as population and agriculture diminish. MALARIA. 465 Bishop Heber, in the narrative I quoted before, bears testimony to facts of the 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 removed several coss, though the country already begins to partake of its in- salubrity. It is remarkable that this insalubrity is said to have greatly increased in the last fifteen years. Before that time, Ruderpoor, where now the soldiers and servants of the Police Thanna die off so 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 depopulation. 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 so checked, has never recovered itself." When persons having intermittent fever are unable to leave the unhealthy situation in which they have been exposed to the influence of the malaria—and especially 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 vis- cera, even in the intermissions; sickness, diarrhoea, dysentery, diseases of the liver.* In Zealand, the biliary functions suffer so much during the complaint, that it is commonly 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 be 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; vvith or with- out induration of its substance. 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 believe 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 tho- roughly 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 succes- sive occasion. It may be that a portion of the blood coagulates; or that inflam- mation of a slow kind is set up in the stretched covering of that organ. At all events, this is a very 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 injurious influence of the malarious districts upon the general health. In this * [Dr. S. A Cartwright, of Natchez, asserts, that \\\e jussieua grandiflora, or floating plant of the bayous 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 puri- fies 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 " mala- rious 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 waterand swamps than any other inhabited district, of the same extent, in the United States."—C] 30 466 INTERMITTENT FEVER. country such 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; they 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 partake of the degeneration of their bodily qualities. It is therefore strange that a notion should ever have prevailed, of the salutife- rous effects 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 of 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 ex- pressly 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 applicable 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, however, been handed down to us by the father of physie himself. Hippocrates says, in the fifty-seventh Aphorism of his fourth Section, vrto erlasuov, rj -ieiavov ivoxXovfisvcp, rtvpstoi iftiysvofiivo^ %vn to vovaqfjia,. And Celsus, in his capital digest of the medical knowledge 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 praesidio 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 vvith 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 few 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 say, in addition to what you must have inferred from what 1 have already said, as to the prognosis in intermittent fevers. In cold countries, such as ours, it is almost always favourable. Of course it will be modified by the previous condition of the patient: if he was beforehand the subject of serious orga- nic visceral disease, or if he be very old or infirm, the supervention of ague may destroy him. But to persons of tolerable health and strength prior to the setting in of the ague, we may confidently promise a cure. In warm countries intermit- tent fevers are much more dangerous: and are sometimes very rapidly fatal. They are often accompanied by most severe affections of the head, stupor, deli- rium, convulsions; and of the alimentary canal, diarrhoea, sickness, and not TREATMENT. 467 unfrequently the black vomit. They are prone, also, in those climates, to run into the remittent or continued form; and this tendency is shown by long pro- tracted paroxysms, or by the anticipation or doubling 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 autumnal inter- mittents are more pernicious and intractable than the vernal. This fact has passed into a proverb in Italy; which proverb has been thus translated into Latin, " Febris autumnalis—vel est longu, vel lethalis." The longer intermittents have lasted, the more difficult also are they to cure: and certainly 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 specific cure for ague, 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 we should be inexcusable, 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 dis- ease, 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 climates. "If the first fit (says the wise and observant Heber- den) 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 pre- vent, 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 hypothetical 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 situ- ated on the very edge of the fenny country which extends 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 hospital; but with very poof success. Now these cases readily gave way—the patient remaining in all other circumstances as before—after the operation of a calomel 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 vvith six or eight grains of rhubarb at bed-time, and commence vvith the quina the next morn- ing. Very lately, in perusing the late Dr. Baillie's posthumous volume, I met with the following passage:—" I 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, when 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 learnt from my friend Dr. David Pitcaim." 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 con- fess to you that I seldom give myself nuich 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 tbe hot stage; to wipe his skin dry, if the sweating should be very profuse or protracted. But in hot coun- tries, and in severer forms of intermittent, 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 bound to do so, because certain measures which I 468 INTERMITTENT FEVER. do not think necessary or judicious, at any rate for the complaint as we see it here, have lately been strongly recommended during the ague fit. LECTURE XL II. 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 continued form, and where, during its violent and rapid course, internal organs are liable to sustain serious damage, the best and indeed almost the only time for the effectual interference of the physician is in the first assault or paroxysm of the disease. The objects of treatment during the paroxysm are, to alleviate the uneasy sen- sations 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 internal congestion long continued, or from the severity of particular symp- toms. Now in the cold stage of ague, diluent drinks have been recommended, and cordials, and external warmth, and opium, 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 I 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 Pharmacopoeia, 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 diluents 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 procured. "In some places it is the custom to await an expected fit in the warm bath. When this cannot so conveniently be obtained, the pediluvium maybe employed; or the patient may be put into a warmed bed, and have bags of hot salt or bran applied 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 stt«e. 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 wiih an embrocation 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 TREATMENT. 469 short the fit; and not without some success. The strongest evidence of its use- fulness in that stage of the paroxysm is furnished by Dr. Trotter, in his Mcdicina 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 warmth 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 pulse from being weak, quick, and sometimes irregular, be- came less frequent, full, and equal; an agreeable warmth was diffused over the whole frame, and every unpleasant feeling vanished, sometimes in a quarter of an hour. The patients were themselves 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 indicated a ihird attack, at the expected period of accession." Notwithstanding this testimony, it appears that opium is 6till better adapted to another stage of the paroxysm. Emetics were formerly much prescribed in the cold stage, at its earliest ap- proach. 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 paroxysm. Vomiting is itself no small distress to many per- sons ; and for my own part, I should not think of giving an emetic unless some indications of a loaded and oppressed state of the stomach were 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 impediment 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 administer the requisite medicines. In hotter climates 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 ex- tolled, but I believe every experienced tropical physician will agree with me in cautioning young practitioners against their indiscriminate employment. Irrita- bility of the stomach is one of the most frequent and troublesome symptoms ; and onc,e 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."* Lately, the practice of blood-letting in 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. Mackintosh 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 sensa- tions 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 * [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 bhbrtened, but the whole pa- roxysm is often rendered milder.—C] 470 INTERMITTENT FEVER. patient feels relief: .which usually consists in liberation from pain of the head and loins; freedom of respiration ; the departure of the painful sensation of cold; and the cessation of the tremors and of the debility. Most of the patients fall asleep after the operation. These effects have been produced by the abstraction of an ounce and a half of blood; they have sometimes (but rarely) required for their production twenty ounces. Now this is the piece of practice to which I adverted at the close of yester- day's lecture, as being, in my humble opinion, inexpedient and not to be recom- mended ; at least in the agues of this country. I have seen a good many cases, first and last, and certainly I have never seen one in which I could have thought such an heroic 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. Mackintosh. His method has been tried, since he first made it public, by various practitioners in this country. Drs. Townsend and Law, of Dublin, 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 its severity, without abridging its dura- tion. In most instances, no modification was produced of the hot and of the sweating stages. In Dr. Kelly's experience, the general effect was, to shorten ihe cold stage, and to render the hot one milder; but in some cases it seemed to aggravate the symptoms. Mr. Gill found that, although the blood-letting might cut short the cold stage, it appeared to lengthen the period of febrile disturbance. Confining myself, then, to intermittents, as they show themselves in this climate, 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 unne- cessary ; 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 respct 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 pro- bable 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 vvith a degree of internal congestion and disturbance which is dangerous to the integrity of vital organs.* * [Mr. Twining, in his work 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 hasfoftml 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 mild 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 engorgements 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. He 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 bedclothes; 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 sufficient 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 the abdomen, and pain or uneasiness in the TREATMENT. 471 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 inflammation. The best remedy of the hot stage in 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 convul- sions 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 in the paroxysm. " Having at that time (says he) twenty-five patients labouring under intermitting fevers, I prescribed an opiate for each of them, to be taken immediately after the hot fit, provided the patient had then any inquietude, headache, or any such symptom usually subsequent to the fever. The consequence was, that nineteen in twenty-two received imme- diate 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 administered it removed the headache, abated the fever, and produced a profuse sweat; which was soon followed by a perfect intermission. Since that time I have prescribed 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 point 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 carefully wilh 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 likely to meet wilh in this country, it is unnecessary, and therefore objectionable, to be over-busy during the paroxysm. Wherever the disorder assumes a distinctly intermitting form, the most important part of the practice is that to be employed during the intermissions. Now there are certain general remedies advised for adoption in this period; and there are certain specific reme- dies. The general remedies 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 ; espe- cially 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 paroxysms by gentler and better means; so that I should not prescribe an emetic unless I 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 opera- tion 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 chest, the disease will seldom be arrested by the first bleeding; in many cases, they will have repeated paroxysms in each of which the use of the lancet will be required. Patients, also, in whom the paroxysm, more especially the cold stage, is attended with vomiting, Mr. 'J'wining has found to require the repeated abstractions of small quantities of blood during the rigors.—C] 472 INTERMITTENT FEVER. grains of calomel with eight or ten of rhubarb at bed-time; and to commence with the specific remedies the next day. 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 possessing similar virtues. I 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 unpro- fessional persons; and yet it is often expedient, in country places, where agues are rife, to provide the poor wiih 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 medica 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 Stahl and Hoffman ; and Boerhaave was never quite reconciled to it. Sydenham, by his example and recommendation, greatly promoted its adop- tion 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 specifies that we can boast of possessing ; and that, unlike most other highly vaunted sub- stances, so far from falling off from the accounts first given of its virtues, it has acquired in the lapse of time an increase and stability 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 bear- ing, is more satisfactory than of many other complaints, vvith 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 salts formed a great era in the history of the materia medica. As far as my own experience goes, the sulphate of quina has quite superseded the necessity for exhibiting any other form of cinchona for the cure of ague. Before quinia 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 justified Mr. 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 vvith 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 whom I have occasion to treat for ague. This plan has succeeded so well, that I have never been tempted 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 paroxysms 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 TREATMENT. 473 ensure the solution 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 vir- tue 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, how- ever, 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 regu- larly at short intervals. I have told you the amount of my own experience, which, however, 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. Elliotson 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 curiosity, to ascertain wilh how little quina you may cure an ague. I repeat that it has not happened to me to be dis- appointed, when I have given the medicine in small doses, as already described : which amount to about twelve grains in twenty-four hours; but, then, I suppose my cases have been well behaved and submissive. Dr. Elliotson states lhat he is continually obliged to give twenty or thirty grains in the twenty-four hours, before he can cure the complaint; sometimes in obstinate quartans, forty-five grains; and he mentions one case in which a scruple of the sulphate of quina, vvith 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 108 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 difficulty 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 sprin- kled 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] 474 INTERMITTENT FEVER. 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.* You must not be satisfied vvith 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 prudent to go on with the quina for ten days or a fortnight after ihe 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 Do- minica, states that if no more of the remedy be taken, in the ^Vest 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 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 each type, seven periodical 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 admi- nistration 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.t Arsenic is another substance which has great and unquestionable power over ague. It carries with 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 chil- dren, 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 sometimes 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 com- plaints ; but, as I said before, I do not recollect ever having been foiled in remov- ing 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 potassae arsenilis 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 pharma- copoeial 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 solution. Ten minims two or three times a day are a full dose for an adult: and you had better commence vvith not more than five minims. Ten minims * [It is very certain that the quinia, even when given freely and in large doses, will occasionally fail in arresting the disease, and that the majority of such cases will be promptly cured by the bark in substance. This we have seen repeatedly to occur.—C] f [The Quinise Sulphas Impurus of the United Slates Pharmacopoaia, known in Philadel- phia under the name of 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] TREATMENT. 475 contain one-twelfth of a grain. Twice that quantity has been administered at once; but this ought never 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 pre- caution 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 diarrhoea; and if the medicine be continued, fainting is often added. Other symptoms, less constant, perhaps, and less im- portant, are painful and hot tumefaction and stiffness of the face and eyelids, or even a tingling eruption something like nettle rash. These effects may, I be- lieve, be controlled by adding a few drops of laudanum to each dose; but I would rather advise you to suspend 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.* When the paroxysms continue to recur in spite of the bark, it has been recom- mended (and I think ihe plan a good one), to try to stop them by arsenic; and then, the periodic 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 olher remedies, I say, have had their praises sung. I 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, therefore, in aguish districts, they may with much propriety and benefit be recommended to the poorer classes, or distributed by Lady Boun- tifuls.f One of these is willow-bark; in substance, or in decoction. If this does cure agues, as it is affirmed to do, it would 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 salicine, in which the febrifuge property is believed to reside. Holly leaves, and ilicine 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 tolerably large scale, and the testimony to its influence in curing agues is very strong. Dr. Craigie has given this account of it. In the year 1760, a num- ber 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 cobweb, in certain forms of the disease. He therefore made trial of cobweb, and found it to answer admirably. He was successful with it in more than sixty cases of different types, in the Isle of Man, and he had fur- ther experience of its utility subsequently in Ayrshire. After this, ihe 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 * [The arsenical solution is a remedy admirably adapted for the cure of intermittent fever when 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, we have never known any disagreeable effects to result from the arsenic, and we have employed it somewhat extensively.—C] f [The ferrocyanuret of iron is certainly a very valuable remedy in cases of intermit- tent fever. Stokes places it in efficacy after quinia and the arsenical solution, and perhaps he is right in so doing; it will, however, often succeed in preventing the recurrence of the paroxysms, given in the dose of six grains every three hours.—C] 476 INTERMITTENT FEVER. 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.* 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 in continued lever, 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 Edinburgh Medical and Surgical Journal. It would seem to be especially use- ful, in those cases in which there is a marked disturbance of the digestive organs; nausea, flatulence, hiccup, diarrhoea, or dysentery. 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 vvith a few grains of rhubarb. If the power of this substance should be confirmed by future observations, a cheap remedy would thus be 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 charcoal it contains; unless it is derived from the confidence his flock is accustomed to place in his specific. The very same remedy, the snuff of a candle, is mentioned by Lind. Piperine, the crystalline 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 the 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 ascertained to con- tain. 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 time, after the bark had failed; but this was before the quina had been educed from it. Heberden 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 Celsus, 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 efficaxesl; quo incasu suspicio erit ventriculum sordibus onustum vin remedii impedire. Itaque vomere oportet; quo facto, febris raro non cedit. Quod si redire perseveret, confugiendum est ad flores chamaemeli, quorum eontritorum scrupulns dandus est loco drachmae cin- chona?, et ad idem praescriptum 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 sul- phate of zinc have been given several times a day; or 3 grains of the oxide of zinc * [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 the quinia; in a few eases, however, it failed.—C] TREATMENT. 477 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 rather 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 fystern, through 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 often been cured by the agency of strong mental emotion, such as sud- den and great joy, anger, terror, or eager expectation. Thus we read that Quin- tus Fabius Maximus was cured of an old quartan on the day of a great battle. Strong impressions 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 but- ter; keeping a spider suspended from the patient's neck in a nutshell, till it dies ; and ihe like. The undoubted success, in many cases, of charms, must be referred to the principle of faith. The patient recovers, because he firmly believes in your power to cure him. Dr. Gregory used to relate the case of a patient in the clini- cal wards in Edinburgh, who, with sundry ceremonies, swallowed some word, written on a slip of paper: the result was, that he had not another paroxysm. And 1 perfectly recollect having a 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 peo- ple who came to be relieved from their ague, that they should have no more of it after such a day; and their implicit reliance upon this prophecy brought about its fulfilment. There seems to be this general principle observable in respect to agues, and to most other diseases which occur in paroxysms, viz., that after they have continued for some time, their further continuance depends more upon the effect of habit than any thing else: and this habit may be broken by strong im- pressions 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 habit in hysteria, and in some cases of epilepsy. Caeteris paribus, that physician will be the most successful in these disorders, who is best able to ac- quire ihe 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 will have gathered from the facts which were staled 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 life. 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 cannot 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. Per- sons who have been exposed to the exciting cause, or who have once had the fever, should, in whatever 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 dis- trict persons should bear in mind the facts, that the miasmata are much more viru- lent 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 goinc 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 478 EPISTAXIS. 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 allow- ance of fermented liquor, are proper also lor 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 English 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 English, Irish, Scotch, West Indians, and American. 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 a