PATHOLOGICAL PHENOMENA 
GENERALIZED. 
H. BACKUS. 
MONTEVALLO, ALABAMA: 
1867. PATHOLOGICAL PHENOMENA 
GENEEALIZED. 
By H. BACKUS. 
“The nature of all affections is the same; they differ only in relation to their seat. I 
think that they only show themselves under so many different forms on account of 
the great diversity of parts where the disease is located. Their essence is one and 
so is the cause that produces them.”—Hippocrates. 
“ It will probably be one of the most certain results of future research, to associate 
together, by the connection of causes of common kind, diseases now regarded as 
wholly distinct in their nature, and arranged as such in our systems of nosology. 
This remark applies very widely throughout all the genera of disease.”—Holland's 
Medical Notes and Reflections. 
Science creates nothing—cannot overturn or set aside a single fact in any order of 
phenomena, its sole province being that of discovering Relations, of connecting 
together scattered fragments of knowledge (isolated facts); systematizing them, 
thereby rendering more available in practice what is already known, or implied in 
the known. \. L'jj , , 
j ■ ■> v ,•/ 
MONTEVALLO, ALABAMA; 
1867, Entered According to Act of Congress, in the year 1869, by 
H. BACKUS, 
In the Clerk’s Office of the Southern District of Alabama. 
Printed at the Office of the Mobile Dally Register. INTRODUCTION. 
To demonstrate the point of agreement among pathological 
phenomena is the object of the following argument. As no single 
individual could go but little way, by his own efforts, in a subject 
so complex and difficult, we must necessarily avail ourselves of the 
labors of others—our predecessors and cotemporaries. It is the 
work of generations, of ages, to construct the complex materials 
with which we have to do, into a Science. 
Science is not made, but grows. 
To develop the subject-matter, then, and show the connections 
among pathological phenomena already attained, we must quote 
largely from others; and the works from which our extracts are 
taken are the common books of reference now in use by the med- 
ical profession—the common text-books of the principal medical 
colleges in Great Britain and the United States—and the infer- 
ence is that no higher authorities are known to medicine. 
To appreciate the scientific significance of those extracts it must 
be remembered that they are generalizations from experience; and 
that, combined, they very nearly exhaust the subject in hand; while 
at the same time no one of their authors wrote with reference to 
such combination. 
Now, we propose to make this combination, to supply the links 
of connection necessary to bring the whole immense variety of 
pathological phenomena under one general law. 
Being dependent upon others for aid in working out this prob- 
lem, no radically new theory can be proposed. As a scientific 
generalization cannot precede the facts to be generalized, it follows 
that whenever pathological phenomena are successfully connected 
together, little that is new, or which is not implied in the knowledge 
of those acquainted with the subject-matter, can be revealed. The 
general law is implied in the most simple pathological state, or 
familiar fact, just as the law of gravitation is implied in the 
familiar fact of the weight of bodies on the surface of the earth. 
A correct theory caunot contradict or set aside known facts in 4 
INTRODUCTION. 
pathology, any more than Newton’s Theory of Gravitation could 
contradict or set aside Kepler’s laws. The known facts are a test 
of the correctness of a theory. Kepler’s facts were demonstrated 
before the theory of gravitation was established, and they were 
a test of its correctness; since, if that was correct, it must lead 
deductively to Kepler’s laws; and it did. Let no one reject this 
theory then because it accords with the Known, since no theory 
could otherwise, by possibility, be true. 
Such was the Introduction to an Essay upon this subject which 
we published in 1800 5 and although there be much repetition in 
what we have now to add, we feel the necessity of doing, in this 
place, all in our power to clear away the difficulties and obstruc- 
tions which lie in our path. We have undertaken to solve a difficult 
problem, and need all the assistance from comparison or analogy 
that we can get. 
We have attempted in the following argument to show the 
Relation which pathological phenomena bear to each other. We 
are not, therefore, to inquire into the u Nature,” u Essence,” or 
“ Efficient ” cause of those phenomena; but simply to ascertain 
their relations of succession and similitude. 
Theological and Metaphysical methods of investigation deal 
with the Absolute, with the nature, essence, or efficient cause, of 
phenomena, and are therefore not applicable to our subject. 
The Inductive Method, on the contrary, deals with Relations— 
the order of occurrence and coexistence of phenomena—and conse- 
quently is the one which must guide and control this argument. 
Admitting the argument to be true, experience teaches that 
there will be difficulties and obstructions in the way of its ready 
reception. 
The first difficulty in the way, is the source from whence it 
springs. We have been asked, how could we, an obscure and 
unlearned man, hope to succeed with a subject where so many 
mighty intellects had failed ! The tendency of this is to pre-judge 
the case—to decide against, before or without investigating the 
argument. We trust that some of our readers will reserve this 
point until they have gone through with wliat we have to say, 
remembering that u a cripple in the right way will beat a racer in 
the wrong.” 
A second obstruction is to be found in our previous conceptions. INTRODUCTION. 
5 
It is extremely difficult for the human mind to at once recognize 
and appreciate conceptions, however true, which come in conflict 
with its previous habits of thought. Hence, one reason why all 
scientific generalizations are rejected for a time by the great ma- 
jority of what are called intelligent minds. In other words: as 
we of this age bear the same relation to phenomena yet to be gene- 
ralized, that the cotemporaries of Newton and Harvey did to the 
phenomena which they respectively connected together, it follows, 
that whoever successfully generalizes pathological phenomena will 
meet with the same kind of difficulties that they did. Although 
Newton’s generalization was correct, how was it received by his 
cotemporaries f “Authority scowled upon it, and taste was dis- 
gusted by it,” says Dr. Chalmers, “and all the beauteous speculation 
of former days was cruelly broken up by this new announcement of 
the better philosophy.” 
As for Harvey, he lost his reputation and practice for years. 
Physicians would not even consult with him; and the very boys 
on the street would cry out as he passed, “ There goes the crack- 
brained Harvey! ” 
“ In the intellectual as in the physical, men grasp you firmly 
and tenaciously by the hand, creeping close at your side, step 
by step, while you lead them into darkness, but when you lead 
them into sudden light, they start and quit you.”—W. Savage 
Landor. 
A third difficulty arises from the influence of Names. Language, 
though a great, is not an unmixed good. “ Being a powerful instru- 
ment for fixing ideas in the mind, it gives equal aid to the false and 
the true, and thereby tends to perpetuate the reign of whatever 
errors have once been clothed in words.” A natural tendency of 
language is to fix in the mind the idea that everything has a 
separate existence which has a separate name; and it requires long- 
experience and familiar acquaintance with the subject-matter, to 
eliminate the error. To a person unacquainted with the subject- 
matter, the separate names, Atlantic, Pacific, Indian, Northern, and 
Southern Oceans, fixes in his mind the idea that there are separate 
existences, or separate and distinct bodies of water corresponding 
to those names; but a person acquainted with the subject-matter 
knows that they are not separate and distinct bodies of water; that 
those names are marks put upon different localities in the same 
great ocean. 
Pathology may be compared to that ocean; and the names of 6 
INTRODUCTION. 
special diseases are merely marks put upon organs, localities, and 
symptoms, to render them subjects of discourse; but like those 
before mentioned, they do not imply separate existences or causes. 
To illustrate: u Congestion of the intestines causes diarrhoea ; 
congestion of the uterus, leueorrlicea; congestion of the kidneys, 
watery, and sometimes albuminous urine; congestion of the lungs 
and pleura, liydrothorax; of the heart, hydropericardium; of the 
abdomen, ascites,” &c.—[ Williams’ Principles of Med.) Now, if the 
names diarrhoea, leucorrliea, albuminuria, hydrothorax, hydroperi- 
cardium, ascites, &c., were connotative, if they implied states or 
conditions, it is evident that their connotation would reside in the 
Common condition—congestion—as the cause of all. 
A fourth impediment arises from the Diversity exhibited by 
pathological phenomena. How is it possible that this great diver- 
sity can be reduced to a common cause ? It may assist in removing 
this difficulty to reflect that quite as great diversity in the phe- 
nomena of the physical world around us, has been reduced to a 
cornmoU law—the law of gravitation. 
Another difficulty arises from the supposed tendency of our argu- 
ment. We have been told that our theory was too mechanical, too 
materialistic; that to subject pathological and physiological phe- 
nomena to invariable natural laws, was but little short of demon- 
strating that sociological phenomena were also subject to such 
laws, and that this doctrine would reduce us to mere machines, 
destroy our responsibility, and have a pernicious tendency. 
The question is not as to any supposed tendency of the argu- 
ment, but simply : Is it true % 
But if sociological phenomena are subject to invariable natural 
laws, it does not follovr that our responsibility would thereby be 
destroyed. 
Down to the time of Copernicus, it was assumed that the earth 
stood still, and the sun revolved around it. Under this 
astronomy made slow progress. Copernicus reversed this opinion 
of his predecessors and cotemporaries, and assumed that the sun 
stood still, and the earth revolved around it. Under this hy- 
pothesis, astronomy rapidly advanced. 
In like manner we must reverse our opinions upon other orders 
of phenomena, if we would get upon the right road. It is because 
social phenomena are subject to invariable natural laws, .and that 
we have a power of modifying those laws, that we are responsible. INTRODUCTION. 
7 
The engineer has no absolute control over his locomotive, or 
he could stop it in an instant ; but he has a relative or limited con- 
trol—can modify the laws which regulate its movements, and 
gradually bring it to a stand; and for this power of modifying 
natural laws, he is responsible. 
In the same way, we are conscious that we have some control 
over our conduct or actions; we have no absolute control over 
them, cannot absolutely control the circumstances which environ 
us and which excite those actions; but we have a relative or limited 
control, and within those limits, are responsible. 
If social or political phenomena were not subject to invariable 
natural laws, what lessons could we learn from History? What 
inferences could we draw from the Past, or what calculations make 
for the Future, upon social or political questions ? Or what utility 
would Observation and Experience be ? 
No one seems alarmed at the expressions that u the circum- 
stances being the same, men will act the same;”—that u history 
repeats itself,” and the like; but these are only different ways of 
expressing the fact that social phenomena are subject to invariable 
natural laws. 
Men cannot quarrel and destroy each other over questions upon 
which they really agree; and if social phenomena are directed by 
chance, by caprice, or by a variable will, it is clear that agree- 
ment is unattainable. 
There was a time when the man who should say that astro- 
nomical phenomena were subject to invariable natural laws, was 
deemed worthy of the Inquisition; a time when nations drew 
their auguries of war from the skies; but civilized nations could 
not now imprison a man for such a declaration, or be made to go to 
war upon an astronomical question. And why ? Because all now 
agree that those phenomena are subject to invariable natural laws. 
When that day comes for sociology—as come it surely will—then 
will legislators understand that they have nothing to do with the 
absolute ; that they have neither the right or power to arbitrarily 
and indefinitely control the laws which govern social or political 
phenomena; that it is only within certain limits they may modify 
those laws for good; beyond those limits, to the injury of all. 
Then will that Moloch of the mind—Absolute Conceptions—that 
theologico-metapliysical Juggernaut—deductions from a priori pre. 
mises, without verification—which has crushed the hopes and 8 
INTRODUCTION. 
hearts of so many millions of our race,* disappear from among 
men, and the u spear be beat into a plough-share, and the sword 
into a pruning-hook.” 
Another impediment: We have been told, that if disease was 
a unit, then the treatment of all special diseases would be precisely 
the same, and that this was contradicted by experience, and was 
evidently absurd. 
Granted that the inference is absurd, it is not our inference. 
Because there is unity, does it follow that there is no diversity? 
There may be points of agreement, equality, or unity among all 
men, but does it follow that there is no diversity among them—no 
degrees of physical, intellectual, and moral power, and that the 
treatment must not be adapted to those degrees ? If there was no 
diversity, then indeed would the treatment be the same in all cases; 
but there being diversity, necessitates a modification of treatment 
adapted thereto; not different in kind, but in extent, or degree. 
All plants and animals originate from cells, and in this particu- 
lar, interesting, and important respect, are equal, or a unit; but 
does it follow that they are equal in all other respects, and require 
precisely the same treatment ? We shall see that the treatment 
must be adaptive—adapted to conditions, to degrees, or to diversity 
as well as to unity. 
We have been asked, supposing our argument true, what good 
will it do ? This question has been asked of every discovery which 
has benefitted mankind. When Fulton was about to put his opin- 
ions of the practicability of applying the power of steam to the pro. 
pulsion of vessels on the surface of water to the test of experiment, 
there were but few in the concourse of people assembled to witness it 
that believed in the possibility of its success; and when he had 
demonstrated it before their eyes, they turned on their heels in con- 
tempt and asked, well, suppose he has succeeded, what good will it 
do ? Their minds were not fitted to conceive the mighty results that 
were to grow out of the success of that experiment. The question is 
not asked by this generation. 
As a Profession, none surpass the Medical in labor and intel- 
*For example: “All men are created free and equal.” The terms of this propo- 
sition are used in an absolute sense, and the proposition itself, and the deductions 
therefrom, are held to be self-evident—furnished by the mind independent of experi- 
ence, needing no verification. 
Now, it would not be difficult to demonstrate that the lives of hundreds of 
thousands of American citizens, and the liberties of the American people, have been 
sacrificed to these absolute conceptions and a priori deductions. INTRODUCTION. 
9 
ligence; but for want of general principles to guide and harmo- 
nize them, much of that labor and intelligence is lost by misdirec 
tion—weakened by being diverted into a thousand different channels. 
To concentrate that labor and intelligence into one channel, must 
speedily be productive of good. 
Again : When the phenomena of the heavens were reduced to 
invariable natural laws, a world of superstition vanished from the 
minds of men, in that order of phenomena. In like manner, to re- 
duce pathological phenomena to invariable natural laws would be to 
rid the mind of a vast amount of superstition in that order of phe- 
nomena also. Moreover, to reduce any order of phenomena to 
invariable natural laws, is to close controversy, and diminish the 
number of causes of strife and contention among men. 
Finally, upon this point, the diseases and remedies of the 
Natural Body furnish a standard of comparison—scientific equiva- 
lents—for those of the Body Politic. Social Science cannot be 
constructed a priori, from materials furnished by the mind inde- 
pendent of experience, as theologico-metaphysical philosophers 
contend, but like other sciences, it must grow out of the ex- 
perience and wisdom of ages—must grow out of the antecedent 
orders of phenomena upon which it depends, and through which 
it can alone be illustrated and explained. The relations of phe- 
nomena are discovered in the order of their complexity, the more 
simple first, and then the more and more complex; and the latter 
can only be explained by bringing them into relation or con- 
nection with the former. Now the diseases and remedies of the 
body politic are one degree more complex and special than are 
those of the natural body ; and the former can only be illustrated 
through the latter. Hence the necessity of first generalizing patho- 
logical phenomena before a social science is possible—demonstrable. 
Other hindrances and impediments will be considered in a more 
general way. 
There would seem to be a misapprehension on the part of many 
as to the real character of a scientific discovery. In the case of 
pathological phenomena many seem to think that whenever the law 
which binds them together shall be discovered, something strictly 
new, some great mystery, or something which will strike the mind 
with wonder and astonishment, will be revealed ; whereas, in truth, 
nothing which is not implied in what is already known, can, in real- 
ity, be made to appear. Take the discovery of the circulation as 10 
INTRODUCTION. 
an example. It was known before Harvey’s discovery that blood 
circulated. His preceptors taught him that blood circulated in 
the veins, in the arteries, and in the lungs; but that they 
were distinct, specific systems, having no relation or connection. 
Harvey generalized—showed the relation which these supposed 
distinct systems bore to each other—connected them together. 
These links of connection were new in this, that they w ere not recog- 
nized before; they extend knowledge, and give a mighty impetus 
to science; but it is easy to see that they do not differ, in kind, 
from the known. They are but connecting links in the Chain of 
Science. 
So of Newton’s discovery. He did not discover that apples 
fell to the ground ; that the earth was round ; that its orbit was an 
elipse; that it revolved on its axis, and around the sun. These 
facts were discovered by his predecessors and cotemporaries. New- 
ton generalized—showed the relation which they bore to each other, 
connected them together; showed that the cause of the fall of an 
apple to the earth, and the cause of the earth’s revolution around 
the sun, was a Unit. 
Now, whoever shall discover the law which binds pathological 
phenomena together, will do so by show ing the relation which they 
bear to each other, by connecting the facts and minor generalizations 
attained by his predecessors and cotemporaries, into one great 
Whole. 
Simple and familiar as is the connection of the circulation to us 
of the present day, how was it received by the cotemporaries of 
Harvey 1 With scorn and derision ! And this is the history of all 
the discoveries w hich have so largely benefitted mankind. 
Scientific explanations are too simple and common to gratify 
our love of the marvelous. Besides, habits of thought, chronic 
opinions, are not easily or speedily surrendered. Ignorance (not of 
literature and dead languages, but) of the Relation of Terms— 
of Natural Law s—of the relations we bear to each other and the 
wrorld around us, is one great cause of our physical, social and 
political sufferings. So long as Relative terms are used in an 
Absolute sense, so long will there be misunderstanding, disputation, 
wrangling, and shedding of blood. But there is a better day coming 
for Humanity. The Inductive method of investigation is inaugu- 
rating that day. 
That method deals only with relations. It is with the relations INTRODUCTION. 
11 
of phenomena, their order of occurrence and coexistence, that we 
have to do. 
To explain an unknown or obscure phenomenon is simply to 
bring it into relation or connection with the appreciable or known. 
What relation does Fever, an unknown or obscure phenomenon, 
bear to Dropsy, a known and simple phenomenon? It bears this 
relation, that the state known as Congestion invariably precedes and 
coexists with each. Why is congestion said to be the cause of flux, 
hemorrhage and dropsy ! 
We understand by the term Cause, the assemblage of conditions 
upon which a phenomenon depends. These conditions are all 
equally essential to the development of the phenomenon, but they 
are not all equally essential, practically, to us ; and we single out 
the most promiuent condition, or the one which we can modify for 
our advantage, and by way of Eminence, or to fix llesponsibility, 
call it the Cause. 
It is in this latter sense that we use the term congestion. 
We do not affirm that all the conditions are the same in every 
special disease, but that one condition—congestion—is common to 
all; the Diversity depending upon the difference in the function or 
properties of the organ or tissue congested. Congestion of the 
brain, for instance, produces phenomena peculiar to that organ. 
Here the brain is one of the conditions of those peculiar phenome- 
na, and congestion is the last condition, or the one upon whose 
occurrence the phenomena appear. How we cannot remove those 
phenomena and restore the subject to health by removing his brain. 
We cannot remove that condition, but we may sometimes remove 
the essential condition of congestion, and thereby remove those 
phenomena. There may be inflammation of the lungs, stomach, 
liver or kidneys, and there may be phenomena peculiar to the 
properties of the organ inflamed; but we cannot remove those phe- 
nomena and restore the subject to health by removing those organs. 
But congestion is an essential condition of inflammation—there 
could be no inflammation in its absence—and we may sometimes 
remove this condition and thereby remove the phenomena. Con- 
gestion, therefore, is the important and practical condition for us, 
the one which we may modify for our advantage, and by way of 
eminence we call it the cause. One of the causes or conditions of 
the diversity exhibited by pathological phenomena, then, is the 
function or properties of the organ or tissue affected. Another is 12 
INTRODUCTION. 
the Degree of congestion. A certain degree of congestion of the 
brain, for instance, produces headache; a greater degree, stupor; 
and greater still, convulsions, or coma. A third and last condition 
which we shall notice here is the Duration of congestion. We are 
in the habit of saying that gravitation is the cause of the earth’s 
revolution around the sun ; but the phrase, “ Law of Gravitation,” 
is a generalized expression of the conditions under which phenomena 
occur; and in the case of the earth’s revolution around the sun, 
one of those conditions is a duration of 305 days for the completion 
of the phenomenon. 
In the same way, a certain duration of congestion is necessary 
to the recognized development of certain pathological phenomena. 
To return to the Question: Why is congestion said to be the 
cause of flux, hemorrhage, and dropsy H Because it invariably 
precedes and coexists with each. But this state also invariably 
precedes and coexists with inflammation and fever ; and if it is not 
the cause of the latter, there is no reason to consider it the cause of 
the former. It is said that flux, hemorrhage, and dropsy, are 
produced by the same cause for the reason that they are convertible 
into each other—that to produce a flux is to relieve a dropsy. The 
same reasoning includes inflammation and fever, since they as often 
result from a suddenly suppressed flux, as does dropsy; and are as 
often relieved by producing a flux, as is dropsy or hemorrhage; 
and if all cases of fever are not relieved by producing a flux, alone, 
neither are all cases of dropsy. They are parallel in all these 
particulars. 
Now fever has ever been considered one of the most complex 
subjects in pathology. And why ? Because along with the in- 
creased arterial action and increased heat, which may be said to 
properly constitute fever, there often appear a great number of other 
phenomena, as flux, hemorrhage, dropsy, pain, dyspnoea, headache, 
stupor, delirium, convulsions, coma, etc. Let us analyze this 
complex state. 
If we apply a ligature to a vein, we dam up the blood behind 
the ligature; the pressure of the accumulating blood dilates or dis- 
tends the vein, and we have the state known as congestion;—the 
retrograde pressure of venous blood extends to the capillaries, and 
when it attains a certain degree, the serum is forced through their 
thin parietes into the surrounding cellular tissue, or into a closed 
cavity, constituting dropsy. But dropsy is not the only phenome- INTRODUCTION. 
13 
non which appears in connection with a retrograde pressure of 
venous blood in the capillaries. If the vein ligatured be the one 
which returns the blood from the bowels, the effusion may take 
place from their free or mucus surface, and then there appears the 
phenomenon known as dux, or diarrhoea. If the pressure passes a 
certain degree, the capillaries are ruptured, and we have hemor- 
rhage. If the veins ligatured be those that return the blood from 
the head, the retrograde pressure of venous blood extends to the 
brain, and there appear headache, stupor, delirium, convulsions, 
coma, apoplexy, paralysis, effusions, etc. If the great veins 
emptying into the heart be ligatured—as they sometimes are by 
dilatation or valvular disease of that organ—there is general venous 
congestion, and a great multitude of other phenomena appear in 
connection with those already mentioned. Now the phenomena 
which have appeared from these experiments are those which some- 
times coexist with fever. Does venous congestion coexist with 
fever ? It does. Then we have an explanation of the attendant 
phenomena. If venous congestion is present and competent to the 
production of all the phenomena which attend fever, may we not go 
one step farther, and say that it is the cause of increased arterial 
action also $ Is it not appreciable that the retrograde pressure of 
venous blood in the capillaries should obstruct the arterial circula- 
tion ; that the pressure of blood upon the left ventricle of the heart 
should thereby be increased; that this increased pressure of blood 
should excite that ventricle to increased action ? The answer is in 
the affirmative, as is recognised in hypertrophy. We may now see 
the point of agreement, the relation which this great multitude of 
phenomena bear to each other. 
Admitting the foregoing analysis of fever to be correct—we 
shall see it demonstrated in the course of this argument—the very 
simplicity of the explanation, for reasons before stated, will hinder 
its reception. We have often been told, when talking upon this 
subject, that there was nothing new in the idea that congestion 
played a conspicuous part in the production of simple pathological 
phenomena j that medical works were full of the doctrine; that 
even common people were always speaking of congestion; forget- 
ting that these facts, of themselves, constituted it of the highest 
possible scientific importance. Common and familiar as is the fact 
of congestion, it is not more so than was that of the weight of 
bodies on the surface of the earth previous to the establishment of 14 
INTRODUCTION. 
the law of gravitation; and yet witness the agency of this familiar 
fact in the construction of the science of astronomy. So common 
and familiar was the fact of the weight of bodies on the surface of 
the earth, that it might be said that every man held the law of 
gravitation in his hands.* So of congestion, it is on every man's 
tongue. 
The agency of congestion, in the production of simple patho- 
logical phenomena, is recognized and admitted; but when we 
advance to more complex phenomena, other causes are deemed 
necessary to account for their production. 
We repeat, that on all subjects, the most simple and common 
facts are the most important; and this, not only on account of 
their being general, but also because they furnish the key to the 
investigation and solution of the complex and difficult. 
Complex pathological phenomena may be said to hold the 
same relation to the simple and common, that the woven fabric 
holds to the single thread. In the complicated web, the single 
thread is so doubled—so folded upon itself— that its continuity seems 
broken, its connection lost; but by patiently pursuing that thread, 
its intricate meshes are at last unraveled, 'and its continuity or 
connection seen to be complete. 
We are now to unravel complex pathological phenomena by 
* “ For example, men had for ages seen pieces of wood, stones, metals, falling to 
the ground. Newton seized on these particular facts, and rose to the idea that all 
matter tends, or is attracted towards all matter, and then defined the law according 
to which this attraction or force acts at different distancesthus giving us a grand 
principle, which we have reason to think extends to, and controls the whole outward 
creation."—(Manning. 
Compare the preceding quotation with the following, and it will be seen that 
they agree as to the frequency and familiarity of the particular facts; and if Dr. 
Watson has not extended the principle to all pathological phenomena, it will be 
recognized that he goes deep into the heart of the subject: 
“ 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 
lood to different organs; and of late the term hypercemia, first invented by M. Andral, 
in France, has been imported into this country and much adopted here. All these 
words and phrases mean in truth the same thing; and their frequent recurrence in 
medical works, is, of itself, sufficient evidence of the frequency and importance of the 
conditions which they express. 
“ If we comprehend rightly this subject of plethora or congestion, we shall be 
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. Inflammation, 
hemorrhage, dropsy, all acknowledge and imply a previous condition of congestion. 
4 There is probably,’ says Dr. Alison,4 no kind of diseased action of which the body is 
susceptible which is not connected, sooner or later, with increased afflux of blood 
towards that part, either as its cause or effect; and the immediate object of all our 
most powerful remedies is to act on these irregularities of the circulation.’”— Watsons 
Practice, p. 42. INTRODUCTION, 
15 
tracing through all their ramifications the single thread of con- 
gestion. 
Our Essay will be divided into two parts: 
In Part I, we shall run a parallel between Inflammation, 
Fever, and Hypertrophy: 
In Part II, we shall employ more directly, and in form, 
the Deductive Method;—shall apply all the tests known to that 
method;—shall bring our argument to a level with that which 
sustains astronomy. More cannot be required. In this part, 
the subject-matter will be so fully developed, that any one 
acquainted with the facts and reasoning which sustain the Phys- 
ical Sciences, will be a competent judge of its validity. 
We cannot proceed to our argument without first acknow- 
ledging our great indebtedness to the works of Lewes, Mill, 
and the immortal Comte. PATHOLOGICAL PHENOMENA GENERALIZED, 
X. 
That Pathological Phenomena have a plan as stable, condi- 
tions as fixed, and an order of occurrence as determinate, as have 
other physical phenomena, and are, therefore, amenable to the 
same method of investigation, few pathologists of this age will 
question. 
If we turn to the history of Physical Science, we see that 
Astronomical phenomena were once referred to Supernatural 
causes—Apollo and his Chariot, then to Metaphysical Entities, 
Numbers, Harmonies, etc., and, finally, through the instrumentality 
of what is called the Inductive Method of investigation, were 
reduced to Positive Science—the Law of Gravitation. 
If we look into the Records of Medicine we see that Pathologi- 
cal Phenomena were once referred to supernatural causes—Superin- 
tending Intelligent Principles, then to Metaphysical Entities, Vital 
Forces, Sympathies, etc., and the inference is that, through the 
application of the same method which perfected Astronomy, they 
too are destined to be reduced to Positive Science—the Law of 
Gravitation. 
The distinguishing characteristic of the method alluded to, is, 
that it proceeds with cultivated caution from the Known to the 
Unknown, and verifies its conclusions by confrontation with Fact. 
Of vital forces we know nothing, and, therefore, can predicate 
nothing. We cannot reach the unknown through the unknown. 
Of Pressure (which is resolvable into Gravitation), we know 
that it can and does produce certain pathological phenomena; and 18 
PATHOLOGICAL PHENOMENA 
it is through the avenues of the known that we are to reach the 
unknown. 
That pressure will produce sensations, pleasurable or painful 
according to its degree and the part pressed upon, any one may 
verify by experimenting upon his own person at will. 
That pressure will obstruct the circulation of blood may be 
demonstrated by the experiment of applying a ligature to a vein. 
That the pressure of blood behind the ligature will Dilate the vein 
and produce the state marked by the term Congestion, will be 
demonstrated in the same experiment. That the dilatation of the 
vein implies Debility, or a relative deficiency of power on the part 
of the vessel (debility being a relative term), is a proposition the 
truth of which cannot be denied. 
The terms Obstruction, Dilatation, Congestion and Debility, 
then, are marks of each other, and marks of Pressure. 
That these terms are marks of each other and marks of 
pressure, is well illustrated in dilatation of the heart, that phe- 
nomenon being produced by pressure, and clearly implying and 
exhibiting congestion, debility and obstruction. 
The illustrations of our argument will be drawn from the 
Heart. 
We shall see that Dilatation of the Heart corresponds to 
Congestion of the Capillary, to Ague of the System, and to all 
Passive diseases ; and that Hypertrophy of the Heart corresponds 
to Inflammation of the Capillary, to Fever of the System, and to 
all active diseases. 
We shall see that Dilatation and Hypertrophy are produced by 
Pressure; and then it w ill followr that all related phenomena are 
produced by pressure also. 
We repeat, that to explain an Unknovui or Obscure phenom- 
enon, is simply to bring it into relation or connection with the 
appreciable or known. Now the cause of dilatation and hypertrophy 
of the heart, is more appreciable and better known, than is the 
cause of congestion and inflammation of the capillary, or ague and 
fever of the system ; and we may hope to explain or illustrate the 
latter by bringing them into relation or connection with the 
former. 
We have said that dilatation of the heart was produced by 
pressure. 
u Dilatation of the heart is a purely mechanical effect of 19 
GENERALIZED—PART I. 
over-distention. Blood, accumulated in its cavities, exerts a pres- 
sure from the centre towards the circumference in every direction; 
and when once it surmounts the resistance offered by the contractile 
and elastic power of the parieties, these necessarily yield and 
undergo dilatation.”—Hope. p. 293. 
Taking dilatation (congestion) as the most simple pathological 
state (abundant evidence of which will hereafter appear), disease 
may be defined to be a changed relation in the pressure of the fluids 
and solids upon each other. It is not without significance that this 
definition of disease reconciles humoralism and solidism. It is the 
province of a correct theory to reconcile long controverted ques- 
tions. We see from the above extract that the term dilatation is a 
mark put upon a relatively increased pressure of blood to the returning 
pressure of the heart or blood vessel. This term, therefore, implies 
congestion, obstruction and debility, or diminished action. Accord- 
ingly we shall see the same phenomena ascribed to each of these 
terms as the cause; and the significance of their connection 
appears in the fact that leading theories in medicine have been 
founded upon them—plethora, obstruction, debility. 
Hypertrophy of the heart is also producedby pressure : 
“ The reader must here again be reminded that the exciting 
causes of dilatation are equally those of hypertrophy; and that, 
supposing no unknown agencies to interfere, as may sometimes 
possibly happen, it depends on the proportion which the cause 
bears to the reacting energy of the Cavity exposed to its influence, 
whether that cavity becomes affected with dilatation, with hyper- 
trophy, or with a combination of the two.”—Hope. p. 252. 
The point of agreement (material to the issue) in the terms 
reaction, inflammation, fever and hypertrophy, js increased action ; 
and as hypertrophy is a mark of pressure, therefore, the terms 
reaction, inflammation and fever, are marks of pressure also. 
Accordingly we shall see the same doctrines held in relation to the 
increased action of the capillaries in inflammation, and the heart in 
fever, and hypertrophy, iu producing congestion, effusions, hemor- 
rhage, etc. It is not to the hypertrophy of the heart, apart from its 
increased action, that agency is attributed; and as we have 
increased action of the capillaries in inflammation, and of the heart 
in fever, we shall see the same opinions held in relation to each. 
They are parallel and illustrative of each other. 
The terms dilatation, congestion, debility, obstruction, reaction, 
inflammation, fever, and hypertrophy, then, are marks of pressure. 
In other, words, the same cause which produces debility, dilatation, 20 
PATHOLOGICAL PHENOMENA 
congestion and obstruction, produces reaction, inflammation, fever, 
and hypertrophy, namely : pressure. 
The connection of all these terms may be recognized and 
appreciated if we reflect that debility or diminished action and 
increased action are relative states, implying more or less only of the 
same kind, and consequently produced by the same cause, or 
differing only in degree. Dilatation corresponds to debility or 
diminished action, and hypertrophy to increased action, and we 
have seen that they were produced by different degrees of pressure. 
This reconciliation of terms must necessarily reconcile the 
apparently opposite opinions founded upon them. 
u Theories of inflammation : Two opposite opinions have of late 
divided pathologists. Both parties admit that the capillaries are 
dilated and contain a larger amount of blood than in health ; but 
they differ widely as to the state of action of the capillaries. By 
one party it is maintained that these vessels are in a state of 
increased action, at least in the early stage of the inflammation, and 
that the phenomena are the direct result of an excessive exercise of 
the vital properties of the part affected; by the other, that they 
are in a condition of debility, at least in relation to the larger vessels 
from which they are derived, and that their expansion is the result 
of a loss of balance between the resisting force of the capillaries 
and the vis-adergo.”— Wood's Practice, v61. 1, p. Jfi. 
We see from the above extract that both parties agree that the 
capillaries are dilated, congested, in inflammation. By one party it 
is maintained that this dilatation and congestion is the result of 
debility; by the other that it is the direct effect of increased action. 
How are these apparently opposite opinions to be reconciled ? 
They are to be harmonized by recognizing that they are not opposite 
but relative: They are to be reconciled through their point of 
agreement—congestion—the state of action being relative: They 
are to be reconciled by connecting them through dilatation with 
hypertrophy—the action being debilitated or diminished by the 
dilatation, and increased by the hypertrophy. 
, This connects states, terms, and opinions: 
“ Excess of blood in a part, with motion partly diminished, 
partly increased—inflammation.”— Williams’ Principles. 
Excess of blood in the heart, with action partly diminished, 
partly increased—hypertrophy; the action being diminished by the 
dilatation (which excess of blood implies), and increased by the 
hypertrophy. 
“Now, what I have just stated is the distinction between GENERALIZED—PART I. 
21 
hypertrophy and inflammation; their general pathology has much 
in common, their causes are often alike, their modes of production 
identical.”—Simons' General Pathology. 
In looking at the condition of the heart in dilatation with 
hypertrophy, then we see the condition of the capillary in 
inflammation. 
Fever is connected with hypertrophy and illustrated by it. 
What are the points of agreement between ague, dilatation, 
fever and hypertrophy ! 
These terms are not “principles” or “entities” capable of 
producing phenomena, but simply marks put upon a pathological 
state after its occurrence. They do not precede, but imply, con- 
gestion. 
They are marks of relative states. It follows that the 
phenomena in ague, dilatation, fever, and hypertrophy, are the 
same in kind. 
Differences in the temperature of the body, in the strength of 
the pulse, in the thickness of the walls of the heart, are not differ- 
ences of kind, but of degree ; and consequently connected through 
causation. Dilatation and hypertrophy represent these differences, 
and we have seen that they were connected through congestion or 
pressure of blood. 
In dilatation of the heart we have the feeble pulse, the cool or 
chilly surface, the pale or livid complexion, the internal congestions, 
glandular enlargements, and passive phenomena of ague. In 
hypertrophy of the heart we have the strong pulse, the relatively 
increased heat of skin, the flushed surface, the internal congestions, 
glandular enlargements, and active phenomena of fever. 
Let Auscultators examine the heart in ague and see if they do 
not And dilatation ; let them examine it in fever and see if they do 
not find the increased action of hypertrophy! 
Sometimes fever does not supervene upon ague. Sometimes 
hypertrophy does not supervene upon dilatation. Sometimes we 
have a low form of inflammation, of fever. This is represented in 
dilatation with hypertrophy, dilatation predominating. 
Sometimes we have active inflammation, active fever. This is 
represented in hypertrophy with dilatation, hypertrophy predomi- 
nating. 
From the earliest records of medicine, inflammation and fever 
have been considered conservative. Hypertrophy, which has only 22 
PATHOLOGICAL PHENOMENA 
been understood in modern times, is considered conservative also ; 
and all for the same reason, namely: That without reaction the 
congestion, ague, or dilatation, invariably terminated in death ; 
that with reaction, whether it amounted to recognized inflammation, 
fever, or hypertrophy, or not, a large majority recovered, or life was 
protracted. Hence it was very natural to look upon inflammation, 
fever and hypertrophy as conservative* 
Finally, for the present, fever and hyperthopliy involve the 
system at large, and a multitude of corresponding phenomena 
coexist with them. 
What is the condition common to fever and hypertrophy which 
is sufficiently general to connect the multitude of phenomena, as 
flux, hemorrhage, dropsy, pain, vomiting, dyspnoea, headache, 
stupor, delirium, convulsions, coma, etc., etc., which sometimes 
coexist with them ? 
That common condition is venous congestion—an increased 
retrograde pressure of venous blood in the capillaries. 
There being no valves to the internal system of veins, including 
those of the head and spine, it is appreciable that the retrograde 
pressure of venous blood may extend to the capillaries of all the 
organs, thus corresponding to the general symptoms. 
We will first establish the fact that venous congestion is 
common to ague, dilatation, fever, and hypertrophy. 
“ The diseases of the heart exert a very marked influence over 
the whole economy; nor is it in a narrow or circumscribed circle 
that these morbid reactions are produced; on the contrary, how 
numerous are the sympathies which the central organ of the circu- 
lation creates in the rest of the organism! It is in consequence 
of their multiplicity and the difficulty of referring them to one 
perfectly settled cause, that we have decided to study the general 
symptoms in a purely analytical order. * * * 'p]ie engorgement 
of the venous system is one of the extraordinary phenomena 
pertaining to diseases of the heart.”—Aran on the Heart, p. 100. 
u And if the local inflammation which can be ascertained to 
take place during fever, is inadequate to explain the characteristic 
typhoid symptoms, it is equally in vain to seek an explanation of 
those symptoms, as some have done, in the mere circumstances of 
irregular distribution and congestion of blood. 
u Even the peculiarities of that form of fever which has been 
described under the name of Congestive, are not to be explained 
by the mere circumstance of internal congestion, the existence of 
which, in the vessels, and especially in the veins of internal parts, 
in these circumstances, is admitted. For although congestion or GENERALIZED—PART I. 
23 
stagnation of blood within the. cranium, may be held to be a suffi- 
cient cause of stupor, yet we are so far from regarding congestion 
in the great veins leading to the heart as a sufficient cause for 
deficient action there, and consequent feeble pulse and cold skin, 
that we have already stated the accumulation of blood in the great 
veins to be apparently the chief cause of the increased action of the 
heart, or the reaction in the more usual form of fever.”—Allison's 
Outlines. 
The four following quotations will also illustrate the connection 
of fever and hypertrophy through the fact that the same doctrines 
are held in relation to their producing, for instance, hemorrhage, as 
apoplexy : 
u There is an alleged exciting cause of cerebral hemorrhage, 
which I think is the more necessary to consider, because I believe 
that very erroneous notions prevail about it even among patholo- 
gists of eminence. I allude to the imputed dependence of cerebral 
hemorrhage upon hypertrophy of the left ventricle of the heart. It 
has been supposed that the powerful contractions of a ventricle thus 
morbidly strong may drive forward the blood with such unusual 
force, as to strain and burst the cerebral arteries. Dr. Hope, in liis 
very complete work upon Diseases of the Heart, uses these words: 
i Instances of apoplexy supervening upon hypertrophy have been 
so frequently noticed, that the relation of the two, as cause and 
effect, is one of the best established doctrines of modern pathology.’ 
Similar opinions are entertained by the most distinguished of the 
French writers on this subject: Andral, Bouillaud, Cruvielhier. 
I think they are all wrong; or at least they state their propositions 
much too broadly and generally. 
u I fully admit, no less from my own observation than upon the 
testimony of others, the frequent coincidence of hemorrhage of the 
brain, and hypertrophy of the left ventricle of the heart; but I 
distrust the reasoning which would always connect these events 
with each other as cause and effect. They may sometimes have this 
relation ; but I have long thought that in most cases, if not in all, 
the coincidence is capable of being explained upon other and more 
satisfactory principles. In the first place, hypertrophy of the left 
ventricle of the heart is very frequently, far more frequently than 
not, accompanied by other structural changes in the organ; changes 
which imply some impediment to the circulation; changes which 
involve or influence its right chambers also. In fact, disease of the 
right heart is not often seen without disease of the left; and one 
of the commonest forms of alteration to which the left side is liable, 
is hypertrophy of its ventricle. Now I have already pointed out 
to you the connection which sometimes subsists between cerebral 
hemorrhage and such disease of the heart as obstructs the ready 
and regular descent of the blood from the head through the veins. 
Many of the cases of apoplexy occurring in persons who have pre- 24 
PATHOLOGICAL PHENOMENA 
viously had cardiac hypertrophy, are, I really believe, cases of this 
kind. The brain affection is dependent, in part, upon disease of the 
heart, but not upon the preternatural strength of its left ventricle. 
The heart acts morbidly upon the brain through the veins, and not 
through the arteries.”— Watson's Practice, p. 326. 
“ Although it is evident from the preceding observations, that 
accumulation of blood in the venous cavity produces this disease 
(apoplexy) in all those cases in which the pulse is weak, in which 
cases it is certain that the blood is accumulated in that cavity, yet 
it may be doubted whether this can be the cause in those cases in 
which the pulse is strong. Increased action of the heart has been 
considered the immediate cause in these cases. 
u In answer to this it may be observed that this disease appears 
generally at that time of life when there is a marked tendency to 
venous plethora, and rarely at that time of life when the action 
of the heart is most powerful. Few cases occur so early as the 
fortieth, most over the fiftieth, many over the sixtieth year of life. 
“ It occurs almost only in those persons who have been habit- 
ually exposed to the operation of the remote causes; particularly 
high living, free drinking, great exertion of mind in deep study, or 
intense application to momentous affairs, and great anxiety about 
the result. The inevitable effect of these is accumulation of blood 
in the venous cavity. The time of life, and the manner of life, 
therefore, both concur in indicating the presence of accumulation of 
blood in that cavity, which is certaiidy present in all such cases. 
u The strongest pulse in earlier life does not produce apoplexy. 
In the most violent fevers I have ever seen, there has been no 
instance of such an effect; and the only instance I have heard of 
from neighbouring practitioners occurred in an old man. 
u The full habit of persons liable to this disease, the time of 
life when they are attacked, the known effect of the operation of 
the remote causes, and the weakness of the pulse in many cases, 
all point to the fact that accumulation of blood in the venous 
cavity is the proximate cause. Increased action without such 
accumulation does not produce apoplexy; without increased action 
the latter does produce the disease.”—Coohe's Pathology, v. 2, p. 177. 
u Other causes of abnormal circulation in the head and neck 
exist. Diseases of the heart itself, of which one, hypertrophy, 
augments the flow of the arterial blood, and of which all induce 
impeded circulation along the veins—a fact of far greater moment—* 
have their influence in inducing the apoplectic state.”—Marshall 
Hall. 
11 In the uncomplicated form of intermittent fever, without 
malignant tendency, the prognosis is almost always favorable. I 
have never seen such a case eventuate fatally. It is possible that, 
when there is a disposition to cerebral disease, with the brain 
perhaps already softened, fatal apoplexy may be induced in the GENERALIZED—PART I. 
25 
paroxysm, either from the venous congestion of the cold stage, 
or by the strong determination of blood in the stage of reaction.” 
Wood?s Practice, vol. 1, p. 236. 
Having now seen that venous congestion is common to ague, 
dilatation, fever, and hypertrophy, we have next to inquire into its 
competency to induce the phenomena which coexist with them. 
That venous congestion or an increased retrograde pressure ot 
venous blood in the capillaries, is competent to the production of all 
the phenomena which coexist with ague and fever, has often been 
demonstrated by the experiment of applying ligatures to the veins 
of animals, thereby producing this state, and the phenomena in 
question. In these experiments there seems to have been no diffi- 
culty in ascribing the phenomena to venous congestion; but when 
we have the same state, and the same phenomena, in ague and fever, 
we must needs go in search of other causes to account for their 
production. 
Is this according to the rules of reasoning in the Anterior 
Sciences ? Having a present and sufficient cause, is it necessary, 
or are we allowed, to assume others ? Let us put the question to 
the test of experiment. 
As dilatation of the heart is an obstruction to the circula- 
tion—operates as a ligature to the great veins emptying into it, 
thereby producing general venous congestion—it furnishes a direct 
experiment on a large scale on the human subject; and if venous 
congestion is competent to the production of all the phenomena 
which coexist with ague and fever, it follows that they should 
here be found.* 
11 In the preceding section I have shown that the effect of 
dilatation is, to enfeeble the heart, and thereby occasion the phe- 
nomena of an obstructed circulation. We have now to examine 
those phenomena as signs of dilatation. 
u General Signs.—The heart, when weakened by dilatation, 
is subject to palpitations of a feeble, oppressed kind, and more or 
less distressing, frequent and prolonged, according to the extent of 
the malady. In general they are protracted. The attacks are 
provoked by any over-exertion or mental excitement. 
“ The pulse is soft and feeble, and, if the debility of the heart 
be very considerable, it is small. Irregularity and intermittence 
* It may be proper to state that Dr. Hope, whose detail we shall follow, was not 
attempting to exhaust the phenomena which appear in this condition of general 
venous congestion. Other authors on diseases of the heart add many more. Indeed, 
If we were to bring them all together, the subject would be exhausted, and out- 
general argument verified. 26 
PATHOLOGICAL PHENOMENA 
are rare, except during protracted and distressing paroxysms of 
dyspnoea, or when the vital powers are much exhausted, as in the 
advanced stage of the disease. 
u The languor of the arterial circulation in dilatation causes the 
extremities and surface to be chilly, the disposition to be melan- 
choly, and the character to be deficient in energy. 
“ The blood, not being freely transmitted by left ventricle, 
accumulates in the lungs by retardation: whence difficulty of 
respiration; cough, sooner or later attended, in many cases, with 
copious expectoration of thin serous mucus ; oedema of the cellular 
tissue of the lungs greatly aggravating the dyspnoea; terrific 
dreams with starting from sleep ; and passive pulmonary hemor- 
rhage of dark, grumous blood in small quantities, forming sanious 
sputa, and generally the precursor of death in individuals affected 
with great difficulty of respiration. After death I have found this 
hemorrhage connected with pulmonary apoplexy, and always with 
great engorgement. 
“ The lungs being obstructed the engorgement is propagated 
backwards to the right side of the heart, to the great veins, and 
finally to all their ramifications. From this venous engorgement 
arises a series of striking phenomena, which we shall review 
successively, premising that the hemorrhage and dropsy do not 
generally come on till a late stage of the disease. 
«1. Serous Infiltration. — This generally makes its ap- 
pearance first in the lower extremities, because it is in them that 
the circulation is most languid, the return of blood being opposed 
by its gravity, while it is little promoted by the action of superin- 
cumbent muscles. The cedema gradually ascends, and, under the 
name of anasarca, may eventually attain the utmost degree over 
the whole surface of the body. Increased serous exhalation takes 
place from the serous membranes also: whence, hydrothorax, hydro- 
pericardium, and ascites ; one or other of which is almost invariably 
present when there is much external dropsy. 
“2. Discoloration of the Face. — If the complexion was 
originally florid, it becomes purple or deep violet on the centre of 
the cheeks, the end of the nose, and the lips, with intumescence of 
the latter, while the intermediate parts are pallid and sallow. If 
originally pale, it becomes cadaverously exsanguine, and lias a 
dusky, leaden or venous cast, especially around the eyes. The lips 
are either livid or very pale. Lividity sometimes shows itself in the 
extremities as well as in the face. 
u 3. Congestion of the Brain.—This produces the usual 
symptoms of passive cerebral congestion, and of the corresponding 
form of apoplexy, namely : dull headache, felt principally along the 
course of the great sinuses; hebitude of the mental faculties; 
stupor, convulsions, and eventually complete coma. It is not 
unusual for these symptoms to supervene a few days before the 
fatal termination. Sometimes they depend, not on congestion GENERALIZED—PART I. 
27 
alone, but partly also on serous effusion into the ventricles, or on 
the surface, resulting from the congestion; sometimes, again, the 
congestion ends in sanguineous apoplexy, of which I have seen 
several instances. Whence it is incorrect to suppose that this 
catastrophe is peculiar to hypertrophy of the heart. 
u 4. Injection of the Mucous Membranes.—It is common to find 
them after death so vascular as to present the appearance of inflam- 
mation. This is especially the case in the stomach and intestines, 
and it is necessary to be aware of the circumstance in order to 
guard against the error of attributing the redness to inflammation. 
u 5. Passive Hemorrhage.:—This takes place from the lungs, 
as already stated, also from the nose, the stomach, the intestines, 
the uterus, and more rarely from the bladder. It results from 
engorgement of the mucous membranes. The effusion consists of 
dark blood exuding in small quantities. When from the stomach, 
and not immediately ejected, it has occasionally the appearance of 
coffee grounds, in consequence of being exposed to the coagulating 
action of the gastric juice. In the intestines it is often blackened 
by the intestinal acids—the carbonic, acetic, and sulphureted 
hydrogen. 
u G. Congestion and Enlargement of the Liver.—This is so com- 
mon a consequence of retardation of the blood on the right side 
of the heart, that few persons so afflicted in any considerable 
degree, are exempt from it. This lias, I believe, been almost 
entirely overlooked by authors on the diseases of the heart, and is 
still very little known. By the obstruction which it occasions in 
the system of the vena porta, it leads to ascites and jaundice; also 
eminently favors luematemesis, intestinal hemorrhage, piles, and, 
though indirectly, uterine hemorrhage—many cases of which I have 
found to be obstinate till the hepatic enlargement was reduced by 
mercury and aperients. This latter fact has been noticed by 
Dr. Locock.”—fHope, pp. 300-2.] 
Does not the preceding experiment settle the question as to the 
sufficiency Of venous congestion to produce the phenomena which 
coexist with ague and fever ? 
Cannot physicians recognize therein, the feeble pulse, the cool 
or chilly surface, the pale or livid complexion, the internal conges- 
tions, glandular enlargements, and passive phenomena of acute 
ague ! 
Let them sit down and make this calculation—take the phe- 
nomena detailed in that experiment from the phenomena presented 
by any, or all forms of acute ague, and give the remainder. 
If physicians will apply this rigid test, we think they will 
agree with us, that dilatation of the heart is simply a chronic ague. 
We will now analyze Fever: 28 
I’A'IHOLOCtIOAL pheno>iena 
The preceding experiment enables isolate the increased 
action of fever from the attendant phenomena, and study it apart; 
enables us to reduce this complex state to its elements. 
We have seen that venous congestion precedes and coexists 
with fever:—consequently the phenomena detailed in the preceding 
experiment may coexist with fever. Let any one take those phe- 
nomena from any form of fever—yellow fever, for instance—and 
look for the remainder, and he cannot foil to recognize the 
connection. 
The phenomena, then, which sometimes coexist with fever, as 
flux, hemorrhage, nausea, vomiting, black vomit, jaundice, dysp- 
noea, pain, headache, delirium, convulsions, coma,* etc., do not 
belong to increased action or fever, as such. They all belong to 
venous congestion without fever, as we have seen demonstrated in 
dilatation of the heart; and as venous congestion precedes and 
coexists with fever, we see that they are not jiroduced by it. The 
question then is reduced to the single point—is congestion, or 
pressure of blood, competent to the production of increased action f 
The answer is in the affirmative, as is demonstrated in hyper- 
trophy; and this leaves but small remainder. 
Increased action or fever itself, then, is the result of verons 
congestion—an increased retrograde pressure of venous blood in 
the capillaries. 
Is this a competent cause? Does this increased retrograde 
pressure of venous blood in the capillaries, connect the increased 
action of the heart in fever or hypertrophy, with the multitude of 
attendant phenomena? 
“It is extremely interesting to observe the influence of im- 
peded or arrested flow of blood in the veins upon the arteries. I 
have already alluded to the experiment of applying a ligature on 
the inferior extremity of the frog in which this is seen under 
the microscope. The phenomenon deserves to be noticed more 
particularly. 
“ If we tie a ligature around the frog’s leg, the web being 
spread under the microscope, we instantly see the whole circula- 
tion, which was equable or nearly so before, become pulsatory. If 
we tie the ligature a little more tightly, the globules of blood are 
observed to oscillate even in the arteries, and to proceed and to 
retrograde, at each systole and diastole of the heart.”—Marshall 
Hall. 
“ Boerliaave proposed a theory of inflammation, which, if it 
was not altogether original, was, at least, an important modification GENERALIZED—PART I. 
29 
of that of Pitcairn, and of the mathematical school. He supposed 
that the blood itself became more viscid, causing a lentor in its 
circulation through the several orders of capillary vessels, an ex- 
cessive engorgement of them; an increased action of the larger 
vessels, and flow of blood initliem, taking place to overcome the 
resistence and congestion. The close resemblance of this hypothesis 
to others much more recently proposed, is very obvious. That the 
action of the larger arteries should be increased, when an obstruction 
to the circulation through the capillaries exists, may readily be con- 
ceded; but that the afflux of blood can be increased, and obstruction 
at the same time exist, is a contradiction in terms.”—Coplands 
Dictionary, vol. 2, p. J/.58, 
u Obstruction in the right auricle, whether from this or any 
other cause, presents an obstacle to the return of the venous blood, 
and therefore, causes retardation throughout the whole venous 
system. Nor. is this all; tor the retardation is propagated through 
the capillaries to the arterial system, and thus at length returns in 
a circle to the heart. In this way is explained what at first sight 
appears an anomaly, namely: that the left cavities are sometimes 
rendered hypertrophous by an obstruction in the heart situated 
behind them in the course of the circulation, as for instance, when 
the left ventricle is rendered hypertrophous by a contraction of the 
mitral orifice.”—Hope, 252. 
It appears, from the preceding quotations, that venous conges- 
tion, or an increased retrograde pressure of venous blood in the 
capillaries, is competent to the production of the increased action of 
the heart and arteries, in fever, or hypertrophy. We have seen that 
it teas present: Therefore— 
In looking at the condition of the system in dilatation with 
hypertrophy of the heart, we obtain a full-length likeness of the 
condition of the system, in fever. 
If the increased action of the heart in fever or hypertrophy 
does not produce the attendant phenomena, what does it contribute 
to their production l In answer : reaction or increased action tends 
to remove congestion or equalize the pressure of the fluids and 
solids upon each other; but failing in this, the increased arterial 
action cooperates with the antecedent retrograde pressure of venous 
blood, to increase the pressure in the capillaries. Reaction may 
therefore diminish or remove congestion in some, parts, and thus 
diminish or remove some of the antecedent phenomena, and it may 
increase the pressure in other parts, and thus add new symptoms 
or increase those that remain. 
“ To this cause, the remora of blood in the veins of the viscera 30 
PATHOLOGICAL PHENOMENA 
during the cold stage, is superadded the arterial congestion of the 
same organs during the stage of excitement.”—Art. Intermittent 
Fever, Cyclopedia Fract. Med. 
u It must be admitted, however, that hypertrophy does not 
produce serous infiltration so readily and promptly as a direct, 
primary obstacle to the return of the venous blood ; a fact which 
admits of a rational and obvious explanation. When there is an 
obstacle to the return of the venous blood, suppose,, for instance, 
contraction of the tricuspid, pulmonic, or mitral orifice, two causes 
conspire to produce the capillary congestion: namely, the direct 
pressure of the arterial vis-a-tergo, and the retrograde pressure of 
the retarded venous blood.”—Hope. 
“ Active dropsies are sometimes spoken of as belonging to the 
left side of the heart; Passive dropsies to the right. What connects 
all these forms of dropsy is a preternatural fullness, in some part or 
the whole of‘the hydraulic machine. And this seems to be the 
grand key to the entire pathology, as well as to the remedial man- 
agement of the disease.”— Watson’s Practice. 
What shall be said of the periodicity exhibited by patho- 
logical phenomena? If we are successful in connecting them 
through causation, with the phenomena of the world around us, all 
will have been done which can be required. 
The principles of treatment deducible from the premises of 
this argument, are in accordance with the principles of treatment 
established by experience. 
We have seen that the term Congestion was a mark put upon 
a relatively increased pressure of blood to the returning pressure of the 
heart or blood vessel. 
The obvious indication of treatment, then, is either to diminish 
the pressure of blood, as by depletion, or increase the counter- 
pressure of the vessels, as by stimulants, tonics, astringents, band- 
ages, etc., or both. We may be said to do both when we prescribe 
blue pill to increase secretion, and follow it with quinine to increase 
the tone or returning pressure of the solids; between the two an 
equilibrium is sometimes established. Abstinence and exercise 
may be said to act in the same manner, and are admirably adapted 
to many minor ailments. 
There is a point of agreement, then, in the action of stimulants 
and depletion, upon which point of agreement, their efficacy de- 
pends. This reconciles the apparent contradictions so often met 
with in medical works, as when one recommends stimulants, and GENERALIZED—PART I. 
31 
another, depletion, in a disease of the same name, and apparently 
with equal success. It depends upon the stage of the disease—the 
degree and duration of congestion—which class of remedies is, at 
first, most appropriate. 
The local treatment for inflammation is the same in kind as 
the general treatment for fever. The symptoms of local fever or 
inflammation—heat, redness, pain, and swelling—are common to 
general fever, but being diffused over a larger surface, may not be 
so prominent in any part. The pathological condition—conges- 
tion—is the same, and therefore the treatment is the same. There 
are the same indications for the use of cold or evaporating applica- 
tions to the surface, the same indications for depletion, and the 
same indications for stimulants, tonics, etc. 
The treatment of acute and chronic diseases is.the same in 
Mnd, though modified in activity by the consideration that in 
chronic cases the vessels have become habituated—from duration 
of congestion—to a state of over-distention, and cannot suddenly 
return to their natural calibre or state upon the sudden 
of pressure. Duration is an element in formation and in cure 
Hence we deplete more gradually or slowly in chronic than in acute 
attacks. 
We have seen that fever, and it* attendant phenomena, were 
connected through venous congestion—an increased retrograde 
pressure of venous blood in the capillaries. Now from the connec- 
tion of the liver with the venous system, to increase its secretion, is 
directly to deplete from that system; is directly to diminish the 
retrograde pressure of venous blood in the capillaries. Hence the 
popularity of purgative medicines, especially those supposed to 
increase the secretions of the liver. Why is calomel prescribed for 
such a multitude of special diseases? How can it be explained, 
except there be a condition, common to all, which the action of 
calomel sometimes diminishes or removes ? Has not every physi- 
cian seen fever itself, and the attendant phenomena, all diminished 
or removed at the same time by the action of a mercurial cathartic? 
Is not this in evidence that they are connected through a common 
cause ? If w e take up an advertisement of a popular or patent 
medicine, do we not see that it is recommended for almost every 
disease that the body is liable to ? There is a significance in these 
facts which is worthy of consideration. 
If we take blood from a vein, or increase the secretion of the 32 
PATHOLOGICAL PHENOMENA 
kidneys—the force of the arterial circulation remaining the same— 
we are still depleting from the venous system. If we continue to 
deplete after the force of the arterial circulation has declined to a 
certain point, we abstract from the blood in actual circulation, and 
will speedily produce the state—congestion—which we are trying 
to remove. The very remedies necessary to remove congestion, if 
carried beyond a certain point, produce that state. Unquestionably, 
many cases of dropsy, and fever, have been relieved by bleeding, 
by abstinence, and also by increasing secretion; but it is equally 
true that a man may be bled, or starved, or purged, into a dropsy 
or fever. Do we not see clearly from this that we are dealing only 
with relations ? Can any other theory explain these facts f 
As with the diseases and remedies of the natural body, so with 
those of the body politic. It is only within certain limits that 
human laws (remedies) operate beneficially; beyond those limits, 
they produce the state they were ostensibly enacted to remove. Do 
not excessive laws defeat themselves'? Do not tyrannical laws 
come back upon their authors, whether those authors be few or 
many ? Let history answer ? 
Undoubtedly, medical Sangrados have done much harm, have 
consigned thousands to premature graves; but who can compute 
the numbers slain by political doctors—legislative Sangrados. 
When the pulse is soft and feeble—when a people are ex- 
hausted—congestion or disease is better relieved by stimulants, 
tonics, encouragement, good nursing, and good diet, than by deple- 
tion ; or if local depletion is necessary in any of these cases, it 
must go hand in hand with general restoratives. 
The effect of the stimulant in these cases is to till up and 
increase the force of the pulse; is to throw an additional quantity 
of blood into the arterial system; which additional quantity of 
blood must necessarily be derived from the veins; so that stimu- 
lants and tonics, as well as depletion, operate, within certain limits, 
or when acting beneficially, by diminishing venous congestion. 
We thus see that though disease be a unit, the treatment must 
be adaptive; adapted to conditions, to degrees, or to diversity as 
well as to unity. 
We have now seen the terms debility, dilatation, congestion 
and obstruction, connected with the terms reaction, inflammation, 
fever, and hypetrophy. This reconciliation of terms must recon- GENERALIZED—PART I. 
33 
cile the apparently opposite opinions which have so long divided 
pathologists. 
Humoralists and solidists: the advocates of plethora, obstruc- 
tion, and debility, on the one side, and of increased action, on 
the other, meet in dilatation with hypertrophy of the heart, and 
are reconciled; meet in the chambers of that organ, and are 
harmonized. PATHOLOGICAL PHENOMENA GENERALIZED. 
PART XX. 
It may be said that if all pathological phenomena are produced 
by congestion—pressure—they should all appear whenever that 
congestion was general, as in dilatation of the heart. If we were 
to add the phenomena observed and noted by other authors to 
those recorded by Dr. Hope, the remainder would be small indeed 5 
but we propose to present the argument in a somewhat different 
form from the preceding, and so nearly exhaust the subject, that 
any remainder cannot rank above a perturbation. 
We are now to employ, more directly, and in form, the 
Deductive Method: and as a basis, or inductive step, we intro- 
duce some experiments, establishing the fact that congestion— 
pressure—venous congestion, an increased retrograde pressure of 
venous blood in the capillaries, is the cause of a multitude of 
pathological phenomena. 
“ In one rabbit I tied the jugular veins on each side of the 
neck. When it was at liberty, it ran about, cleaned its face with 
its paws, and took green food. Its respiration was reduced to 
sixty-eight inspirations in a minute, which is about half the natu- 
ral number. After four hours it ran about as if nothing had 
happened, and eventually recovered. 
“ When it was killed and injected, I found, on each side, three 
anastomosing veins, passing from the anterior to the posterior part 
of the jugular veins, and conveying the blood from the head to 
the heart. 
“ In a second rabbit, I tied the jugular veins of the neck as 
before. The animal’s respiration became slow, but it ate green 36 
PATHOLOGICAL PHENOMENA 
food, ran about, and was difficult to catch; but for five days after 
it appeared dull, its ears had dropped. On the seventh day it was 
seen to be convulsed, and frequently rolled over. Its voluntary 
powers were lost, as well as its sensation, in a great degree. On 
this day it died. On examination, a clot of blood was extrava- 
sated in the left ventricle of the brain. lienee it follows that 
apoplexy will occasionally result from an obstruction to the return 
of blood in the jugular veins; and this I have known to happen 
froni enlargement of the glands in the neck of a boy.”—Sir Astley 
Cooper’s Experiments. 
u The adequacy of venous obstruction to produce dropsy, is 
well illustrated by some experiments of Lower. He tied the 
jugular veins of a dog, expecting the animal to die of apoplexy; 
instead of this result, the face and head of the animal became 
much swelled with oedema. He then tied the ascending cava; 
ascites and anasarca of the lower extremities were the result. 
Disease affords numerous examples of dropsy and dux from ven- 
ous obstruction.”—Williams’ Principles of illed., p. 182. 
u The fact, then, which is beyond dispute, of the frequent 
preexistence of local engorgement and distention of the capillary 
circulation, gives support to the hypothesis that, (in certain cases 
at least,) the issue of blood results from pressure, whereby the 
blood in substance is urged through passages naturally imper- 
meable by its red particles, but now mechanically dilated in conse- 
quence of the vis-a-tergo. Although the dilatation cannot be made 
sensible to the eye, this seems the simplest and most obvious 
explanation applicable to some forms of idiopathic hemorrhage, 
and to the secondary species of that which is symptomatic. That 
blood may be thus exhaled, independently of any disease of the 
vessels themselves, we know from experiments on animals, and 
from the observation of what sometimes occurs in the healthy 
human body. Boerhaave produced hemorrhage into the intestinal 
canal of a living dog by placing a ligature on the vena porta. An 
extreme turgescence of the whole venous system is one of the 
results of sudden strangulation. Dr. Yelloly accordingly found 
such turgescence conspicuous in the bodies of five criminals who 
had recently suffered death by hanging; and in two of these in- 
stances, blood in considerable quantity had exhuded from, and 
coagulated upon, the mucous membrane of the stomach.”—Watson, 
Cyclopaedia Pract. Med. 
u 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 GENERALIZED—PART II. 
37 
upper half only. His arms were so hugely anasarcous that he 
could not bring liis 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 ap- 
peared preposterously small and out of proportion. The poor man 
looked as if the upper part of his body had been stuffed, for acting 
some ridiculous part on 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.”—Watson18 
Practice, p. 172. 
u A ligature drawn round any part of the body, so as to inter- 
cept the communication of the great vessels and the heart, may 
cause that part to perish. But the effect of the ligature is not the 
same in all cases; and it does not always produce mortification in 
the same way. You apply a bandage round the arm before you 
bleed a patient, to make the veins of the forearm become dis- 
tended, the object being merely to stop the circulation in the super- 
ficial veins. If you take it off at the end of a few minutes, the 
hand is at once just as it was before the ligature was applied. If 
you were to leave it on for twelve hours, the whole hand and fore- 
arm would become swollen; and would remain swollen for some- 
time after the bandage was removed. The swelling in such a case 
arises from the congested state of the veins, and from the conse- 
quent effusion of some of the serum of the blood into the cellular 
membrane. If the ligature round the arm be still tighter, so as to 
obstruct the circulation to a greater extent, but without arresting 
it altogether, the same effect is produced, namely, serous effusion, 
which may continue for sometime after the cause which produced it 
is taken away. The first effect, then, of a ligature which obstructs 
the circulation without arresting it completely, is to produce serous 
infiltration of the cellular membrane, and cedematous swelling. The 
different kinds of dropsy depend on the same principle. Disease 
of the heart, impeding the circulation through it, gives rise to 
anasarca of the legs, and dropsy of the pericardium and pleura. 
Disease of the liver produces dropsy of the peritoneum. 
“ But let us suppose that a ligature is applied in this manner 
around the arm, and allowed to remain, so that the impediment 
continues. A low sort of inflammation is set up, the cedematous 
swelling and tension are aggravated, and this may terminate in 
mortification. 
u Parts may be killed by pressure. The mode of death here is 
nearly the same as when parts are killed by ligature. The differ- 
ence being simply this : the pressure is like a ligature applied to a 
broad surface, operating not on the arterial and venous trunks, but 
on all the small vessels and capillaries.”—Brodie’s Lectures. 
u The effects of pressure have often been observed by experi- 38 
PATHOLOGICAL PHENOMENA 
merits on animals. If the cranium of a dog is trepanned and 
pressure performed on the dura mater to a certain extent, the ani- 
mal shows signs of great uneasiness, and is affected with general 
convulsions ; if the pressure is increased, the convulsions cease, the 
breathing becomes stertorous, the animal torpid and comatose; if 
the pressure is diminished, the breathing becomes more free, and 
the convulsions return; and if it is entirely removed, the animal 
soon completely recovers. The principal causes of pressure are 
congestion, effusion, etc.”—Cyclopedia Pract. Med. 
u I confess that the difficulty is not wholly relieved by these 
considerations. But it is a difficulty which cannot invalidate the 
evidence of numerous facts that attest the agency of. pressure, as, 
at least, one cause of coma. The presumption of agency aiises 
whenever coma immediately succeeds to pressure; and it is con- 
verted into certainty, if, upon the removal of pressure, the coma 
immediately departs. Now the- annals of physic are full of in- 
stances of this kind. In experiments upon animals, stupor has 
been brought on, and made to cease, at the pleasure of the 
operator, by applying pressure to the exposed brain, and by remit- 
ting that pressure. Nay, the experiment has been tried on the 
human brain itself. A man who had undergone the operation of 
trepanning, and had recovered, was in the habit of exhibiting him- 
self for money in Paris, where Haller saw him. He suffered the 
spectators to make pressure upon his brain, where it was covered 
by the integuments only. This always put him into a state of 
coma or deep sleep; but sensibility and the power of voluntary 
motion returned at once when the pressure was taken off.”—Wat- 
son’s Practice, p. 310. 
Connect these experiments with the one performed by nature 
on the human subject in dilatation or valvular disease of the heart, 
and we see the multitude of phenomena which are unequivocally 
produced by congestion-—pressure. This much is secure, since we 
can produce these phenomena, whenever "wS will. 
Can they be produced in any other way than through conges- 
tion! This state being a lenown cause, it belongs to those who hold 
that other causes, as blood poisons, etc., may produce them, to 
bring forward a case or cases in which congestion is absent. Meta- 
physical assumptions or disquisitions will not do here. They must 
produce a case, or give positive demonstration, in the absence of 
congestion, or the question is settled in favor of this argument. 
In any order of phenomena, if we connect a large number or a 
majority of them together through a common cause, and then can 
carry that common cause into the remainder, the question is set- GENERALIZED—PART II. 
39 
tied. We have discovered the law, or the invariable relations of 
succession and similitude, which they bear to each other. 
Now we have already connected a majority of pathological 
phenomena together through congestion, and shall carry that state 
into the remainder. 
The preceding experiments and reasoning lay the foundation of 
our argument in solid fact; furnish the particulars, or the inductive 
step, from which to ascend to the general conclusion that all patho- 
logical phenomena are connected through congestion. 
Assuming that all pathological phenomena are produced by 
congestion, it follows, or we deduce— 
1. That all exciting causes of disease produce the state 
marked by the term congestion. 
2. That this state precedes and coexists with all pathological 
phenomena more complex than itself. 
3. That the treatment of congestion illustrates the treatment 
of all special diseases. 
4. That this state is a constant post mortem appearance, 
whether there be recognized organic change or not. 
These deductions verified, and we submit that the argument 
which sustains Astronomy, does not rest upon more secure founda- 
tions— 
1. That all exciting causes of disease produce the state 
marked by the term congestion. 
u The causes of congestion are: 1st. Those which act by 
primarily depressing the organic nervous influence; such as ad- 
vanced age; the continued or prolonged impression of cold; 
mental anxiety, and all the depressing passions and moral emo- 
tions ; prolonged sleep; mental and physical inactivity; miasmal, 
contagious, and infectious emanations; various vegetable, animal 
and gaseous poisons; and the rapid loss of the natural electrical 
tension of the frame. 2d. Those which mechanically impede the 
return or the circulation of the blood itself; or which change its 
quantity or quality, either locally or generally; as excessive heat; 
general plethora, produced either by too full living, or by the sup- 
pression of the natural, or accustomed discharges ; interrupted 
circulation through the heart, the lungs, liver, &c.; a long con- 
tinued posture by debilitated persons ; the use of unnecessary 
ligatures, and tight lacing; improper and unwholesome food ; con- 
tamination of the blood by the absorption or introduction into it 
of noxious, mineral, vegetable, and animal substances, or gaseous 
fluids; and changes taking place in its constitution, from the 
interrupted secretion or elimination of hurtful matters from it. 40 
PATHOLOGICAL PHENOMENA 
3d. Those causes which exhaust the irritability or vital tone of 
the vessels, by previously exciting them above their natural state 
of action.—Copland’s Dictionary. 
Attention is directed to the exhaustive character of the pre- 
ceding quotation; and its significance is apparent if we reflect that 
its author was not attempting to sustain any general theory. 
This verifies our first deduction. 
2. That this state (congestion) precedes and coexists with all 
pathological phenomena more complex than itself. 
To bring the whole subject clearly into view, we throw it into 
a form of the syllogism : 
All pathological phenomena are produced by pressure ; dilata- 
tion and hypertrophy of the heart are pathological phenomena ; 
therefore they are produced by pressure. 
“ The causes of hypertrophy and dilatation are often the same, 
though acting upon different principles. Whatever stimulates the 
muscular action of the heart, may produce the former affection ; 
whatever has a tendency to distend the walls, may produce the 
latter. Now no stimulus is greater, probably, to the muscular 
fibres than the pressure of the blood within the cavity they sur- 
round; and no cause tends more strongly than this to produce 
distension.”— Wood’s Practice, vol. £, p. 167. 
We have seen that a “ relatively increased pressure of blood 
to the returning pressure of the heart or blood-vessel,” Avas marked 
by the terms debility, dilatation, congestion, and obstruction. 
Increased action is marked by the terms reaction, inflamma- 
tion, fever, and hypertrophy. 
Dilatation, then, is congestion; and hypertrophy, reaction; 
and as dilatation and hypertrophy are produced by pressure, there- 
fore, congestion and reaction are produced by pressure. 
As dilatation with reaction or hypertrophy, and congestion 
with reaction or inflammation, and debility with reaction or fever, 
have the same antecedents or cause, and as dilatation and reaction 
or hypertrophy, are produced by pressure, therefore, congestion 
with reaction or inflammation, and debility with reaction or fever, 
are produced by pressure also. 
We are now to carry the simple state of congestion into all 
pathological phenomena; to witness the whole immense variety 
connected with the terms dilatation, obstruction, debility, and con- 
gestion ; and through these terms, with pressure. These are the 
points to which we direct attention. GENERALIZED—PART II. 
41 
u Retardation of the flow of blood in the small vessels, coinci- 
dent Avitli dilatation of their calibre and accumulation, and at last 
stagnation of the blood corpuscles in the vessels, constitute the tirst 
phenomena constantly appreciable by the microscope in the inflam- 
matory process as seen in the frog. The macroscopical phenomena 
of inflammation in man, being similar to those observed in the 
frog, seem to warrant the inference that the microscopical ones also 
are essentially the same in him as in the frog. The explanation of 
these phenomena, therefore—their sequence and relations—is justly 
considered the key of the whole theory of inflammation. 
u That the dilatation of the small vessels is primary, and the 
retardation of the flow of blood in them is secondary—-the neces- 
sary physical result of the preceding dilatation—is the opinion of 
most recent authors.”—Jones Opthalmic Med., p. 50. 
u If we wish to advance a step farther and tread in the regions 
of hypothesis, then it seems a reasonable doctrine that the primary 
disturbance of the functions of the nervous system acts first on the 
capillaries or extreme vessels of the surface as well as throughout 
the internal organs, and produces, not spasm, as was imagined by 
Hoffman and Cullen, but rather, according to modern views of the 
state of the capillaries in inflammation, a state of atony, relaxa- 
tion, and distension, and consequently obstruction to the passage 
of the blood; that the disturbed state of the circulation is an effort 
excited by the stimulus of this obstruction for accomplishing its 
own removal.”— General Doctrines of Fever. Tiveedic's Library. 
The following quotation illustrates and illuminates the two 
preceding: 
“ The physical cause of hypertrophy, in nineteen cases out of 
twenty, is some obstacle, mechanical or virtual, to the perfect 
accomplishment of the function of the chamber; some obstruction 
opposed to the free and thorough exit of the blood from it; or 
something which hinders the easy play of the organ : hence, in the 
flrst place, a gradual yielding, or tendency to yield, in the sides of 
the affected chamber, from the continued and unwonted pressure of 
the accumulated blood against it; and in the second place, a striving 
action of the muscle to overcome the hindrance, or to counterbal- 
ance the obstacle; and consequently, according to the law formerly 
announced, an augmentation in the bulk of the muscle whereof the 
function is thus increased. If the hypertrophy, which is the result 
of a truly conservative process, keeps pace exactly with the amount 
of the obstacle, and exactly balances it, no dilatation happens, or 
next to none. But this is comparatively seldom the case. Accord- 
ing to the principles of mechanics, a little distention of the sphe- 
roidal cavity must require an increase of force to propel from it a 
given quantity of blood, in the same time, through a given dis- 
charging orifice; so that incipient dilatation becomes (in addition 
to the supposed obstacle) an efficient cause of hypertrophy; and 42 
PATHOLOGICAL PHENOMENA 
the two, the dilatation and the hypertrophy, commonly make pro- 
gress together.”—Watson’s Practice, p. 661. 
“ When, from mechanical obstruction or any other cause, blood 
is inordinately accumulated in the heart, the organ is provoked to 
extraordinary efforts; it struggles against the obstacle; it frets 
and labors to overcome it; the coronary arteries are excited to 
increased activity; augmented nutrition (hypertrophy) ensues.”— 
Hope, p 2 If If. 
“ Whence it appears, that then (in the cold fit) the bloody 
humors do stagnate at the ends of the capillary vessels, and that 
there is, notwithstanding, at the same time some cause that irri- 
tates the heart.” “ So that the two quick contraction of the heart, 
with an increased resistance at the ends of the capillary vessels, is 
sufficient to complete in us the idea of all acute fevers.”—Boer- 
heave’s Aphorisms. 
“ It is, therefore, evident that there are three states which 
always take place in fever: a state of debility, a state of cold, and 
a state of heat; and as these three states regularly and constantly 
succeed each other in the order we have mentioned them, it is pre- 
sumed that they are in the series of cause and effect with respect 
to one another. This we hold a matter of fact, even although 
we should not be able to explain in what manner, or by what me- 
chanical means these states severally produce each other.”—Cullen’s 
First Lines. f 
Cullen supposed that spasm of the capillaries connected de- 
bility with fever; but we have seen that debility implies venous 
congestion, and that it was the increased retrograde pressure of 
venous blood in the capillaries which connected debility with fever. 
“His (Brown’s) theory differed in no essential respect from 
Cullen’s. ‘Like his predecessor,’ says Dr. Smith, ‘Brown attributes 
all fevers to debility; and affirms that the distinctions which physi- 
cians have made about the differences of fever are without founda- 
tion; that they are all the same, differing only in degree.’”—Clymen 
on Fever. 
Our own distinguished countryman, Dr. Benjamin Rush, advo- 
cated the unity of disease, and maintained that debility was the 
only predisposing cause. 
“ The terminations and consequences of debility are (a) im- 
peded or interrupted secretion; (b) changes of the circulating 
fluids; (c) various states of irritation or inflammatory action in 
particular organs or tissues; (d) general reaction of the vascular 
system associated with various grades of vital power, from the 
lowest or most asthenic, to its highest or most sthenic form, with GENERALIZED—PART II. 
43 
tlieir modifications; (e) changes in the firmness, elasticity, nutri- 
tion, color, form, and vital cohesion of the soft solids, and, in some 
instances, ultimately in the hard solids also; (/) effusion of fluids— 
aqueous, serous, sanguineous, &c.—from mucous or serous sur- 
faces, or in cellular or parenchymatous structures; (g) the forma- 
tion of new or adventitious tissues or productions, as tubercles, 
tumors, melanosis, cancer, hydatids, worms, gangrene, &c.; and 
(i) lastly, death.”—Copland’s Dictionary, vol. 1, p. 555. 
“ The most impressive illustration of the debility connected 
with internal congestion, and of the effect of copious blood-letting 
in relieving it, is, perhaps, that which is furnished by the epidemic, 
or, as it is commonly termed, spasmodic cholera. In the pamphlet 
published by the London General Board of Health, by authority of 
the Privy Council, the following passage occurs: ‘ But the remedy 
which is described to have been most uniformly successful, when it 
could be used, is bleeding, and this even in cases where the pulse 
was scarcely perceptible at the wrist. This practice seemed to 
apply itself to the root of the disease, by relieving the. congestion 
of the venous system, which was invariably found loaded on exami- 
nation after death, and which congestion (though only an effect of 
of the first impression made by the attack of the disease on the 
constitution,) appeared to be the immediate cause of death. In the 
lighter cases, or in those of a severe nature which came under 
medical treatment before the pulse at the wrist was lost, or had 
become fluttering, bleeding was attended with the most decided 
advantage. The oppression of the chest, the burning heat of the 
praecordia, the spasms, the vomiting and purging, are stated in 
some instances to have ceased at once; in others, on a repetition of 
bleeding. In such as allowed a free abstraction of blood, these 
effects very uniformly occurred ; but even in some, when the pulse 
was indistinct, bleeding was successful, if it could be carried to the 
exient of eighteen, twenty-four, or thirty ounces, the pulse rising 
in power and becoming more distinguishable in proportion to the 
flow of blood. If the pulse in this state of feebleness was distinct 
enough to give the finger the feeling of oppression, bleeding was 
almost always successful. The blood drawn was black, whether 
procured from a vein or an artery, and flowed with great difficulty, 
commonly first coming from the vein in drops, and gradually in a 
stream; but before it could be induced to flow with freedom the 
patient often required warm baths, frictions, external and internal 
stimuli, to produce a sufficient quantity for his relief. If a small 
quantity only could be procured, the heart seemed to feel the loss 
without being relieved, the bulk of the blood actually circulating 
being reduced, while the great mass of it, congested in the inferior 
and superior vena cava, did not make its way to the heart. The 
effect of bleeding was mechanical, and acted only as removing an 
obstruction to the passage of the blood from the distended venous 
system; and if not carried far enough to remove this impediment 44 
PATHOLOGICAL PHENO^fENA 
and allow the large veins to empty themselves into the heart, such 
weakness was produced as is occasioned by the loss of blood in 
a constitution worn out by disease.”—Art. Plethora. Cyclopedia 
Tract. Med. 
u It is reasonable to believe that the remote causes of phthisis, 
however variously they may appear to operate, do so by inducing 
s >me peculiar or determinate derangement of the system—some 
positive pathological condition, which, being constantly present 
wherever tuberculous disease is found, may be regarded as neces- 
sary to its production. Although we hesitate not to say, that, in 
the actual state of our physiological and pathological knowledge, 
we are unable to define with certainty all the conditions in which 
tuberculous disease has its origin, we think it would not be diffi- 
cult to point out some of the more important links of the chain 
which connects special functional disorder with the formation of 
tuberculous cachexia. On sgme future occasion we may take an 
opportunity to enter more fully upon the subject ; our limits at 
present merely permit us to call the attention of the reader to that 
morbid condition which, in our minds, constitutes the most obvious 
and important in a practical point of view. 
“A congestive state of the venous system of the abdomen is 
the condition to which'we refer ; it is one which was familiar to the 
pathologists of the last century, and, although it has not been quite 
overlooked, it has been too much neglected by the moderns. Such 
of our readers as are familiar with the writings of the German 
physicians of the middle of the last century, particularly Stahl, 
Hoffman, and above all Kaempf, and his disciples, will be aware of 
the extensive influence and importance attached to this state of the 
abdominal circulation at that time. Referring to those works 
where the facts upon which the doctrine rests are fully exposed, we 
shall restrict ourselves here to a few observations more particularly 
bearing upon the subject of this article, and which it is but justice 
to ourselves to say were established in our mind as the result of 
practical observation, before we were aware of the existence of the 
German doctrines of abdominal infarctus. 
u I11 children originally of a strumous habit, we observe a 
constant disposition to this congestive state of the abdominal cir- 
culation ; and unless we succeed in obviating it, they become 
tuberculous and die early in life. I11 youth we find the same state 
of congestion as a precursor of tuberculous cachexia; but it is 
during the middle period of life, from thirty-five to forty, that it is 
accompanied with more marked symptoms, such as dyspepsia with 
its various concomitants, which exist often for a very considerable 
time, and not unfrequently obscure the pulmonary affection till 
tuberculous disease has made considerable progress. This is the 
form of the affection which has been denominated dyspeptic phthisis; 
and if the term referred merely to the cause of the pulmonary dis- 
ease, there would be little harm in retaining it; but if used to GENERALIZED—PART II. 
45 
designate a species of phthisis differing from the tubercular, we 
consider it decidedly objectionable; because, however prominent 
the dyspeptic symptoms may he, tubercular disease of the lungs 
is the cause of death. While we admit to the fullest extent the 
necessity of attention to the state of the digestive organs, we must 
object to the pathological view which limits the attention of the 
practitioner to the dyspeptic affection, neglecting other and equally 
essential parts of the treatment. We do not know such a disease 
as dyspeptic phthisis as constituting a particular species; but we 
are well acquainted with that form of tubercular phthisis which is 
long preceded and accompanied in its progress with dyspepsia. 
Indeed, tubercular phthisis rarely occurs in the middle period of 
life without this complication; but it cannot be doubted that the 
deranged condition of the digestive organs is, in these cases, very 
often a mere consequence of a long preexisting state of congestion 
of the venous system of the abdomen; and which, if not corrected 
by more efficient measures than those generally applied to relieve 
the dyspeptic symptoms, may soon terminate in pulmonary con- 
sumption. The profession are highly indebted to Dr. Wilson 
Philip, for calling their attention to the congestive state of the 
hepatic system, and pointing out some of the most effectual means 
of obviating it, but we cannot admit that this dyspeptic phthisis 
differs in its nature from common tubercular phthisis. 
u The effects of congestion and derangement of the abdominal 
viscera have long been remarked as causes of phthisis; they were 
regarded by Kaempf and his disciples as giving rise to most of the 
chronic diseases of the chest. Portal observes, that it is certain 
that engorgement of the liver and other affections which derange 
the secretion and even excretion of bile, may become a cause of 
pulmonary phthisis ; and several other authors have remarked the 
connection of phthisis with abdominal disease, but in a manner so 
vague and undefined as to attract little attention. 
u Abdominal plethora, when once established, gives rise to a 
series of deranged functions in the digestive organs, the lungs, 
skin, &c., which by impeding digestion and assimilation affect the 
whole animal economy. These are manifested in imperfect biliary 
secretion, constipated bowels, and irritated mucous surfaces, in 
congestion of the lungs, and a dry and harsh state of the skin. In 
consequence of the over loaded condition of the venous system, the 
heart, generally feeble in the tuberculous constitution, is oppressed, 
and the arterial circulation impeded and enfeebled. In this state 
of the system, very slight exciting causes induce disease, inflam- 
mation and hemorrhage; hence arises the constant liability of 
strumous subjects to inflammatory diseases of a sub-acute or 
chronic character, and hence also we derive an explanation of the 
hemorrhages to which they are peculiarly liable even at a very 
early age. The same pathological state of the abdominal circula- 
tion forms the remote cause of the various congestive and chronic 46 
PATHOLOGICAL PHENO^IENA 
diseases so common in the strumous subject; such as glandular 
swellings, cutaneous eruptions, &c., &c.”—Art. Tubercular Phthisis, 
by Sir James Clark. Cyclopedia Pract. Med. 
u It may be said, generally, that when congestion is constant 
in a cavity, dilatation is more commonly the result; and that when 
there is only resistance to the expulsion of the. blood without con- 
stant engorgement* of the cavity, it is more common for hyper- 
trophy to be produced. Contraction, for instance, of the aortic 
orilice causes hypertrophy of the left ventricle in a greater degree 
than dilatation ; whereas patescence of that orilice, attended with 
regurgitation and constant congestion of the cavity, causes dilata- 
tion in a greater degree than hypertrophy.”—Hope on the Heart, 
p. 252. 
u The sequel® of liypercemia are multiplex, varying with the 
duration, the repetition, the degree of congestion. Much likewise 
depends upon the character of the affected organ, the congestion 
being significant in proportion to the general importance of such 
organ, and the vulnerability of its texture. Organs are prone to 
congestion proportionate to their vascularity and to the degree of 
their functional activity. Under particular circumstances of life, 
of occupation, of civilization, certain organs, such as the brain and 
its membranes, and the lungs, are hardly ever entirely free from 
congestion. Congestion affects morbid growths equally with nor- 
mal formations. 
u Intense congestion suddenly developed in organs essential 
to life (the brain or lungs) may prove fatal directly, as so-called 
vascular apoplexy, or the sudden effusion of blood serum into the 
textures—acute oedema. 
u High degrees of congestion occasion laceration of capillaries, 
and parenchymatous hemorrhage (apoplexy with bloody extravasa- 
tion) in the brain, the lungs, and other organs. 
“ The same causes lead, by an over loading of blood vessels, to 
absolute palsy of the blood vessels, to stasis, inflammation, and 
gangrene. 
u Moderate but habitual or repeated congestion gradually, en- 
genders oedema and the dropsy of serous cavities—genuine dropsy, 
increased exudation of blood plasma, preternatural nutrition of the 
textures—hypertrophy, augmented secretion. 
u In this relation, abiding mechanical congestions, from heart 
disease, are worthy of especial notice, with their unfailing conse- 
quences—hypertrophy of the glandular abdominal viscera; preter- 
natural secretion of the intestinal and bronchial mucous membranes; 
excessive, saturated secretion of bile. 
“ Hyperceinia create and bequeath permanent dilatation and 
elongation with coil-like or serpentine deflection—properly termed 
varicosity—of the blood vessels, as more particularly exemplified 
in the less resinent veins. GENERALIZED—PART II. 
47 
11 Hypercemia frequently occasion and obviously accompany 
the development of various heterologous growths. Finally, in some 
organs, a proportion of blood-pigment, effused with the plasma, 
constitute the basis of rust-colored, slate-grey, bluish-black colora- 
tion, as in the lungs, or on the intestinal mucous membrane. 
“ Organs attacked by a high degree of congestion present 
different shades of dark red, become swollen, loosened in texture, 
and consequently friable, lacerable.”— Pathological 
Anatomy. 
u When a congestion is extensive it has constitutional as well 
as local effects. In proportion as blood accumulates in‘a part, it 
leaves the rest of the body with less than its proper share, and the 
limbs and surface generally may show various symptoms of weak 
circulation and want of blood. Thus with considerable congestion 
of the lungs,. liver or brain, the surface is pallid and chilly, the 
pulse weak and small, the extremities cold, there is a peculiar 
feeling of langour or weariness, and all the functions are indiffer- 
ently performed. Such an effect-on the system may be produced 
artificially by applying a tight bandage around both thighs at 
once, or even both arms in a weak person: the limbs beyond the 
ligature become congested, leaving a deficiency of blood in the rest 
of the system. The extreme of this condition is the cold fit of an 
ague, in which extensive internal congestions are the most essential 
pathological change. 
u As in this example, so with other extensive congestions, 
more especially if suddenly induced, as by cold, a reaction may 
ensue, causing quickened pulse and circulation, hot skin, and other 
phenomena of fever. Where this reaction is vigorous, it may 
fulfil its object in sweeping back the congested blood into the 
circulation, and thus restoring the balance. Where the reaction is 
weak, it will fail to remove the congestion, but constitutes a low 
feverish excitement, often remittent in type, with depraved func- 
tions, foul tongue, impaired excretions, restless nights, etc., which 
may proceed for an indefinite period, until a critical evacuation by 
sweat, urine, or diarrhoea terminates it, and with it sometimes the 
congestion which has induced it.”— Williams1 Principles. 
u In the present lecture I propose sketching for you the chief 
changes which occur in inflammatory effusions; those changes at 
least which lead to suppuration, or to chronic thickening in organs. 
11 I must begin by carrying you back to the subject of my last 
lecture, and by reminding you of what occurs when the capillary 
blood-vessels are overloaded with blood. I stated to you that, 
under these circumstances, the capillaries suffer a certain propor- 
tion of their fluid contents to exude. I stated likewise that they 
changed this fluid as it exuded, and that the change thus accom- 
plished (which distinguishes the serous fluid in question from the 
plasma of the blood) will vary, according as the pressure which 48 
PATHOLOGICAL PHENOMENA 
drives it through is little or much above the healthy and normal 
pressure of the circulation. If the pressure be very slightly in ex- 
cess, the material which transudes is a weaker solution of the salts 
of the blood with a trace of albumen; as the pressure increases, the 
proportion of albumen becomes larger; at length fibrin is found, 
perhaps only in flakes; a stage further, and it becomes sufficiently 
plentiful to impart to the transuded material the property of spon- 
taneous coagulation; and finally, the pressure may be such as to 
cause the rupture of the capillary vessels, and impart to the effu- 
sion a more or less admixture of blood-corpuscles. 
“ These various degrees are well illustrated in the pathological 
history’of the kidney. If you ha ve congestion of that organ in- 
duced, either by interference with its escaping blood, or by too 
much impulse in that which goes to it, an increased exhalation 
occurs into the tubules, and you get the symptom called albumi- 
nuria—one precisely analogous in its mode of production to that of 
ordinary serous effusion in the cellular tissue of the body. If the 
disease advance, the Malpighian tufts pour out not only serum, but 
fibrin; and in this stage, if you examine the urine microscopically, 
you find this fibrin in the shape of little threads: these are accu- 
rate casts of the minute urinary tubules into which the fibrin was 
originally poured, and from which it brings down, entangled in its 
substance, a certain quantity of the cell-growth of the tubule, the 
epithelium or endothelium. Finally, go a stage further, and instead 
of seeing these little threads transparent, colorless, and of pure 
fibrin, you see a quantity of blood-corpuscles entangled in them; 
the capillaries of the malpighian tufts have broken with the pres- 
sure, and have let all the elements of their blood escape: so that, 
instead of getting a mere fibrinous mould of the microscopical 
tubule, you get its little mould made of a thread of coagulated 
blood. These changes exactly illustrate the history of congestive 
and inflammatory effusions in all organs of the body; and as the 
kidney is peculiarly liable to such diseases—diseases, moreover, 
which are of the utmost interest and importance—you can hardly 
select a more convenient organ for exhibiting the changes in ques- 
tion.”—Simon's General Pathology. 
A comparison of the preceding quotations will show that the 
same phenomena are ascribed to dilatation, obstruction, debility, 
and congestion as the cause. This, we submit, connects them to- 
gether; connects—through pressure—the theories founded upon 
them. Volumes of similar, extracts might be adduced did repeti- 
tion beyond a certain point add to the weight of testimony. 
We will now carry the thread of congestion through the dis- 
eases of the nervous system. 
u Congestive Disorders of the Nervous System.—I 
have previously pointed out the peculiar nature of the circulation GENERALIZED—PART II. 
49 
within the cranium and vertebral canal, and shown that, although 
well defended under ordinary circumstances against any mis- 
chievous change, still when such change does occur it operates in 
a peculiar manner. In other words, as long as the bones are capa- 
ble of resisting atmospheric pressure, although the amount of fluid 
within these cavities cannot change as a whole, yet the distribution 
of that amount may vary infinitely. Thus by its being accumu- 
lated sometimes in the arteries, at other times in the veins, or now 
in one place, and then in another, unaccustomed pressure may be 
exercised on different parts of the nervous centres. This, according 
to its amount, may either irritate or suspend the functions of the 
parts, a fact proved by direct experiment, as well as by innume- 
rable instances, where depression of bone lias caused nervous phe- 
nomena, which have disappeared on removal of the exciting cause. 
That congestion does frequently occur in the brain and spinal cord, 
there can be no doubt, although it cannot always be demonstrated 
after death. The tonic contraction of the arteries is alone sufficient 
to empty them of their contents, and turgidity of the veins may or 
may not remain according to the symptoms immediately preceding 
death, and the position in which the body is placed. But it is 
observable that every cause which excites or diminishes the action 
of the heart and general powers of the body, are at the same.time 
those which induce nervous disturbance, as well as occasion a 
change of circulation in the cerebro spinal centres—such as the 
emotions and passions, plethora, and anemia, unaccustomed stimuli, 
uterine derangement, etc., etc. 
“ It is only by this theory that we can understand how such 
various results occasionally occur from apparently the same cause, 
and again how what appear to be different causes produce similar 
effects. Thus violent anger, or an unaccustomed stimulus may, in 
a healthy person, induce a flushed countenance, increased action of 
the heart, a bounding pulse, and sudden loss of consciousness. 
Again, fear or exhaustion may occasion a pallid face, depressed or 
scarcely perceptible heart’s action, feeble pulse, and also loss of 
consciousness. In the first case, or coma, there is an accumulation 
of blood in the arteries and arterial capillaries, and a corresponding 
compression of the veins; in the second case, or syncope, there is 
distension of the veins and venous capillaries, with proportional 
diminution of the calibre of the arteries. In either case, owing to 
the peculiarity of the circulation within the cranium, pressure is 
exerted on the brain. Hence syncope differs from coma only in the 
extreme feebleness of the heart’s action, the cause, producing loss 
of consciousness, sensation, and voluntary action, being the same 
in noth. Indeed it is sometimes difficult to distinguish these states 
from each other, and that they have been frequently confounded 
does not admit of doubt. 
“ In the same manner, partial congestions from either cause 
may occur in one hemisphere, or psfrt of a hemisphere, in the brain, 
or in any particular portion or segment of the spinal cord. The 50 
PATHOLOGICAL PHENOMENA 
pressure so occasioned may irritate and excite function, or may 
paralyze or suspend it: nay, it may so operate as to suspend the 
function of one part of the nervous system, while it exalts that of 
another. Thus all the phenomena of epilepsy are eminently con- 
gestive, the individual frequently enjoying the most perfect health 
in the intervals of the attack, although the effects are for the time 
terrible, causing such pressure that, while the cerebral functions 
are for a time annihilated, the spinal ones are violently excited. In 
the same manner are explained all the varied phenomena of hys- 
teria and spinal irritation, for inasmuch as the spinal cord furnishes, 
directly or indirectly, nerves to every organ of the body, so conges- 
tion of this or that portion of it may increase, pervert, or diminish 
the functions of the nerves it gives off, and the organs which they 
supply. Congestion, therefore, we conceive to be chief cause of 
functional nervous disorders originating in the great cerebro spinal 
centre.”—Bennett's Clinical Lectures, pp. 4.03-5. 
u The cases which have just now been reported, have shown 
the principal forms symptomatic of hypercemia of the cerebral 
hemispheres. On combining with those few cases which ended in 
death several others of the same kind which terminated favorably, 
we have been led to the inference that cerebral congestion may pre- 
sent itself to us in one of the eight following forms: 
u The first form is characterized principally by dizziness of 
greater or less intensity : the patients may be affected at the same 
time with pain of the head, dizziness, tinnitus aurium, momentary 
aberrations of vision, temporary embarrassment in speech, a sense 
of formilation in the limbs, and sometimes at the face. The coun- 
tenance is generally flushed, eyes injected, pulse in general not 
frequent, and of variable strength. This state may last for some 
moments, or some hours; but it may also be prolonged for several 
months, or may continue even for several years. In some persons 
it shows itself but once ; in others it reappears at intervals more or 
less remote. We have seen a man fifty-nine years of age, who, for 
the last thirty years, had not passed a single day without having in 
different degrees one or other of the symptoms mentioned in the 
preceding paragraph. Another person had experienced them from 
the age of thirty years till he was thirty-four. He then became 
completely freed from it till the age of forty-eight, at which time 
he was again attacked with violent dizziness. We noticed the case 
of several persons in whom every year, nearly in the same month, 
these attacks of dizziness reappeared. In some females they mani- 
fest themselves at the return of each menstrual period. 
“ After this dizziness has lasted a shorter or longer tim#, it 
may happen that they attain all at once such an intensity as to be 
changed into a sudden loss of consciousness; but the latter may 
likewise supervene without having been preceded by dizziness. It 
is this sudden loss of consciousness, with or without preceding 
dizziness, which characterizes the second form of cerebral conges- GEJSEltAElZED—PART II. 
51 
tion. In this form tbe patients fall to the ground, deprived sud- 
denly of all understanding, sensation, and motion; but if their 
limbs be raised, they do not fall back again by their own weight, 
and some patients can sustain them in the air. There is not then, 
properly speaking, any paralysis. They may remain in this state 
from some minutes up to twenty-four or thirty hours: then they 
come to themselves, and are quickly restored, without any lesion 
either of sensation or motion remaining. Others, after having 
come to themselves, retain for some days a little difficulty in the 
performance of some of the functions of the life of relation. Thus 
their speech is embarrassed, or their different movements are 
difficult. 
“ At the same time that the patients fall, deprived of con- 
sciousness, they may be struck with paralysis, either general or 
confined to only one side of the body. This is the third form of 
cerebral congestion. But almost at the same time that the loss of 
consciousness disappears, the paralysis is also seen to disappear, so 
that cerebral hemorrhage cannot be admitted to have taken place 
in this case. The cases we have cited prove the possibility of this 
paralysis without any effusion of blood having taken place into the 
brain. Instead of general or partial suspension of motion, this 
function may be performed in a manner disorderly and irregular, 
and without any participation of the will. Then at the same time 
that there is loss of consciousness, there are observed either different 
convulsive movements or permanent contraction of a certain 
number of muscles; all these symptoms last at the utmost for some 
hours, they then disappear without leaving any trace behind. 
This constitutes the fourth form of cerebral congestion. In a fifth 
form there is no longer loss of consciousness—it is paralysis that 
comes on at the very first, sometimes limited to certain muscles of 
the face, sometimes extend to the entire of one side of the body. 
This paralysis disappears very promptly, oftentimes a few hours 
after having commenced; and from this circumstance it is not to 
be presumed that it is connected with a hemorrhage or softening. 
Our fourth case actually proves the contrary. The course of this 
paralysis was very remarkable in the following case: A middle- 
aged man, working in the quarries near Paris, was suddenly 
seized, on finishing his dinner, with numbness of the right hand ; 
an hour after the entire upper extremity was totally deprived of 
motion; no pain is felt in it, nor does he complain of his head. At 
five o’clock in the evening he had a sense of formication in the right 
toot; soon the power of motion was equally lost in the lower 
extremity of the right side; he entered the hospital Cochin. On 
the following morning the hemiplegia of the right side was com- 
plete ; the sensibility of the paralysed limbs was still retained; he 
cannot move the right cheek, and when he speaks the left commis- 
sure of the lips is drawn up; the direction of the tongue is straight; 
intellect perfect; he feels a numbness (this is his own expression) 
towards the frontal region ; he was bled to sixteen ounces. In the 52 
PATHOLOGICAL PHENOMENA 
course of the day he was able to make some slight motion with the 
extremities of the right side. On the following morning there was 
no trace of paralysis. This certainly is not the way in which the 
effects of cerebral hemorrhage disappear, or of any lesion affecting 
the interior of the nervous mass. 
u The sixth form of cerebral congestion is characterized by the 
sudden appearance of convulsive movements, partial or general, 
without preceding loss of consciousness. These movements 
promptly disappear, without leaving any trace behind them. They 
may also come on after the persons have experienced attacks of 
giddiness for a shorter or longer time, and the latter may even 
survive them. In a seventh form the cerebral congestion no longer 
produces coma ; it no longer exercises any perceptible influence on 
the movements; the intellect is the function here especially dis- 
turbed ; violent delirium is observed, accompanied with great 
development of muscular strength; most frequently, sometime 
before death, the delirium is replaced by a state of coma, which 
becomes more and more profound. However, we have ourselves 
seen cases in which, up to the moment of death, the patients 
retained great agitation of the limbs and ceased not to speak and 
vociferate. The most remarkable case of this kind which we met 
was that of a middle-aged man who for several hours uttered 
incessantly cries so loud as to disturb the rest of the entire ward. 
Suddenly he was no longer heard ; when we approached his bed he 
was dead. A thunderbolt could not have struck him more 
promptly. On opening the body no other lesion was detected 
except considerable injection of the nervous mass. We shall now 
notice the eighth form of cerebral congestion, of which our fifth 
case presents us an example. In this form we see continued fever 
appear at the commencement, during which those symptoms prin- 
cipally predominate, which appertain to the first form of cerebral 
congestion already described. We particularly observed this form 
in some young soldiers who were admitted in considerable numbers 
into our wards in La Pitie, in the beginning of the summer 1831. 
After laborious exercise several of these soldiers were seized with 
violent pains of the head, vertigo, ringing of the ears ; some even 
fell suddenly deprived of consciousness, and on coming to them- 
selves they remained with the symptoms above detailed. On 
entering our wards a little after the attack of their malady they 
presented to us the following state : Face red, eyes injected and 
moistened with tears ; ringing of the ears, vertigo ; great dizziness, 
which prevented thein.irom standing erect without being threatened 
with falling ; frequent epistaxis ; general debility ; continued ten- 
dency to sleep; pulse strong and frequent; skin hot ; no appre- 
ciable alteration with respect to the digestive and respiratory 
organs. This group of symptoms lasted from between three to 
twelve days. Almost all of them were bled. Some were merely 
subjected to diluent drinks. By degrees the fever lessened accord- 
ing as the symptoms of cerebral congestion disappeared. No doubt GENERALIZED—PART II. 
53 
it was not demonstrated that all the disease in these cases was in 
the brain ; perhaps there existed only mere general over-excitement, 
in which this organ participated. But the prevailing symptoms 
were always those of cerebral congestion, and, on the removal of 
the fever, these were the only symptoms observed, and the only 
therapeutic indication was to combat them. None of these cases 
terminated fatally. In one patient only there was momentary de- 
lirium ; in others the attacks of dizziness were for some days so 
violent that we dreaded that they should terminate in apoplexy.”— 
AndraVs Medical Clinic. 
“ Neuralgia is so intimately related to palsy and apoplexy as to 
entitle it to have been viewed as the not infrequent antecedent and 
concomitant of these maladies, and to have been considered as one 
of their most important complications. But it is equally allied with 
other maladies, as with epilepsy, coma, and convulsions; and it, in 
common with those and with the several states of palsy and 
apoplexy, depends upon a variety of organic lesions of the brain, or 
of its envelopes, or of the spinal cord and its membranes, which 
lesions, according to their seat, grade and nature, occasion either of 
these maladies—the same lesion even, according to its seat and de- 
velopment, producing either or even all of them in succession, and 
after indefinite periods, or even intervals or intermissions. A 
tubercle or tumour of any kind, for instance, may first occasion neu- 
ralgia or epilepsy, or neuralgia following epilepsy, or convulsions, 
and successively partial palsy, hemiplegia, and ultimately apoplexy, 
or profound coma, or asphyxia.”—Copland on Palsy and Apoplexy. 
u There is a manifest connection between hysteria, catalepsy, 
palsy, and apoplexy. * * Although these diseases are so 
different as to render them nosologically distinct, yet they all, with 
the addition of chorea, convulsions, and even insanity, comprising 
puerperal mania and convulsions, present a more or less intimate 
pathological relation in respect both of their physiological pathology 
and of their organic changes.”—Ibid, p. 186. 
u Apoplexy, long as this term has been familiar to the profes- 
sion, still conveys a very indefinite meaning. Some authors use it 
to distinguish a particular class of symptoms and effects of disease ; 
others to distinguish the pathological condition which gives rise to 
the symptoms. I think it is applied too generally to the effects of 
disease instead of the cause. The classification of diseases of the 
brain which I have adopted is founded on pathology, not on 
symptomatology. I propose using it to designate pressure on the 
brain or encephalon, produced by extravasation of blood or serum, 
or by distension of the vessels without extravasation, such extrava- 
sation not being the result of violence, as a blow upon the head. 
Whenever I employ the term apoplexy, I use it as synonymous with 
cerebral pressure, and I believe that all its varieties depend on the 54 
PATHOLOGICAL PHENOMENA 
amount of the effusion and the part of encephalon injured.”—Solly 
on the Brain. 
u The difference between augmented flow of blood along the 
arteries and its impeded return by the veins, on the intermediate 
blood channels and organs, is extreme. 
“ The most violent exercise, as in running, the respiration 
being free and proportionally accelerated, only suffuses the face 
with florid blood freely circulating; violent effort, on the contrary, 
as in lifting, in which respiration is arrested by closure of the 
larynx, induces a purple tumefaction of the tissues of the face and 
neck, from impeded flow and stagnation of venous blood. It is the 
difference between augmented and impeded circulation. 
u There is a great difference, too, between the degrees of im- 
pediment to the return of venous blood: the violent efforts in ordi- 
nary vomiting, fits of coughing, etc., fill the tissues of the face with 
venous blood; but still more violent acts of vomiting, the efforts of 
parturition, the convulsions of epilepsy, actually cause the thin 
parietes of the blood-channels of the face to yield, and induce 
minute ecchymosis, seen in the eyelids and on the temples. 
“ Let the impediment to the reflux of venous blood be greater 
still, and more specifically of the veins of the neck, and we cannot 
be surprised at the occurrence of loss of consciousness—cerebral 
epilepsy, if transient, apoplexy, if more permanent, with or without 
cerebral ecchymosis. A tumor, a ligature, or spasmodic action of 
the muscles, compressing the veins of the neck, produces this 
effect.” 
u It seems probable that the mere pressure of the veins of the 
neck may sometimes be partial—greater on one side of the neck, or 
on one vessel, than the other, or others ; and that in this manner 
partial congestion may occur, and induce more or less temporary 
hemiplegiac paralysis. One patient, the subject of epilepsy, had, in 
the first instance, attacks of transient hemiplegia! In like manner 
the epileptic seizure frequently affects on one side more than the 
other ; and the apoplectic is frequently conjoined with more or less 
of partial convulsive affection—so allied are these diseases. 
u The influence of indigestible, and therefore of irritating food, 
of constipation, as causing of sleep especially, and of posture, and 
of repletion of the stomach and bowels as augmenting this venous 
congestion, is obvious to every one.”—Marshal Hall, London Lancet, 
Aug., 18^8. 
The preceding quotations are so exhaustive, and .so high in 
evidence from the experience and ability of their authors that it is 
not deemed necessary to introduce additional testimony under the 
present head. 
Those extracts have passed in review before us the long list of GENERALIZED—PART II. 
55 
special diseases, and it has appeared that the simple state of Con- 
gestion was common to all. 
This, we submit, verifies our second deduction—unravels the 
complicated web of pathological phenomena, and shows their 
continuity unbroken, their connection complete. 
Our third deduction is— 
3. That the treatment of congestion, illustrates the treatment 
of all special diseases. 
Our deductions support each other. If congestion is common 
to all pathological phenomena, it follows that the treatment of this 
state should illustrate the treatment of all. 
“ Eemedies for Congestion.—The most important means in 
the removal of congestions are those which contribute to the re- 
moval of their causes. Thus the loosening of a ligature, or the 
reduction of a tumor, compressing veins—the moderating the inor- 
dinate and inefficient action of a diseased heart—the restoration of 
the secretion of the liver—will severally tend to diminish the con- 
gestions resulting from these different causes of venous obstruction. 
“ So, also, in the treatment of congestion from atony or weak- 
ness of the capillaries, it is important to remove the circumstances 
which have caused this atony. In many cases it is over-distention 
from gravitation; here change of posture gives relief. Thus, in 
congestive fevers, and other states «of continued weakness, it is 
useful to change from time to time the position of the patient from 
supine to prone, or lying on either side. With congestion of the 
head, this part should be supported high. The recumbent posture 
gives much relief to congested hemorrhoidal or uterine vessels, as 
we see it reduce the swelling of varicose limbs. 
“ Pressure is sometimes a remedy for congestion, by sup- 
porting the weak vessels, and promoting their contraction. This 
forms a chief part of the useful operation of bandages, adhesive 
plasters, and even of poultices, in various external congestions. It 
probably might be more extensively applied to these, and even 
to some internal congestions, in the modes suggested by Dr. 
Arnott, by mercury, or by the soft slack air-cushion pad. 
u Friction is a modification of pressure especially suitable to 
some forms of congestion, being calculated to give the motion that 
is defective, as well as to support the weak vessels. It is obviously 
useful in external congestions, from cold; and sometimes in visceral 
congestions, as those of the liver and abdomen generally. Exercise 
operates somewhat in the same way. 
u Another class of remedies for congestion comprehends those 
which promote the contraction of the dilated vessels by augmenting 
their contractility or tone. In this way, astringents and cold ope- 
rate ; as in the use of solutions of alum, sulphates of zinc or cop- 
per, acetates of zino or lead, and infusion or decoction of oak bark, 56 
PATHOLOGICAL PHENOMENA 
catechu, kino, nut galls, &c., in various congestions, particularly of 
the conjunctiva, throat, rectum, and vagina. The most obvious 
part of the action of bark, quinine, and arsenic, in the cure of ague, 
is in their reducing the great visceral congestions, which form their 
most remarkable, and perhaps their most important, pathological 
element. 
u The utility of astringents in congestion is limited by the fact, 
visible under the microscope, that they commonly contract the arte- 
ries more in proportion than the capillaries and veins, which are 
most distended. Hence they may still farther impair the motion of 
the blood, and increase the congestion. A reaction, however, some- 
times occurs, which converts the operation of the astringent into 
that of a stimulant, which is another kind of remedy for congestion. 
The same remark is applicable to cold ; and even more so, inasmuch 
as it also causes a physical obstruction to the flow of blood, in the 
manner formerly described. 
“ Stimulants sometimes are remarkably effectual in removing 
congestions. Thus, diluted spirit lotion to a congested conjunctiva, 
capsicum gargle to a congested throat, a stimulating wash or oint- 
ment to a purple sore or surface, will often signally reduce the con- 
gestion. Other congestions are removed by exciting the circulation 
generally ; a stimulant draught, or even one of any hot liquid, re- 
lieves the pulmonary congestion which has induced a fit of asthma; 
a congestive headache is sometimes mitigated by similar means. 
AVell regulated exercise tends to disperse congestions in various 
parts. Various agents whicfi specifically excite particular organs 
or parts, are often useful in removing congestions from them. 
Thus mercury is, in some cases, a remedy for a congested liver; 
some diuretics, as digitalis and cantharides, for congested kidneys ; 
squill, benzoin, and other expectorants, for bronchial congestion. 
u The influence of stimulants on congestion may be illustrated 
by the microscope. A solution of capsicum applied to a frog’s web, 
congested after previous irritation, causes an enlargement of the 
arteries, and an increased flow of blood to and through the con- 
gested vessels. This flow restores motion where it was deficient, 
sweeps away the accumulated blood, and, in some instances, causes 
the vessels to contract afterwards to their natural size ; so that the 
congestion is completely removed; in that case, the cure is com- 
plete. In other instances, however, the stimulants tail to clear the 
congested vessels ; the enlarged arteries pour in more blood ; but 
this not overcoming the obstruction, increases the hypercemia, and, 
as we shall afterwards see, may convert it into inflammation. Thus 
it appears that stimulants as well as astringents, although occasion- 
ally proving remedies for congestion, sometimes tend to increase it: 
and this they are most likely to do when the congestion is extensive, 
or of long continuance, or when its causes are still in operation. 
“ Under such circumstances, congestion is better relieved by 
another class of remedies, depletion, and various evacuents. Blood- 
letting, by puncture or incision in the congested parts, enables the GENERALIZED—PART II. 
57 
distended vessels to unload themselves, and they may recover their 
size; and the utility of this expedient is shown in scarifications of 
congested conjunctiva, and tonsils, and leeches to a congested os-uteri. 
But the blood is more usually drawn from the vicinity of the con- 
gested part, as by cupping, or leeches to the chest or side for 
congested lungs or liver; to the sacrum for congested uterus; or 
leeches to the arms for congested intestines. Or, without actually 
shedding blood, it may be drawn away from the congested part by 
derivation ; that is, by agents which cause determination of blood or 
congestion in other parts; as dry cupping, mustard plasters, and 
other stimulating applications to the surface, and by purgatives 
and other evacuants from the interior. A still more powerful 
agency of the class of derivants is that of removing atmospheric 
pressure from a limb by enclosing it in an air-tight vessel and par- 
tially exhausting the air. This was invented by Dr. Arnott, and 
has been lately employed by Sir James Murray, and several French 
practitioners. Tltese act by inducing determination of blood, or 
even inflammation in another part, and thereby drawing away from 
the congested parts. Some means, however, may be employed 
which prevent or remove congestion by damming up the blood in 
other parts, and thus inducing a counter-congestion. It has long 
been practiced with success to stop a fit of ague by applying a 
tourniquet to the thigh. Dr. Buckler, of Baltimore, following a 
popular practice of a similar kind, has called the attention of the 
profession to the general utility of the remedial measures which he 
terms hmmotme; which consists in the temporary application of 
ligatures to one or more limbs, which are thereby so much con- 
gested, that there is not blood left in the circulation sufficient to 
supply the congested vessels, and these, relieved of pressure, may 
contract and expel the accumulated blood. I have employed this 
plan in several cases in which temporary congestions were pro- 
duced in the liver and lungs, and sometimes with a very remark- 
able preventive effect; but it has little influence on congestions 
which ha ve long been formed, and acts chiefly on the distribution 
of blood in the larger blood vessels. 
u The operation of several of the foregoing agents, in combina- 
tion or succession, is generally more effectual than that of single 
ones in the cure of congestions. Thus congestion of the liver may 
resist the action of mercury, and may even be aggravated by it, 
until the vascular distention has been partially reduced by local 
blood-letting or derivants; then the mercury, by increasing the 
secretion, reduces the remaining congestion. Congestion of the 
kidneys is augmented rather than diminished by diuretics, which 
then fail to increase the secretion of urine, but may only render it 
more albuminous. But after some relief has been given by cupping 
to the loins, and hydra gogue purgatives and diaphoretics, then 
some diuretics, particularly digitalis and cantharides, cause a freer 
flow ot urine with less albumen. The same point might be further 
exemplified ; but it is unnecessary to multiply instances. 58 
PATHOLOGICAL PHENOMENA 
“ The cause of congestion being, in many instances, atony of 
the vessels, it may often be counteracted by circumstances which 
augment the tone of the vessels, locally or generally. Thus cold, 
astringent, or, occasionally stimulant applications, by bracing the 
fibres and invigorating the circulation in a part, render it less liable 
to congestion from disease; and general tonic measures operate in 
a similar way on the whole system. The efficacy of bark and 
arsenic in preventing, as well as in removing the congestions of 
ague, probably depends on their power of augmenting the tone of 
the vessels of these parts, so that they no longer yield to the dis- 
tensive accumulation of blood within them. A similar virtue seems 
to be possessed by iodine and its preparations, especially the iodide 
of potassium; under the use of which the disposition to local con- 
gestions is diminished, and those formed are sometimes dispersed, 
as exemplified by the external use of iodine in lepra and other 
congestions of the skin, and of iodide of potassium in congestive 
headache. Mineral acids and other tonics have a like effect in 
cases of general weakness. The treatment calculated to relieve the 
results of congestion will be considered under the subjects, hemor- 
rhage, flux, dropsy, and inflammation.”—Williams1 Principles of 
Medicine, pp. 162-165. 
To fully appreciate the exhaustive character of the preceding 
quotation, we have only to take the treatment therein detailed for 
congestion, from the treatment of any special disease, as inflamma- 
tion, fever, flux, hemorrhage, dropsy, etc., etc., and look for the 
remainder. 
The scientific significance and power of this elimination appears 
in the fact that Dr. Williams was not attempting to support any 
general theory—was not attempting to exhaust the treatment of all 
special diseases, and yet has scarcely left a residue. 
Assuredly, taken in connection with what has gone before, this 
amounts to a demonstration of the truth of our argument. 
We see in that quotation the point of agreement in all remedial 
appliances—they all tend to remove congestion. 
This verifies our third deduction. 
Our fourth deduction is— 
4. That the state marked by the term congestion, is a con- 
stant post mortem appearance, whether there be recognized organic 
change or not. 
This last deduction is universally admitted—congestion— 
venous congestion—is a constant post mortem appearance. 
This fulfils the requirements of the Deductive Method. 
Our argument is ended. Experience accords with it. Reason- GENERALIZED—PART II. 
59 
ing and experiment verify it. If it be said that it wants the 
scientific character of prevision, it is replied, that it finds an 
equivalent, in point of certainty, in our power of modifying circum- 
stances—in our power of producing pathological phenomena, in 
accordance with the theory, and only in accordance with it, when- 
ever we will. It is the only possible theory, therefore, which can 
accord with all the facts.