1 :*!*.••*." cennjftBBiisrcn;: .ViK ^aw/.v Ste?* •^■/x noo rav- tv,v. **T*i *"*****-*'-'" •jcr.-*-- ftV-V.- -v.-ar-y.-y.-r-; «v.v.;-**■""V-?^* *r*- -.•.*• .vy.* w .av, &&■ z.w. kt/A*i jsn .- He IPSfi IMA«» -Ytn-i™ 0B9Cv,\y f. A xSl-Xv. . ran. jw BK^V"-^ ffigv.v. »' EWUjit .V„..'AV: NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service 1* "0 LECTURES / THE PRINCIPLES AND PRACTICE PHYSIC, OPIXIOXS OF THE PRESS WATSON'S PRACTICE OF PHYSIC. It would appear almost superfluous to adduce commendatory notices of a work which has so long been established in the position of a standard authority as " Wat- son's Practice." A few extracts are, however, subjoined from reviews of the new and improved edition. The fourth edition now appears, so carefully re- vised, as to add considerably to the value of a book already acknowledged, wherever the English lan- guage is read, to be beyond all comparison the best systematic work on the Principles and Practice of Physic in the whole range of Medical literature. Every lecture contains proof of the extreme anxiety of the author to keep pace with the advancing know- ledge of the day, and to bring the results of the labours, not only of physicians, but of chemists and histologists, before his readers, wherever they can be turned to useful account. And this is done with such a cordial appreciation of the merit due to the industrious observer, such a generous desire to en- courage younger and rising men, and such a candid acknowledgment of his own obligations to them, that one scarcely knows whether to admire most the pure, simple, forcible English—the vast amount of useful practical information condensed into the Lectures— or the manly, kind-hearted, unassuming character of the lecturer shining through his work. — London Med. Tiviee and Gazette, Oct. 31, 1857. Thus these admirable volumes come before the profession in their fourth edition, abounding in those distinguished attributes of moderation, judg- ment, erudite cultivation, clearness, and eloquence, with which they were from the first invested, but yet richer than before in the results of more pro- longed observation, and in the able appreciation of the latest advances in pathology and medicine by one of the most profound medical thinkers of the day.—London Lancet, Nov. 14, 1857. The author has evidently been at much pains to follow the course of modern research; the prac- titioner, and the student of medicine in its practical aspect, will equally feel indebted to Dr. Watson, for having found time to communicate to them so large an amount of novel information as is introduced into this new edition, in so pleasing and instructive a manner. — Edinburgh Med. Jour., Nov. 1857. Lecturers, practitioners, and students of medicine will equally hail the reappearance of the work of Dr. Watson in the form of a new—a fourth—edition. We merely do justice to our own feelings, and, we are sure, of the whole profession, if we thank him for having, in the trouble and turmoil of a large practice, made leisure to supply the hiatus caused by the exhaustion of the publisher's stock of the third edition, which has been severely felt for the last three years. For Dr. Watson has noi merely caused the lectures to be reprinted, but scattered through the whole work we find additions or altera- tions which prove that the author has in every way sought to bring up his-teaching to the level of the most recent acquisitions in science.—Brit, and For. Medico-Chir. Review, Jan. 1858. A few of the commendations with which previous editions have been honoured in this country are likewise added. One of the most practically useful books that ever was presented to the student—indeed, a more admi- rable summary of general and special pathology, and of the application of therapeutics to diseases, we are free to say, has not appeared for very many years. — N. Y. Journal of Medicine. To say that it is the very best work on the sub- ject now extant, is but to echo the sentiment of the medical press throughout the country.—N. 0. Med. Journal. Of the text-books recently republished, Watson is very justly the principal favourite.—Holmes's Report to Nat. Med. Association. As a text-book it has no equal; as a compendium of pathology and practice no superior.—N. Y. An- nalist. We know of no work better calculated for being placed in the hands of the student, and for a text- book : on every important point the author seems to have posted up his knowledge to the day. — Ameri- can Medical Journal. From the late Professor of TJieory and Practice of Medicine in the University of Pennsylvania. Watson's Practice of Physic, in my opinion, is among the most comprehensive works on the subject extant, replete with curious and important matter, and written with great perspicuity and felicity of manner. As calculated to do much good I cordially recommend it to that portion of the profession in this country who may be influenced by my judgment. N. CHAPMAN, M. D. Philadelphia, September 21th, 1844. LECTURES PRINCIPLES AND PRACTICE PHYSIC DELIVERED AT KING'S COLLEGE, LONDON, BY THOMAS WATSON, M.D. FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, LATE PHYSICIAN TO THE MIDDLESEX HOSPITAL, AND FORMERLY FELLOW OF ST. JOHN'S COLLEGE, CAMBRIDGE A NEW AMERICAN, FROM THE LAST REVISED AND ENLARGED ENGLISH EDITION. WITH ADDITIONS BY D. FRANCIS CONDIE, M. D., FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; MEMBER OF THE , AMERICAN PHILOSOPHICAL SOCIETY, ETC. ETC. WITH ONE HUNDRED AND EIGHTY-EIVE ILLUSTRATIONS ON WOOD. '* ••*;*#*& kli^u.u\^€> PHILADELPHIA: BLANCH ARD AND LEA. 1858. W34-.2L I85g Entered, according to the Act of Congress, in the year 1858, by BLANC HARD AND LEA, in the Clerk's Office of the District Court of the United States for the Eastern District of Pennsylvania. COLLINS, PRINTER. PEEFACE BY THE EDITOB. In the edition of which the present volume is a reprint, the lectures of Dr. Watson have undergone a thorough revision, and whatever of value recent research has added to our stock of knowledge in the various departments of medical science has been carefully incorporated in them. The lectures on fever especially have been greatly enlarged and im- proved: the positive distinctions that have been insisted upon by eminent pathologists between typhus and typhoid fevers, are recognized as being founded in truth. The extent of these additions is shown by the fact, that notwithstanding a very considerable enlargement in the size of the page, the work has been increased by about two hundred pages. The very full and accurate exposition of the present state of pa- thology and therapeutics, in reference to the diseases embraced in these lectures, has rendered it unnecessary to augment materially the size of the work by frequent or extensive additions. In regard to a few of the forms of disease more particularly interesting to the American physician, the account given by the Author will be found somewhat defective, while he has omitted to notice one or two affections endemic to the United States. It is to remedy these deficiencies that the Editor, in preparing the present edition, has mainly directed his attention. The intrinsic merits of Dr. "Watson's Lectures are sufficient to ensure for them a favourable reception. For comprehensiveness of matter, accu- racy of detail, candour in the discussion of those questions upon which a difference of opinion exists among physicians, and perspicuity and felicity in the manner of presenting the several subjects embraced in them, they stand unrivalled. If by the additions he has introduced, the Editor has succeeded in increasing the value of this edition in any slight degree, he will be amply repaid for his labour. The few illustrations introduced by the Author have been considerably added to, from a conviction that, in this manner, the interest of the student in the descriptions given in the text will be enhanced. The Editor's additions are enclosed in brackets [ ]. Philadelphia, July, 1858. (vii) ADVERTISEMENT TO THE FOURTH LONDON EDITION. That these Lectures have remained for three years "out of print" has been caused by the necessity for their revision, and by the Author's want of leisure for revising them. Anxious as he has been to make them less undeserving of the favour which they have hitherto met with, he has still, in excuse of their many imperfections, to plead unceasing demands upon his whole time, strength, and thoughts, by the more imperative obligations of his pro- fessional life. September, 1857. («) ADVERTISEMENT THE FIRST LONDON EDITION, The following Lectures were put together, with unavoidable haste, during the Medical Session of 1836-37, in which they were first de- livered. They were repeated, with slight variations, for four successive years; the Author always meditating, but never finding time to accom- plish, their thorough reconstruction and revision. They were afterwards printed, to fulfil a rash promise, in the pages of the Medical G-azette: and they are now published, in a collected form, at the request formally con- veyed to him in writing, of many who had heard or read them, in- cluding several of his Colleagues at King's College. Writing for mere beginners, and without any thought of future pub- lication, the Author took no pains to note authorities as he went alono* He may often therefore have used, without acknowledgments, not onlv the facts and reasonings, but sometimes, perhaps, the very words of others. This omission he regrets, but is now unable to supply. Neither has he leisure to correct, if that were desirable, the colloquial and fami- liar style in which the Lectures were originally composed. Should they attract the notice of any who are no longer in statu pupil- lari, he would request such readers to bear in mind for whom these lessons were intended. They do not profess to present a formal and complete treatise on the Practice of Physic, much less to exhaust the various subjects upon which they touch. His chief hope is that they may prove useful as a text book for Students. As they were passing through the press, such additions and alterations have been introduced as the Author would have made, had he continued to deliver the Lectures orally. Henrietta Street, Cavendish Square, September, 1843. CONTENTS. LECTURE I. PAGE Introductory Lecture,............S3 LECTURE II. Pathology — meaning of the term. Pathology, general and special. Morbid altera- tions of the solid parts of the body. Alterations in bulk. Hypertrophy — laws of its production — its effects. Atrophy—its causes and consequences. Changes in form. Alterations in consistence. Induration — its various kinds, . . 41 LECTURE III. Softening; its causes and varieties. Transformations of Tissue. Changes of situa- tion —in the Chest, of the Lung, of the Heart—in the Abdomen and Pelvis, Hernia, Intus-susception, Prolapsus,...........51 LECTURE IV. Morbid Alterations of the Fluids, especially of the Blood. Changes in its quantity and distribution. [Leucocythaemia.] General and Local Plethora. Poverty of Blood. Active Congestion—its Phenomena—State of the Vessels as seen by the Microscope. Mechanical Congestion. Passive Congestion. Relations of these forms of Conges- tion to Inflammations — to Haemorrhages — to Dropsies, . . . . .57 LECTURE V. Different modes of Dying. Pathology of Sudden Death. Death by Anaemia, its Course, Phenomena, and Anatomical Characters. Death by Asthenia, its Course, Pheno- mena, and Anatomical Characters. Syncope. Death by Inanition. Death by Apnoea: Death by Coma: their Course, and Phenomena, and the Anatomical Characters com- mon to both. Application of the principles obtained from the investigation of the Phenomena of Sudden Death, in elucidating the Symptoms and Tendencies of Disease, 67 xii CONTENTS. LECTURE VI. Causes of Disease: distinction between predisposing and exciting causes. Enumera- tion of causes, as connected with the Atmosphere—Food and Drink — Poisons — Exercise—Sleep—Mental and Moral Conditions — Hereditary tendencies—Malfor- mations. Temperature. Effects of Heat and of Cold, . . . . .76 LECTURE VII. Causes of Disease, continued. Laws by which the operation of Cold upon the Bodily Health is regulated. Circumstances that favour its injurious effects, and respect, first, the Body itself; secondly, the manner in which the Cold is applied. Modifying influence of certain states of the Mind—of Sleep—of Habit. Means of protection. Influence of the different Seasons. Impurity of the Air. Hereditary tendencies to Disease, . . . . ..........87 LECTURE VIII. Symptoms. Their Uses in Relation to the Diagnosis, the Prognosis, and the Treat- ment of Diseases. Signs, as distinguished from Symptoms. Pathognomonic, Com- memorative, Direct, and Indirect Symptoms. Examples of Symptoms as they consist of uneasy Sensations, disordered Functions, or changes of Sensible Qualities, 99 LECTURE IX. Inflammation. Its Morbid and its Salutary Effects. Sketch of the Local and Consti- tutional Phenomena of Inflammation as it occurs in External Parts. Examination of the Symptoms of Inflammation: Pain ; Heat; Redness; Swelling. State of the Capillary Blood-vessels and of the Blood in a part inflamed, . . . 113 LECTURE X. Inflammation, continued. Buffy Coat of the Blood. Terminations or Events of In- flammation. Resolution; Delitescence; Metastasis. Effusion of Serum. Exuda- tion of Coagulable Lymph, or Fibrin. Organization of this Lymph. Suppuration. Ulceration, . ..... 124 LECTURE XI. Mortification, as an event of Inflammation. Inflammatory Fever. Hectic F Typhus-like Fever. Modification of Inflammation by differences of Tissue: Areola' Tissue; substance of Glands and Solid Viscera; Serous Membranes; Synovkl Membranes; Tegumentary Membranes - Skin — Mucous Membrane;'Muscular Tissue; Arteries; Veins; substance of the Brain, 135 CONTENTS. xiii LECTURE XII. Varieties of Inflammation: Acute and Chronic; Latent; Specific. Scrofulous In- flammation. Tubercles. Relative frequency of Scrofulous Disease in different Organs. Signs of the Strumous Diathesis,........146 LECTURE XIII. Cancer: its Species or Varieties. Scirrhus; Encephaloid Cancer; Colloid Cancer. Its mode of Growth and Dissemination. Habitudes of the several Varieties.---- Treatment of Inflammation. Antiphlogistic Regimen. Blood-letting, . . 159 LECTURE XIV. Treatment of Inflammation, continued. Recapitulation. Bleeding. Purgatives. Mercury. Antimony. Digitalis. Colchicum. Opium.----Local Remedies. Ex- ternal Cold. External "Warmth. Counter-Irritation.......175 LECTURE XV. Haemorrhage: — most commonly Capillary. Habitual Haemorrhages. Vicarious Haemorrhages. Idiopathic Haemorrhages. Active and Passive. Symptomatic Haemorrhages. Usual Situations of Haemorrhage. Symptoms and Diagnosis. Principles of Treatment,...........184 LECTURE XVI. Dropsy: its General Pathology. Passive Dropsy; Cardiac, and Renal. Active Acute, or Febrile Dropsy. Prognosis; and General Principles of Treatment in Dropsies,..............192 LECTURE XVII. Diseases of the Eye. Catarrhal Ophthalmia. Purulent Ophthalmia of Adults, . 204 LECTURE XVIII. Purulent Ophthalmia, continued. Gonorrhoeal Ophthalmia. Purulent Ophthalmia of Infants. Strumous Ophthalmia,..........214 LECTURE XIX. Strumous Ophthalmia, continued. Recapitulation. Treatment of Strumous Ophthal- mia. General Remarks on Conjunctival Inflammations. Iritis: its Symptoms and Treatment. Causes of Iritis,..........223 xiv CONTENTS. LECTURE XX. Iritis, concluded. Rheumatic Ophthalmia. Amaurosis,......233 LECTURE XXI. Diseases of the Brain and Nervous System. Difficulties of the subject. Short Review of some points in the Physiology of the Brain and Nerves. Peculiarity of the Cerebral Circulation. Pressure,..........244 LECTURE XXII. Symptoms of Cerebral Diseases. Inflammation of the Dura Mater and Arachnoid, from external injury; from Disease of the Bones, of the Ear, and of the Nose; from the poison of Syphilis. — Inflammation of the Pia Mater......253 LECTURE XXIII. Acute and general Inflammation of the Encephalon. Period of Excitement. Modes in which the disease may commence. Period of Collapse. Treatment. Delirium Tremens, . ......... t 263 LECTURE XXIV. Delirium Tremens, concluded. Chronic Inflammation of the Brain. Softening, Sup- puration, Abscess, Induration, Tumours in the Brain, .... . 271 LECTURE XXV. Hypertrophy of the Brain:—Atrophy. Acute Hydrocephalus: its Anatomical Cha- racters ; its Scrofulous Nature; Premonitory Signs; different Modes of Attack; Stages of the Disease; Causes, .... oqo LECTURE XXVI. Acute Hydrocephalus, continued. Prognosis and Mortality of the Disease. Treat- ment: Blood-letting; Purgatives; Cold; Mercury; Blisters. Prophylaxia. Spu- rious Hydrocephalus. Chronic Hydrocephalus, or Dropsy of the Brain. Shape of the Head and Face. Anatomical Conditions. Symptoms, . . 297 LECTURE XXVII. Treatment of Chronic Hydrocephalus; Internal Remedies; Mechanical Expedients- Bandages, Tapping. [Meningitis encephalica.] Symptoms of Spinal Disease! Inflammatory conditions of the Spinal Marrow, . . . 0f. CONTENTS. XV LECTURE XXVIII. Inflammatory and Structural Diseases of the Spinal Cord, continued. Treatment.---- [Cerebro-spinal meningitis.] Apoplexy. Its General Symptoms and Diagnosis. Symptoms characterizing the Apoplectic State. Pressure the ordinary Physical Cause. Hemiplegia. The Palsied Muscles rigid, or limber, .... 323 LECTURE XXIX. Apoplexy and Palsy, continued. Conditions of the Brain left visible after Death. Cerebral Haemorrhage. Changes of and around the Extravasated Blood. "White softening of the Brain. How produced. Parts of the Brain most commonly im- plicated, . . ............341 LECTURE XXX. Apoplexy, continued. Relations between the Symptoms and the Appearances found in the Brain after Death. Special Diagnosis and Prognosis. Relations between Cerebral and Cardiac Disease. Predisposition to Apoplexy and Palsy—Natural and Accidental. Precursory Symptoms. Exciting Causes. Treatment, . . .346 LECTURE XXXI. Spinal Haemorrhage. Paraplegia. Facial Palsy and Facial Anaesthesia; their Symp- toms, Prognosis, and Treatment. Other Forms of Local Paralysis, and Local Anaesthesia,..............360 LECTURE XXXII. Tetanus. Its Symptoms and Varieties. Causes. Diagnosis. Pathology. Treat- ment ; Opium ; Blood-letting; the Warm Bath; the Cold Bath, .... 373 LECTURE XXXIII. Treatment of Tetanus, continued. Wine; Mercury; Purgatives; Digitalis; Tobacco ; Musk; Prussic Acid; Belladonna ; Carbonate of Iron; Oil of Turpentine; Strych- nia ; Surgical Expedients; General Rules. Hydrophobia,.....384 LECTURE XXXIV. Hydrophobia, concluded. Various Questions considered respecting the Disease as it appears in the Human Subject, and respecting Rabies in the Dog. Pathology of the Disorder. Treatment. Preventive Measures, ...... 397 xvi CONTENTS. LECTURE XXXV. Epilepsy. Its Symptoms and Varieties; duration and recurrence of the Paroxysms ; periods of life at which they commence; warnings. Effects of the Paroxysms, im- mediate and ultimate. Pathology. Anatomical characters. Causes, . . . 408 LECTURE XXXVI. Epilepsy, continued. Recapitulation. Exciting causes. Simulated Epilepsy. Diag- nosis. Prognosis. Treatment; during the fit; during the intervals; during the warnings,..............417 LECTURE XXXVII. Chorea. Symptoms; Pathology; Complications; Causes; Treatment. Chronic Chorea. Other Nervous Disorders to which the same name has been applied, . 428 LECTURE XXXVIII. Paralysis Agitans. Mercurial tremor. Hysteria: two forms of Hysteric Paroxysm ; Diagnosis from Epilepsy; Class of Persons most liable to Hysteria; Diseases apt to be simulated by Hysteria; Treatment: Prevention,......441 LECTURE XXXIX. Catalepsy. Ecstasy. Neuralgia: Tic-douleureux; Sciatica; Hemicrania, . . 456 LECTURE XL. Intermittent Fever. Phenomena of an Ague Fit. Species and varieties of Intermit- tents. Predisposing causes. Exciting cause. Malaria: known only by its effects; places which it chiefly infests; conditions of its production ; its effects upon the human body; influence of soils in evolving it,..... < 4gg LECTURE XLI. Ague continued. Speculations respecting its periodicity. Habits and properties of the Malaria; most noxious at night; lies near the ground; is carried along by winds; cannot pass across water; attaches itself to trees ; is diminished by th* in- crease of cultivation and of population. Ultimate effects of the poison on the body. Ague formerly thought salutary. Prognosis. Propriety of stopping the disease . 480 LECTURE XLII. Treatment of Intermittent Fever; during the paroxysm; during the intermissions. Prophylaxis. [Bilious Remittent Fever.}, .... 40n CONTENTS. XVll LECTURE XLIII. J-Jpistaxis. Bronchocele; Cretinism; their Phenomena and probable Causes. Medical and Surgical Treatment of Bronchocele, ........514 LECTURE XLIV. Cynanche Parotidaea. Spontaneous Salivation. Aphthae. Cynanche Tonsillaris. [Hypertrophy of the Tonsils in Children.],........527 LECTURE XLV. Acute Laryngitis. Symptoms. Treatment; Blood-letting, Tracheotomy, Mercury, Antimony. Anatomical Characters of the Disease. Causes. Secondary Laryn- gitis. GSdema of the Glottis. Chronic Affections of the Larynx, . . . 540 LECTURE XLVI. Cynanche Trachealis; Symptoms; Pathology; Prognosis; Treatment. Diphtheritis. Child-crowing, or Spurious Croup. [Spasmodic Laryngitis.], .... 552 LECTURE XLVII. Diseases of the Thorax. General observations. Dyspnoea. Cough. Methods of exploring the physical conditions of the chest, by the senses of sight, touch, and hearing, . . ............572 LECTURE XLVIII. Catarrh; its varieties. Acute Bronchitis. Dry Sounds attending the Respiration; Rhonchus, and Sibilus: Moist Sounds; Large and Small Crepitation: how these are produced, and what they denote. Treatment of Acute Bronchitis. Collapse of the Lung — diffused, and lobular. Sudden infarction of a large Bronchus. Peri- pneumonia Notha, . ...........583 LECTURE XLIX. Influenza. Symptoms and progress. Conjectures as to its cause. Treatment. Hay asthma. Chronic Bronchitis. Its varieties. Morbid anatomy of these affections. Dilatation of the Bronchi,...........595 LECTURE L. Hooping-cough: symptoms; duration; complications; pathology; treatment. Pneu- monia : its stages and morbid anatomy; auscultatory signs......611 xvm CONTENTS. LECTURE LI. Pneumonia continued: its general symptoms; pain, dyspnoea, cough, expectoration. Course of the disease. Prognosis. Treatment. [Pneumonia in children. Typhoid Pneumonia], . . • •.........b LECTURE LII. Pleurisy. Its anatomical characters; false membranes; liquid effusion; effects of these upon the shape and contents of the chest, and upon its healthy sounds. Symptoms of pleurisy, . . .........649 LECTURE LIII. Pleurisy continued. Recapitulation of Symptoms; of Diagnostic Signs. Causes of Pleurisy. Pneumothorax; its Conditions and Signs. Treatment of Pleurisy. Empyema. Paracentesis Thoracis, . . ......660 LECTURE LIV. Pulmonary Haemorrhage: its varieties; its connexion with pulmonary consumption, and with disease of the heart. Pulmonary Apoplexy. Prognosis in Haemoptysis. Symptoms. Treatment,...........674 LECTURE LV. Pulmonary Emphysema; vesicular and interlobular. Anatomical characters of vesi- cular emphysema; physical signs; general symptoms; causes: treatment. Inter- lobular Emphysema; its anatomical characters, symptoms, cause, and cure. GSdema of the lungs. Phthisis Pulmonalis, . # gg4 LECTURE LVI. Phthisis continued. Vomicae; adhesions of the pleurae; ulceration of the larynx and trachea — of the intestines; fatty liver; waxy liver; auscultatory sio-ns of a vomica; gurgling, cavernous respiration, pectoriloquy: general symptoms of phthisis;. cough, expectoration, dyspnoea, pain, hectic fever, diarrhoea, wasting oedema, aphthae,......... ^qo LECTURE LVII. Phthisis continued. Diagnosis. Forms and varieties of Phthisis, Ordinary dura- tion. Age at which it is most frequently fatal. Influence of sex; and of occupa- tion. Question of Contagion. Treatment, ... LECTURE LVIII. Melanosis of the Lung; true and spurious. Accidental intrusion of solid substances into the air-passages,....... 727 CONTENTS. xix LECTURE LIX. Diseases of the Heart: usually partial. Changes in its Muscular Texture. Mechan- ism of those Changes. Natural Dimensions of the Heart. Natural Sounds. Modi- fications of these by Disease. Review of the Physical and General Signs that ac- company Cardiac Disease,...........735 LECTURE LX. Diseases affecting the muscular texture of the heart; and their treatment. Fatty de- generation. Rupture. Changes to which the valves of the heart are subject. Effects, and diagnosis, of those changes. Angina pectoris,.....747 LECTURE LXI. Pericarditis; its frequent connexion with Acute Articular Rheumatism. Rheumatic Carditis. Anatomical characters of Acute Inflammation of the Pericardium; of the Endocardium. General symptoms. Auscultatory signs. Relations of Carditis with Rheumatic Fever,...........764 LECTURE LXII. Treatment of Acute Pericarditis, and Endocarditis: blood-letting: mercury; blisters. Chronic and partial Inflammation of the Pericardium. Disease of the Aorta. Thoracic Aneurisms; their various situations, and symptoms; plan of treatment, 780 LECTURE LXIII. Diseases of the Veins; Phlebitis; adhesive, and suppurative: consecutive scattered Abscesses. Treatment of Inflammation of Veins. Effects of the gradual obstruc- tion of large Venous Trunks,..........793 LECTURE LXIV. Asthma: its nature; complications; exciting causes; and treatment. Diseases of the Oesophagus; Inflammation; Stricture; Spasm; Dilatation, . . . .801 LECTURE LXV. Diseases of the Abdomen; sometimes difficult to identify. Method of investigating these diseases; by the eye, the hand, the ear. Inflammation of the Peritoneum; its symptoms; and causes. Puerperal Peritonitis. Peritonitis from Perforation, . 813 LECTURE LXVI. Treatment of Acute Peritonitis; Bleeding, Mercury, Opium. Chronic Peritonitis: Granular Peritoneum. Ascites; Ovarian Dropsy; Diagnosis of these diseases. Other forms of Abdominal Dropsy, .........829 XX CONTENTS. LECTURE LXVII. Pathology of Chronic Ascites ; of Ovarian Dropsy. Treatment of these two disorders. Internal remedies. Extirpation of the ovarian sac: Paracentesis Abdominis, . 837 LECTURE LXVIII. Acute Gastritis: symptoms; anatomical characters; treatment. Chronic Inflamma- tion of the Stomach; thickening of the Mucous Membrane; Ulceration; symptoms and treatment of the disorder; Softening and Perforation by the Gastric Juice. Cancer of the Stomach, . ..........848 LECTURE LXIX. Haemorrhage from the Stomach: sometimes from a large vessel, usually capillary. Idiopathic Haematemesis. Vicarious Haematemesis; Haematemesis from Gastric disease or injury; from disease in other organs. Melaena. Haematemesis from a morbid state of the blood. General phenomena of Haematemesis. Diagnosis Treatment,..............867 LECTURE LXX. Dyspepsia. Physiology of digestion. Symptoms of Dyspepsia. Treatment and Prevention, Dietetic and Medicinal,.........874 LECTURE LXXI. Enteritis: its symptoms; causes; treatment. Mechanical occlusion of the Intestinal Tube. Colic. Colica Pictonum; its symptoms, complications, treatment, and pre- vention. [Encephalopathy],....... ggg LECTURE LXXII. Diarrhoea. Sporadic, or Summer Cholera. Epidemic Cholera. [Cholera Infantum], 906 LECTURE LXXIII. Dysentery. Diarrhoea Adiposa. Intestinal Concretions. Worms, . 929 LECTURE LXXIV. Entozoa continued. Hydatids. Trichina Spiralis. The Guinea-Worm. Strongulus Gigas. Origin of Entozoa. Question of Spontaneous Generation. General Symp- toms of the presence of Intestinal Worms. Particular symptoms, and remedies, of the common Round Worm, of Thread-Worms, of Tape-Worms, CONTENTS. xxi LECTURE LXXV. Diseases of the Liver. Acute Inflammation. Abscess of the Liver. Causes and Treatment of Acute Hepatitis. Chronic Hepatitis. Jaundice. Its Symptoms, Causes, and Species,............963 LECTURE LXXVI. Treatment of the various Species of Jaundice. Diseases of the Gall-bladder; of the Spleen; of the Pancreas. Diseases of the Kidneys. Nephritis and Nephralgia. Phenomena constituting a " fit of the Gravel." Different kinds of Gravel. Diseased Btates of the Urine. Description and Remedies of the Lithic, Phosphatic, and Oxalic Diathesis,.............979 LECTURE LXXVII. Suppression of Urine. Diabetes; Qualities of the Urine; Symptoms; Anatomical Appearances; General Pathology of the Disease. Treatment. Diuresis, . . 1000 LECTURE LXXVIII. Albuminous Urine. Means of detecting the Albumen. What it imports. Anatomi- cal characters of Bright's Kidney. Symptoms to which this renal disease gives rise. Nature of the affection,..........1015 LECTURE LXXIX. Anasarca; its consideration resumed. Distinction of chronic General Dropsy into cardiac and renal. Characters and signs of each of these varieties. Treatment, 1033 LECTURE LXXX. Chylous Urine. Haematuria; its diagnosis, general and particular; Local disorders of the Urinary Organs on which it depends; Treatment. Disease of the supra- renal capsules; Bronzed Skin. Abdominal Tumours,.....1044 LECTURE LXXXI. Acute Rheumatism; Symptoms; Varieties; Treatment. Chronic Rheumatism; Phenomena; Plan of Cure. Gout: Description of a Paroxysm; Progress of the Disease; general state of the Health in Gouty Persons; Causes of the Disease; Diagnosis between Gout and Rheumatism,.............1056 LECTURE LXXXII. Pathology of Gout. Prognosis. Prejudices respecting the disease. Treatment: during the paroxysms; during the intervals. Cutaneous Diseases, . . . 1070 XX11 CONTENTS. LECTURE LXXXIII. Exanthemata. They are contagious; sometimes epidemic. Period of the eruption; period of incubation. Theory of contagious Febrile Diseases. Continued Fevers, 1078 LECTURE LXXXIV. Typhus Fever, continued. Phenomena of the second week; Delirium, Mulberry Rash : of the third week ; Recovery, or death in the way of Coma, of Apnoea, of Asthenia. Symptoms that precede and usher in those modes of dying. Typhoid Fever; points of distinction between it and Typhus in respect of symptoms, of modes of attack. Rose-coloured Spots. Ulcerations of the Intestine, . . 1091 LECTURE LXXXV. Relapsing Fever. Causes of Fever. Exciting and Predisposing Prophylaxis, . 1102 LECTURE LXXXVI. Continued Fevers, concluded. Treatment. Small-pox. Its essential 8ymptom8 Distinction into discrete and confluent. Periods and modes in which it proves fatal [Yellow Fever], . ...........1114 LECTURE LXXXVII. ..........1152 LECTURE LXXXVIII. Chicken-Pox. Measles. Scarlet Fever ' ......1169 LECTURE LXXXIX. The Plague. Erysipelas. Erythema nodosum. Urticaria. Prurig0. Scabies> ^ ^ LECTURE XC. Herpes; Eczema; Pompholix; Lepra; Psoriasis; Impetigo- TVl „ Purpura; Scurvy. Conclusion of the Course, . * ' ^ °arbuncIe' . 1198 Index, , * * • • • 1215 LIST OF ILLUSTRATIONS. UO. PAGE 1. Hypertrophy of left ventricle of heart (from Gross' Pathological Anatomy), . 43 2. Hypertrophy of aorta (from Gross' Pathological Anatomy), ... 43 3. Hypertrophy of muscular fibres of urinary bladder (from Gross on Urinary Organs),.............44 4. Atrophy of cellular structure of thigh bone (from Gross' Pathological Anatomy),............ 49 5. Blood in leucocythaemia (after Bennett),.......61 6, 7, 8. Pus corpuscles,...........122 9. Vessels in the web of a frog's foot, under the stimulation of alcohol (after Bennett),.............123 10, 11, 12. Blood clot (from Kirkes' Physiology),......124 13. Yellow tubercle (after Jones and Sieveking),.......151 14. Grey tubercle (after Jones and Sieveking),.......151 15. Tubercle corpuscles from peritoneum (after Bennett),.....151 16. Tubercle corpuscles from lungs (after Bennett),......151 17. Tubercle corpuscles from a mesenteric gland (after Bennett), . . . 151 18. Isolated tubercle corpuscles (after Jones and Sieveking), .... 151 19. Fibrous stroma of scirrhus (from Gross' Pathological Anatomy), . . . 161 20. Cells from encephaloid of tongue (after Erichsen),.....162 21, 22. Colloid tumour (from Gross' Pathological Anatomy), .... 162 23. Subarachnoid effusion (after Jones and Sieveking),.....263 24. Purulent effusion under the arachnoid membrane (after Jones and Sieveking), 263 25. Deposit of tubercular matter in Sylvian fissure of the brain (after Jones and Sieveking),............291 26. Hydrocephalic skull (after Jones and Sieveking),.....306 27. Apoplectic effusion in brain (after Jones and Sieveking), .... 342 28. Haemorrhage in right lateral ventricle, etc. of brain (after Jones and Sieveking).............342 2tt. Goitre (from Gross' Pathological Anatomy),.......517 ( xxiii) XX1V LIST OF ILLUSTRATIONS. 30. Ossified thyroid gland (from Gross' Pathological Anatomy), . . . 517 31. Section of bronchocele, showing calcareous deposits (after Druitt), . . 517 32. Bronchocele (after Druitt)...........518 33. Hercy's inhaler for inflamed throat.........537 34, 35, 36. GEdema of the glottis (after Gross, Druitt, and Miller), . . . 548 37, 38. False membrane of trachea in croup (after Gross and Miller), . . . 556 39. False membrane of bronchial tubes (from Gross' Pathological Anatomy), . 556 40, 41, 42. Regions of the thorax,........579-580 43. Injection and stasis of vessels of bronchial mucous membrane in bronchitis (after Jones and Sieveking),........ 590 44, 45. Dilated bronchi (after Jones and Sieveking, and Gross), . . . .609 46. Obliteration of the bronchi (from Gross' Pathological Anatomy), . , 610 47. Splenified lung (after Jones and Sieveking),..... g2Q 48. Lung in a state of inflammatory engorgement (after Da Costa), . 620 49. Elements observed in lungs that had been in a state of chronic hyperemia (after Da Costa),....... fi2n 50, 51. Appearance of lung tissue in red hepatization (after Da Costa, and Jones and Sieveking),......... 52. Elements in peculiar "yellow" condensation of lung (after Da Costa), . . 622 53. Microscopic character of the contents of an air vesicle in grey hepatization (after Jones and Sieveking), .... 54. Elements found in the lung in grey hepatization (after Da Costa), . . ' . 623 55, 56. Lymph of pleuritis (after Jones and Sieveking), . . .' 65Q 57. Portion of lower lobe of left lung, compressed by tarbid serum in the pleural' cavity (after Jones and Sieveking), 58. Pulmonary apoplexy (after Jones and Sieveking), 59. Portion of emphysematous lung (after Jones and Sieveking) ' 6g4 60. Vesicular emphysema of lung (from Gross' Pathological Anatomy) ' ' 685 61. Interlobular emphysema (from Gross' Pathological Anatomy) ' rQ1 62, 63, 64. Miliary tubercle of lung (after Jones and Sieveking) ' ' ' m/Z, 65. Hexagonal appearance caused by mutual pressure of air cells of lung filled' with yellow tubercular matter (after Jones and Sieveking) fiQft 66. Microscopic appearance of minute vessels, surrounding air cells'in tubercuhr ' pneumonia (after Jones and Sieveking), 67. Section of an air vesicle filled with yellow tubercles (after iones'and' ^ Sieveking), . . # u ^ ^eveLng)1^ "^ ^ *^ ^" W J«L. ^ ' ^ 69. Apex of lung containing numerous cavities with tubercula'r dep'osit int., ' ^ vening (after Jones and Sieveking), . . . deposit mter- 70. Tubercular disorganization of lung (after Jones and Sieveking) * ' 698 71. Pulmonary caverns (from Gross' Pathological Anatomy) * * 6" 72. Cicatrix at apex of lung from arrest of tubercular disease'Uft' t ' * 6" and Sieveking), . . . [mer Jones 73. Internal section of summit of left lung, showing the'stellated pucke'rin/ ^ at the apex, etc. (after Bennett), . . Pokering • 700 LIST OF ILLUSTRATIONS. XXV 74. Melanic deposit in cells of engorged lung,......727 75. Hypertrophy of left ventricle of heart (from Gross' Pathological Anatomy), 736 76. Specimens of fatty degeneration of heart (after Jones and Sieveking), . 751 77. Rupture of the heart (from Gross' Pathological Anatomy), .... 752 78. Aneurism of left ventricle of heart (after Jones and Sieveking), . . 752 79. Fibroid thickening of mitral valve (after Jones and Sieveking), . . . 755 80. Fibroid thickening of pulmonary valve (after Jones and Sieveking), . 755 81. Ossification of mitral valves (from Gross' Pathological Anatomy), . . 755 82. Opaque and thickened aortic valve (after Jones and Sieveking), . . 756 83. Atheromatous deposit in valves of aorta (after Jones and Sieveking), . . 756 84. Calcareous deposit in aortic valves (after Jones and Sieveking), . . 756 85. Ossification of aortic valves (after Jones and Sieveking), .... 756 86. Appearance of recently effused lymph in pericarditis (from Gross' Pathological Anatomy),..........765 87. Aneurism of arch of aorta (after Jones and Sieveking), .... 784 88. Growth of aneurism prevented by coagulum (after Jones and Sieveking), 784 89, 90. Aneurism of arch of aorta (after Druitt),......786 91. Aneurism of aorta with caries of vertebrae (after Pirrie), .... 787 92, 93. Aneurism of aorta with absorption of ribs (after Pirrie), . . . 787 94. Fibrinous phlebitis (after Miller),........793 95. Uterine veins containing phlebolites (from Gross' Pathological Anatomy), 793 96. Enlargement of external veins, . . . . . . . . 800 97, 98. Obstructed veins........... 800-801 99. Stricture of oesophagus (after Druitt),.......810 100. False membrane of peritonitis (from Gross' Pathological Anatomy), . . 816 L01, 102, 103. Ovarian cyst (after Jones and Sieveking, and Gross), . . . 839-840 104, 105, 106. Chronic ulcer of stomach (after Habershon), . . . 852-853 107. Perforating ulcer of stomach (after Jones and Sieveking), . . . 854 108. Scirrhus pylori (after Jones and Sieveking),......865 109. Strangulation of intestine,........ 110. Intussusception of caecum and ascending colon (after Habershon), 111. Appearance of intestine in a case of inflamed colon (after Habershon), 112, 113, 114, 115. Ascaris lumbricoides (from Gross' Pathological Anatomy), 116. Ascaris vermicularis (from Gross' Pathological Anatomy), 117. Trichocephalus dispar. trichuris (from Gross' Pathological Anatomy), 118, 119. Taenia solium (after Gross, and Jones and Sieveking), 120, 121. Taenia lata (after Gross, and Jones and Sieveking), 122. Acephalocyst (from Gross' Pathological Anatomy), .... 123. Young acephalocysts (from Gross' Pathological Anatomy), . 124, 125, 126. Cysticerus (from Gross' Pathological Anatomy . 127, 128, 129. Cysts of the spiral trichina (from Gross' Pathological Anatomy), 130. Dracunculus (from Gross' Pathological Anatomy), .... 131. Strongle of urinary bladder (from Gross' Pathological Anatomy), . 132, 133. Cirrhosis of the liver (after Jones and Sieveking, and Gross), 134, 135, 136, 137. Fatty degeneration of the liver (after Jones and Sieveking), 138, 139. Scirrhus of the liver (from Gross' Pathological Anatomy), 942 942 944 44-945 945 946 947 948 949 950 951 968 970 971 sxvi LIST OF ILLUSTRATIONS. 140, 141. Calculi of gall bladder (after Budd and Gross).....975-976 142. Gall stones (after Budd)...........977 143. Cholesterin tables from gall bladder (after Jones and Sieveking), . . 978 144. Calculi of kidney and ureter (from Gross' Pathological Anatomy), . . 987 145. Dilatation of ureter and pelvis of kidney (from Gross' Pathological Anatomy), 987 146. Urea (from Lehmann's Physiological Chemistry),.....990 147, 148, 149. Uric acid (from Lehmann's Physiological Chemistry), . . 990 150. Urate of soda (from Lehmann's Physiological Chemistry), .... 991 151. Biurate of ammonia (from Lehmann's Physiological Chemistry), . . 991 152. Nitrate of urea (from Lehmann's Physiological Chemistry), . . . 991 153. Urinary deposit of magnesia and ammonia (from Lehmann's Physiological Chemistry),............995 154. Urinary deposit of triple phosphate (from Lehmann's Physiological Chemistry),............995 155,156. The triple or neutral phosphate of magnesia and ammonia (after Bird), 995 157. Oxalate of lime calculus (from Gross on Urinary Organs), . . . 997 158, 159, 160, 161, 162, 163. Oxalate of lime (after Bird)......997 164. Cystine from urinary calculus (from Lehmann's Physiological Chemistry), 999 165, 166. Cystine (after Bird),......... ggo 167, 168. Granular degeneration of kidney (after Gross, and Jones and Sieveking), 1017 169. Serous cysts of the kidney (from Gross' Pathological Anatomy), . . 1018 170, 171, 172. Cystic degeneration of kidney (from Gross' Pathological Anatomy),............1Qlg 173. Hemorrhage into Malpighian capsules (after Jones and Sieveking), . 1019 174. Red deposit from urine in intense renal hyperemia (after Jones and Sieveking), . .........1Q22 175. Fibrinous deposits in granular kidney (after Jones and Sieveking), . 1027 176, 177. Diseased condition of kidney (after Jones and Sieveking), . 1027-1028 178, 179. Bright's disease (after Jones and Sieveking), . -. 02q 180. Epithelial cells in urine (after Bird), 181. Atrophied kidney (after Jones and Sievekin?) „„„„ * * ♦ • 1030 182. Granular kidney (after Jones and Sievekinsr) **•••• 1030 183. Solitary glands of small intestine (after Boehm), . 184. Part of patch of so-called Peyer's glands (after Boehm), . 185. Ulceration of the glands of Peyer (from Gross' Pathological Anatomy), ' lm LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. INTRODUCTORY LECTURE. Gentlemen, In approaching any new course of systematic inquiry, there are certain points con- cerning which the inquirer should always be careful to satisfy himself. He should comprehend, distinctly, what it is that he proposes to learn; its subject matter, and its objects. He should consider whether he is about to adopt the most easy, direct, and effectual means for obtaining his purpose; and whether he is qualified, by the possession of the requisite preliminary information, for pursuing his inquiries with intelligence and profit. To these points, and to some others, as they are connected with the duties which have been entrusted to me in this College, I wish briefly to direct your attention on the present occasion. It will be my endeavor to furnish you, at the outset, with clear notions of the nature and the ends of that branch of study upon which you are now about to enter; to explain why it is taught, and how far it may be taught, by oral discourses; to point out to you what may reasonably be ex- pected from me, and what, to render my attempts prosperous, will be required on your parts. Something also it is expedient that you should know beforehand re- specting the general order and arrangement of the course: and a short explanatory comment upon some of the terms that we shall constantly be employing, will clear the way for the succeeding lectures, which forming, more strictly than the present, a part of the series, will also be more strictly didactic in their character. The subject of our study is that wonderful thing, the animal body — and more par- ticularly the human body; its construction and qualities; its actions and its sufferings ; its derangements; its decay. In this study, which affects the mind with a strong feeling of curiosity, not un- mixed with awe, you have already advanced a certain way: for you have observed the outward form and configuration of the body; examined its internal composition and structure; and learned what is known of its various endowments, the working and the uses of its several parts. This amount of knowledge was indispensable to your further progress. But it forms a portion only of what you assemble here to learn : or rather it is the necessary preparation for that ulterior knowledge which it is your main purpose to acquire. The sublimer speculations springing naturally from the researches in which you have as yet been engaged, have not, I trust, been unregarded. You cannot have looked into the mechanism of that intricate, but perfect work,—you cannot have contem- plated its fulness of exquisite contrivance, its endless examples of means adapted to ends, its prospective expedients against future needs, its compensations for inevitable 3 (33) o4 INTRODUCTORY LECTURE. disadvantages, its direct provisions for happiness and enjoyment, — without recemnb the profouiidest conviction of the being and the attributes of its Maker It is upon human anatomy that Paley, in his unrivalled argument for Natural ±heoIogy,_ takes his stand;" and sixteen centuries before him, Galen had felt that, in writing his anatomical treatises, he was composing a hymn to the Deity; that an exposition so in- dicative of the wisdom, the power, and the goodness of God, was an act ot piety and praise. But beyond, though not above, these higher objects of a diligent investiga- tion of man's bodily fabric,"we have another and still a noble end; and it is my busi- ness to take you one step nearer to that end. Hitherto you have been told of structure and of function. Henceforward our theme must be of health and of disease. Of health, that we may understand disease; of disease, that we may, under Providence, restore health. Our objects are to preserve the one; to prevent, remove, or mitigate the other. What then do these contrasted terms denote ? Health we regard as a standard condition of the living body. But it is not easy to express that condition in a few words, nor is it necessary. My wish is to be intel- ligible rather than scholastic; and I should probably puzzle myself as well as you, were I to attempt to lay down a strict and scientific definition of the term health. It is sufficient for our purpose to say, that it implies freedom from pain and sickness; freedom also from all those changes in the structure of the body that endanger life, or impede the easy and effective exercise of the vital functions. It is plain that health does not signify any fixed and immutable condition of the body. The standard of health varies, in different persons, according to age, sex, and original constitution; and in the same person even, from week to week, or from day to day, within certain limits it may shift and librate. Neither does health necessarily imply the integrity of all the bodily organs : it is not incompatible with great and permanent alterations, nor even with the loss, of parts that are not vital; as of an arm, a leg, or an eye. If we can form and fix in our minds a clear conception of the state of health, we shall have no difficulty in comprehending what is meant by disease, which consists in some deviation from that state : some uneasy or unnatural sensation of which the patient is aware; some embarrassment of function perceptible by himself, or by others; or some unsafe, though hidden condition of which he may be quite unconscious : some mode, in short, of being, or of action, or of feeling, different from those which are proper to health. I use the word disease generically. Various terms in our language bear nearly the same meaning, and endeavors have been made to appropriate some of these more dis- tinctively. Thus the word disorder has sometimes been applied to simple derange- ments of function, where no alteration of structure is seen, or can reasonably be in- ferred to exist; while the term disease has been restricted to maladies, which are attended with appreciable change of texture, or which run a short and definite course. I see no great utility, but, on the contrary, some risk of confusion, in tying ourselves rigidly down to such distinctions: indeed, we cannot always make them, burin^ life it is often no easy thing to determine whether the parts, of which the functions are disturbed, preserve their integrity of structure or not: and even when the peccant organ is placed before our eyes after death, and the most careful scrutiny fails to dis- cover in it any faultiness of texture, there may still be ground for suspecting that some material change, too subtle for detection by our senses, may have been wrought in its finer and more delicate organization. I shall take care to point out to you,&as we go along, the cases in which we can trace organic change, and the cases in which ,we cannot; but, for the sake of simplicity, I shall call all deviations from the healthy standard, whether of function or of structure, by the generic term disease • and to avoid the perpetual and tiresome recurrence of the same word, I shall not scruple to employ the several terms disorder, complaint, malady, distemper, illness, as its svnon vms ihe number of these deviations from the standard of health, (in other words* the whole number of diseases,) if we include all their differences in kind and in decree is scarcely calculable; and the first thing requisite towards investigating the laws°that govern their phenomena, is, that we should break them into groups, and dispose then according to some principle of order. Now there are various methods in which this first broad classification of disease might be framed. a INTRODUCTORY LECTURE. 35 The most cursory examination of the animal economy suffices to show that it is made up, not merely of separate parts, but of several distinct systems. There is one set of organs for the mechanical circulation of the blood; there is an apparatus ex- pressly designed for the repeated exposure of the blood to the air; a system for regu lating the movements and the feelings of the body; another for receiving, preparing, and appropriating its nourishment; another for the elaboration of matters that are useful or essential to its functions; another for carrying off its impurities, and for removing its superfluous or effete materials; and another for the continuance of the species. Now each of these systems is liable to changes of structure and interruptions of function, peculiar to itself; and these peculiarities must be token into account, what- ever may be the order adopted in treating of diseases in detail. But I shall not divide the subject, as some have done, into diseases of the circulating system — diseases of the respiratory system — diseases of the nervous system — and so on; for this, among other reasons, that there are many forms of disorder that affect all these systems in common, or simultaneously, and comparatively few that are strictly confined to any one of them. Neither, in the lectures which I am about to commence, shall I classify diseases according to the several tissues of which the animal frame is composed. In speaking of diseases in general, it will, indeed, be both proper and necessary to explain in what manner the same morbid process may be modified by the nature of the special tissue affected. But as the entire body is more or less penetrated and pervaded by the intermixture of several of these tissues, so no useful nor lucid arrangement of diseases could be founded on this basis. Nor shall I attempt to construct a nosological system by grouping together certain sets of symptoms, and calling each set, in its collective form, a disease. To say the truth, I shall consider convenience and usefulness, in framing my plan, rather than an appearance of scientific precision; and if I make one principle of arrangement more prominent than another, it will be that which relates to the anatomy of regions,—the place and position of organs. At the same time, I shall not omit to borrow in part from some of those other methods to which I have just been referring. Before, however, we treat of the nature of particular diseases, it will be requisite to give some general account of the different ways in which the various parts of the body are liable to be altered in structure, or disordered in function; and before we speak of the signs of particular diseases, it will be proper to take a general view of symptoms, and of their ascertained relations with the several forms of altered struc- ture : for doubtless you are aware that, although diseases are not constituted by symp- toms, they are, in the living body, disclosed by symptoms. Sometimes the symptoms are outward signals which alone reach our senses, and through which internal changes declare themselves; and we then have to decipher and to interpret those signals. Sometimes we see the morbid changes themselves on the surface of the body, or in parts within our ken. Some internal changes we can appreciate as surely by the touch, or by the sense of hearing; and of some we infer the existence from alterations in the chemical or in the sensible qualities of the natural excretions. After death, diseases are often to be traced by visible changes of structure in the internal parts of the body. These changes are extremely interesting, as illustrative of morbid processes : they throw light upon what is past; they afford some guidance for the time to come. But, for obvious reasons, those signs which reveal diseases during life are, practically, of chief moment. In truth, the great object of our art is to prevent or postpone the disclosure of the others. The instruction afforded by the dead body comes too late to be of use in that particular case. I have already intimated that the morbid physical conditions from which the symptoms flow, are not always to be detected, either before or after dissolution. Neither, when they are detected, is their connexion with the symptoms always evident. Besides inquiring into the modes in which the various organs and textures of the body may be spoiled, and into the signals or symptoms by which the presence of dis- ease may be ascertained, it will be expedient to premise something, in a genera] manner, of the causes of disease, both with a view to its cure, and, what is much 3(5 INTRODUCTORY LECTURE. better, to its prevention. We shall also find it very useful to institute a short inquiry into the different ways in which death may take place —the different processes ox yThere is one morbid condition or process, to which all parts of the body are liable and which contributes so largely and so frequently to alterations both of texture and function, that it claims our especial attention when discussing the more general tacts and doctrines of pathology: I allude to that change, or series of changes, which we comprehend under the term inflammation. . It will be necessary, therefore, in the preliminary part of the course to give a general account of inflammation; and this account must chiefly be drawn from those of its phenomena which are most familiar to us—which we can see and handle; those which we witness when the disorder is seated in or near the surface, in the skin in certain of the mucous membranes, or in the subjacent areolar tissue. Then we shall pursue the examination of its peculiar phenomena as they are presented in the other tissues of the body —the mucous, serous, fibrous, parenchymatous, muscular, and nervous tissues; and here the general principles of treatment applicable to inflam- mation may be laid down, with the modifications required according to the tissues interested. In this part of the course may also be conveniently discussed the modifications of inflammation, and of morbid conditions generally, by the influence of certain diatheses, or peculiar dispositions of the body. Some constitutional morbific tendencies we shall find to be innate or hereditary; such are the scrofulous and the cancerous dispositions : others, again, are plainly acquired, as that in which the whole system is tainted for a longer or shorter period by the venereal poison. Hemorrhages, also — and serous accumulations, or dropsies — as they are liable to occur in all parts of the body, require to be treated of generally, before they pass under our notice in the list of particular maladies. There are certain facts and rea- sonings common to all inflammations, to all haemorrhages, to all dropsies. By com- bining these "generalities" into one comprehensive statement, we help the memory, avoid needless repetitions, and find room for the exposition of principles. Diseases themselves, in the mass, are sometimes distinguished according as they are local, or general. Taking these epithets in their popular sense, we should say that local diseases are those which occupy a definite portion only of the body; general diseases, those which pervade the whole body. But let us endeavour to obtain clear notions upon these points. Certainly there are many diseases which, occupying a definite portion only of the body, leave all the remaining parts, and the system at large, healthy both in texture and in function. Such diseases we have no hesitation in calling local. Again, there are many other diseases which, occupying a definite portion only of the body, yet occasion a manifest and serious disturbance in the functions of various other parts, and (it may perhaps be said) of the whole system. Inflammation of a small portion of the frame may give rise to much secondary or symptomatic fever * but here also we properly speak of the disease as being local; the secondary o-eneral disorder resulting from the local and primary, following it in point of time and sub- siding upon its cessation. But there are still other forms of disease which show themselves, not like inflam- mation now in this and now in that part, but in many or most parts of the system at the same time. I will take the complaint called purpura, characterized by purple spots scattered throughout the body, as an example of what I mean. It is in truth a haemorrhage affecting many or all the tissues simultaneously. For this reason it is commonly regarded as a general disease. But if we look somewhat closer into the matter, we shall, I think, perceive that most, if not all, of those which have been thus reputed general, are in fact re ducible to the class of local diseases. The fluids are as much parts of the bod'v as the solids; and if it be true, as I believe it is, that the essential and primary change in purpura is a change in the blood, its characteristic phenomena will be apt to me sent themselves wherever there is blood circulating—that is, throughout the whole system. The disease is local, inasmuch as its original seat is in that particular fluid the blood : it appears to be general, because the morbid blood is everywhere present' INTRODUCTORY LECTURE. 37 The same observations apply to a large class of febrile contagious diseases; to that state of the general system which is commonly called anaemia: also to certain spas- modic affections, where the seat of the actual disorder is in the whole nervous system. What are called general diseases, therefore, are those in which the whole of some one system that pervades the entire body happens to be similarly deranged. Whether diseases can ever be truly said to be general in any more strict or absolute sense than this, is much to be doubted. I have mentioned dropsy as a malady which, like haemorrhage or inflammation, may occur in various parts of the body separately. It may also extend at once to all parts capable of receiving and retaining serous effusions: in other words, besides filling the large serous cavities, the effused fluid may occupy the universal areolar tissue. But even this apparently general dropsy will be found, upon careful investi- gation, to resolve itself, in most cases at least, into local disease within the thorax, or within the abdomen. The diseases which, in the sense now explained, may be called general, I shall arrange among the diseases of those parts of the system from which they have been ascertained, or may be presumed, to arise. The first part, then, of the course will embrace an outline of general pathology, with an especial reference to those morbid conditions which fall to the care of the physician. In its relations to surgery and to midwifery, pathology will be more par- ticularly taught by the respective professors of those distinct though kindred depart- ments of medicine. Do not, however, imagine that I take no interest in these, or that there can be anything different in the principles upon which the several branches of pathological knowledge are founded. The truth is, that you cannot, if you would, separate the one from the other. You can neither understand what may be called medical, without learning much which belongs as strictly to surgical pathology; nor can you be ignorant of either, without being in many important respects deficient in the other also. But the open field of pathology is of wide extent, and although we may, and must, survey the whole, yet its artificial divisions, its inclosures and allot- ments, will be cultivated best, and most improved, by a division of labour. Afterwards, separate diseases are to be described and considered: all such, at least, as admit of being individualized, or presented under a definite shape. And here, I repeat, I shall chiefly pursue an anatomical order, as being comprehensive and inartificial, and as tending to facilitate diagnosis. The diseases of parts which lie near each other are the most liable to be confounded. I shall begin, therefore, with the diseases of the parts that appertain to the head and spinal cord, and then proceed in succession to those of the parts belonging to the neck, the thorax, and the abdomen; to those of the joints, the muscles, and the skin. I shall not scruple, however, to deviate from this order, whenever, by doing so, I can promote your convenience or advantage. With that portion of the course which relates to particular diseases, I shall also interweave certain pathological considerations, applicable not so much to the whole body as to the several great systems of which it is made up. Thus, when I come to the brain, I shall speak of the functions peculiar to the nervous system, and of the obstructions and disturbances to which those functions are obnoxious, by way of pre- face to a detailed examination of the various affections of the several parts of that system. Before discussing the diseases of the chest, I shall bring before you, in a general view, the manner in which the great functions of respiration and of circula- tion are liable to be impeded, or otherwise disordered. As preparatory to the con- sideration of the diseases of the abdomen, I shall treat, in the same way, of the func- tions of nutrition; and of waste, which implies an interruption of those functions. Still there would remain certain diseases, which would not necessarily find a place in this arrangement, inasmuch as their seat is uncertain, or only guessed at. Ague is one of these. Cholera perhaps another. It is quite unimportant whereabouts in the course such maladies are considered. I feel no concern about any imputations of imperfect or clumsy arrangement with which the plan that I propose to adopt may appear chargeable. I had rather not be cramped and hampered by attempting what abler heads than mine have failed to achieve, and what, in truth, I believe, in the present state of our science, to be impossible, a complete methodical system of nosology. 38 INTRODUCTORY LECTURE. My object will be to furnish as much instruction and information as I can, in the way that seems most likely to be practically useful to you. Ague I shall take leave to include among the disorders of the nervous system ; and with it, the important subject of malaria will necessarily engage much of our attention. The great question of contagion I shall consider in connexion with continued fevers, which I rank among that remarkable class of diseases, the contagious exanthemata of Cullen. Of sympathetic and of hectic fever, Imust speak when upon the subject of inflammation. This, then, is a sketch of the method I propose to follow. In the earlier lectures, with the general pathology, I shall endeavour to lay down principles. To these principles I shall continually refer, as occasions offer, both in those prefatory remarks with which I purpose to introduce the diseases belonging to the several great systems that contribute to form the body; and also in what I shall subsequently have to say concerning those diseases themselves in detail. In this way I hope to combine the advantage of repetition, which was the peculiar advantage of two short courses in a season, with that of greater completeness, which forms the recommendation of a single extended course. The same great advantage of repetition — or I should rather say of recapitulation — will be further aimed at in the stated examinations of the class. Such being a summary of the topics to be embraced in the ensuing series of lectures, and of the order in which I hope to take up those topics, it seems proper that I should now say a few words in explanation of the scope and objects of the course. The prospectus informs you that it will comprehend the Principles and Practice of Physic. What is the true import and promise of these words ? By the principles of medicine are meant those general truths and doctrines which have been ascertained and established, slowly indeed, and irregularly, but still with considerable precision, by the continued observation of attentive minds throughout the entire progress of medicine as a science. These principles I profess to teach you. The practice of medicine, or the particular application of those general facts and doctrines, I shall describe to you; but I cannot profess to teach it in this room : nor can you learn it, except in a very imperfect sense, from my description of it. It is the science that I shall here endeavour to unfold. Skill and facility in turning that science to useful purposes I am unable to impart. These are qualities that do not admit of being communicated from one mind to another. The practice of physic, like every other practical art, is to be learned by its repeated exercise; by habit; by carrying its various acts into direct effect again and again; or, if they happen to require no manual dexterity, by looking on, and seeing them done again and again. There is this capital difference, however, between the art of healing and some other arts : that the blunders of early attempts may be both grievous and irremediable — may hurt or spoil Ihe goodly and precious fabric they are intended to repair. There is this also peculiar to our art — that it proceeds upon observations made at the very time when its exercise is wanted; and that it requires shill in observing as well as skill in acting. You will find, what, perhaps, previously to positive trial, you might not suspect, that the senses —the eye, the ear, the touch — however sharp or delicate they may naturally be, require a special course of training and education before their evidence can be trusted in the investigation of disease. I do not know that these views are capable of being rendered plainer by illustration ; for you must have observed a similar distinction between the science and the art in various other branches of human knowledge. The principles of navigation may be thoroughly comprehended by a person who scarcely knows a rudder from a cable, and who would not be trusted nay, who would not trust himself, with the conduct of the simplest boat A man may master the beautiful science of astronomy — may acquire the power of working upon paper its subhmest and most abstruse problems —and yet remain in comnlete ignorance of the method of adjusting and using a telescope, and unable to ascertain for himself the position or the movements of a single star. But place such a nersnn night after night in an observatory — let him notice, and imitate the proceeding of some one already skilled in examining the phenomena of the heavens —and he will soon acquire the requisite tact and facility himself. Just so it is with that branch of knowledge with which we are concerned. It is in the wards of a hospital or in INTRODUCTORY LECTURE. 39 the domestic chamber — it is among the sick and the dying — and there alone — that you can either thoroughly or safely learn to practise physic. In what, then, you may fairly ask, consists the value or the use of lectures on the practice of physic, if the practice of physic cannot be taught by lectures ? The main object of systematic lectures, explanatory of the principles, and descrip- tive of the practice of medicine, is to prepare the hearer for observing to the best advantage the actual phenomena of disease and the power of remedies over it. They are intended to fit him for seeing with intelligence—to enable him to read, and under- stand, and interpret, the book of nature when it is laid open before him — in short, to qualify him for clinical study. One man shall travel into a foreign land, knowing nothing beforehand of its scenery or its climate, of its natural productions, its manu- factures, or its works of art, and ignorant alike of the manners, customs, history, laws, and language of its inhabitants. Another shall visit it after having furnished his mind with information on these subjects by reading, and by conversing with men who have already passed over the same ground. Supposing the visit to be limited in each case to a certain, but not long period of time,-^I need not ask your opinion as to which of these travellers will reap the greatest harvest of enjoyment and of profit- able knowledge from his tour. Not less striking is the difference, in point of instruc- tion and of interest, perceived by different students, upon their admission to the bedsides of the sick, according as they have been well or ill prepared for the multiform spectacle of bodily suffering then first displayed before them. There are persons, indeed, who seriously, and I make no doubt in perfect good faith, warn the student against bringing to the contemplation of disease any preconceived opinions; who tell him that he must come with a free and unprejudiced mind, and see, and note, and judge of all things for himself. I also would have him exercise, and ultimately abide by, his own judgment; but surely if every man were to depend upon his own unassisted observation for his knowledge of disease, every man would be marvellously ignorant, and the science of medicine would stand still, or cease to be. " If no use be made (says Dr. Samuel Johnson) of the labors of past ages, the world must remain always in the infancy of knowledge." In truth, a person who, without any previous informa- tion concerning diseases, should betake himself to a hospital with the design of im- partially and resolutely investigating their phenomena, such a person, however clear and strong his intellect might be, would find himself, for a long time, more puzzled than instructed by what he saw around him. He would be perplexed by the shifting and seemingly contradictory characters presented by the same malady in different patients : or in the same patient at different times: and not less so by the outward resemblance of disorders essentially unlike. He could not but be confused by the multitude of symptoms that crowded upon his attention on every side; and at a loss to distinguish important facts from those which, for the chief ends of his pursuit, were trivial, or useless. The business, therefore, of a lecturer upon the Principles and Practice of Medi- cine, or, as it is sometimes worded, the Nature and Treatment of Diseases, is first to fix upon some order in which to treat of the various subjects comprised in his course. The simpler and less artificial his arrangement, the better. The chief use of this classification is to facilitate the recollection of particular facts; and I have already told you that if I can distribute and connect the multifarious forms of disease in such a manner as that they shall appear plain to your understanding, and take a secure hold upon your memory, I shall not trouble myself nor you with a vain search after that phantom—a perfect methodical nosology. " In all such classifications," writes Lord Brougham, " we should be guided by views of convenience rather than by any desire to attain perfect symmetry; and that arrangement may be best suited to a particular purpose which plants the same things in one order, and separates them and unites them in one way, when an arrangement which should dispose those things differently might be preferable, if we had another purpose to serve." Having settled this framework of his discourses, the next aim of the lecturer must be to collect and arrange from the voluminous and bewildering records of medicine, and from the necessarily more slender stores of his personal experience, whatever it may seem of consequence that his hearers should know concerning each distinct form of disease, as it comes before them for consideration: to state all the facts which are well ascertained, and which tend to explain its symptoms, to elucidate its origin, to 40 INTRODUCTORY LECTURE. identifv its nature, to direct its treatment, to accomplish its prevention : to sift the true facts from the false, the important from the trivial, the essential from the accidental: to analyse the relations of these facts, and ascending from particulars to generals, to point out those great principles and precepts which constitute the keys, both to the knowledge and to the management of all diseases of the same kind. It may even sometimes be his duty to notice and discuss mere theoretical opinions; to express his own sentiments upon disputed or undecided questions; and to admonish his audience against the danger of being led away by ingenious refinements, by the speciousness of novelty, or the boldness of speculation, from the more secure and settled results of careful observation improved by patient thought. These duties of a lecturer on medicine are metaphorically, but aptly, expressed in the following passage from Lord Bacon : — " Formica colligit, et utitur, ut faciunt empirici; aranea ex se fila educit, neque a particularibus materiam petit, ita faciunt medici speculativi ac mere sophistici; apis denique caeteris se melius gerit. Haec indigesta e floribus mella colligit, deinde in viscerum cellulis concocta maturat, iisdem tamdiu insudat, donee ad integram perfec- tionem perduxerit." I may venture to paraphrase it thus : — The lecturer must not be the ant, collecting all things indiscriminately from all quarters, as provender for his discourses; Nor the spider, seeking no materials abroad, but spinning his web of speculative doctrine from within himself; But rather the bee, extracting crude honey from various flowers, storing it up in the recesses of his brain, and submitting it to the operation of his internal faculties, until it be matured, and ready for use. Such, gentlemen, are the main objects which I shall endeavour to keep steadily in view during the series of lectures I am about to commence; and I should ill deserve the chair I have the honour to occupy, if I did not feel the great responsibility under which I speak to you. The subjects with which we have to deal are not matters of mere speculative curiosity or intellectual amusement — to be taken up to-day and dis- missed perhaps with unconcern to-morrow — but they involve questions of life and death. The opinions you are now to form or to embrace, are for the most part the opinions upon which in after life you will confidently and constantly be acting. The comfort or the misery of many families may probably hang upon the notions that each of you will carry from this place. Therefore it is that I feel myself to be engaged in a very serious undertaking. Doctrines and maxims, good or bad, flow abroad from a public teacher as from a fountain, and his faulty lessons may become the indirect source of incalculable mischief and suffering to hundreds who have never even heard his name. These reflections fill my mind with an almost painful sense of the obliga- tion imposed upon me, by my present office, of closely sifting the facts, and of care- fully examining the principles to be derived from those facts, which I propose to employ for your instruction and guidance. But amid all the responsibilities, gentlemen, both of teacher and of learner the profession which you and I have chosen, or which circumstances have prescribed to us, is a noble profession, and worthy the devotion of a life-time. If you fit yourselves now for its high functions, and pursue it hereafter in earnestness and truth it will probably conduct you to an honourable competence, and it will assuredly prove a salutary school of mental and of moral discipline. Trials, no doubt, belong to it and difficulties; but it has also privileges and immunities peculiar to itself Affording ample scope and exercise for the intellect, it is conversant with objects that tend to elevate the thoughts, to temper the feelings, and to touch the heart I have alrpidv reminded you how it brings beneath our minute and daily notice that most remirl-.blp portion of matter, which is destined to be for a season the tabernacle of the i* spirit, and which, apart from that singularly interesting thought, excites increaSn* wonder and admiration the more closely we investigate its marvellous construct^8 The sad varieties of human pain and weakness with which our daily vocation is famt har, should rebuke our pride, while they quicken our charity. To us are entru tA in more than ordinary measure, opportunities of doing good to our afflicted fell*? creatures —of showing love towards our neighbour. Let us beware how we idT" LKCT. II.] PATHOLOGY. 41 neglect, or selfishly abuse, a stewardship so precious, yet so weighty. The profession of medicine, having for its end the common good of mankind, knows nothing of national enmities, of political strife, of sectarian divisions. Disease and pain the sole conditions of its ministry, it is disquieted by no misgivings concerning the justice or honesty of its clients' cause; but dispenses its peculiar benefits, without stint or scruple, to men of every country, and party, and rank, and religion, and to men of no religion at all. And like the quality of mercy, of which it is the favourite hand- maid, '* it blesseth him that gives and him that takes;" reading continually to our own hearts and understandings the most impressive lessons, the most solemn warnings. It is ours to know in how many instances, forming indeed a vast majority of the whole, bodily suffering and sickness are the natural fruits of evil courses; of the sins of our fathers, of our own unbridled passions, of the malevolent spirit of others. We see, too, the uses of these judgments, which are mercifully designed to recall men from the strong allurements of sense, and the slumber of temporal prosperity: teaching that it is good for us to be sometimes afflicted. Familiar with death in its manifold shapes, witnessing from day to day its sudden stroke, its slow but open siege, its secret and insidious approaches, we are not permitted to be unmindful that our own stay also is brief and uncertain, our opportunities fleeting, and our time, even when longest, very short, if measured by our moral wants, and intellectual cravings. Surely, gentlemen, you will not dare, without adequate and earnest preparation, to embark in a calling such as this; so capable of good if rightly used, so full of peril to yourselves and to society if administered iguorantly or unfaithfully. And even when you have made it, as you may, the means of continual self-improvement, and the channel of health and of ease to those around you, let not the influence you will thus obtain beget an unbecoming spirit of presumption; but remember that, in your most successful efforts, you are but the honored instruments of a superior power — that, after all, " It is God who healeth our diseases, and redeemeth our life from destruction." LECTURE II. Pathology — meaning of the term. Pathology, general and special. Morbid altera- tions of the solid parts of the body. Alterations in bulk. Hypertrophy — laws of its production—its effects. Atrophy — its causes and consequences. Changes inform. Alterations in consistence. Induration — its various kinds. I propose to devote several lectures, in the commencement of the course, to pathol- ogy, as it relates to medicine. And I must first of all explain to you what I mean by the term pathology. Many persons speak of pathology as if it were the same thing with morbid anatomy. That is not the sense in which I purpose to use the term. Pathology is morbid anatomy, but it is something more. A knowledge of pathology (in the full and proper acceptation of the word) implies indeed a knowledge of altered structures and of diseased conditions; — but it implies also an explanation of these — a knowledge of what precedes them, and a knowledge of what results from them. It comprehends therefore the following particulars: — 1. A knowledge of the material changes to which the several parts of the living body are subject in disease: 2. A knowledge of the processes or actions whereby these changes may be wrought: 3. A knowledge of the causes which may set these processes on foot: and 4. A knowledge of the consequences of the same changes, or of the symptoms they occasion. On some of these points our actual knowledge is still scanty and imperfect. Yet a good deal of valuable information has been collected concerning each of them, and 42 HYPERTROPHY. [ucr. n. this I shall endeavour to place before you as distinctly, and at the same time in as small a compass, as I can. Pathology is general or special. General pathology treats of the morbid conditions which are common to the entire system, or to the whole of each of the several tissues that pervade and compose the system. Special pathology contemplates particular diseases. An acquaintance with general pathology prepares us for, and conducts us to, that which is special: and when I say that the earlier lectures of the course will be given to a consideration of the leading facts and doctrines of pathology, you will of course understand me to speak of general pathology. I shall begin by inquiring what are the morbid changes to which the component parts of the living frame are liable : and I speak chiefly of sensible changes; leaving unnoticed for the present those unnatural conditions which are perceptible only through the microscope. There are, then, various ways, capable of intelligible description, in which the different parts of the body may be sensibly altered by disease. The solid parts may be altered in bulk; inform; in consistence; in their intimate texture, i. e., in the qualities and arrangement of their component particles; and in situation. The fluid parts may also be altered in quantity ; in quality ; and in place. And many of these alterations may exist in combination with each other. Let us first consider the solids. They may be simply altered in bulk without any change of texture; and that in two ways. They may become larger than is natural, or smaller than is natural. In the one case the change is called hypertrophy, and in the other atrophy. We find the best illustrations of hypertrophy in the muscular system. The huge fleshy masses visibly prominent in the arm of a blacksmith or a pugilist, and in the leg of an opera dancer, afford familiar examples of it. In these cases the increased bulk, although it may be unsightly, as being out of proportion to other parts, is not disease, and does not interfere with the most perfect health. By constant exercise the muscles acquire preternatural volume, and weight, and power. It seems to be a law which prevails extensively in the animal economy, that increase of function should lead to augmentation of bulk. The function of the muscular system is contraction and more frequent and energetic contraction begets an addition of substance. But the same principle obtains in various other parts and tissues. It is especially notice- able in some of the organs that are double. If one kidney wastes, oris spoiled by disease, an increase of function devolves upon the other, and by a beautiful law of compensation the sound organ, without any alteration of its peculiar fabric, enlarges. The same is observed to be the case with the lungs. The law resembles, somewhat, ?W JS f 7 7 P° ltlCt economists> aud « expressed by them in the maxim - that the supply of a marketable commodity is regulated by the demand for it. If in re'lsitLTdiSnTbT °fJ7e *>Ktodly nJed, fce necessity generate" the requisite addition of bulk, which implies an augmentation of force. One kidnev becoming inefficient it is necessary that the other should secrete a larger quantity of UrTtavThl1" feCU tJ H °btaiUed by thG eQlar^nt * the secret^g organ J I say this law is of extensive operation in the living body: but it is not universal It does not hold, for instance, in respect to the organs of Ihe special senses One eye does not become hypertrophic when the others blind; no/one ear ° ow lar^ Sites iz rt £S£5- into the blood to be takeu out of the body. The nutritioo eseeeds ,hewaste &* 1ECT. II.] HYPERTROPHY. 43 hypertrophy does thus result from an excess in the process by which parts are nourished and built up, and not from a defect in the process by which they are continually unmade and removed, is rendered probable by the fact that an increased quantity of nutrient blood is sent to the part hypertrophied. Its arteries grow larger. This we perceive by comparing these vessels with others where no accession of bulk has occurred. This opinion is further strengthened by the converse effect produced upon an hypertrophied part, the thyreoid gland for instance, by tying its principal nutrient artery. The magnitude of the bronchocele diminishes. It is curious that it should still be a matter of debate among pathologists, whether the nerves of the part partake also in its enlargement. Now these examples of hypertrophy clearly have not the nature of disease. But hypertrophy is often plainly connected with disease, while still it is not itself a morbid process. Thus we have it in the hollow contractile organs, the office of which is to propel fluids: — in the heart when the progress of the blood suffers some mechanical impediment; in the bladder and in the intestinal canal, when their respective con- tents are somehow hindered in their natural course; or when, from some undue stimulus or irritation, these parts are urged for a long time together to excessive, or too frequent, action. I show you preserved specimens of each of these changes. You will find that muscular tissue may become apparent, under the influence of disease, where very slight traces of it, or none at all, were visible before. We some- times observe this in the air tubes, the trachea and bronchi, when the respiratory functions have been long embarrassed; and in the gall-bladder, when the exit of the bile has been chronically obstructed. And it is worth remarking, that this new, or greatly exaggerated appearance of muscular tissue, which is the consequence of disease in the human body, is analogous with the natural and healthy structure of the corre- sponding organ in some of the inferior animals. The several instances of hypertrophy that I have now been mentioning, if they are to be looked upon as morbid, are morbid in a particular and limited sense — morbid, merely as being associated with disease, but not so either in their own processes or in their tendencies. Many indeed of the writers who notice them, speak of the hyper- trophy as constituting a source of disease, and a cause of danger to the patient. But I shall have occasion to show you hereafter, that in most cases it is really a compen- satory change, and conservative of life; — a resource of nature by which impending danger is postponed, and existence prolonged. Fia. 1. Fro. 2. Hypertrophy of left ventricle of the heart. Hypertrophy of the Aorta. From Dr. Gross' From Dr. Gross' collection. collection, a the heart, b the aorta. 44 HYPERTROPHY. Fio. 3. [lect. h. Hypertrophy of the muscular fibres of the urinary bladder. From Dr. Gross' collection. It may be said of hypertrophy, that its relation to disease depends very much upon its seat. As regards the muscular system —in the voluntary muscles it is generally innocent, in the involuntary it is generally connected with disease; sometimes as a cause, much oftener as a remedial consequence, sometimes as both cause and conse- quence. One way in which hypertrophy may manifestly be a cause of disease is by the pressure of an enlarged organ upon the parts in its neighborhood, and a consequent interference with the functions or the sensations of those parts. I am not sure whether, to those among you who are beginners, I make myself understood. An example or two will render my meaning obvious. It often happens that the aortic orifice of the left ventricle of the heart becomes narrow and constricted, in consequence of disease in the semilunar valves there situate. Under these circumstances, it is requisite, for the due propulsion of the obstructed blood, that the ventricle should contract with increased force. Its walls accordingly become thicker and stronger. Here the hypertrophy of the left chamber is evidently a consequence or effect of the disease that previously existed at its outlet. On the other hand, when the thyreoid gland is enlarged, it sometimes presses so much upon the parts that lie behind it, as to impede the breathing, or the swallowing. In this case, the hypertrophy is the cause of consecutive disease. Hypertrophy is exceedingly common in other tissues as well as in the muscular. Of its affecting the glandular system we have good examples in what I have just mentioned, the true bronchocele; in certain forms of enlarged prostate; in the thymus gland not unfrequently. Of a state of the brain which is considered to constitute hypertrophy, I shall speak more particularly when we come to the morbid conditions of that organ. Hypertrophy is also said (I am not certain with how much propriety always) to occur in the cutaneous, mucous, and vascular systems, in the bronchial, mesenteric, and mammary glands, in the liver, spleen, and pancreas. Of these parts I suspect that the enlargements to which the term hypertrophy has been sometimes applied, most frequently combine some alteration of texture with the increase of size, and therefore are not examples of pure hypertrophy. You ought to be aware that hypertrophy of one or more of the component tissues of an organ may exist, while the others either remain unaltered, or are changed in some other way. It frequently happens that when one component part is thus over- nourished, it is so at the expense (as it would seem) of another which becomes atrophied. There are parts of the heart upon which a certain quantity of fat is usually deposited. It is not uncommon to meet with this fat in excess, and at the Bame time to find the muscular texture of that organ pale, flabby, soft', and wasted. What has been deemed hypertrophy of the female breast consists, almost always I LECT. II.] HYPERTROPHY. 45 believe, in excessive development of its adipous tissue, without any enlargement of the gland itself—or even with its diminution. Hypertrophy of the adipous tissue is often general throughout the body, producing obesity; and this may become so extreme as to amount to disease, when it is called by nosologists polysarcia. I have seen one fatal instance of this kind: perhaps two. The mother of a large family, whom I long knew as a slender and elegant woman, began suddenly to grow fat; and in about fifteen months, without any other discoverable malady, she gradually enlarged into a corpulent unwieldy monster. At length her legs and thighs became cedematous as well as fat, her lips blue, her breath was short, and her pulse feeble. One night she was found dead in her bed. The body was not examined; but her death was mainly owing, as I believe, to fat collected upon the heart, oppressing its movements, and at last stopping them altogether. In the majority of cases the size of an hypertrophied organ is augmented; it has a larger superficies than is natural: and therefore I have introduced hypertrophy to your notice among the alterations to which parts are liable in bulk. But it is not always so. There may be hypertrophy of an organ without enlargement — in at least three different ways : — 1st, In hollow organs, where the additional substance is deposited centrically, and the hypertrophy takes place at the expense of the cavity: 2dly, In any organ, whereof the hypertrophy is confined to one or more tissues, while the others are proportionably wasted : and, 3dly, Hypertrophy may even be consistent with no alteration of shape, or increase of bulk in any direction, the organ occupying exactly the same space and preserving the same absolute dimensions as before, but becoming more full of component particles, more compact, heavier. This state is well exemplified in certain cases of hypertrophy of bone; the spongy or cancellous texture of the bone disappears; its specific gravity is increased; it becomes hard, firm, and like ivory. The structure appears, to the eye, to be changed, yet remains the same, except in respect of its density. I have told you that hypertrophy is usually a conservative and salutary change. We shall meet with many illustrations of this as we proceed. But I may take the present occasion for pointing out to you some of the beneficial tendencies of this change when it takes place in bone. For, since the diseases of the bones do not belong to my province, I may have no other opportunity. You probably know that in the disorder called rickets, occurring principally during childhood, the bones are soft, and deficient in their more solid ingredient; so that they bend under the weight of the body, or the contraction of the muscles attached to them. After a certain period this disproportion in the constituent particles of the osseous tissue ceases; but the bones are permanently distorted, and, therefore, less adapted to their office, and less strong, than if they had remained straight. Now the natural remedy that ensues is very striking and beautiful. The bent bones become hyper- trophied in certain places; they grow thicker, denser, harder, and consequently stronger, at the very concave part where the stress of the pressure is the greatest. The following experiment showed the same thing in a somewhat different manner. An inch of the middle part of the fibula of a quadruped was cut out. A long time afterwards the animal was killed. The tibia was then found to have become considerably larger exactly in that part of it which corresponded to the defect in the fibula.1 The same principle appears still more conspicuously in a case of disease ielated by Cruveilhier. He saw in the hospital at Limoges a young man who had lost (from necrosis with suppuration) the middle third of his tibia; of the larger of the two bones of the leg. The lost bone had not been reproduced, but the fibula, the naturally slender bone, had become thick and strong enough to support the whole weight of his body. I was explaining to you that hypertrophy may exist, without enlargement. On the other hand there may be enlargement, without any change of structure, and yet no hypertrophy. The liver and spleen are apt to acquire a considerable increase of bulk from mere congestion apd distension of their vessels by blood. An immense spleen will shrink into its proper size in a few hours, after haemorrhage from the stomach, whereby the gorged venous system of the abdomen has been relieved. Dr. Townshend Mr. Stanley's Lectures, Coll. Surg. 46 HYPERTROPHY. [LECT. II. mentions a remarkable example of the same kind respecting the liver. The inferior cava had been compressed by an aneurismal tumour, so that the passage of blood Irom the liver was greatly impeded. Under these circumstances the liver became so large as nearly to reach the crest of the ilium. Suddenly the aneurism burst, the pressure was taken from the cava, the hepatic veins were allowed to empty themselves, and before the body was opened for inspection, the liver had nearly resumed its natural situation and dimensions. In the profound, yet clear and instructive views of this subject exhibited by Mr. Paget in his recent lectures (1847) before the College of Surgeons, the conditions which give rise to hypertrophy are stated to be chiefly, or only, three, namely : " 1. The increased exercise of a part in its healthy functions. " 2. An increased accumulation, in the blood, of the particular materials which a part appropriates in its nutrition, or in secretion. " 3. An increased afflux of healthy blood." In the hypertrophy of the muscular tissue the first and third of these conditions coincide. The more frequent and vigorous contractions of the muscle accelerate the passage of the blood through its vessels, and so augment the quantity which flows towards and into them in a given time. The enlargement of the nutrient arteries is secondary to the hypertrophy; and in turn contributes to sustain and augment it. But the increased afflux of blood may be primary. Of this Mr. Paget adduces instances, in the growth of rank hairs around the edges of sores which have con- tinued long inflamed, and about old diseased joints; in the rapid increase of the spur of a cock when transplanted from the bird's leg to its comb; and (probably) in cer- tain cases of congenital or spontaneous hypertrophy of a single member, of a hand or a foot, or of one or more fingers. When one kidney augments in size upon the destruction or inaction of the other, we have coincidence of the first and second conditions. Mr. Paget thus explains the process. " The principal constituents of the urine are, we know, ready formed in the blood, and are separated through the kidneys by the development, growth, and discharge of the renal cells, in which they are for a time incorporated. Now when one kidney is destroyed, there must, for a time, be an excess of the constituents of the urine in the blood; for since the separation of the urine is not mere filtration, the other kidney cannot at once, and without change of size, discharge a double quantity. What then happens ? The kidney grows, more renal cells develop, and discharge, and renew themselves. In other words, the existence of the constituents of the urine in the blood that is carried to every part, determines the formation of the appropriate renal organs in the one appropriate part of the body." In the same manner the increased formation of adipous tissue may be ascribed to the presence of abundant hydro-carbon principles in the blood, which are the chief elements of fat. A few isolated facts, bearing upon some points connected with this inquiry, may be worth mentioning. In the first place, certain localities appear to be influential in the production of certain forms of hypertrophy. Thus bronchocele is very frequent aniono- the in- habitants of certain districts : especially in close or marshy valleys at the feet of hi°*h mountains. Its real cause is to be sought in some condition, hitherto undetermined of the air in those places, or more probably of the water, or of both. 2ndly, Certain congenital or acquired conditions of the system, tend to produce local hypertrophy. In that peculiar diathesis which we call the strumous__and of which 1 shall have much to say hereafter—certain parts of the body, as the upper lip, and the extremities of the long bones, undergo a kind and degree of enlargement that seems properly to fall within the definition of hypertrophy. 3dly, Certain habits of life have a distinct effect in promoting certain forms of hypertrophy. A full diet, with bodily inactivity, leads to hypertrophy of the adinous tissue. So general is this tendency, that we confidently act upon it in the fattening of animals. Shut a healthy pig up in a small sty, and give him as much food as he is willing to eat, and you ensure his rapid pinguescence. If you cannot so certainlv attain the same result by similar means in the human animal, it is chiefly I belie because moral causes, and especially mental anxiety, will effectually counteract those LF.CT. II.] ATROPHY. 47 means. A healthy man, with a quiet mind, using habitually a full nutritious diet, and leading a sedentary life, will fatten, I apprehend, as unfailingly as a calf or a turkey. Sometimes, indeed, fat accumulates, to an enormous extent, in spite of abstinent habits, and very active exercise. 4thly, It is a curious fact that the removal of certain parts of the hody, as the testicles from male animals, and the ovaries from females, increases the disposition to accumulate fat. The same tendency appears to be given, for a time, by the extir- pation of the spleen. Of the curative methods that hypertrophy may require it would be premature to speak at present. The bulk of parts may be also augmented in various other ways. The hollow organs may be inordinately distended by an undue accumulation of their natural contents; or by matters that do not enter them in health. The solid organs may have their size increased by the presence of matter foreign to their natural composition, collected in their interior, or distributed through the interstices of their proper tissues, or de- posited upon their surface: and in either case the functions of the part itself may be disturbed or suspended; or the functions of parts immediately contiguous to it may sustain damage from its pressure ; or the functions of distant parts connected with it by dependency of office may be disordered; or all these cousequences may ensue together. Numerous examples of them all will hereafter be brought under your notice. Let us next attend to that condition which is the opposite of hypertrophy — to atrophy, namely, in which parts become notably smaller than natural, without other alteration of texture. The two conditions contrast strongly with each other in their nature and origin, as well as in their physical character. Hypertrophy depends essentially upon an increase — atrophy upon a diminution or defect, of the nutritive functions. You will find that atrophy plays an important part in altering the bodily organs, both in health and in disease. Of the effect of atrophy in causing alterations consistent with health, I shall merely remind you of some instances, that you may the better comprehend its morbid operation. There are parts of the body, as you well know, destined for a temporary purpose only. Upon the cessation of their especial function they dwindle, or disappear. We have examples of this in the thymus gland, and in those parts of the mechanism of the circulation which are peculiar to the foetal state. The atrophy here begins as soon as the child is born, and is not only consistent with, but necessary to, its perfect health. As life advances, we see the same principle at work, remodelling from time to time those structures of which the office has only a limited duration. After the child-bearing period in women is over, when the functions of the ovaries expire, these organs shrink, through atrophy. It is so with the testes of old men. Indeed, atrophy, to a certain extent, pervades all parts of the system in old age: the muscles diminish in size, the whole body is less plump, the bones lose a portion of their sub- stance, and become brittle. Even in the period of foetal life this process, by which parts are starved and stunted, sometimes displays itself. But here it is no longer compatible with the integrity and well-being of the system. The arrest or retardation of the nutritive function produces changes of great interest, and gives rise to various kinds of mon- strosity. Harelip-—fissure of the palate — certain malformations of the heart—are familiar examples of the consequences of intra-uterine atrophy. Atrophy, considered as a morbid change, is conspicuous, no less than hypertrophy, in the muscular system. We see it in the voluntary muscles, whenever a limb remains long in a state of inaction — whether from palsy depending upou disease in the brain or spinal cord; or from pain connected with disease of a joint; or from perversion of the will, as in the self-inflicted penance of the Fakir. The same law, therefore, obtains here, which was previously announced; the development of a part is proportioned to the activity of its function. In most cases, I believe, the atrophy will be found to resolve itself into a deficient supply of healthy arterial blood. Building materials are not provided, or are provided inadequately. Mere inaction will produce atrophy; but it is probable that the inaction operates simply by abridging 48 ATROPHY. [lect. IT. . the flow of arterial blood to the muscle. If (as some contend, and as I am disposed to believe) what is called a change in the innervation of a part tends sometimes to occasion its atrophy; if, for example, the altered state of the nervous influence has some share, beyond the inaction which it produces, in causing the atrophy of a para- lysed limb — it still acts, I conceive, indirectly, and by reducing somehow the supply of healthy arterial blood. The nerves belonging to palsied and atrophied muscles are found to diminish in size. It is with the arterial circulation, however, that atrophy is most concerned. It is upon a diminution of the number of the smaller, and per- haps also of the capacity of the larger arteries, that senile atrophy often depends We find atrophy of the brain accompanying certain diseased conditions of its main arteries. So the testicle withers when the spermatic artery is tied for the cure of varicocele. _ Take notice how the laws of atrophy and of hypertrophy tally also in their exemptions, and are alike inapplicable to the organs of the special senses. I showed you that, although a kidney grows larger when the function of its fellow gland is lost. it is not so with an eye. Neither does the eye dwindle under mere disuse. Of this we have a remarkable illustration, as Mr. Simon has pointed out, in the boy who, born blind, was couched at the age of fourteen by Cheselden. His organs of vision were perfect in function and in bulk, after the almost total suspension of their office for so many years. Pressure of any kind, permanently exercised either upon the large arterial trunks, or upon the capillary vessels, so as to lessen without completely preventing the supply of blood, will be found to give rise to atrophy, whenever the due quantity of blood is not furnished by the establishment of a collateral circulation. I say permanently exercised, because intermittent pressure has often the exactly contrary effect. It was a maxim of Mr. Hunter's, that pressure from without produces thickening; pressure from within thinning and absorption of parts. Of the former we see an example in the thickening or hypertrophy {conservative hypertrophy) of the cuticle on the soles of the feet in persons who walk much, and on the palms of the hands of those who labour with tools. But Mr. Paget has superseded this principle by one of wider extent and of more exact application. He has shown that it is not upon the direction of the pressure that its different results depend; but upon the circumstance of its being constant, or only occasional, whatever may be its direction. " All the thicken- ings of the cuticle are the consequences of occasional pressure — as the pressure of shoes in occasional walking, tools occasionally used with the hand, and the like; for it seems a necessary condition for hypertrophy, in most parts, that they should enjoy intervals in which their nutrition may go on actively. But constant pressure, whether from within or from without, always appears to produce absorption." He does justice to Mr. Hunter's sagacity, however, by remarking, that " nearly all pressures from without are occasional and intermittent, and nearly all pressures from within arising as they do from the growth of tumours, the enlargement of abscesses, and the like" are constant." Chronic inflammation is sometimes attended by the wasting of the part which it occupies. It acts, in all probability, by unfitting the capillary arteries for transmitting the requisite quantity of blood. Various diseases, by which the supply of nutriment to all parts of the body is checked at its source in the digestive organs, or by which some unnatural drain upon the system is kept up —by which, in short,'the quantity of the nutrient fluid is diminished, or its quality impaired — produce a greater or less degree of general atrophy; but to this universal wasting we usually apply the term emaciation. Atrophy, then, such at least as is morbid in its nature, may he the consequence of inaction, of abiding compression, of chronic inflammation, and of various diseases * but in all cases the defect of nutrition which constitutes the atrophy seems to be resolvable into a diminished supply of healthy blood through the arteries As in hypertrophy, so likewise in atrophy, the change may be limited to some one or more of the component tissues of a part: —and by these altered proportions of it* constituent tissues the appearance of the part may be remarkably modified ho, also, as hypertrophy may exist without any increase of absolute size, may occur without any decrease : as in the heart, when the cavities are dilated in tW exact degree in which their walls become thinner. Bones, externally sound in LECT. II.] INDURATION. 49 Fig. 4. Atrophy of cellular struc- ture of the thigh-bone. pearance, have had their specific gravity so greatly reduced by internal atrophy, that they would float, like a cork, upon water. It is a curious fact — which I mentioned in other terms before — that an atrophied part is sometimes plentifully en- compassed by fat. But this is by no means a necessary accompaniment. Why it happens in one case, and not in another — whether the adipous hypertrophy is ever the cause of the atrophy associated with it, or the atrophy the cause of the hypertrophy: — these are questions which, in the present state of the science of medicine, do not admit of any positive solution. It is scarcely necessary to observe that the changes of bulk which we have been considering, imply often, though not always, changes of form also. You may have one or two of the chambers of the heart greatly enlarged, while the others remain of their natural size. Of course this altered propor- tion modifies the shape of the organ. Signal changes of form are produced also by inflammation, by pressure, and in various other ways. But, after all, modi- fications of figure are rather to be considered as accidents of disease than among its important elements; and I pass on to other alterations. Various parts of the body are liable to be changed in con- sistence. They may become harder and firmer than before : or they may become softer. To the state of increased or un- natural hardness the term induration has been applied; the same word is used also to express the process of hardening. To the state of diminished consistence we give the name of softening. The French pathologists, who first noticed this condition as an element of disease, call it ramollissement. You are already aware — those of you who have attended the lectures of the pro- fessors of midwifery and of anatomy — that a slow process of natural and healthy induration is going on throughout the body from the earliest period of uterine life to extreme old age. There are several ways in which imnatural induration may take place. Induration of an organ may happen, without any other alteration of its proper tissue, in consequence of inordinate fulness of its blood-vessels. This is apt to occur in the lungs, or liver, whenever the free exit of blood from these organs is in any way impeded. They become stretched, tense, resisting, hard. In like manner induration of the hollow organs, or of cellular parts, may arise (without any change of their texture) from an undue accumulation of fluids within them :—of bile, for example, in the gall-bladder; of urine, in its receptacle; of gases in the stomach and intestines; of serosity in the cellular tissue. In either of these kinds of induration the unnatural hardness may be temporary only, or it may be the permanent accompaniment of other disease. It is necessary that you should be aware of its occurrence, and of its nature. I say, of its nature, because this is not always understood. In the induration arising from the last cir- cumstance I mentioned, viz., from infiltration of the cellular tissue with the serous or albuminous parts of the blood — from ozdema, in short — the hardness has some- times been erroneously ascribed to some other morbid condition. Dr. Carswell has shown that in the curious disease of new-born children who are said to be skin-bound, the hardness of the surface is the consequence of simple oedema of the subcutaneous cellular tissue. The same phenomenon is remarkable in oedema of the tongue. I believe the induration belonging to oedema will be found to be the greater, in propor- tion as the effusion is large and recent, and has taken place rapidly. Again, induration may accompany, and be a consequence of, simple hypertrophy. Of this I have already shown you examples : especially in the eburnation, (as it has been called) of hypertrophied bone. Induration of an organ may also result from the expression of its fluid, and the compression of its solid parts. We see this extremely well in the lung, when it has been thrust and flattened against the vertebral column by fluid effused into the pleura; 4 50 INDURATION. [LECT* "" or when it is still more tightly bound down by an investing layer of plastic lymph. In this way, therefore, induration may be consistent with atrophy, lhat tne naiurdi structure of the hardened lung is not always lost in these cases we know, Decause we can restore, to a certain extent at least, its bulk and spongy feel, by forcibly inflating it. The spleen sometimes exhibits the same kind of induration, under the constrictive force of an investing false membrane. I am mentioning samples only of these changes. More frequently induration depends upon the presence, u the internal texture ot parts, in the little spaces left between their component tissues, of fluid or solid matters which are not found there in the healthy state. Bony or earthy particles are some- times laid down, and the part thus changed is said to be ossified. Ihere are few parts of the body in which this kind of induration does not occasionally take place. It is especially common in the coats of arteries, and in the subserous tissues. Blood, or fluids separated from the blood, may fill and obliterate the natural interstices, and concreting, tend to consolidate and harden the part which they occupy. What is called hepatisation of the lung is a good instance. I need not tell you that the healthy lung is spongy and crepitant under pressure; in this altered state it nolonger crackles between the fingers; its spongy character is lost; it resembles liver in its compactness and colour, and it is therefore said to be " hepatised." This is a consequence of inflammation; and induration of this kind is a very common consequence (as we shall see) of the same morbid process in various other parts and organs. Another instance of induration of the pulmonary substance we have in what is badly named pulmonary apoplexy. This is independent of inflammation. Blood is collected and coagulates in a part of the lung which should contain air — in the vesicles of one or more of its lobules; the lobules thus gorged with blood become even harder and firmer than when hepatised; but by a different process. In the instances last mentioned, fluids after escaping from their proper vessels, i. e., in technical phrase, after being extravasated, pass into the solid form, and thereby render the parts which they pervade harder and more firm. But fluids may concrete and harden within their proper vessels, and so lead to another form of induration. Thus the blood, under certain circumstances, coagulates in the living veins — nay, sometimes even in the heart itself: and we may hereafter have to consider the condi- tions under which this coagulation is liable to occur, and the serious consequences which it involves. The bile again, as you probably know, sometimes concretes, by a rude kind of crystallization, into what are called gall stones: and the passage of these calculi through the narrow ducts that connect the gall bladder with the bowel is apt to be attended with pain the most intense. The formation of urinary calculi is not exactly of the same kind. Numerous specimens of all the changes I have been describing are on the table before you. You may examine them at leisure after lecture, or in the museum. I have yet to notice another source of unnatural induration, in the deposition or growth of irregular masses of matter within the body, differing remarkably from any of the solids or fluids that enter into its healthy composition. These unnatural formations vary considerably in their nature and appearance, and in their consistence, at different periods. Sometimes they exist in distinct and separate masses, and whether hard or soft in themselves, cause induration by their pressure upon surrounding textures; sometimes they are diffused through or among the natural tissues of a part! which thus they indurate. All the varieties of tubercle, and of cancer, all those forms of disease which have been styled malignant, fall under this head. These new and morbid products play a fearful part in disorganizing the bodily frame, and in embittering and shortening life. They will necessarily occupy much ot our attention in the progress of the course. At present I merely point them out as illustrations of the manner in which the consistence of parts may be increased lhct. in.] SOFTENING. 51 LECTURE III. Softening; its causes and varieties. Transformations of Tissue. Changes of situation — in the Chest, of the Lungs, of the Heart — in the Abdomen and Pelvis, Hernia, Intussusception, Prolapsus. We were occupied with that branch of pathological inquiry which relates to the various ways in which the several parts and organs of the living body are liable to be sensibly altered by disease. We considered the changes to which the solid parts are subject in bulk and in form; and that alteration of their consistence which constitutes hardening or induration. The opposite condition to this is softening, diminished consistence, a less degree of cohesion of parts and tissues than is natural. This also is a change of which it is important that you should comprehend the nature, and causes, and varieties; and the share that it often has in breaking down the structure of organs, and in destroying life. There is scarcely any tissue of the living body, in which softening may not take place. I shall here, however, as before, mention a few illustrations only of its occur- rence, taking those instances in which the phenomenon is most evident, or is best understood. Softening is perhaps never more strikingly obvious to our senses than when it affects the brain or spinal cord. We find portions of these organs manifestly softer than the rest. You are familiar with the usual consistence of the adult brain : you will find it sometimes reduced, in places, to the consistence of cream : a gentle stream of water suffered to fall upon the softened pulp suffices to wash it away, and a cavity is left in its place. The cellular tissue — or let us rather call it, with Professor Todd, the areolar tissue, since minute anatomists now affirm that all the tissues in their embryonic state are cellulai---the areolar tissue is another part in which softening is exceedingly common, although the change is not so readily perceived. This is the great connecting tissue of the body; and we are made sensible of its diminished consistence, when parts which it unites become separable with unusual ease. Thus you may sometimes, by exerting a very slight degree of force, strip off a serous membrane from the parts which it invests, or a mucous membrane from the surface lined by it. This ready separation is a consequence of the diminished consistence of the subserous, or the submucous, areolar tissue. The membranes themselves, in such cases, may be in a perfectly natural state. Muscles, again, are often palpably softer than they should be; the fleshy substance of the heart, for example. Here the muscular fibre may itself have undergone a change of consistence; or the muscle may simply appear to be softened, in consequence of the softening of the threads of areolar tissue by which its fibres are tied together. The mucous membranes very frequently present the phenomenon of softening. This is more commonly seen in the stomach than elsewhere. Instead of being raised from the subjacent tissues in large flakes, the mucous membrane, when seized between the blades of a forceps, breaks off in small fragments; or it may be crushed and mashed by the pressure of the finger, or washed away in shapeless pulp by a little current of water. This condition of its lining membrane is usually limited to parts of the stomach; but occasionally it is general. Even the bones are liable to this change of consistence. There is a disease called mollities ossium, in which the bones even of adults become soft and pliant, and capable of being bent in any direction. Upon what these altered qualities are believed to depend, I will explain to you presently. The accidental products to which I adverted when speaking of induration — especially some of the varieties of cancer — are sometimes remarkably soft, resembling 52 TRANSFORMATIONS OF TISSUE. [lect. hi, brain in consistence and appearance, or cream, or jelly. But in these cases we can scarcely consider the change as an example of softening of the textures of the body; it rather consists in the addition of parts that are themselves soft and half fluid. Now softening may occur under very different circumstances. One very general cause of softening is inflammation. Every part, I believe, that is inflamed undergoes, in the first instance, a diminution of its consistence. This appears to be almost the necessary consequence of stagnation of the blood, the effusion of serosity, and the suspension of healthy nutrition. These are circumstances to which I shall recur. I cannot avoid alluding occasionally to things with which you are supposed to be as yet but little acquainted, and which will engage our particular attention as the course advances. It would be a great mistake, however, to imagine that all softening results from previous inflammation. Doubtless it often proceeds directly and simply from deficiency of nutrition, and is then closely allied, as I said before, to atrophy. Thus softening of the brain is, sometimes, due to inflammation : we meet with it where the inflam- mation has been unequivocal, and was caused by external injury; but sometimes also it is quite independent of inflammation, and is owing to disease or obstruction of the cerebral arteries, whereby the brain, or a portion of it, is deprived of its full supply of arterial blood, and ceases to be properly renovated. Hence a loosening of its texture, a separation of its component particles, an approach to the fluid state. I shall, of course, hereafter endeavor to point out to you more particularly the means we possess of distinguishing these two forms of cerebral softening. They constitute morbid conditions of the highest interest. I may observe, that we have an illustration of the principle now laid down, in that general softness, flaccidity, and slight cohesion of parts, noticeable in children, and others, who are imperfectly nourished. We find this general absence of the natural firmness coincident with paleness, and a thin watery condition of the blood. Ma«-endie kept animals upon food unsuitable for them, containing no azote, and incapable of supplying sufficient nourishment; and one curious consequence was a loss of substance in the cornea, which melted down and disappeared. There is another source of softening which requires to be mentioned__I mean the gastric juice, which has the power of dissolving not only food that is submitted to its action, but the mucous membrane of the stomach itself, and even all its tissues and coats. This cause of softening operates, however, in the dead body only; but its effects have often been mistaken for the consequences of disease; and therefore it will be necessary for me hereafter to call your attention to the circumstances under which those effects may be looked for, and to the points of distinction between them and other changes that are more properly called morbid. Upon the whole, it may be said that every form and kind of softening in the livin* body —whether it proceed from inflammation, from disease or obstruction of the arteries from insufficient sustenance, or from altered qualities of the blood —may ultimately (like atrophy) be resolved into suspended or defective nutrition Furthermore as there is a hardness of parts resulting from repletion and distension so there is a softness rather than a softening, from their emptiness and flacciditv • as of the breast immediately after the child has sucked; of the abdomen soon afte delivery; of the integuments in those who, having been fat, have wasted, either from disease or from advancing age; and so on., ' lut;i irum On former occasions, I thought it right to lay before you the views of M An^l Snf^ear *? haye,beei\ad0Pted als°t>y Sir R Carswell) respecting what hat been called the transformation of tissues. " In the nroner nlaop «f ™„ I , . Dee" remarked) we sometimes find another, which UT&L^Z ir, / ^/T *(I situation, but natural in all other respects. The new tissue is nol ^ t0 -1? elsewhere in the body, but it is not such as propeXlelZs to th »? ^^ ^ Either the original tissue has been graduallycoLerid into the t*J^ £ "^"i tissue has disappeared, and the new tissue has been subsritutedfor^ it^Tf example, which should be cartilage we sometimes find to be bone '' ' ' f°r folbwinrp^rm^l-G ^^ haS ^^ ^^ °r diS*laCed ^ - one of the two " Either its natural function has been for a long time suspended • lect. in.] TRANSFORMATIONS OF TISSUE. 53 " Or, it has been accidentally called upon to fulfil a purpose for which it was not originally designed. " In the former case it gradually approximates towards areolar tissue, which at length is all that remains. " In the latter it assumes the characters of that other tissue of which it has taken up the office." Now the analogy which M. Andral thought he could perceive between changes of this kind, and the changes that occur during the growth and progressive development of the human body, does not in reality obtain. More recent and more exact micro- scopical researches have shown that the several tissues do not commence by being areolar tissue — which is the sense in which M. Andral uses the word cellular — and therefore that in the dwindling of any given tissue into the areolar, there is no return, as he had supposed, towards the primitive state of the tissue so wasting. A muscle remaining for a long time in complete inaction, loses bulk, but does not pass from the condition of muscular into that of areolar tissue. When wasted to the utmost it may still retain its proper anatomical elements. The areolar tissue is quite as complex and advanced a tissue as the muscular. There is no true conversion of the one tissue into the other. It is commonly stated, indeed, that when a muscle comes accidentally to invest a dislocated joint, the dislocation remaining unreduced, it assumes by degrees the characters, together with the uses, of those tissues which naturally inclose the joint, and is converted from muscular into fibrous or ligamentous tissue—just as in the vegetable kingdom, the cut end of a willow branch, planted in the earth, takes up the office, and gradually acquires the form and properties of a root. But here again the analogy is more fanciful than real. The formation of a false joint implies no actual conversion of tissues. The muscular fibres shrink and disappear, while the areolar tissue augments, and is transformed only into the fibrous; these two, the fibrous and the areolar, being essentially and primarily the same tissue. The change from cartilage to bone approaches more nearly than any other to actual transmutation; but even this resolves itself into a simple increase of one of the natural constituents of both the tissues concerned; phosphate of lime, which exists in healthy cartilage. I spoke of local and of general additions of adipous tissue occurring in the body, as forms of hypertrophy. But fat is apt to be produced, by a sort of transformation, in atrophy also. Mr. Paget, indeed, whose remarks on this subject possess a very high interest, makes fatty degeneration to be one kind of atrophy. He describes atrophy without change of texture, (in which sense I have been using that term,) and atrophy with degeneration of texture. Although there is no necessary connexion between them, the two often exist together, but one of the two predominates. The degeneration proceeds under the ordinary conditions and causes of simple atrophy; and it is a common result of that imperfection of the formative process which accom- panies the infirmities of old age. In this form of atrophy the fatty matter is not deposited, as in hypertrophy, from the blood-vessels, and laid up in cells or vesicles; but it is apparently the result of some chemical change wrought in the affected tissue itself, throughout which the molecules of fat are irregularly distributed. It is a process and a mark of decay. It is met with in unexercised voluntary muscles, whether their action be suspended by paralysis or by the immobility of the parts which it is their function to move. It occurs under the deteriorating influence of disease, or of age, in that involuntary muscle, the heart; in the arteries, of which the muscular element is probably the first to suffer; in the bones; in the cornea, where it becomes visible even during life as the arcus senilis; and in various other organs of the body. What is called the fatty liver is an example. The altered liver is larger than natural, of a light tawny colour, of diminished specific gravity, retains the impression of one's finger, is tender, and tears easily: it greases the knife that cuts it, or bibulous paper in which it is wrapped. By boiling it you may obtain a concrete oil, which has all the characters of fat. Under the microscope, the molecules of fatty matter are recognised, in this and in other tissues, by their peculiar refraction of light. They sometimes run together into larger unequivocal oil-drops. Chemistry detects their nature by their 6olubility in ether. What is very curious in respect to this morbid condition of the liver is, that we 54 TRANSFORMATIONS OF TISSUE. [lect. hi. can produce it, at will, in some at least of the lower animals. You know that the "foie gras," procured from certain birds, is an article of great luxury among epi- cures. It is obtained by a very cruel process. Geese, or ducks, are confined in baskets just large enough to contain them, but not large enough to allow them any movement: they are kept continually in the dark also; sometimes even, I am afraid, their eyes are put out, but this I should imagine to be a useless and superfluous piece of cruelty, it being the absence of light, and not the absence of the power of vision, which helps to bring about the desired effect. At the same time the birds are sedu- lously crammed with food. Under this discipline their livers acquire the requisite size, and greasiness, and the true flavour. The history of these unfortunate fowls is not barren of instruction in respect to the more limited bad effects of full diet, want of exercise, and a short allowance of day- light, upon the " featherless biped," man. Fatty degeneration affecting the muscular substance of the heart, and rendering that main instrument of the circulation soft, weak, readily stretched by the blood which it compresses, and easily torn, becomes a frequent and an intelligible cause of dire distress, and of death. Concerning this most perilous cardiac disease, our know- ledge is of recent acquisition. In the larger arteries also, where it has long been known under the name of atheroma, the same form of decay leads to dilatations, to aneurisms, to fatal ruptures. When it occupies the smaller branches of the same vessels it tends to softening of the parts which those branches then fail to nourish and maintain, and to the escape of blood from their broken channels into and among the softened textures. This is a very common source of cerebral mischief—of apo- plexies, and of palsies. Following out Mr. Hunter's original views, Mr. Paget has satisfied himself that the singular disease of bones described by English writers under the name of molli- fies ossium, is also owing to this fatty degeneration. Nay, the same morbid change may pervade the whole body. In all ranks of life there are two well-marked forms of senile decay: and every one will at once, I think, recognise the fidelity of the fol- lowing graphic sketch by Mr. Paget's pencil. " Some people, as they grow old, seem only to wither and dry up—sharp-featured, shrivelled, spinous old folks, yet withal wiry and tough, clinging to life, and letting death have them, as it were, by small instalments slowly paid. Such are the ' lean, and slippered pantaloons/ and their ' shrunk shanks' declare the pervading atrophy. "Others — women more often than men — as old and as ill-nourished as these — make a far different appearance. With these the first sign of old age is that they grow fat; and this abides with them till, it may be, in a last illness sharper than old age, they are robbed even of their fat. These too, when old age sets in, become pursy, short-winded, pot-bellied, pale and flabby; their skin hangs, not in wrinkles, but in rolls; and their voice, instead of rising «towards childish treble/ become gruff and husky. "Now, these classes of old people may represent the two forms of atrophy —of that atrophy by decrease, and that by degeneration of tissue —to which we shall find nearly every part of the body liable. In those of the first class you find all the tissues healthy, hardly altered from the time of vigour. I examined the muscles of such a one lately —a woman, seventy-six years old, very lean, emaciated, and shrivelled The fibres were rather soft, yet nearly as ruddy and as strongly marked as those of a vigorous man; her skin too was tough and dry; her bones/slender indeed yet hard and clean : her defect was a simple defect of quantity. ' "But in those that grow fat as they grow old, you find, in all the tissues alike bulk with imperfect texture; fat laid between, and even within, the muscular fibrU fit about the heart, the kidneys, and all the vessels; and the bones so greasy that no ar can clean them : the defect of all these is the defect of quality " J ^ All these fatty changes are plainly morbid. The transformations that are effected in false joints are as evidently methods of accommodation and repair. The sam7 be said of the transformation-which is not conversion-0f areolar tissue intTsy™ vial membrane Synovial membrane consists chiefly of condensed areolar tissue ^Sir Benjamin Brodie, in his book on Diseases of the Joints, gives instances of synovia membranes being formed, where none before existed. "In a young ladv wh!Za mained the age of ten or twelve years, labouring under the inconvenience of a club I. F, C T. III.] LESIONS OF NUTRITION. 55 foot, a large bursa was distinctly to be felt on that part of the instep which came in contact with the ground in walking. In another young lady, who had apparently recovered of a caries of the spine, attended with a considerable angular curvature, a bursa appeared to have been formed between the projecting spinous process and the skin." In like manner we find that sinuses, fistulous openings and tubes, in various parts, become lined, through the intervention of the areolar tissue, with a surface which in its appearance and in its properties resembles the mucous membranes. Like them it is with difficulty made to take on adhesive inflammation; and therefore it is that sinuses of this kind, and chronic abscesses, are often so troublesome to the surgeon, and require to be laid open before they can be abolished. On the other hand, the mucous membranes, under peculiar circumstances, approxi- mate to the skin in their physical aspect and qualities. When, for instance, a portion of the mucous lining of the rectum, or of the vagina, protrudes externally, is perma- nently exposed to the air, and subject to the friction of clothes or of neighbouring parts—that is to say, when it is placed under the same conditions as the skin—it- assumes somewhat the characters of the skin: it gradually loses its red colour and approaches the tint of the skin, ceases to pour forth mucus, becomes dry, obtains even a sort of permanent cuticle, acquires firmness and density, and is less sensible to the contact and pressure of foreign substances. It is impossible not to perceive the bene- ficial nature of this transformation. The greater number, then, of those interesting changes in the living body which have been classed under the head of transformations of tissue, have a restorative tendency. They exemplify the working of what the older pathologists discerned, and called the vis medicatrix naturae. This is a phrase that has been much sneered at; but (as I conceive) very unjustly, and sometimes ignorantly. It is simply a short formulary, expressive of a great general truth, viz., that the animal frame is so con- stituted as to contain within itself the elements of repair, and of conservative adapta- tion. To a great extent it is a self-mending machine. Surely this is an admirable provision, and clearly indicative both of wise contrivance and of beneficent design. The intimate texture of parts may be further altered — not simply by some modifi- cation or reconstruction of the ordinary tissues, but — by an absolute disappearance or confusion of all regular structure. This is usually a consequence, either of the effusion, in the natural interstices of the parts, of fluids, which afterwards pass into the solid state, or it is a consequence of the growth of solids which do not belong to the healthy body. In this sketch of general pathology I must content myself with thus briefly alluding to this source of morbid change. I may as well observe here, that the alterations with which we have hitherto been occupied, of the solids of the body, fall, almost all of them, under the head of lesions of nutrition, as the French pathologists speak. That is to say, they commence and have their primitive seat, in that process and place where the blood, having reached the capillary system of vessels, performs its special purposes. It is in or through the capillaries that the fluids and solids accomplish their vital union. Each solid receives from the blood, and assimilates with its proper substance, material particles, identical in their nature with those of which it already consists. Each solid gives up also to the blood, and so dismisses, other particles, which before formed a portion of itself, but which have become unfit or superfluous. Now any departure from this continual building up and pulling down—any excess or defect of the particles added, or of the particles subtracted — any irregularity in the manner in which they are deposited — any variation from their right consistence, or in their kind and quality—in short any deviation from the regular process, as I have briefly described it — is called a lesion of nutrition. The few changes already spoken of, and not included among the lesions of nutrition are: — The distension of the hollow organs by an undue accumulation of fluids within them; The coagulation of the fluids in their proper vessels, excluding however the capil- laries ; The escape of the fluids, as such, out of and beyond their containing vessels; and The solution of tissues, after death, by the chemical agency of the gastric juice. 56 LESIONS OF NUTRITION. [lect.iii- None of these, properly speaking, constitute lesions of nutrition, although t ey sometimes lead to them. Lastly, let us take a glance at the changes of situation to which the solid parts of the body are liable. They are sometimes of very serious import. rtmotl-mp„ :tq These changes of place - sometimes the consequence of ,disease, BometameB its cause, and not unfrequently the cause of death - respect chiefly the. *iscera.and most especially the viscera of the chest, abdomen, and pelvis. I omit dislocations ot ioints, as belonging exclusively to surgery. . „„„+Qv,™i J In the chest,Da whole lung may be displaced, and compressed against the vertebral column, by blood, or serum, or air, effused into the cavity of the pleura. An altera- tion of this kind, whereby one-half of the respiratory apparatus is rendered incapable of its peculiar function, cannot be otherwise than full of peril. The very same causes operating on the left side of the thorax may dislocate the heart, thrust it over to the right of the sternum, where it may be felt, and heard and seen, to pulsate. This again cannot happen without greatly disturbing the vital func- tion of circulation, and putting life in jeopardy. , Yet neither of these serious displacements is necessarily fatal. Both admit, under certain circumstances, of remedial treatment; as I hope to prove to you hereafter. In the abdomen and pelvis, the various forms of hernia may be adduced as involv- ing very dangerous changes in the place and relative position of parts. Portions of the intestinal tube are apt to pass through accidental openings in the diaphragm—or between the edges of the linea alba surrounding the navel — or out at the abdominal ring__or through some other natural or accidental aperture. I need not tell you how fearfully life is compromised when, in consequence of such faulty position, the bowel becomes constricted—when its contents can no longer pass onwards, and inflammation, or gangrene, is present or impending. Even when there is no strangulation, the mere displacement, arising from the escape of some of the contents of the abdomen and pelvis from their natural limits, maybe productive of much discomfort, deformity, and hazard. Of this the historian Gibbon presented a remarkable example. He had an immense scrotal hernia; so large it was, that it hung down very nearly as low as his knees. After his death it was found that almost the whole of the omentum, and the greater part of the colon, had descended into the scrotum, and had dragged the stomach after them; so that its pyloric orifice lay close to the abdominal ring. Akin to hernia is that partial displacement of the bowel in which a portion of it passes, not through any natural or accidental opening, but into the bowel itself: just as one portion of the finger of a glove is sometimes pulled into the remaining part, by the withdrawal of one's hand. The contained portion of intestine is liable to be nipped and strangulated by the containing portion — and all the peril of hernia re- sults, with much less chance of relief by art. This state of things is called intus- susception. Exactly of the same nature, though less alarming, is prolapsus of the rectum, or of the vagina. Here also a portion of the tube passes into the contiguous portion; but being near the extremity of the canal, the inverted part protrudes externally, and becomes, in most cases, a source of distress and suffering, rather than of dano-er. Inversion of the uterus is another example. Thus much, then, of the changes to which the solid parts of the body are subject in bulk, inform, in consistence, in texture, in situation. You cannot fail to perceive the injurious effects which many of these changes in the various solids are calculated to produce upon the movements and workino- of the living machine; how some of them must impede or derange its natural actum • some stop that action altogether. Now the fluid parts of the body are liable also to alterations, which, if they be not always so obvious as those of the solids, are certainly not of less moment. You are probably aware that, for many centuries, the fluids were supposed to be the primary agents in every form of disease; that all maladies were attributed to some acrimony or peccant state of the humours; and that however else the theories of medicine might vary and fluctuate, the humoral pathology, till a comparatively recent period, ran through almost all of them. At length, the absurdity of the hypotheses lect. iv.] MORBID ALTERATIONS OF THE FLUIDS. 57 and still more the dangerous practice, which this doctrine generated, began to be manifest, and led to its total abandonment. Rather more than a century and a half ago, the foundation of the opposite doctrine appears to have been laid, by the writings of Grlisson in this country, and by those of Baglivi in Italy; and presently the notion came to prevail throughout the schools, that all the morbid conditions of the body had their exclusive origin in the solids. The pendulum of opinion swung at once, as is usual, into the opposite extreme of error. It promises, in our time, to settle at the juster medium. Reviving under new and more faithful evidence, the humoral doctrine again asserts its rightful but modified claims upon our acceptance. That its old extravagancies still find favour among the ignorant, and are commonly adopted by the quack, are circumstances which illustrate the fact that the mischievous influence of unsound theories survives the duration of the theories themselves. The scientific physician of the present day can only wonder how exclusive solidism, or exclusive humoralism, should ever have found advocates. LECTURE IV. Morbid Alterations of the Fluids, especially of the Blood. Changes in its quantity and distribution. General and Local Plethora. Poverty of Blood. Active Con- gestion—its Phenomena—State of the Vessels as seen by the Microscope. Mechanical Congestion. Passive Congestion. Relations of these forms of Congestion to Inflam- mations— to Haemorrhages — to Dropsies. After running over the principal alterations to which the solid parts of the body are liable, we were beginning to inquire into those no less important morbid changes which are apt to take place in its fluid constituents. I reminded you that, respecting the whole of this subject, pathologists had passed from one extreme of opinion to another; that for a very long period the humoral pathology prevailed in the schools, and that, in times not very remote from our own, it was entirely superseded by the opposite doctrine of exclusive solidism. It is strange that either misconception should have so long maintained its ground. If we consider the definite relation subsisting between the solids and the fluids of the body, and the unceasing agencies which they mutually exercise on each other — how, for instance, on the one hand, all the solids are originally built up, and are afterwards perpetually sustained and repaired by materials furnished from the blood — how, again, on the other hand, some of the solids are continually employed in the reciprocal office of feeding and renewing the blood, while others are as constantly at work in decompounding it by the various secretions — we cannot avoid perceiving that distinctions of the kind I have mentioned, founded upon mere differences of consistence, are futile. Flesh and blood are almost convertible terms: thoir compo- sition, the chemists tell us, is identically the same. To use the strong expression of Bordeu, Le sang est de la chair coulante. You may be certain that no notable alter- ation can take place in the solids of the body which will not soon affect in some way its fluids; and that every important change in its fluids must lead to, or proceed from, a corresponding and proportionate modification of its solids. The long dispute between the solidists and the humoralists was altogether baseless and unprofitable. Mr. Paget, in the admirable lectures to which I have already referred, cites and adopts the proposition of Treviranus, that " each single part of the body, in respect of its nutrition, stands to the whole body in the relation of an excreted substance." " In other words, every part of the body, by taking from the blood the peculiar substances which it needs for its own nutrition, does thereby act as an excretory organ, inasmuch as it removes from the blood that which, if retained in it, would be injurious to the nutrition of the rest of the body. For example, the polypiferous 58 CHANGES IN THE BLOOD. [lect. iv zoophytes all excrete large quantities of calcareous and siliceous earths In those which have no stony skeleton these earths are absolutely and utterly excreted, idui in those in which they form the skeleton, they are, though retained within the Dooy.yet as truly excreted from the blood and all the other parts, as if they had been thrown out and washed away. So the phosphates which are deposited in our bones areas effectually excreted from the blood and the other tissues, as those which are discharged with the urine." . .. , , . i„ ,1 This doctrine, if it be true, as I think it is, puts in a strong light, not only the constant relation and interchange subsisting between the solid tissues of the body and its fluids, in health, but their inevitable sympathies also, in disease. The animal fluids are —the blood, the fluids that enter the blood, and the fluids that proceed from the blood. The fluids that enter the blood are of two kinds. 1. Those by which it is renewed and enriched. 2. Those which enter it in order that they may be conveyed out of the body. Now, although we cannot doubt that any considerable modification or defect of the fluids that feed and renovate the blood, and particularly of the chyle, must have a direct influence upon its composition and quality, we really know but little about them, except in their effects. We seldom have any means of procuring these the first products of nutrition so as to examine them, or to test their qualities; yet we can perceive causes that are likely to deteriorate or deprave those fluids (unfit aliment, impure air), and we know that, under the continued operation of such causes, the blood, replenished by these fluids, is actually and sensibly modified. Again, we cannot doubt that some of the matters derived from the body itself, and taken into the blood in order to be conveyed away, may, and often do, directly alter and contaminate the blood, and act as poisons upon the system; matters, for instance, absorbed from parts of the body that are diseased, or dead and putrefying; in this way, doubtless, disorders which were at first strictly local may come to affect the whole economy: — matters, again, which, though harmless while merely transitory, and in minute quantity, prove noxious when retained and accumulated in the blood, in consequence of faulty or, deficient action of the organs destined to eliminate them from the circulating fluid. The injurious effects of some of the substances which thus become deleterious, — as urea, of which the blood, during health, is continually purified by the kidneys; and bile, which is naturally separated therefrom by the liver; and carbonic acid, which it is the office of the lungs to excrete — will furnish topics of interesting inquiry hereafter. The fluids that leave the blood may be considered under a threefold division. 1. Those which are directly expended in the growth or maintenance of parts, some of them becoming fixed and solid, and others retaining their fluid condition. Of these the principal alterations have been briefly pointed out among the lesions of nutrition. 2. Those that are employed in aid of some definite function of the body: as the saliva, the gastric juice, the bile, the pancreatic secretion, the tears, the synovia of the joints, and so on. Now, these may be secreted in excessive abundance, or in too scanty quantity, or of imperfect quality, or not at all: and all, or any, of these deviations from the healthy standard may be the result of very serious disease or may cause very serious disease; and they will be spoken of hereafter when the disorders of the parts or functions connected with each shall be discussed. 3. Those which are separated from the blood merely to be excreted, as the urine certain discharges from the bowels, and from the bronchi and skin. Some of these are extremely worthy of study, as furnishing, in their altered qualities, indications of disease; but they require no particular consideration in this part of the course Dismissing, therefore, for the present, all further account, as well of the fluids that concur to form the blood, as of the fluids that issue from the blood let us inauire what morbid changes the blood itself is liable to undergo. ' 4 The blood, then is subject, first, to remarkable variations in its quantity, both in respect to the whole system, and in respect to particular organs and tissues 2. Closely connected with these differences of quantity is the variety which i« observable in regard to the proportions between the several proximate constituents of LECT. IV.] GENERAL PLETHORA. 59 the blood. The changes that occur of this kind are sometimes strikingly evident to our senses. For example, we not unfrequently perceive that the blood drawn from a vein is thinner, manifestly more watery, less rich in red corpuscles and in colouring matter, than blood of the standard quality. 3. Again, independently of mere alterations in the relative proportions of its proximate constituent parts, the blood is liable to great change in its chemical com- position, and, therefore, in its physical quality. This appears to be the case in sea- scurvy, and in the analogous disease called purpura, and it is doubtless so in many other complaints. The composition of the blood cannot fail to be affected by a deficient supply of the elements of nutrition from without; by diseases of the digestive organs, interfering with the process of chylification; by diseases of the organs of respiration, interfering with its change from venous to arterial; by diseases of other channels of excretion — the bowels, the biliary apparatus, the kidneys, the skin—interfering (as I have already hinted) with its appointed purification; nay, by disease in any part, if Treviranus' theory be allowed; by foreign contaminating matters, finding entrance (as they may when in solution, or in a gaseous form) through artery, vein, or any membranous substance, such as bladder and intestine: lastly, the composition of the blood may be altered, there is good reason to believe, by certain states of the nervous system. But contenting myself with having indicated these latter changes, or sources of change, I shall defer giving a more particular account of any except those that relate to the quantity and the distribution of the blood. I say the blood may undergo important alterations in its quantity. It may exist in too great abundance throughout the body; and it may exist in too great abundance in certain parts only of the body. These states have been recognised for ages. Sometimes they are called, respectively, general and partial plethora; sometimes general and local congestions of blood; people speak also of irregular determinations of blood to different organs; and, of late, the term hypersemia, first invented by M. Andral in France, has been imported into this country, and much adopted here. All these words and phrases mean, in truth, the same thing; and their frequent recur- rence in medical works, is, of itself, sufficient evidence of the frequency and import- ance of the conditions which they express. If we comprehend rightly this subject of plethora or congestion, we shall be pre- pared to understand some most important morbid states, of which it seems to be in many, if not in all cases, the earliest approach — the initial step. Inflammation, haemorrhage, dropsy, all acknowledge and imply a previous condition of congestion. " There is, probably," says Dr. Alison, " no kind of diseased action of which any part of the living body is susceptible, which is not connected, sooner or later, with in- creased afflux of blood towards that part, either as its cause or its effect; and the immediate object of all our most powerful remedies is to act on these irregularities of the circulation." That the blood may be differently distributed in the capillaries at different times, we know by the variable colour of the surface, which depends upon the varying de- grees of fulness of the cutaneous blood-vessels. The phenomenon of blushing, the red cheek of anger, the heightened colour of the skin under brisk exercise, are fami- liar facts illustrative of partial plethora of the capillaries, consistent with health. There are reasons (which I shall hereafter lay before you) for believing that a similar sudden accumulation of blood, taking place in internal parts, may sensibly disturb their functions; causing transient fits of giddiness, insensibility, and some- times death itself, when the congestion affects the cerebral blood-vessels; and attacks of difficult breathing when the capillaries of the pulmonary tissue are concerned; and even these attacks, for aught that I know, may end fatally. It often happens that when certain portions of the surface, as the cheeks, are visibly redder and fuller of blood than usual, or when such symptoms as I have just men- tioned denote the probability of some internal congestion, other parts of the surface, as in the extremities, are visibly paler: and there are, at the same time, corresponding and palpable differences of temperature. Perhaps it may not be so obvious that the whole quantity of blood, throughout the body, is sometimes in excess. 60 A N.EM I A. [lect. iv. That in the adult state, when the growth and development of the body have been completed, blood may be made in greater abundance, and more rich in the materials of nutrition than the wants of the body require, is not only conceivable, but true, w e are able to assign circumstances in which this is likely to happen, and we find tnat under such circumstances it actually does happen. Full living, and a sedentary lite are causes likely to occasion general plethora —and they do occasion it. 1 lie lull diet, so long as the digestive powers are perfect, provides more chyle, conducts into the blood a larger quantity of its proper pabulum. The sedentary life precludes that freer circulation of the blood, and that more liberal expenditure of it through the skin, and by means of the other organs of secretion, which would occur under more active habits. Persons thus circumstanced are apt to grow fat; the adipous tissue seeming, in these cases, to form a kind of safety valve for the diversion of the super- fluous blood. Such persons have turgid and florid cheeks, red lips, red mucous mem- branes, and (not uncommonly) ferrety eyes. Their entire vascular system is preter- naturally distended. If you open a vein, you find that they bear a copious abstrac- tion of blood without fainting, and are even refreshed by it; and the blood drawn separates into a large and firm mass of coagulum, with but little serum.^ Keeping to the nomenclature we have already employed, we might say that there is here hyper- trophy of the blood. When inflammation arises in the subjects of this general plethora, it runs high, and requires active treatment. But they are not, as you might naturally expect them to be, and as many writers state them to be, peculiarly prone to suffer inflammatory complaints. There is general fulness of the vascular system, but no irregularity, nor any necessary tendency to irregularity, in the distribution of the blood. You will observe that the relative proportion of the more solid to the more fluid constituents of the blood is increased in these cases of general plethora: the blood is not only more abundant, but it is richer also in fibrin, and in red particles. The means to be adopted for redressing this unnatural and unsafe condition of the circulation, are those which common sense would suggest. The removal of a portion of the superfluous blood, a more restricted diet, a larger allowance of active exercise. It will be worth our while to contrast this state of general plethora with its opposite — that in which the blood is scanty and poor—what Andral calls (though with questionable propriety) ansemia. Oligsemia is the cacophonous but more exact name assigned to it by Gendrin; but poverty of the blood is the ordinary English phrase for it, and the best of the three. This is a state which we can produce at will, by abstracting blood from the body in moderate quantity, but repeatedly, and at short intervals. It occurs also, frequently, in spontaneous disease, and from various causes; from a privation of the materials destined to replenish the blood; and in cases in which these materials appear to be turned to little account, as in chlorotic girls. We see it in those who habitually and often lose a certain quantity of blood, in disease * in per- sons, for example, who are subject to piles, and who bleed daily from the 'rectum • still oftener in women who suffer repeated haemorrhages from the uterus. When the drain has been long-continued, these persons become very pale; even those parts which are naturally most red, as the lips and tongue, become almost white * their faces look like wax; and if still you draw blood from a vein, and allow it to coagulate you will have a small clot floating in an abundance of serum, and that small clot will be of a light rosy colour; showing a great diminution in the proportion of fibrin • and a still greater deficiency of the red particles. The blood, as they say, is " turned into water." It is a curious pathological fact, that the red particles require more time for their restoration than the other constituents of the blood. And I may mention to vo now, what I shall have to repeat, that —in conjunction with the obvious curative measures comprised in arresting the habitual loss of the vital fluid, and in affording sufficient nutriment to the system —the preparations of iron, and the respiration of pure air, have signal efficacy, in renewing the red particles, and giving back their native hue of redness to the cheek and lips. b again ips. In connexion with this subject, I would direct your attention to some interesting stetements of Dr. Owen Rees' in his Gulstonian Lectures, delivered before the Coiwf of Physicians in 1845, and subsequently published in the Medical Gazette ge According to Dr. Rees, the true condition of the blood, as it exists in the livin LECT. IV.] LEUCOCYTHJEMIA. 61 blood-vessels, is that of a liquid (the liquor sanguinis) in which the fibrin of the blood is dissolved, and in which coloured corpuscles float. He shows, by satisfactory experiments, that these corpuscles are not soft solids, but closed bags or cells, containing a fluid : — that the contained fluid is of a red colour, while the investing membrane is white, or colourless. Through this investing membrane, in obedience to the law of endosmosis, the fluids without and within the corpuscle reciprocally pass. Placed in a liquid of greater specific gravity than the average specific gravity of the liquor sanguinis, the corpuscles shrivel, and the liquid is much reddened. On the other hand, if the surrounding liquid have a specific gravity less than that of the liquor sanguinis, it is but slightly reddened, and the corpuscles plump up. In pure water they burst. The iron of the blood resides in the colouring matter dissolved in the liquid which is enclosed in the colourless envelope. The blood is fed by the chyle. The chyle, like the blood, separates, when removed from the body, into two parts — serum and crassamentum. The serum of the blood contains no iron; the serum of the chyle contains iron in abundance. The crassamentum of the blood contains iron; that of the chyle only such a trace of it as may be accounted for by the adhering serum. Again — the specific gravity of the chyle is far below that of the liquor sanguinis. Hence, on the mingling of these fluids, an endosmotic transmission of iron in solution will take place into the corpuscles. It follows, that if the specific gravity of the liquor sanguinis be any-how lowered, or that of the chyle much increased, the supply of iron to the corpuscles will be so far impaired. These considerations may hereafter be found applicable to the elucidation both of the nature, and of the treatment of certain forms of disease. [Dr. Hughes Bennett has recently directed attention to a diseased condition of the blood, in which there is a morbid increase of corpuscles, resembling the white or colourless ones naturally present. This condition has been denominated leucocythamia, or white cell blood. It is not of very common occurrence, but more so, perhaps, than is generally supposed. When a drop of blood, drawn during life from an individual affected with leucocythaemia, is examined microscopically, the red corpuscles appear but little changed from their natural condition, and often arranged in rouleaux, leaving intermediate spaces more or less crowded with white corpuscles. The latter bearing a proportion to the former, varying in different cases from one-third to one-half: but upon this point, in consequence of the limited number of observations that have yet been made, it is impossible to speak with precision. Many of the white corpuscles are considerably larger than the natural size. They have more coarsely granulated contents than the normal ones, with a single, double, or tripartite internal nucleus. The envelop and nucleus are distinctly brought into view by the action of acetic acid, which renders the granular contents transparent. Occasionally, a crescentric nucleus is to be seen in the cells, and some free nuclei are observed, also, between them. In fatal cases of leucocythaemia, the blood is often p - found imperfectly coagulated — sometimes grumous, '' and of a dirty brown colour. Where decolourized, the @ p*^ (©) coagula have not the aspect of healthy fibrin, but are J^1®® ®> ,%t /">, of a more opaque dull yellow, and, when broken up, ^ Jjf €| @ %®* a&® \J!) resemble thick creamy pus. Their peculiar aspect is J&3^ w @>^|l @ (&) due, probably, to the very numerous white corpuscles ^/t^ J^T^S^ r- they contain. In the case in which the blood was © %, •*$ ^ (& analyzed, the fibrin exceeded the normal amount. The ** increase is probably more apparent than real, in con- Blood in Leucocythaemia —four sequence of numerous white corpuscles being included f *?* w1?^ COIJ™cl*s h*ve b^D • ii. cu • rm. j i • • i 1 v • treated with acetic acid. From Dr. in the fibrin. Ihe red corpuscles are invariably dimi- H Benilett>g 0 k nished — the solids of the serum but little altered. It is chiefly in the spleen, liver, and lymphatic glands, that morbid changes are observed. The spleen is often very greatly enlarged, apparently by a true hypertrophy of its nuclear structure. It has, however, been found healthy. The liver is far less fre- quently enlarged; but its texture is more or less altered. In the majority of the 62 ACTIVE CONGESTION. [lect iv. cases reported, the lymphatic glands seem to have been enlarged or cancerously diseased. f The morbid condition of the blood under consideration has been much more fre- quently observed in males than in females; more often in adults, and in those ot advanced age, than in youth. „ The respiration is often interfered with in consequence of the abdominal distension; diarrhoea is a frequent symptom; vomiting is less often present; haemorrhage, from various parts, was observed in the majority of cases; in one instance, it was attended with purpura hsernorrhagica; dropsy was present in about one half the cases, general attendant upon abdominal tumours; some slight febrile disturbance is not unfrequent, but of short continuance; anaemia is commonly well marked, and, in the fatal cases, emaciation is described as extreme. There seems no reason to suppose that the affec- tion is in any way directly connected with ague or the malarious poison.—C] In general plethora every part is preternaturally full of blood, and the blood itself is full of the elements of nutrition. General plethora therefore implies, in one sense, local plethora of every organ and tissue. In strictness, however, local plethora is only predicable of a part that contains more than its share of red blood. Now the converse of this is not true, as it might be expected to be, of the opposite condition. A deficiency in the whole mass of red blood contained in, and circulating through, the body, does not protect the parts of the body from congestion — from having an undue quantity of blood sent to them. Far from it. Local determinations of blood are very common in persons in whom the mass of that fluid, and the propor- tion of its nutritive materials, have been considerably diminished by disease, or by haemorrhage. This remarkable tendency, under such circumstances, to an unequal distribution of the blood in the capillaries, admits (I think) of the following explanation. A due supply of healthy blood is requisite for the steady and equable performance of the functions of the brain and nerves. When this supply is defective, or uncertain, those functions become disordered and irregular, and, in their turn, influence the various solids, disturb their action, and derange the balance of the circulation. That capillary blood-vessels may be filled to excess, or completely emptied, by causes operating through the nervous system — by moral emotions, for example — we are sure from the phenomena just now adverted to, the blush of shame or anger, the paleness of fear; and there can be no doubt that morbid congestions, which sometimes are separated from those that are consistent with health by very slight shades of difference, are often determined through the agency of the same nervous system. And persons endowed with great sensibility or irritability of the nervous system are very liable to partial and irregular congestions of blood. But this is not the only way in which local congestion may arise. We can produce it, upon the surface of the body at least, at pleasure, and that in various ways; by friction, by exposing the part to a high temperature, by certain stimulating applications, mechanical (as a cupping glass), or chemical (as a mustard poultice) : we produce an injection of the small cutaneous blood-vessels • there is evidently, more than the usual quantity of blood attracted to the part, or detained in the part —a degree of redness, which soon subsides if the cause of it be withdrawn in time. Congestion thus occasioned is not inflammation, but it is the first obvious step to- wards that complex process; and for this reason it deserves all your attention Apply the exciting cause a little longer, or increase, in a slight degree, its intensity'and the phenomena of inflammation begin to manifest themselves. " I said we can excite local congestion, when we please, upon the surface of the bodv * but there can be no doubt that a similar state may be produced by analogous causes' in internal parts. Look at this representation of the stomach of a do- (one of Dr Roupell s plates). You see one portion of it of a bright red colour^ actively and vividly congested. This was the consequence of a dose of alcohol We mLT certain that something of the same kind is the result, in the human stomach, of everv visit to the gin shop. > cvery Local congestion thus produced, or of this kind, is said to be active M And™l whose nomenclature has come much into fashion of late years, calls it sthenic, 0r LECT. IV.] ACTIVE CONGESTION. 63 active hyperaemia. The arteries, perhaps, have more to do with it, in the first in- stance, than the veins. But it is in the capillary vessels, which are distinct from, and interposed between the minute arteries and veins, that further changes are wrought, when the process advances a stage beyond mere local plethora. What has been observed, by the aid of the microscope, with respect to the blood-vessels, I will endea- vour to describe to you. I take the account I am about to give you chiefly from Kaltenbrunner, a German pathologist, who has recently investigated the subject experimentally, and whose observations are believed to have been most carefully and skilfully conducted, and their results no less faithfully narrated. His observations were made upon the circu- lation as it appeared in the web of a frog's foot, under a powerful microscope. It would be idle, and something like committing a fraud upon you, were I to lay any stress upon my own knowledge or experience in this matter, for I cannot pretend to any great skill in the use of that instrument, and my opportunities of noticing, by its help, the phenomena of the circulation, have been too few to render their results of much value. Yet it may be in some degree satisfactory to you to know that I am not blindly repeating the remarks of others, and that what I have witnessed is per- fectly in accordance with the statements of Kaltenbrunner, and affords me a strong assurance of his accuracy and fidelity. There is another reason, too, why I consider him the more trustworthy—he has no theories to which he might be disposed to bend or accommodate his facts. Before I detail to you his account of the phenomena of congestion, I may briefly describe the scene which presents itself when the web of a frog's foot is looked at through a good microscope. It is a most beautiful and wonderful spectacle, and particularly interesting to those who, like ourselves, are desirous of gaining some insight into the healthy and diseased states of the circulation. It is a sight which I hope and believe you also will have many opportunities of seeing in this place. You perceive, then, occupying the circular field of the instniment, a number of blood- vessels, through which the blood, with its corpuscles or globules, is in active motion : and you see at once that there are three different kinds of vessels before you. First, you notice the blood shooting swiftly along tubes which divide and subdivide into smaller and smaller branches, each branch (speaking generally) going off at an obtuse angle : these are plainly arteries. Then, in another part of the field of view, you see the blood moving in the contrary direction, more slowly, in larger trunks, which are formed by the continual union and accession of smaller and tributary vessels of the same kind, that meet, for the most part, at acute angles; these you know to be veins: and all the intermediate and surrounding surface in view is occupied with other vessels or channels, which connect themselves with the ultimate ramifications of the arteries on the one hand, and with the primary radicles of the veins on the other, but which differ from both arteries and veins in these particulars — that they interlace and anastomose in all parts, in a very irregular manner, and at all angles, and that they retain everywhere the same uniform size. They neither collect into larger and larger trunks, nor separate into smaller and smaller branches, but are disposed like the threads forming the meshes of a net, except that the interstices are irregular in size and shape. These are the true capillaries, intermediate between the arteries and the veins, and perfectly distinct in character from each, but communicating and contiguous with both. If now you press upon the animal's leg, so as to obstruct the circulation a little, the motion of the blood is retarded, especially in the capillaries. You see the red globules following one another slowly. These so-called globules are not really, in their standard degree of distension, little spheres; but circular discs, or flat cells. Sometimes one of them sticks to the side of a capillary channel, and dams up the current; other globules accumulate behind it, till at last they all pass on again together. Now Kaltenbrunner irritates the web by pricking it, and soon afterwards the following appearances present themselves : — There is an increased afflux of blood to the part, so that arteries, veins, and capillaries, receive a column of blood two or three times as great as usual; the velocity of the blood is accelerated; the sides of the distended vessels seem to tighten round the stream of blood which they contain. With this alteration of the circulation, the natural functions of the part begin to be modified. The change of the blood from arterial to venous is interrupted. The 64 MECHANICAL CONGESTION. [lect. iv. globules, passing with great rapidity through all the vessels, retain the characters of arterial globules even when they arrive at the veins; they present a bngnt com , show a tendency to stick together, and often form little clots, which pass tnrou0n the capillaries and become visible in the veins. _ . , One of the natural functions of the web is the secretion of a kind ot lympiii, out this secretion is now suspended. The parenchyma itself begins to be slightly tumid, and assumes a brighter tint than common. # . All these phenomena begin from a circumscribed spot, of which the circumference gradually expands as the affection increases; and they cease insensibly at that circumference. This is active congestion. . . A certain period always intervenes between the first action of the irritant cause, and the commencement of true congestion. This period, the occurrence of which you will be good enough to bear in mind, Kaltenbrunner calls the period of incubation ; the period in which the congestion is hatching. It seems probable, from observations since made by Mr. Paget, that the state of the blood-vessels during this period is a state of contraction or closure. Active congestion, as such, does not continue long. It either passes on into inflammation, as I shall hereafter explain, or it begins to decrease. When it has been very slight, the quantity of blood, and the rapidity of its movement, diminish gradually from the circumference towards the centre; and in this way the congestion insensibly vanishes. But, in other cases, when it has not been so slight, the congestion terminates by an evident crisis, which Kaltenbrunner thus describes : — The blood, receding from the circumference of the congested part towards the centre, gives out, by exhalation, a liquid. The exhalation takes place by fits, and here and there, through the sides of the capillary tubes, and generally on the surface of the organ. The moment of ex- halation is very transient; but it is repeated often, and in different spots, until the congestion has disappeared. It is evidently critical, for the congestion is relieved and extinguished in proportion as the exhalation is repeated. I shall follow these consequences of active and continued local congestion no further at present; but merely remind you again that the changes I have last mentioned constitute the earliest appreciable modification of structure leading or belonging to inflammation. What we thus may see (and it is what I myself have had some oppor- tunities of seeing) in the transparent textures of animals, we reasonably infer to take place, under analogous circumstances, in those parts of the body which are internal and opaque, and consequently hidden from our view. I will just observe, also, that as active congestion is the parent of inflammation, so it sometimes causes haemorrhage, and is relieved by it. But comparing this form of congestion with another which I am about to mention, the connexion of haemorrhage with it is, relatively, unfrequent. One obvious mode of remedying this congestion is the mechanical abstraction of blood from the loaded part. But it is seldom that this measure alone suffices; and sometimes it would be ultimately hurtful to adopt it. The state of the constitution may be such, that the disposition to local plethora would be increased by the loss of blood. Undue susceptibility and disordered action of the nervous system are liable to be aggravated by bleeding; and in proportion as the nervous functions are irregu- larly performed, does the tendency to unequal distribution of blood in the capillary vessels augment. We have daily examples of this in hysterical youno- women It is not, therefore, the mere congestion that we have to consider; we must look deeper for its cause. Leave in the finger a small thorn : the blood will be collected there in consequence of its irritation, and will continue to collect in spite of depletion But extract the thorn, and your remedial measure of taking away blood is at o cesstul. bo it is also with internal congestions of blood—of which the p™*;™ and sustaining cause is not always so well known. Contrasted, in some important particulars, with active congestion such as I have been describing is that morbid fulness of the capillary vessels which arises when the return of the blood from them towards the heart through the veins, is impeded bv some mechanical obstacle. With this mechanical congestion the veins are exclusively LECT. IV.] PASSIVE CONGESTION. 65 Congestion of this kind may be strictly local. It may be confined to a single limb, when the principal venous trunk belonging to that limb is compressed, or otherwise diminished in size; and when no collateral and compensatory channels for the return- ing blood have been established. If there be disease of the liver, of such a nature as to prevent a free passage of the blood through that organ, congestion will ensue in all those parts of the capillary system from which the blood is conveyed by the veins that ultimately concur to form the vena portae. The force of gravity alone is sufficient to produce venous congestion, and consequently congestion of the capillaries, in parts of the body in which, under ordinary circumstances, the circulation through the veins is aided, instead of being opposed, by that force. If, for instance, the head be suffered to bang downwards for a certain time, we see the unequivocal signs of such congestion in the tumid condition and the purplish red colour of the lips, cheeks, eyelids, and ears. When an impediment to the free transmission of blood exists in the heart itself, a tendency to stagnation is produced, first in the venae cavae, then in the smaller ramifications by which these veins are fed, and at length in the general system of capillary vessels: and thus even general congestion may proceed from a fixed mechanical cause; the parts that are the most vascular being also the most readily and the most completely gorged. There is yet a third form of local congestion, differing, in some respects, both from active and from mechanical congestion. The capillaries become loaded, and the course of the blood in them is languid and sluggish, without any previous increased velocity of the blood in the arteries, and independently of any mechanical obstacle in the veins. To this form of congestion the term passive is applied. Andral denomi- nates it passive or asthenic hyperaemia. I will tell you the class of facts from the observation of which the real existence of this passive plethora has been ascertained. In persons enfeebled by age, or by disease, the lower parts of the legs, the insteps and ankles, and the skin which forms the surface of old scars, are often habitually purplish, or violet-coloured. There is congestion of dark blood in those parts. You may, perhaps, be ready to ascribe this to the mere influence of gravity upon the blood, but this cannot be the whole explanation, because the force of gravity is the same with all persons, and at all ages. A horizontal position of the limb will perhaps diminish the livid redness, or may even sometimes entirely remove it. But the depending position ought not to cause it, and would not cause it, if the blood-vessel. were in a healthy condition. Neither can the difference of posture be any source of irritation to the congested part. The capillaries themselves appear to have lost, in a great degree, their natural elasticity; they easily dilate under the pressure of the blood, which, being thus retarded, accumulates in the part. The employment of friction, or some stimulating application, will often remove this congestion. I say all this is often to be noticed when there has been no cause of irritation operating upon the part, and no preceding state of active congestion. But it is im- portant to mark the very frequent connexion that exists between these contrasted conditions. The one very often succeeds the other: the vessels become dilated under the force of the active hyperaemia, and, the irritation ceasing, they do not at once recover their tone, but remain passively loaded and distended. They are frequently left in the same state upon the subsidence of inflammation. Take another illustration from what you may any day witness in respect to indolent ulcers. You will find that the large, flabby, and livid granulations which they pre- sent, may be made to contract and to assume a more healthy and florid hue, by local stimulants : these evidently act by quickening the previously languid circulation, and unloading the congested capillaries. Observe, again, what not unfrequently happens in regard to the eye; a little organ indeed, but one that supplies us with more striking lessons in pathology and thera- peutics than any other portion of the body. You know that the conjunctiva and scleroticar through which, while healthy, colourless fluids alone circulate, are tra- versed, under various forms of disease, by innumerable vessels bearing red blood. Now, it is notorious that, in certain cases, the application of any stimulating sub- stance to the surface of the organ will increase the existing redness, multiply the number of visible vessels, and aggravate the complaint. These are cases of active congestion, dependent upon irritation that is still subsisting. But it is equally well known to practical men that the blood-vessels of the eye are liable to congestion of a 66 PASSIVE CONGESTION. [lect. IV. very different kind. They are seen to be distended, somewhat tortuous, almost v - cose, and the redness has a browner tinge, and is less vivid, than init tie x°r . In this kind of vascular fulness,-or in this stage of it, for it sometimes succeeds to active congestion, —emollient applications do harm rather than good, wnl'* Sl™^ astringent and even irritant substances will often promptly dissipate the Jascula"^* These° again, are cases illustrative of congestion of the asthenic or passive character The strong topical irritants restore to the feeble and relaxed vessels thennatua elasticity, stimulate them to contract upon their contents, and to force onwards the red blood, which they cease to admit from the arteries; and the redness vanishes. In the production of active congestion the arteries appear to be principally con- cerned: in the production of mechanical congestion, the veins. _ In passive conges- tion the capillaries —which, strictly, are neither arteries nor veins, but he between the arteries and the veins—are the vessels chiefly in fault. If we turn our thoughts from the visible textures of the body to those which are hidden internally, we shall find reason to believe that these also are equal y liable to similar conditions of passive congestion. Take those exceedingly vascular organs, the lungs,' through which the whole of the blood circulating in the living body has to pass. The lungs, as might be expected, are very liable to congestion and engorge- ment of their capillary vessels. Ofttimes this is clearly active, and the result of some irritating cause. But it is not always so. Many of you recollect the epidemic disorder called the influenza, which was so prevalent here in the spring of 1831, and again in the early part of 1837. Among the most constant and striking characters of the disease were the symptoms of pulmonary catarrh; and it was remarkable how long, in some persons, these symptoms persisted. After the pulse had regained its natural frequency of beat, and when all fever had ceased, the patient would continue to breathe with constraint and some labour, to wheeze a little, to cough, and to ex- pectorate mucus. As all febrile disturbance had subsided, and no further benefit seemed to flow from adhering to what is called the antiphlogistic system, it was a reasonable conjecture that this disappointing obstinacy of some of the symptoms might depend upon a lingering but passive congestion of the pulmonary mucous membrane. And the nature of the juvantia showed the correctness of this conjecture. Tonics and stimulants, so far from aggravating the pectoral symptoms, speedily removed or abated them. You cannot fail, I think, to perceive the important bearing of these distinctions between active and passive congestion upon our notions of disease and our choice of remedies. These distinctions are not to be discovered by the knife of the anatomist. You must take care not to confound a knowledge of pathology, in the proper sense of that word, with a knowledge of morbid anatomy. Pathology comprehends not only the visible changes of structure which accompany disease, and are disclosed by death, but the processes by which those changes are effected in the living body, and the laws which govern those processes. There is one important law ascertained in respect to both active and passive con- gestion; viz., that it is apt to recur; that those parts are most likely to suffer it (or inflammation, which implies it) that have suffered it before. We may often turn our knowledge of this general fact to good account, in what is termed the prophylaxis of disease — in devising means for warding off disorders. I have stated that active and passive congestion sometimes occur in succession, the latter being a sequel of the former. So, also, it may be said of passive and of mecha- nical congestion, that they often exist together. If the capillaries of a part or organ be much enfeebled, the mechanical effect of the gravity of the blood may suffice to bring them into a state of congestion. It is thus that Andral explains the occurrence of a gorged condition of the posterior portions of the lungs (evinced by symptoms during life, as well as by inspection of those parts after death), in persons who havin°* laboured under no previous pulmonary affection, have been confined to a supine pos£ tion by long-continued disease or debility. This state of the capillaries is called by Lerminier the " engorgement of position;" and by Laennec, " the pneumonia of the dying-"^ It neither proceeds from irritation, nor has it the essential characters of in- flammation; although it is apt to be considered an evidence of inflammation by the mere morbid anatomist. Again, as active congestion, when continued or intense, is antecedent and condu- LECT. V.] CONDITIONS OF LIFE. 67 cive to inflammation; so is mechanical congestion, when it reaches a certain point, the prolific source of haemorrhage, and the almost constant precursor and immediate cause of a large class of dropsical accumulations. I spoke a little while ago of general plethora, as a state in which the whole mass of blood circulating in the body is excessive in quantity, and rich in quality — full of colouring matter, thick with globules. But the blood, as a mass, may be in exces- sive quantity, yet poor in its materials, serous, deficient in globules, and fibrin, and colour; and in this condition of the blood also, as we shall hereafter see, dropsies are apt to arise. We have now, therefore, laid the foundation for the better understanding of those three great classes of disease — Inflammations, Hemorrhages, and Dropsies. There is no region or organ of the body exempt from these diseased conditions and their consequences; and of each of them some general account must be given, before we come to consider the special diseases incident to the several parts and organs. But previously to entering upon this general account of inflammation, of haemor- rhage, and of dropsy, we have still some other preliminary matters of importance to discuss. The causes and modes of death. The causes of disease. A sketch of the nature, classification, and import of symptoms. Our inquiries hitherto have related to the manner in which the physical conditions of the various parts of the body are capable of being altered in disease, and their functions disturbed or suspended. But how it happens that some of these alterations of structure, or interruptions of function, are incompatible with the further continu- ance of life, and put a stop to the working of the whole machine, is an inquiry of no less interest, though of a somewhat different kind. LECTURE V. Different modes of Dying. Pathology of Sudden Death. Death by Anamia, its Course, Phenomena, and Anatomical Characters. Death by Asthenia, its Course, Phenomena, and Anatomical Characters. Syncope. Death by Inanition. Death by Apnaia: Death by Coma: their Course, and Phenomena, and the Anatomical Characters common to both. Application of the Principles obtained from the investigation of the Phenomena of Sudden Death, in elucidating the Symptoms and Tendencies of Disease. I propose to devote the present lecture to the following inquiry : — wherefore it is, and how it is, that some of the corporal changes which we have been considering, or the diseased conditions connected with those changes, come to be incompatible with the further continuance of life ? how is it that they put an end to the working of the living animal machine? why the machine should not continue to work, though perhaps imperfectly, notwithstanding such changes ? When our watches stop, we take them to a watchmaker to ascertain why they have stopped. The watchmaker knows that there are various ways in which the movements of the instrument may have been arrested. The main spring may have broken; or the little chain that connects the barrel with the fusee may have parted; or the teeth of some of the wheels may have become inextricably entangled; or the watch may have ceased to go (as the saying is) simply because it has not been wound up. Now the examination which the watchmaker undertakes in respect to the watch, I am desirous of making in respect to the human body. I am going to inquire into the several processes and modes of dying—the steps, or ways, by which the vital functions of the body are extinguished. A very little experience in the sick chamber, or in the wards of a hospital, will suffice to teach you that, although all men must die, all do not die in the same manner. In one instance the thread of existence is suddenly 68 CONDITIONS OF LIFE. [lect. v. snapped; the passage from life, and apparent health perhaps, to the condition of a corpse, is made in a moment: in another the process of dissolution is slow and tedious, and we scarcely know the precise instant in which the solemn change is completed. One man retains possession of his intellect up to his latest breath: another lies unconscious, and insensible to all outward impressions, for hours or days before the struggle is over. . We seek to ascertain the mechanism and the laws of these mysterious differences. The inquiry is not one of merely curious interest, but has a direct bearing upon the proper treatment of disease. It will teach us what we have to guard against, what we must strive to avert, in different cases. In speaking of particular diseases, I shall constantly refer to the facts and reasonings which I am now about to lay before you. In pursuing this inquiry, we need not go into any deep physiological disquisition respecting the conditions that are essential to life. It is sufficient for our purpose to remark that life is inseparably connected with the continued circulation of the blood So long as the circulation goes on, life, organic life at least, remains. When the blood no longer circulates, life is presently extinct: and our investigation of the different modes of dying resolves itself into an investigation of the different ways in which the circulation of the blood may be brought permanently to a stand. Observe the ample provision that is made, in the construction of the body, for carrying on and maintaining this essential function. First, there is an extensive hydraulic apparatus distributed throughout the frame, — consisting^ of the heart and other blood-vessels. Next, there is a large pneumatic machine, forming a considerable part of the whole body, — composed of the lungs, and the case in which they are lodged. Lastly, the power by which this machine is to be worked and regulated is vested in the nervous system. Each of these systems must continue in action, or the circulation will stop, and life will cease. The functions they respectively perform are, consequently, called vital functions: and their main organs — the heart, the lungs, the brain (by which I understand the intercranial nervous mass) — are denominated vital organs. The functions of any one of the three being arrested, the functions of the other two are also speedily extinguished. But the phenomena of dying vary remarkably according as the interruption begins in the one or in the other organ. Hence Bichat, who in his Recherches sur la Vie et la Mort, laid the foundation of the distinctions I am about to describe, spoke of death beginning at the head, death beginning at the heart, and death beginning at the lungs. This nomenclature is, however, unsatisfactory and insufficient, as you will presently perceive. That the heart may continue to propel the current of the blood, two things are necessary: first, a certain power or faculty of contracting; and, secondly, a sufficient quantity of blood in its chambers, to be moved, and also to stimulate them to contract. If this, the proper stimulus to the internal surfaces of the heart, be withheld, or much deficient, it will soon cease to beat. There are plainly, therefore, two ways in which death might be said to begin at the heart; and these require to be distinguished. The respiration is entirely subservient to the circulation of the blood. The two organs, the heart and the lungs, respond intimately to each other. The whole of the blood is sent by the right heart to the lungs, simply that it may there be submitted to the chemical action of the atmosphere. The respiratory apparatus is added to the body for the sole purpose of thus repeatedly ventilating the blood. To this purpose also (setting aside all accidental impediments) two things are requisite : first, circumfused air to enter and depart at short intervals; and, secondly, alternating movements of the chest, to cause its entrance and exit. Now these movements, although they admit of being regulated by the will, are essentially involuntary. The ordinary acts of respiration depend upon a certain condi- tion of the medulla oblongata. If this condition fail, the mechanical part of the respiratory process, and, consequently, the chemical part also, is arrested. The respiration hangs, therefore, directly upon the nervous system. On the other hand, the action of the heart is not directly or necessarily dependent upon any constant nervous influence proceeding from the brain or spinal cord. The circulation goes on in an acephalous foetus; it may be kept up, by maintaining arti- ficial respiration, in a decapitated animal: nay, even when both brain and spinal cord have been abstracted from the body. But though the cerebro-spinal nervous influence is not necessary to the movements leci. v.] PATHOLOGY OF SUDDEN DEATH. 69 of the heart — further than as it is necessary to the respiration, and to the introduc- tion of nutriment — it has been clearly ascertained that very sudden and extensive injury or shock to the great nervous centres may instantly paralyse the heart, and so stop its action. Of the intercranial mass, then, it may be affirmed that there are certain states, which, without directly affecting the heart, bring the motions of respiration to a pause: and that there are certain other states which act directly on the heart and arrest its play. That is, there are two different ways in which death might be said to begin at the head. Hence, I say, the nomenclature employed by Bichat is defective and inaccurate. In order to see clearly the steps by which the circulation, and with it life, finally terminates, in the various forms of dying, we must study the problem under its sim- plest forms. We must examine the cases in which the vital functions are, each in their turn, suddenly stopped, by some known cause, operating upon this or that vital organ. We must take advantage of the experiment (if I may so call it) which is performed before our eyes whenever a healthy man is cut off at once by external violence, or by poison, acting directly upon a particular organ or system of organs. The inquiry might be assisted, and, indeed, it has been mainly carried on, by experi- ments made upon living animals of a similar conformation with man. But the pathology of sudden death is happily now too well understood to require any further recurrence to that painful mode of " interrogating nature." Death, when it results from disease, is usually complicated. Many parts are affected, and different functions languish, and various disturbing causes are in opera- tion, at the same time. Occasionally, however, the process of dissolution is as simple and obvious as in death produced by violence; and in most cases some primary and predominant derangement may be traced of this or that vital function; and a ten- dency is more or less clearly manifest to one or the other of the modes of dying, which we may now proceed to consider in succession. And first let us examine that form of death which is caused by a want of the due supply of blood to the heart. This is called, with much propriety, death by anaemia. The best examples of death taking place in this way are those in which it is the consequence of sudden and profuse haemorrhage. The circulation fails, not because the heart has lost its power of contraction, but because blood does not arrive in its chambers in sufficient quantity. We assure ourselves of this in two ways. In the first place, when the body of an animal is examined immediately after death from sudden and copious loss of blood, the heart is not found dilated and full of blood, as it would be if it had ceased to act from a want of power to contract upon its contents; but it is found empty, or nearly so, and contracted. Secondly, this conclusion is confirmed by the reverse experiment: by the effect, I mean, of the transfusion of blood. It is a fact well ascertained, first by experiments made upon animals, and afterwards by most happy trials upon the human subject, that in cases of apparent death from violent haemorrhage the suspended functions may be restored by conveying a timely supply of blood into the vessels of the seemingly dead animal from the veins of a living animal of the same species. Now it is quite clear that this introduction of fresh blood could be of no avail in a case where the heart was unable to act upon the blood which had already reached it. The phenomena which attend this mode of dying are paleness of the countenance and lips, cold sweats, dimness of vision, dilated pupils, vertigo, a slow, weak, irregular pulse, and speedy insensibility. With these symptoms are frequently conjoined nausea, and even vomiting, restlessness and tossing of the limbs, transient delirium; the breathing is irregular, sighing, and, at last, gasping; and convulsions generally occur, and are once or twice repeated, before the scene closes. It is thus that women often die, in whom "flooding" happens after childbirth. Sometime the sudden bursting of an aneurism occasions this form of death. It is common on the field of battle, and in accidental injuries whereby large blood-vessels are wounded. Internal haemorrhage, depending upon diseases - to be hereafter described, may also prove fatal in the same manner. This, then, is one form of death beginning at the heart. Another form, the con- verse of this, but spoken of also as death beginning at the heart, is that in which there 70 SYNCOPE. [lect. v. is no deficiency of the proper stimulus to the heart's action, but a total failure of con- tractile power in that organ. This is well denominated death by asthenia. Death occurring in this way is not uncommon. The effects of some kinds ot poison furnish a good illustration of it. There are certain substances which, applied to some part or other of the body, speedily extinguish life : and when, after their tatal opera- tion, the thorax is opened, each chamber of the heart is found to be filled with its proper kind of blood, upon which it has been unable to contract. , . ,.c . This was distinctly made out by Sir Benjamin Brodie, in his able and scientific in- vestigation of the effects of different poisons. You may read with advantage his papers on this subject in the Philosophical Transactions for 1811 and 1812. lie ascertained, upon examining the chest after death occasioned by the upas antiar, that the heart was not empty, but full, there being purple blood in its right and scarlet blood in its left cavities. These are the anatomical characters of this kind of death j and they prove that the action of the heart has not ceased from a defect of the neces- sary stimulus, but from a loss of its contractile power. ^ The state of suspended animation common to both these forms of dying —(the ulti- mate external phenomena being nearly the same in each, and the result in each being the simple failure of the circulation) — is often expressed by the term syncope. Besides the essential distinctions between them already mentioned, there is this fur- ther point of difference. In death by anaemia, the suspension of the functions of the nervous system arises from a lack of the blood which should be sent to the brain from the heart. Hence the well-known effect of mere position. Syncope is sooner pro- duced by venaesection when the person bled is sitting up than when he is recumbent: and the first remedy for the fainting state is to lay the patient flat upon the ground, or even to place his head a little lower than the trunk of his body. In the one posture the current of the blood towards the head is impeded by the force of gravity; in the other it is not. In sudden death by asthenia this order is reversed; the nervous sys- tem is the part first affected, and through it, consecutively, the heart. This appears from the fact that sudden death by asthenia is sometimes produced by causes which we know to act primarily upon and through the nervous system; by strong mental emotion — as intense grief, joy, terror. Instances of fatal concussion, where the brain is jarred by some bodily shock—and death occurring almost in a moment from blows on the epigastrium—are of this kind : though in the latter case the mortal influence is probably conveyed through the ganglia of the great sympathetic nerve. Lightning and electricity kill too, when they kill at all, in the same way. And we shall here- after see that certain varieties of apoplexy, and several other diseased conditions, destroy life by suddenly arresting the contractile power of the heart. When death by asthenia occurs more slowly, from disease, the phenomena are some- what different. The pulse becomes very feeble and frequent, and the muscular debility extreme; but the senses are perfect, the hearing is sometimes even painfully acute, and the intellect remains clear to the last. The tendency to death of this form is remarkably manifest in acute inflammation of the peritoneum, in what is called malignant cholera, and in cases of extensive mortification. Akin to this form of dying is that in which the living powers are slowly exhausted by lingering and wasting disorders, as in many cases of phthisis, in diabetes, and in dysentery; or by haemorrhages moderate in amount, but frequently repeated; or by any other long-continued drain upon the system. The death is partly, however, to be ascribed to a deficient supply of the natural stimulus to the heart's action. The type of these mixed modes of dying is seen in death by starvation, which may be con- sidered intermediate between death by anaemia and death by asthenia. Death from inanition can never be sudden. The blood, renewed no longer from without and fed only by absorption from the system itself, diminishes gradually in quantity, while its quality deteriorates. Gradually also the contractile power of the heart, as well as of the muscles generally, is weakened; and from these combined causes its movements at length cease. Accordingly, after death by starvation the heart is not found to be so much contracted, nor so nearly empty, as after death by sudden and copious haemorrhage. Certain diseases of the throat or of the oesophagus, prohibiting the introduction of food; of the stomach, preventing its retention; of the digestive organs generally hin- dering its assimilation, are fatal in this manner. lect. v.] DEATH BY APNCEA. 71 We have yet to consider how death is produced by the suspension of the respira- tory function — in other words, by a want of the due arterialization of the blood. There are two perfectly distinct modes in which this cause of death may proceed; distinct, I mean, in regard to the steps of the process, although identical in regard to the ultimate result. 1. When the access of air to the lungs is suddenly denied by some direct obstacle to its entrance; 2. When the muscular actions required for breathing cease in consequence of in- sensibility, caused by disease or injury of the brain. The first of these two forms of dying is commonly called death by asphyxia. The second is conveniently termed death by coma. Bichat spoke of them respectively as death beginning at the lungs, and at the head. It is of much importance to get rid, when we can, of improper names. They are very apt to warp our notions concerning the real nature of the things which they are intended to express. This term asphyxia, though in everybody's mouth, is very in- appropriate, if we look to its etymology, to the kind of death which it has come to denote. It signifies, literally, you know, pulselessness, the want of pulse; and there- fore it might express any kind of death whatever; or if applied to any particular mode of dying, it would seem to belong to that which we have just been considering, namely, death beginning at the heart. And you will presently see that it is peculiarly inapplicable to all those cases where death results from the nonarterialization of the venous blood. Its current signification has, I am afraid, been too long established by custom, to allow of its being restored to its proper meaning without much confusion. But, at any rate, I can and shall avoid its use, and adopt in preference the generic term apncea (privation of breath) as justly expressive of the mode of death to which the word asphyxia is commonly given by authors. The generic English term is suffocation. The entrance of air into the lungs may be prevented in various ways: by stoppage of the mouth and nostrils (smothering) : — by submersion of the same inlets in some liquid (drowning); or in gases which, though not in themselves poisonous, contain no oxygen; such are hydrogen and azote : — by mechanical obstruction of the larynx or trachea from within, as by a morsel of food (choking), or from without, as by the bow- string (strangulation ; both these varieties are included in the term throttling) : — by forcible pressure made at once upon the chest and abdomen, preventing all movement of the ribs and of the diaphragm; this happens sometimes to workmen employed in excavating, who are buried, their heads excepted, by the falling of a mass of earth; it was near happening, Dr. Roget tells us, to an athletic black man, of whose body, as an academic model, a cast was attempted to be taken, by one operation, and in one entire piece; " as soon as the plaster began to set, he felt on a sudden deprived of the power of respiration, and to add to his misfortune, was cut off from the means of expressing his distress; his situation was just perceived in time to save his life;" in this way the victims of Burke and Hare were stifled; and the same immovable state of the lung-case is sometimes produced in tetanus, or by the poisonous influence of strychnine, all the respiratory muscles being fixed in rigid spasm : — by paralysis of the same muscles, from injury or disease of the spinal cord above the origin of the nerves that give off the phrenic nerve, and therefore above the origin of the inter- costal nerves also; or from section of the phrenic and intercostal nerves : — lastly, by such breaches in the walls of the thorax as admit air freely to the surface of both lungs, and spoil the pneumatic machine, as a pair of bellows is spoiled when deprived of its valve. Of course the same consequences ensue when both pleurae become filled with liquid of any kind. Whenever the privation of air is sudden and complete, the following external phc nomena present themselves. — Strong but vain contractions occur of all the muscles concerned in breathing, and struggling efforts to respire are made, prompted by that uneasy sensation which every one has experienced who has tried how long he can hold his breath, and which, when unappeased, soon rises to agony. This extreme distress is transient, being almost immediately succeeded by sensations, not unpleas ant, of vertigo, and then by loss of consciousness, and convulsions: at length all effort ceases, a few irregular twitchings or tremors of the limbs alone perhaps remaining; the muscles relax, and the sphincters yield; but still the movements of the heart, 72 DEATH BY APNCEA. [lect. v. and even the pulse at the wrist, continue for a short time after all other signs of life are over; there is no asphyxia (properly so called) till the very last. During this process, which does not occupy more than two or three minutes, the face at first becomes flushed and turgid, then livid and purplish, the veins of the head and neck swell, and the eyeballs seem to protrude from their sockets; at length the heart ceases to palpitate, and life is extinct. The internal changes, which correspond with and cause these outward symptoms, have been carefully studied, and accurately, though slowly and lately ascertained. They all proceed from the prevention of the chemical alteration naturally produced in the blood, within the capillary vessels of the lungs. The blood, continuing venous, passes at first in considerable quantity through the pulmonary veins, into the left side of the heart, and thence through the arteries, to all parts of the body. This venous blood however, loaded with carbonic acid, is inadequate to sustain, or sufficiently to excite, the functions of the parts it thus reaches. In the brain the effect of the unnatural circulation is felt at once; and shown by the convulsions and insensibility that ensue. The motion of the blood in the pulmonary capillaries is also, from the first, impeded, and its current gradually retarded, until it stagnates altogether; the lungs remaining full, the right chambers of the heart distended, and therefore less capable of contracting, while venous congestion becomes general. The main cause of this impediment in the lungs appears to be the check given to the diffusion of carbonic acid out of the air cells. The blood, charged with this gas, cannot pass readily through the pulmonary capillaries. Meanwhile the dark and languid stream, flowing more and more tardily and scantily into the left chambers, leads by its unnatural quality, as well as by its deficient supply, to feeble contractions; and this side of the heart is comparatively empty. In this state, even after the heart has ceased to beat, but not long after, if the cause which has excluded the air be withdrawn, and fresh air readmitted — in other words, if artificial respiration be instituted—the blood in the pulmonary capillaries under- goes the required change, becomes arterial, begins again to pass onwards, and by degrees the circulation is restored, and the patient saved. In this mode of death, the circulation is first arrested, and death truly begins, in the lungs. When the carcass of an animal that has thus perished of apnoea is immediately afterwards examined, (so speedy an inspection of the human body being, for obvious reasons, seldom practicable or proper,) the left side of the heart is found to contain a small quantity of dark blood, while its right cavities are greatly distended, and the lungs, the cavae, and the whole venous system, are gorged with blood of the same character. These are, in few words, the anatomical characters of sudden death by apnoea. The pathology of this mode of dying has, I say, been thoroughly understood only of late._ It will not be uninteresting, and may, I think, be useful, to trace briefly the successive steps by which the true explanation has been attained. Haller was of opinion that the quiescence of the lungs, consequent upon the cessation of the alternate movements of the thorax, formed a mechanical impediment to the further transit of blood through them; and that death resulted from obstruction of the circulation in the lungs. He was partly right; but he erred in supposing that the stream of blood was arrested absolutely, and at once, and by a mechanical obstacle. Apnoea, with all its peculiar phenomena, occurs, when atmospheric air is excluded, although the luno-s continue to play; as in persons who breathe azote or hydrogen gas. H was clearly shown by Dr. Goodwin, in his Essay upon the Connexion of Life with Respiration that the unaerated blood passed through the lungs, and entered the left auricle and ventricle of the heart; but he thought that it went no further. His notion was that arterial blood is the only stimulus which can excite the contraction of the left cavities of the heart, and that when venous blood arrives in them, the oro-an becomes motion- less; and no blood being sent to the brain, the person dies. Had this theory been true, the left chambers would be found full of blood after death (which they are not") and the mode of dying would not have differed essentially from that which we have already considered as death by asthenia. The well-devised experiments of Bichat carried the investigation a step further, and proved that the unaerated blood not only reached the heart, but was propelled by the contractions of that organ to every part LECT. V.I DEATH BY APN(EA. 73 of the body, through the arteries. Having applied a ligature upon the trachea of a living animal, he made a small opening in one of its carotid arteries. Presently the slender stream of blood that issued began to lose its florid tint, and to assume the dark colour of venous blood; but it continued to flow, and the afflux of this dark blood upon the brain was marked by convulsions and insensibility. Bichat conceived, therefore, the erroneous belief that the blood underwent no obstruction in its passage through the lungs, but that, remaining unpurified and venous, it acted as a poison upon every part to which it was carried by the arteries — first upon the nervous system, and ultimately (passing through the coronary arteries) upon the muscular substance of the heart itself. There are, however, two well-known facts, which upon this theory would be inexplicable — the comparative emptiness of the left chambers of the heart, and the restoration of the suspended functions by the timely perform- ance of artificial respiration. The air could never reach and revivify or depurate the venous blood, stagnating in the capillaries of the heart. It was reserved for Dr. Kay1 to correct the unsound parts of Bichat's doctrine, and to show that the blood begins to stagnate in the capillaries of the lungs, in consequence of its failing to undergo the change from venous to arterial; and that the movements of the left heart are brought to an end, principally by the deficient supply of blood from the lungs. His experiments tend moreover to prove that venous blood circulating through the arteries has no directly poisonous operation, but is capable, though much less effectually than arterial blood, of supporting in some degree the irritability of the muscles. A muscle will continue to contract longer when supplied with venous blood by its arteries, than when supplied with no blood at all. Doubtless, in death by apnoea, the movements of the heart are weakened, partly in consequence of the imperfect stimulus afforded by the venous blood that penetrates its substance; but the primary and main cause of the failure of the circulation seems to be the difficulty with which the non- arterialized blood finds its way through the capillaries of the lungs. This theory is consistent with all the phenomena observed. For a detailed account of the experi- ments and reasonings upon which Dr. Kay's conclusions are founded, I must refer you to his work on Asphyxia. More recently Mr. Erichsen has published, in the Edinburgh Medical and Surgical Journal, some well-devised and convincing experi- ments, illustrative of the series of changes which I have been describing. Sudden death by apnoea is not very often witnessed as the result of disease. "It sometimes is caused by a spasmodic closure of the rima glottidis. It is no uncommon consequence of accidents, in which the upper cervical vertebrae are broken or dis- placed. I have seen several instances of death rapidly produced, with all the symp- toms of sudden suffocation, generally in intoxicated persons, in whom the chink of the glottis has been found closely plugged by a fragment of meat, which " had gone the wrong way." But there are numerous forms of more chronic disease, in which the tendency to death by apnoea is plainly discernible, sometimes for a long while before their fatal termination arrives. And the phenomena are similar in character to those which are noticed when the struggle is short. We hear the patients complain of the " want of breath." We see how they labour to satisfy this want, when it becomes urgent, by the elevated shoulders, the dilating nostrils, the energetic action of all the muscles that are auxiliary to the respiration. We perceive by the dusky and loaded countenance, the livid lips, and ears, and eyelids, that the blood is but imperfectly arterialized. The diminished capability of such blood to support the functions of the brain is made evident by the vertiginous sensations and the delirious thoughts of the gasping sufferers; and after death we find the same distension of the right chambers of the heart, while the left are nearly empty — the same gorged condition of the pulmonary arteries and venous system generally, which constitute the anatomical characters of this mode of dying. These appearances are even more constantly visible in the dead body, when apnoea has been gradually produced, than after sudden suffocation; simply, I believe, because they are more permanent. After sudden death, however caused, the blood seldom coagulates; and the venous turgescence consequent upon rapid apnoea, although great at first, has time to subside and disappear before the body is examined. Now, Sir James Kaye Shuttleworth. 74 DEATH BY COMA. [lECT. V. In protracted cases, death does not take place purely in the way of apnoea ; the heart is weakened, and the nervous influence impaired by the continued circulation of imperfectly arterialized blood; but the symptoms belonging to apnoea are plainly predominant. When (as is most common) the privation of air is incomplete, and a scanty and in- sufficient supply is admitted, morbid changes take place in the lungs themselves -^ the air-tubes and cells become charged with serous fluid, which operates as an additional cause of suffocation. The same phenomenon is observed when the par vagum is divided on both sides. Death by apnoea in disease is extremely common. It may be produced by anything which narrows the chink of the glottis; by warts that sometimes grow there, by oedema of the sub-mucous tissue of the larynx; by inflammatory tumefaction of its lining membrane : it may result from the presence of what are called false membranes in the windpipe and bronchi, such as are formed in the distemper named croup: it may be the consequence of disease situate in the substance of the lungs themselves, rendering them incapable of receiving the requisite quantity of air; of this we have examples in pneumonia, and in pulmonary apoplexy : or it may proceed from disorders of the pulmonary mucous membrane, the air passages becoming choked up with exces- sive and unnatural secretions, as in bronchitis. Phthisis is sometimes fatal fin the way of apnoea; more commonly it tends to death by asthenia. Diseases of the pleurae attended with effusion, and causing pressure upon the lungs; diseases of the heart and great thoracic blood-vessels, affecting the quantity of blood in the same organs; even certain abdominal maladies, accompanied by swelling, and thrusting the diaphragm upwards—terminate by the same mode of dissolution. Death by coma, although common enough, and of much importance to be under- stood, need not detain us long. Certain morbid states of the brain (it is unneces- sary at present to inquire into their nature and origin) produce stupor, more or less profound; the sensibility to outward impressions is destroyed, sometimes wholly and at once, much oftener gradually; the respiration becomes slow, irregular, stertorous; all voluntary attention to the act of breathing is lost, but the instinctive motions con- tinue ; the stimulus conveyed by the pulmonary branches of the eighth pair of nerves, and probably by certain branches too of the fifth, still excites, though perhaps im- perfectly, the reflex power of the medulla oblongata, which sustains the involuntary movements of the thorax. At length this function fails also — the chest ceases to expand — the blood is no longer aerated—and thenceforward precisely the same in- ternal changes occur as in death by apnoea. You will observe that the extinction of organic life takes place in exactly the same manner in both cases; the difference between the two forms of dying bein°- this — that in death by apnoea, the chemical functions of the lungs cease first, and then the circulation of venous blood through the arteries suspends the sensibility; whereas, in death by coma, the sensibility ceases first, and in consequence of this the move- ments of the thorax, and the chemical functions of the lungs, cease also. So that the circulation of venous blood through the arteries is in the one case the cause and in the other the effect, of the cessation of animal life. The causes that destroy the sensibility leave no constant or necessary traces of their operation. The essential anatomical characters of death by coma and of death by apnoea, are therefore the same. Death occurring in the way of coma has this peculiar kind of interest belon ^ CarrieS with i4 a stronS 5. There is no doubt either that the character nf th« ;„fl„ * * • ,. ,, to be considerably modified, from the first, by the l^^^tf^. ,\lu"fl persons who have been habitually intemperate - or who it the patient In continued excitement of the nervous system 0f any kind t^, mh£c{to lonf inflammation approaches more or less to^theType otyphus fever' \h™ ^ f^ mng. The febrile reaction is less strongly pronounced ThWt V^ ^T are sooner and more deeply involved fnYhe train of ^m^ l?1™* ^A delirium are apt to occur; with extreme debility and ir^ri^Z ♦ ?W **? untary muscles. Still more conspicuous are these peculfar£?Zs™. V*° flamed veins; and whenever inflammation is produced o a clmpanTed bvTh.8 iV" duction of certain animal poisons into the system. accompanied by the intro- leci. xi.] HECTIC FEVER. 139 6. The relative duration of the inflammatory fever is subject to some variety. It may persist for a little while, for a few days even, after all the local signs of inflamma- tion have disappeared: this happens chiefly in persons of an irritable habit. We watch such cases narrowly, not without some apprehensions of a relapse. On the other hand, a rapid abatement of the febrile symptoms sometimes takes place, while the local changes continue, or even for a time increase in extent. Nevertheless, we hail this change as a favourable augury of the ultimate result. When inflammation, external or internal, has gone on to the formation of pus, that %vent is frequently marked by the supervention of peculiar symptoms; and the cha- racter of the fever undergoes, for the most part, a striking alteration. It is very important to ascertain the time when this event of inflammation takes place, or is at hand : for the measures which might have been proper and necessary while any prospect remained of the resolution of the inflammation, may be useless and even hurtful, if continued after that prospect is at an end. When the surgeon perceives any indication of the formation of pus in an external part, he mostly despairs of being able to bring about resolution; ceases to abstract blood from the part, or from the system; and applies perhaps warmth and moisture, by means of a linseed poultice, to promote the suppuration. And a corresponding change of plan is required in internal inflammations. Now, the commencement of suppuration is often marked by rigors; and its con- tinuance by hectic fever. If, after the symptoms of inflammation have lasted for a certain time, the patient be attacked by cold shiverings, which are followed by some increase of heat, that cir- cumstance alone is enough to make us suspect that pus is formed, or is about to be formed: and to teach us that the measures employed to effect a resolution of the inflammation have not been successful. Rigors are very striking symptoms; but they are by no means necessarily connected with suppuration. They usher in, as I presume you know, most forms of fever, ap- pearing at the very outset of the disease. They recur, at regular intervals, in inter- mittent fevers. Slight causes will, sometimes, produce them. For instance, they often follow the introduction of a bougie into the urethra. But when they occur after symptoms of internal inflammation have been for some time present, they de- note, in most cases, the production of pus in the part or organ inflamed. Sometimes one such shaking fit only is observed: sometimes several take place. When they recur, it is usually at irregular intervals; but cases do happen in which the shivering? indicative of internal suppuration are so strictly periodic, that unless all the circum- stances be carefully taken into account, they may be mistaken for signs of ague. The leading symptoms of hectic fever (by which, I say, the continuance of suppu- ration is commonly marked) are an abiding frequency of pulse; alternations of chilli- ness with heat and flushing, followed by perspiration; a gradual wasting of the body; and progressive debility. I shall hereafter have to speak of a very different kind of disease, in which, how- ever, there is a succession of symptoms resembling more or less closely the series that characterizes hectic; I mean remittent fever ; the succession of symptoms being chil- liness, heat, perspiration. But these two disorders are in most cases discriminated from each other by the circumstances under which they occur. The symptoms of hectic fever often creep on, at the outset, insidiously, and aiiafa' imperceptibly. "A very slight degree of emaciation, a pulse a little-curst symp- ordinary, with a small increase of heat, especially after meals- ^-cullen has described toms which can lead us to suspect the formatw trie twenty-four hours — one about hectic fever as consisting of jtvK%^-Tjui in many cases the latter alone is distinctly noon, the other jQSrrfieels shivery and cold towards night; then the skin becomes marked.^ryPvespecially in the palms of the hands and the soles of the feet, and the iulsebecom'es more frequent; and in the middle of the night, or towards morning, he wakes from short and uneasy sleep, in perspiration, which is often profuse. Some- times however, there are two or three fits in a day. The paroxysms are shorter and less regular than those of intermittent or of remittent fever. Each of the three phe- nomena constituting the series may, in its turn, be wanting : and even if the paroxysms 140 INFLAMMATION. [lect. XI. are regular for two or three times together, they never continue to be so. Many cir- cumstances connected with the paroxysm itself are very distinctive. " The hectic patient," says Dr. Heberden, who has left us a very good account of this affection in his Commentaries, " is very little or not at all relieved by the breaking out of the sweat; but is often as restless and uneasy after he begins to perspire as he was while he shivered or burned. All the signs of fever are sometimes found the same after the perspiration is over; and during their height the chilliness will in some patients return, which is an infallible character of this disorder. Almost all other fevers begin with a sense of cold, but in them it is never known to return and to last twenty minutes or half an hour, while the fever seems at its height, which in hectic wjll sometimes happen." Hectic fever is one of the fearful accompaniments, and sometimes the most strongly marked symptom, of pulmonary consumption : and where the existence of that com- plaint is suspected, yet a matter of doubt, we look for indications of hectic fever with the greatest anxiety and dread. With relation to hectic fever, considered as an indirect symptom that suppuration has succeeded to inflammation, and is still going on, it will be worth your while to notice the strong contrast it offers, in many particulars, with the inflammatory fever that attends the earlier stages of inflammation. The pulse loses much or all of its hardness and strength, but it remains perma- nently more frequent than the pulse of health ; the appetite returns in great measure; the thirst abates; the tongue, instead of being covered with a white fur, becomes clean and moist, and towards the end is sometimes unnaturally red, or speckled with aphthae; there is no longer headache or confusion of thought. A few more touches will suffice to fill up the picture of hectic fever. The face is usually pale; but during the exacerbations it is partially flushed, and very often a characteristic circumscribed red spot appears upon either cheek. Besides the evident emaciation, various minor changes mark the want of proper nourishment: the skin, when not perspiring, is harsh and scurfy; little branny scales may be rubbed from the legs, merely by the friction produced in drawing off the stockings ; the hairs become fine and fall off; the finger-nails are incurvated into an adunque form; and the sclerotic coat of the eye, as seen through the conjunctiva, becomes of a pearly white. As the disease advances, oedematous swellings of the ankles are very apt to come on. The connexion between hectic fever, and the formation of pus in some part or other of the body is so frequent, that it has been deemed, by persons of great experience and sagacity, a universal fact. Dr. Cullen tells us, in his First Lines, that he had never seen hectic in any case, when there was not evidently, or when he had not ground to suppose there was, a permanent purulency or ulceration in some external or internal part. And Dr. Jno. Thomson, speaking of the opinion that hectic might occur independently of suppuration, uses these words :—" But till facts more decisive, and cases more accurately described than any which have yet appeared, are produced in proof of that opinion, I shall think myself justified in adopting the common opinion; and in believing that hectic fever is in every instance connected, if not with the absorption, at least with the formation of pus." The notion alluded to in the latter part of this quotation was at one time very com- monly entertained, viz., that hectic fever resulted from the re-absorption of pus into the blood; but there are many facts decidedly opposed to this belief. Considerable blood,' v,q of matter not unfrequently disappear, i. e., are taken up again into the accompany, and ocasiqning the slightest approach to hectic. Again" hectic will will sometimes cease at oncd;***^ scrofulous joint attended with an open sore and it by amputation ; although a greater quantity oi^pan the removal of the diseased limb been secreted in the diseased part previously to the operated by the stump, than had I think, that hectic is not simply a consequence of the absorption1^ these prove, blood: and they seem to have suggested to Mr. Abernethy the notion'rwh?fft the held, indeed, by John Hunter also) that sympathetic hectic fever is a teased not' % the system, endeavouring to throw off what annoys it: the cause of irritati™ l removed, it ceases forthwith. irritation being And there is another conclusive circumstance to be mentioned. Notwithst- d' LECT. XI.] AREOLAR TISSUE. 141 the opinions I just now quoted from Cullen and Dr. Thomson, I believe few persons who have attended to the subject, doubt, now, that there is such a thing as idiopathic hectic; hectic unconnected at least with suppuration anywhere. We often see hectic, or a general state of the system not to be distinguished from hectic, in mothers who have suckled their infants too long: we see it too, sometimes, if I mistake not, in newly-married husbands: and it may be noticed as occurring more or less distinctly in those who labour under diabetes. What is common to all these cases is, that there is an habitual drain upon the system beyond what the nutriment taken into it can supply and counterbalance. It is certain, too, that hectic fever sometimes happens in phthisis, not only before there has been any expectoration of puriform matter, but prior even to the softening and suppuration of a single tubercle. I call to mind one instance in particular of this. The hectic was distinctly marked, and continued long. The patient died, at last, comatose, after two attacks of convulsion. Two or three large scrofulous tumours were found imbedded in the substance of his brain. Various other organs were infested with tubercles; but the tubercles were all of them still hard and crude. However, setting aside these rarer cases of exception, there can be no doubt that hectic fever, considered as a constitutional symptom of mischief that, may reveal itself by scarcely any other token, and especially as a sign of suppuration, deserves all the attention we can give it; and for that reason have I spoken of it rather at large. Whenever I mention hectic fever in the further progress of these lectures, you will know all that I wish to express by that term. I have very little to say at present respecting that modification of the general febrile disturbance, which sometimes attends mortification as an event of inflamma- tion. I stated before that the fever is apt in these cases to assume those features which belong to the later stages of typhus fever; and to be characterized by sinking of the pulse, shrunken features, coldness and clamminess of the skin, a dry and black tongue, low muttering delirium or stupor, tremors of the voluntary muscles, with spasmodic startings of their tendons, and insensibility to the passage of faeces and of urine. I must, however, now inform you that these typhus-like symptoms are no constant or necessary concomitants of mortification. The natural mode of death, under gangrene, is death by asthenia. But typhus in its advanced state involves the nervous functions, and tends to death by coma. Whenever, therefore, typhus-like symptoms supervene upon inflammation which ends in sphacelus, they may with much probability be attributed to some contamination of the blood by an animal poison; and such contamination may have taken place previously to the mortification, and have even helped to produce it, as when inflammation arises during the progress of the contagious febrile disorders; or it may occur as a consequence of the mortification itself, by the direct absorption into the system of some of the putrefying and poison- ous elements, into which the dead part has been resolved. One circumstance, worth bearing in mind, as sometimes indicating the super- vention of internal mortification, is the sudden cessation of pain: giving hope to the patient and his friends that the danger is over; but not deceiving the experienced physician. So much, then, for the local and constitutional events of inflammation, considered generally. It remains for me to make some observations upon the modifications of inflamma- tion, according as it affects the different tissues of which the body is composed. Many of these observations I have, indeed, alraady anticipated; but it will be useful to bring together, under one view, the most material facts ascertained on this matter. When inflammation affects the areolar tissue, all the events of inflammation which I have taken some pains to describe are apt to occur; and for that reason, inflamma- tion of this tissue, as it exists beneath the skin, was chosen by me as a convenient type, or general representative of the inflammatory process. It is, therefore, the less needful that I should take up much of your time in speaking of the characters of inflammation exhibited in areolar tissue. There is a strong tendency to form circum scribed abscesses: the extension of the suppuration is prevented by a wall of lymph 142 INFLAMMATION. [LECT. XI. built up around it. The adhesive inflammation sets bounds to the suppurative. There is a good deal of pain when the areolar tissue is so situated that tension is occa- sioned by its swelling. But sometimes no such boundary wall is erected, and the inflammation spreads and diffuses itself, and becomes a very terrible disease, destroying the areolar tissue over a large and undefined space by a process compounded of sloughing and of bad suppura- tion. When the skin also is implicated in the inflammation, the disease is usually called erysipelas plegmonoides: when the skin is not involved, it has been called diffused inflammation of the cellular membrane. This diffused form of inflammation frequently follows the introduction of animal poisons into the system; and accompa- nies the inflammation of veins and of absorbent vessels. It is this disease which is so often fatal to members of our profession, when it results from wounds or punctures received in opening dead bodies. Dr. Craigie has recently put forth the opinion that in these cases of spreading inflammation it is the adipous tissue that is affected. The substance of the larger glands, and of the solid viscera of the body, suffers changes analogous to those observed in the areolar tissue: probably because areolai tissue enters largely into their composition. Acute inflammation of the liver, when it does not terminate in resolution, leads to abscess in that organ. Abscess is rare in the lungs, perhaps for the reasons mentioned in the last lecture. Gangrene is also uncommon in the pulmonary substance: and quite unknown, I believe, in the liver, and very rare in the kidney. Inflammation of the latter organ is not unfrequently attended by purulent collections. Inflammation of the substance of the viscera is not, in general, attended with much pain. The areolar tissue is liable to be rendered permanently thick and hard by chronic inflammation, as well in the parenchyma of internal organs as where it is spread out beneath the skin, or beneath serous or mucous membranes. Chronic induration and thickening of the areolar tissue which composes Glisson's capsule is no unfrequent result of slow inflammation ; producing that particular change in the liver which the French pathologists denominate cirrliose; and of which I shall have more to say hereafter. The inflammation of serous membranes is characterized by sharp and severe pain; by hardness of the pulse: and by buffy blood; by its tendency to spread; by the effusion of serous fluid, and of coagulable lymph; and sometimes, when the inflam- mation is very violent, or air gets admitted to the inflamed surface, by the effusion of pus. Speaking generally, however, it is adhesive inflammation which we most expect in this tissue. False membranes, consisting of organized lymph, belong to it: and the agglutination of contiguous surfaces. Sometimes the lymph, instead of being deposited in flakes or layers, appears in the form of numerous small granules: this is a phenomenon frequently observable in inflammation of the arachnoid, and of the peritoneum. Sometimes it has a villous or papillary or shaggy arrangement; or is cellular like a honeycomb. This is common in the pericardium. The surface (to use the happy simile of Laennec) resembles that which may be produced by separating two flat plates between which a layer of soft butter had been spread: and it probably depends upon a similar cause; since in health a perpetual sliding motion of the peri- cardium over the heart is going on. Ulceration of a serous membrane is very uncom- mon. I mean ulceration commencing in that tissue; for these membranes are frequently perforated by ulcers which approach them on their attached side, and which begin in other tissues, especially the mucous. Neither does mortification occur in serous mem- branes, except sometimes by communication from other parts. The effect of chronic inflammation of the serous surfaces is to thicken, harden, and pucker them. We see this effect in the omentum frequently; in the peritoneal covering of the liver; in the serous membrane which forms so large a portion of the valves of the heart. The synovial membranes have a strong analogy with the serous. Gendrin includes the two in the same category: yet their behaviour under inflammation displays, in some respects, a marked distinction between them. They are less liable to inflamma- tion than the serous membranes: they rarely throw out coagulable lymph, and, con- sequently, adhesion of their opposite surfaces is very uncommon. Joints do not become immoveable, or what is called anchylosed, in consequence of the agglutination of their synovial surfaces; but, generally, by means of granulations arising upon those surfaces after they have ulcerated. Very seldom indeed does pus form in the LECT. XI.] MUCOUS MEMBRANES. 143 synovial sacs, except (again) the inflammation has been caused by mechanical injury, which has laid open the joint, and admitted air. When this is the case, very serious constitutional disturbance is apt to take place, and the existence of the sufferer is endangered. That this does not depend upon the mere violence of the exciting cause. is evident from the circumstance that the same acute inflammation, the same general affection of the system, and equal danger, often result from the careful incision made into a joint by the surgeon, for the purpose of removing loose portions of cartilage. I have now at the hospital an out-patient who has, among other ills, a large cartilage floating about in fluid in one of his knee-joints: but I believe that Mr. Arnott, whom I have consulted on the case, will be very slow to recommend its extraction, unless the inconvenience produced by it becomes so great as to incapacitate the patient from pursuing his employment, and other methods of relief shall fail. Suppuration of the joints is also one of the occasional consequences of phlebitis. Inflammation of the synovial membrane speedily leads to a serous effusion into the joint, which often, especially in rheumatism, is as speedily taken up again. Let us next inquire into the modifications which inflammation undergoes when it affects the tegumentary membranes. Considering the skin as one membrane, and neglecting its subdivisions into epider- mis, rete mucosum, and cutis vera, we find that inflammation assumes a variety of forms in this external covering of the body. Many of these belong to specific dis- eases, and do not fall within my present purpose, which is that of noting how com- mon inflammation varies in the different tissues. When the inflammation is superficial, it frequently is denoted by a diffused red blush only, which may be banished for the moment by the pressure of one's finger, and which after a certain time disappears of its own accord—terminates by resolution ; the only consequence of the inflammation being the separation of the cuticle in small branny fragments; in one word, desquamation. We call the superficial inflammation in this case, erythema. If the inflammation have been a little more intense — as in some cases of erysipelas, in scalds, and in that which we are every day exciting by cantharides — a serous fluid is poured out, which elevates the cuticle in larger or smaller patches of vesication. Remove the cuticle and admit air, and the serous effusion becomes purulent effusion : and if the inflammation be pressed beyond a certain point by any other stimulus besides that of air, we may then too have pus poured out. Erysipelatous (which is also a specific) inflammation of the skin is cha- racterized by its remarkable tendency to spread: and a most singular circumstance attends several of the other specific inflammations of the skin — viz., that having occurred once, they never occur again : this peculiarity belongs, however, to the great constitutional diseases, of which the cutaneous affection forms merely a part. Inflammations of the internal tegumentary membranes — of the three internal surfaces that communicate with the air, and are clothed with mucous membrane—are very interesting to the physician : and the first thing which strikes our attention in respect to them is the indisposition they manifest to adhesive inflammation : and we are struck at the same time with the beauty of this provision. If the mucous mem- branes were as ready to throw out coagulable lymph, and to adhere to each other, as the serous, almost every occurrence of inflammation in them would prove necessarily fatal; by closing up the inlets of the air passages; or the outlets of the urinary pas- sages ; or any part of that long mucous canal which, passing through the body, requires a free opening at both of its extremities. But the inflamed mucous mem- brane pours out serous fluid; or viscid mucus; or pus; or blood. The product partakes at first of the character of the secretion proper to the part inflamed ; or it is mixed with some of that secretion. Inflammation of these membranes is, however, sometimes attended with the exudation of something which is very like coagulable lymph. The tracheal, bronchial, and pulmonary mucous membrane, the oesophageal, the intestinal, and that which lines the uterus, are all more or less subject to the formation of adventitious membranes under inflammation. Casts of the smaller branches of the air-tubes have, in rare instances, been repeatedly coughed up iu large quantity; constituting what have been very inaptly called bronchial polypi. The membranous exudation of croup is well known; a tubular substance is formed in the trachea, and, sometimes, fortunately expelled: but too often it suffocates the patient. Similar concrete exudations, broken into irregular shreds, are occasionally voided by 144 INFLAMMATION. [lECT. XI. stool. It is said that a long membranous mass of the same kind, in size and shape like an earth-worm, has been discharged from the urethra; having formed there in consequence of the injudicious use of stimulating substances, injected with the view of checking the more innocent effusion of pus." The films, or membrane-like flakes which are thus incidental to inflammation of the mucous surfaces, resemble, I say, in their general appearance and disposition, the strata or layers of coagulable lymph which are the ordinary product of inflammation of the closed serous surfaces. But they differ from these in some remarkable points. They are softer. They never contract permanent or strong adhesions to the subjacent or inflamed membrane; but are partially separated from it by the intervention of thinner matters, serous or puriform. Above all, they never become organized. They appear to consist of inspissated and altered mucus; and are composed, in a great measure, of albumen. An opinion has been entertained that the want of apposition of the opposite surfaces has a great deal to do with their indisposition to cohere. The mucous a?>-tubes are kept open and apart by their structure: the stomach and intestines by their contents,' or by the frequent passage of solids and fluids through them : and therefore (it has been supposed) they have no opportunity of adhering. But there can be no doubt that these mucous membranes are but little disposed to throw out true plastic lymph at all: and when their opposite surfaces do grow together, I believe it will almost always be found that some abrasion or ulceration of the mucous surface had previously happened. Inflammation affecting the mucous membranes has sometimes a strong tendency to spread and wander: sometimes, on the contrary, it is strictly confined to a small and definite space. In the former case it commonly restricts itself for a long time, or altogether, to the mucous tissue, leaving the neighbouring tissues untouched. In the latter it is apt to penetrate to the subjacent parts, and,to produce obvious and enduring alterations of structure. The membrane becomes fastened to the parts which it should loosely clothe, and not unfrequently it ulcerates or sloughs. The spreading form of inflammation is most often met with in the air-passages. Ulceration and sloughing, and circumscribed inflammation, are more common in the alimentary canal. There is a remarkable contrast between the serous membranes and the mucous, in respect to the pain which attends their inflammation. Very little pain is experienced in many cases, when inflammation affects the mucous lining in any of the three systems, except towards their openings, where the membranes are about to become continuous with the external skin: in the mouth and throat, for example, the pharynx, the rectum, the vagina, the extremity of the urethra. And as inflammation of the mucous membranes is attended with less pain, so also it is accompanied by less fever than when the serous membranes are attacked; and the blood more seldom exhibits the buffy coat. The muscular tissue appears to take on the actions of inflammation very reluctantly: and its vessels seldom, if ever, pour forth any of the products of inflammation. The chief effect of inflammation upon muscle is the destruction of its contractile properties. Serum and lymph, and even pus, are sometimes found diffused through muscular parts; but there is reason to believe that these effusions are rather the consequence of inflammation of the areolar tissue which enters into the composition of the muscle, and ties together its fleshy fibres, than of inflammation of those fibres themselves. I have remarked already that inflammation of an artery presently leads to the effusion of lymph, and the coagulation of the blood, within the artery. But arteries do not readily inflame, except under mechanical injury: they do not often suppurate either : and they possess a singular power of resisting mortification. Dr. Jno. Thom- son declares that he has seen cases of phlegmonous erysipelas, in which " several inches of the femoral artery were laid completely bare by the o-anr/rene ulceration, and sphacelus of the parts covering it, without its giving way before death." Inflammation of the veins is much more common than that of the arteries * and it is a disease of fearful interest. In some cases it leads to a deposit of fibrin upon the inside of the vessel, " furring it over," as Mr. Hunter says. The blood soon coagu- lates, and blocks up the inflamed vein, or leaves, perhaps, a narrow passage in its centre. From this mechanical obstruction to the current of the blood new symptoms arise. The part from which the venous trunk" receives its tributary branches becomes LECT. XI.] BRAIN. 145 oedematous or dropsical. Inflammation of the femoral vein, obliterating its cavity, is the essence of the complaint known to pathologists under the name of phlegmasia dolens: a complaint which may happen to persons of any age, or of either sex; but which is most common in women, soon after parturition. This, which may be considered the adhesive form of phlebitis, is also its most innocent form. Too frequently the inflammation runs into suppuration : and then it proves a most terrible and almost hopeless disorder. The vein remains pervious; pus, of an unwholesome and poisonous quality — or some morbid product of the in- flammation— is carried into the blood; which thus scatters, in its course, the seeds of inflammation, and determines the rapid formation of purulent collections, in various and distant parts of the body, and especially in the lungs, the liver, and the larger joints. Great constitutional disturbance ensues, and fever of a type like that of typhus is often established. To this, the destructive form of the disease, parturient women are also peculiarly liable. Phlebitis of the uterine veins constitutes the source of the most dangerous and deadly varieties of puerperal fever. It is the same disease which gives to a vast majority of those surgical operations that are followed by death, their fatal character. We hear continually of inflammation of the brain; but what is so called is, most commonly, inflammation of the membranes which invest the brain. Inflammation of the cerebral substance itself is, however, not very uncommon; but it is more fre- quently the result of injury than of spontaneous disease, and it is usually confined to a limited portion of the brain. Softening and suppuration are its ordinary events. Sometimes pus is met with occupying a distinctly circumscribed space; the pus is collected into an abscess. Sometimes, on the other hand, it lies loose, as it were, and surrounded by broken-down cerebral matter, or it is infiltered into the cerebral pulp. Around the softened portions the inflamed substance of the brain is more dense and firm, sometimes, than is natural. Whether this be owing to the presence of coagu- lable lymph, has not (so far as I know) been clearly ascertained. Mortification must be very rare in the nervous substance. Dr. Baillie has described it as occurring after violent injury. Once or twice in my life, portions of brain have been shown to me, protruding through an aperture in the skull, dead, of a dark colour, and having an offensive smell. Excepting in these cases of hernia cerebri, I have never seen sphacelus of the brain from any cause. Perhaps, however, I am incorrect in saying this. I formerly told you that portions of the brain often become soft and diffluent, when there has been no inflammation; but simply from atrophy, depending on a diseased state of the nutrient arteries of the brain. Now this is, by some persons, called mortification of the cerebral substance. They consider it quite analogous to the gangrena senilis, which results from a similar cause, although it happens in another part of the body. The nature of the change, they say, is the same, although its physical characters differ. If this be so, I have seen gangrene of the brain some scores of times; but still I should be able to declare, that with, perhaps, the exception already mentioned, I have never seen unequivocal mortification of the cerebral substance as the result of inflammation: which is what we have now been considering. This concludes, gentlemen, what I have to say concerning the phenomena of common inflammation, as they are perpetually witnessed in the various textures of the body. I have not, indeed, gone through all the tissues; I have said nothing of the peculiar effects of inflammation in cartilages, for example, and in bones; but I have glanced at all those tissues, in the inflammation of which the physician is chiefly concerned. Upon such points as I have purposely omitted, you will be amply instructed by my colleague, the Professor of Surgery. 10 146 INFLAMMATION. [LECT. XII LECTURE XII. Varieties of Inflammation: Acute and Chronic; Latent; Specific. Scrofulou* Inflammation. Tubercles. Relative frequency of Scrofulous Disease m different Organs. Signs of the Strumous Diathesis. We have now, gentlemen, considered the phenomena of inflammation, local and general; its symptoms and its events; and the intimation of those events which is afforded by the state of the system at large; and we have surveyed the principal tissues of the body, and observed the modifications and peculiarities to which the process of inflammation is liable, according as it is situated in one of those tissues, or another. In respect to this part of our subject — and indeed in respect to the whole subject of inflammation — I cannot too strongly recommend to you the diligent study of Mr. Paget's invaluable Lectures on Surgical Pathology. There are still some varieties of inflammation; and some epithets applied to in- flammation ; which require to be explained. Acute, and chronic, inflammation : these are words perpetually in our mouths. I have frequently employed them already. What do they mean ? Is acute inflamma- tion different from chronic in kind'? No; they differ only in degree. When the disease runs its course rapidly, and is attended with much general as well as local disturbance, it is said to be acute. When, on the other hand, the local and constitutional symptoms are less violent, and the inflammation runs a longer course, its phenomena following each other in slower succession, it is said to be chronic. The process is the same, but its features are less strongly expressed. The disease passes through similar stages in both cases, but it travels at a different pace. The characters, then, of acute inflammation are intensity of symptoms and rapidity of progress: and the characters of chronic inflammation are mildness of symptoms and slowness of progress. Inflammation can scarcely be very violent, and at the same time of very long duration. When violent, it has been likened (by Mr. Law- rence, whose language I have here adopted) to a blazing fire, which soon burns itself out. It may, however, be mild in its symptoms, and yet quickly over. The two terms acute and chronic are not directly opposed to each other: acute has more relation to the intensity, chronic to the duration of the disease; and some term is wanted—although it is hardly worth seeking for—to denote such a degree of inflam- mation as exists in a pimple: which is neither severe nor long-continued. Now, in respect to intensity and duration, there are innumerable shades of difference in different cases of inflammation; and the same difficulty occurs here which always occurs when general terms are employed to express mere differences of degree. We feel no uncertainty or hesitation about those cases which occupy the two extremes of the scale; but with regard to those which lie in the middle we are often at a loss. To meet this difficulty some pathologists have invented a third epithet, viz., sub-acute, intending to designate thereby cases which hold an equivocal rank; which are neither decidedly acute nor plainly chronic; in which the inflamma- tion may run a brief course, and be attended with a certain degree of fever; but attains no great intensity, works no profound changes, and does not require very energetic remedies to control it. Do not suppose that, because chronic inflammation is attended with less tumult and disturbance, it is necessarily on that account less dangerous or less destructive than acute. The latter is commonly more obedient to the influence of remedies than the former; it is usually soon brought to an end : whereas chronic inflammation is often obstinate and abiding, and leads to very serious changes in the part upon which it fastens. Speaking generally, it tends to thicken and indurate when it is situated in the interior of organs, and to the effusion of pus when it affects membranes or surfaces. It is more common in weakly and debilitated persons than in others • but 70u must not forget that such persons are also very liable to acute inflammation. LECT. XII.] INFLAMMATION. 147 Chronic inflammation is not unfrequently a sequel of acute inflammation. And that the two differ merely in degree, and not in kind, is evident from this: that acute inflammation may sink or subside into chronic; and that, on the other hand, chronic inflammation may readily be aggravated into acute. There is another, but less intelligible division of inflammation into active and passive. I believe that they who use the term passive inflammation, intend to signify by it that languid and sluggish kind of inflammation which is apt to occur under the same circumstances, and in the same conditions, with passive congestion. When the granulations of an ulcer are in that state in which they may be made brighter, smaller, and healthier, by the application of a stimulus : when the blood-vessels of the eye are left, after acute inflammation, turgid and tortuous; and that condition is improved, instead of being worsened, by the use of a stimulating lotion : in such cases as these, some persons would say there was passive inflammation. But I see little difference between this and chronic inflammation; nor do I know any difference between active and acute inflammation. The term latent inflammation is one of modern introduction. It is applicable to those cases in which internal inflammation runs its course silently, treacherously, and unperceived; without the usual warning tokens of its presence; without its more Btriking and prominent signs. The smouldering fire is hidden from our view. Pneumonia, going on to disorganization of the lung, may arise, proceed, and even prove fatal, without any of the symptoms which ordinarily announce that disorder: without notable cough, or obvious dyspnoea, or complaint of pain, or the expectoration proper to pneumonia. And the same is true of other inflammations. We discover, with surprise and horror, the traces of their operation, when we come to examine our patient's dead body. This is a most important form of inflammation; for though it does not declare. itself to ordinary observation, neither does it occur absolutely without symptoms; but it requires that the symptoms should be looked for. The auscultatory signs of pneu- monia, all those symptoms which are furnished by the physical condition of the affected organ, are present, and speak as clearly as in the more flagrant cases. Latent inflammation is apt to creep on during the progress of certain disorders, whereby it is modified and masked. It belongs to those states of the system in which the sensibility is dull, and the vital powers languid. In continued fever not only have I known the lung pass into suppuration, when the existence of pneumonia had been unsuspected; but I even have seen one case in which that usually torturing accident, perforation of the bowel, took place, with the escape of its contents into the cavity of the abdomen, and extensive peritonitis—yet the patient expressed no sense of pain, and the inflammation was revealed, while he continued to live, by no intelligible symptom. Inflammation of this insidious and lurking character is most to be apprehended in the aged, in those who are habitually intemperate, and in persons of sluggish tempera- ment. It sometimes occurs during convalescence from acute diseases. Besides the varieties which have been mentioned in degree, there are also differences in kind among inflammations. What I have been speaking of during the preceding lectures I have called common inflammation. It is the most common form in which that process displays itself. All persons are liable to it; and that again and again. None are at any time privileged from its attacks. But there are several forms of inflammation different from this, which are called specific. There are various forms of specific inflammation affecting the skin, discriminated from each other by the local appearances they exhibit, and by the constitutional disorder which attends them. The rash and the fever of measles are very unlike the rash and the fever of scarlatina; and both differ remarkably from those of small-pox, the eruption of which consists of little phlegmons. In each of these diseases the application of a specific poison is required for its production : and whereas common inflammation has a tendency, when once it has happened, to happen in the same part again — to recur — these forms of specific and contagious inflammation never, or almost never, occur more than once. There is again the gouty inflammation — differing from common inflammation in several signal respects; in the production of chalk-stones; in its attacking those who are descended from ancestors who have had the disease, and scarcely any others. Then there is rheumatic inflammation, cousin-german to the gouty, yet distinguishable from 148 INFLAMMATION. [LECT. Xlt. it. And another variety of inflammation is that which arises from the introduction of the syphilitic poison into the system. Of the specific forms of inflammation now adverted to I shall speak when 1 come to consider gout and rheumatism, and the contagious exanthemata, as distinct diseases. But there is one variety of inflammation — I mean the scrofulous — which meets us on every side; and is apt to affect so many parts of the body, and so great a number of persons; and has so fatal a tendency in most cases, that it cannot be left out of the account that I have been desirous to give you of inflammation in general. Scrofulous or strumous inflammation (for struma and scrofula are convertible terms) is a slow process; it falls therefore within the class of chronic inflammations. It is not attended with much pain, or heat, nor for some time with much change of colour; and the redness which does accompany it has often a livid or purplish tinge. These, however, are the negative properties of merely chronic inflammation. But suppuration at length occurs, which also lasts long: and the pus formed is peculiar and characteristic; and by no means laudable. It is not homogeneous or smooth, but consists partly of a thin serous whey-like fluid, and partly of fragments of a substance resembling curd: and the ulceration that ensues is marked by corresponding peculi- arities. The ulcers are indolent; show but little disposition to heal. Scrofulous inflammation, compared with common, or what is called healthy inflammation, is in general but little influenced by remedies. Besides this scrofulous inflammation, it is necessary that I should now direct your attention to another form of disease, which is likewise properly denominated scrofu- lous. It is marked by the appearance, in various parts of the body, of what are called tubercles. These tubercles are masses of unorganized matter — also resembling curd or new cheese, more or less; but of various shapes and sizes. They suffer gradual changes ; soften or break down ; undergo a sort of suppuration; and the softer matter into which they thus (as it were) melt, has the characters that distinguish the pus of a scrofulous ulcer or abscess. Now tubercles and scrofulous inflammation occur very continually in the same indi- viduals : and what is remarkable, although they affect a very large portion of the whole human race, and conduce more often and more surely than any one thing else to shorten the natural period of human life, yet they belong, almost exclusively, to certain classes of persons. We can tell, beforehand, that such and such persons are likely to become affected with scrofulous inflammation, or with tubercles: and we say of those persons that they have the scrofulous diathesis. I will not positively affirm that these forms of disease cannot be produced in any or in all persons; but thus much is certain—that some persons are particularly prone to them : fall into them as it were spontaneously; or on the operation of very slight external causes; and even when all possible care is taken to prevent the operation of every ascertained cause; while other persons never show any tendency to scrofula, even when continually exposed in the same manner: or if they do become scrofulous at all, it is only when the external influences most favourable to the production of such disease have been intense in degree, and protracted in their application. The occurrence of scrofulous inflammation in various parts constitutes distinct diseases; and the occurrence of tubercles in various organs, constitutes other diseases. It will facilitate our future inquiries into these several diseases, if I take this oppor- tunity of stating to you what is known respecting the scrofulous diathesis generally: and of the modifications of inflammation which are determined by its presence. A good deal of discrepancy, obscuring the whole subject, and puzzling the student, has existed — and I believe I may say still exists — among pathologists, as to the nature, and origin, and precise seat of tubercles, and as to the changes which they undergo. In general they have been loosely described as being round masses of firm but friable matter, deposited in various parts of the body. Laennec, who paid great attention to tubercles, states that they are, at first, small, firm, greyish, semi-transpa- rent bodies, which gradually enlarge and become opaque. In that condition he calls them crude tubercles. At length, after an indefinite period, these crude tubercles begin to grow soft in their centres, and are by degrees converted each into a liquid mass, having the consistence of cream. There is much of error in this description. Andral, another great authority, says that tubercles are, in the outset, small round, LECT. XII.] TUBERCLES. 149 opaque, yellowish bodies, unorganized, and of various degrees of consistence. He ascribes their softening (not to any spontaneous changes in their central parts, but) to the admixture of pus, poured out by the textures immediately surrounding the tubercle; which has irritated and inflamed those textures as any other foreign body might. In some respects this statement is nearer the truth than Laennec's. But in the account which I am about to give you, I shall chiefly follow our coun- tryman, Sir Robert Carswell, the first Professor of Pathological Anatomy in University College; who is one of the latest, and, as I think, most satisfactory writers on the subject. His opinions were formed after a long and careful examination, for himself, of the parts infested by these tubercles. He devoted several years to the study of morbid anatomy, in Paris, where he made a very large collection of drawings, in which various diseased appearances are beautifully, and doubtless faithfully delineated. Some of these he has since published. I show you enlarged copies of those which relate to tubercle. They bear out some novel opinions which are stated in the letter- press that accompanies them. After all, the points in question possess more of curious interest than of practical importance. But as you cannot help forming some notions respecting them, I think myself bound to lay before you those which most recommend themselves to my own judgment. At the same time you are to understand that I do not vouch for their absolute correctness. Tubercles, then — or rather tubercular matter, — is deposited from the blood. Whether it is something totally new, something foreign to the natural materials of the body, introduced into the blood from without — or whether, as seems more likely, it is the result of some defect or error in the due elaboration of the blood itself— I cannot satisfy you. If, as has been supposed, the deposit be at first fluid, it after- wards becomes firmer, through the absorption of its more watery particles; and there then remains a " pale yellow or yellowish grey, opaque, unorganized substance." This tubercular matter, so deposited, does not always assume a round form: far from it; the shape in which it appears depends upon the nature of the part wherein it is planted. It used to be held that the tubercular matter was always laid down in the areolar tissue. But Sir R. Carswell asserts that its most favourite seat (if one may so speak) is the free surface of mucous membranes. In whatever organ it is met with, if mucous tissue enter into the composition of that organ, that particular tissue is either (he says) exclusively affected, or much more extensively affected than any of the other component tissues. These remarks apply to the lungs, the alimentary canal, the liver, the urinary organs, and the organs of generation; but the presence of the tubercular matter is much more easily detected in the mucous tissue of' some of these organs than in that of others. It is very conspicuous in the fallopian tubes and uterus. But tubercular matter is often deposited on serous surfaces also; among which Sir R. Carswell includes the plates of the areolar tissue. It is even to be seen sometimes in the blood itself: not indeed while it is yet retained in its proper vessels, but when it is collected in the cells of the spleen. You know that the spongy texture of that organ allows the blood to accumulate in it in considerable quantity: and the tubercu- lar matter may be seen forming in the blood at some distance from the walls of the cells in which the blood is contained. In one cell, according to Sir R. Carswell, you you may perceive simply the blood coagulated: in another, it may be coagulated and deprived of its colouring matter: and in another, converted into a mass of solid fibrin, having in its centre a small nodule of tubercular matter. Now when a speck or morsel of tubercular matter has been any where deposited, it is liable to increase. It grows larger by continued accretion; by additional deposits upon its surface. This being the case, we see plainly enough how it happens that tubercles assume different shapes, according as they occur in different parts. The round form which is so often observed is purely accidental. When a tubercle is depo- sited in the substance of the brain — and becomes larger by the repeated accession of fresh tubercular matter upon and around it — it naturally takes a spherical form, because there is nothing to limit its enlargement, except the soft cerebral matter itself, which presses it with equal force on every side. For the same reason tubercles depo- sited in the areolar tissue are globular. In like manner, if tubercular matter be laid 150 INFLAMMATION. [LECT. XII down in one of the pulmonary vesicles, so as to fill it up, it exhibits the roundish form of the vesicle. When it fills the cavity of a mucous follicle, it has a similar figure. But in the smaller bronchi it takes a more cylindrical arrangement. When (as often happens) it occupies one of these tubes, and also all the air-cells to which that tube leads, then we have twigs of tubercular matter, with cauliflower terminations. You see this depicted in the drawings before you. In the cavity of the uterus, and the fallopian tubes; in the infundibula and pelvis of the kidney, and in the ureters; and in the lacteal and lymphatic vessels; the tubercular matter is moulded to the forms of these parts respectively. We are more in the habit of examining tubercles in the lungs than anywhere else: and you will observe that in making sections of these organs, and looking only at the surfaces of those sections, we may easily overlook the branch-like disposition of the tubercular matter in the smaller bronchial tubes. We see the transverse section only of the tubes, which is necessarily more or less circular. On the surfaces of serous membranes, whether natural or adventitious, the tubercular matter will assume a rounded, or a lamellated form, according as the morbid secretion in which it originates has taken place from separate points, or from a continuous surface. From what has now been stated, you will perceive that no alteration can be ex- pected to take place in the tubercular matter after once it has been deposited, except through the agency of the parts around it and in contact with it. It is never organ- ized, or capable of organization ; and, consequently, no vital change in its consistence can originate in the tubercle itself. If any spontaneous change arise, it must be a chemical one : and of such we have no evidence at all. It may therefore seem odd, that so accurate an observer as Laennec should have persuaded himself that the softening of tubercles begins in their centre. Now Sir R. Carswell has given what appears to me a sufficient explanation of this mistake. Take the lungs; the morbid conditions of which were the most especial object of Laennec's investigations The tubercular matter is effused (principally) upon the mucous surface: upon the inner lining of the air-cells, and of the bronchial tubes communicating with them. Yet it need not so accumulate as to fill these cavi- ties ; and it often does not; there is left a central vacuity, which contains mucus, or other secreted fluids: and if the lung be cut across under these circumstances, the divided air-vesicles will look like rings of tubercular matter grouped together; and each divided bronchial tube will present also the appearance of a tubercle, with a cen- tral depression, or soft central point. On the other hand, when the tubercular matter has completely filled and blocked up these cavities, both vesicles and bronchial tubes will look, when divided, like sections of round solid tubercles. These Laennec seems, in fact, to have regarded as crude tubercles: while he mistook the former appearances for tubercles which were beginning to soften in their centres. But you sometimes find large masses of tubercular matter in the lungs, or else- where : and in these masses you see that the process of softening is going on at several points, within the mass, at the same time. How is this to be explained ? Why these large masses are formed, in fact, by the aggregation of many smaller masses, which, lying near each other, have coalesced as the deposit continued to increase : and the areolar and other tissues originally intervening between these coa- lescing masses at length suppurate; and by their suppuration, they soften, and gra- dually break down the tubercular matter which they enclose, and by which they are also enclosed. This is just the process by which tubercles are frequently expelled from the body. They increase till the surrounding parts take on inflammation, just as they might do if any foreign body exercised the same degree of pressure upon them. The inflammation thus excited is of the scrofulous kind; the thin pus which is thrown out pervades and loosens the tubercular matter; a process of ulceration goes on in the surrounding textures; and at length (supposing the lung to have been the seat of disease) the detritus of the tubercle is brought up, gradually by coughing. The account which I have now given you, and which I hope I have made intelli- gible, is, I think, extremely interesting — and much credit is due to Sir R. Carswell for having so greatly simplified our views of a subject which had previously been wrapped in profound obscurity. In no earlier writer, that I know of, is there to be found so complete and credible an explanation of the origin of tubercles; of the forma LECT. XII.] TUBERCLES. 151 they assume; of the phenomena attending their enlargement, and subsequent soft- ening, and occasional expulsion. [According to Barthez and Rilliet, who have given the most complete and accurate description of tubercle, the various forms under which tubercle is found are the fol- lowing : — the miliary or grey tubercle, the yellow or crude tubercle, the grey and yellow forms of infiltration, the gelatinous infiltration, and tuberculous dust. There is no reason for ascribing these forms of tuberculous matter solely to tubercle of the lung. As M. Valleix remarks, incontestible proofs may be adduced to prove that the grey granulations of Laennec occur in all the organs, and as the researches in patho- logical anatomy have been more carefully conducted, these proofs have been multi- plied. M. Papavoine, in his interesting memoir "On Tubercle considered particularly in Children," expresses himself thus: — "We cannot admit the seat of the grey granulations to be only in the pulmonary vesicles: forms of alteration exactly similar, are to be met with in the lymphatic glands, in the liver, in the spleen, and on the serous membranes, especially in certain cases of general and acute tuberculization." The statement of M. Nelaton leaves no doubt of the development of grey semitransparent granulations in the osseous tissue. He has been able, repeatedly, to determine that the tubercles of the bones, like those of the lungs, recognise for points of departure, the grey semitransparent granulations described by Laennec, Louis, and others (Re- cherches sur I'affection tuberculeuse des os, 1836). Dr. Glover has observed, in Fig. 13. Fio. 14. Yellow tubercle; crude mass. Grey tubercle; miliary granulation. Fia. 16. Tubercle-corpuscles, granules, and molecules, from a soft tubercular mass in the lung. 250 diameters linear. Fio. 18. Isolated tubercle-corpuscles. On the right are four blood-globules. Fig. 15. /•?-0*o. &*© Tubercle-corpuscles from the peritoneum, a, the same, after the addition of acetic acid. Ml Fio. 17. Tubercle-corpuscles, from a mesenteric gland. 152 INFLAMMATION. [LKCT. XII. granular meningitis, the forms of grey granulation, and yellow particles, answering very well to the yellow points which appear in the grey granulations of the lungs. The miliary tubercle may exist in all the organs, and it is in the form of grey infil- trated matter, granular to the microscope, more or less diffused through the substance of a gland, that we detect the first occurrence of mesenteric tubercle; afterwards we find a more crude or yellow appearance of the tubercle matter, as in the lungs. The appearance of infiltrated grey matter is especially marked in effusions organized be- tween the tunics of the intestinal canal. Some of the illustrations presented by Dr. Glover (Pathology and Treatment of Scrofula) show the tubercular effusion in a mesenteric gland:—lstly, in a diffused form throughout the hypertrophied tissue of the organ; 2dly, forming striae and patches, varying in hue from grey to yellow; 3dly, in cysts filled either with a tuberculous powder or with a curdy matter; 4thly, in masses of lardaceous consistence, implicating either the whole gland, or more or less of its structure. We have specimens, likewise, remarks the same author, of bronchial glands, and bronchi sprinkled over, as it were, with a tuberculous powder, and studed with cretaceous particles. " The grey granulation," as Rilliet and Barthez observe, " exists in all the organs, not only in the intestines, peritoneum, and pleura, but in the spleen, the liver, the kidneys, the lymphatic glands and cerebral meninges."—{Maladies des En fans.) In fact all the forms of tubercle which occur in the different organs are brought about chiefly by mechanical causes, and differ very slightly in a physiological sense, never in their more minute anatomy. Thus, for example, the liver is an organ, in which tumours generally are of large size, and of various and irregular shapes; in the lungs, the air-cells and the membranous character of the tissue tend much, if the effusion be not rapid, to surround it, while progressing and stiffening, with envelops of a mem- branous nature. The brain, from its structure, must oppose pressure in every direc- tion in which the progress of a deposit in its interior can take place, and thus we find tubercles of the brain generally of small size and regularly circumscribed. Between layers of membrane we find the deposit stretched out in flakes. In the sub-cutaneous cellular tissue it forms irregular masses. On the free surfaces of mucous or serous membranes its figure is irregular, or it occurs in superficial layers. In the bones, in general, it is in little round granules, or in very circumscribed masses. — C] These processes—of softening, produced by surrounding inflammation, and of ulti- mate expulsion—may be regarded as a natural mode of cure. Such a cure is in truth sometimes accomplished. A scrofulous abscess forms in the glands of the neck : and pus and tubercular matter are discharged. At length the ulcer heals, and no trace of the diseased process remains, beyond a scar. The same thing takes place also in the lungs; and, if there have been only one or two masses of tubercle deposited, the patient may thus get quite well: but unfortunately, as the scrofulous matter is extir- pated from one part of the lung, it is apt to be multiplied in another, till at length we have death by hectic, and all its melancholy accompaniments. But I am desirous of pointing out to you another way in which tubercular disease may be said to be cured by a natural process. And this also has been better described by Sir R. Carswell than by any preceding writer. One form of scrofulous disease, exceedingly common too, especially among children, is what is called " tabes mesen- terica." Tabes and phthisis, the one a Latin and the other a Greek word, signify, I need scarcely tell you, the same thing: a wasting away, or a consuming: and phthisis is applied to the same disease in the chest, to which tabes is applied in the belly. The common English word is consumption; and we might very well speak of thoracic consumption, and of abdominal consumption; but the technical name of the latter complaint is tabes mesenterica. This is not only a very common but a very fatal dis- ease in children and young persons. The glands of the mesentery enlarge and become charged with tubercular matter : but they very rarely suppurate. Their enlargement is commonly connected with scrofulous disease and ulceration of the mucous follicles of the intestines; and the little patients die, because the lacteals are no lon-rer able to take up from the food a sufficient supply of nutriment: they die starved. But some few do recover from tabes mesenterica. Sir R. Carswell relates an interesting case in which such recovery took place, and in which he had an opportunity of ex- ■♦uiining the glands at a subsequent period. He says, " The patient, who when a LECT. XII.] TUBERCLES. 153 child had been affected with tabes mesenterica, and also with swellings of the cervical "lands, some of which ulcerated, died at the age of 21, of inflammation of the uterus, seven days after delivery. Several of the mesenteric glands contained a dry cheesy matter, mixed with a chalky-looking substance; others were composed of a cretaceous substance; and a tumour, as large as a hen's egg, included within the folds of the peritoneum, and which appeared to be the remains of a large agglomerated mass of glands, was filled with a substance, resembling a mixture of putty and dried mortar, moistened with a small quantity of serosity. In the neck, and immediately beneath an old cicatrix in the skin, there were two glands containing in several points of their substance (which was otherwise healthy), small masses of hard cretaceous matter." Now what Sir R. Carswell here saw in the mesentery and in the neck, is what sometimes occurs in other parts of the body: in the lungs; and particularly in the bronchial glands at their root, and about the bifurcation of the trachea. From these situations, the hard chalky matter left by the absorption of all the more watery part of the morbid deposit, and by the concretion of its earthy salts, is often coughed up. But it may remain, when the tubercles are few, and there is no tendency to their in- crease, for years, as an inert, and almost harmless mass. I mentioned just now that the secretion or separation of the matter of tubercle from the blood takes place, by preference, upon the free surface of mucous mem- branes, and very frequently also upon the surface of serous tissues, including the areolar. It may not be uninteresting to inquire into the relative frequency of scrofulous disease in different organs, or in different parts of the same organ. The facts which we possess on this head afford us very valuable assistance sometimes in respect of diagnosis. During the periods of childhood and youth, the lymphatic glands are exceedingly prone to scrofulous inflammation : especially the mesenteric and the cervical glands. But in adult age tubercles are, beyond all comparison, most frequent in the respira- tory organs; and they occupy the summit of the lung much more commonly and thickly than any other part. The superior and posterior portion of the upper lobe is the spot in which, if any tubercles at all exist in the lung, they are almost sure to be found. It is here also that they first begin to suppurate or soften. This law has long been well known : and so constant is it, that Sir R. Carswell holds the formation of tubercles in any other portions of the lung to be always of secondary occurrence. He declares it to be the result of his experience (and few persons can have had more opportunities of examining diseased lungs), that there is no deviation from this rule, except when some other portion of the lung may have been the seat of an inflam- matory attack, which has determined the priority of tubercular disease in that por- tion. We shall see hereafter what a very important bearing a knowledge of this law has, in settling the nature of a complaint which might, without it, be doubtful. Scrofulous ulceration of the larynx, or trachea, when it occurs, is usually the con- comitant of tubercular deposits in the lungs. Next, tubercular or strumous disease is exceedingly common in the digestive organs: most of all in the mucous follicles of the small intestines; both in those follicles which are separate, and are called glandulae solitariae; and in those which are collected into roundish or oblong groups, the glandulae agminatae. It is secon- darily to these affections of the follicles, in many cases at least, that the glands of the mesentery become implicated. Tubercular deposits are frequent also in the solitary glands belonging to the caecum. The ulceration which follows the evacuation of the strumous matter from these parts gives the interior of the bowel an appearance some- what resembling that of a moth-eaten garment. Tubercular matter is seldom de- posited in any other parts of the intestines, great or small, than those which I have mentioned. Sir R. Carswell supposes that it may often be secreted upon the free surface of the membrane, but that, not being entangled or confined in any mucous crypt, it is removed as soon as it forms. It is not often that scrofulous tubercles are found in the liver of adults: they are not very uncommon in that organ in children, but even then they are few in number and small in size. It is a curious fact that they are much more frequently seen in the spleen also in children, than in grown up persons. The uterus, the testicle, the prostate gland, are all liable to them: they are common enough upon the surface of the peritoneum. 154 INFLAMMATION. [LECT. XII. In the nervous system tubercles are by no means unfrequent: they are met with oftener in the brain than in the spinal cord. That fearful disorder of childhood, known by the name of hydrocephalus, occurs principally, if not altogether, in con- nexion with the scrofulous diathesis. Strumous deposits are rare in the organs of circulation. Tubercles have been seen, I believe, in the muscular substance of the heart: but this must be a very un- common thing. Scrofulous disease is not at all unfrequent in bone, especially in the bodies of the vertebrae, and in the spongy extremities of the long bones. It is very seldom indeed that scrofulous tubercles occur in any one organ only. Almost always they are met with in at least two, and frequently in all the parts at once which are liable to be infested by them. Sometimes the lungs alone are affected; but generally both the lungs and the intestines are occupied by the disease. It has been affirmed by a great living pathologist, M. Louis, that if you find tubercles in any other organ, you are sure to find them also, and in greater number, and further advanced, in the lungs. But this, though true as a general rule, is not without ex- ceptions. I have seen the peritoneum crowded with myriads of these tubercles, when the most careful examination could not detect a single-one in the lungs. And similar examples have fallen under Sir R. Carswell's observation. [The general diffusion of tubercular matter is»much more common in children than in adults. Thus, in 358 cases where tubercles existed in the lungs in adults, M. Louis notices the existence of tubercular matter in the brain or its membranes only once; in the bronchial glands it was detected in about one-fifth of the cases; in the mesenteric glands, in one-fifth; in the liver, only twice; in the kidneys, five times in one hundred and seventy cases; on the other hand, ulceration of the larynx existed in one-fourth; ulceration of the bowels, in five-sixths of the cases. In 180 cases in which tubercles of the lungs existed in children, Dr. Green found the brain to be affected with tubercles in one-ninth of the cases; the bronchial glands, in 100 out of 112; the mesenteric glands were tuberculous, in one-half; the liver, in one-ninth; the kidneys in one-eighteenth of the cases; but ulceration of the larynx occurred only once, and ulceration of the bowels, sixteen times in 112 cases. M. Cless, of Stuttgard, has also published the results obtained from the examina- tion of upwards of 180 bodies affected with tubercular disease. In 152 examinations of adults, M. Cless found the lungs free from tubercles six times. In 21 examina- tions of children, he only found the lungs free from tubercles once. This was in a boy eleven years of age, who, besides a considerable serous effusion into the ventricles of the brain, had two large masses of tubercle in the cerebellum, many small ones on the surface of the liver, and caries of the vertebrae. In 146 adults affected with tubercles in the lungs, there were only thirty-five in whom the disease was confined exclusively to the lungs. In children there were only three cases out of twenty in which all the other organs were free. M. Cless never found the bronchial glands in children affected with tubercular deposit without the existence of tubercles in the lungs also. In thirteen adults and one child, there were tubercles in the pleura. In sixty-one adults, and four children, the tubercles were limited^ to the peritoneum eight times. The four children were between six months and ten years of age. In 152 adults affected with tubercles, the small intestines were affected eighty-three times, and the large intestines thirty-seven times, and in twenty- one children, the small intestines were affected seven times, the large ones only once. Among 152 adults, thirty-two had tubercles of the mesenteric glands, while they occurred in these glands in seven out of twenty-one children. In all the cases tuber- cles were found in the other organs. Tubercles of the liver occurred once in an adult, twice in children, while other organs were also affected. In four adults, and twelve children, the spleen was affected with tubercles, these at the same time existing in other parts of the body. In children, M. Cless remarks, the parenchyma of the spleen is often completely invaded by tubercles. In the kidneys, tubercles were met with four times in adults, and three times in children; of five children, aged from eight months to eleven years, in whom the membranes of the brain presented tuber- cles, four died of acute hydrocephalus. In all these there were tubercles in the lungs and other organs also. The tubercular granulations had always their seat on the external surface of the arachnoid, between this membrane and the pia mater, never LEcr. xn.] SCROFULOUS DIATHESIS. . 155 within the cavity of the arachnoid. In twenty-seven children who died from tuber- cles, four had tubercles of the brain, as well as in other organs; M. Cless never found any in the brain of adults. Besides their existence in the mesenteric and bronchial glands, M. Cless found tubercles in the glands of the neck in five adults, and one child. See Condie on Diseases of Children, 4th edition.— C] The question has been much and eagerly discussed, whether the deposition of tubercular matter be not, what I should call, an event of inflammation. Some persona have strenuously argued that the curd-like substance is nothing more than a particular kind of vitiated or imperfect lymph, and that it is never poured out except as a con- sequence of inflammation; and they cite cases of patients who always had enjoyed good health, until inflammation was accidentally excited in their lungs; immediately after which the well-known signs of phthisis began to display themselves; and, after death, the lungs were found full of tubercles. But they forget to take into the account another fact equally well established, viz., that tubercles are found, in great abundance, in the lungs of persons who were never known, in their lives, to have any functional disturbance of those organs; and whose lungs present, after death, no other traces of having been inflamed. We even find tubercles in the lungs of unborn children. Not that this is conclusive; for inflammation does sometimes attack the foetus in utero, and leave permanent and unequivocal traces of its action. Moreover, inflammation continually happens, in all the component textures of the lung, in the forms of bronchitis, pneumonia, and pleurisy, without the subsequent development of tubercles. I admit that this fact, to be of weight, should be proved of persons who possess the scrofulous diathesis; and I believe the proof might be found : but the search for it would require much carefulness and candour. In my own opinion, there is not a shadow of evidence to show that the deposit of tubercular matter is always and necessarily preceded by inflammation. Yet an un- doubted and most important connexion obtains between the occurrence of inflamma- tion and the occurrence of tubercles. Tubercles will cause inflammation, and inflam- mation will determine the development of tubercles. The enlarging tubercles excite inflammation in the surrounding textures by the pressure they exert upon them; and probably in other ways; by mechanically interfering with the healthy circulation of the blood, for example : and the inflammation lit up is usually of the scrofulous kind; it is slow, and partial, and easily quieted by treatment, though scarcely to be cured. On the other hand, there are numerous facts to prove that, in a person having the scrofulous diathesis, the occurrence of inflammation within the chest may rouse that previously dormant tendency into action, and become the exciting cause of the secre- tion or separation of tubercular matter from the blood. The cases in which other parts of the lung than the apex are found exclusively occupied with tubercles, are also cases in which, apparently, the same parts had been the seat of inflammatory action: of which we sometimes see other traces, in adhesions of the neighbouring pleura. The connexion between tubercles and inflammation is shown also by their occur- rence in the substance of false membranes. And the same phenomenon marks the fact that they are something distinct and different from coagulable lymph. You must not suppose, from anything I have said, that persons of the scrofulous habit are not susceptible of common inflammation : we know that they are, by the readiness with which slight injuries often heal in such persons; but there is always much reason to apprehend that inflammation occurring in them will take on the scrofulous form; become chronic, if it were not so at first, suppurate tardily, and produce that unhealthy kind of puriform secretion which is characteristic of strumous disease. Another question relating to tubercular diseases is, whether they are contagious. capable, i. e., of being communicated from one individual to another. The general belief, in this country, is that they are not. Indeed, their very dependence upon a peculiar diathesis would seem to disprove the supposition. Yet some practitioners, even here, have, I know, misgivings on the subject; and in some parts of the con- tinent, in Italy particularly, consumptive patients are shunned, from the persuasion that their complaint is infectious. I shall revive this question when I speak of phthisis hereafter. 156 INFLAMMATION. [leot. XII. I have stated that scrofulous disease appears, almost exclusively, in certain dfasses of persons, of whom, therefore, we say, that they have the scrofulous diathesis. It is both interesting and useful to be able to distinguish those in whom the scrofulous habit of body, or the predisposition to strumous disease, exists. Now there are certain physical and moral characters which teach us to apprehend the existence of a tendency to scrofulous disease, even when there has not, hitherto, been any local manifestation of such disease. Again, we infer the scrofulous diathesis, in many persons, from knowing that scrofula has existed among their progenitors. On these two points I have a few observations to make: and first, on what may be considered the external tokens of a scrofulous constitution. The persons, in whom scrofulous disease is most apt to declare itself, are marked, during childhood, by pale and pasty complexions, large heads, narrow chets, protube- rant bellies, soft and flabby muscles, and a languid and feeble circulation. They present many of the features belonging to that pattern of body which is denominated the leucophlegmatic. But the strumous disposition very often indeed accompanies a variety of the sanguine temperament also; and is indicated by light or red hair, grey or blue eyes with large and sluggish pupils and long silky lashes, a fair transparent brilliancy of skin, and rosy cheeks. This red colour, which is well defined in general, is easily changed, however, by cold, to purple or livid; the skin is thin and readily irritated; the sclerotic has often a peculiar pearly lustre; and the extremities are subject to chilblains. Such children are, many of them, extremely clever and ready of apprehension, of eager tempers, and warm affections, lively, ardent, imaginative, and susceptible. This precocity of mind and intellect, while it delights the fondness of the parent, awakens the fears of the more far-seeing physician. But the disposition to scrofula is by no means confined to persons of the serous or of the sanguine temperament. It is frequent, though less common, in what has been called the melancholic or bilious temperament; in persons of dark muddy complexion and harsh skin; in whom the mental and bodily energies are more sluggish and dull. And it is remarked that in persons of this cast, scrofula, when it does occur, is even more than usually obstinate and intractable. Scrofula does often indeed appear in persons who exhibit none of those signs of a strumous disposition which I have been enumerating; but it is more likely to appear, caeteris paribus, where those signs are observed. There are several alleged marks of a scrofulous diathesis, which are, in fact, instances of scrofulous disease. Such, for example, is that chronic lippitudo, which so frequently disfigures strumous children, rendering them what is called blear-eyed : and chronic inflammation of the conjunctiva, lasting long, without much redness or heat, and with extreme impatience of light, and a tendency to form little pustules near the edge of the cornea. The tumid and chapped upper lip; the redness and swelling of the columna nasi, and lower parts of the nostrils, so common in children, especially during winter, are early fruits of the strumous taint. Certain maladies of the joints, what are popularly called white swellings, are instances of scrofulous disease. So may perhaps rickets ,be considered; at any rate, ricketty children are very often affected with scrofula also. Moist eruptions behind the ears; chronic enlargement of the glands of the neck; that slow, eating, ulceration of the nares, termed lupus; may all be included within the class of strumous disorders. When any one of these scrofulous affections has once shown itself in any person, we know, by that circumstance, that he possesses the strumous constitution; and we look for the recurrence of his complaint in the same part, or in other parts. In a former lecture I mentioned scrofula as one of those distempers the hereditary tendency to which is indisputable. The scrofulous diathesis is hereditary: and some- times scrofulous disease is so too. I have seen lungs, taken from the body of a foetus, stuffed with tubercles. There were some fine examples of this in Mr. Langstaff's museum, in the city. We have, therefore, in respect to scrofula, the rare conjunction of congenital disease, and hereditary disposition. I need not repeat here the remarks I made before, respecting hereditary diseases in general. No one, of the least obser- vation, can doubt that the disposition to consumption is very often transmitted from parent to child. We see whole families swept away by its ravages. Like other hereditary tendencies, it may skip over one or two generations, and reappear in the LECT. XII.] SCROFULOUS DISEASE. 157 next, just as family likenesses are known to do. There are other families in which you can trace no such predisposition; but such families are perhaps few. A little leaven is sufficient, sometimes, effectually to taint a whole pedigree. The tendency, however, exists in various degrees. It may be so strong that no care, no favourable combination of circumstances, will prevent its local manifestation; and it may be so faint that it would never break out into actual mischief if the exciting causes of scrofulous disease could be warded off. It is important, therefore, to know what these exciting causes are. " They may all be ranked together (to use the language of Dr. Alison) as causes of debility, acting permanently, or habitually for a length of time, although not so powerfully as to produce sudden or violent effects." The circumstances to which, acting separately or in combination, we most confi- dently ascribe the power of developing scrofula, are insufficient nutriment, exposure to wet and cold, impurity of the atmosphere, the want of natural exercise, and mental disquietude. To estimate the separate effect of each of these causes may be difficult; but their combined influence is unquestionable. There can be no doubt that improper diet, or rather imperfect nourishment, is one main exciting cause of scrofulous disease. Yet of this it is not an easy thing to ob- tain evidence, which shall be entirely free from fallacy. The disease occurs very often among the poor; but then it very often occurs also in the families of the rich. There is one fact which has always struck me as very instructive and convincing on this point. Infants at the breast, supplied with good milk, and with plenty of it, seldom show any signs of scrofulous disorder: whereas, as soon as they are weaned, they become subject to various complaints of a strumous kind. When an unweaned child is brought to us with ophthalmia, we expect almost always to discover inflam- mation of the common and acute kind ; the purulent eye. In nine children out of ten who come after weaning, we look for and find some form of scrofulous inflamma- tion, such as pustular ophthalmia. Mr. Phillips (Scrofula, its nature and causes), has succeeded in establishing very conclusively the influence of bad and deficient food, and of an excess of vegetable aliment, in the production of scrofula. — C] The greater prevalence of scrofulous disease among the poor may be ascribed, in great measure, to their frequent exposure to wet and cold. [Barthez and Rilliet were only able to find two cases out of 314 tuberculous chil- dren, where exposure to humidity appeared to be the sole cause of the tubercles. The researches of Mr. Phillips would tend also to prove that the influence of humidity has been much overrated___C.] Scrofula seldom breaks out in the mild and dry weather of summer. The influence of climate in fostering or repressing the disease is notorious. There is no climate in which it flourishes more than in our own. Consumption is called, in some parts of the continent, the English disease. Persons who migrate from this country to warmer and more equable climates, seldom become scrofulous; nay, it very often happens that the incipient indications of strumous disease are completely arrested or quieted by the change. Phthisical patients, much troubled by symptoms here, are sometimes so thoroughly freed from them soon after their arrival in Madeira, as to be deceived into the belief that their case had been mistaken. They think themselves well. A return to this country undeceives them. The native inhabitants of hot regions are by no means, however, exempt from struma, in any of its forms. When they come into these latitudes they are more subject to scrofula than we ourselves are. And the same effect of climate is very distinctly visible in the lower animals. The physicians in ordinary to the inmates of the Zoological Gardens will tell you that the beasts and birds which are brought hither from warm latitudes perish in great numbers from scrofulous diseases. John Hunter observed this long ago in respect to monkeys. Of the debilitating influence of impure air I spoke in a previous lecture. That it promotes the evolution of scrofulous disorders we have proof, on a large scale, in the great mortality produced by such disorders among the lower classes in large cities as 158 INFLAMMATION. [LECT. XII, compared with agricultural districts. The per-centage of deaths from consumption, hydrocephalus, and various other diseases which spring from a strumous habit, is much greater in London than in the country. Even in individual cases this influence is too manifest to be overlooked or mistaken. It is impossible to question the beneficial effect, upon children afflicted with scrofula, of a removal from London to the sea-coast. I said, when I first began to speak to you of inflammation, that it was the only dis- ease which we were able to excite at will: that we could cause inflammation, in vari- ous ways, whenever we desired to do so; but that to make a cancer or a tubercle was beyond our power. Now in strictness of language, and in the practical meaning of these words, this assertion is quite true. It is certainly true as respects exciting causes; it is probably true as respects predisposing causes also. But the latter of these propositions has been denied, and experiments have been appealed to in dis- proof of its correctness. It has been said that, by so arranging external influences as to heighten and concentrate their hurtful tendencies, tubercular disease may, in the lower animals at least, be engendered. It is affirmed that tubercles may be produced at will in the liver of a rabbit, by shutting the animal up in a cold, damp, dark, and narrow place, and feeding it upon food not natural or suited to it. Mr. Simon has shown the strong probability that all such experiments have been fallacious. A liver, occupied with so-called tubercles, thus produced, was brought to him for examination. He found that the supposed tubercles were really minute oblong eggs, or larvae, of some entozoon. He then made many experiments himself, to try if he could create tubercle artificially. He dissected also many rabbits on which no experiments had been made. The result was, that he never saw a tubercle in a rabbit. It may be questioned whether the animal be susceptible of that form of disease. I have lately met with the following curious statement, bearing upon this question, as it regards the human animal: — "According to the very trustworthy report of Dr. Schleusner, who was sent by the Danish Government a few years since to inves- tigate the sanitary condition of Iceland, no combination of what are commonly accounted the predisposing causes of consumption and scrofula could be more com- plete than that which exists among the mass of the Icelandic peasantry. Whole families are huddled up with their sheep, not only during the night but during the greater part of the day, for half the year, in most miserable hovels, destitute of any venti- lation but that afforded by the chimney. Their clothing is not once put off or changed during the whole of that time; their food is scanty; and the external atmosphere is both cold and damp. The unhealthy condition of the population is evidenced by its extraordinary liability to epidemic disorders; and by its want of increase, or even in some districts by its absolute diminution. And yet amongst this remarkable people, the best-educated peasantry in Europe so far as regards what is commonly accounted education, scrofula and consumption are unknown." The writer (in the Westminster Review) ascribes this immunity " to the highly oleaginous nature of their diet, which consists in great part of the oily bodies of piscivorous birds." A more likely cause, to my mind, for such immunity, if it really exist in that race of men, is their probable exemption from the scrofulous diathesis. Of course, no experiments like those practised upon the rabbits can be purposely made upon a healthy man; but accidental opportunities arise of witnessing an ap- proach to a similar trial of the human species. Instances are recorded of persons, previously well (but having probably the strumous diathesis), becoming affected with scrofula after being confined in the dungeons of a prison, and there scantily fed. Something of this kind I have, very recently, had the opportunity of seeing. A number of male prisoners, chiefly young men, began to exhibit glandular swell- ings, of the neck, after incarceration for some length of time in the Penitentiary at Milbank. The circumstances of their health led to a relaxation of their punishment. Instead of being kept in solitary confinement in a coldish cell, and on the prison diet, they were permitted to work, for several hours daily, in each other's company, in the garden of the establishment. Some porter was at the same time given them, and their allowance of meat was increased. The improvement in their condition was rapid and striking. Here we have the disorder germinating under one state of exter- nal circumstances, and checked immediately under the opposite state. if you consider the way of life of the children of the poorer classes in this metro- LECT. XIII.] CANCER. 159 polis, and in our large manufacturing towns, you will find that they are much exposed to most of those injurious influences, the combination of which has been thought likely to generate tubercles. They live usually in an atmosphere made stagnant by narrow streets; and in small, crowded, ill-ventilated, and dark rooms in those narrow streets. The stagnant atmosphere is contaminated in a thousand ways. They arc very insufficiently protected from transitions of temperature, against cold and wet, by their clothing. They are commonly ill fed — their diet being frequently scanty, and generally of a kind quite unsuited to their growing years. We need not be sur- prised, therefore, at the ravages which scrofula, in its manifold shapes, makes anion" the children of the poor in large and populous towns. If ever scrofula be generated, in this country, independently of any hereditary strumous taint in the constitution, it is in them. But in most cases I believe it is the latent disposition that is called into action. Moderate exercise, in pure air, and in the open daylight, with suitable nourishment, sufficient clothing, and attention to the state of the bowels: thuse cir- cumstances comprise nearly all that we can attempt, in a given climate, towards pre- venting the development of struma: and from each and all of them many of these poor children are habitually debarred. LECTURE XIII. Cancer: its Species or Varieties. Scirrhus; Encephaloid Cancer; Colloid Cancer, Its mode of Growth and Dissemination. Habitudes of the several Varieties. Treatment of Inflammation. Antiphlogistic Regimen. Blood-letting. I have more than once coupled cancer and tubercle in the same sentence. Though very different in many respects, they are alike in their intractable character and de- structive tendencies. Of the two, cancer, while it is happily much the more rare, is also much the more painful, loathsome, and hideous in its consequences. It is to cancerous diseases that the epithet malignant especially belongs. Not resulting from any change in the natural textures of the body, but constituting an addition to them, and therefore assuming, usually, the shape of tumours, they are commonly and cor- rectly spoken of as cancerous growths. But there are other growths which, by com- parison, are innocent; which do not imply any necessary destruction of contiguous parts, nor any inevitable danger to life, nor even any marked deterioration of the general health. Such are certain fatty tumours, and fibrous tumours, and osseous tumours. All these last, as their names denote, resemble in their sensible qualities some one of the healthy and natural textures. They have accordingly been styled analogous, or homologous growths; while cancer and tubercle, which find no counter- parts in the sound body, are said to be heterologous. Some varieties of cancer are, however, very similar in outward appearance to the substance of the brain; and microscopic observers say that in their minute and original structure there is no per- ceptible distinction between the most innocent and the most malignant growths; nay, that both agree in their primary corpuscular elements with the healthy tissues of animals, and even of plants. [This statement is not perfectly accurate. The microscope has not, it is true, thrown much light upon the nature and causes of morbid growths; it has, however, shown that in many of the particulars of their intimate structure, they not only differ from the healthy tissues of the body, but that they differ in this respect from each other. That such is the case, is rendered evident by the result of all the more recent re- searches into the intimate structure of cancerous formations. By Miiller and other pathologists, cancerous formations have been arranged in two 160 CANCER. [lect. xin. great families or groups—the encephaloid and the scirrhous. — Of the first there are three subdivisions. 1. Medullary Carcinoma; in which there is a predominance in the medullary mass, of round globules over loose fibrous tissue. The globules are of various sizes; but the smallest are larger than pus-corpuscles. Each contains a granular substance or nucleus within. They are very similar, in many respects, to those of common cancer, and of reticulated carcinoma or scirrhus. 2. Medullary Carcinoma, consisting of pale, elliptic, non-elongated corpuscles, and of a fundamental cerebriform mass. These corpuscles are usually twice or three times as large as the globules of the blood. There is never any appearance of fibres pro- ceeding from their surface, and they rarely exhibit any traces of nuclei within them. 3. Medullary Carcinoma, with fibrated or puriform corpuscles. This species of encephaloid structure has, at times, on laceration, a sort of fibrous aspect, when the puriform corpuscles are arranged in a somewhat determinate direction; according to which the morbid mass will present a radiated or a tufted appearance. In many cases their directions are so various that the lacerated surface exhibits no traces of fibres anywhere. The puriform corpuscles are sometimes nucleated, at others they contain granular points, but without distinct nuclei. They are elongated, on one or two sides, into fibres of different lengths. They may be considered as cells that are arrested at the period of transition from the cellular to the fibrous condition. The three forms of disease now described, may, most probably, be regarded as so many degrees or stages in the development of the same tissue; these successive stages being characterized, 1, by rounded nucleated globules; 2, by elongated oviform glo- bules, which are either non-nucleated or indistinctly so; and 3, by puriform globules. These several kinds of globules may be regarded as so many successive epochs of evolution through which a cell must pass before it can become a fibre. Thus we find, it is true, that in an encephaloid mass there is the same transformation of the primi- tive elements, as occurs in many normal tissues — with this difference only, that the process of evolution is not complete — being arrested before the fibrin is perfectly formed. The essential element of an encephaloid tumour is the presence of cells. In some cases the entire mass is composed of them, placed one alongside of the other, but without having any perceptible bond of union, while in others there is a network of fibrous or cellular tissue interposed between the cells. When the fibrous tissue pre- vails, the encephaloid then approaches in character to the scirrhous structure. In the latter the existence of the two elements, cells and fibres, is always more distinctly marked than in the former. The fibres are often quite perceptible to the naked eye. Sometimes they are lengthened, and run parallel to each other; at others, they form rounded capsules, within which the globules are contained. As in the case of the newly-formed fibres of the cellular tissue, so those of a scirrhous formation are de- stroyed by acetic acid, leaving nuclei or nucleated fibres behind. The fibres some- times exhibit, at different points, a sort of varicose enlargement, within each of which a nucleus is found. This appearance is often observed in fibrous tumours—not genu- ine scirrhus — of the uterus and other parts. In the reticular carcinoma of Miiller, the white network which encloses the scir- rhous globules in its meshes, is formed of round, opaque granulations, three or four times as large as the blood globules; they are, occasionally, agglomerated into rounded masses. The genuine scirrhous tissue, of a pale greyish colour, is composed of glo- bules that, on the whole, resemble those of the first stage of an encephaloid formation. These globules are either round or somewhat oval; along with them, according to Vogel, we find free nuclei with their nucleoli. From a variety of observations, it may be reasonably concluded that the cells of scirrhus are formed around the nuclei of which M. Vogel speaks; their contents are at first granular and almost opaque. When the process of softening commences, the granulations disappear, the globules become transparent, and within them are formed new cells, which at first are few in number, and gradually multiply, until they en- tirely fill the parent cell. M. Valentin, who, in part at least, admits this account of the progress of the cell, declares, that the parent cells eventually burst and discharge their cellules; we may thus account for the presence of young free cells in scirrhous formations that have become softened. LECT. XIII.] CANCER. 161 The inter-cellular substance seems to undergo certain modifications corresponding with the evolution of the cells; the granulations or granular points which it often contains, usually disappear, and it becomes limpid, while, at the same time, the space which it occupies is diminished by the enlargement and multiplication of the cells. The fibrous network does not appear to follow, in its alterations, the development of the cells : it may remain firm and resisting while the cells are far advanced in their evolution. Even when a scirrhous tumour has become completely softened, this tissue sometimes forms shreds that retain their original character. In alveolar cancer, the basis of the morbid tissue consists of white fibres and lamellae, which cross and intercross with each other, containing, between the meshes thus formed, limpid cells, either closed or communicating with each other, of various sizes, from that of a grain of sand to that of a large pea, and filled with a transparent, gelatinous substance. In this substance there are cells, which contain other cells more minute. The smallest of these cells exhibit, at one point of their parietes, a distinct dark yellowish nucleus, and sometimes, also, many free and unattached gra- nules floating within them. To this species Miiller refers the gelatiniform and areolar cancers of Laennec and Cruveilhier. The cells of this species of the disease appear to be only an advanced or more mature degree of the cells of scirrhus. — C] This very agreement, if it really be so complete, shows that in classifying morbid growths we must reject the aid of the microscope, and attend to their grosser and more palpable features. And, inasmuch as cancerous formations have, by some pathologists, been ascribed (very erroneously, in my opinion) to inflammation as their cause, I shall scarcely be going out of my way if I state here some of the broad facts which have been ascertained upon this very interesting subject. Cancer, or carcinoma, considered as a genus of disease, comprehends two or three species, which present among themselves very striking differences, and of which the varieties have received a puzzling multiplicity of names; scirrhus, stone cancer, me- dullary sarcoma, encephaloid or cerebriform disease, soft cancer, fungus hoematodes, colloid or gum cancer, and several more. The simplest division, founded upon the consistence of the morbid growth, is into hard and soft cancer. But the most modern and scientific system recognises three species, — viz. scirrhus; encephaloid, or brain- like cancer; and colloid, or gum-like cancer. The physical characters of these three species offer strong points, not merely of difference, but even of contrast. Scirrhus, as that word implies, is remarkable, in its early stages, for its hardness. It is as firm as cartilage, and creaks when divided by a sharp knife. The surfaces exposed by its Fig. 19. division present a glistening, satiny appearance, ,#,_,. ,,./.. and a white, or grey, or bluish-white colour. ^ /■/* '-'ilV' stance run opaque intersecting bauds, having a ; S;J\\ fibrous aspect. By strong pressure a thin juice £.V"_'.----''-'- ■ may be made to ooze from a slice of the scirrhous f li- tumour. ?m ;.;/ Encephaloid cancer is also well named. It is ^ ,"'- 'v; composed, in great measure, of a soft, white, "v opaque, pulpy substance, very closely resembling, " x^5^^^;/^''^/';^ both in colour and in consistence, that of the healthy brain. This cerebriform pulp is traversed Fibrous stroma of scirrhus. and circumscribed by fibrous septa, which are sometimes extremely thin and delicate. In both these species of cancerous growth, therefore, there is a contained and a containing element. The same feature is still more distinctly marked in the third species, the colloid cancer, which exhibits the appearance of small portions of a greenish-yellow trans- parent gum, or jelly, arranged in regular cells. Hence it is sometimes denominated alveolar cancer. You may ask upon what principles structures so dissimilar in their physical appear- ance have been assigned to the same genus ? Why, for these reasons. They are all strictly destructive or malignant forms of disease. Although in any shape they are of somewhat rare occurrence, yet when they do occur, two, or all three of the species 162 CANCER. [lect. xiii. Fig. 20. Fig. 21. Cells from Encephaloid of Tongue (rapidly growing). tion in the collection of Dr. Gross. are often found to co-exist in different organs of the same individual; nay, in conti- guous parts of the same organ. More than this : if a tumour consisting of one spe- cies be amputated, and a fresh growth spring (as too often it does) from the same spot, this secondary growth is frequently of another species. There can be no doubt that all are connected by some very intimate bond of union ; and the facts I have just stated suggest the question, whether instead of being different species of the same genus, they ought not rather to be regarded as mere varieties of the same species. Of all three it has been ascertained, by much and fatal experience, that occurring in any one part of the body they are prone to multiply in various other parts; that they are commonly attended, during some part at least of their progress, with very severe pain; that they are incontrollable by any known remedy; and tend always, sometimes slowly, sometimes with frightful rapidity, to augment in bulk; eating away contiguous parts by their invasion and pressure; breaking out, when near the surface, into foul and repulsive ulceration ; producing often the most ghastly disfigure- ment; and ultimately destroying life. Sometimes vital parts are slowly disorganized by the corroding extension of these tumours; sometimes large blood-vessels are laid open, and death is suddenly brought about by haemorrhage; and sometimes the powers of life sink gradually under the wearing influence of the disease, and that degeneracy of the blood which it causes or accompanies. There is scarcely an organ or texture of the body which is not liable to be attacked by this terrible foe: the brain, the eye, the lip and face, the lungs, the stomach, the intestines, the liver, the kidneys, the breast, the womb, the testicle, the bones. But some parts are more often the seat of cancer than others. Among these may be reckoned the female mamma, the uterus, the stomach, the liver, and the testicle. The mode in which cancer originates is uncertain; the modes in which it spreads and multiplies are better understood. An individual tumour may enlarge by the progressive insinuation of the cancerous matter into the interstices of the neighbouring tissues, which, thus fastening upon, it consolidates. The disease may be communicated, by imbibition, from one organ to another which is in mere contact with it. But how does it come to occupy at the same time, or in quick succession, several separate and distant organs ? This is a question of the greatest interest and importance, and it admits of a distinct reply. Cancer often makes its appearance in a single spot on the surface of the body; in the female breast, for instance. We see and feel it there while it is yet small, and while the general health of the patient seems to be otherwise perfect. By degrees the tumour increases, and at length it softens in some places; the glands of the axilla LECT. XIII.] CANCER. 163 become swollen, hard, painful, and filled sometimes with cancerous matter; the tumour breaks perhaps through the skin, and presents the shocking spectacle of " open cancer;" the general health gives way, and the skin assumes a straw-coloured tint. During this process, unless the patient dies prematurely, or the original disease is removed by a surgical operation, cancerous tumours form in one or in several of the internal organs, and give notice of their presence by appropriate symptoms. There is an original morbid growth, and there are subsequent morbid growths; a primary tumour, and secondary tumours; and the latter are caused by the former. This is a most important fact, if indeed it be true. Now, Miiller has discovered, by means of the microscope, and the discovery has been confirmed by other observers, that the contained matter, in the several species or varieties of cancer, consists of very minute cells, with nuclei attached to their walls, and of granules still more minute, which are supposed to be the rudiments of new cells. It is (apparently) by the amplification of these granules into cells, and by the development of the nuclei into other cells, and by the growth and evolution of young cells, which, in some instances, are included generation after generation within parent cells, that the original tumours enlarge and extend themselves; and it is by the transference of certain of these cells and granules from the original tumour that a crop of secondary tumours is sown in remote parts of the body. The cells, and probably the granules also, are endowed with a power of self-increase and pro- pagation, whenever they find a fitting soil. Possessing, like the seeds of plants, an inherent vitality of their own, they merely require, in order to germinate, to be placed in contact with some living tissue, wherewith they may form vascular con- nexions, and wherefrom they may draw the materials of their nourishment. Cohering together, for the most part, with but little force, they are easily detached from the parent mass. It is matter of fact that the secondary tumours form most surely and most rapidly when the primary tumour is of a soft kind; and that when they succeed to scirrhus, it is after the process of softening has commenced in that originally hard structure. These germs — which present in their forms and mode of generation, striking analogies with those of some of the lower animals, as well as with those of plants—these germs are carried sometimes through the lymphatic vessels to absorbent glands in the vicinity of the primary growth; from a cancerous breast, for example, to the glands of the axilla: but there can scarcely be a doubt that the blood is the main channel by which the seeds of this dreadful malady are conveyed from its first to its subsequent sites, and thence perhaps, if life continue long enough, to tertiary locations. The gross matter of cancer is often to be found in the veins that proceed from the primary tumour, — nay, in large venous trunks at a distance; so that some distinguished pathologists have too hastily conjectured that it may originate in the veins. You are doubtless aware that foreign substances, circulating with the blood, stop or are entangled more often in some organs than in others. Minute globules of mercury, when that metal has been introduced into the veins, are found strewed through the substance of the lungs, and of the liver. Pus, received into the blood in phlebitis, is arrested, and forms scattered points of inflammation and abscess, in the same organs: and it is in the liver and the lungs that separate tumours of secondary cancer are most commonly met with. If this be the true theory of secondary cancerous formations, I need scarcely point out to you the urgent importance of the rule which prescribes to the surgeon the most complete extirpation of the primary tumour, at the earliest possible period of its existence. The disseminated cancer-germs are not scattered to this organ or to that, to the lungs or to the liver, indiscriminately or by chance. Their distribution bears a certain relation, as you may readily conceive, to the situation of the primary disease. Since the blood, in its return from the stomach, the intestines, the rectum, passes through the portal system of veins before it reaches the lungs, you would expect that cancer- cells conveyed from those parts would be stopped in their journey through the capillary vessels of the liver—and it is so. A few, in very rare instances, pass on to lodge and grow in the lungs. Again, the blood from the breast goes direct to the vena cava, and the lungs are the first to receive and entangle whatever seeds of disease it may carry: for what is true of cancer-germs is true of pus also, and of other morbid materials. The pulmonary capillaries, however, are more easily permeable by such matters than the hepatic. Some of the genus pass through them, and enter the 164 CANCER. [lect. xm. general circulation; and the liver, as well as the lungs, frequently becomes contami- nated: and germs may thus settle in other parts. In these facte we see one reason why cancerous growths are more often met with in the liver than in any other organ of the body. Primary cancer of the kidney is, in like manner, apt to be disseminated through the medium of the vena cava; and we might expect that cancer-germs from the uterus would take the same course, and affect the lungs earlier and more often than the liver. But that is not always the case. The liver is liable to be secondarilj affected from malignant disease of the womb; and Dr. Budd gives the explanation of this apparent anomaly. The rectum and the haemorrhoidal veins, which return th< blood to the vena porta, very frequently become implicated in the uterine disorganiza- tion. Fortunately, cancer of the uterus, which is a fearfully common disease, is not so often disseminated as cancer of the stomach, or of the mamma. The origin of primary cancer is involved in much obscurity. It seems, howevei (and this, after what has just been stated, you might expect), that the germs of the disease are capable of being transferred from one human being to another; and even to an animal of a different species. Langenbeck injected cancerous matter, just taken from a living body, into the veins of a dog. After some weeks the dog began to pine away, and was then killed, and cancerous growths were found in its lungs. Several instances have occurred—I have myself known of two—of cancer of the penis in men whose wives laboured under cancer of the uterus. Here it is presumable that the cancerous germs received upon a delicate and vascular surface, and suffered perhaps to lodge there through neglect of cleanliness, might fasten upon the part, take root there as it were, and grow. One very curious circumstance connected with this subject is, that the frequent contact of common soot seems to have the power of producing cancer. There is a form of carcinoma, affecting chiefly the scrotum, and familiar to surgeons as the chimney-sweeper's cancer. A case is recorded of cancer of the same variety occurring in the right hand of a gardener, who for years had been in the habit of sprinkling soot over his flower-beds with his hands. There are not wanting, then, plausible grounds for the hypothesis, that the seeds of cancer may be introduced, in some way which eludes observation, from without; that cancerous growths are strictly parasitic, and independent of the body, excepting so far as they derive their pabulum from its juices. The difficulties involved in this supposition are not greater (as we shall see hereafter) than those that hang over the source and origin of certain entozoa, with which the body is liable to be infested. But whether this hypothesis be true, or whether the cancer cells and germs are merely morbid elements of the native tissues of the body, developed by some perverted energy of the formative process, remains yet to be determined. From the tables contained in the Reports of the Registrar-General, it would appear that women are more subject to this fearful disorder than men, in the large ratio of five to two. It fixes chiefly upon the female organs of reproduction; the mammas and the uterus. The mortality from cancer, estimated with due reference to the whole number of persons existing at different ages, increases steadily as life advances. There are still some general habitudes of the different varieties of cancer, with which I should wish you to be acquainted. The secondary formations are most commonly of the encephaloid kind, whatever the primary form may have been. Encephaloid cancer, as compared with scirrhus, is abundantly furnished with blood- vessels : and upon this difference in their degree of vascularity other remarkable differences between the two varieties seem to depend. First, encephaloid tumours generally augment with much greater rapidity, and attain a much larger size, than scirrhous tumours. Occasionally their magnitude comes to be enormous. Again, cerebriform growths seldom happen singly, but occupy several organs of the body at once. Scirrhus, increasing slowly, occurs also in fewer sites; it is sometimes even solitary. More tissues, too, appear to be obnoxious to the soft than to the hard variety. Now (as Dr. William Budd has well remarked) a large apparatus of blood-vessels, bringing a proportionally plentiful supply of nourishment to the parasitic tumour, accounts sufficiently for its rank and rapid growth; and the same condition, especially when conjoined with softness of the parent mass, affords obvious facilities for the LECT. XIII.] CANCER. 165 liberal dissemination of its* germs through numerous returning channels. In fact, the soft varieties alone have, as yet, been found in the veins. The same multitude of its blood-vessels, and slender cohesion of its comppnent parts, serve to explain another peculiarity of the cerebriform species. Intermixed with, or diffused through, the brain-like substance, there is often to be seen a quantity of extravasated blood: and when the disease breaks out into ulceration, red, ragged, and bleeding growths, of fungous aspect, sprout rapidly from the open surface. To these accidents of cancer the term fungus hae.matod.es is to be traced. We do not find scirrhus to be the seat of similar interstitial haemorrhages. Encephaloid cancer has less tendency to contract adhesions with contiguous parts than scirrhus has. Of the alveolar variety, which has been more lately discriminated from the others, and less studied, less is known. It occurs principally in the abdomen, affecting the pyloric orifice of the stomach, and the omentum. It appears also occasionally in the bones, in the breast, and in the testicle. It spreads chiefly by contact and inoculation; the cells of this species of cancer being too large to be readily conveyed to distant parts through the veins. Although sometimes combined with the two other species in the same person, it is often alone, and limited to a single organ. I believe it has not been met with except in adults. For more minute information on this subject, so interesting and important both in its pathological relations and in its practical bearings, I must refer you to Professor Walshe's very able and elaborate work on cancer; and to a short but admirable essay on the same topic, by Dr. William Budd, published in the Lanct\ From these sources has been derived much of what I have now been stating. [We may also refer the reader to the full and excellent paper of Dr. Carswell, on Scirrhus, in the Cyclopaedia of Practical Medicine. — C.] Returning to our current theme, I proceed, in the next place, to speak, in a general manner, of the measures to be adopted when we are called upon to administer to the relief of a person labouring under inflammation: of what is sometimes called the cure; but, more correctly, of the treatment of inflammation. In describing the phenomena and progress of inflammation, I took external inflam- mation as a type, and I shall keep that type principally in view in what I have to say respecting its treatment: making, however, such reference to the inflammation of internal parts as the subject will permit. You will bear in mind that my design at present is merely to explain the principles of treatment, generally: I shall point out, by and by, the application of those principles, and the modifications they may require, in respect to particular cases. I speak also, now, of common inflammation, occurring in a previously healthy person. There are many observations that concern all inflam- mations alike, whether external or internal, and by despatching these in the outset, I hope to avoid much repetition hereafter. In all cases of inflammation, our first object is, if possible, to obtain resolution: and if that be not possible, we next aim at securing that event of inflammation which would be the most fortunate in the particular case before us. In external inflamma- tions good suppuration will generally, next to resolution, be the most desirable event: in internal inflammations it will be sometimes suppuration, sometimes adhesion. It is necessary to keep in view the distinction between the treatment proper for the inflammation itself; and the treatment that may be required for the effects of the in- flammation. At present we are concerned only with the inflammation itself. I stated to you in a former lecture, that a knowledge of the cause of a disease mio-ht help us in its treatment. Knowing the cause, our first care must be to remove it, if we can. In the case formerly supposed, we should extract from the inflamed arm the fragment of glass. If the inflammation have been excited by the extremity of a fractured bone, of a broken rib for example, we take measures for bringing the separated bones into their proper places, and for keeping them there : if the mere displacement of a part have occasioned the inflammation, as the dislocation of a joint, the protrusion of the bowel in hernia, the first thing to be attended to is the restora- tion of the part to its natural situation : if there be any chemical source of irritation 166 INFLAMMATION. [lect. xtii. (in the stomach, for instance, threatening or producing inflammation there), we eject, neutralize, or dilute it. I know of but one exception to this rule, and it belongs to surgery: to wit, when a bullet or a splinter is so lodged in the interior of the body, that its extraction would be more hurtful or hazardous than its being left where it is. A knowledge of the cause of an inflammatory disease may help us in another way. We do not treat a joint that is inflamed in consequence of external violence, as we should treat the same joint when inflamed in rheumatism. But it is very seldom, except when the inflammation is external, that we can ac- complish the removal of its cause. In most internal cases, either it cannot be got at, or it has already ceased to be applied; as when the inflammation has been excited by exposure to cold. Yet it may be possible, and it is of the utmost importance when possible, to prevent any re-application or repetition of the same cause, which would be likely to frustrate our endeavours to bring about resolution. Next in importance to the removal and avoidance of the exciting cause, must be placed, in most instances, the observance of what is called the antiphlogistic regimen. This may seem an old-fashioned phrase, but it is a very convenient one; being a brief form of expressing the sum of several distinct provisions for the welfare of the sick, and for the conduct of their attendants. The word antiphlogistic is derived, indeed, from an obsolete theory; but we retain it as a useful arbitrary term, without reference to its etymology, or to its original meaning. The object of the antiphlogistic regimen is to put and keep the patient in that state which is most favourable for the spontaneous subsidence of the disease, or for the sanative influence of remedies. This regimen consists in the avoidance of everj stimulus or disturbing influence that can be avoided, whether external or internal. Common sense will suggest to you the details. It implies a total abstinence from solid animal food, and from strong drink of all kinds. It prescribes the exclusion of all that might excite or exercise the mind, or produce a strong impression upon the senses : noise; bright light; great heat or cold. The patient should be kept in a temperature of about 62°, and in a well-ventilated apartment. He must not be allowed to converse, nor to attend to matters of business; unless, indeed, his mind happens to be disturbed and anxious about some point which one short interview with a friend may effectually settle. All causes of strong emotion, and mental agitation, should be strictly guarded against. Whatever tends to quicken the circulation is to be shunned; and therefore not only those influences which operate through the nervous system, but also all needless bodily effort and exertion, must be prohibited. The patient (in the serious cases I am now contemplating) must remain in bed: and in a position which facilitates, or at least does not impede, the free return of the blood by the veins from the suffering organ. If the inflammation be seated in or about the head, that part should be elevated by pillows. If one of the lower extremities be affected, even when the disease is not so intense as to require confinement to bed, the limb must be sus- tained horizontally, or be even still more raised up. On the same principle it is that we suspend an inflamed hand or forearm in a sling. In some cases of internal in- flammation— in pleurisy for example — the patient will choose his own position. He is admonished, by the pain and distress they occasion, that certain postures would be hurtful or dangerous, and he carefully avoids them. We often derive much informa- tion from this instinctive caution on the part of our patient. The function of the organ inflamed should also be spared its exercise whenever, and in as great a degree as, that can be done. As you would not allow a patient to move an inflamed joint, so you must not permit him to gaze with an inflamed eye; to speak more than may be absolutely necessary with an inflamed lung, or larynx; to exert by thinking, and by attention to external excitements, an inflamed brain. This last rule is essential, even when the brain is not the seat of the inflammation : it is to be observed in all febrile disorders. The adoption of this antiphlogistic regimen is not, indeed, necessary, nor even proper, in all cases and stages of inflammation. The inflammation may be so slight as not to require it; particularly in external cases, of which the causes and the extent are known; as slight contusions, trifling wounds, and some kinds of eruption. But this exception must always be applied with great caution to cases of internal inflam- mation, about the causes, and extent, and tendencies of which we may be less sure. LECT. XIII.] BLOOD-LETTING. 167 In chronic forms of inflammation again, as in scrofulous inflammation of the lympha- tic glands, or of the eyes, attended with but little pain or heat, the antiphlogistic regimen would often fail to be beneficial: the state of the general system being such as to require support and strengthening measures, more than the local symptoms re- quire an opposite treatment. So also when suppuration or gangrene has supervened, the antiphlogistic regimen must generally be modified, or abandoned. But in the outset of all cases of serious inflammation, when the strength is entire, and the inflammation intense enough to produce pyrexia, all the particulars of the antiphlogistic regimen may require to be observed. Of all the direct remedies of inflammation, the abstraction of blood, bleeding, or h\oodi-letting, as it is called, is by much the most powerful and important. We should, I think, be prepared to expect this, prior to any experience of it. Blood being the natural stimulus of the heart, we should deem it probable that the removal of a por- tion of that fluid would diminish the force with which the heart contracts : and as an inflamed part contains a preternatural quantity of red blood, and as (with the excep- tion of resolution and mortification, which really are terminations of inflammation) all the events of inflammation depend upon the exudation of certain parts of the blood from its containing blood-vessels, we should be inclined, d priori, to believe that the amount of those exudations would be checked and limited by lessening the supply of blood to the inflamed organ, as well as by abating the force with which the blood reaches it. And we find it in fact to be so. The results of experience confirm, in this matter, the suggestions of our reason. Blood forms the pabulum of the whole process. " If," (says Mr. Lawrence), "we may be allowed to use figurative language, the obvious increase of heat in the part is analogous to that of fire; and blood is the fuel by which the flame is kept up: in fact, if we could completely take away its blood from the part, we should be able entirely to control or arrest the increased action." But it is not every case of inflammation that requires or warrants the abstraction of blood; and when blood-letting is requisite, the mode of taking away the blood, the quantity proper to be taken, and the propriety of repeating the bleeding, all vary greatly in different cases. It is obviously of vast importance that you should learn so to use this valuable remedy as not to abuse it. Its power is great for evil as well as for good; and in rash or inexperienced hands it too often becomes an instrument of fatal mischief. There are, as you all are aware, several modes of abstracting blood: phlebotomy, arteriotomy, scarification, cupping (which is merely a variety of scarification), the application of leeches. Bleeding performed in either of the first two of these methods is called general bleeding. The rest are, in most instances, topical or local: but they are not merely topical in all cases. The main object of general bleeding is to diminish the whole quantity of blood in the system, and thus to lessen the force of the heart's action. The object of local bleeding is, in most instances, that of emptying the gorged and loaded capillaries of the inflamed part. Sometimes the blood is thus taken directly from the turgid vessels themselves; more often, I fancy, topical blood-letting produces its effect by diverting the flow of blood from the affected part, and giving it a new direction, and so indirectly relieving the inflammatory congestion. General bleeding has also incidentally a similar tendency to deplete the vessels concerned in the diseased process: and, on the other hand, a dexterous cupper, under favourable circumstances, will take away blood from a part as copiously and rapidly as if it were made to flow from an opened vein; and then the effect upon the system will be alike in the one case and in the other. The same may be said of leeches, when they are applied in the enormous numbers which our neighbours, the French, are fond of using. In whatever way the blood is drawn, whether from a vein or from an artery, or by the pressure of a cupping glass around a surface previously scarified, or by the suction of leeches, the general effect upon the system will be in proportion to the quantity of blood abstracted in a given time. The most convenient and effectual mode of general bleeding, upon the whole, is certainly the common one, from the veins at the bend of the arm. But sometimes those veins are small or deep, especially in fat people : and we fail in our efforts to get the blood to flow from them in a full stream : and then we may open some other vein or an artery, or call in the cupper to our assistance, or cover 168 INFLAMMATION. [LECT. XIII the neighbouring surface with leeches; according to the situation of the part inflamed, and to other circumstances. Let us now briefly consider what the indications are by which we judge of the expediency of taking away blood. We are guided very much by the degree of pyrexia; by the quality of the pulse; by the importance of the organ affected; by the violence of the inflammation, in what manner soever that may be measured; by the period or stage of the disease; by the age, and sex, and general condition of the patient; and frequently also by the ordinary character and course of the disease, when inflammation happens to be, or to accompany, an epidemic disorder. It is not one of these circumstances alone, but several of them, that we have to take into the account, in most cases; and what I have now to say in reference to them must needs be very general. The presence of pyrexia, especially when the febrile disturbance is well marked, admonishes us, indeed, to search after other indications of the propriety of blood- letting, and confirms them if they are found; but is not, of itself, a sufficient reason for resorting to that remedy. There may be high febrile symptoms without any in- flammation at all; as in the hot stage of an ague fit. Again, a smart attack of fever may spring out of local inflammation, and yet the known course of the disease, or the nature of the part affected, may render the abstraction of blood unnecessary, and therefore improper. Nay, the presence of fever, when it is not the consequence but the precursor of the inflammation — when it depends upon a specific poison in the blood, and the inflammation has arisen as one of its casual complications — may pro- hibit any form of blood-letting. Our judgment is more often determined by the quality of the pulse, although we are by no means to be wholly directed by this. The quality of the pulse which — other things being the same—bespeaks the necessity of blood-letting in inflammation, is hardness. I described this quality to you in a former lecture : it may coexist with a large or a small, a slow or a frequent pulse. Most commonly (and yet the excep- tions are numerous) in acute inflammations the pulse is full and frequent as well as hard. The hardness is ascertained and measured by the resistance which the throb of the artery makes to the pressure of your finger. The pulse is sometimes said to be incompressible; which means that, although you apply your finger with consider- able firmness, the blood still forces its way through the vessel beneath it. Now this hardness or strength of the pulse is sometimes our best warrant for active depletion by means of the lancet; yet I say we must not trust to this alone; for a hard pulse may habitually exist, where there is no inflammation. Certain chronic diseased conditions of the heart may occasion it; and it probably results also some- times from some unnatural state, which is not inflammation, of the whole of the circulating system. When you happen to know your patient, and have ascertained what kind of pulse he has when he is well, and are previously aware that his pulse during health is not a hard pulse, you learn from that circumstance that the new quality it has now acquired denotes the presence of inflammation; and usually of active inflammation, likely to go on, if not controlled, to the destruction of the part it has seized upon. Many persons, and young practitioners in particular, are apt to look to the fre- quency of the pulse, when they wish to ascertain the expediency of blood-letting; but really its frequency is very subordinate in importance to its hardness or softness: and this is very unlucky, because anybody with his stop-watch in his hand can count a pulse; but it is not every one who can tell a hard pulse when he feels it. The finger requires a certain education for that purpose; and there are some persons who seem never to attain the tactus eruditus. I should advise you to attend particularly to this quality of the pulse, and to compare your perceptions of the hardness or soft- ness of the pulse in individual cases, with those of your companions, and of your clinical teachers. The frequency of an inflammatory pulse ranges for the most part between 90 and 120. Wheu the hard pulse is much more frequent than this, it commonly occurs either in young children; or in persons who are more than usually nervous and sus- ceptible ; or in persons who were previously labouring under some chronic and wast- ing complaint, in which the pulse was already frequent, though not hard : as, for example, in phthisical patients, when acute pleurisy supervenes upon tubercular dis- LECT. XIII.] BLOOD-LETTING. 169 ease of the lungs. In all such cases, the extreme frequency of the pulse is, per se, dissuasive of the use of the lancet. As the hardness of the pulse is, with certain exceptions at which I have just glanced, our lawful warrant for general bleeding, so the disappearance of that hard- ness is a token that the blood-letting has been carried far enough. Again, the nature and importance of the organ affected will influence our judg- ment in respect to the question of abstracting blood. If the organ inflamed be a vital organ ; or if we are not sure about that, but have any reason to suspect that it may be a vital organ; I need scarcely say that, other indications concurring, we must act upon the worst supposition, and bleed. But when the part is of less importance in the economy of the body; or when inflammation is known ordinarily to run its course in that part without producing any abiding damage; it may not be worth while, even though the fever be high and the pulse hard, to have recourse to this potent remedy, for the sake of subduing inflammation which is attended with so little danger. In this predicament may be placed many instances of cynanche tonsillaris, and of acute rheumatism. The subsequent debilitating effects of the loss of blood upon the system may be more certain and more hurtful than the effect of the bleed- ing upon the local inflammation is likely to be beneficial. [Without pretending to advocate the employment of blood-letting in every case of cynanche tonsillaris and of acute rheumatism, we must dissent from the correctness of Dr. Watson's position, that " even though the fever be high and the pulse hard," it may not be worth while to bleed " for the sake of subduing inflammation which, in these affections, is attended with so little danger." When acute rheumatism occurs in young, robust, and plethoric subjects, and is attended with considerable fever and a hard and accelerated pulse, we know of no remedy from which such decided advantage is to be obtained as from a well-timed resort to the lancet. The extent to which the bleeding is to be carried and the propriety of its repetition, must be determined by the circumstances of each case, and the effects produced by the first operation. We are no advocate, under any circumstances, for the profuse and repeated bleedings re- commended by M. Bouillaud as a means of cutting short an attack of acute rheuma- tism ; we have had, however, ample experience of the very decided relief obtained by a prudent and well-timed use of the lancet in this disease. In many cases of cynanche tonsillaris, also, an early and full bleeding will have the effect of arresting the inflammation, and thus of saving the patient from much suffer- ing, if not danger. Even when the arrest of the disease is not affected by it, the in- flammation is reduced in violence and shortened in duration. — C] The period or stage of the disease forms a most important element, the most im- portant indeed of all, in the question before us. It is of inflammation while yet in its earliest progress, that blood-letting may emphatically be pronounced the cure; while the disease is still within the possibility of resolution; before there is any great amount of exudation, or any serious disorganization of structure. The sooner we bleed, the more surely will the inflammatory process be moderated and limited, even when it cannot be wholly quenched. In no case within the range of medical practice is the maxim " principiis obsta" more imperative. Those among you who happen to be attending the wards of the Middlesex Hospital may wonder indeed, after hearing my estimate of the power of blood-letting over inflammation, that I so seldom pre- scribe venaesection there. The truth is, not that I undervalue the remedy, but that the time for its employment has generally gone by. The poor are unwilling to re- linquish the occupations by which they subsist: they struggle on as long as they can, and resort to hospitals only when they are compelled to do so by the exigency of their malady. Many of them, labouring under inflammation, have been freely bled before admission. It is commonly too late, when they present themselves, to expect that the course of the disease can be so arrested. The first effect of blood-letting is to deplete and relieve the labouring circulation. But when it is again and again re- peated, it becomes (as the French say) spoliative; it robs the vital fluid of its nutrient and plastic materials. Pushed still further, it produces a peculiar state of the nervous system, marked by great weakness and irritability. Now although blood-letting is the summum remcdtum for active inflammation at its very commence- 170 INFLAMMATION. [LECT. XIII, ment, there is a point beyond which it not only does no good, but is positively in- jurious. And this point it is not always easy to hit. On one side is the danger that the inflammatory action may continue and extend; on the other the danger that the strength of the system may be so reduced as to prove unequal to the process of restoration : for, to remove the interstitial extravasations, and to repair the damage that has accrued, a certain degree of vital power is requisite, and a sufficient quantity of healthy blood. Bleeding may cure inflammation, but it will not always cure the effects of inflammation ; nay, it may render them lingering in their departure, or even determine their fatality. I cannot too often, or too strongly inculcate the precept, that in order to extinguish or check acute inflammation, you must, above all, bleed early. We judge that the bleeding has been carried far enough when the inflammatory fever subsides, or changes its character; when the pulse regains its^ softness, or undergoes some marked alteration; when any of the signs (already specified) of sup- puration appear. Upon these points I hope to give you more explicit instruction when we come to special instances of inflammation. Whenever inflammation supervenes on other chronic disease; whenever it arises in the progress of idiopathic fever, or whilst the constitution is contaminated by some specific poison; whenever suppuration is inevitable, or even probable: in all these cases general blood-letting may be necessary, but it must always be employed with great caution. Nor can we, safely, neglect the age, the sex, the general condition of the sick person, when we are turning in our minds the propriety of bleeding. The very young, the old, the feeble, the cachectic, do not bear well the loss of much blood. This consideration is not to deter you from bleeding such persons when they are attacked by dangerous inflammation; but it especially enforces, with respect to them, the general rule, that no more blood should be abstracted than seems absolutely re- quisite to control the disease. It is also very necessary to study the character and tendency of the reigning epidemic: whether that may depend upon some predisposition silently and gradually wrought in men's bodies by the agency of causes that are but little understood: or whether it may result from some peculiarity in the exciting cause of a particular epidemic disease. I have been long enough in practice in London to have learned, in common with others, how much the character of continued fevers may alter. Since about the time when the virulent form of cholera made its first appearance among us, continued fevers have neither needed nor borne the abstraction of blood, as they did bear and need it for some years prior to that period. Perhaps some varia- tion in the intensity of the poison may partly explain the comparative malignity — the greater tendency, I mean, to what is called lowness of type—which marks certain epidemics of scarlet fever, small-pox, and measles. The influenza, or epidemic catarrh, which was almost universal in this town and kingdom in the years 1833, 1837, and 1817, afforded a striking illustration of the point I am endeavouring to set before you. The inflammatory symptoms—the bronchitis, and sometimes pneumonia — were in many cases strongly marked, and it appeared necessary to abstract blood; but persons suffering under influenza bore bleeding exceedingly ill, and where the use of the lancet could not be avoided, it was never resorted to without reluctance and misgiving. I would not, however, limit these remarks to fevers, or to specific inflam- mations. I share in the belief which has grown out of the experience of many thoughtful and observing men, that in this country at least, the human constitution has for several years been suffering a gradual change: that almost all inflammatory disorders assume now-a-days a more adynamic type, and require less energetic treat- ment than in the early part of the present century. When we bleed in acute inflammation of an important organ, we endeavour, I say, to effect our purpose as speedily as possible, and with as little expenditure of the vital fluid as possible It would be quite ridiculous to pretend to give any precise direction as to the number of ounces of blood that should be taken. You must stay by the patient, and bleed, in such cases as I am now contemplating, until you produce some distinct impression by the bleeding; and one of the best guides in this matter is the state of the pulse. If you find, as you sometimes will do, that the most pressing symptoms give way while the blood is still flowing — that the pain, for instance, is LECT. XIII ] BLOOD-LETTING. 171 mitigated — that the respiration (when the lungs are concerned) becomes easier and deeper — that (in affections of the brain) the patient emerges from a state of stupor or delirium — you may be sure that you are doing right in bleeding; but you must keep your finger upon your patient's wrist, and suffer the blood to flow, until the hard pulse is sensibly softer, or until symptoms of impending syncope appear; and then you had better tie up the arm, and wait a few hours, and repeat the bleeding if the symptoms which at first demanded it again become urgent. As it is desirable to produce the necessary effect upon the system as quickly as may be, the blood should be taken pleno rivo ; i. e., a sufficiently large orifice should be made in the vein : and sometimes it may be right even to open a vein in both arms : and the patient should be bled in the upright position. Faintness and syncope depend upon a defective supply of blood to the brain; and therefore will be likely to occur the sooner when the force of gravity facilitates the descent of the blood from the head through the veins, and retards its ascent towards the head through the arteries. And conversely, the first thing to be done towards remedying syncope is to lay the person flat in a horizontal posture, or even with his head lower than his body. If you neglect these smaller matters, and make an insignificant slit in the vein, and suffer your patient to lie down whilst you are bleeding him, you will be obliged to take much more blood in the end; or you may drain him of his blood and of his strength by repeated bleedings of this sort, and make no impression after all upon the disease. It is one of the numerous cases in which parsimony is not true economy. The quantity of blood requisite to be taken in order to produce the due effect is exceedingly various. It is a remarkable circumstance, well worth attending to, and much insisted upon of late years, especially by Dr. Marshall Hall, that a patient under the influence of mere inflammation will bear to lose a far greater quantity of blood without becoming faint, than he could bear in health : that the state of the system produced by the presence of inflammation supports it against the ordinary conse- quences of loss of blood. The amount of the bleeding requisite to occasion syncope will be in proportion to the exigency of the case. This fact—if it be really a fact, as indeed I believe it is — is evidently one of the highest value and importance, for it furnishes, what is always so desirable, especially in an uncertain art like ours, a simple rule of practice. Yet it is not a rule so firmly established as not to admit of exceptions. If the mere state of syncope were the curative influence required, we should have no difficulty. That the faintness does constitute a part of that influence I fully believe. Dr. M. Solon relates a case in which it even sufficed to the cure of erysipelas of the head and face, attended with high fever. The patient fainted from alarm before the vein was opened. The inflammatory symptoms thereupon ceased: but with returning animation they presently recurred. Again preparation was made for venaesection; and again the young lady lapsed into syncope; and this time the inflammation and fever disappeared, never to return. She is described as having been quite well the next day. I cannot, however, entertain a doubt that the with- drawal of a certain quantity of blood is, in almost every fit case, conducive to the permanent control of common acute inflammation, attended with strong pyrexia : and it may be advisable to keep persons, who, like M. Solon's patient, are of a timid disposition, and liable to syncope from slight causes, in a recumbent posture, in ordei that the necessary discharge of blood from the system may be obtained. In equivocal cases (and there are many such), where it is questionable whether the symptoms proceed from inflammation or not, the diagnosis may often be settled by observing the quantity of blood which, taken in the upright posture, suffices to bring on incipient syncope. Another criterion — more exact perhaps than this, but requi- ring more time, knowledge, and skill for its due application — is afforded by the pro- portion of fibrin in the blood abstracted. Dr. Hall's book, On the Effects of the Loss of Blood, is well worth your attentive perusal. He suggests that a scale of diseases might be formed, representing the sus- taining influence of some maladies against the effects of blood-letting; and the oppo- site influence of some others in producing preternatural susceptibility of those effects. "It would begin (he says) with congestion of the head, or tendency to apoplexy; inflammation of the serous membranes, and of the parenchymatous substance of vari- ous organs, would follow; then acute anasarca; and lastly, inflammation of the mu- cous membranes. This part of the scale would be divided from the next by the con- 172 INFLAMMATION. [LECT. XIII. dition of the system in health. Below this would be arranged fevers; the effects of intestinal irritation; some cases of delirium; reaction from loss of blood; and disor- ders of the same class with hysteria; dyspepsia, chlorosis, and cholera morbus. As to the propriety of repeating venaesection, it is his remark, that if at the first blood-letting much blood flowed before any tendency to syncope manifested itself, an early repetition of that remedy will probably be required — and at any rate_ an early repetition of our visit to the patient will be proper. But this last precept is of uni- versal obligation in all cases of serious inflammation. I am almost afraid to tell you how much blood I have seen taken at one bleeding, lest I should seem to encourage you to imitate such heroic practice. I once stood by, and saw, not without trembling — although I was quite free from responsibility in the matter — a vein in the arm kept open until seventy-two ounces (four pints and a half) of blood had issued from it: and then, and not till then, did the patient become faint. The event of the case quite justified the bleeding in that instance, for the man got rapidly and perfectly well. It was a case of general dropsy, which had come on suddenly, in a young and robust man. It occurred in the clinical wards of the Infir- mary at Edinburgh : the physician had desired the clinical clerk to bleed the patient in the erect posture, until some sensible effect was produced upon his pulse : and no such effect could be perceived until the enormous quantity I have mentioned had been abstracted. It is very seldom that such large bleedings are required, or defen- sible : you will generally find that from sixteen to twenty or thirty ounces taken pro- perly, will be sufficient to accomplish the purpose of the measure. Sometimes one such bleeding will extinguish, as it were, the inflammation, or curb its destructive force; sometimes two or three, or half a dozen may be necessary: and we judge of the propriety of repeating the venaesection by the effect of the former bleeding; by the character of the pulse; by the appearance of the blood already drawn. • It would be impossible, in a general account like the present, to lay down any minute directions on this head. I have hitherto been speaking of bleeding as we perform it for the cure of active inflammation, occurring in a person previously healthy, affecting an important organ, and attended with high febrile disturbance of the system. But the removal of blood is scarcely less valuable as a remedial measure in chronic inflammation, when the system at large scarcely sympathises at all with the local disease. And here it is that what is properly called local bleeding is so useful — by cupping glasses, or a moderate number of leeches. The object is always the same, viz., to unload and relieve the turgid capillary vessels of the part: and this we could not do by general bleeding without carrying it to an extent which would be dangerous to our patient's welfare. These local bleedings for chronic inflammation usually require to be often repeated. Considered as a remedy, blood-letting resembles some other remedies in this, that it must be proportioned and adjusted to the rate of progress, and the duration, of the disease. The remedy must be used chronically when the malady is chronic. A pa- tient may lose, on the whole, much more blood for the cure of a chronic inflammation, than for the cure of one that is violent and acute; but then the bleeding must be spread over a larger space of time. With respect to the relative merits and advantages of cupping and of leeches, as topical remedies for local inflammation; it may be said in favour of cupping, that the precise quantity of blood taken away is more accurately determined in that manner, and the operation is sooner over, and is less fatiguing, than the suction of leeches. But on the other hand the leeches seldom bungle in the operation; while the surgeon sometimes does. It requires a good deal of practice to become handy and dexterous in the application of the glasses — to avoid torturing and burning the patient — and therefore it is that in large towns, as in this metropolis, cupping is an art carried on by a distinct class of expert persons. You may apply leeches also to parts where the cupping glasses could scarcely be used. General bleeding then is best adapted to acute inflammations; and topical bleeding is most appropriate in those which are chronic and slow. But a combination of the two is often highly proper and useful. You may lessen the tension and force of the general circulation by venaesection; but the small vessels of the inflamed part may remain unable to rid themselves of their excess of blood, and continue dilated and full. Such, at least, we may reasonably suppose to be sometimes the case: and LECT. XIII .] BLOOD-LETTING. 173 certainly we often act successfully upon that theory; that is, we bleed from the arm, and at the same time, or presently after, we empty the capillaries of the labouring organ, or the neighbouring vessels, by the help of leeches, or by the scarificator and exhausted cup. The good effect of local bleeding, after the general febrile disturb- ance has abated under venaesection, is often very marked in the relief of pain. I have recommended blood-letting to you when, among other circumstances, the pulse is full and hard; and have stated that the blood should be suffered to flow until some distinct impression is made upon the system. But I wish also to apprise you, that you ought not to be deterred from bleeding merely because the pulse is small. It is very apt to be so in dangerous inflammations within the abdomen; and it is a very curious thing that the pulse will often rise, and the artery develop or expand itself even while the blood is issuing. Now you must look upon thai circumstance as a distinct impression made upon the system, although it is one of a rather different kind from what I spoke of before. You had better, in my opinion, pause when this effect is fairly obtained : for so great is the tendency to death by syncope in abdominal inflammation that it would not be prudent to urge the influence of the blood-letting further, at one time, than the change I have just mentioned. Wait, therefoie, and repeat the venaesection if the circumstances should again render it necessary.1 1 The principles laid down in the foregoing lecture have, even while these pages are passing through the press, been arraigned as unsound and fallacious by a physician whose eminence compels attention and respect to every deliberate expression of his opinions. When no less a person than the Professor of the Institutes of Medicine in the University of Edinburgh proclaims his belief that, with respect to internal inflammations, "the principles on which blood-letting and antiphlogistic remedies have hitherto been practised, are opposed to a sound pathology," I, who, for one, still adhere, from conviction, to the same principles which I have formerly taught, can scarcely help taking upon myself to review—very briefly, and in all courtesy and candour— some parts of the Professor's reasonings, and to inquire into their validity. Although Dr. Hughes Bennett intends his observations to have a general application, he chooses inflammation of the lungs for the main topic and illustration of his argument; and he begins by setting aside as worthless all so-called experience of that disorder, of an earlier date than the invention of auscultation. Cullen and Gregory, and writers yet older than they, were not able (he says) to recognise pneumonia in the living body, and therefore cannot be said to have had any real or certain knowledge of its behaviour under remedies. Now, it may be granted that neither Cullen nor Gregory could assure himself, as any student of the second year might now do, of the changes wrought by pneumonia in the living lung; but they certainly were competent to ascertain, beyond all doubt, that inflammation was going on somewhere within the chest. Against such inflammation they learned, by watching, the efficacy of early venisection. They obtained most trustworthy evidence and experience of its power to control inflammation; which is precisely what Dr. Bennett contests. That they might not be certain as to the exact seat of the internal inflammation, is nothing to the purpose. This part of Dr. Bennett's argument flies wide therefore of its mark. I venture to call in question the accuracy of Dr. Bennett's positions, that inflammations can never be cut short; but whether they are to end favourably or unfavourably, must and always will run through a certain course: that it is the physician's proper business to promote rather than to impede this their natural progress : that the formation of pus-corpuscles is essential to the elimination of the products of inflammation from the body. I believe, on the contrary, that inflammation may sometimes be extinguished in its very infancy, before any of its customary pro- ducts have occurred; and that even after they have some of them occurred, the intensity of acute inflammation may be abated, and its extension stayed, by the judicious use of the antiphlogistic regimen and remedies. I cannot think, as Dr. Bennett seems to think, that every step after the very first step in the inflammatory process is to be regarded as nature's mode, and the only mode, of bringing that process to a satisfactory termination. In affirming it to be impossible that bleeding from the arm can directly affect the coagulated exudations of inflammation, Dr. Bennett combats a doctrine which, so far as I am aware, has no defenders. Who treats, knowingly, the extravasated products of inflammation by general bleeding? The primary object of that measure is to anticipate, and if it may be to prevent, such products. Still, in my judgment, it is not improbable that the abstraction of blood may sometimes promote the reabsorption of the matters exuded. Whatever may be the ultimate beneficial result (and I believe that it will be immense) of that scrutiny, chemical and micro- scopical, into morbid textures which modern science has achieved, the information thus obtained is not yet complete or ripe enough to warrant any exclusive reliance upon it as a guide to treat- ment ; more especially when its teaching appear.s to clash with the prior teaching, for hundreds of years together, of well-conducted though empirical observation. And see what experience has really attained in this matter. Facts which no one can gainsay, attest the immediate influence of blood-letting in incipient inflammation. The emergence from coma, or from delirium, while the blood is still flowing, in intracranial inflammations — the Budden relief of pain, tightness of the chest, and restricted breathing in pneumonia itself, its 174 INFLAMMATION. [lect. XIII. presence being further assured by the pneumonic crackling and the pneumonic sputa, — are familiar facts of that kind. Dr. Alison has testified to the unmistakeable benefit experienced by himself under the employment of the lancet in a sharp attack of pleurisy; and 1 have no doubt whatever that my own life was once rescued by bleeding in inflammation of the bowels, so prompt, unequivocal, and decided was the amendment which fellowed that remedy. Facts such as these being abundant on all sides, and undeniable, to allege that the patients were ultimately the worse for the treatment pursued—that they would have recovered sooner, or more thoroughly, had no bleeding been instituted,—is a mere begging of the question at issue, which we, of the older belief, may fairly decline to grant. That which at first sight appears to be the strongest point in Dr. Bennett's argument, is his appeal to the evidence of statistics. But the "numerical method," as it is called, though of excellent use in many researches, and indispensable to the acquirement of exact information of some kinds, has no conclusiveness at all, but, on the contrary, may easily mislead, when it is applied to the treatment of separate cases of disease. To be guided by statistical results here, is to adopt the irrational and dangerous rule of prescribing after the name of a disorder; whereas each case requires its special study, speaks its proper language, furnishes its peculiar indica- tions, and reads its own lesson. Take the very disorder considered by Dr. Bennett — take pneumonia, as certified to exist by its auscultatory signals. Surely no sane person professes to treat all instances of it in the same manner. The great majority of such cases are, by common consent, treated without venisection, and probably much as Dr. Bennett would himself treat them; some are properly treated by stimulants even; some by opium; some with mere "ex- pectation." The exceeding value of statistical returns in determining the causes of disease has been admirably set forth by Dr. Alison; but, for directing the treatment of individual cases, it is far more profitable (as some one has well expressed it) to watch, than to count. To use or to withhold a given remedy simply because it is found, by numerical calculation, that in cases nominally the same, recoveries have been more frequent when that remedy was employed on the one hand or omitted on the other, would be to sacrifice the plain and perhaps pressing indica- tions of a particular case, to the statistical averages of diseases having merely a common deno- mination. To repeat what I have said elsewhere — we do not necessarily take the same symp- toms as indications of treatment, which we trust to as signs of disease. We treat, indeed, not the so-called disease, but its accidents; the vital manifestations which proclaim its character and intensity, foreshow its tendencies, and illustrate its course. With respect to pneumonia, it is very true that there is much less bleeding practised now than formerly; partly, I do entirely believe, from a change in those vital manifestations to which allusion has just been made; partly because we more easily and surely estimate the extent, conditions, and progress of the inflammation. Or rather, perhaps, it should be said (setting aside what may be due to the mere fashion of the day) there is apparently less bleed- ing, because many more instances of disease are brought within the category of pneumonia, by the testimony of the ear. We grant that bleeding, like all other potent remedies, is powerful for evil as well as for good; but we advocate its prudent use, not its careless adoption, or its routine abuse. We believe that the plan which would dispense with blood-letting in all cases of acute inflammation, is too simple and facile to be the right or a safe plan. It is objected to venaesection that "it deteriorates the blood, rendering it poorer in corpuscles and richer in water," and therefore (presumably) less fit for the purposes of repair. But it should be remembered that the blood is liable to deterioration of a more pernicious kind by the presence and persistence of acute inflammation. Herein consists a marked difference between fevers, and common inflammation occurring in a previously healthy person. In fevers the blood is primarily diseased. In inflammation there is reason to believe that it is the very part inflamed which gradually spreads infection through the general mass of the blood; and thia contamination we prevent or limit, if we can arrest the inflammation. After all, Dr. Bennett admits that though large and repeated blood-lettings are opposed to a correct pathology, benefit may nevertheless accrue from a limited abstraction of blood, when there is no great debility. He even thinks it probable (speaking, however, of what he infers to have been obstruction to the circulation rather than inflammation) that the "inexpressible relief" derived in some cases of "great dyspnoea and pain," from the loss of only a few ounces of blood, may have arisen from its "diminishing the tension of the whole vascular system." [n these admissions I apprehend that the whole matter in dispute is virtually conceded. For who shall say, in a given case of severe inflammation, what is a large, and what a small bleed- ing ? These are relative and even convertible terms. So that the Professor here appears to me to come back to the ancient ways, and the accredited practice; which is, neither to exclude bleeding, nor to bleed in excess of the present necessity. So to bleed as to secure the advan- tages of the remedy, and to avoid its disadvantages, is the precept I believe of all teachers. I have no room to discuss the question, answered in the negative by Dr. Bennett, whether febrile inflammatory diseases may change their type. He takes pains to show that the process of inflammation, in its several steps, its products, and its local effects, are at all times the same. What he has not shown is, that the human constitution is incapable, from influences to us unknown, of undergoing alterations, in respect to the manner in which it is affected by inflammation, and by the reputed remedies of inflammation. For my own part, I am firmly persuaded, by my own observation, and by the records of medicine, that there are waves of time through which the sthenic and asthenic characters of disease prevail in succession; and hat we are at present living amid one of its adynamic phases. LECT. XIV.] BLEEDING. 175 LECTURE XIV. Treatment of Inflammation, continued. Recapitulation. Bleeding. Purgatives. Mercury. Antimony. Digitalis. Colchicum. Opium. Local Remedies. External Cold. External Warmth. Counter-Irritation. After pointing out to you, yesterday, the necessity of guarding your patient, as much as possible, from all stimulants and sources of irritation, both internal and ex- ternal, the avoidance of which constitutes what is called the antiphlogistic regimen, I began to speak of the remedies of inflammation. Now the great remedy in acute and dangerous inflammation is blood-letting: and when this remedy is used at all, it should be used freely, and so as to produce a de- cided impression : and its efficacy for good will always be the greater, in proportion as it is applied in the earlier stages of the inflammation. The objects of the abstrac- tion of blood are two-fold : to lessen the force of the heart's action is one object; to ease the gorged capillaries of the part inflamed is the other. We effect the first of these objects, or both of them at once it may be, by making an orifice with a lancet, in the trunk of some convenient vein or artery, and allowing the blood to escape; we accomplish the second by making little incisions with a scarifier through the skin as near the inflamed part as we can, and forcing the blood through these little wounds by the pressure of the atmosphere: i. e., we take off the pressure from the part sca- rified, by placing over it a glass cup, from which the air has been in great measure exhausted, and then the unbalanced weight of the atmosphere upon the surrounding surface forces out the blood; or we suffer leeches to scarify the skin, and to suck out the blood. These two modes of drawing blood, from the trunks of the blood-vessels on the one hand, and from the capillaries on the other, we call, respectively, general bleeding, and topical bleeding. I say themiain point to be achieved in general bleeding is so to manage the opera- tion as to make a decided impression, as quickly as possible, upon the pulse or the heart: and to do this we place our patient in an upright position, and make a free orifice in the vein of one or both arms. And when the force of the general circulation has been thus abated, it will in many cases be proper and necessary to take away blood from the capillaries also, in the neighbourhood of the suffering organ. This is almost always safe and good practice : there can seldom be any reason for abstaining from it, unless the general bleeding has had so great an effect that the abstraction of a few more ounces in any way might be hazardous. But the employment of local depletion presently after general is then espe- cially indicated, when the local symptoms remain unrelieved; when, although the indirect symptoms which manifest themselves through the medium of the system at large have been moderated by the general blood-letting, yet the direct symptoms be- longing to the part, and disturbing its functions, the pain, for example, or the labour- ing breath, or the stupor, have not undergone a proportional improvement. Under such circumstances, the unloading the oppressed capillaries by means of leeches or cupping-glasses will often be attended with the happiest effects. I mentioned that the most common way of performing general blood-letting in this country is by venaesection; and that the veins chosen, as the most suitable for that purpose, are the cephalic and basilic veins at the bend of the arm : but that when, from accidental circumstances, blood cannot be obtained easily and abundantly from those veins, any other large and superficial blood-vessel may be opened. It matters little which, in my opinion, so far as regards the effect of the abstraction of blood upon the disease. Some persons are fond of opening the temporal artery when the inflammatory disease is situated in or about the head : and certainly, when we see this vessel starting from the surface like a cord, and tortuous from its fulness, and visibly throbbing, we feel tempted to give vent to the blood which is distending it. But arteriotomy is not so easily managed as phlebotomy. It is sometimes difficult to get the blood to flow properly; and it is sometimes difficult to stop its egress when we 176 INFLAMMATION. [LECT. XIV. wish to do so; and sometimes there are after-consequences which are far from being pleasant: little aneurismal tumours are apt to arise. It is, besides, desirable to avoid the necessity of bandaging the head, in order to restrain the further efflux of blood from the artery. Other practitioners recommend opening the external jugular vein in head cases, especially in children, whose veins in the arm are small. This is a plan which I have never adopted, and which, I am bound to tell you, I do not like: first, because I think it seldom can be necessary; secondly, because I think it is often unsafe. It is seldom necessary: for in children we can always get as much blood by topical bleeding as will be equivalent to a general blood-letting. And it is unsafe in two ways. In the first place, it is not always an easy matter to stop the bleeding from the jugular vein, especially in a struggling and unmanageable child; and the differ- ence of a few ounces of blood may be % fatal difference. Here also any compression of the neck, to stay the hemorrhage, might affect injuriously the cerebral circulation. Again, there is a distinct and peculiar danger attending the incision of this vein, that, namely, of admitting air into it. You perhaps are aware that if air enter a large vein near the heart, and pass on to that organ, it kills outright. If you open the jugular vein of a horse, and blow forcibly into it towards the heart, the animal drops down dead. The celebrated Bupuytren was performing some operation about the neck, in the course of which he cut across one of the veins there situate; some bubbles of air rushed in at its open mouth, with an audible clucking noise, and, in an instant, his patient expired. The same frightful accident has occurred during operations per- formed in this country, and in America. I was told very lately that in one of our metropolitan hospitals it was thought right, for some reason or other, to bleed an adult patient by opening his jugular vein. The opening was made very near the clavicle, so that pressure between the orifice and the heart was difficult to effect. Of course the blood soon leaves the. portion of the vein nearest the heart: and whether by some suction power of the heart itself upon the veins, or how, one scarcely knows, but air rushed in, and the patient was presently a dead man. Perhaps misadventures of this kind may be capable of being prevented by using great caution in such cases; but as it is the etiquette for physicians to direct but not to perform these manual services towards the sick, and as, therefore, I should incur all the responsibility, and at the same time be able to ensure none of the necessary care, I confess that I am shy of recommending venaesection to be made in that particular place. Whether, all other things being the same, the abstraction of arterial blood may be more or less effectual in restraining inflammation than the abstraction of venous, is more than I can tell you. When topical bleeding is employed with the view of disburdening the turgid capil- laries, it would seem most expedient to get as near to the part affected as we can. To apply, for example, our cupping-glasses or our leeches to the temples, or behind the ears, or just below the occiput, in inflammatory affections of the head; to the chest or the praecordia, when the lungs or heart are the seat of the disease: to the surface of the abdomen, in inflammation of the liver, or stomach, or intestines, and so on. And this is the plan which I have almost always adopted; and with such satisfactory results that I have felt little inclination to try any other. But many persons do be- lieve that local bleeding is more useful when it is performed at some distance from the affected part. They would put leeches, for instance, on the insteps, to relieve an inflamed throat; and they attribute the benefit that ensues to what is called revulsion. They suppose that the suction of the leeches solicits the blood, as it were, to that quarter, and diverts it from the vessels of the part that is inflamed. It seems to me that the revulsive influence of topical bleeding would be greater in the neighbourhood of the inflamed part than far from it. I know, however, some very practical men who have been much struck with the results of this distant blood-letting, which they had seen practised in the Parisian hospitals. Leeches are also sometimes applied at a distance from the seat of the inflammation, on another principle — that of drawing the blood directly from the veins which communicate with the diseased part. In abdominal affections, in inflammation of the liver or intestines, the French are in the habit of applying leeches in great numbers to the verge of the anus; because, they say, the blood is then abstracted from the very veins through which it is returning towards the. already overloaded organs. It is right that you should be aware of these LECT. XIV.J PURGATIVES. 177 opinions, and of this practice. I can say but little of it from my own knowledge, 1 can well believe, however, that it is good and useful practice: but in this country we should find it difficult to persuade many of our patients to submit to have leeches planted round the anus: and I have seldom been disappointed of the benefit I ex- pected from topical bleeding, when it has been employed at the surface, as near the part inflamed as possible. The evacuation next in importance to blood-letting, is purging. This is an expe- dient which in cases of violent inflammation, or high general fever, should scarcely ever be omitted. To keep the bowels what is called open, forms indeed a part of the antiphlogistic regimen; but in acute inflammatory diseases, active purging is often of very great service. These two points are gained by it. The stomach and intes- tines are freed from accumulated faeces, or other matters which, by their bulk or their acrimony, might prove irritating: and at the same time depletion is carried on by means of the serous discharge which is produced from that large extent of mucous membrane. There are some cases of inflammation in which the operation of purga- tive medicines is of especial benefit; as in inflammatory affections of the head, either external or internal, of which part these medicines assist or cause the depletion in a very sensible manner. We have an illustration of this in the paleness of the face, which often, during health, accompanies the action of a brisk cathartic. The useful- ness of repeated purgatives is less distinctly seen in inflammations situated within the thorax; although in these cases also they are often very beneficial. They are efficient remedies too in all inflammatory conditions of the liver. But when inflammation has fastened upon the stomach or bowels themselves, although it may be indispensable that they should be unloaded of their contents, which are often composed of irritating ill-digested food, and of morbid secretions no less teasing and hurtful, the propriety of going beyond this point is extremely questionable. I believe that much harm is often done by pressing the inflamed alimentary canal with active purgatives. But to all these points I shall have occasion to return. Next to blood-letting, as a remedy, and of vastly superior value upon the whole, to purgation, in serious inflammations of various kinds, is mercury. This mineral is really a very powerful agent in controlling inflammation ; especially acute, phlegmo- nous, adhesive inflammation; such as glues parts together, and spoils the texture of organs. It is of the greatest importance that you should accurately inform yourselves concerning the various effects of mercury upon the system : the changes it produces; the changes it arrests or prevents; the cases in which it does good; the cases in which it does harm; that you should learn, in short, how to wield a very potent, but a two-edged weapon. If we inquire what mercury does when it is administered to a person in health, we find three very marked effects following its internal use. They vary, indeed, in different cases, and under different circumstances; but we know that the employment of mercury under any of its usual forms of exhibition is often followed by increased watery evacuations from the intestines; or by an increased discharge of bile; or by an increased flow of saliva: that is to say, it determines (as the phrase is) to certain secreting organs—the mucous membrane of the bowels, the liver, the salivary glands; it augments their natural secretion; and in this augmentation of secretion is implied an increased afflux of blood to the secreting part. It is probable that mercury has a similar influence on most or all the secreting surfaces of the body, altering the condi- tion of the capillary circulation throughout. And an explanation of its curative power in inflammation has been drawn from this fact: it has been supposed that mercury thus tends to equalize the circulation; that by causing the blood to be dis- tributed in larger quantity than common upon several surfaces at the same time, it obviates, pro tanlo, its excessive congestion or accumulation in any one organ. Whether this hypothesis in respect to the modus operandi of mercury be true or not, I will not pretend to say; but it certainly is not an unreasonable hypothesis. If you push this remedy in healthy persons, other effects ensue: inflammation is actually produced; the gums become tender, and red, and swollen, and at length they, ulcerate; and in extreme cases, and in young children especially, the inflamed parts may perish: the cheeks, for example, sometimes slough internally. Not only the gums, but the throat and fauces, grow red, and sore, and sloughy. Now you will do well to observe what is the character of the inflammation thus 12 178 INFLAMMATION. [lect. xiv. produced. It is superficial, spreading, erysipelatous: it leads to ulceration without any distinct occurrence of suppuration; the ulcers enlarge. Of the three processes which I formerly pointed out as going on in different degrees, at the same time in an ulcerated surface, that of absorption is vastly predominant; and you will find that persons in whom this local affection, this condition of the parts within the mouth, has been produced, get rapidly thin: their fat disappears: they become emaciated. That is, the absorption of the old materials throughout the body exceeds the deposit of new matter. Patients who are kept under the influence of mercury grow pale as well as thin: and Dr. Farre, who has paid great attention to the effects, remedial and injurious, of this drug, holds that it quickly destroys red blood; as effectually as it may be destroyed by venaesection. As an example of this he was in the habit of relating in his lectures the case of a lady who was attacked with haematemesis : and whose gastric system and liver were gorged with blood. " Her complexion," said the Doctor, " was compounded of the rose and the violet. Under a course of mercury she was blanched, in six weeks, as white as a lily." There are still other, occasional, effects of the continued introduction of mercury into the body: a peculiar eruptive disease; a peculiar condition of the nervous system : but with these I do not now meddle; they will come under our more par- ticular consideration hereafter. At present I am desirous to place such facts before you as may help you to determine in what cases mercury is a fit remedy for inflam- mation ; in what cases it would be improper to give it. The facts I have already mentioned show that it has a loosening effect upon certain textures; that it works by pulling down parts of the building. But the great remedial property of mercury is that of stopping, controlling, or altogether preventing the exudation of coagulable lymph; of bridling adhesive inflammation ; and if we, in our turn, could always bridle and limit the influence of mercury itself, it would be a still more valuable resource. From the little I have now said you will readily understand in what description of cases mercury is likely to be useful. In common adhesive inflammation, whether of the serous or the areolar tissues; whenever, in fact, you have reason to suppose that coagulable lymph is effused, or about to be effused, and mischief is likely to result from its presence, then you may expect benefit from the proper administration of mercury; as an auxiliary, however, to blood-letting, when blood-letting is indicated, — not as a substitute for it. On the other hand, mercury is likely to be hurtful in those forms of disease " where the morbid action approximates to its own action :" in cases of erysipelatous inflam- mation having a disposition to gangrene; in scrofulous diseases; in inflammatory complaints attended with general debility, and an irritable condition of the nervous system, or a manifest tendency to take on a low and typhus-like character. When we have to contend with acute inflammation, and desire to prevent or arrest the deposition of coagulable lymph, our object is, after such bleeding as may have been proper, to bring the system as speedily as possible under the specific influence of mercury. How may this best be done ? and how are we to know that it has been achieved ? I will answer the last of these questions first. We know that the whole system has been brought under the specific influence of mercury, as soon as its effects become even slightly perceptible in the gums and breath of the patient; and in adults we cannot be sure of it before. The gums grow red and spongy; the patient complains that his gums are sore; and that he has a metallic taste, a taste like that of copper in his mouth. At the same time, an unpleasant and very peculiar foetor, easily recog- nised again when it has been once perceived, is smelt in his breath. These symptoms are enough : you need not in general look for any more decided affection of the mouth, such as ulceration of the gums, swelling of the glands beneath the jaw, and of the tongue, and a profuse flow of saliva. Formerly, when it was believed that the material cause of the disease was carried out of the body with the saliva, the mercurial treat- ment was continued with the view of producing the discharge of many ounces, and even of a pint or two, in the twenty-four hours : but all that is requisite is that the gums should become distinctly tender, and that the mercurial foetor should be unequi- vocally manifest, and that these symptoms should be kept up for a certain time. Now this is best effected, usually, by giving some form of mercury in equal and LECT. XIV.] MERCURY. 179 repeated doses, by the mouth. For urgent cases calomel is the best form in which it can be administered: two or three grains given every four or six hours, will generally suffice to touch the gums in the course of thirty-six or forty-eight hours. If it act as a purgative, its specific effect upon the whole system will be postponed by that circumstance; and it then becomes expedient to combine with it just so much opium as will prevent its passing off by the bowels. A quarter of a grain of opium with two grains of calomel — or a third of a grain of opium with three or four grains of calomel—will generally be sufficient to restrain the purgative operation of the latter. When a speedier effect is desirable we give larger doses; such as five or ten grains every three, or even every two hours : or we combine mercurial inunction with the exhibition of calomel by the mouth. It is impossible to lay down any precise rule that will fit all cases. Blue pill, or else the hydrargyrum cum cretd, may, in certain cases, be preferable to calomel; but they must be given in greater quantity. Some practitioners believe that a combination of blue pill and calomel acts sooner, and answers better, than a proportional dose of either, given alone. This mode of administering mercury, so as to affect the system at large, is eminently useful in many instances of acute phlegmonous inflammation, after bleeding has been carried as far as the circumstances of the case may warrant. I repeat that it must not be allowed to supersede blood-letting, when that remedy would of itself be eligible. Previous bleeding renders the body more readily susceptible of the influence of mer- cury ; and the operation of the mercury comes in aid of the salutary effect of the abstraction of blood. The two remedies accomplish by their joint power what neither of them might be able to accomplish singly. It is important to know that different persons accept, or resist, the specific agency of mercury, in very differant degrees; so that in some patients the remedy becomes unmanageable and hazardous, while in others it is inert and useless. It is most grievously disappointing to watch a patient labouring under inflammation which is likely to spoil some important organ, and to find, after bleeding has been pushed as far as we dare push it, that no impression is made upon his gums by the freest use of mercury. Such cases are not uncommon; and unfortunately they seem most apt to occur when the controlling agency of mercury is most urgently required. On the other hand, there are persons in whom very small quantities of mercury act as a violent poison; a single dose producing the severest salivation and bringing the patient's existence into jeopardy. This history was told to Dr. Farre by a medical man, under whose notice it fell. *A lady whom he attended said to him, at his first professional visit to her, aNow, without asking why, or speculating about it, never give me mercury, for it poisons me." Some time afterwards she met with the late Mr. Chevalier, and spoke to him about her complaints; and he prescribed for her, as a purgative, once, two grains of calomel, with some cathartic extract. She took the dose, and the next morning showed the prescription to her ordinary attendant. " Why (said he) you have done the very thing you were so anxious to avoid; you have taken mercury." She replied, " I thought as much, from the sensations I have in my mouth." Furious salivation came on in a few hours; and she died at the end of two years, worn out by the effects of the mercury, and having lost portions of the jaw-bone by necrosis. Another medical man informed me that he knew a person so susceptible of the influence of mercury, that when his wife had rubbed a very small quantity of white precipitate ointment upon her neck, for some cutaneous affection, his gums were ten- der for three or four days, after his sleeping with her, and slight salivation took place. This did not happen once only, but three several times. On one occasion this same man took two blue pills, as preliminary to a common purge, and he was salivated pro- fusely for six weeks. Cases similar to these occur now and then to most medical men; we cannot tell beforehand in whom such effects are to be looked for, but it is never prudent to neglect any warning which the patient gives of his own previous experience on this point. You will generally find that where the affection of the gums and salivary organs goes on to a troublesome or distressing extent, it has surpervened upon the employment of a very moderate quantity of mercury. So distressing sometimes are these effects of mercury upon the mouth, that I may pause a moment to tell you what I know about the means of remedying them. You 180 INFLAMMATION. [LECT. XIV. will constantly be called upon to do something for the relief of this disease (for so we must call it), which you yourselves, or some of your brethren, have with the best in- tentions inflicted. I have tried all sorts of expedients; and I have asked a great number of my friends what is the best plan to adopt in such cases; but I never could get much satisfactory information from them. Some thought purging was the best thing. Others recommended alum gargles, or gargles made with the chloride of soda; and these last certainly have one good effect, that of correcting the foetor. A dilute solution of chlorine in water, much used at the Middlesex Hospital, is better still. Others believed that sulphur, which has long been prescribed in such emergencies, was really of service; and some advised that the patient should be as much as possible in the open air; a few commended iodine. All admitted that they knew of no certain remedy. Neither do I. But there are two or three expedients which I am confident are often of very great use in checking the violence of the salivation, and in removing the most distressing of its accompaniments. If there be much external swelling, treat the case as being, what it really is, a case of local inflammation: apply eight or ten leeches beneath the edges of the jaw bones, and wrap a soft poultice round the neck, into which the orifices made by the leeches may bleed; and I can promise you that, in nine cases out of ten, you will receive the thanks of your patient for the great comfort this measure has afforded him. Pure tannin, moistened and smeared upon the spongy gums, is remarkably efficacious in rendering them the firmer and more comfortable. But this is not always to be procured : and when the flow of saliva, and the soreness of the gums, formed the chief part of the grievance, I have found nothing more generally useful than a gargle made of brandy and water; in the proportion of one part of-brandy to four or five of water. This last piece of practice I learned from the present apothecary to the Middlesex Hospital; I have tried it over and over again; and I tell it to you as a thing worth remembering. These little points are by no means to be despised. A very fashionable and successful physician, now dead, used sometimes to say when he met others of his brethren in consultation, " It is all very well to speculate about the exact situation and the precise nature of the disorder, but the question with me is, ' what is good for this, that, or t'other thing ?' " A wise physician will seek to combine with an accurate knowledge of disease, and settled principles of treatment, those practical expedients and minor appliances which are picked up by casual experience; which could never have been reasoned out; and which sometimes constitute nearly all that we can do for our patient's benefit. But to return to mercury as a remedy against inflammation. It is of great service in many cases of chronic inflammation; and I may repeat here the observation I for- merly made when speaking of blood-letting—that the treatment must keep pace, as it were, with the disease. When textures have been slowly altered by a gradual deposi- tion of coagulable lymph, we should gain little or nothing by suddenly or speedily salivating our patient. The lymph, if it can be dispersed at all, must be gradually taken up again: and mercury, given with the view of promoting its absorption, must be slowly and gradually introduced into the system; and its specific influence, when at length it is felt, must be sustained for a considerable length of time. You must not expect any good, but the contrary, from the exhibition of mercury in scrofulous inflammations; and where the scrofulous diathesis is well marked, you should be cautious in giving mercury at any time. But I am certain that many men are too scrupulous in this respect; and that, through over-tenderness of your patient's constitution, you may risk his life, by withholding mercury because he shows tokens of scrofula. You may recollect my stating that scrofulous persons are not exempt from attacks of common inflammation; and in some such cases the possible aggrava- tion of their general ill health, by mercury, is not to be put in competition with the immediate danger from the local inflammation. I have again and again seen scrofu- lous patients benefited by moderate salivation; which, if it proved injurious at all to their general condition, was certainly less injurious than the unchecked local com- plaint would have been. There are some other remedies for acute inflammation which, in this general account of its treatment, I must briefly notice. Antimony is one of them; and a very valuable remedy it is in some forms of inflammatory disease. Antimony, properly administered, subdues the action of the heart and arteries, producing nausea, pale- ness, and sinking of the pulse, and frequently great relief to the local symptoms. LECT XIV.] ANTIMONY. 181 You bring the circulation into that state into which it may be brought by free blood- letting. But when the violence of the inflammatory symptoms recurs again and again, you cannot again and again employ the lancet: or if you do so employ it as at length to extinguish the inflammation, you reduce your patient to a state of pitiable, and even perilous, debility. Now you may continue or repeat the depression of the circulation by means of antimony, without any dread of such subsequent weakness. Antimony, so far as my own observation goes, is admirably suited to cases of active inflammation, in which mercury would either be not so useful, or could not be brought to bear. It is in inflammation of the mucous membrane of the air passages that antimony is so signally beneficial. You will see a patient labouring for breath, unable perhaps to lie down, with a turgid and livid countenance from imperfect arte- rialization of the blood. He has been ill but a short time; it is an acute affection; and upon listening at his chest you hear that peculiar wheezing sound which we call sibilus, in every part of his lungs. I shall have to describe this sound, and its causes, and its meaning, in a future part of the course. You give such a patient re- peated doses of antimony; he becomes sick, vomits perhaps, but he feels nausea: his pulse becomes less forcible, his face grows pale, and he can breathe again. The nausea is not a pleasant sensation; but the want of breath is a far more distressing one; and that is greatly mitigated. Perhaps free secretion takes place from the congested membrane, and then the patient is easy and safe. Now you could not effect this change so quickly and readily, or so conveniently, by mercury, and perhaps not at all. Bronchitic affections are very common in children, in whom it is usually difficult to induce the specific influence of mercury. On the other hand, antimony does not appear to be nearly so valuable a remedy as mercury, when serous membranes are inflamed. The French and Italian physicians place much reliance upon antimony for the cure of inflammation; and they seem to know little or nothing of the remarkable agency of mercury upon that disease. For my own part, I do not see how any useful comparison can be made between these two substances in respect to inflammation, considered generally, as we are now considering it. There are some particular forms of inflammation to which the one remedy is better suited, and there are others in which the other is most effectual. I must content myself for the present with having adverted to these distinctions. As to the form in which the antimony should be exhibited, I apprehend that we shall all come at last to freshly-dissolved tartar emetic. The antimonial powder is of very uncertain strength; and the antimonial wine contains too much spirit to allow of its being given in large and frequently-repeated doses. It is a curious circum- stance, that although vomiting and purging are apt to be produced by the first two or three doses, they usually cease when the same quantity is persevered with. Tole- rance of the remedy is established. But although these unpleasant primary effects cease, the curative agency of the antimony appears to continue. When you desire to obtain its full influence in a short time, you may dissolve a grain of the tartar emetic in two ounces of hot water, and give a fourth part of the solution every half- hour. If the patient become pale and sick, you pause awhile and allow him to recover himself; and if the inflammatory symptoms return, you repeat the medicine. It sometimes acts violently upon the bowels, and then it is necessary to add a few drops of laudanum to each dose. [The remarks of Dr. Watson upon the remedial effects of tartar emetic in inflam- matory affections, are perfectly correct in reference to these diseases as they occur in the adult; in the inflammatory diseases of infants and young children, however, the tartar emetic is not a remedy that can be safely employed; it produces in them always very considerable and enduring disturbance of the stomach, and in many cases a state of extreme, and, as remarked by a late writer — Dr. Wilton, (Prov. Med. and Surg. Journ.) — even fatal depression of the vital powers___C] Digitalis is another powerful medicine, from which as a remedy for active inflam- mation much was at one time hoped; but this hope has been in a great measure dis- appointed. It is not a manageable remedy in such cases. Its singular property of retarding the circulation, of bringing down the number of the heart's pulsations, and 182 INFLAMMATION. [LECT. XIV. abating its force, led to the expectation that it might render the use of the lancet unnecessary; that it might check the inflammatory process without permanently re- ducing the strength of the patient. But if you give moderate doses of digitalis, its peculiar effect upon the pulse comes on at very uncertain periods, and may be post- poned until it is too late to be of any service. If, on the other hand, you give it in such quantity as speedily to affect the heart's action (which is what we want in acute and serious inflammation), then you are never secure against what may be called its poisonous effects; deadly faintness, frightful syncope, and even death itself. _ Most practitioners can tell of cases in which patients, who were taking full doses of digitalis, have suddenly expired; and when the remedy has appeared to have had a greater share than the disease in producing the fatal event. There are men, however, and I know one of them, who affirm that digitalis may be given, after due depletion, and in acute inflammation, in very large, and I should say startling doses, with the very best effects —- doses which range from half a drachm to half an ounce, and even six drachms of the officinal tincture. I confess to you that I should be very unwilling to sanction this mode of using digitalis. I never attempt to employ it with the view of knocking down acute inflammation — to which alone you will observe that my pre- sent remarks apply. Digitalis is often of great service in other complaints; but I am not at present discussing the remedial virtues of digitalis, or of any other drug, except so far as they relate to the cure of recent and active inflammation. Colchicum is a drug which is often prescribed in inflammation. It is a most valu- able remedy in certain specific forms of inflammation. But for repressing common phlegmonous inflammation we have much more certain and better remedies. For this purpose colchicum is, I believe, a very unimportant medicine. I have formerly been asked, by students attending here — and therefore I antici- pate the question now — respecting the utility of opium as a remedy in inflammation. Certainly opium, like most of our powerful medicines, may do much good, as it may do much harm, in different inflammatory diseases; and it is not very easy to point out clearly, in a general view of the treatment of inflammation, the rules for its admin- istration by which we must be guided in different cases. Yet there are a few general observations which I may make now on this subject. The administration of a full dose of opium has been strongly recommended after that free and effective bleeding which I have already described. It prevents the re- kindling of the inflammation which is apt to result from irritation of the nervous system—a kind of irritation, you will remark, which the copious abstraction of blood is calculated to produce, or to augment if it find it already existing. The opium soothes this nervous irritability; and it must be given, when given at all, in doses which will have that effect. It is best adapted to those cases in which a natural irri- tability is inherent in the constitution of the patient — to those in which such irrita- bility has been acquired by bad habits of life — and to those in which the local dis- ease is attended with much pain, which is in all constitutions a source of irritation. However, this is a remedy which requires to be used, in inflammation, with great caution and discrimination. In cases of active inflammation within the cranium, its propriety is very questionable. It is apt to confuse both the patient and his physi- cian, who is unable to say, after a full dose of opium has been given, how much of the stupor that follows is owing to the disease, how much to the drug. It is a very ticklish remedy in pectoral inflammations. I believe that by the free use of opium I saved the life of a relation of my own, an old lady, who was in danger of being worn out by the cough and bronchial affection which attended the influenza. On the other hand, I certainly have known more than one person, labouring under extensive and severe bronchitis, so effectually quieted by a dose of the same medicine, that they never woke again. As a general rule, 1 should say that you must be very careful how you venture upon opium in inflammatory diseases that tend to produce death by coma, or by apncea. If there be any unnatural duskiness of the face, if ever so slight a tinge of purple mingle itself with the red colour of the lips, this is an ap- pearance which (with certain exceptions, to be specified hereafter) should warn you against opium. It shows that the blood is imperfectly arterialized; and imperfect arterialization of the blood, as I hope you all know now, either results from, or con- duces to, a state of coma. On the other hand, it is, cceteris paribus, in cases where the tendency is towards LECT. XIV.] OPIUM. 183 death by asthenia, that the use of opium, as a remedy for inflammation, is most serviceable. It has a capital effect often, after free bleeding, in cases of peritonitis, and of enteritis. It probably does good in various ways : by quieting the nerves — by sustaining the faltering action of the heart — by keeping the inflamed parts at rest. There are some frightful accidents in which we can expect little from blood- letting, but in which the judicious employment of opium affords some glimmering of hope. I allude to those cases of intense and general peritonitis which arise upon the escape of irritating substances into the cavity of the belly; the contents of the in- testines, from ulceration or from external injury; urine from rupture of the bladder; and so on. If there be any hope in such cases, it is to be found in the continued exhibition of opium in considerable doses. But upon all these points I shall go more into detail when we come to consider individual diseases. A very few remarks, in respect to external remedies in cases of inflammation, will terminate both this lecture and what I have to say, thus generally, of the treatment of inflammatory complaints. The application of external cold will aid us very powerfully, in certain serious cases of inflammation; and especially in cases of inflammation within the cranium. It is really wonderful what a sedative and soothing effect this expedient frequently has in allaying delirium, the result of active inflammation of the brain or its mem- branes. Thin folds of linen, kept constantly moist and cold by cold water, are placed upon and around the shaven head. We often apply ice in the same wav. But I need not go at present into any detail on this subject: I will only observe, that we have a most excellent and simple guide as to the probable usefulness of cold appli- cations to the head, in the sensations of our patients. It is very lucky that it is so. As long as the cold cloths, or the bags of ice, are pleasant and grateful to the patient, so long we sedulously continue to apply and renew them; as soon as the patient dis- likes them, they had better be intermitted. Cold applications to the chest, and to the belly, in active inflammation of parts situated within those cavities, have been praised by some practitioners; but I believe are very seldom employed. I have no personal experience either of their utility, or of their hurtfulness. I confess that I should not like to use them. I should fear that the effect of the cold, in driving the blood from the cutaneous vessels, and ac- cumulating it in internal parts, might even be injurious. The totally opposite measure, that of applying warmth to the surface, is of very great service in many cases of internal inflammation, especially in inflammations of the abdominal organs. We speak of cold lotions, and of hot fomentations. These last are managed in various ways, into which I do not at present enter. They seem to do good by determining to the surface; they promote perspiration; they mitigate pain, and persuade to sleep. In cases of external inflammation, sometimes cold applications are found to be of use, and sometimes warm. In this matter also the sensations of the patient furnish the best criterion. Both of them tend, in different circumstances, to promote reso- lution. We have an illustration of the beneficial agency of cold applications for this purpose in the treatment of recent burns and scalds, particularly when the injury is superficial, and the skin has not been destroyed. Probably there is scarcely any one present who has not experienced the relief given to the pain of a burned finger, by dipping it in cold water; and the return of the pain upon taking the finger out again. The cold may be so constantly applied that the pain will cease to recur when the application is at length suspended. Dr. John Thomson relates a case in which a burned arm was kept immersed in cold water for two days and two nights inces- santly; and inflammation was thereby wholly prevented. I have known this ex- pedient fail, however. A nurse in the Middlesex Hospital fell as she was carrying a pail of hot water upstairs, and in her fall thrust one of her arms into the scalding liquid. Without loss of time she plunged the same arm into cold water; but after a while was obliged to desist; the cold immersion bringing on severe rigors. In erysipelas, I am persuaded that warm fomentations not only afford more com- fort, but are more effectual and safer, than cold lotions. Independently of their occasional influence in promoting resolution, warm appli- cations—warm soft poultices for instance — are often used with the view of forward- ing suppuration. Hence this rule. Whenever resolution of the inflammation is 184 HAEMORRHAGE. [LECT. XV. possible, but suppuration is likely to ensue, warm applications are the most proper: because under their use we have an equal chance of obtaining resolution, with less hazard of retarding or rendering untoward the process of suppuration, in case reso- lution does not take place. Counter-irritation, by means of blisters, sinapisms, embrocations, irritating oint- ments, setons, issues, or moxas, is often very beneficial. It probably operates by attracting blood into the neighbouring parts, and in the same degree diverting it from the inflamed part. It is most serviceable in chronic inflammations, and towards the decline of those which are acute. It is particularly adapted to scrofulous affec- tions. There is an objection to the use of counter-irritation during the height of the inflammatory fever, on account of the increase of general irritation which it might then occasion. Neither in local inflammation should counter-irritation be applied very near to the inflamed part. Blisters upon the head, or neck, are not proper therefore, at least in the early stages of the disease, in acute inflammation within the cranium; but they are sometimes applied in such cases, with advantage, to the lower extremities. To the chest, however, in thoracic inflammation, and to the belly in abdominal, blisters are often not only perfectly safe, but of the greatest use, as will, I trust, be apparent as we go on. LECTURE XV. Haemorrhage:—most commonly Capillary. Habitual Haemorrhages. Vicarious Haemorrhages. Idiopathic Haemorrhages. Active and Passive. Symptomatic Haemorrhages. Usual Situations of Haemorrhage. Symptoms and Diagnosis Principles of Treatment. In the course of that somewhat cursory account which I have been endeavouring to give you of the general facts and doctrines of pathology, as a preparation for the better understanding of special forms of disease, we reached, some lectures back, the subject of local plethora, or congestion. From that point our road branched off in three several directions. We have pursued the first and main branch to its termina- tion ; that which led to the discussion of inflammation. We must now go back to the same point again, and follow first the one and then the other of the two remain- ing tracks, which conduct respectively to the consideration of haemorrhage and of dropsy. These tracks are shorter than that along which we were last travelling; but they are not uninviting; they will open to us, if I mistake not, some interesting views of the country of which we purpose, in the end, to make a more particular survey. You are to observe that I treat of haemorrhage, only so far as it falls to the care of the physician. The subject is exceedingly full of interest in its relation to sur- gery : and it will receive at the hands of my colleague all the attention which its great importance, as a surgical accident, demands. But we also, as physicians, have much to do with haemorrhage; with what, for distinction's sake, I may call medical haemorrhage; which differs in kind, in cause, in its consequences, and in the treatment it requires, from that which surgery con- templates. In surgical or traumatic haemorrhage the blood flows from some considerable vessel, which has been cut, or torn, or somehow ruptured. You would greatly mistake if you inferred from that circumstance (as you naturally might) that it is usually so —■ the only difference being in the situation of the vessel — in medical haemorrhage also. Yet that is the popular notion. When blood gushes out from internal parts, through any of the natural apertures of the body, the person is said and supposed to have broken a blood-vessel. LECT. XV.] HEMORRHAGE. 185 But this is rarely, though it is sometimes, the case. In nine instances out of ten, if there be any rupture at all, it is rupture of the numerous capillaries only; but even of this there is often no palpable evidence. Blood may exude abundantly from a surface which presents, to the naked eye at least, no appreciable injury or change. When, for example, haemorrhage has occurred so profusely from the stomach or bowels that the death which ensued could be sufficiently accounted for by the mere loss of blood, the whole track of the alimentary canal has been diligently scrutinized, and has exhibited no ruptured blood-vessel, no breach or abrasion even of its surface, nor any perceptible alteration of texture. Sometimes its mucous membrane appears, here and there, of a red colour, and, as it were, charged with blood. Sometimes it is pale and transparent, while the vascular net-work visible immediately beneath it is gorged and turgid. Sometimes the whole is colourless, the same net-work of vessels having been completely emptied by the previous haemorrhage. The same thing is true of" other surfaces of the body: nay, in some rare cases, the process of transudation has been actually witnessed. There are well-authenticated instances on record of cutaneous haemorrhage: where a dew of blood, or of its colouring matter, has appeared upon some portion of the skin, has been wiped away, and has reappeared; and that again and again, without any discernible change of the affected surface, beyond some occasional variation in its colour. Facts of this kind suggested the hypothesis that the exudation of blood from unbroken surfaces takes place precisely as sweat oozes from the skin, mucus from the lining of the bowels, and serum or synovia from the membranes that respectively furnish those fluids; and pro bably by the very same outlets. And this hypothesis, that the blood proceeds from the same exhalant vessels and apertures, which, in health, pour out the fluids natural to the part, appeared to receive support from the fact, that certain haemorrhages are ushered in and succeeded by an increased efflux of the fluids which belong to the sur- face concerned. In haemorrhages from the mucous membranes the following succes- sion of events is, in some persons, habitual. First, there is an augmented flow of mucus alone; then of mucus tinged with blood; then of pure blood: and the haemorrhage recedes by a similar but inverse gradation, towards a mucous drain, which itself at length decreases or disappears. But I am assured by those whose knowledge of minute anatomy is much more accurate and trustworthy than mine, that the hypothesis of a mere exhalation of blood is untenable; that haemorrhage from a surface without rupture of capillary vessels is physically impossible; that if the red corpuscles of the blood, which measure from 4^qq to 3q^q of an inch in diameter, could pass through lateral pores in those vessels, such pores must be large enough to become visible under the micro- scope. Nay, it is asserted that while it shows no such pores, the microscope does reveal a multitude of distended and broken capillaries in the structure of organs from which haemorrhage has proceeded. I give up therefore the phrase haemorrhage by exhalation, which I have heretofore been accustomed to use in these lectures, and I adopt in its stead the less objection- able term capillary hemorrhage. The distinction is broad enough between bleeding from a papable leak in a large vein or artery, and bleeding from countless capillaries, whether these be torn or entire. Now, although internal haemorrhage may happen in other ways; as from the burst« ing of an aneurism, or from an opening made in a large vessel by progressive ulcera- tion; yet in by far the greater number of cases it takes place from innumerable capillaries. Capillary haemorrhage is the rule — other modes of haemorrhage furnish the occasional exception. I must exclude, however, from this general statement one very important haemor- rhage. In the brain, the former exception becomes the rule. In most cases cerebral haemorrhage results from the rupture of a blood-vessel of appreciable magnitude. There are various kinds of capillary haemorrhage. I will bring them before you, in succession, as clearly and as concisely as I can. In the first place there are haemorrhages which, although they do not belong to the state of health, if we take mankind in general, yet when they do occur can scarcely be called diseases. There are some persons — I believe I may say there are many persons — who are subject, during the greater part of their lives, to discharges of 186 HEMORRHAGE. [lbot. xv. blood; which happen again and again, commonly at regular intervals, without^ any perceptible detriment to the general health, independently of any obvious exciting cause, and (as it would seem) from some inherent property or necessity of the system. Haemorrhages thus occurring, I will call habitual hemorrhages. They proceed more commonly from the rectum, and from the nostrils, than from any other parts; although instances are recorded of their taking place from the bladder and from the bronchi. Appertaining to the original constitution of the body, this disposition to periodic haemorrhage has been sometimes observed to be hereditary. You will at once be struck with the analogy which obtains between these habitual haemorrhages occurring in either sex, and the monthly discharge which is peculiar to the female. The analogy is even closer than it may at first sight appear: but it is more distinctly marked in some individuals, liable to habitual haemorrhage, than in others. It was one of the singular notions of the celebrated phrenologist, M. Gall, founded upon this analogy, that there is such a thing as male menstruation. The points of resemblance between the two phenomena will be manifest in the following summary of the characters belonging to habitual haemorrhage. Like the catamenia, these haemorrhages do not ordinarily prevail throughout the whole course of life. In most cases they do not commence before the period of ado- lescence ; and they cease altogether, or recur at distant intervals only, in declining age. Their first eruption is sometimes preceded by a state of general indisposition, more rarely by slight febrile disturbance, and even (according to some observers) by a sort of chlorosis similar to that which affects young girls in whom the menstrual evacuation is delayed or suspended. The haemorrhage sometimes occurs at precisely regular intervals, and by monthly periods more commonly than any other: being announced, on each occasion, by the same preludes, proceeding from the same part, continuing for the same space of time, and furnishing always about the same quantity of blood. Its accidental interruption is almost uniformly the cause or the consequence of some derangement of the health : and when it becomes excessive, it becomes, like too profuse menstruation, a disease. It forms a very curious part of the general history of haemorrhages that they are not unfrequently vicarious, or supplemental, sometimes of each other, but more often of the monthly discharge from the uterus. Females are liable to perverted menstrua- tion (so to call it) through other channels than the natural one: and here again the analogy between catamenia and habitual haemorrhage comes into view. The haemor- rhages which belong to the constitution are apt to wander in their seat. As bleeding from the lungs, stomach, rectum, or skin, sometimes follows upon the suspension of the menses, so bleeding from the bladder, from the mouth, and from other parts, has been occasionally observed to succeed the suppression of habitual haemorrho'is. These haemorrhagic deviations take place commonly by the same organ on each occasion; more seldom by different organs in succession. It is almost always in this supplementary manner that the rarer forms of haemorrhage occur, and those of the skin in particular. This singular migration, this interchange of place between certain haemorrhages, seems calculated to throw some light upon the obscure doctrine of revulsion ; a doc- trine to which I have already more than once referred, and which, though it is very imperfectly understood, is of frequent avail in the practice of physic. Vicarious haemorrhage always denotes a disordered state of the general health; and must be considered, in itself, as a malady. Again, there are certain forms of haemorrhage, not habitual, which may be denomi- nated idiopathic: inasmuch as they are apt to arise without any perceptible connex- ion with antecedent local disease. In other respects, however, they differ considerably, and require to be further dis- tinguished : and the terms active and passive, which are in common use, will suffi- ciently express the two forms of idiopathic haemorrhage that I wish to bring under your notice. Active haemorrhage is preceded by active congestion, and therefore is akin to in- flammation ; and it often requires the treatment of inflammation. Passive haemorrhage often occurs without any apparent previous congestion of any kind. Haemorrhage of this passive character has been ascribed to some change in the condition of the small vessels or channels through which the healthy exhalations are LEOT. XV.] ACTIVE AND PASSIVE. 187 transmitted; the change being of the nature of morbid debility or relaxation. ^ This view of the matter derives its chief support from the occasional efficacy of astringent substances (either applied locally, or taken into the system) in checking the effusion of blood, when other remedies have failed. But as we are forbidden to speak of hae- morrhage by exhalation, we may suppose that in these passive haemorrhages the capil- lary blood-vessels have somehow become tender and fragile, so as to give way and spill their contents under the ordinary pressure of the circulating blood. A more probable hypothesis perhaps is that which supposes some alteration in the condition and consistence of the blood itself; which thus becomes attenuated, and capable of passing through channels or orifices that healthy blood, under ordinary circumstances, cannot penetrate. We know that the serous ingredient of the blood may and does filter through the pores of the minute vessels, and we may conceive that with it may at the same time transude the haematosin or colouring matter of unhealthy blood; and this supposition is consonant with the fact that haemorrhages are known to occur where the blood is more thin, pale, and serous than common: and still more remarkably where that fluid has undergone a demonstrable change in its^ chemical nature, or is even visibly altered in its sensible qualities; as, for example, in certain cases of purpura and sea-scurvy. And haemorrhages of this kind are often cured by measures calculated to repair the blood, to restore it to its natural condition by improvement in diet, or by food of a peculiar kind, such as the juice of lemons. Whatever may be the true explanation of the differences in question, there can be no doubt that they exist, and are often strongly pronounced in cases of haemorrhage, which, inasmuch as they cannot be traced to any pre-existent local disease, we class together as idiopathic. And it will be worth while to run over the distinctive cha- racters of active and passive haemorrhage, as in well-marked cases they are broadly and decidedly visible. Active haemorrhage (which is preceded, I repeat, by active congestion) occurs prin- cipally in persons who are young and robust, who live fully, and lead indolent lives, and are subject to the influence of those causes which tend to generate plethora. Occasionally the haemorrhage can be traced to some exciting cause; it may be expo- sure to heat, strong mental emotion, violent exercise, or great bodily effort. More frequently, perhaps, no exciting cause is apparent. It is sometimes ushered in by a set of symptoms expressive of what has been called the molimen haemorrhagicum. The patient experiences a general feeling of indisposition, with wandering and obscure pains that gradually settle in the part from which the blood is about to be discharged. A series of local symptoms, such as a sensation of weight, or of tension, or of heat and tingling, sometimes a slight degree of turgescence and redness, and a visible ful- ness of the larger veins, indicate the afflux of blood towards the labouring organ, and the parts in its vicinity : while chilliness, paleness, and shrinking of distant parts, and especially of the feet and hands, denote an opposite condition of the circulation in them. And to this state of things there often succeeds a general increase of heat, with a frequent, full, and bounding pulse,— a pulse which is so characteristic some- times, as to have acquired a name: you may often hear or read of a hemorrhagic pulse. The blood, when at length it breaks forth, commonly escapes with rapidity; is of a florid colour; proceeds from a single organ; and readily coagulates, though it does not always separate distinctly into serum and crassamentum. While it is flowing, the signs of local congestion diminish and disappear; warmth returns to the extre- mities, and the pulse regains its natural strength and frequency. The patient becomes conscious of a sensible relief, and feels stronger and more lively than before. This kind of haemorrhage is, in some sort, its own remedy; it ceases in virtue of the dis- charge of a certain quantity of blood, and it is followed by morbid consequences only when that quantity has been excessive, or when it inflicts some mechanical injury upon the parts along which the blood passes. I said that active haemorrhage is preceded by active congestion, and is consequently akin to inflammation. Perhaps it may be more true that in some of these cases we actually have the initial stage of inflammation, of which the haemorrhage proves the natural cure; strangling it in its birth: that remedy being applied, in the very mo- ment when it is most effective, which I told you, in the last lecture, was the most potent of all the remedies of inflammation, namely, early loss of blood. Passive haemorrhage on the other hand is characterized by circumstances of an ex- 188 HEMORRHAGE. [lect. xv. actly opposite nature. It occurs in those who are naturally feeble, or who have been debilitated by disease, fatigue, insufficient nourishment, great evacuations, or the de- pressing passions. It is not, in general, announced by any precursory symptoms, nor attended by any reaction. The effused blood is of a dark colour, serous, and but little disposed to coagulate: and it often is poured forth from several parts of the body at the same time. If the quantity lost be at all considerable, the natural debility of the patient is rapidly augmented : his face becomes pale, and his body loses its heat. The haemorrhage leaves him in a worse condition than that in which it found him. The flow of a certain quantity of blood is not, as in the cases of active haemorrhage, sus- pensive of its further effusion; frequently, indeed, passive haemorrhage resists the means opposed to it the more, in proportion as it has continued longer, or has been more profuse. Haemorrhages of the kind I have now been describing — that is to say, depending upon no palpable disease of any organ, and, therefore, idiopathic — are of no uncom- mon occurrence, whether we regard the active or the passive form in which they appear: but by far the greater number of capillary haemorrhages are symptomatic; that is, they result from some previous disease, either in the organ from which the blood proceeds, or in some other organ connected therewith by community or depend- ence of function. These secondary or symptomatic haemorrhages are preceded by congestion, but for the most part the congestion is not of the active, but of the mechanical kind; and haa more to do with the veins of the part than with the arteries. Thus we have haemorrhage from the bronchial membrane, in consequence of crude tubercular matter in the lungs filling up a portion of the pulmonary tissue, and ob- structing the circulation of the blood through it. This is an example of symptomatic capillary haemorrhage, depending upon previous disease in the organ itself from which the blood proceeds. In some of these cases the presence of pyrexia renders it probable that the haemorrhage is the consequence and the relief of active congestion, provoked by the irritation of tubercles; rather than the result of a mechanical obstruction of the circulation. Again, we have haemorrhage into and from the lungs, as a consequence of such disease of the heart as mechanically impedes the return of the blood from the lungs to that organ: a narrowing of the mitral orifice, for instance. Here the blood is barred up, as it were, in the lungs, till at length the capillaries, incapable of further distension, are lacerated under the internal stress. In precisely the same way blood is poured out from the mucous membrane of the stomach and bowels, in consequence of disease in the liver, obstructing the portal circulation. These are examples of symptomatic haemorrhage, depending upon previous disease, not of the organ itself from which the blood proceeds, but of another organ intimately connected with the former. When I say that haemorrhage into and from the lungs may result from such dis- ease of the heart as implies an impediment to the circulation, you must not suppose that the lungs are the only channel through which the mechanical congestion can be relieved. Disease of the central moving organ of the circulation leads often, at length, to universal venous congestion; and the haemorrhage, which is apt to be the conse- quence of such congestion, may burst forth from any part where the veins are so overloaded. Haemorrhages from various portions of the mucous membranes are in truth very common effects of cardiac disease. The influence of mechanical congestion as a direct cause of haemorrhage is some- times very distinctly seen in the bodies of persons who have been hanged. You know that when suffocation has been produced by suddenly cutting off the access of air to the lungs, the right side of the heart, the great veins, and indeed the venous system generally, become loaded and distended with dark blood. Dr. Yelloly examined the stomachs of five men who had been executed by hanging: he found them all exceed- ing vascular: and in two of the five cases, blood was actually extravasated, and adhering to the surface of the membrane. There had been, in short, unequivocal haemorrhage. There are several things, worthy of notice, in respect to capillary haemorrhage, of whatever kind. LECT. XV.] SYMPTOMATIC. 189 In the first place, it occurs much more frequently and readily from some tissues of the body than from others : and most especially of all, from mucous surfaces. Thus we have haemorrhage from the mucous membrane lining the nasal cavities; from the pulmonary mucous membrane; from the stomach and bowels; from the urinary organs; and from the uterus; constituting distinct forms of disease, which we are, by and by, to investigate more particularly. Epistaxis, hemoptysis, haematemesis, melaena, hemorrho'is, hematuria, menorrhagia, are names descriptive of haemorrhage, as it is apt to occur from different parts of one or other of the three tracts of mucous membrane met with in the body: and you will find that these comprise very nearly all the complaints enumerated by nosological writers under the head of haemorrhage. Now this is a very remarkable fact: and very interesting questions arise out of it. Has it any relation to the manner in which these membranes, and the tissues sub- jacent to them, are supplied with a capillary circulation ? or may the fact be explained by the laxity of their attachment, which facilitates and favours the accumulation of blood in the vessels of the submucous tissue ? or do the minute blood-vessels belong- ing to the mucous membranes receive a less firm support from the tissue in which they lie, than those belonging to membranes of closer texture ? Whatever answers may be given to these questions, you will do well to recollect the fact which has sug- gested them. Capillary haemorrhages are not, however, exclusively confined to mucous surfaces. They are liable to occur, but much more rarely, from serous membranes. In the majority of cases, however, in which blood is found effused into any of the serous sacs, it has either been an event of inflammation, or the blood has been poured out from an accidental opening in some considerable vessel. Cutaneous haemorrhage is also very rare; probably because the cuticle opposes a barrier to the exit of the blood : for the little red spots which characterize purpura are in fact haemorrhages, although the blood has not penetrated the epidermis. There are cases, however, as I men- tioned before, in which blood has transpired, in a sort of dew, from the external sur- face of the body. Another important general fact in respect to capillary haemorrhages is, that they proceed more frequently from certain parts of the mucous membranes than others, according to differences of age. Thus in children they are most common from the membrane that lines the nasal cavities; in youth from the mucous membrane of the lungs and bronchi; in the middle years of life, and towards its decline, from the rectum, uterus, and urinary organs. I should add here, from the blood-vessels of the brain, in old age; except that this, as I have already intimated, is not (speaking generally) capillary haemorrhage. Of course when I say that, in the instances specified, the blood is commonly poured out by the capillaries, you will understand that the haemorrhage sometimes occurs from the laying open of a single vessel of some magnitude. Thus haemorrhage from the fauces may be the result of ulceration there, which has penetrated the coats of a vein or artery: haemoptysis is occasionally produced by the laceration of a blood- vessel during the softening and expulsion of tubercles: haematemesis sometimes is the consequence of a breach made in a considerable blood-vessel during the progress of cancer of the stomach, or by the extension of small corroding ulcers: haemorrhage from the bowels is no uncommon effect of ulceration, such as happens in fever, of the mucous follicles of the small intestine : calculous matter in the kidneys will often lead to the rupture of some of the blood-vessels there, and to the discharge of blood by the urethra. Aneurisms also may burst into almost any part of the body. But events of this kind are unfrequent when compared with capillary hemorrhages from the same internal parts. In the head, however, the ratio is reversed. Blood does sometimes, I believe, proceed from the hair-like vessels of the brain or of its membranes, but much more commonly cerebral haemorrhage is caused by the giving way of a diseased artery in the brain. How, in all these cases, to distinguish whether the blood has oozed out by many small ruptures from a surface, or has escaped from a hole in the sides of a vein or artery, will form matter for future inquiry. Sometimes we can make the distinction; and sometimes, it must be confessed, we cannot. You will readily understand that haemorrhage must vary greatly, in respect to its 190 HEMORRHAGE. [lect. XV. importance, and to the danger which it implies, according to the part from which it proceeds, and the circumstances under which the blood is poured out. It sometimes happens that death ensues from the mere loss of blood; either at once, by one profuse bleeding, or more slowly, by repeated bleedings which we are unable to restrain: but this is comparatively rare, and when it does happen, the blood is generally found to have proceeded from one considerable vessel, which has been ruptured or eroded. The case approximates to traumatic haemorrhage, except that we cannot cut down upon and tie the injured vessel. Much more commonly danger arises from the presence and pressure of the extravasated blood in and upon internal parts : upon the brain, for example, in cerebral haemorrhage; in the lungs, in pulmonary. \ The symptoms also are liable to much variation in different cases. Even the diag- nosis of haemorrhage is not always equally easy or certain. When the part into which the blood is directly poured communicates with the exterior of the body, the expulsion of some of that fluid will, generally, sooner or later, demonstrate the case to be one of haemorrhage. I say generally, because cases have been known to occur, in which patients, previously in a state of great weakness, have died outright, by syncope, from the mere extravasation of the blood, and before any of it made its way out of the body. The stomach and bowels have been found full of blood, when none had passed either by vomiting or by stool. And when the blood does make its appearance outwardly, it is sometimes not easy to determine whether it has come from a certain organ, or from the parts that lie between the same organ, and the natural outlet by which the blood ultimately escapes. For instance, it is sometimes a matter of uncertainty whether the blood, in haematuria, proceeds from the kidneys, or the bladder, or the urethra. The blood, itself, when it reaches the exterior, will generally be more fluid, and brighter, in proportion as it is effused in greater quantity, and nearer the surface; more in clots, and darker in colour, in proportion to the length of time that it has remained within the body after its escape from its proper vessels : and this length of time may depend upon the smallness of the quantity of blood effused, and the conse- quent tolerance of the organs through which it may have passed; or, upon the actual space traversed. Kespecting the colour, however, of the effused blood, I shall have some curious explanations to offer you when I come to speak of haematemesis as a disease. It would be superfluous to enter upon them now. If the site of the haemorrhage do not communicate with the external air, we are without that certainty which results from the actual spectacle of the blood. But in such cases we are much assisted by local disturbances of function, springing from the pressure upon, or the laceration or distension of, the suffering organ, or of the parts contiguous to it. And we may derive good information from observing the indirect symptoms which declare themselves through the system at large; many of which indirect symptoms are the same whether the blood reach the exterior or not. They principally vary according to the quantity of blood poured out, and to the rapidity of its effusion; and some difference will occur according to the age and strength of the patient. Some of these indirect symptoms have not always been imputed to their true cause. Paleness of the face, feebleness of the pulse, coldness of the extremities, and a ten- dency to syncope—symptoms which are apt to be connected with haemorrhage—have sometimes been ascribed to the alarm and sense of danger which the sight of the blood is calculated to produce on the mind of the patient. This may, to a certain extent, be sometimes true; but the explanation cannot apply to those cases in which the haemorrhage is strictly confined to the interior of the body, yet in which the symptoms just alluded to are often strongly marked. They then depend__and pro- bably in all cases they chiefly depend—upon the actual abstraction of the blood from the circulation. The management of individual cases of haemorrhage must be mainly regulated by the particular circumstances under which they occur. The few observations that I have at present to make respecting their treatment cannot be otherwise than very general. But a preliminary question, of some importance, presents itself. Is it in all cases of haemorrhage proper, or safe, to attempt to stop the bleeding ? Without going into detail, it may, I think, be laid down as a rule, that what I have lect. xv.] SYMPTOMS AND DIAGNOSIS. 191 called habitual haemorrhages ought not to be interfered with, so long as they have no perceptible injurious influence upon the health, and so long as they proceed (as they mostly do) from parts of which the structure is not likely to be spoiled, nor the func- tion impaired, by the repeated passage of the blood. The most common seat of these habitual haemorrhages I have stated to be the rectum; — to which the two conditions just mentioned are, fortunately, both of them applicable. Epistaxis supplies a less frequent example of the same kind. When they deviate from their usual channel, and are transferred (as it were) to some more important organ, it will generally be right, among other remedial measures, to endeavour to recall the original haemorrhage. It is very seldom that the metastasis takes place for the better—i. e., from a part where the bleeding is attended with danger, to one where it is comparatively harmless. However, when these habitual haemorrhages happen, as they often do, in plethoric persons; and when they are urged and kept up, as they frequently are, by intem- perate and luxurious habits; we ought not to content ourselves with merely looking on. Haemorrhoiis often performs the office of a safety-valve in such persons; and there are many who have what are called bleeding piles, and who would rather con- tinue to have them, than submit to any change in their mode of life, or to the em- ployment of other means of evacuation. Certainly these are cases in which nothing should be done to stop the bleeding; yet such patients ought to be told that the hae- morrhoidal discharge is but a precarious, and often an inadequate relief of the ple- thora ; that while the plethora is suffered to exist there is danger of a cessation of the piles, and of the supervention of serious or fatal affections of other parts, and especially of the head. Apoplexy, from cerebral haemorrhage, has frequently been known to follow hard upon the suspension of constitutional haemorrhois. These pa- tients should be admonished also that the discharge of blood from the vessels of the rectum may become excessive; that if it be aggravated by exercise or in any other way, it may lead to inflammation about the anus, and to great inconvenience; and that there are safe and tolerably sure methods of getting rid of the plethora (which is what chiefly constitutes the danger of such cases), if they will submit to the ob- servance of them. It is in the intervals between the haemorrhages that the danger of which they are in some sort the token may best be met. Again, it will seldom be proper to employ direct expedients for stanching the flow of blood, in the small class of active idiopathic haemorrhages; unless the quantity lost is so great as to endanger the safety or the well-being of the patient. Such hae- morrhages have commonly a tendency to cure themselves, by relieving the general plethora, or the local congestion, on which they depend. For these haemorrhages, which bear so strong an analogy to inflammation, the treatment of inflammation may often be requisite, as an indirect mode in which their amount may be moderated, and their recurrence combated. With these exceptions, both direct and indirect measures are to be used, for arrest- ing the effusion of blood as speedily as may be. _ To this end, the patient is to be surrounded as much as possible with cool fresh air, and kept in a state of absolute quiet. All motion of the body and emotion of the mind, all kinds of stimulating food and drink—everything, in short, which has a tendency to hurry the circulation, should be diligently avoided; and that position of the body should be chosen which is the least favourable to the afflux of blood towards the part affected. The horizontal posture will be proper in haemorrhage from the bowels, the uterus, or the urinary organs. In epistaxis, and in cerebral haemorrhage, the head should be raised. In two words, the antiphlogistic regimen should be strictly enjoined in all cases of haemorrhage sufficiently severe to require medical assistance. Of the actual remedies used for checking the further escape of the blood, one of the most important has already been alluded to — I mean venaesection. Herein we are guilty of homoeopathy; to prevent bleeding, we draw blood. After what was stated respecting the use of blood-letting in inflammation, I need not dwell upon the objects aimed at by this measure: they are, briefly, to abate the propulsive force of the heart's contractions, to lessen general vascular tension or plethora when it exists, to remove local congestion, and to divert the current of the blood from the suffering organ. The method, and the amount, and the repetition of the blood-letting, must of course be regulated by the circumstances of each particular case. And the same 192 DROPSY. [lect. XVI. objects may sometimes be effected by other modes of general depletion, especially by the use of purgative medicines. Another important remedy for inward bleedings is mercury. Whatever may be the modus operandi of that mineral, the fact is certain, that haemorrhage, which had resisted other modes of treatment, has, in very numerous instances, ceased at once upon the occurrence of a moderate degree of salivation. Next to blood4etting and mercury, astringents constitute the great resource against actually existing haemorrhage: and among these, cold is one of the chief. It may be placed in direct contact with the bleeding surface : — as when ice is swallowed to restrain haematemesis; or cold water injected into the rectum in excessive and ex- hausting haemorrhois; or into the vagina, in flooding from the uterus. Or it may be applied to the surface of the body, as near as possible to the seat of the haemorrhage; as to the nose andjforehead in epistaxis; to the chest in haemoptysis; to the epigas- trium in haemorrhage from the stomach; to the lower part of the abdomen, or to the perinaeum, in haemorrhage from the intestines, uterus, or urinary organs. But the influence of cold in constringing the smaller vessels is not confined to the part with which it is in contact; it will stop haemorrhage by the sympathetic shrinking which it produces in distant parts. Epistaxis, for example, has often been arrested by the sudden apposition of cold water to the neck, back, or genital organs. The nursery remedy consists in slipping a cold key down the back between the clothes and the skin. Of even the mischievous power of cold in this way we have continual illustration in the suppression of the catamenia by cold and wet accidentally applied to the feet. There is a long catalogue of medicinal substances which are esteemed to possess more or less of a specific virtue, when taken internally, in checking the flow of blood. Most of these are of an astringent nature, and some of them are eminently useful. The acetate of lead enjoys, in this country, a higher character, perhaps, than any other of these substances. Many vegetable matters, and some artificial compounds, frequently employed in internal haemorrhages, seem to owe their astringent and styptic properties to the gallic acid which enters into their composition. Such are the rhatany root, uva ursi, bistort, tormentil, the pomegranate, kino, catechu, the several preparations of gall-nuts, and the nostrum called Ruspini's styptic. It is better, however, in appropriate cases, to give the gallic acid itself, which may now be obtained in substance, in the form of a grey crystalline powder. The power of arresting internal haemorrhage has also been confidently ascribed, by different persons, to nitre given in large doses, to the mineral acids, to the muriated tincture of iron, to alum, to the oil of turpentine, to the secale cornutum or spurred rye, to the matico leaf, and to various other substances, a more particular account of the rules and indications for administering which, I may return to, when I have to speak of individual haemorrhages. LECTURE XVI. Dropsy: its General Pathology. Passive Dropsy; Cardiac, and Renal. Active, Acute, or Febrile Dropsy. Prognosis; and General Principles of Treatment in Dropsies. ^ There remains now only one subject, of the pathology of which it will be conve- nient, and, I hope, instructive, to take a short general view, before we enter upon the consideration of special diseases. I proceed to speak of Dropsies: by which I mean collections of serous liquid in one or more of the shut cavities of the body, or in the areolar tissue, or in both, independent of inflammation. LECT. XVI.] DROPSY. 193 We have already considered serous effusion when it occurs as an effect or event of inflammation. We are commonly able to say of this, that it has originated in inflam- mation; either from its being mixed with some of the less equivocal products of that disease, such as coagulable lymph; or from its having taken place while symptoms of inflammation existed. But there are numerous examples of serous accumulation, which cannot with any show of reason be regarded as events of inflammation. It is to these that.I would apply the simple term dropsy. The liquid collected is serous ; it is not the liquor sanguinis; it holds no fibrin in solution. This is one main dis- tinction, which you will do well to bear in mind, between the generality of inflam- matory serous effusions, and dropsies. It has been said — and said with much truth — that dropsy is rather a symptom of disease, than a disease in itself. And it has been affirmed that it would be more philosophical and scientific to treat of the original malady upon which the effusion or accumulation depends; to erase dropsy from the list of substantive diseases, and to place it in the catalogue of mere symptoms. But this, in my mind, is a very mistaken view of the matter. For, first, it is oftentimes uncertain, while the patient is yet alive, what or where the primary disease maybe; and even after death we sometimes can discover no organic change that would satisfactorily account for the effusion. Practically speaking, in such cases the dropsy is the disease, and the sole object of our treatment. And, secondly, dropsy is, in fact, to a medical eye, in all cases, something more than an effect or symptom of disease. The imprisoned liquid is often a cause of various other symptoms; embarrassing, by its pressure, important functions, and even extinguishing life. The removal of the dropsy (although its original cause, of which it was a symptom, may remain behind, untouched, to be again productive of effusion under circumstances favourable to its operation)—the removal of the dropsy will often restore a person to comparative comfort; or even to what, so far as his sensations, and powers, and belief are concerned, is, to him, for the time, a state of health. You see, then, already, that in a dropsical person, whose dropsy depends upon organic disease, there are two sets of symptoms to be distinguished: those, namely, which depend on the primary disease, and those which depend on the collected fluid. The latter, often the most grievous, are often to be got rid of: the former, frequently permanent, are frequently also but little complained of or felt by the patient, except when effusion is the result. Some persons, I fancy, have regarded dropsy as a less attractive subject of investi- gation than it might be if it were less frequently, in its nature, incurable. But as far as the dropsy itself is concerned, the complaint often is curable; and there are some forms of dropsy that are curable in a more absolute sense: that is, both the effusion, and that condition which was the physical cause of the effusion, are some- times remediable. Besides, it is our business to cure when we can; but whether we can cure or not, to relieve and palliate human suffering; and this, under Providence, we are able to do, in many or most cases of dropsy, to a very considerable extent. Wherever there is a shut sac, or wherever there is loose and permeable areolar tissue, there we may have dropsy. Thus there may be dropsy of the ventricles of the brain, or of the meshes of the pia mater, leading to death by coma: of the pleurae, of the areolar texture of the lungs, or of the submucous areolar tissue of the glottis, any of which may cause death by apnoea: of the pericardium, producing death by syncope. I mention these instances in particular, to show that almost every mode of dying may result from dropsical effusion; and to win your attention to a disorder so full of peril. When the cerebral ventricles are distended with water, we express the diseased condition by the term hydrocephalus. When serous liquid collects in the pleurae, or in the pericardium, we say that the patient has hydrothorax, or hydropericardium. If the cavity of the peritoneum be the seat of the effusion, we call the complaint ascites. When the areolar tissue of a part becomes infiltered with serous fluid, the part is said to be cedematous; and anasarca is the name given to the more or less general accumulation of serum into the areolar tissue throughout the body, and espe- cially to visible subcutaneous oedema of considerable extent. Finally, the term 194 DROPSY. [LECT. XVI, general dropsy signifies the combination of anasarca with dropsy of one or more of the large serous cavities. Other local dropsies indeed there are; but as they belong entirely to surgery, I need not enumerate th»m. Now what reasonable account can be given of these remarkable conditions ? How is it that the hollows and interstices of the living body, or of parts of the body, become thus water-logged ? To solve this question, we must carry in our minds some physiological recollections. The closed cavities, or the interstitial tissues, within which the fluid of dropsy is confined, are kept moist, during life and health, by a continual serous secretion from their surfaces, and they are kept merely moist, for the fluid thus constantly secreted is as constantly re-absorbed into the circulation. When these tissues or cavities, without having undergone inflammation, become filled and distended with the serous fluid which they habitually secrete, one of three things must have happened. Either the quantity of fluid exhaled has been aug- mented, the absorption remaining the same; or the absorption has been diminished, the exhalation continuing the same; or else the exhalation has been increased, while at the same time the absorption was either lessened or not proportionally increased. The last is a mixed case; and we need only consider the two others. Now the balance between exhalation and absorption is often deranged, and dropsies do actually arise, in each and all of these ways. It will best suit my purpose to speak first of those dropsies which are occasioned by defective absorption, and which are usually called chronic or passive dropsies. The direct agency of the blood-vessels in the production, as well as in the removal, of dropsy, although indicated by many common and obvious facts, has not been generally recognised till a comparatively recent period. Perhaps I should rather say that more importance used to be assigned, in these respects, to the agency of the lym- phatic absorbents, than they are really entitled to. You will find that pathologists, even in modern times, speak of a want of tone, of deficient energy, in the absorbents, as a cause of dropsical accumulations; the superfluous fluid of the part is not ade- quately taken up (they say) by the enfeebled absorbents, meaning the absorbents strictly and anatomically so called. And this view of the matter, connecting dropsy always with debility as its cause, has led to a corresponding plan of treatment: the object aimed at being the stimulation of the absorbents to more energetic action. But to the doctrine that dropsy is a consequence of the deficient action of the absorbents, this obvious difficulty presents itself,—that absorption really goes on, and goes on very actively, in dropsical patieuts : their adipous matter disappears, they become "wretchedly thin.. There is no complaint in which wasting and emaciation go to a greater extent than in dropsy. You will find also that persons labouring under anasarca are readily enough affected by mercury; which must of course be absorbed before it can produce any of its specific effects. It must be confessed that our knowledge respecting the mechanism of absorption is neither complete nor certain; but there is good reason for supposing that the process is shared among the lacteals, the lymphatics, and the veins; and it is probable that it may be distributed between these sets of vessels somewhat after this manner; — that the lacteals absorb the chyle from the surface of the alimentary canal, and convey into the blood the materials of its renovation; that the office of the lymphatics is to take up and carry into the blood those old and effete portions of the solid constituents of the body, which require to be removed to make way for a fresh deposit; while the veins imbibe the serous fluid exhaled from the surfaces of serous membranes, and into the meshes of the areolar tissue, as well as poisons and other substances that are soluble and dissolved in that fluid. If this be so, the difficulty just now mentioned vanishes. Of the two sets of absorbing vessels, the lymphatics and the veins, one set may continue to perform its functions, while the other fails to do so. This theory is quite consistent with the actual phenomena of dropsical disease; and whether it be altogether true or not, a part of it is certainly true; that, namely, which assigns to the veins a large share in the whole process of absorption. The experiments of Magendie and of others are quite conclusive upon that point. It has also been fully established, that fluids may and do pass into or out of the LECT. XVI.] DROPSY. 195 veins, in the living body, not by any vital process, but by mere physical imbibition and transudation, through the coats of those vessels; that when the veins are dis- tended to a certain degree with watery fluid, the entrance of more of the same fluid, through their sides, is impeded or prevented ; that, when the distension is still greater, the aqueous part of the blood may even pass in the other direction out of the vessel; and that, on the other hand, when the veins are comparatively empty, the surrounding serous fluid passes readily into them, or, in common language, is absorbed. The venous absorption is explicable therefore upon the principles of endosmose and exosmose, as laid down by Dutrochet; or I would rather say, accord- ing to the more general and more simple laws of heterogeneous attraction, as explained by the late Professor Daniell. Imbibition being a form of that attraction, belongs in various degrees to all the tissues of the body. Its rapidity — and even its direction in respect to the elastic coats of a vessel surrounded by fluid, and also carrying fluid of a certain consistence —will vary with the varying distension of the vessel. When the vessel is moderately full, the exterior fluid passes uninterruptedly inwards, and is conveyed away by the internal current. When, on the other hand, the vessel is kept much distended by its contents, the contained fluid, or its thinner part, passes continually outwards; and there is an intermediate degree of distension, at which the pressure is just sufficient to prevent the transit of fluid in either direction. Magendie found, accordingly, in a well-conducted and conclusive series of experiments, that by regulating the condi- tions of comparative emptiness or fulness of the circulating system, he could acce- lerate, or retard, or suspend altogether, the operation of a poison dissolved in the hu- mours of the body. In other words he could thus accelerate, retard, or prevent, the process of absorption or imbibition through the blood-vessels. Bearing these physiological truths in remembrance, we shall have no difficulty in showing that the chronic forms of dropsy are attributable partly, and chiefly, and in many instances entirely, to undue plenitude of the veins; and that this venous reple- tion is produced, almost always, by some impediment to the free return of the blood towards the heart. When the areolar tissue of a limited part of the body becomes filled and distended by serous liquid, we call the swelling oedema; but this is exactly the same in its nature as anasarca. Now, oedema is often the consequence of some mechanical obstruction to the venous circulation. We can produce it whenever we will. Our countryman, Dr. Lower, 170 years ago, tied the jugular vein of a living dog. When a few hours had elapsed, he observed that all the parts beyond the ligature, reckoning from the heart, were much swollen: and upon dissecting the animal after death he found that the areolar tissue of the head and face was filled, not with red blood, as he had expected it might be, but with clear and limpid serum. On another occasion he placed a ligature upon the vena cava, just above the diaphragm : death soon ensued, and a large quantity of water was discovered in the cavity of the peritoneum, " non alitor quam si ascite diu (canis) laborasset." These experiments were not instituted with any reference to the pathology of dropsy; yet that Lower perceived their bearing upon that subject is plain from this sentence: " Quantum haec ad ascitis et anasarcae causas investigandas conducant, aliis judican- dum relinquo." He even explains the extravasation of the thinner or serous part of the blood as taking place by infiltration, " velut in filtro," through the pores of the vessels. Precisely similar phenomena succeed the compression or obliteration of a large vein in various parts of the body. In operating for popliteal aneurism, Mr. Travers was obliged to tie the femoral vein : the areolar tissue of the limb was speedily infiltered with serous fluid. Long-abiding oedema of one foot and ankle has been cured at once by the reduction of a crural hernia, which had been pressing for the same length of time upon the femoral vessels. You have heard, I have indeed already spoken, of the disease called phlegmasia dolens; a disease that is very common in women soon after childbirth, although it is not peculiar to them, nor to the female sex. The foot, leg, and thigh become enormously oedematous. The essence of this disorder ia inflammation of the femoral vein; blocking up that vessel near the groin, and retard- ing or precluding the return of the venous blood from the limb. One arm often swells in the same way, and from a similar cause, in women who are afflicted with 196 DROPSY. [LECT. XVI. cancer of the breast. In pregnancy, the gravid uterus sometimes presses upon the iliac veins, and obstructs the current of blood within them: the consequence is, ana- sarca of the lower extremities, which disappears as soon as the pressure is removed by the delivery of the woman. The flow of blood through the vena portae is frequently hindered, by disease in the liver, or by other causes; and serous liquid accumulates in the peritoneum, constituting ascites. A French physician, M. Tonnelje, narrates several cases in which serosity was found in the cavity of the arachnoid, in conjunc- tion with obliteration of the venous sinuses of the dura mater. In all these instances we have retardation of the venous current, undue plenitude of the veins, and dropsy of the part from which they proceed. The natural exhalation goes on, and the ex- haled fluid collects and stagnates because the channel through which it ought to be drained away is choked up. The larger the vein, and the nearer we approach the heart, the more extensive is the dropsical accumulation : and if we could, plant an obstacle at the very termination of the venous stream, we should dam up the blood in the whole system of veins, and produce a general dropsy. Such an obstacle is frequently placed there by disease. The returning blood is checked at its entrance into the heart; at the confluence of all the veins of the body, where they unite to empty themselves into the right chambers of that organ: and then anasarca of the universal areolar tissue comes on, and water collects in all or most of the great serous cavities. It is no part of my present purpose to inquire how such disease of the heart as is productive of dropsy arises. Commonly we find the right auricle and ventricle enlarged in capacity, the opening between them unnaturally wide, and the tricuspid valve unequal to its office of closing that aperture. Such a morbid state of the right heart may be occasioned by any cause which impedes the flow of blood out of its cavities. The diseased condition of those cavities may be primary; but it is oftener perhaps consecutive to other disease. It may be produced by disease of the lungs, preventing the right ventricle from freely delivering its contents into the pulmonary blood-vessels. Or the retarding cause may be still more distant, in the left side of the heart, keeping the pulmonary blood-vessels unduly full, and thereby hindering indirectly the passage of the blood from the right ventricle. The dropsy may ulti- mately depend, therefore, upon some bar to the circulation, placed even at the mouth of the aorta. Obstacles situated anywhere in the circuit formed by the right heart, the lungs, and the left heart, have the effect of producing secondary changes in the parts behind them. But disease, thus propagated in a direction retrograde to the course of the blood, is propagated gradually, and sometimes very slowly. These are points of much interest, which we shall investigate together by and by. I allude to them now, that you may not be perplexed by a knowledge of the fact, that diseases of the heart often exist for a long while without inducing dropsy. It is with disease of the right side of the heart, whether primary or secondary, that passive dropsy is especially associated. As if to furnish the experimentum crucis in respect to this doctrine, disease does sometimes, with a curious precision, dam up one only of the two great venous trunks, at the junction of which the right auricle is placed : and then the dropsy is as curiously limited to that half of the body in which the tributary veins of the obstructed trunk originate. The first example of this which I ever saw was a most remarkable one. The patient was dropsical in his upper half only. His arms were so hugely anasarcous that he could not bring his elbows near his sides : his neck and face were hideously bloated and exaggerated, and his eyes prominent and staring; while his lower limbs were of their natural size, and appeared preposterously small, and out of proportion. The poor man looked as if the upper part of his body had been stuffed, for acting some ridiculous part upon the stage. The cause of this strange and distressful state was found to be the obliteration of the vena cava superior, close to the auricle. Its sides had been pressed together by a large aneurism of the aorta; and a portion of the vein was fairly sealed up. I have seen two or three similar cases since. Objections have, however, been taken to the accuracy of the conclusions drawn from such cases as I have related; and it is fit that you should be aware of them. Thus it is stated that veins have been found obliterated, and yet there was no dropsy. Now to this objection it may be replied, in the first place, that it is not every vein, the obliteration of which would cause manifest oedema. It must be the principal venous LECT. XVI.] PASSIVE DROPSY. 197 trunk of the part concerned. When some of the secondary and smaller veins alone become impervious, the blood may reach, and return by, the primary branches with sufficient readiness to relieve the turgid capillaries, and prevent any serous accumu- lation. But (it may be said) the principal vein itself has been found converted into a solid cord, and still there was no dropsy. Granted : but it does not follow that there never had been dropsy. You know that when a large artery is tied, the circulation is carried on in the corresponding limb, by means of collateral arterial branches : imperfectly indeed at first; but, at length, as the supplemental channels become more numerous and free, the supply of blood to the limb is as copious as ever. It is precisely the same, mutatis mutandis, with the veins; only that the anastomosing venous tubes are not (perhaps) so readily developed as the arterial. Now I am not aware of any instance in which it has been shown that the principal vein was obliterated, and yet there neither was, nor had been, any oedema of the limb. The recorded cases have been met with in dissecting rooms, and the previous history of the subject has been unknown or unregistered. Mr. Kiernan has told me that he once examined the body of a woman who had excited much curiosity among the medical men by whom she had been seen during life, on account of a remarkable and enormous dilatation of the superficial veins of the abdomen. She was not dropsical, and the cause of the huge varix was sought for with great interest after her death. The inferior cava was obliterated. Here the compensating result was obvious to the sight; the new channels had answered their purpose, and performed the functions of the original channel. The history of this case was incomplete: it was not ascertained whether the woman had always been free from dropsy. I hold this objection therefore to be invalid, until some authentic instance shall be brought forward of the obliteration of a large venous trunk, without a correspond- ing accumulation of serous fluid, either at the time when the observation is made, or at some previous time in the life of that individual. It is, besides, possible enough, that the obstruction of a large vein may be effected gradually, by the slow encroach- ment, for instance, of a growing tumour; and the collateral circulation may begin to be enlarged with the first impediment in the vein, and may keep pace with and coun- terbalance that increasing impediment, till the closure of the vessel is complete: so that, from first to last, there may be no noticeable dropsy. Again, it is affirmed, and truly affirmed, that anasarca often occurs, without any obliteration of veins, and independent of any discoverable organic disease in the heart, or anywhere else. We see this every day in weak chlorotic girls, with blood- less cheeks and pale lips. Some of you saw a case of this kind which was lately under my care in the hospital; besides the anasarca, the systolic sound of the heart was accompanied by a loud, unmistakeable bellows sound. This girl got quite well, and left the hospital without bellows sound, or any other trace of disease. There could not then have been any organic change; in fact, there was not. Yet was there, virtually, a retardation of the venous circulation; not by any mechanical obstacle opposed to its course, but in consequence of the debility of that hollow muscle, the office of which is to propel onwards with a certain degree of force the blood that reaches it. Girls of this description have weak and flabby voluntary muscles; and it is reasonable to presume that the involuntary muscle, the heart, partakes of the general debility of the muscular system, and becomes incapable of sending the blood forwards with the requisite energy. Nay, I believe that a heart thus feeble may yield a little and dilate under the resisting pressure of the blood that enters its chambers; and that so an occasional but temporary bellows sound may arise^from the altered relation between the cavities of the heart and their outlets. Certainly this view of the matter is strengthened by the juvantia and Icedentia. If you are tempted^ by the pain complained of by your patient, or by the violence'with which her heart is throbbing, to take away blood, you find that she is ultimately made worse by the depletion; on the other hand, if you give her steel, feed her well, keep her bowels free, and place her every morning under a cold shower-bath, you find that she recovers her lost strength, that colour returns to her lips and cheeks, that her palpitations cease, and her dropsy vanishes. In proportion as the muscular system in general receives fresh tone and vigour, does that particular muscle the heart also regain the degree of power necessary for the effectual discharge of its proper func- 198 DROPSY. [LECT. XVI. tion, which is very much that of a forcing-pump. Such is the way in which I should explain both the cause of the dropsy, and the cause of its cessation. In such cases our patients do not simply recover; they are cured. I should apply a similar expla- nation to some other forms of dropsy. Andral describes a certain cachectic disposition of the body as being a cause of dropsy; persons may be bled into a dropsy, or starved or weakened into a dropsy. These are genuine instances of dropsy from debility, which is what the ancients conceived all dropsies to proceed from. The thin and watery quality of the blood induced by frequent bleedings, by insufficient nourish- ment, by certain poisons, or by other causes, may doubtless facilitate, or even deter- mine, the passage of its aqueous part through the coats of the veins. But admitting this as a concurrent cause, I am disposed to the belief that all passive dropsies occurring under the circumstances just adverted to, and without any apparent organic disease or change, are mainly to be abscribed to debility of the heart: and viewed in this way, they are all brought under the same general principle; viz., the retardation of the blood in the veins. A large class, then, of passive dropsies, depending upon mechanical congestion, and defective absorption by the veins, are traceable, in their origin, to the heart; and we call them, accordingly, cardiac dropsies. But another class, perhaps as numerous, are connected in a remarkable manner with certain diseased conditions of the kidneys; and these, for the sake of distinction, we style renal dropsies. I shall say a few words respecting them, after I have briefly considered the other source of dropsical swell- ings, adverted to in the commencement of this lecture: namely, excessive exhalation of serous liquid. Dropsy so caused comes on suddenly and tumultuously, and is spoken of as being acute or active. It borders closely upon inflammation, and some- times can scarcely be discriminated from inflammation with serous effusion. The condition of the capillary circulation is supposed to be intermediate between that in which the ordinary amount of secretion is maintained, and that in which inflamma- tory effusion takes place. The excessive increase of secretion is analogous to what we observe in other parts and predicaments of the body; to the abundant perspira- tions, for example, that are occasioned by violent exercise; to the plentiful flow of tears caused by any irritation of the eye, or by the passion of grief; to the augmented watery discharges from the mucous membrane of the bowels produced by purgative medicines; all of which may be independent of inflammation, but all of which are attended with congestion that might readily be pushed into inflammation. In point of fact, if the secretions to which I have now referred were poured into close cavities, instead of proceeding from surfaces that are situated on the exterior of the body, or that communicate readily with the exterior, they would constitute dropsies. The phenomena of active dropsy are of this kind: a labourer is engaged in some employment, which, while it requires considerable bodily exertion, and causes copious perspiration, necessarily exposes him also to the influence of external cold and moisture : he has been digging (perhaps) in a wet ditch, in winter time, and he pauses to take his meal; or he has been unloading a wagon, and rides home, some miles, in a heavy rain that wets him to the skin; or he has been mowing, in the heat of summer, and lies down to sleep upon the damp grass. All these suppositions are derived from actual occurrences. The perspiration is suddenly checked; and in the course of a few hours he becomes universally anasarcous. Again, a patient recovering from scarlet fever ventures out into a cold atmosphere, while the process of desquamation is yet going on; and he is attacked with dropsy of the areolar tissue; and, it may be, of some of the larger cavities also. The urine at the same time is observed to be scanty, troubled, mixed with blood. To comprehend this rapid change from a state of health to a state of dangerous disease, we must again have recourse to the findings of physiology. Besides the constant exhalation which takes place from the inner faces of the shut serous cavities, a large amount of watery fluid is continually thrown out of the system, by all those surfaces that communicate with the air — by the skin, the lungs, the bowels, the kidneys. Now it is well ascertained that when the excretion of aqueous fluid from one such surface is checked, the exhalation from some other surface becomes more copious. It is probable that the aggregate quantity of water thus expelled from the system in a given time, cannot vary much, in either direction, without deranging the whole economy. But we are sure that the amount furnished by any excreting lect. xvi.] ACTIVE DROPSY. 199 surface may vary and oscillate within certain limits consistent with health, provided that the defect or excess be compensated by an increase or diminution of the ordinary expenditure of watery liquid through some other channel. Sound health admits and requires this shifting and counterpoise of work between the organs destined to remove aqueous fluid from the body. This supplemental or compensating relation is more conspicuous in regard to some parts than to others. The reciprocal but inverse accom- modation of function that subsists between the skin and the kidneys affords the strongest and the most familiar example. In the warm weather of summer, when the perspiration is abundant, the urine is proportionally concentrated and scanty. On the other hand, during winter, when the cutaneous transpiration is checked by the agency of external cold, the flow of dilute water from the kidneys is strikingly aug- mented. All this is well known to be compatible with the maintenance of the most perfect health. But supposing the exhalation from one of these surfaces to be much diminished, or to cease, without a corresponding increase of function in the related organ, or in any excreting organ communicating with the exterior, then dropsy, in some form or degree, is very apt to arise. The aqueous liquid thus detained in the blood-vessels, seeks, and at length finds some unnatural and inward vent, and is poured forth into the areolar tissue, or into the cavities bounded by the serous membranes. Dropsy of one part sometimes supervenes suddenly upon the rapid disappearance of a watery collection from another part. It is no uncommon thing to see the swollen unwieldy legs and thighs of an anasarcous patient quickly unload themselves, and resume .their natural bulk and symmetry. His friends congratulate him, and each other, that his disease is leaving him; but as his legs are emptying, he becomes drowsy, forgetful, comatose, apoplectic; and after his death we find the ventricles of his brain distended with serous fluid. Or the dropsical accumulation may be transferred from its place through a safer channel. The best instance of this that occurs to my recollection I heard related by Dr. Farre. A gouty individual had hydrocele; dropsy of the tunica vaginalis. After the disease had lasted for some time, he got very drunk one evening, with rack punch, which greatly disordered his alimentary canal, and brought on a kind of cholera. He had profuse vomiting and purging, which quite exhausted him; and at length he fell asleep. When he awoke in the morning, he found that his hydrocele, which had been a large one, was gone: and it never returned. Such an accidental cure is most instructive. If water be injected, in some quantity, into the blood-vessels of a living animal, the animal soon perishes; dying generally by coma, or by suffocation : and when the carcase is examined, the lungs are found to be charged with serous liquid, or water is discovered in the areolar tissue of some other part, or in the shut serous membranes. If, however, the animal be first bled, and then a quantity of water be injected equal to the quantity of blood abstracted, the injection is followed by no serious consequences. Facts like these throw, as it seems to me, a strong light upon a confessedly obscure part of pathology. It appears that under various circumstances the blood-vessels may receive a considerable and unwonted accession of watery fluid, and that they are very prone to get rid of the redundance. When they empty themselves through some free surface, their preternatural distension is relieved by a flux. If, on the other hand, the surface be that of a shut sac, in discharging their superfluity they cause a dropsy. Why sometimes this organ, and sometimes that, is selected as the channel by which the superabundant water shall be thrown out of the vessels, we can seldom tell. We often find it difficult to determine which of the two facts in question is to be considered the antecedent, and which the consequent. For not only is it true that when the blood-vessels become overloaded with serous fluid, they readily deposit a part of it; but also that when they are in the opposite condition of comparative emptiness, when they contain less blood than is natural, they are equally ready to replenish themselves by absorbing fluids from any source to which they can find access. In the case of the man who was cured of his hydrocele upon the occurrence of profuse watery discharges from his stomach and bowels, it seems clear that the expenditure of serous liquid from one part led to its absorption into the blood from another. WThen anasarca suddenly leaves the extremities, and fatal coma follows, it appears probable that the absorption is the first of the changes, and the effusion the 200 DROPSY. [LECT. XVI. second: and had this effusion been determined to the mucous membrane of the intestines, to the skin, or to the kidneys, it would have brought relief and safety to the patient, instead of causing his death. We have obtained, then, a glimpse of one or two most important principles in respect to the pathology of dropsy. The blood-vessels, when preternaturally full of aqueous fluid, have a"strong tendency to empty themselves; when preternaturally empty, they readily drink up watery fluid wherever they come into contact with it. From the discharge of their superfluity of water arises a dropsy, or a flux. The cause, and the cure, of many dropsies, lie in these propositions. The application of these principles to the supposed case of active dropsy must be obvious. No doubt, in some such cases, actual inflammation takes place; but in many of them there is merely the dropsical effusion, without any other trace or evi- dence of inflammatory action. The two facts which it chiefly concerns us to remark are these — first, that the aqueous portion of the blood, which in health is habitually carried off to a very considerable amount by the skin, is suddenly diverted from that tissue; the perspiration, sensible and insensible, is suppressed : and secondly, that the areolar tissue, or the large serous bags, or both, become filled with serosity. It is not by any necessity, however, that the vicarious excretion is turned upon these serous surfaces. In truth, the intercepted perspiration more often escapes, or labours to escape, from some free surface; and then we have, not a dropsy, but a flux. Diarrhoea, for example, is more common, under the supposed circumstances, than anasarca or ascites : apparently because there is a closer analogy of structure, and a more direct consent or agreement in function, and a stronger reciprocal influence, between the skin and the mucous membrane of the alimentary canal, than between the skin and the serous tissues. Brief allusion has been made to a large class of chronic dropsies, connected with and dependent upon a particular renal disease. This important species of dropsy will require a detailed examination hereafter. It is more complex, and of more obscure pathology, perhaps, than cardiac dropsy. It certainly has a more direct relation also to what I have just been describing as active dropsy : of which it may almost be regarded as the chronic form. Sometimes the kidney disease, of which the dropsy is an incidental and not an essential symptom, springs up silently, and without obvious cause. Sometimes it may distinctly be traced back to its origin in an attack of acute dropsy: in which complaint the kidney always and manifestly labours, its functions being violently deranged, and the urine being small in quantity, and mixed with blood. In this chronic and renal dropsy, the watery accumulation is accounted for by the deficient excretion through the customary channels. The blood-vessels deposit that excretion in a wrong place. The urine, in the outset of the dropsy at least, is scanty The skin is almost always dry, harsh, and unperspiring. The anasarca usually increases or decreases, as the quantity of urine diminishes or augments. Remarkable alterations take place also in the qualities and composition of the urine itself: it has a low specific gravity, contains albumen, and is deficient in urea. The blood degene- rates too; and other organs of the body, and especially the heart, are apt to fall into disease. The suppression of perspiration, and the appearance in the urine of blood or serum, unchanged by the secerning power of the kidney, form striking links of connexion between acute and renal dropsy. In the sketch that I have been endeavouring to give you of the pathology of dropsy, I have taken extreme cases to elucidate the two varieties of that disease which have been respectively denominated active and passive. Let me once more present to you, in a summary view, the points of resemblance, and the points of distinction between them. They resemble each other in the result; namely, in the collection of serous liquid in the circumscribed cavities and vacuities of the body. They differ in the rate at which the collection augments. In the well-marked acute dropsies the liquid is rapidly effused, in quantity much beyond the natural amount of exhalation. In the well-marked passive dropsies the exhalation goes on as usual, but the fluid exhaled is not taken back again into the LECT. XVI.] RENAL DROPSY. 201 circulating vessels with sufficient facility. In one case the circulation is disturbed and tumultuous; in the other, it remains tranquil. It is probable that in the more acute forms, the serum transudes through the coats of the arteries, or of the capillary vessels next adjacent to the arteries. In the completely chronic and cardiac forms, there is a defect of absorption by the veins. Active dropsies are sometimes spoken of as belonging to the left side of the heart, passive dropsies to the right. But there are intermediate degrees, in which the full veins are not only unable to admit any addition of aqueous liquid, but also to retain that which they already hold; and serosity gradually exudes through their parietes. What connects all these forms of dropsy is a preternatural fulness in some part, or the whole, of the hydraulic machine. And this seems to be the grand key to the entire pathology, as well as to the remedial management of the disease. I scarcely need point out to you the fact, that the water of dropsy is liable to change its place, in obedience to the force of gravity. In general anasarca, when the serous accumulation slowly augments, it first becomes visible about the feet and ankles. There are two causes for this; the one occasional in its operation, the other general. The veins of the lower extremities are apt, when the patient is erect, to be more turgid than other veins; for unless the action of their valves be quite perfect, those vessels sustain the weight of a large superincumbent column of blood, which concurs with other causes to retard the upward current, and to keep the depending capillaries unduly full. Under such circumstances the effusion, or the arrest of absorption, may take place around the insteps earlier than in any other part. But in general it is not so. In most cases, the truer and simpler reason of the earlier mani- festation of dropsical swelling about the ankles, is merely that the serous liquid which fails to be removed from the areolar tissue in all parts of the body, gravitates towards the lowest part; and being thus collected into a comparatively small space, is rendered more perceptible. During the night, when the horizontal posture is main- tained for several hours, the oedema of the ankles disappears, but the neck and face, perhaps, become bloated and puffy. And it is obvious why, in these cases, the feet, towards evening, swell more than the hands. The hands receive the serous fluid from the areolar tissue of the arms alone; the feet, that which sinks down, not only from the legs and thighs, but from the head and trunk also. The limbs may be looked upon as bags, which fill up in proportion to the quantity of liquid detained. And the lungs are similarly bags : and in these cases we commonly may hear the crepita- tion of pulmonary oedema in their lowermost portions. I mentioned an instance in which one-half only of the body was. anasarcous, and that the upper half. The descent of the dropsical fluid was prevented by the dress of the patient; the waistband of his trousers having compressed the areolar tissue, through which alone the gravitating liquid could seek a passage. So, sometimes, it is stopped at a lower point of its descent by tight garters, and the thighs swell earlier than the insteps. It is not at all uncommon to see persons who, in the daytime at least, and in the erect posture, are anasarcous in the lower half only of the body. We do not so often meet with anasarca of one moiety of the body, the division being made by an imaginary plane drawn through its axis. Yet this does occasionally happen. This curious phenomenon is usually the result of a mere accident, the anasarcous patient being unable to leave his bed, or to lie at all except on one side; and then the accumulating liquid gravitates to that side. I have, however, seen one case to which this explanation would not apply. I believe that some local obstruction to a large vein in the neighbourhood of the shoulder caused oedema there, and the fluid sank down and filled the areolar tissue of that side alone. As the man re- covered, I had no means of verifying the truth of this conjecture. Cozteris paribus, those parts of the body become the most loaded with serous fluid, and show the anasarca the plainest, of which the areolar tissue is plentiful and loose; as the eyelids, and the scrotum. But in extreme cases the liquid pervades the same tissue, where it is much more dense and compact: as where, for example, it is sub- jacent to mucous membranes. In the examination of a dropsical corpse, the mucous coat of the intestines may sometimes be seen to be elevated by the water collected beneath it. It then looks like jelly, and the valvulae conniventes, which are flat and thin in their ordinary state, become round and convex. Dropsy of the submucous tissue of the air-passages is frequently a cause of death. 202 DROPSY. [LECT. XVI. Many persons seem disposed to ascribe these anasarcous swellings, especially when they make their appearance suddenly, to inflammation; and much is said about the frequency of inflammatory dropsy. But the facts we have just been considering suf- ficiently refute this theory. If the serous liquid be the product of inflammation, what is the part inflamed ? It cannot be, as some appear to think, the distended areolar tissue itself; for if so, the inflammation must shift its quarters under the in- fluence of gravity. The term inflammatory dropsy may not perhaps be indefensible when applied to that class of dropsical affections that have been spoken of under the head of active dropsy. I am far from denying the frequent agency of inflammation in producing changes which, in their turn, lead to dropsy, but we shall do well not to confound those collections of serum mixed with blood or with coagulable lymph, which are distinctly events or products of inflammation, with other collections of serum which resemble the former in that respect only, but differ entirely from them in every other particular. To the class denominated active, which occur suddenly, from defect of some one or more of the usual channels of aqueous excretion, and which are usually attended with much disturbance of the whole system, the epithet febrile would not be inappropriate. There may be some few cases in which it is im- possible to determine whether the effusion be inflammatory in its origin or not. If the serum be turbid, if we can discover in it the smallest admixture of pus, or of flakes of lymph, or if the disease have been marked by the ordinary signs of internal inflammation, we need not hesitate in our opinion. One of the latest systematic writers on dropsy in this country holds that all dropsies are more or less inflammatory. We can see one reason for this mistake (for a mistake it surely is) in the relief and amendment which often ensue upon the employment of blood-letting in dropsy. The general prognosis in this disease may be readily gathered from what I have said of its causes and conditions. The anasarca which occurs in chlorotic young women is the least perilous, and the most curable. Of the rest, febrile dropsies are more obedient to treatment, and oftener admit of complete recovery, than the passive or chronic. Local dropsies are to be regarded with hope, in proportion as the ob- struction on which they depend is capable of being removed, or of being compensated by the development of fresh channels for the delayed blood. As far as the mere water is concerned in the chronic forms of the disease, cardiac dropsies are more readily dispersed for a time, but more likely also to return, than dropsies which are complicated with renal disease. It is obvious also that the immediate danger of drop- sical accumulations will depend much upon the place the liquid may occupy. The difference in this respect is immense between the tunica vaginalis, and the pericar- dium ; between the areolar tissue of a limb, and that which lies beneath the mucous membrane of the glottis. It remains that I should offer a very few final remarks concerning the principles upon which dropsies are to be treated. The first object is to get rid of the preternatural accumulation of watery fluid : the second is to prevent its collecting again; in other words, to remedy the diseased con- ditions which gave rise to the dropsy. Indeed, if we can accomplish this second object without delay, the dropsy will generally disappear of its own accord. Now venaesection will often sensibly reduce the dropsical swelling. In what has been called active or febrile anasarca, general blood-letting is advantageous in several ways. It helps to relieve the congestion, akin to inflammation, upon which the effusion de- pends : it tends to abate the undue action of the heart: and by emptying the blood- vessels, it facilitates the re-absorption of the effused liquid, and its ultimate ejection from the system. But although blood-letting is the most direct and certain way of unburdening the loaded veins, and therefore, in many instances, the most effectual remedy for the dropsy, it is by no means adapted to all, nor even to many, forms of the malady. It will always indeed remove a portion of the aqueous ingredient of the blood, but it expends at the same time its fibrin and its red particles. It impoverishes the circu- lating fluid, and thus enfeebles the patient more than would the indirect measures, to be mentioned presently, for evacuating the collected liquid. Perhaps, by rendering the blood more watery, venaesection may indirectly favour the transuding of its serum outwards whenever the venous current happens to be retarded. It certainly weakens the central organ of the circulation; and to muscular debility of the heart we have LECT. XVI.] TREATMENT. 203 already seen that certain forms of general dropsy may owe their origin ; and thus it is that ill-timed or excessive bleeding may be the cause of dropsy. In these forms of anasarca, instead of robbing the veins of their blood, we seek to repair the quality and richness of that fluid, and so to restore the deficient tone and vigour of all the muscles, and of the heart among the rest. In most cases then it is inexpedient to let blood; and we endeavour to empty the vessels indirectly, and in such a manner as to withdraw from them the more watery parts only of their contents. In other words, it becomes our object to augment the discharge of watery fluid from one or more of the secreting surfaces of the body : but it must not be the inner surface of a shut sac. I noticed before the close analogy that obtains between dropsies and fluxes. Dropsy is a flux into a closed cavity. Fluxes would be dropsies if the fluid poured forth did not escape. And you are to observe that we frequently try to cure a dropsy by pro- ducing a flux. By what surface or channel this artificial drain shall be attempted, is often a matter of great nicety and importance. In some cases we strive to promote the discharge of the superabundant water by the way of the kidneys: in others by the mucous lining of the alimentary canal: in others by the external skin. The circumstances by which our choice must be determined will come under review hereafter. s Passive dropsies are much more difficult of cure than active, and will often baffle our best-directed efforts. You are not, however, to regard those passive dropsies which depend upon the obliteration of a large vein as necessarily incurable; for if a collateral venous circulation be accomplished, the dropsy will permanently disappear. But we must give nature the credit of the cure in such cases. Time is the best remedy; and all that we can sometimes do is to alleviate in the meanwhile the most distressing or threatening of the symptoms. I mentioned, in the outset of the lecture, that the presence of the dropsical fluid may constitute nearly all the suffering of the patient, as well as much of his danger. Now, when we cannot get rid of the water by bleeding, or by internal remedies which excite serous discharges, we may often afford great present comfort to our patient, and prolong his days, by letting the water out by a slight mechanical operation. Para- centesis is the scientific, and tapping the vulgar name for this proceeding. It has been performed successfully, by means of a small trocar, to evacuate the water from the brain in chronic hydrocephalus; it is often resorted to for the purpose of empty- ing the peritoneal cavity, and the tunica vaginalis testis; and it is not seldom prac- tised to let out the fluid of anasarca; for acupuncture of the legs and thighs and scrotum is only another form of tapping. In the local variety of dropsy that is called hydrocele, the re-accumulation of the liquid is sometimes prevented by exciting just so much inflammation of the membrane as may cause its opposite surfaces to cohere; whereby the cavity itself being abolished, any return of the disease is rendered impossible. This is an expedient which we scarcely dare to employ in other species of dropsy; in ascites, for example; first, because the inflammation itself would place the patient's existence in imminent peril; and secondly, because if it could be safely conducted, the adhesion and obliteration might seriously embarrass and impede the functions of important organs. The circumstances which require and justify this mechanical remedy; the rules and precautions to be observed in its performance; and the measures to be adopted for preventing the recurrence of the accumulation, by the removal of its efficient cause, will all be considered in detail when we come to treat of the special forms of dropsy. 204 DISEASES OF THE EYE. [lect. xvii. LECTURE XVII. Diseases of the eye. Catarrhal Ophthalmia. Purulent Ophthalmia of Adults. Having brought my observations on general pathology to a close, I next proceed to the consideration of individual diseases; and I shall take them up one by one, in that anatomical order to which I adverted in the introductory lecture of this course. That is to say, I shall go a capite ad calcem: interpolating those disorders which, although they have a name, have as yet no ascertained local habitation, wherever it may seem most convenient to introduce them. I mentioned before one advantage, as it seems to me, of bringing together, in juxtaposition, all the diseased conditions to which the same part, or the same neighbourhood, of the body is liable — namely, the facility thus afforded of comparing the phenomena by which they are characterized, and of discriminating one disorder from another. In taking the parts in succession from the head downwards, we adopt a sort of order, definite enough for the purpose of aiding the memory, and yet free from the trammels which belong to all attempts at arranging diseases according to their essential nature and affinities. I propose then to speak, in the first place, of certain diseases of the organ of vision. Diseases of the eye occupy a sort of neutral ground, upon which the surgeon and the physician may both lawfully enter. For some of them there are no means of relief, but in manual operations of the most delicate kind. On the other hand, many of the internal parts of the eye require, when diseased, exactly the same species of general treatment which the physician adopts in diseases of other internal parts. We seek to change the condition of a small portion of the body, by remedies which act upon and through the system at large. My real and only motive, however, for beginning with a few of the numerous morbid states to which this little part is liable, is this: — that we find, in the eye, more satisfactory and plain illustrations of the general facts and doctrines of pathology, as I have been endeavouring to set them before you, than in any other single organ of the body. " Here" (to use the words of Dr. Latham, whose published Lectures on Clinic I Medicine I strongly recommend you to study)—"here you see almost all diseases in miniature: and from the peculiar structure of the eye, you see them as through a glass; and you learn many of the little wonderful details in the nature of morbid processes, which but for the observation of them in the eye would not have been known at all." " Within the small compass of the visual apparatus," says Mr. Lawrence, " we meet with a greater variety of structures than in any other parts of the body. Indeed the eye, with its appendages, exhibits specimens of every one of the animal tissues. We find in it bone, cellular and adipous substance, and blood-vessels : mucous, fibrous, and serous membranes; the conjunctiva exemplifying the first; the sclerotica, the sheath of the optic nerve, and the lining of the orbit, the second; the surfaces con- taining the aqueous humour, the third: muscular, nervous, and glandular parts: common integument, and hairs. Besides these, it contains several tissues of peculiar nature, to which there is nothing strictly analogous in other parts." The eye itself, taking it apart from its appendages, the spheroidal eyeball itself, is scarcely an inch in its longest diameter. Yet it seldom happens that disease, of any kind, occupies the whole, even of this small space, at once. Inflammation, for ex- ample, is often confined to one of the tunics of the eye, external or internal; and when it affects more, it is usually in consequence of the extension of the inflammatory process, from some one texture in which it took its rise. You will not expect me to treat of the vast number of disorders to which the several parts of the eye are liable. I shall bring, I repeat, a few of them only under your notice; and I shall select those concerning which the physician is most frequently consulted; which every one, what- ever branch of the profession he may follow, ought to be competent to treat; and, more particularly, which are calculated to elucidate other diseases, and above all, other internal diseases, that are usually assigned to the care of the physician. With the lect. xvn.] CATARRHAL OPHTHALMIA. 205 anatomy and physiology of the organ, I may take for granted that you are already acquainted. I will first briefly inquire into the inflammatory affections of what may be consi- dered the mucous membrane of the eye. Like other mucous membranes, it forms a surface communicating with the external air. Some of these affections are very trifling : some are very severe. There is a mild form of inflammation of the conjunctiva, which constitutes the most common disease of the eye to which adults are subject. It results, in most cases, from vicissitudes of temperature; or from certain conditions, or sudden varia- tions, of the atmosphere. It is very apt to be excited by exposure to a stream or draft of air, especially in the night and during sleep. It has a strong analogy—indeed it is the same disease, except in situation—with that moderate degree of inflammation, produced by the action of the same causes, in the mucous membrane of the nasal cavities, the throat, and the bronchi, which in common parlance we style a cold in the head, or in the chest, as the case may be: and accordingly that inflammation of the conjunctiva of which I speak is often called by the unlearned, a cold in the eye ; and the same analogy is expressed in its technical appellation: the cold in the head or chest is termed by nosologists a catarrh; and the cold in the eye of the vulgar is, with them, catarrhal ophthalmia. The suddenness (sometimes) of its accession has procured for it also the denomination of a blight in the eye. The term ophthalmia is at present used to denote inflammation of the eye generally ; it conveniently expresses in one word what would otherwise require more. Formerly, when the diseases of the eye were not so well understood in this country as they are at present, almost all the inflammatory conditions to which that organ is subject were lumped together under the common appellation of ophthalmia, or the ophthalmia. That word now requires some epithet to distinguish the seat or the kind of inflamma- tion that is meant. It can scarcely be otherwise than interesting to mark the phenomena which occur in catarrhal ophthalmia, when we reflect that in its cause and nature it is the same with inflammation of a similar surface, in parts which we cannot so well inspect as we can the conjunctiva. This membrane, as you know, lines the eyelids, and covers about a third part of the globe of the eye anteriorly. The inflammation, in catarrhal ophthalmia, is confined to the conjunctiva and the meibomian follicles. Its leading symptoms are redness of the surface of the eye; some pain and uneasiness there; an increased discharge from the affected membrane and the follicles; and a sticking to- gether of the eyelashes and lids. The redness is worth notice, both in respect to its tint, and to the arrangement of the vessels in which it appears. It is superficial; and of a bright scarlet colour; and usually irregular, or diffused in patches, some fasciculi of vessels being more distended than others. When, however, the inflammation is more intense, the whole surface, except that of the cornea, becomes of a scarlet red. The vessels of the conjunctiva, thus rendered visible by inflammation, anastomose continually with each other, and form a net-work, which can be slipped and dragged about over the subjacent surface by moving the eyelids with the finger. Frequently some of the meshes of this net- work are filled up with little patches of extravasated blood; the eye is what is called blood-shot, or, to speak learnedly, there is ecchymosis; and sometimes all distinction of separate vessels is nearly lost. In the commencement of the complaint the redness is confined to that part of the conjunctiva which lines the lids; and it afterwards advances gradually, from the angle where it is reflected over the eyeball, towards the cornea. Now all these particulars are of consequence, since they are diagnostic of the seat of the disease; and to show this I must mention by anticipation, the appearance, and the arrangement, of vessels that are observed when inflammation affects some of the textures which lie deeper than the conjunctiva, and especially the sclerotica. The sclerotic redness is seen through the conjunctiva. It is of quite a different tint from that of the conjunctiva. Instead of showing a bright scarlet colour, it is pink, or sometimes of a slight violet hue. The vessels are much smaller and finer than those belonging to the conjunctiva, like hairs. They are straight also, and arranged regu- larly, after the manner of radii in a circle. They lie in the sclerotic, round the cornea, like what is called by painters a glory; or like a halo, or zone surrounding the 206 DISEASES OF THE EYE. [LECT. XVII. central cornea; and they cannot be made to shift their place by any dragging of the lids. These are very important distinctions. They are such as are easily recognised when two eyes are examined in which the two membranes in question are separately inflamed and vascular; and they are still more palpable perhaps when both mem- branes are simultaneously inflamed, as they often are, in the same eye. Then, unless the conjunctiva is so universally red as to prevent our seeing the sclerotica through it, the contrast between the larger, more tortuous, scarlet, and reticular vessels of the conjunctiva, and the fine, straight, rose-coloured, radiating vessels of the sclerotic, is exceedingly striking; and those of the conjunctiva which lie naked on the loose mucous membrane, admit of being slipped about over the fixed zone of vascularity which is presented by those of the fibrous tunic. The pain which attends catarrhal ophthalmia is slight and trifling. At the outset there is generally some uneasiness when the eye is exposed to the light; but there is no intolerance of light when the disease is fairly developed. The patient complains rather of a sensation of stiffness and dryness, and feels as though there were some foreign substance in the eye, between the globe and the lids, especially when the eye is moved; a grain of sand, or of gravel, or a little fly. So exact is the resemblance of this feeling, that you can with difficulty persuade the patient that there is nothing of that sort in his eye. No doubt this sensation is produced by the inequality and roughness of the surface, consequent upon the irregular distension of the vessels of the inflamed membrane: irritating the organ mechanically, just as a piece of dust might irritate it. Now in this respect again, there is a marked difference between conjunctivitis and sclerotitis. In the latter disease the pain is much more severe, of a dull aching cha- racter, with a sense of tightness : the part inflamed is denser, and less yielding than the conjunctiva. The pain is attended, also, frequently, by throbbing, and it is felt in the surrounding parts more severely perhaps than in the eye itself; in the brow, temples, and head. It is a very remarkable circumstance, too, that the pain is dis- tinctly aggravated towards night; increasing in violence from the evening till after midnight, abating towards morning, and ceasing in a great measure during the day, to be again renewed in the evening. I am speaking now particularly of inflammation of the sclerotica produced by the same causes as give rise to catarrhal ophthalmia; of what is generally called rheumatic ophthalmia. The increased discharge that takes place from the eye in catarrhal ophthalmia is not a discharge of tears. In the beginning of the complaint there is sometimes a slight degree of lacrymation. But this soon ceases, and the mucous secretion from the surface of the membrane is augmented in quantity, and changed in quality. At first it is somewhat thin, but it soon becomes thicker, and it is often puriform; i. e., opaque and yellow: sometimes it retains more exactly the characters of mucus, is transparent and viscid; so that the eye looks moist to a bystander, while to the patient it feels gummy. The puriform secretion is not, in general, in any great abundance. You may see it lying in the angle between the eye and the lower lid, upon pulling them apart; or it makes itself visible at the corner of the eye, or be- tween the eyelashes along the edges of the lids, which it glues together at night. Sometimes, however, the discharge is more copious, so as to approximate to what is observed in the less severe forms of another disease I shall presently mention • viz., purulent ophthalmia. There is seldom much swelling of the conjunctiva. If there be any, it results from an effusion of serous fluid into the meshes of the areolar tissue that connects the membrane with the subjacent sclerotica; by which effusion the conjunctiva is partially raised and separated. This kind of effusion often goes to a very great ex- tent in purulent ophthalmia, or in violent inflammation of the external membranes, as I shall show you by and by. So much, then, for the symptoms, and causes, of catarrhal ophthalmia. It is necessary that you should be familiarly acquainted with them; not so much because the complaint is very serious in its nature, but because it is common ; because you are sure to be again and again consulted about it, and because it is of great im- portance to distinguish it from other forms of ophthalmia, in order to adopt the proper treatment. ^ A mistake of diagnosis might lead to mischievous activity on the one hand; or to still more pernicious inertness on the other. lect. xvn.] CATARRHAL OPHTHALMIA. 207 When the inflammation does not extend beyond the mucous membrane, it will run a certain course, and then, under favourable circumstances, subside. But if it be improperly treated, or if the patient cannot guard himself against a repetition of its exciting causes, it may continue for weeks, and harass him a good deal, and even produce such a change in the inflamed lids as may prove a source of permanent irri- tation, and of chronic disease, of the cornea over which they sweep. Remedies of an active kind, such as influence the whole economy, are scarcely ever necessary. The patient should observe the main particulars of the antiphlogistic regimen, and avoid exposure to drafts or currents of air, and to cold and moisture generally. When the external weather is inclement, he should remain in rooms of a uniform temperature. It will be right to purge him in the outset with calomel and jalap, or with calomel followed by a black dose. If the system at large sympathize with the local disease, it may become necessary to draw blood from the arm, or to apply leeches; but neither of these measures is requisite, unless the inflammation is unusually severe, or the disease has been neglected or mismanaged. After the bowels have been thoroughly cleared by an active purgative or two, remedies which encourage moderate perspiration will be likely to forward the cure : such as warm diluent drinks; five grains of Dover's powder, and immersion of the feet in warm water, at bed-time; and saline draughts containing two or three drachms of the liquor ammonia acetatis, taken at intervals during the day. But in this complaint local measures are of greater importance than those which are addressed to the general system: stimulating or astringent applications to the affected membrane itself. Almost all modern writers on diseases of the eye agree in this. Dr. Mackenzie, of Glasgow, states it as the result of his observations on Beer's practice in Vienna, and of his own subsequent experience, upon an extensive scale, at the Grlasgow Eye Infirmary, that " general remedies in this disease are inferior to local ones; that violent general remedies are worse than useless; and that a local stimulant treatment may almost entirely be relied on." Mr. Melin, in a report of ocular diseases at the General Hospital, Fort Pitt, states that he had treated nearly 300 cases, some of them severe, upon the same principle, without either local or general bleeding: and that he had satisfied himself of the efficacy of this plan of management. And Mr. Lawrence, who for ten years was one of the surgeons to the Ophthalmic Infirmary, in Moorfields, and who during that period had ample oppor- tunities of studying this disease of the eye as well as others, says that it is one to which the use of powerful astringents is more particularly applicable. In disorders which manifest a strong natural tendency to terminate in recovery, it is only by taking advantage of the conclusions derived from extensive observation that we can be quite sure of our ground; and when the same result is reached by different and independent observers, we may safely place confidence in their concurrent testimony. Dr. Mackenzie and Mr. Melin both employ, and recommend, the same application; viz., a solution of the nitrate of silver in distilled water, in the proportion of four grains to the ounce. A large drop of this solution is to be applied to the membrane once or twice, or three times, in the course of the day. If the patient recline his head backwards, and the drop be placed in the hollow formed in the internal angle of the eye, it will be diffused over the globe upon the separation and subsequent winking of the lids. After a minute or two this causes a pricking or smarting sensation, which subsides in from ten to twenty minutes, and the eye then feels much easier than it did before the drop was applied. Dr. Mackenzie says that the feeling as if of sand in the eye, is uniformly relieved, and the inflammation abated, by the use of this solution, which he speaks of as a remedy of sovereign utility in the puro- mucous inflammations of the conjunctiva. The eye continues easy, after its applica- tion, for five or six hours perhaps; and whon the symptoms return, they are again to be met by the introduction of another drop. As the disease subsides the remedy gives less and less pain, till at last it is scarcely felt. He tells us that " he has some- times alarmed other practitioners by proposing to drop upon the surface of an eye highly vascular, affected with a feeling as if broken pieces of glass were rolling under the eyelids, and evidently secreting puriform matter, a solution of lunar caustic; and that he has been not a little pleased and amused at their surprise when, next day, they have found all the symptoms much abated by the use of the application." He 208 DISEASES OF THE EYE. [lect. xvii. declares also that the acetate of lead, and the sulphate of zinc, substances which are much used in what are called collyria, or eyewashes, are greatly inferior, as local applications, to the nitrate of silver, in this disease. There is another expedient that requires to be attended to in these cases._ When the eyelids are gummed together by the viscid discharge, much hurtful irritation is often produced by the hasty attempts which the patient makes to separate them. Now all this may be obviated by smearing their tarsal edges at bed-time with any mild ointment; the spermaceti ointment, or a bit of lard. There is no necessity, as I believe, in this form of disease, to use medicated or stimulating salves: the object is to prevent the mutual adhesion of the lids; and this is accomplished by simple grease* Purulent Ophthalmia — is another disease of the conjunctiva; differing from catarrhal ophthalmia in degree, in the severity of its symptoms, in the danger which it implies to the sense of vision, and in its exciting causes. It takes its name from the profuse discharge of pus that pours from the inflamed surface. There are three remarkable varieties of purulent ophthalmia; called respectively—1, purulent ophthal- mia of adults, or Egyptian ophthalmia, or contagious ophthalmia; 2, gonorrhoeal ophthalmia; and 3, purulent ophthalmia of newly-born children. The symptoms of the two first-mentioned varieties, especially in their severer forms, are so much the same, that it would involve us in mere repetition if I did not take them together. In truth it appears to me much the simpler and better mode to look upon purulent ophthalmia as one disease; and to specify, as we go on, the differences by which its several forms are characterized: and not to split it into three different diseases, and to give a separate description of each. Although purulent ophthalmia is inflammation of the very same part that is inflamed in catarrhal ophthalmia, from which it differs chiefly in degree, it is a hideous com- plaint, either to suffer or to treat; on account of the rapid progress it frequently makes, and its destructive tendency. The inflammation is greatly more intense; the surface becomes, in the worst cases, highly vascular throughout. A copious discharge of thick, yellow, puriform matter is speedily established; this flows out from between the swollen lids, and runs over the cheek, which it often excoriates. At the same time considerable effusion takes place into the areolar tissue that connects the sclero- tica and the conjunctiva. You are aware that the conjunctiva extends over the whole anterior face of the globe; adhering, however, so much more closely to the cornea than to the sclerotica, that we might doubt at first whether it did not stop at its margin. This close and firm adhesion over the cornea, and the looser attachment to the sclerotica, give rise to a very singular phenomenon. The conjunctiva is raised to some distance from the subjacent sclerotica by the effusion that takes place between them; and it projects around the cornea in the shape of a large thick ring, leaving the cornea buried, as it were, in a pit; nay, sometimes the swollen and prominent membrane will lap over, so as nearly to exclude the cornea from our sight. The same kind of effusion takes place also, sometimes very rapidly, into the areolar tissue that connects the conjunctiva with the palpebrae, producing great external tumefaction, and a livid red appearance of the eyelids, which project forwards in large convex masses, and often prevent our seeing the globe of the eye at all: the upper lid espe- cially becoming hard and stiff, and completely"overhanging the lower. This swelling from effusion into the subconjunctival tissue is of a pale red or flesh-colour, sometimes marked here and there with patches of extravasated blood. The appearance is called chemosis: not ecchymosis, as the similarity of the sound has led some erroneously to suppose, but chemosis. Ex^D/uostj, from ix%su>, effundo, signifies an effusion, and by common consent among medical writers, an effusion of blood. X-^coatj, the root of which is zw*> hiatus, means a gap or hollow. Now this puriform or purulent inflammation, so long as it is confined to that part of the membrane -which lines the eyelid, is not of any serious importance ; but it is prone to extend itself to the cornea, and the whole anterior surface of the eye, and to produce ulceration or sloughing of the cornea, either in consequence of the actual inflammation of that part, or in consequence of the pressure made upon and around it by the swelling of chemosis. Frequently, when the cornea remains visible, a furrow or trench of ulceration may be seen at its margin; sometimes forming a complete lbjt. xvii.] PURULENT OPHTHALMIA. 209 ciicle, sometimes portions of a circle, sometimes going quite through; and when this happens, or when the cornea bursts from the effects of deeper-seated inflammation, the aqueous humour is evacuated, and the iris protrudes through the aperture. Even when these horrible results do not take place, the eye is often as effectually spoiled for the purposes of vision by an interstitial deposit between the laminae of the cornea, rendering it opaque, and permanently precluding the passage of light towards the retina. And when neither of these lamentable effects of the inflammation is produced, it is apt to leave behind it a chronic and very troublesome condition of the membrane. The conjunctiva that lines the lids remains thickened, granular, hard, and rough, instead of regaining its natural smoothness, softness, and polish. One consequence of this is a perpetual irritation of the surface of the cornea, by the mechanical friction of the rough and hard lid in opening and closing the eye, and in the various motions of the eyeball. The continuance of this irritation leads at length to haziness or opacity of the cornea, which becomes traversed also by visible red vessels. Chronic inflammation of its investing membrane is produced, and kept up. The most severe forms of this disease are attended, at length, with a good deal of pain; doubtless because the inflammation penetrates to the deeper-seated textures of the organ. The pain then presents those characters which I mentioned before as belonging to certain inflammations of the sclerotica : i. e., it is pulsative; and some- times sharp and lancinating, sometimes dull and aching; and it is intermittent, or if constant, it is aggravated by paroxysms; the paroxysms coming on at night, and abating towards morning: and it is not confined to the eye itself, but extends to the parts around it. The circumorbital pain is characteristic of inflammation of the sclerotica and cornea, and of the internal tunics, the choroid and iris. When the eye is not visible, from the swelling, we may conclude that the inflammation is as yet con- fined to the conjunctiva, if the pain be only scalding or "sandy;" and that it has extended to the sclerotica and cornea if the pain be severe, throbbing and paroxysmal. In the cases in which the latter kind of pain is felt, the cornea generally gives way. Sometimes this event brings relief to the pain, and sometimes the pain continues to return after the bursting of the cornea. It is curious that with all this, there is seldom much intolerance of light. In the earlier stages of this malady, it is entirely local: the system at large is scarcely disturbed at all. But the constitution begins to sympathize and suffer when the local symptoms increase in severity; the pulse becomes frequent, and the tongue white, but there is seldom much thirst or fever; and when blood is drawn from a vein, it does not, in general, exhibit the buffy coat. A good deal of variety in these respects has been noticed however in different cases. Children manifest more consti- tutional disturbance when labouring under purulent ophthalmia than adults. If there be not much fever, there is always much uneasiness and irritation, and the sleep is broken by the nocturnal accessions of pain. Such being the general features and course of the disease, at least as it occurs in adults, or in patients beyond the period of infancy, we may next inquire into the circumstances under which it has been observed to arise. Purulent ophthalmia has been ascertained to be a common disease in hot climates : in India, Persia, and Egypt. It was brought into England, from the latter country, by our troops in the beginning of the present century, after the well-known contest which there took place between the French army and our own under Sir Ralph Aber- cromby. In this way it got the name of the Egyptian ophthalmia. It naturally excited very great attention at that time, and it does not appear to have been accu- rately described before. To give you some notion of its prevalence in certain places and at certain periods, and of its serious" nature, I may state that, according to returns made from the Mili- tary Hospitals at Chelsea and Kilmainham, there were, on the 1st of December, 1810, no fewer than 2317 soldiers a burden upon the public from blindness in consequence of ophthalmia; and in this number those soldiers who had lost the sight of one eye only were not included. Again, in the year 1804, within nine months, i. e., from April to December, nearly 400 cases of purulent ophthalmia occurred at the Royal Military Asylum; and within 14 210 DISEASES OF THE EYE. [LECT. XVII. six years from that time, without including relapses, upwards of 900 cases had taken place in the same establishment. You will find these statements in a paper in the third volume of the Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, by the late Sir Patrick Macgregor. Many of our best regiments were for a time crippled and rendered unfit for service by this disease; which they carried from Egypt to other foreign stations as well as to this country, especially to Sicily, Malta, and Gibraltar. Nor were the French troops affected by it in less number. Assaliui, who wrote an account of the ophthalmia of Egypt, states that two-thirds of the French army were labouring under it at one time. It occurs also, but fortunately not to such an extent, in civil life. It broke out, some years ago, in a large boys' school in Yorkshire; and blindness in one or both eyes, or serious injury to sight, from opacity of the cornea, and other consequences, took place in nearly twenty cases. You perceive, therefore, that this formidable complaint has been ascertained, within the last fifty years, to have prevailed as an epidemic; attacking great numbers d persons living under the same circumstances, and having constant communication with each other. And one of the first questions that naturally arises in one's mind is, whether it is capable of being propagated from one person to another by contagion. Much difference of opinion has existed on this subject. For my own part I cannot imagine how any one can doubt its contagious properties. I will give you a case or two, as related by Sir Patrick Macgregor, proving two very important facts; first, that the disease is capable of being excited in the eye of a person, previously healthy, by the direct application of the puriform discharge from an eye affected with this ophthalmia; and secondly, the very rapid operation of the poison so applied. One of the nurses employed at the Military Asylum, while syringing the eye of a boy who had much purulent discharge, found that a considerable quantity of the matter had spurted into her own right eye. This was at four o'clock in the afternoon. She felt little or no smarting at the time; but towards nine o'clock the same evening her right eye became red and somewhat painful, and when she awoke the next morn- ing, the eyelids were swelled, there was purulent discharge, and she complained of pain in the eyeball. The usual remedies were begun in the morning, and she reco- vered in the space of three weeks or a month. The left eye, into which none of the matter had gone, remained free from disease. On another occasion a precisely similar mischance befel another of the nurses, ex- cept that the matter spurted into her left eye, about nine in the morning. Sir P. Macgregor happened to be in the hospital at the time when the accident occurred. He desired the nurse to bathe her eye immediately with lukewarm water, and she did so for several minutes; but notwithstanding this early precaution, about seven o'clock in the evening the left eye began to itch to such a degree that she could not refrain from rubbing it. When she awoke next morning the eye was considerably inflamed, the lids were swelled, and upon moving the eyeball she had a sensation as if some sand were lodged beneath them. In the course of the same day purulent fluid issued from the eye, and other symptoms followed, which were similar to those of the children under her care. The disease subsided, under the usual treatment, in fourteen days. In this case also the other eye remained sound. A third nurse in the same institution did not come off so well. She was sponging, with warm water, the eyes of a boy suffering severely from purulent ophthalmia; and she inadvertently applied the sponge she was using to her right eye. This happened at eight o'clock in the morning. She mentioned the circumstance to the other nurses, but she took no means to prevent infection. Between three and four o'clock of the afternoon of the same day, itching of the right eye came on; and before she went to bed it was considerably inflamed. Next morning her eyelids were swollen, she com- plained of pain in moving them, the whole anterior surface of the eyeball was in a state of high inflammation, and a purulent discharge began to trickle down the cheek from the inner canthus. The symptoms increased in severity in spite of all the means employed to check them, and on the fourth day the eyeball burst. The sight of the eye was irrecoverably lost, and the inflammation continued for upwards of three months. The left eye did not suffer. These were cases in which the poisonous matter was accidentally applied. But a lect. xvn.] PURULENT OPHTHALMIA. 211 similar application has been made intentionally and by way of experiment, and with the same results. Dr. Guilli6, of Paris, introduced the puriform secretion furnished by some children affected with purulent ophthalmia, under the eyelids of four other children belonging to a separate institution for the blind. These four children were amaurotic, but the external surface of their eyes was healthy and entire. In each instance a regular attack of purulent ophthalmia followed the introduction of the matter. Facts of this kind prove, I say, beyond the possibility of question, that the disease may be propagated from a diseased to a healthy eye by actual contact of the puriform matter. Here we have not one case (which might be considered as an accidental coincidence), but several: the morbid secretion is applied to one eye only; the symptoms of inflammation commence, and the regular form of the disease is fully developed within a few hours after the first application of the pus; and that eye only is affected. It is impossible to get over evidence of this kind. The only questions, therefore, that can be raised respecting the sources of the disease are these : — whether the malady can be communicated through the medium of an atmosphere impregnated with the effluvia that proceed from the diseased part, without any actual contact of the pus in substance ? — whether the disorder is ever produced in any other way than by contagion ?—and if so, hoto it is then excited ? I ought to observe, that independently of such isolated examples of the direct communication of the complaint, by contact with the diseased matter, as I have just laid before you, the history and progress of ophthalmia, since it has been noticed in Europe, are very strongly indicative of its contagious nature. I have already stated that it was not known in Europe till the commencement of the present century — till after the Egyptian campaign in fact. It is not alluded to by any of the authors on disorders of the eye who wrote previously to that period; although some of the Italian physicians and surgeons, and many of the Germans, had paid great attention to ophthalmic diseases. It spread from Egypt both to France and to this country, and to other places in which detachments of the Egyptian force were subsequently stationed : in Sicily, to wit, and in Gibraltar and Malta. Whenever it has prevailed among our troops at home, this circumstance has been uniformly observed: that it first broke out in soldiers who had come from Egypt, or had communicated with regi- ments which had been in Egypt. In all cases its origin could be traced to the intro- duction of fresh troops into the regiment or the barracks. Again, the manner in which it spreads is exceedingly instructive on this point, ll diffuses itself rapidly, when once introduced, in places where a considerable numbei of persons are collected together; especially under circumstances favourable to the propagation of contagious maladies; as among soldiers assembled in barracks, where many of the men live in the same apartments, and use the same towels: while the officers, who live in larger and better ventilated rooms, and apart from each other, generally escape. And the good effect, in checking the further extension of the disease, of separating the healthy from the sick, and of restricting every one to his own washing utensils, and clothes, and towels and sponges, leads to the same conclu- sion. Rust, a German author, mentions this striking fact in corroboration of what I have just been saying. The disease broke out in the town of Mayence. This place was garrisoned by Prussian and Austrian troops. The ophthalmia began and spread extensively among the Prussian soldiery; while the Austrians, who were stationed in separate barracks from the Prussians, in another quarter of the town, remained quite free from it. Those persons who deny, or who doubt, the contagious nature of purulent ophthal- mia, rest their opinions upon some such considerations as these. They hold, in the first place, that the peculiarities of the atmosphere, in Egypt, where the disease has been found so common, are sufficient in themselves to account for it. That the inhabitants of that country never dream of its being caused by contagion. Assalini, who saw the complaint raging in the French army, professes his belief that it did not arise or spread by contagion. He remarks that the atmospheric conditions which are known to occasion catarrhal affections, are very frequent and powerful in Egypt: the days are very hot, the nights chilly, and attended with heavy dews; and men's eyes are perpetually exposed, in the day time, to a dazzling glare of light from the white and arid surface, while the air is full of floating particles of hot sand, which are 212 DISEASES OF THE EYE. [lect. xvii. raised from the ground by the slightest breeze. His opinion, therefore, and the opinion of others who saw the disease as it prevailed in that country, was, that it consisted simply of acute catarrhal inflammation of the conjunctiva; and that it affected those persons most who were most exposed to the exciting causes of such inflammation; the common soldiers, therefore, more frequently than the officers. Other circumstances adduced by the disbelievers, or sceptics in respect to contagion, are that many who have intercourse with the sick escape the disease; and that when bodies of men, among whom purulent ophthalmia has been prevailing to a great extent, are broken up and dispersed, the complaint is not thereby disseminated, as they say it ought to be, supposing it to be communicable from one person to another; that, in fact, this dispersion, the disbanding of troops for instance, and sending them to their friends and families all over the country, is the surest way of stopping the disorder. Again, many ineffectual attempts have been made to inoculate the eyes of animals with the matter of purulent ophthalmia. Miiller, a German, with that pains-taking industry for which the Germans are so remarkable, collected on a camel's hair pencil matter from the eyes of patients labouring under purulent ophthalmia, early in the morning, before they had washed them, and inserted it under both the lids of each eye, in a great number of animals, leaving the pencil there for a few seconds, and then pressing it so as to squeeze the matter out. He also smeared the pus copiously and repeatedly along the edges of the lids. He served in this way five cats, ten dogs, two rabbits, two squirrels, two blackbirds, a starling, a yellowhammer, and a cock. And in none of them did the inoculation produce the slighest effect. It is a sufficient answer to these negative experiments, however, that other persons were more successful in producing the disease in this manner. Vasani and Grafe have both excited it repeatedly in dogs and cats, by the application to their eyes of matter taken from human patients. And I have already informed you of many instances in which the disease was generated in men by accidental, and even by in- tentional, inoculation. No amount of negative evidence can do away with positive testimony so often repeated. And with respect to the other objections, and especially the main objection, that persons may associate and hold close intercourse with individuals labouring under purulent ophthalmia without contracting the disease; I would have you remark that this is no more than what continually happens in regard to diseases which are ac- knowledged on all hands to be contagious, and to have no other source at present, however they may have originated at first, but contagion : the small-pox for example. I think there is some reason for believing, from the facts which I have been relating, that purulent ophthalmia, like the small-pox, is capable of being communicated from one person to another, not only by positive contact, but by transmission of the specific poison somehow for a short distance through the air. But many persons exposed to the contagion of small-pox escape it altogether: and more persons still, perhaps, fail to be affected, though fully exposed, at one time, and yet readily accept the disease at another time, even when the exposure may seem much more slight than on previous occasions. Now what is true of the small-pox may be presumed to be likely, although perhaps in a different degree, of purulent ophthalmia. As" to the circumstance that the disbanding of a regiment infected with the disease prevents instead of favouring its dissemination, that circumstance is really no argu- ment at all against our belief in its contagious nature. We shall see hereafter, that when fever patients are collected in nnmbers in distinct wards, or in fever hospitals, that disease is very apt to be communicated to the nurses and medical attendants of the sick; whereas when such patients are distributed here and there among others, in a general hospital, the disease is scarcely ever known to spread. In the one case the poison is concentrated and effective, in the other it is diluted and harmless.1 1 [That diseases, of the contagious character of which there can he no doubt, are rendered more virulent when a number of patients affected with them are crowded together in ill-ventilated apartments, is unquestionably true, hut these diseases do not cease to be contagious, when those labouring under them are distributed here and there among the non-affected. We know of no more effectual means of disseminating small-pox than by introducing single cases of it, here and there, among persons predisposed to its attack. The fact is, that the perfect safety attendant -jpon the dispersion of fever patients among unaffected communities, and the stop put to the lect. xvn.] PURULENT OPHTHALMIA. 213 Dr. Mackenzie indeed has come to the conclusion, from what he has himself observed, that the discharge in catarrhal ophthalmia, especially when it is distinctly puriform, if conveyed from the eyes of the patient to those of others by the fingers, or by towels, and so forth, is capable of exciting inflammation of the conjunctiva, still more severe, more distinctly puriform, and more dangerous, than was the original ophthalmia. And with respect to the disease which I have been speaking of as purulent ophthalmia, or Egyptian ophthalmia, this author calls it contagious ophthalmia. He holds that the inflammation of the conjunctiva, whether in the mild or the more severe form, may and often does originate from common atmospheric influences; but that when so caused it may be communicated from person to person, especially when it is attended with a puriform discharge. And this is an opinion which, I think, is fully warranted by the facts of which we are in possession upon this subject. There is a strange reluctance, which I have never been able to account for, in some medical men, to admit of the operation of contagion, as a cause of disease. Undoubtedly there are some difficulties belonging to the doctrine of contagion, and I hope in the progress of the course, and especially when I come to speak of fevers, to give that subject the careful attention which its great importance demands; and to enable you to make up your minds respecting it. At present I will only remark, that there is nothing absurd, nor unlikely, in the supposition that diseases may first arise from some other source, and then become capable of spreading by contagion; and that in all cases, even when the contagious principle is most manifest, there seems to be something else required besides the presence of contagious matter; there must be a readiness to receive it, a susceptibility of its influence, on the part of the person exposed to it: a predisposition which is less common in regard to some diseases than to others; but without which there is scarcely any complaint that can be so propagated. At any rate I would desire to impress upon you the expedience and propriety of acting, whatever your doubts or your belief may be, upon the safe side. We are bound to proceed, in all questionable cases of this kind, upon the most unfavourable supposition. Very great discredit and loss of reputation have fallen upon practitioners who, having themselves no belief that a given complaint was contagious, have neglected those precautions which, under a contrary impression, they would have thought necessary. Perhaps they may have sometimes suffered unjustly: but you had better not commit yourselves, especially while you are young in years and in experience, by strong assertions of the non-contagiousness of any disease, the mode of propagation of which is at all equivocal. And as for the disease that we are now con- cerned with, you will do well to act as though it were certainly contagious; whether you meet with it as a sporadic or as an epidemic complaint, whether it be severe in its symptoms, or mild. You should forbid the use of your patient's towels and washing vessels by other members of the family; you should avoid employing the same instruments or sponges to any sound eye, which you have been using for one that is affected with this complaint; and you should take care to wash your own hands, after touching a diseased eye, before you apply your fingers to another that is yet, in this respect, healthy. occurrence of new cases so soon as a removal is effected of all the inmates of the houses or the inhabitants of the localities where it prevailed, is an almost positive proof that the fever ori- ginated solely in local causes, and cannot be communicated by contagion. — C] 214 DISEASES OF THE EYE. [lect. xviii. LECTURE XVIII. Purulent Ophthalmia, continued. Gonorrhoeal Ophthalmia. Purulent Ophthalmia of Infants. Strumous Ophthalmia. When we last met, I spoke of catarrhal ophthalmia, i. e., a mild and common form of inflammation of the conjunctiva, resulting from atmospheric influences. I described its characteristic symptoms, and explained the treatment that has been found most successful for its cure : consisting chiefly in local stimulating or astringent applications. I began also to speak of the severer forms of inflammation affecting the same part, and included under the head of purulent ophthalmia. The symptoms and course and consequences of the two varieties of this complaint, as it occurs in adults, are so essentially the same, that one description of its phenomena is enough. There are certain differences, however, that require to be noticed, in respect to its exciting causes. I laid before you the reasons which satisfy me, that what is called the Egyptian ophthalmia is a contagious disease; and which make it probable that the complaint is capable of being propagated from person to person, through the medium of the air, without the necessity for any substantial application of the morbid secretion from a diseased to a sound eye. These reasons, briefly stated, afe as follows: that the disease was unknown to Europe till after the war in Egypt; that, arising among our own and the French troops in that country, it was conveyed by them to various places, and extended itself to soldiers who had intercourse with those troops; that when once introduced it spreads rapidly wherever men are crowded together within a small com- pass, pay insufficient attention to cleanliness, and use the same towels and utensils; that it has been propagated again and again by the direct application of the morbid secretion; and that its progress is checked by measures which provide against such accidental application, and by separating the diseased from the healthy. On the other hand, it has been contended that the disease is nothing more than an extreme degree of catarrhal ophthalmia; that the peculiar conditions of the atmosphere in Egypt and other hot countries, where it is prevalent, are enough to account for it; and that when troops are disbanded, they do not give the disease to their friends and families all over the country, but, on the contrary, the dispersion of the sick in this way is the most effectual mode of stopping the disease. To these arguments the proper answer is, that the same difficulties meet us in respect to some other diseases which are confessed by all persons to be strictly con- tagious. My own creed upon the matter is this—that the disease may, and often does arise, independently of contagion, from the agency of ordinary causes of inflammation; and that having so originated, it acquires contagious properties, which develop themselves only under circumstances that favour the propagation of most of the contagious complaints. I shall next advert to purulent ophthalmia as it is observed to occur, in the adult, in connexion with gonorrhoea. If we look to the mere phenomena presented by the inflamed eye, we find nothing to distinguish the gonorrhoeal from the Egyptian oph- thalmia. Taking the average of a large number of cases, the gonorrhoeal is the severer form of the two, and runs th more rapid course. It is said, also, that the inflammation usually commences on the lids in the Egyptian variety, while it attacks the whole conjunctiva at once in the gonorrhoeal. But, comparing individual instances, these mere differences, and slight differences too, in degree and situation, will not help our diagnosis. But other circumstances may guide us. If a patient present himself with severe purulent ophthalmia, who has not been exposed to any of the known atmospheric causes of that disease, and at a time when purulent ophthalmia is not prevailing as an epidemic, and if this patient have a clap, we may conclude that we have to deal with a case of gonorrhoeal ophthalmia; and this conclusion will be further strengthened if lect. xviii.] GONORRHOEAL OPHTHALMIA. 215 the disease affect one eye only. For what, through the lack of any better nomen- clature, I am constrained to call Egyptian ophthalmia, seldom restricts itself to a single eye. Dr. Vetch says, " there is but one case in a thousand in which one eye only becomes affected." Walther observes that contagious ophthalmia almost always appears in both eyes together, but not in the same degree; and Eble (another German author) states that the contagious ophthalmia has not confined itself to one eye in any instance. These round assertions require, however, some qualification; the nurses, whose cases I quoted in the last lecture from Sir Patrick Macgregor's paper, suffered each in one eye only. On the other hand, gonorrhoeal ophthalmia mostly, but by no means always, is limited to one eye. In Mr. Lawrence's instructive book On the Venereal Diseases of the Eye, he mentions fourteen cases of gonorrhoeal ophthalmia. In nine of these, one eye only was inflamed. It is always a matter of some interest to make out whether the disease has or has not any connexion with gonorrhoea; even though we may gain nothing, in respect to the treatment, by the distinction. Purulent ophthalmia has been said to be connected with gonorrhoea in three several ways: 1st, by direct contact of the gonorrhoeal discharge from the urethra with the conjunctiva; 2d, by metastasis of the inflammation from the urethra to the eye, with- out any such contact of matter; and 3d, independently of either of these ways; i. e., purulent ophthalmia has been supposed to occur in connexion with clap, just as ulce- ration of the throat is apt to occur in venereal diseases. Now the last two of these three modes of origin are more or less questionable; the first is certain. Very odd speculative opinions are apt to possess themselves of the minds of medical as well as of other philosophers. Some who believe that the disease is communicable to the eye by direct contact of gonorrhoeal matter, yet hold that it must come from the urethra of another person; that the Hudibrastic aphorism is true, " No man of himself doth catch." Dr. Vetch seems to have fallen into this opinion through the very common mistake of drawing positive conclusions from negative experiments. He had known a hospital assistant, who "with more faith than prudence," conveyed the matter of gonorrhoea from his urethra to his eyes, with impunity. He stateg also the converse experiment: a soldier in a very advanced stage of Egyptian ophthalmia, attempted to divert the disease from his eyes by applying some of the matter they were discharging to the orifice of his urethra: no effect followed this trial. But in another case the matter taken from the eye of one man labouring under purulent ophthalmia, was applied to the urethra of another man; and inflammation commenced there in thirty-six hours, and he had a very severe attack of gonorrhoea. Some per- sons, judging from such cases as this, and from the similarity of the discharge in the two diseases, " have gone the length of concluding (according to Dr. Mackenzie) that gonorrhoea has been originally an inoculation of the urethra by the matter derived from the eye in the Egyptian ophthalmia; whilst others are of opinion that this last disease is nothing else than the effect of an inoculation of the conjunctiva with matter from the urethra in gonorrhoea." To satisfy you that a person may "catch" the complaint from himself or from others, it is right that I should bring before you one or two well-marked examples. It is a common persuasion, among the lower classes, that to bathe the eyes in human urine is good for the sight. This piece of practice has cost several persons their vision. A gentleman belonging to the class mentioned to me the other day two cases of purulent ophthalmia so produced, which he had seen among Mr. Guthrie's patients at the Ophthalmic Hospital. In the one, a young woman, not so healthy as she ought to have been, used her own water; in the other, an older woman, for what reason it did not appear, preferred her husband's to her own. Mr. Lawrence alludes to several similar cases. He details an instance also, in which partial sloughing of one cornea occurred; the disease having been caused by the patient's wiping his eyes with a towel soiled with the gonorrhoeal discharge from his own urethra. But one of the neatest and most conclusive instances of the production of the disease in this way has been furnished by Dr. Mackenzie. A patient was brought to him from the country with his left eye violently inflamed and chemosed, and discharging a large quantity of purulent fluid; the lower lid everted, and the cornea totally opaque. Thirteen days before, this man, who had then a profuse gonorrhoea, but whose eyes were per- 216 DISEASES OF TLTE EYE. [LECT. XVIII. fectly well, while stooping down and shaking away the discharge from his penis, flung a drop of it fairly into his left eye. Violent inflammation immediately set in, was confined to the eye that was thus inoculated, and produced the results I have men- tioned : the gonorrhoea going on just as before. Numerous authentic cases have been recorded of gonorrhoeal ophthalmia produced by the application to the eye of gonorrhoeal matter from another individual. Mr. Wardrop met with the following example. An old lady went into the dressing-room of her son, who had gonorrhoea, and washed her face with a towel which he had re- cently been making use of. Purulent ophthalmia quickly supervened, and destroyed the eye in a few days. Delpech mentions the instance of a young and healthy woman, who bathed her eyes with goulard water, by means of a sponge which had been used by a young man who had a clap: violent inflammation soon arose, and the sight of one eye was lost. Several cases of purulent ophthalmia have been observed in laun- dresses, who had been employed in washing linen, foul with the discharge of gonorrhoea. Mr. Lawrence seems to be of opinion that purulent ophthalmia is not a very frequent consequence of the application of the urethral discharge to the eye of the same person. " When we consider," he says, " how this matter is diffused over the linen of patients, both male and female, how often the fingers must be smeared with it, and how inat- tentive to cleanliness the lower classes are, we cannot help concluding that the gon- orrhoeal discharge must be often applied to the eyes of the same individual; yet gon- orrhoeal ophthalmia is comparatively rare." Dr. Mackenzie, on the other hand, thinks that the application of the matter to the eye is seldom made. " The instinctive closure of the eyelids," he observes, "when the finger approaches the eye, making it actually difficult for a person to touch his own conjunctiva, unless with one finger he draws down the lower lid, and intentionally applies another finger to the eye, will serve in some measure to explain the rarity of this kind of inoculation." It has been noticed that women are much less frequently the subjects of gonor- rhoeal ophthalmia than men. Does gonorrhoeal ophthalmia ever occur by metastasis ? This question does not admit of a positive answer. Practical men are divided in opinion on the subject. In the majority of cases of gonorrhoeal ophthalmia, we are unable to trace any appli- cation of the urethral discharge to the eye, either from the same or from another individual. Yet it does not follow that no such application took place. The German and Italian writers believe in metastasis. " In all the instances," says Beer, " which I have seen, this ophthalmia has occurred in young, plethoric, robust, and truly athletic men; and it has always taken place in a very short time, generally in a few hours, after the suppression of gonorrhoeal discharge from the urethra." Mr. Law- rence never knew the urethral discharge stop upon the coming on of the ophthalmia; it has generally diminished, but in some instances has continued as copious as before. He seems to regard the occurrence of the ophthalmia as analogous to those successive attacks of distant parts that are common in gout and rheumatism. Dr. Mackenzie evidently doubts the occurrence of metastasis at all in this disease, and is inclined to refer all the cases in which it has been alleged, to inoculation, or to an accidental con- currence of purulent ophthalmia and gonorrhoea in the same person. The supervention of purulent ophthalmia as a part of the gonorrhoeal malady, inde- pendently of inoculation and metastasis, seems to me extremely problematical. The eye is well known to suffer, as well as other organs, in the secondary forms of syphi- litic disease, but the conjunctiva is not the part that is attacked. I have never seen nor heard of any satisfactory example of purulent ophthalmia alternating with gonor- rhoea, where the possibility of inoculation was excluded. And, upon the whole, my own opinion — (you will take it for whatever it may seem worth)—is against the ex- istence of this alleged form of purulent ophthalmia. Whether it exists or not is of very little consequence in regard to the main question; namely, what is the proper mode of treating the purulent ophthalmia of adults 1 Now the two chief points to consider, so far as respects the treatment, are — first, blood-letting; and secondly, the application of strong astringents to the inflamed membrane. Blood-letting has been carried to a very great extent in this disease, or in these dis- eases, if you choose to consider the Egyptian purulent ophthalmia and the gonorrhoeal lect. xviii.] GONORRHOEAL OPHTHALMIA. 217 purulent ophthalmia as two different inflammations. Its effects have not been very decisive or satisfactory; indeed, we could hardly expect that they would. In the first place, the inflammation is so rapidly destructive, that, in many of the worst cases, irreparable mischief is done before the patient applies for medical assistance. In forty-eight hours, or a little more, Mr. Lawrence tells us, the affection may have pro- ceeded to such an extent as to be beyond our control. Of course this reason for the want of success is equally applicable to every remedy that has been, or could be, pro- posed. But independently of this, even when the disease is seen and submitted to treatment in its very beginning, we should have the less confidence in the power of general blood-letting to control it, for these two reasons; that the part affected is a mucous membrane ; and that there is so little constitutional sympathy with the local inflammation. Free venaesection tells most upon inflammation, when it is attended with high fever and a hard pulse, i. e., with increased action of the heart; which the abstraction of blood tends to abate. It is also a matter of experience, that general bleeding has more influence over the inflammation of serous and fibrous membranes than over that of the mucous tissues. Accordingly, though bleeding has been even lavishly employed in purulent ophthalmia, it has too often disappointed the practi- tioner. There is one lesson, however, to be learned from copious blood-letting in this disease, even when it fails of its object. It clearly demonstrates what may be hoped for, from an early recourse to that measure in internal inflammations. " You see a person," says Mr. Lawrence, who has both had, and used freely, very numerous op- portunities of putting this remedy to the test, "you see a person with his eye bright red, and very painful; he cannot face the light, and tears gush out, with great suf- fering, if he attempt to do so. You bleed to fainting, and immediately the capillaries are emptied, so that the organ resumes its natural paleness; the pain is gone, the eye is opened without difficulty, and the full influx of light can be borne without an un- easy sensation. For the time the part has passed from violent inflammation to a nearly natural state. With the restoration of the circulation the inflammation will recur after this temporary suspension; but its violence is diminished, and it often gradually abates." Mr. Lawrence is here speaking of acute inflammation affecting the textures of the eye generally, and not of purulent ophthalmia in particular; but I am desirous that, in passing, you should take notice of this direct effect of bleeding to syncope, upon the capillaries of the eye, because it teaches us what the same ex- pedient may do for the capillaries of any other internal part, which we cannot see, when that part is attacked with inflammation. In purulent ophthalmia, however, if you trusted to bleeding alone, you would often reduce your patient to a very dan- gerous state of weakness, and after all fail of your mark. Dr. Vetch bears strong testimony to the usefulness of blood-letting when freely employed in the early stages of Egyptian ophthalmia. In young and robust persons, and at the very outset of the disease, it may aid the local expedients which I shall presently mention; and if the patient be not seen till the globe of the eye is invisible for the swelling, the propriety of abstracting blood will be still further indicated by the occurrence of throbbing and circumorbital pain, returning in nocturnal paroxysms; for this symptom denotes that the inflammation has descended deeper than the conjunctiva. The bleeding, when performed at all, should be performed in the way I formerly spoke of as being required in serious inflammations: the patient should be bled from the arm, in the upright position, till fainting is about to ensue, or the pulse begins to falter. You will do more towards obtaining safety for your patient's vision in this way, and at less expense of his strength, than by bleeding him many times to a smaller amount. When the patient begins to rally from his faintness, from twelve to twenty-four leeches may often be applied with advantage; round the eye, and not upon the tumid lids, where their bites are apt to add to the existing irritation, and to fester. You had better bleed your patient from the arm, and not from the jugular vein, or the temporal artery, for reasons which, as I have fully stated them already, I need not now repeat. But of late years more reliance has been placed by most practitioners upon local stimulants, for checking this horrible malady, than upon general or topical bleeding. Dr. Vetch strongly recommended the insertion of undiluted liquor plumbi acetatis, and Mr. Briggs, in his translation of a work of Scarpa's on the eye, advised the intro- duction of a very minute quantity of the oil of turpentine, between the eyelids. But Mr. Guthrie has the merit of having applied, in its full extent, this principle of curing 218 DISEASES OF THE EYE. [LECT. XVIII. conjunctival inflammation, even in its severest forms, by stimulant and astringent substances. I told you, when speaking of catarrhal ophthalmia, that Mr. Melin and Dr. Mackenzie treat that complaint with a wash, made by dissolving four grains of lunar caustic in an ounce of distilled water. I might have added other authorities in favour of the same kind of practice. Now Mr. Guthrie treats purulent ophthalmia on the same principle, but with a much larger dose of the nitrate of silver. The greater intensity of the disorder is met by increasing the strength of the remedy. He con- siders it to be a local disease of a peculiar character; and, acting upon the aphorism of John Hunter (an aphorism, however, which requires some qualification) that two diseases or actions cannot go on in a part at the same time, he proposes to set up in the inflamed conjunctiva a new action, which shall supersede the original disease, and create another that is more manageable. In this point of view Mr. Guthrie's ratio medendi agrees with that of Hahnemann, about which there has been so absurd a noise made of late years. I have never had the advantage of seeing Mr. Guthrie's plan tried, but, from all that I have heard of it, I believe it to be a valuable discovery. A priori, we should expect that the caustic application would add to the existing mischief, and destroy all chance of saving the inflamed eye. But it is not so. Even Mr. Lawrence, who was, I have reason to think, formerly very sceptical on this point, appears to be so no longer. In his treatise On the Venereal Diseases of the Eye, he uses this cautious language: — "Destructive or injurious consequences have so fre- quently resulted under the usual management of this disease" — he is speaking of gonorrhoeal ophthalmia — " that I should certainly employ the local astringent, if I met with a case favourable for the trial; i. e., where the affection had not extended beyond the conjunctiva. Blood-letting might be resorted to at the same time; in most cases, however, our aid is not sought until the cornea has become affected, and it is therefore too late for the astringent plan." But he subsequently added a note, to the effect, that after the statement I have just quoted was written, he had employed the caustic solution in two cases of conjunctival inflammation with the best results. Mr. Guthrie's plan, therefore, you ought to be acquainted with. After many trials, he has arrived at the conclusion that the best appliance, in this formidable complaint, is an ointment, made by mixing ten grains of the nitrate of silver, reduced to an impalpable powder, with a drachm of hog's lard. This is what he calls his ten-grain ointment. Before applying it to the diseased eye, the discharge must be well cleansed away by a solution of alum; then the ointment having been inserted beneath the lids, they are to be moved freely up and down, so that the whole conjunctiva may get its due share of the remedy; and that it has done so is shown by its turning white. If the surface do not turn white, the ointment has not been sufficiently applied, and will not answer the purpose. If we wish to be quite sure, he says, we turn out the eyelids, and rub the ointment on them. This application gives pain, which lasts for half an hour, or an hour, or more. "Warm narcotic fomentations may be applied to relieve uneasiness, and opium given to allay pain, and to obtain sleep; while a solution of alum, in the proportion of a drachm to a pint, should be injected from time to time into the eye, to clear it; but should the patient sleep, he must not be disturbed. A mild ointment may be applied to the edges of the lids at night, to prevent their sticking together. The next morning the discharge is again to be removed, and the ointment to be reapplied; for on no account should the action we are desirous of exciting be allowed to cease." Of course Mr. Guthrie means it is not to be suffered to cease prematurely. This, with a free but not excessive venaesection, is the sub- stance of his peculiar mode of treating purulent ophthalmia; and it appears to have been eminently prosperous in his hands. I have been informed, by one of yourselves, that purulent ophthalmia has been successfully treated, on a large scale, in Manches- ter, by applying the nitrate of silver, in substance, to the surface of the conjunctiva; that this gives less pain than the ten-grain ointment, though perhaps it may require to be oftener repeated. I say I have never seen this method of Mr. Guthrie's carried into effect; but after what I have myself witnessed of the intractable and destructive nature of the disease, under the treatment ordinarily adopted before his ointment was devised, I will say also, that were I so unfortunate as to be attacked with severe purulent ophthalmia, I should desire to have the caustic applied without delay. lect. xviii.] PURULENT OPHTHALMIA. 219 There are some minor points in the treatment that require a cursory notice only. Some persons, and Mr. Guthrie among the rest, recommend the exhibition of mercury, so as to affect the gums. Now I believe that mercury is quite useless in this complaint; and if useless, mischievous. The disease is too rapid to be over- taken by the mercury, and if you could obtain the specific influence of that mineral in time, i. e., before any of the destructive effects of the inflammation were accom- plished, you would do no good thereby. This is not the kind of inflammation over which mercury exercises any useful control. Mr. Lawrence tells us that he has seen both the ordinary purulent, and gonorrhoeal ophthalmia, proceeding apparently un- checked, under the full mercurial action. Practical men are not agreed about the propriety of scarifying the conjunctiva when it is swelled and elevated by chemosis. Mr. Lawrence objects to it, as likely to increase the local irritation; a disadvantage not compensated by the quantity of blood discharged from the divided vessels. Dr. Mackenzie recommends it, stating that the incisions will bleed copiously, and greatly allay the symptoms. Who shall decide in this puzzling discrepancy of opinion ? Mr. Guthrie's caustic ointment would, I presume, supersede any other meddling with the inflamed surface. But when the question happens to lie between scarification and no scarification, I should give my vote for scarifying; not because I think any useful depletion of the blood- vessels could be brought about by that measure, but because, if properly performed, it would evacuate the serous effusion from the areolar tissue between the conjunctiva and the sclerotica, which effusion constitutes the chemosis, and hastens, if it do not cause, the sloughing of the cornea, by the mechanical pressure that it exerts around it. Are blisters of any use? Hear Dr. Mackenzie. "Counter-irritants are highly serviceable in this disease, and ought always to be employed. There is generally a marked change in the quantity and appearance of the discharge from the eye, as soon as a counter-discharge is established by blisters on the temples, nape of the neck, or behind the ears." But listen to Mr. Lawrence. " Experience does not warrant us in ascribing much efficacy to blisters." Now the truth is, I believe, that during the active stage of the disease, blisters are not of any use; but that in the more advanced and chronic periods, they are. Indeed Mr. Lawrence admits that they may be regarded as auxiliary measures, and resorted to after antiphlogistic means. I agree with the same gentleman in thinking that no reliance is to be placed, in gonorrhoeal ophthalmia, upon any attempts to reproduce the urethral discharge; indeed, in most cases it is not suspended. Although I have not mentioned purgatives, you will conclude that they form a very proper and necessary part of the treatment during the activity of the complaint. After what has already been said of purulent ophthalmia in the adult, and of gonorrhoeal ophthalmia, it will not be necessary for me to take up very much of your time in speaking of purulent ophthalmia as it occurs in newly-born children. This is a very common disease : it is very serious when neglected: it is very easily managed when it is seen and treated in time. These are all reasons why you should make yourselves familiar with the complaint, and with the mode of curing it. You may perhaps never have occasion to treat a case of purulent ophthalmia in the adult: you are sure to be consulted about the purulent eye of infants, the ophthalmia neo- natorum. The importance of the disorder is apt to be overlooked by mothers and nurses; they say the baby has a cold in the eye, which will go off; and they wash it perhaps with a little of the mother's milk, or some such insignificant fluid. Meanwhile the eyelids swell, the mischief that is going on beneath them is concealed from sight, and when at last a medical man is consulted, he too often finds that one of the eyes has perished, or both: the cornea has sloughed; or become opaque; or protrudes, and constitutes what is called staphyloma; prolapse of the iris has taken place; or the coats of the organ have shrunk up. The inflammation usually comes on about three days after the child is born, although it may commence later. It is confined, at first, to that part of the mem- brane which lines the lids. Their edges are observed to stick together when the infant wakes: there is more intolerance of light, apparently, than is suffered in the analogous diseases of adults. The little patients cannot indeed tell us their sensa 220 DISEASES OF THE EYE. [lect. xviii. tions by words, but they express them significantly enough by keeping their eyes shut, by knitting their small brows, and by turning their heads away from the light. At length the inflammation extends to the conjunctiva that covers the eyeball, the eyelids swell, sometimes enormously: and an astonishingly copious discharge of pus takes place. By the adhesion of the edges of the lids the puriform matter is some- times pent up, causing them to protrude; and when they are separated it escapes in a profuse hot gush. The eyelids are sometimes everted during the cries and strag- gling of the little sufferer, and their mucous surface is then seen to be villous and shaggy, and of as bright a scarlet as you ever saw the injected mucous membrane of a foetal stomach. At last those destructive consequences to the eye take place which I have already mentioned. The disease, however, may continue for eight or ten days without any affection of the transparent parts; and so long as these remain uninjured, the eye is safe, provided that proper treatment be adopted. This disease is probably much the most fertile source of blindness with which we are acquainted. It is believed to originate most commonly, if not always, in con- tagion. We might, perhaps, expect this, from the analogy of the severe inflammation of, the same parts in adults. And it is matter of fact, that in a very large number of cases the mother has been affected, at the time of her confinement, with some kind of vaginal discharge — leucorrhcea, or gonorrhoea; and the eyes of the children are exposed to these morbid secretions, as they are brought into the world. The circum- stance of the disease commencing so regularly on the third day, is greatly in favour of the supposition that it results from inoculation of the eyes by the unhealthy fluids of the mother. The discharge from the infant's eyes has been ascertained to be highly contagious. Dr. Mackenzie mentions a lamentable illustration of this fact, which fell under his observation at the Eye Infirmary, in Glasgow. An infant and its grandfather became his patients there at the same time; the latter having been inoculated from the former. Both were so severely affected that the infant had one eye left in a state of total, and the other of partial staphyloma: while in each eye of the old man, the greater part of the cornea remained opaque, and adherent to the iris. However, the disease certainly occurs in the infants of mothers who seem to be healthy, and who deny that they have any unnatural discharge. It may probably be brought on, sometimes, by bad management on the part of the nurse : by exposure soon after birth to draughts of cold air, or to the injurious influence of a hot and bright fire ; or by the introduction of soap into the eye in the primary ablutions, or of gin, wherewith the lower classes, in some absurd persuasion of its strengthening virtues, are wont to bathe the unlucky infant's head. The disorder is observed to be most common in damp and cold weather; in low crowded places; and among the children of the poor. [Contaminated air, with its often associated morbific causes, neglect of cleanliness, defective nourishment, or improper food, and want of sufficient exercise, is liable to produce a general tendency to disease in the mucous tissues of children. The mouth, the anus, and the vulva, under such circumstances, being all alike liable to affections terminating rapidly in gangrenous ulceration. It is asserted, upon good authority, that in cases of purulent ophthalmia in children, the vagina is liable to be affected with a purulent discharge, precisely similar in appearance to that from the conjunctiva. See Condie on Diseases of Children, 4th Ed. Dr. Mildner, speaking of the disease as observed in the Foundling Hospital of the city of Prague, says that most of the chil- dren affected with it manifested an " albuminous crasis of the blood," characterized by a catarrhal condition of the mucous membranes generally, with marasmus and debility. The influence of atmospheric causes in the production of the disease were, according to Dr. Mildner, very evident. Often, when the wards were crowded with puerperal women, especially if the air was cold and damp, from six to ten children would be seized in one day, and usually in both eyes. When, he remarks, the catar- rhal cases assumed a septic character, numerous cases of umbilical phlebitis, purulent infection, gangrenous erysipelas, croup, &c, were observed. Dr. Mildner describes a croupal form of the disease, characterized by an exudation of various thickness, which may assume a membranous form with newly developed vessels. It is often accompanied with the occurrence of membraniform exudations in the mouth and pharynx. When in this form of the disease a septic tendency was lect. xviii.] STRUMOUS OPHTHALMIA. 221 manifested, loss of vision might be predicted, even when but a small portion of the cornea was affected. Annates d'Oculistique ; ser. 4, torn, ii, p. 140. — C] One striking difference between the disease as it exists in adults and in newly-born children I have already adverted to; viz., its rapid and often incontrollable progress in the former; and the facility with which it yields to suitable and timely treatment in the latter. If a child be brought to you with purulent ophthalmia, and you are able to separate the lids sufficiently to obtain a glimpse of the cornea, and perceive that it is still brilliant and uninjured, you may confidently tell the anxious mother that, with due care on her part, her child's eye is safe. If the cornea have lost its transparency, it is still within the reach of recovery, but the chances are against it; if you cannot get a sight of the cornea at all, you will do wisely to give a doubtful prognosis, or even an unfavourable prognosis; for such is the ignorance of the vulgar (and I include both rich and poor under this phrase) that if they are not forewarned of the danger, they are very apt to attribute the blindness that ensues to your stuff, as they call it. In the severer forms and stages of the complaint, if the lids are very much swelled, and red externally, and especially if you are unable to obtain any satisfactory view of the cornea without using a degree of violence that might be hurtful, it will be right to apply a leech. In this case it may be placed upon the centre of the tumid upper lid; and you should, whenever that is possible, stay by the little patient until the animal drops off, and the bleeding ceases; for sometimes the bleeding is difficult to stop, and it must not be trusted to the care of the nurse; and the loss of blood occa- sioned by the bite of a single leech will often blanch the infant's skin, and make you fear that the depletion, slight as it is in actual amount, has yet been too much. The child's bowels should be emptied by a little castor-oil; and a lotion, made by dissolv- ing two grains of acetate of lead in an ounce of water, may be applied to the inflamed organ. In less severe cases, and I believe in all cases in which you can see the uninjured cornea gleaming through the pus that bathes it, it will be quite sufficient to keep the infant's bowels open with magnesia; to apply a little lard along the edges of the lids, that they may not stick together; and to inject carefully into the eye, beneath and between the lids, a solution of alum; in the ratio of four grains to one ounce of water. Such, Mr. Lawrence tells us, was the treatment in forty-nine cases out of fifty at the London Ophthalmic Infirmary when he was surgeon to it: no other means being used than magnesia internally, and the solution of alum locally: and out of many hundred instances he scarcely recollected one that suffered in any respect, if the cornea were clear when the infant was first seen. I had, for a considerable period the advan- tage of watching Mr. Lawrence's patients under that treatment; and the result of it was so entirely and uniformly satisfactory, that I should never think of employing any other. If the eye became at length insensible to the stimulus of the alum, a solution of the nitrate of silver, (from one to four grains in the ounce of water,) was substituted with advantage. Mr. Guthrie uses, I fancy, his caustic ointment; but I am sure that the simple and less severe plan I have been describing is quite sufficient. There is just one more disease belonging to the conjunctiva, that I wish to bring before you; and then I shall have done with the morbid affections of this external membrane of the eye. It has received several names. Sometimes it is called pus- tular ophthalmia, from the appearance of little pustules upon the surface of the organ. Dr. Mackenzie, who looks upon it as an eruptive disease, affecting the conjunctiva not so much as a mucous membrane, but rather as a continuation of the skin, names it phlyclemidar ophthalmia. It has also acquired the title of scrofulous or strumous ophthalmia, from its continual occurrence in children of a scrofulous habit, and its very frequent association with scrofulous disease in other parts. It is a disorder of childhood, and it is so common a form of disorder, that, of ten cases of inflammation of the eyes in young persons, nine will be of this kind. I shall call it strumous oph- thalmia. It is a form of ophthalmia that differs in many striking points from those which we have been considering. In the first place, it is intimately connected with the scrofulous constitution; the 222 DISEASES OF THE EYE. [lect. xviii. peculiarities of which I formerly explained. Although a disease of children, it is not a disease of infants at the breast. It is most prevalent from the time of weaning to about the age of eight. I mentioned to you, in a previous lecture, the remarkable fact —showing the strong influence of unsuitable or insufficient nourishment in de- veloping scrofulous disease — that when asked to prescribe for children haying bad eyes, you will find, in nineteen cases out of twenty, that you have to deal with puru- lent ophthalmia if the child be still at the breast, and with strumous ophthalmia it it The leading symptoms of this disease are, slight redness; great intolerance of light; the formation of little prominences or pustules on the surface of the conjunctiva; and specks which are the result of these. The complaint sometimes occurs in one eye alone, oftener in both; but then one eye is generally worse than the other Mere catarrhal ophthalmia is apt to degenerate into this affection in scrofulous children. After seeing two or three cases of strumous ophthalmia, you cannot fail to recognise it whenever you meet with it again. The redness has this peculiarity, that it is slight and partial. Sometimes it is altogether confined to that part of the membrane which lines the eyelids : generally a few vessels, collected into little bundles, are seen proceeding from some point of the circumference — more commonly from the angles of the eye than from any other point —towards the cornea: the vessels are evidently superficial, often prominent. These scattered bundles of vessels (sometimes there is but one) stop when they reach the cornea, or occasionally encroach a little upon it; and where they stop, tlm small elevations of the membrane may be observed, which are called pustules. This is the most common situation of these elevated points, just at the line of junction between the sclerotica and the cornea, or near that line. Sometimes, however, you may see one or two near the centre of the cornea. They are smaller in size when they appear on the cornea, than when they are situated near its edge. These pimples may be absorbed, and leave behind them a temporary white spot; more frequently they break and form little ulcers. When these ulcersare beyond the cornea they are of less consequence: when they are situated upon it, they become sources of danger in two ways; they may penetrate the cornea, and let out the aque- ous humour, and cause prolapsus iridis and various other mischief: or they may leave, after healing, a permanent opaque white speck, (called leucoma,) which, according to its size and its exact place, will interfere more or less with the patient's vision. The intolerance of light is a very prominent symptom of this disease, and some- times it really is the only symptom that manifests itself. It is curious that this inability to endure a bright light bears no regular or definite proportion to the inten- sity of the other symptoms. It is not that the eye is painful when protected from the light; but that the access of the ordinary light of day occasions extreme suffer- ing ; the eyelids being spasmodically closed and the orbicular muscle in such strong, and apparently involuntary action, as effectually to resist all attempts at opening them. Children that are affected with this disease carry it legibly written in their physi- oo-nomy. Although you cannot tell what is the actual condition of the eye without examining it, you can tell, as soon as you look at the patient, what is the nature of the inflammation under which he is suffering. The child's brow is knit and con- tracted, while his alae nasi and his upper lip are drawn upwards: those muscles of the face (they happen to be also muscles of expression) are instinctively put in action, which tend to exclude the light without quite shutting out the perception of external objects; producing a peculiar and distinctive grin. In the severer cases the child will skulk all day in dark corners; or if in bed, will lie upon his face, or under the clothes; and while the light is thus kept off, he does not appear to suffer. If brought towards a window, he holds his head down, and presses his hands or arms over his eyes. When you attempt to open his eye to examine it, a profuse discharge of scald- ing tears takes place: these pass partly into the nose, and excite fits of sneezing, and partly over the skin, which they sometimes inflame and excoriate; and then, fre- quently, pustules arise, and produce a discharge that crusts over the cheek and extends to the forehead and temples. This is called crusta lactea, and is very charac- teristic of the scrofulous habit; it occasionally spreads over the whole body. You might suppose, from this extreme intolerance of light, that the retina was inflamed or in danger. But it is not so. The affection of the retina is purely sym- lect. xix.] STRUMOUS OPHTHALMIA. 223 pathetic, and need not of itself excite any fears about the vision. Towards dusk indeed, in the twilight, the child can generally open his eyes, and then is quite as able to see as if he were well. Dr. Mackenzie endeavours to explain the connexion of intolerance of light, spasmodic contraction of the lids, and lacrymation, even when there is but little visible redness, by the distribution of the lacrymal nerve; which, after supplying the lacrymal gland, goes to the conjunctiva, and to the orbicularis palpebrarum. Doubtless they are all refiex phenomena. Of this epithet I shall have much to say hereafter. We have the same set of symptoms when a bit of dirt gets into the eye, and fixes itself beneath the upper lid. When little or no redness exists, this extreme intolerance of light has been called photophobia scrofulosa. With this strumous affection of the eye there are usually present other evidences also of scrofulous disease. Swelling and redness of the alae nasi and upper lip; en- largement of the absorbent glands about the neck; eruptions upon the head; sore ears; a large and hard belly; disordered bowels; offensive breath; grinding of the teeth; and general debility. And the ophthalmia will alternate sometimes in severity with some of these other local scrofulous complaints; getting better as they get worse, and vice versa. LECTURE XIX. Strumous Ophthalmia, continued. Recapitulation. Treatment of Strumous Oph- thalmia. General Remarks on Conjunctival Inflammations. Iritis: its Symptoms and Treatment. Causes of Iritis. When we separated yesterday, I was about to describe the treatment which has been found by experience to be the best for relieving strumous or phlyctenular oph- thalmia. Before I take up the subject where it was then dropped, let me briefly remind you of the character and principal symptoms of the disorder. It is a form of inflammation of the conjunctiva, to which scrofulous children, from the time when they are weaned to about the age of eight, are extremely liable. It may occur considerably later. Sometimes it is the first and only token of the existence of the scrofulous diathesis; generally it is observed in children who bear other marks of the strumous habit, and are afflicted with other forms of strumous disease. Its symptoms are—first, slight vascularity; the redness being partial, and proceeding from one or more fasciculi of superficial vessels, which advance from the circumference of the visible part of the eye towards the cornea, where they usually stop : sometimes, however, they pass a little beyond its edge. At the extremities of these fasciculi, upon or near the line of separation between the cornea and the sclerotica, small prominences appear, which are sometimes absorbed, sometimes break and form ulcers. Less frequently the phlyctenae are situate towards the central part of the cornea. Secondly, with this partial vascularity and these pimples, and sometimes even without them, there is extreme intolerance of light. The pain produced by exposing the eye to the influence of light imparts a characteristic expression to the countenance of the suffering child. Tears flow over the cheek, and inflame it often, and give rise to the eruptive appearance termed crusta lactea: or, from its sometimes covering the cheek like a mask, porrigo larvalis. I may add to this summary of what was stated in the last lecture, that sometimes the vessels which pass along the conjunctiva and over the cornea, instead of leading to pustules, extend laterally: so that several bundles of vessels unite by their mutual ramifications; and that part of the conjunctiva which covers the cornea becomes thick, as if it were darned ; and more or less opaque. Indeed, the greater portion or the whole of the corneal covering may thus be rendered patchy and vascular. The appearance presented by the eye under these circumstances is called pannus. You will readily believe, from what has been said of this complaint, that it is an 224 DISEASES OF THE EYE. [LECT. XIX. obstinate and troublesome one. Even when it has been cured it is very apt to recur. The scrofulous habit on which it depends we cannot get rid of; and whenever the exciting causes of scrofulous disease come into action, this form of scrofula is very prone to declare itself, at the period of life which I have already mentioned. More good is to be done by general treatment, applied to the system at large, in this form of ophthalmia, than in those we were occupied with before; and this is one strong point of difference between them. In the first place we must endeavour to correct that unnatural condition of the whole system, and especially of the digestive organs, which is commonly so striking a con- comitant of the local disease. It will be proper to clear out the bowels in the outset, and occasionally, by a mercurial purge; and to regulate them at other times by laxatives, such as rhubarb, or the confectio sennae, or castor oil. The recovery will be greatly promoted also by those measures which are found to benefit the general health in such constitutions; warm clothing, frequent ablution of the body, nourishing though plain food, the respiration of a pure atmosphere, change of air, and regular exercise. In addition to these measures, tonic medicines should be administered; the prepa- rations of iron, for example, or the dilute mineral acids: but the best remedy of this kind is, undoubtedly, the sulphate of quina. This may be given to a child in grain doses, three times a day, dissolved in water, with a drop of the dilute sulphuric acid, and some syrup of orange-peel. Dr. Mackenzie, in particular, has put this medicine fairly to the test, having employed it in a very large number of cases with the happiest results. In most of his patients he declares that it acted like a charm, " abating, commonly in a few days, the excessive intolerance of light and profuse epiphora; promoting the absorption of phlyctenulae, and hastening the cicatrization of ulcers of the cornea." And Mr. Lawrence adds his testimony to the same effect; and his experience in this disease, like Dr. Mackenzie's, has been large enough to make it highly valuable. A few words will suffice to explain the kind of local treatment that has been found useful. You may feel tempted to apply leeches round the eye. This is seldom requisite, except when there is more redness and pain than common, and the tongue becomes white, and the skin hot. Certainly you must not take the intolerance of light as a fit indication for the use of leeches. Abstraction of blood rather aggravates that symptom ; apparently by increasing the irritability of the retina. Warm fomen- tations are generally very comfortable to the patient's feelings. When the general disorder of the system has been somewhat rectified, local stimu- lants and astringents are of great service. The vinum opii, and the solution of lunar caustic, are the best. These are often tedious cases, and therefore it is necessary that you should be aware of one great objection to the long-continued employment of the nitrate of silver wash, which objection has been pointed out by Dr. Mackenzie. It is apt (but only when frequently repeated for a long time together), to stain the con- junctiva of an indelible olive colour. For this reason the vinum opii is to be preferred in slow cases, and in cases where frequent relapses happen. The good effects of either of those preparations are very striking; they diminish the irritability of the eye, and promote the healing of the ulcers. The red precipitate ointment, and the citrine ointment of the Pharmacopoeia, diluted, are also found beneficial. Counter-irritation is another local measure, which is of undoubted utility in this complaint. A great change for the better in the state of the organ often occurs, almost suddenly, upon the rising of a blister placed behind the ear, or at the back of the neck. And issues in tne arms are not only serviceable in promoting the cure, but have a marked effect in many children, in preventing relapses. Mr. Welbank, in his notes to Frick's Treatise on Diseases of the Eye, states that he has seen chronic strumous ophthalmia, of seven years' duration, quickly and effectually relieved by an issue in the arm. " Having once (says he) in the case of a boy in Christ's Hospital, directed the healing of an issue which had been made above twelve months, I found the immediate consequence to be a relapse of strumous inflammation and ulceration of the cornea, resisting every measure but the renewal of the issue." He suggests also (what parents are sometimes more willing to assent to) the advantage of making counter-irritation by piercing the lobe of the ear, and inserting a ring, or silk; and " a very convenient form of vesication will be found in the appli- lect. xix.] STRUMOUS OPHTHALMIA. 225 cation of a strong thread, smeared with the emplastrum cantharidis, and firmly tied behind the ear at the angle of its reflection." When ulceration is going on in the cornea, and threatening to penetrate it, the progress of the ulcer may be checked by touching its surface once in two or three days with a pencil of lunar caustic which hajs been scraped to a fine point. When the more urgent symptoms have abated, and the discharge of hot and irritating tears has ceased, the crusta lactea may very easily be got rid of. The crusts are to be removed by a light poultice, or by warm water; and then the part must be bathed from time to time with a lotion made by mixing the oxide of zinc with water; a drachm to four ounces is the proportion I am in the habit of prescribing. If rose- water be used instead of common pump-water, the prescription will be thought the more elegant. This lotion will speedily dry up the discharge, and in a short time no vestige of the ugly-looking crust will remain. Parents are highly delighted and very thankful when you thus accomplish the removal of a large, disfiguring, and dis- gusting scab, which they naturally enough felt apprehensive might leave behind it a corresponding scar. But it is quite superficial. I have now done with the exterior membrane of the fore part of the eye—with its mucous membrane. In examining some of its diseases, we have had the opportunity of noticing several things which illustrate the pathology of the mucous tissues generally, and which exemplify the influence of other circumstances also, as well as of peculiarities of tissue, upon the morbid processes to which these membranes are obnoxious. We have seen that the mucous surface of the eye readily enough takes on inflam- mation, under vicissitudes of external temperature, and from the agency of other atmospheric conditions; that the inflammation is apt to spread, often rapidly, over the whole surface of the membrane; and that, in some cases, it may be strictly limited for a long time together, or entirely, to the mucous tissue in which it began; but that when intense, or under special circumstances, it may dip through and extend to the subjacent textures: that, on the other hand, the inflammation sometime"*** occupies separate specks only of the membrane, and then is more likely to penetrate to the deeper seated tunics: that although the membrane is folded upon itself, so that different portions of it are mutually in apposition and contact, these opposing surfaces do not become adherent to each other under inflammation; on the contrary, that they readily pour forth pus. This tendency to the formation of pus I formerly showed you to be commonly observable, whenever the air finds free access to the inflamed part. The pus thus poured out possesses the remarkable property of exciting the same kind of inflammation when placed in contact with a healthy mucous membrane of the same or of another individual: whether it be the conjunctiva of the eye, or the internal lining of the urethra. The pus, in short, acts locally, upon certain parts at least, as a poison. And we perceive, in this fact, how a disorder that originates in common and accidental causes may become capable of propagating itself indefinitely—may become, in one word, contagious. We have seen also that the most intense inflam- mation may occur in this membrane, without exciting much or any constitutional disturbance; an illustration of the fact that the inflammation of mucous membranes is not so prone to light up fever, is not in general attended with so much pyrexia, as inflammation of some other tissues, and especially of the serous and fibrous tissues : and in proportion as this constitutional sympathy with the local disease is small or absent, so the influence of general bleeding upon the inflamed part is slight or ineffectual. The effect of a new and strong local irritation, in altering or superseding the original inflammation in some cases, has been illustrated in the treatment of purulent ophthalmia as it occurs in the adult subject. The influence of age in modi- fying the phenomena, and in qualifying the plan of treatment, has been made perceptible in the differences noticed in these respects between purulent ophthalmia in infants and in grown-up persons. We have witnessed, too, the remarkable charac- ters impressed upon inflammation of the very same part, by the presence of the scrofulous diathesis. We shall hereafter meet with numerous examples of chronic inflammation, and the deposition of tubercular matter, and the formation of ulcers in consequence of the elimination of that matter, in other mucous membranes. Whether the phlyctenae, or pustules, which appear upon the surface of the eye in strumous 226 DISEASES OF THE EYE. [lect. XIX. ophthalmia, result from a similar separation of tubercular matter from the blood- vessels near the extremities of which these prominences are placed, has not been clearly ascertained. One other lesson we have learned from this review of conjunctiva] inflammation, viz., that general bleeding, carried so far as to produce syncope, will sometimes completely empty the capillaries of an inflamed part of the red blood wherewith they were, just before, so turgid. I shall next request your attention to a part of the organ which is strictly internal — to the iris: that thin curtain, with a circular aperture nearly in its centre, which hangs between the cornea and the crystalline lens, and is bathed on both sides by the aqueous humour. This little part, the office of which is to regulate the quantity of light admitted to the retina, is of exceeding interest in respect to its morbid as well as its healthy conditions. It is frequently the seat of inflammation; and, small as it is, the inflammation seems to be entirely confined to it, or to the surfaces immedi- ately before and behind it. No doubt, with inflammation of the iris, there is in many cases inflammation of the choroid and retina also, and of the sclerotica. But the inflammation seems to make the iris its point of departure, and there it works its most striking changes. We cannot see so well what is the actual condition of the choroid and retina; but we have this proof, either that they do not always participate in the disease, or that they often suffer less than the iris; viz., that when the natural pupil has been closed up by lymph, and a new or artificial one is formed, vision is frequently restored. The little cavity across which the iris is vertically stretched, is lined by a smooth membrane, the source of the watery fluid always contained in the cavity. This mem- brane is analogous in its smoothness, in its forming a shut sac, and in the nature of its secretion, to the serous membranes met with in other parts of the body: it is analogous also to the serous membranes, in its behaviour under inflammation. It is, in fact, the serous membrane of the eye. Now we have the means of inspecting a portion at least of several of the mucous surfaces of the body; but this serous cavity, constituting the anterior chambers of the eye, is the only serous cavity into which we have the privilege of looking, and of noting what is going on, when the membrane that forms its boundary is inflamed; and this it is that makes iritis, to me, one of the most interesting of all diseases. There is no single part of the body from which you .■an derive so much instruction concerning some of the minuter processes of inflam- mation, and concerning the power of certain medicines over those processes, as you may by watching a few examples of inflammation of the iris. All the changes which occur in iritis depend upon the circumstance that the inflammation, like that of the serous membranes generally, is of the adhesive kind; i. e., is attended with the effusion of coagulable lymph. By means of this lymph the form and the colour of the part are changed: the size and figure of the pupil undergo alterations, or that aperture is completely closed up; the motions of the iris are limited, or entirely put an end to. The symptoms which characterize inflammation of the iris are very obvious. To be perceived and understood, they require only to be looked at. Yet they long escaped notice, and even now are not always so carefully studied as they deserve to be. Not a great while ago I had to convince a surgeon of some pretensions, that he did not know this disease when he saw it. And English surgeons and physicians were all of them ignorant even of its existence as a distinct disease, until a most excellent account of it was published by a German, Schmidt, in the first year of the present century. What are these plain and obvious symptoms that were so long overlooked, or that were not understood when seen ? They are the following. I will first enumerate them, and then speak of each rather more particularly. Redness of the sclerotica; a change in the colour of the iris itself, and in its general appearance; irregularity of the pupil, produced by adhesion of the iris to the neighbouring parts; immobility sometimes of the pupil from such adhesion; a visible deposition of coagulable lymph. All these changes are apparent and conspicuous. Scientific writers term them objective symptoms. Then there are also the subjective symptoms, of which the patient alone is conscious — impaired sight; pain in the eye, and around it. The redness is such as I formerly described as resulting from the vascularity of the LECT. XIX.] IRITIS. 227 sclerotic. The cornea is surrounded by a zone of fine straight converging pink lines, very different in appearance from the tortuous, anastomosing, scarlet blood-vessels of the inflamed conjunctiva. These hair-like converging lines stop abruptly at the edge, or just before they reach the edge of the cornea; they dip through the sclero- tic, in fact, to go to the iris. The vascular zone therefore is well defined in front, while it becomes fainter from before backwards, and is gradually shaded off; the pos- terior portion of the sclerotic being generally pale. As the disease advances, and in violent cases, the more superficial conjunctival vessels also sometimes enlarge, and mingle their tint of redness with that of the sclerotic, and more or less confuse or conceal it. Now this red zone or halo continues as long as the inflammation of the iris continues, and disappears when that ceases. It is an important symptom therefore. The change in the colour of the iris itself is also a remarkable circumstance. You know that what is called the colour of the eye is simply the colour of the iris. When lymph begins to be effused into the texture of this coloured part, it deepens, and at the same time alters, its tints. A gray or blue eye is thus rendered yellowish or greenish. A dark eye presents a reddish tinge. The change is such as would be produced by a mixture of the colour of the lymph with that which is natural to the iris. But besides a variation of colour, the peculiar brilliancy of the surface is spoiled. It becomes dull and tarnished as it were, and the fibrous arrangement, which is usually so evident, is confused or gone. The change commences at the inner or pupillary margin of the iris, and extends gradually towards the outer or ciliary edge. This is a symptom which you can scarcely overlook. It is rendered certain and unequivocal by comparing the sound eye with that which is inflamed. The change of colour which I have been describing is occasioned by the effusion of lymph. But the same event of inflammation leads to various other changes, not less striking, and more important, in so far as the functions of the organ are con- cerned. The lymph becomes visible upon the surface of the iris. Its precise ap- pearance varies considerably in different cases. Sometimes it presents little spots like freckles, or specks of rust: or a thin stratum of the same colour is deposited. Some- times it exhibits the appearance of drops, or (as they have improperly been called) tubercles, embossing the surface, and projecting from its pupillary edge. These are commonly of a yellowish or reddish brown colour, and they vary in magnitude from the size of a small pin's head, to that of a large shot. There are seldom more than two or three of these masses. The lymph thus effused upon, or thrusting forward the surface, is confined almost always to that part of the iris which is nearest to the pupil, to the annulus minor; while its ciliary portion, or annulus major, is dull and clouded. Sometimes, when the inflammation is very violent, or the disease has been neglected, actual suppuration takes place. A reddish yellow prominence arises from the surface of the iris, and at length breaks, and discharges matter which sinks down to the bottom of the anterior chamber, and presents the appearance that has been called hypopyon. All these changes, I say, become perceptible near the margin of the iris; its free edge, which in the natural state is clear and sharp, becomes rounded and blunt: and at the same time the pupil often begins to lose its jet-black colour. Another very common consequence of the effusion of lymph from and upon the surface of the iris (from its hinder surface, that is, which is called the uvea, or from its pupillary edge), is its adhesion to the capsule of the crystalline lens, which lies, you know, behind the iris and very near it. And the pupil itself is apt to become blocked up by lymph. The motions of the iris are seriously impeded by the mere effusion of lymph into its texture. At first it moves sluggishly under variations of the light; gradually the pupil contracts, and becomes fixed and motionless. The adhesion of the iris to the capsule of the lens still more decidedly restrains the action of the part. When it adheres at one or more points of the margin, and remains free elsewhere, the pupil is deformed; loses its circular shape; becomes angular; and this deformity is the most marked when the eye is examined either under a weak light, which allows the pupil to dilate, except at the points where the iris is tied down to the lens; or under a very strong light, which forces the free portions of the margin, and those only, to approach the centre. Still more palpable does the alteration of figure become when the pupil is artificially dilated. 228 DISEASES OF THE EYE. [lect. xix. Vision is always impaired in this complaint: partly because the posterior tunics of the eye are liable to be implicated in the inflammatory process; partly by the detri- ment done to the proper function of the iris, which should duly measure the quantity of light admitted to the retina; partly by the presence of more or less lymph, filling up the pupil; and partly by a change, not yet mentioned, which is apt to take place, especially in severe cases, in the cornea, and perhaps in the aqueous humour. The cornea becomes hazy and dull, and loses its bright polish. It looks like a piece of glass that has just been breathed upon. It has been thought (on the ground of analogy chiefly) that the aqueous humour grows turbid under the inflammation of the membrane that secretes it: just as serous effusion into the pleura is often found to be troubled and thick. But there is no sure evidence that this is the case. While the cornea remains transparent, the aqueous humour is seen to be clear: when the cornea is dim and semi-opaque, we cannot distinguish the state of the aqueous humour. Acute iritis is attended with pain and intolerance of light. To the latter circum- stance is probably owing the contraction of the pupil during the progress of the inflammation : and then the lymph fixes the pupil in that state of smallness and con- traction. There is pain in the eyeball itself, and in the parts about the eye, the brow and temple, most severe at night. There is much variety, however, in regard to the pain. Sometimes it is constant and severe, but still more aggravated in nocturnal paroxysms. Sometimes, even when the quantity of mischief that is visible is very great, scarcely any pain at all is experienced. The same remark applies to the constitutional symptoms. In some instances these are but slightly pronounced; but in most cases, particularly in acute cases (for iritis, as I have hinted before, is sometimes a chronic disease), there is a good deal of fever and headache, the pulse is full and hard, and the tongue white, and the sleep is broken. If the progress of the inflammation be not checked, it extends itself beyond its original seat. It creeps from the pupillary margin to the ciliary; and thence it passes on to the ciliary body, to the choroid coat, and to the retina; and as this takes place, the pain and the pyrexia increase, and blindness is usually the result. The delicate texture of the retina is spoiled for ever. I have thus described the phenomena of iritis generally: and I will next consider, in the same manner, the treatment which it requires. It will afterwards be necessary for me to mention certain modifications of the disease, in respect to its rate of pro- gress, its causes, and the circumstances under which it occurs. I say it will be necessary to mention these modifications, because they require a corresponding ad- justment of the plan of treatment. When we have to deal with iritis alone — that is, when the inflammation and the changes to which it may have led, are confined to the iris — the disease is always, I believe, manageable; and affords a beautiful instance of the power of well-directed remedial measures. We cannot always tell whether the inflammation has been restricted to the iris or not. We have three powerful weapons wherewith to combat iritis : blood-letting ; mer- cury; and a remedy that hitherto has not been mentioned in these lectures, belladonna. If I were restricted to the use of one of these means, I should choose mercury; if to two, mercury and belladonna; but the combined employment of the three has the most powerful effect in curing the disease; and cases that have seemed almost desperate, have been retrieved and rescued by these remedies. With respect to blood-letting, I shall not run the risk of fatiguing you by dwelling at any length upon the mode in which it should be employed, or the indications for its adoption. I shall content myself with saying that the intensity of the local symp- toms, especially of the pain, — and the degree in which the general symptoms, the fever, and the hardness of pulse, are present, — offer the best measure, both of the necessity for bleeding, and of the amount to which it ought to be carried. Both must be estimated also in reference to the strength and constitution of the patient. Bleeding from the arm till some decided impression is made upon the circulation; cupping from the temples; or both these modes of taking blood, together or in suc- cession, may often be required. At the same time active purgatives should be exhi- bited ; and the whole of the antiphlogistic regimen strictly enforced. But bleeding, assisted by purgatives, and the antiphlogistic regimen, will not cure LECT. XIX.] IRITIS. 229 the disease; or it will not cure one case in a hundred. It may stop the infiammation probably, but not till the organ has been spoiled. Such a termination cannot with any propriety be called a cure. We want not only to put an end to the inflammatory process, but to repair the mischief which may have been already done. Yet bleeding is not to be held cheap, or neglected, because it is unequal to the cure of iritis. It is often productive of direct benefit by abating the force of the circulation, and by checking the progress of the local inflammation : and it is pro- ductive of great indirect benefit by preparing the system to submit itself more readily and rapidly than it otherwise would, to the specific influence of mercury. Mercury is our sheet-anchor in this disease. After free blood-letting, then, or after such abstraction of blood from the system, or from the part, as the circumstances of the case may dictate, you must administer mercury in the manner that I formerly recommended. The object is, in acute cases, to affect the gums as speedily as possible; the soreness of the gums, and the peculiar foetor of the breath, being the tokens that the whole capillary system feels the specific influence of the remedy. Calomel with opium is, in most cases, the best form in which mercury can be introduced into the system ; the purpose of the opium being to prevent the calomel from running off by the bowels. Two, three, or four grains of calomel, with one-fourth, one-third, or one-half of a grain of opium, should be given every four, or six, or eight hours. Equal doses at equal intervals. Some persons prefer giving the calomel still more frequently; one grain, for in- stance, with one-tenth or one-eighth of a grain of opium, every hour. If the gums do not rise in the course of thirty-six or forty-eight hours, and a speedy effect be desirable, inunction of the mercurial ointment should be added. And in some cases mercurial frictions alone may be sufficient, and the most expedient. Or the hydrar- gyrum cum creta, in five or ten grain doses. You may have bled your patient sufficiently, and purged him well, and yet, on looking into his eye, you perceive the mischief to be still going on, and the deposition of lymph increasing. But the instant that his gums and breath acknowledge the specific agency of mercury upon his system, a welcome change becomes apparent: the red zone surrounding the cornea begins to fade; the drops of lymph to lessen; the iris to resume its proper tint; and the puckered and irregular pupil once more to approach to the perfect circle; till, at length, the eye is restored to its original in- tegrity, and beauty, and usefulness. I speak now of favourable cases. The changes for the better that I have been describing are sometimes rapidly accomplished, sometimes slowly. If the disorder have been long neglected, irreparable damage may have been done; the effused lymph may have become organized; or firm adhesions may have been already contracted between the iris and the lens. But even in cases of some standing, when the inflam- matory action has in a measure subsided, the use of mercury will sometimes greatly improve, sometimes altogether restore, the impaired vision. With the mercury, both before and after its specific influence is ascertained, We combine the use of belladonna. Doubtless you are all aware of the singular effect of this vegetable poison upon the iris. It dilates the pupil. Now it is of great importance in iritis, to prevent the tendency to contraction which the pupil manifests. If we can artificially dilate the pupil, we may prevent the iris from forming adhesions with the capsule of the crystal- line lens; and if it have recently contracted such adhesions, we may, while the lymph is yet soft, stretch or break them. And this power of artificially dilating the pupil we possess in the agency of belladonna, and of certain other narcotic vegetables. This remarkable power of the belladonna was first discovered, accidentally, by our country- man, the celebrated Ray. He tells us that a noble lady of his acquaintance applied a leaf of the plant to a small ulcer, suspected to be cancerous, just below one of her eves. The pupil of that eye became greatly dilated, and the membrane remained motionless under the strongest light. This effect gradually subsided when the leaf was removed. But it took place on three several occasions, and was witnessed by Ray himself. Other vegetables have the same property; henbane, for example, stramonium, and the cherry laurel. And there are others which have it not, although we might have expected that they would possess it, from the analogy they bear to the 230 DISEASES OF THE EYE. [lect. xrx. former in other respects. It has been ascertained that neither hemlock, nor aconite, nor foxglove, nor opium, have any such power. Preparations of belladonna are chiefly, if not exclusively, employed in ophthalmic disorders in this country. The extract is used in two ways. After being made soft and semifluid by admixture with distilled water, it is smeared freely around the eye, upon the lids, and brow, and forehead. This is washed off after remaining an hour: generally it produces a marked effect upon the pupil. A more efficacious and speedy mode of dilating the pupil is to drop a solution of the extract into the eye itself. The solution is to be made by rubbing down a scruple of the extract in an ounce of distilled water, and filtering the fluid through linen. Two or three drops of this solution are to be introduced between the eyelids. Some very interesting experiments have been made in Germany by Dr. Reisinger upon this power of belladonna and of hyoscyamus to contract the iris—in other words, to dilate the pupil. The result of these experiments is given in the 24th volume of the Edinburgh Medical and Surgical Journal. Dr. Reisinger procured atropine and hyoscyamine, the active principles of the two plants, and made comparative ex- periments with these principles, and with the coarser extracts; and he concludes that the former are much to be preferred to the latter. Thus, he dissolved a grain of hyoscyamine in ten minims of water, and introduced a small drop of the solution into the eyes of several dogs and cats. No irritation whatever of the eye was produced in any instance, but the pupil was so much widened by the application, that in an hour's time only a small ring of the iris could be seen beyond the edge of the cornea • and after three hours, the pupil seemed as large as the cornea itself. The dilatation did not begin to diminish till after three days; and the pupil did not recover its na- tural dimensions until the sixth day. Then he applied a solution of the extract of hyoscyamus, made by mixing five grains with ten minims of water. This evidently caused irritation of the organ, which lasted from five to eight minutes, and was evinced by a discharge of tears, by the animal's shutting its eyes, and rubbing its eyebrows with its paws. Much less dilatation of the pupil followed, and continued not more than six or eight hours in dogs, and about twenty-four hours in cats. As soon as Dr. Reisinger had satisfied himself that the hyoscyamine had no injurious influence either upon the conjunctiva, or upon the deeper seated textures of the organ, he applied it to the human eye. He dissolved a grain of hyoscyamine in a drachm of distilled water, and inserted a drop of the solution into the eye of an old lady of seventy-one, who had cataract. So great was the consequent dilatation of the pupil, that only a narrow ring of the iris remained visible. No irritation whatever of any part of the eye was produced; and the dilatation continued for seven days. As chemistry is now furnishing to us every day, in greater abundance, and with more ease, the active principles of various of our medicinal vegetable substances, we shall soon, in all probability, adopt hyoscyamine or atropine, for artificially dilating the pupil, instead of the preparations now in use. Till that time arrives, you had better smear the surrounding skin with the moistened extract of belladonna whenever the eye is painful or much inflamed. But under other circumstances, the solution dropped into the eye is to be preferred for its readier action, and its greater power. The use of this curious virtue, possessed by certain plants, is not confined to the cure of iritis. It enables the surgeon to introduce instruments through the pupil with greater facility and safety. It affords us also the means of examining the deeper seated textures of the eye :' and it is of great service to many persons who are par- tially blind; to such, for example, as have central specks on the cornea, or central opacities of the crystalline lens. To such persons it gives the power of enlarging the window of the eye; of admitting more light; and of having painted upon the retina, and represented to the mind, the images of objects which, but for the mysterious agency of these poisonous vegetables, they could never hope to see at all. For- tunately, this power of belladonna over the iris does not diminish by repetition. Mr. Lawrence mentions two patients of his, one of whom had used it habitually for four or five years, and the other for fourteen or fifteen; and it dilated the pupil just as i The study of the textures lying deep within the living eye has been wonderfully aided by the modern invention of the ophthalmoscope; an instrument which Mr. Bowman assures me is not less instructive and valuable in respect to ophthalmic diseases, than the stethoscope in respect *o the diseases of the heart and lungs. LECT. XIX.] IRITIS. 231 well at the end of these periods as at the beginning. By carefully examining an eye in which lymph has recently been effused, you may distinctly see the good effects of the artificial dilatation of the pupil. Little strings of adhesion are often visible, con- necting the edge of the iris with the surface of the lens; and these are stretched, and not unfrequently broken, under the influence of the belladonna: and minute black spots may sometimes be seen upon the capsule, marking the points where the uvea had stuck, and where it left behind it, when it was detached by the belladonna, a portion of its peculiar pigment. These black points are indelible. There is one case recorded in which the pupil, after being dilated by belladonna, became fixed in that condition; probably by lymph subsequently effused into its texture, and binding to- gether its fibres. Even this is better than that the pupil should be contracted and fixed. These three remedies, then—bleeding, mercury, and belladonna—are the means by which we may hope to subdue inflammation of the iris, and to repair the ravages it has occasioned. With respect to the most important of the three, mercury, there are some points that require to be further noticed. You may ask to what extent the mercury should be pushed, and how long it should be continued ? Why we have, in iritis, an illustration of what I have more than once mentioned before, viz., that the rapidity of a disease will require a corresponding haste in the use of its remedy. In acute and violent cases, the mouth should be made decidedly sore, as quickly as possible; and when that has been done, the further administration of the mercury may be suspended. " Full salivation," says Mr. Lawrence, " quickly produced, cuts short recent disease, as if by a charm." In cases of longer standing, or of slower progress, we must be slower in the introduction of the remedy: it will be enough to obtain any, the smallest certain evidence of its action, in the gums and breath; and we must keep up that moderate influence for some time. For what pre- cise time it is impossible to say; but till the redness is gone, and the natural colour of the iris returns, and all the visible lymph has disappeared, and the sight is per- fectly restored; and this may require a month or two. When you look from day to day into the aqueous chamber of an eye in which iritis has recently produced its peculiar changes, and after the due effect of mercury upon the gums has been achieved, you will be surprised as well as delighted to see large masses of lymph rapidly disappear, melt away, as it were, from the surface of the iris, while that which had been deposited in its intimate texture, rendering it confused and discoloured, as quickly clears off. And you will be inclined to believe, as many have done, that mercury has a vast influence in promoting and accelerating absorption. It may have such a power: I am not disposed to deny it; but that it really has so we cannot safely infer from such circumstances. It clearly has the power of arresting the deposition of lymph; of putting an end to the adhesive inflammation. Whether it does anything more towards completing the cure, we have these reasons for doubt- ing. When blood chances to be effused into the anterior chamber; or pus; or when, as frequently happens, pieces of a cataract that has been broken up pass through the pupil, and show themselves between the iris and cornea; they (the blood, the pus, the fragments of the lens) disappear, i. e., are absorbed, just as rapidly as the lymph in iritis, although not a particle of mercury is taken. Mr. Lawrence even gives a case of syphilitic iritis, which got well without any affection of the gums by mercury, and which had been marked by the deposition of a large mass of lymph on the iris; and he says that the lymph was immediately absorbed, as soon as the inflammation ceased; and that he never saw it disappear more quickly under any circumstances. There is one local use of mercury which I must not omit to mention, because though it probably has no share in curing the complaint, it is productive of great comfort and relief to the sufferings of the patient. It is adapted to those cases in which severe pain is felt round and over the orbit of the eye at night. Ten grains of the strong mercurial ointment, intimately mixed with two grains of finely powdered opium, and well rubbed into the temple a little while before the nocturnal pain is accustomed to recur, will in many cases completely prevent it. We owe this piece of practice to the Germans. Iritis is apt to occur from different causes, and in connexion with different diseased states of the system. It is no uncommon accident from surgical operations performed 232 DISEASES OF THE EYE. [lect. xix. upon the eye, the iris suffering mechanical injury. The inflammation thus excited is usually violent and acute, and requires that the whole plan of treatment that I have been sketching out should be actively prosecuted. But inflammation of the iris sometimes arises slowly and insidiously, without vas- cularity enough to call attention to the eye, and without pain. This generally happens when the eye has been strained by over-use; in women who occupy themselves with fine needle-work; in engravers, and such as are accustomed to look at minute objects, or at bright objects. A more common effect of continued exertion of the eyes in this way, is a diseased state of the retina; but (however the fact may be explained) the iris is sometimes the part that suffers. In this form of the disease mercury will often be found a successful remedy; but its influence must be gradually brought about; and it is not so certainly productive of benefit as when it is employed in acute iritis : — probably because the chronic inflammation has involved the posterior tunics also. But most frequently iritis is met with in combination with syphilitic, or with rheumatic disease, which manifests itself at the same time in other parts of the body. Syphilic iritis is more common than any other. It is one of the secondary symptoms of syphilis; and accordingly it is commonly associated with other secondary symp- toms; with syphilitic eruptions, nodes, pains in the limbs, and ulceration of the throat. It is also one of the earlier of these secondary affections, and therefore is sometimes the only one to be seen; and occasionally it declares itself before the pri- mary disease is well. The pain that attends this species of iritis is chiefly felt at night, but at that time it is apt to be very severe and distressing, so as entirely to prevent sleep until it takes its departure in the morning. We cannot, I believe, dis- tinguish syphilitic iritis with any certainty from other acute varieties of the same complaint, by mere inspection of the eye. However, there are some points worth remembering in respect of the local phenomena which it most commonly presents. Syphilitic iritis is never attended (according to Mr. Lawrence) with abscess of the iris, and hypopyon; the lymph is usually deposited in distinct masses ; and the pupil becomes angular, and is not unfrequently displaced towards the root of the nose, by the adhesions which the iris has contracted with the parts behind it. In another variety of inflammation of the iris (which I shall mention to-morrow, arthritic iritis) lymph is equally effused from the margin of the iris, but it is not usually deposited in a distinct drop-like form. We ascertain the variety of irritis with which we have to do by these peculiarities; by the co-existence of other tokens of syphilis; by the pe- riodical character of the nightly pain; by taking into our account the age, the consti- tutional habit, and the probable state of morals of our patient. Syphilis, you know, is not uncommon in children; it is sometimes even congenital; but it very seldom affects the iris at that early period of life. Among a large number of syphilitic chil- dren brought to Mr. Lawrence, he never witnessed iritis but once. It was in syphilitic iritis that the curative power of mercury over adhesive inflam- mation was first distinctly recognised. But you must not fall into the error of sup- posing that the_ success of the remedy depended upon the specific character of the disorder; upon its connexion, I mean, with the venereal virus. Mercury is fully as serviceable, and as sure, in common acute inflammation of the iris. Upon this point all men of experience are agreed. " Its influence (says Mr. Lawrence) is not confined to the syphilitic form of the disease, but extends equally to the idiopathic.'' And Dr. Farre bears testimony to the same effect. LECT. XX.] IRITIS. 233 LECTURE XX. Iritis, concluded. Rheumatic Ophthalmia. Amaurosis. The principal theme of the last lecture was that most interesting disease, inflamma- tion of the iris. The symptoms of iritis are these: a radiating zone of vascular redness situated in the sclerotica, and surrounding the cornea; a change in the colour of the iris, from gray or blue to a yellow or greenish tint, from brown or hazel to a dusky reddish hue; a visible deposit of lymph upon the anterior and innermost portion of the iris; a thick- ening of its free edge; contraction, irregularity, and immobility of the pupil; closure of the pupil by lymph; adhesion of the uvea to the membrane of the crystalline lens. All these we can see and ascertain for ourselves. We can ascertain also the presence of fever, which attends the acute forms of the disease. And we learn from the testi- mony of our patient that his sight is impaired; that the influx of light into the eye hurts him; and that he experiences pain in and around the organ, especially at night. The grand remedies in iritis are three: 1. Blood-letting: of which the objects are to abate the force of the heart's action ; to moderate the febrile disturbance; and to facilitate the operation of the second remedy: which is 2. Mercury. This is to be given so as to produce soreness of the gums, and the peculiar foetor of the breath : and these effects are to be sought for rapidly or gradu- ally, according as the inflammation of the iris is recent and acute, or moderate and chronic. The object of this remedy is to arrest the effusion of coagulable lymph; to put a stop to the adhesive inflammation. 3. The application of the extract of belladonna, or of a solution of atropine, to the conjunctiva, or to the skin around the eye, so as to dilate the pupil. The objects of this measure are to prevent the adhesion of the iris to the parts in its neighbourhood; to detach it from the lens when it has already been glued thereto by soft lymph; and to stretch and elongate the bands of adhesion when they cannot be broken : and thus to obviate any impairment of the free movements of the iris, and any deformity of the pupil, and the inflammation shall have ceased. I began to speak of the causes of iritis. I say it may be occasioned by mechanical injury; as during the operation for the extraction of a cataract. A clean cut, however, is frequently followed by no bad con- sequences ; a portion of the iris has been shaved off by the knife in making the section of the cornea, without any injurious results. When iritis is excited by mechanical violence, it is acute. 2dly. A chronic form of iritis is sometimes brought on by excessive employment of the eye, in looking at minute or bright objects. 3dly. The most common species of iritis is that which arises in connexion with syphilitic disease. It is one of the early secondary symptoms of syphilis. It is marked by the co-existence of other secondary consequences of the introduction into the system of the syphilitic poison, and by the periodical character of the nightly pain; it is never attended with abscess of the iris and hypopyon; the lymph that is effused is deposited in separate masses; and the pupil is often displaced towards the root of the nose, as well as rendered irregular, by the adhesion of the iris to the capsule behind it. 4thly. It is curious enough that iritis has actually been ascribed to mercury, as a cause. This notion can only have arisen from that loose kind of logic, and hasty generalization, for which, I am sorry to say, medical reasoners are too often distin- guished. Mercury is perpetually exhibited for the cure of syphilis; and people who have been treated for syphilis are very liable to iritis. This seems to be the only foundation for the opinion in question. When we come to appeal to facts, we find no ground for believing that this mineral is thus, both bane and antidote. If it were 234 DISEASES OF THE EYE. [lect. xx. so, Benvolio's advice to the slighted Romeo might be very pertinently offered to the patient in such a case: " Take thou some new infection to thine eye, And the rank poison of the old will die." Mr. Lawrence has seen no instance of iritis, of whatever kind, in which there has appeared to him any reason for attributing the occurrence of the complaint to this cause. I have never heard it alleged that persons who have taken large quantities of mercury for other diseases, as for affections of the liver in India, are particularly subject to inflammation of the iris. On the other hand, iritis has come on, in hundreds of cases, in connexion with syphilis, though not a particle of mercury had been swallowed by the patients. Lastly, there is a peculiar form or variety of iritis, called the arthritic or rheumatic. This affection is characterized by the following general features. It occurs in persons who are subject to gout or to rheumatism, and often forms a part of the attack of the one or the other of those diseases. Like them it is liable to return again and again; and this circumstance it is which makes arthritic iritis a serious disorder. It is seldom that much or permanent damage to vision is effected by a single attack; but adhesions readily form under it, and lymph is effused; and in each successive attack fresh effusion takes place: the pupil becomes more and more contracted; and it may be filled up, at last, by an opaque plug of lymph. Some patients, however, will suffer ten or a dozen recurrences of the disease, and recover almost completely, and enjoy perfect vision in the intervals, before the sight becomes much impaired. Some of the local appearances are more or less characteristic of this variety of iritis. It is seldomer attended than the syphilitic variety by a deposition of lymph in distinct masses; the contracted pupil keeps its central position, and is not displaced towards the root of the nose, as it is apt to be in syphilitic iritis. The adhesions that bind the iris to the neighbouring parts are said to be whiter in this variety of iritis than in others. It is also a very remarkable circumstance that the zone of red vessels encircling the conjunctiva does not approach so close to the cornea as in other species of iritis; but a white ring is left between the cornea and the anterior margin of the zone. Sometimes the circular white stripe is partial, being most marked towards the angles of the eye; sometimes, on the other hand, it is as perfect as if it had been described with a pair of compasses. I believe, with Mr. Welbank, that the appear- ance of this bluish ring depends upon the less intense degree of the sclerotic inflam- mation. He says that he has noticed its coming on, when syphilitic inflammation of the iris was beginning to yield to the action of mercury; although there had been no such interval during the height of the inflammation. Again, the colour of the zone is not so bright as in other forms of iritis; it is of a somewhat livid, or slightly purplish tint; and the larger vessels at the back part of the eye, belonging to the conjunctiva, are apt to become tortuous and varicose. Rheumatic iritis is often met with in combination with what is called rheumatic ophthalmia: a disease which I have not before mentioned. But each may exist alone. And as rheumatic iritis, though frequently an independent disease, does also in many instances grow (as it were) out of rheumatic ophthalmia, I will take this opportunity of shortly describing the latter complaint. What is called rheumatic ophthalmia, then, is inflammation affecting the fibrous coat of the eye, the sclerotica. We know that the fibrous tissues throughout the body are frequently the seat of rheumatic inflammation. Some persons are more liable to rheumatism than others—are more readily affected by its external exciting causes, which are vicissitudes of temperature, and exposure to and cold wet. In such persons there seems a tendency to take on inflammatory action in all the structures of the same kind: and most particularly in the fibrous membranes, and tendons, that help to form the various joints; and as the sclerotica partakes of this fibrous texture, so it is apt to suffer, in its turn, from rheumatic inflammation. The connexion of the moveable eyeball with the head may be considered as a sort of joint. The local symptoms are not in general of a violent kind; and, as in other parts, the rheumatism seldom leads to any permanent alteration of structure; seldom, at least, when the ophthalmia is confined, as it often is, to the sclerotia alone. Perhaps the best way to put you in possession of the features that belong to rheumatic ophthalmia will be to lect. xx.] RHEUMATIC OPHTHALMIA. 235 describe an actual instance of it. I will take a well-marked example, related by Mr. Lawrence. He was sent for to see a gentleman who was suffering from what is com- monly called rheumatic gout: swelling, some redness, and severe pain of one foot and knee, and one hand; aching of the back; and great constitutional excitement. He got well under the treatment adopted. After a short interval, upon Mr. Lawrence's calling to inquire how he was, he said there was something the matter with his eyes; and asked to have them examined. " I looked at them hastily," says Mr. Lawrence : " the room was dark, and the day dull; and I saw no appearance of disease. When I called again, after a few days, as the complaint was repeated, I examined more attentively. On bringing him towards the window, he obviously felt the light trou- blesome; he drew down the eyebrows, and half closed the lids, to avoid it. The conjunctiva was natural; but the whole of the sclerotica had a livid red, and mottled appearance, which might have been called dull, or almost dirty, in comparison with the red colour of common active inflammation. The sclerotic vessels were partially distended; the redness terminated short of the cornea, so that there was a distinct white rim round the latter. Vision was perfect; there was no pain so long as the eye remained at rest; but exertion of the organ, particularly under strong light, brought on uneasiness. The nature of this gentleman's occupations, and of his tastes, which were literary, prevented him from giving his eye the necessary repose; and the condition of the sclerotica just described lasted for three or four months :" so that Mr. Lawrence was apprehensive that some serious mischief would ensue to the organ. The affection remained confined, however, to its original seat, evincing only that obstinate character which belongs to disorders of such structures; and at last, it dis- appeared completely, leaving the eyes with their organization and powers unimpaired. The treatment that appears to answer best in simple rheumatic ophthalmia of this kind, consists in moderate topical bleedings, and counter-irritation: with such other measures as conduce to improve the general health; and among these change of air and scene have sometimes a decided effect. Those remedies also are to be given which have been found by experience to be beneficial in rheumatic inflammation, although we cannot always depend upon finding them useful: colchicum, I mean; bark; sar- saparilla; the iodide of potassium. In these abiding or frequently recurring forms of disease, you will often be obliged to try the so-called specific remedies one after the other. Now when the rheumatic inflammation is not confined to the sclerotic, but creeps inward, as by their vascular connexions it easily may, to the iris also, we name the disease according to the most important part that it occupies — arthritic iritis. On the other hand, when, with that affection of the sclerotic which I have been de- scribing, there is combined a moderate degree of inflammation of the conjunctiva, this complex disorder receives a compound denomination: it is called catarrho-rheu- matic ophthalmia. Dr. Mackenzie states it as the result of his experience, that arthritic iritis seldom occurs in connexion with the earlier appearance of gout, while the patients still retain strong powers of digestion, and have the means of indulging their appetites; but rather with the asthenic and irregular forms of gout and rheumatism : when repeated attacks have been followed by mental depression, indigestion, flatulence, and languor. He has generally met with the disease in subjects beyond the age of fifty, very fre- quently in tobacco-smokers, and whisky-drinkers, who have often suffered rheumatic affectionSj who are teased by headaches, acidity of stomach, bad gums and teeth, and lowness of spirits: in persons, that is, whose health has been impaired and broken by intemperate habits. I believe you will find this to be a very correct statement; although arthritic iritis may also take place in those who are more robust. After what has now been stated you will be prepared to believe that arthritic iritis neither requires nor bears those free emissions of blood, and that liberal use of mer- cury, which are necessary for the cure of other varieties of the complaint. Mercury, pushed to salivation, is sometimes found to do more harm to the system than good to the eye; and in a disease which is so apt to recur, we must not be continually sali- vating our patient. I can only say that the treatment must be conducted on the principles already laid down, and adapted to circumstances. If there be much fever, and a hard pulse, and a white tongue, you should bleed and purge your patient, and afterwards give him from twenty minims to half a drachm of the wine of colchicum 236 DISEASES OF THE EYE. [lect. xx. two or three times a day. When the symptoms are less active, you must be less active too: strive to set the disordered digestive organs right, and to correct the bad habits of the patient: give small doses of mercury (such as five grains of Plummer's pill) three or four times a week; excite counter-irritation by blisters, or by the croton- oil liniment. After the use of bleeding or leeches, and the regulation of the bowels, preparations of iron, the sulphate of quina — tonics, in short, — have been found, in not a few cases, extremely beneficial. I should have mentioned another remedy, which of late years has been recom- mended in iritis, and especially in syphilitic iritis, by Mr. Carmichael of Dublin : not as being a better remedy in itself than mercury, or so good, but as having considerable power over the disease, and as affording, therefore, a valuable resource when from any cause the exhibition of mercury is forbidden. This remedy is the oil of turpentine. He gives it in drachm doses, three times a day. He relates cases of syphilitic iritis in which the pain, redness, and other symptoms, were quickly removed, and effused lymph was absorbed, and vision restored, under the use of this medicine. It is necessary to its beneficial action that the bowels should not be confined. In other instances of the same disease Mr. Carmichael was not so successful. Mr. Guthrie, who has also tried this remedy, reports of it that " in some cases it succeeded ad- mirably, in others it has been of little service, and in some unequal to the cure of the complaint." I do not know that it has been fairly put to the test in arthritic iritis. I proceed next to quite a different kind of ophthalmic disease from any that we have yet considered. I have spoken of inflammation of the exterior membrane of the eye occurring separately; and of inflammation of certain internal parts, and parti- cularly of the iris, occurring separately. Between these exterior and interior tunics, the sclerotica forms a sort of natural barrier or shield, the chief point of connexion between them being near the edge of the cornea, where the sclerotic vessels dive through to reach the iris. Inflammation of the sclerotic itself has also been de- scribed. When vision is impaired or destroyed in consequence of any of the com- plaints which have hitherto engaged our attention, that effect results from the partial or total exclusion of light from the retina. The cornea is left opaque, or it bursts; the pupil, or aperture in the iris, is shut up by a web of lymph ; or the capsule of the lens to which the iris adheres has undergone a change, and lost its transparency. In each case the retina suffers an eclipse. But light may be freely admitted, and yet no vision ensue. The transparent parts of the eye, the several media, so skilfully and exquisitely adjusted for the due refrac- tion and collection of the rays of light into an image of the object from which they flow, may all be perfect and in order; but the beautiful apparatus is useless; the patient cannot see with it. The fault is in the nervous matter that should receive and transmit the impression, and render it an object of perception to the mind. Now persons in this condition are said to have amaurosis. The term is derived from the Greek word a^avpoj, which signifies obscure or dark. It expresses various degrees of imperfect vision, from defective nervous function. The words gutta serena are applied to that form of amaurosis in which vision is totally lost. It was formerly supposed that this sort of blindness was caused by the effusion of some humour or fluid behind the pupil: and this was held to be a clear fluid, because the natural blackness of the pupil is sometimes not troubled in amaurosis. Milton has literally translated this term when, speaking of his own eyes, he says, " So thick a drop serene hath quenched their orbs." Amaurosis is a very obscure disease. It is capable of being caused by various changes, the exact seat and nature of which we often have no means of determining during life : and which frequently leave no traces behind them in the dead body. It would take a much larger space than I can possibly devote to it in these lectures, thoroughly to discuss this difficult but interesting subject. I shall endeavour to give you such a sketch of it as you may fill up and complete by future observation, and by reading, for yourselves. It will be something to learn the direction and objects of our inquiries into what is yet unknown in the pathology of this affection. There is one division of the disorder which immediately suggests itself. The cause LECT. XX.] AMAUROSIS. 237 of defect may exist in the brain, at or beyond the origin of the optic nerve; or it may be situated in any part of the course of that nerve, from its commencement at the base of the brain to its termination in the retina; or it may be confined to the retina itself. There is reason to believe that the functions of the retina may be impaired or sus- pended by deviations from the natural quantity of blood sent to it; by disturbances of its circulation. Various degrees of amaurosis are common among persons who employ the sense of vision overmuch, and strain the eye. This over-use is likely to produce congestion, or chronic inflammation, in the vessels of the retina; and very slight changes of that kind may seriously affect the function of a part so delicate and tender. I say we frequently meet with amaurosis among those whose occupations oblige them to look attentively at small or bright objects during many hours of the day; or what is still more pernicious, during many hours of lamp or candle light; so as habitually to fatigue the eye; — engravers, printers, watchmakers, tailors and milliners, mathematical instrument makers, persons who gain their bread by writing, miniature painters, cooks who are exposed to the heat and glare of large fires, men who have the charge of forges or furnaces, and so on. Here a continual stimulus leads to a chronic disorder, which increasing in intensity may terminate in total blindness. We call these cases of amaurosis, but they may be justly considered to be instances of chronic inflammation of the retina. We cannot indeed see the suffering part during life; and the complaint is not a fatal one, and, therefore, we have few opportunities, or none, of examining after death the condition of the retina while the amaurosis is yet recent. But judging from the nature of the causes that precede the defect of vision, and from the nature of the remedies that are often found to remove it, we are warranted in regarding the essence of the disease to be retinitis. The same condition, apparently, may be suddenly produced by the transient operation of some more powerful cause of congestion; such as intense light. I will illustrate this form of amaurosis—amaurosis, that is, dependent upon congestion which perhaps amounts to inflammation, sometimes slowly established, and sometimes very suddenly — by the narration of a few cases. I may as well premise, however, that the treat- ment which promises most, or I should rather say, which has performed most, in this form and kind of amaurosis, is very nearly the same (excepting the use of belladonna) that I have already recommended for chronic and acute iritis : blood-letting, general or topical, according as there are more or less pain, and fever, and fulness of the system, and according as the amaurosis is more or less recent; and above all mercury, so administered as to affect the gums, and rapidly introduced into the system in the acuter cases; more slowly in proportion as the disease has crept on more gradually and lasted longer. This treatment is very often quite successful; the mercury is the most important part of it; and we have in this fact a strong corroboration of the in- ference drawn from the nature of the exciting causes, viz., that the complaint is es- sentially inflammatory. And again, supposing it inflammatory, we need not be sur- prised that a remedy, the curative effect of which we can see in inflammation of the iris, should be equally serviceable when the same diseased process is set up in the retina, which we cannot see. Purgatives, counter-irritation, and perfect repose of the eye, are necessary parts of the treatment in both forms of disease. Mr. Allan gives the following account of the master of a printing office who became blind. He had corrected the press, and was otherwise engaged in reading, for eighteen hours daily out of the twenty-four. He continued this practice for twelve months, notwithstanding an evident failure of his sight. At the end of that time the amaurosis was so complete that he could not distinguish one object from another, but was merely capable of just perceiving the light, so as to grope his way along the streets. He continued in this state for several years, but ultimately recovered his vision. The next instance that I shall cite is recorded, in these words, by Mr. Lawrence. "A young woman, of florid complexion and full habit, came to the London Ophthal- mic Infirmary complaining that she had lost the sight of one eye. She was cook in a family, and occupied for several hours daily before large fires, supporting her strength by free living. The pupil was slightly dilated; the iris motionless. A faint and scarcely perceptible pink tint was observed in the sclerotica near the cornea. Vision was dim, and had been so for three days. There was headache, flushed coun- 238 DISEASES OF THE EYE. [lect. xx. tenance, heat of skin, whitish tongue, and thirst. I considered the case to be pure retinitis; and to afford a favourable opportunity for showing whether the affection could be arrested by antiphlogistic treatment. At that time (now many years ago) I did not possess the knowledge of the power of mercury in inflammation of the retina, which subsequent experience has given me. I directed a full bleeding from the arm, free purging, low diet, repose of the organ, and general rest. At the end of two days the sight was worse: cupping and a blister were now ordered; but there was no im- provement at the end of two days more. I now determined on trying mercury, and ordered two grains of calomel every four hours. Before the remedy had affected the system, vision was quite lost, or at least reduced to the mere power of distinguishing light from darkness. Full salivation, which took place in about a week from the first application of this patient at the infirmary, suspended all the symptoms; the sight immediately improved, and was soon completely restored." A soldier, unacquainted with the proper method of observing an eclipse of the sun, employed for that purpose a piece of opaque glass, with a transparent point in its centre. Notwithstanding the vivid and painful impression he experienced from the rays that passed through the lucid part of the glass, he continued to look at the sun till the eclipse was over, using his right eye. He was soon after seized with vertigo, and pain in the right side of the head, and found himself almost entirely deprived of the sight of the right eye. Some weeks afterwards, the pain in the head continuing, he came under the care of Baron Larrey, who observed that the vessels of the eye were injected; the pupil somewhat smaller than that of the other eye, retaining, however, its natural freedom of motion; the vision very obscure or almost gone. This man recovered his sight completely after two bleedings, one from the temporal artery, the other from the jugular vein; blisters to the temple and nape of the neck; ice to the head, and moxas.—(Mackenzie, from the Memoires de Chirurgie.) In the year 1832, a young man standing in a door-way, by a lamp-iron, in a thunder-storm, was struck by the lightning, fell backwards, and was convulsed. He said afterwards that the lightning appeared to enter his eye with a scorching sensa- tion. During the night vision was quite lost. The next morning there was no red- ness, nor any unusual appearance of the eye. The iris was motionless, however, and the patient could not see even the sun. He was treated with calomel, and his sight returned; but the retina remained extremely irritable, and unable to bear the light. A month afterwards, when this account was written, he could see distinctly enough, but he could not use his eyes without the protection of blue glasses.—(Lawrence.) In these cases the nervous apparatus that ministers to vision is not, I believe, in general, the only part of the nervous system that is injured. In August, 1839, Phoebe Judge, a delicate-looking girl, eleven years old, became my patient in the Middlesex Hospital. She had lost, in a great degree, the power of using her legs: when she attempted to stand they separated, and she sank down. She had not per- fect control over her bladder. The desire to make water was frequent, and if not immediately attended to, the urine escaped in spite of her efforts to retain it. The same urgency, and inability to wait, occurred whenever her bowels were about to act. Sensibility in the legs and thighs was impaired, but not extinct. Her parents informed me that some time previously, while stooping to raise up a sister in a room at Hampstead, she had been struck by lightning, fell backwards, became blind, and remained so for ten days. She did not lose her consciousness, but complained immediately that the lightning had hurt her eyes. They presented no visible injury or defect, but the upper lids fell, and she was unable to raise them. It was soon found, however, that when pressure was made on the right eyelid she could open the other eye. The palsy of her limbs commenced, by degrees, two or three days afterwards. The power of vision returned suddenly, and at the same mo- ment the power of moving her limbs was restored: but it gradually went again. When she lay down her limbs were still; but they began to tremble and to be agitated as soon as she sat up. Even when lying in bed, she had, occasionally, a sensation and dread, as if she were falling down. She had been in this state nearly three weeks. • She was put upon steel, and a tonic plan of treatment, and in ten days she could walk, dragging her left leg a little after her. In ten days more she was dismissed quite well, and able to run from one end of a long ward to the other. LECT. XX.] AMAUROSIS. 239 The greater number of the cases of amaurosis depending upon a morbid condition of the retina itself, belong to the class that I have now been mentioning; there is congestion of the vessels of the retina; or inflammation, chronic or acute. In a few instances a totally opposite condition of the blood-vessels is presumed to exist. I say presumed to exist, because our judgment of this matter is founded, as before, upon the nature of the circumstances that have caused the affection, and upon the nature of the treatment that removes it. On these grounds some cases of amaurosis (few in number, speaking comparatively) may fairly be ascribed to a deficient supply of blood to the vessels of the retina. We know that a temporary defect of sight may be pro- duced by a diminished circulation through the retina, as in approaching syncope under haemorrhage; and we can therefore the more readily believe that more permanent amaurosis may be occasioned by causes that gradually lessen the quantity of blood circulating in the body, and debilitate the whole system. " It is well known (writes the late Dr. Gooch) that large losses of blood enfeeble vision. I saw a striking instance of this in a lady who flooded to death. When I entered the chamber she had no pulse, and she was tossing about in that restless state which is so fatal a sign in these terrific cases. She could still speak; asking whether I was come? (she knew I had been sent for) and said, 'Am I in any danger ? — How dark the room is! I can't see.' The shutters were open, the blind up, and the light from the window facing the bed fell strong on her face. I had the curiosity to lift the lid, and to observe the state of the eye. The pupil was completely dilated, and perfectly motion- less, though the light fell full upon it. Who can doubt that here the' insensibility of the retina depended on the deficiency of its circulation ?" One might ask, also, who can doubt that the retina may become insensible from a similar state of the circulation in it, brought on by some long-continued drain upon the system ? Amaurosis of this kind, proceeding from too profuse and protracted a secretion (which may be considered a sort of haemorrhage), is sometimes noticed in nurses. Mr. Lawrence describes the case of a young mother of slender make, who suckled her first child, which was strong, and took the breast very often: her milk was abundant. After two or three months she began to feel very weak, could not lift a weight, and cried frequently, without having any moral reason for grief. She became totally blind, and was led to his house by a friend. He found her pallid, with a small feeble pulse. The pupils were of middle size, and the irides moved slightly. The retina was completely insensible. She could not discern the situation of the window, nor see a lighted candle held close to her. After weaning the child, and using generous diet, she got perfectly well. Some counter-irritation was employed in this instance, but I question whether it had anything to do with the recovery. Such cases are not uncommon, and their well-known occurrence has probably tended to en- courage the notion — too prevalent among both patients and practitioners — that amaurosis is always and essentially a disease of debility, and requires tonic and stimu- lant remedies; bark, and high feeding, and strychnia, and electricity. "Our eyes are weak," say they, u and we require strengthening medicines." You must perceive from what has already been said, how necessary it is to discriminate in such cases: to look closely into all the circumstances under which the disease has occurred. When amaurosis is the result of pressure or of disease, in the course of the optic nerve, or in the sensorium, the complaint is generally less within the power of reme- dial measures. We cannot say, indeed, in many instances, where the cause of defect lies : and in obscure cases, I should always advise a trial of the mercurial plan. I have again and again seen slight palsy of some of the voluntary muscles, evidently depending upon some morbid condition of the brain, clear away rapidly upon the affec- tion of the gums by mercury; and the lost power of the retina will sometimes return under similar treatment. There is something very peculiar in the expression of countenance, and in the gait, of an amaurotic person, by attending to which alone, you may almost recognise his disease. He comes into a room with an air of uncertainty in his movements; the eyes are not directed towards the surrounding objects; the eyelids are wide open; to use a strange but common and intelligible phrase, the patient seems gazing upon vacancy—has an unmeaning stare; and there is a want of that harmony of movement and expression which results in a great measure from the information obtained by the exercise of vision. This seeming stare at nothing at all, is not observed in patients 240 DISEASES OF THE EYE. [LECT. XX. who are blind in consequence of opacity of the crystalline lens or its capsule, i. e., in consequence of cataract. They, on the contrary, while they cannot see, still seem to look about them, as if they were conscious that the power of sight remained to the retina, although light was shut out from it. When the amaurosis is incomplete, the motions of the iris are sluggish, and the pupil is larger than ordinary. When the blindness is total, the commonest condition of the eye is that of great dilatation of the pupil, with complete immobility of the iris. A mere ring of iris is all that is visible, and no change takes place in the diameter of the pupil, under the greatest variation of the light that falls upon it. Sometimes, on the other hand, though the amaurosis be total, the iris is as active as ever; and this is a very interesting circumstance, and may help us, in some degree, to conjecture the actual seat of the malady. When the amaurosis is confined to one eye, this may happen. You examine the diseased eye, and you find that the pupil enlarges or contracts, as you diminish or increase the light. But the other eye is open. Shut the sound eye, and try the amaurotic eye again, and you find the pupil fixed, although you vary the light. The motion you formerly noticed was sympathetic with the motion of the iris in the healthy eye. We express this otherwise by saying that the associated movements of the iris were natural and lively, but its independent movements were lost. But sometimes the independent movement is unaffected: nay, the motions of both irides may be perfect, although both eyes are completely amau- rotic. I may state, by the way, that ceteris paribus, when both eyes are affected, that is a ground for supposing the cause of the disease to be situated within the cra- nium. And I should come to the same conclusion if, in the case where one eye alone was amaurotic, I found the independent motion of the iris of that eye unimpaired. We know that in the healthy condition of the parts, the brightness of the light admit- ted to the retina determines the size of the pupil; but the motions of the iris do not depend solely or directly upon the retina. It has been ascertained, by experiments made upon animals, that the pupil may be made to contract either by mechanical irri- tation of the optic nerve within the cranium, or by irritation of the third nerve; a motor nerve which sends filaments to the ophthalmic ganglion, whence the ciliary nerves, passing to the iris, are derived. Now the optic and the third nerves have some link of connexion within the brain; and if the morbid condition upon which the amaurosis depends is situate deeper than that point of connexion, we may understand, I think, how disease so placed may destroy the power of vision, and yet leave the connexion between the retina and the third pair unaffected: and then the influence of light falling on the retina, though it fails to create a perception in the mind, will be reflected back upon the third pair of nerves, and so continue to govern the motions of the pupil. In conformity with these views, M. Andral relates cases in which amau- rosis connected with disease in the cerebellum was attended with brisk movements of the iris. There are other causes of amaurosis besides those that I have already adverted to. It is sometimes produced by the presence of worms in the alimentary canal. SThat amaurosis is frequently dependent upon irritations seated within the stomach bowels, and upon derangements of the digestive organs generally, there can be little doubt. We have met with many cases of this kind, and they are repeatedly referred to, more especially by the German writers on the disease. Children confined in ill-ventilated and ill-lighted apartments, and supplied with coarse and indigestible food, are often affected with a certain degree of amaurotic blindness, which is readily removed by a proper hygienic treatment, and such remedies as are adapted to restore the regular functions of the stomach and alimentary canal. We have observed the disease, also, in children who have been, at too early an age, confined in crowded school-rooms for many hours of the day, while their minds were compelled to the performance of tasks beyond their powers. Complete blindness, we have known suddenly to occur in consequence of the presence of indigestible food in the stomach, and to be as quickly removed upon its expulsion. For further information on this subject, the reader is referred to the chapter on amaurosis by Dr. Taylor, in the 2d volume of Tweedie's Library, Philadelphia edition, page 515, and to the very able paper of Dr. Jacob on the same subject in the Cyclopaedia of Practical Medicine, Philadelphia edition, vol. i., page 78. — C] LECT. XX.] AMAUROSIS. 241 It has some obscure connexion with teething, probably through irritation of the facial branches of the fifth pair. A physician of my acquaintance, residing in London, had a young son, who on two or three occasions caused him great uneasiness, by becoming blind in one eye without any obvious cause, and with no visible change in the organ; but the blindness on each occasion went off again, apparently in conse- quence of the extraction of some teeth which had grown irregularly. I am assured by Dr. Ashburner that such cases are common. Mr. Lawrence relates a very singular instance of dental irritation giving rise to amaurosis. A man, thirty years old, was suddenly attacked with violent pain in the left temple near the eye, and in that side of the face generally. The pain continued to recur from time to time, and at length he discovered that he was blind in the left eye. By and by the cheek swelled, and some spoonfuls of bloody matter were discharged by a spontaneous opening in the lower eyelid, and then the pain subsided; but after some months it returned with great severity. The patient then went to Wilna, with the intention of having his eye extirpated, and consulted Professor Galenzowski, who found the left eye totally insensible to light, with the pupil dilated, and no other visible alteration. He ascer- tained, however, that the first molar tooth on that side was carious: it had never caused the patient much uneasiness; and the toothache which he had occasionally suffered had not been coincident, in point of time, with the pains in the head and eye. Dr. Galenzowski thought fit to extract this tooth, and was greatly surprised at seeing a small substance protruding from the extremity of its fang. This proved to be a little splinter of wood about three lines in length, which had perforated the centre of the tooth, and had probably been introduced in using a wooden toothpick. A probe passed from the socket into the antrum, from which a few drops of a thin purulent fluid escaped. The pain ceased almost entirely, and on the same evening the eye began to be sensible to light. The vision gradually improved, and on the ninth day from that time, after thirteen months' blindness in that eye, he was able to see with it as perfectly as with the other. M. Galenzowski has since been in England, and he showed Mr. Lawrence the tooth, and the splinter of wood. Doubtless he felt some pride in exhibiting these trophies of his exploit. Amaurosis is said also to occur as an hysterical affection; and I am certain that I have seen this myself. An unmarried lady, of a very nervous and susceptible habit, came to town in great apprehension about her eyes, the sight of one of them being quite gone. I could perceive no defect in the eye itself. I saw her in consultation with Mr. Travers, who took an unfavourable view of the case, and thought the chance of recovery was very slender. I had one reason for hoping a better result, in the knowledge of some facts which Mr. Travers was not aware of till I mentioned them to him. I had been acquainted with this lady for some years, and during that period she had several times almost entirely lost, and again recovered, the use of her lower extremities. On two occasions she had been affected with aphonia, and unable to speak, except in a whisper, for months together; and then, on a sudden, without any apparent cause, her voice returned. I trusted, therefore, that this suspension of the power of vision in one eye might be a similar freak; and so it turned out. A few weeks subsequently, the sight returned, she knew not how; and she afterwards lost it a second time, and a second time regained it. Certain poisons will produce temporary amaurosis; and the suppression of certain natural evacuations, as of the perspiration, of the menstrual fluid, and of the bleeding from piles, and the repulsion of certain eruptions, have been charged, by authors, with producing the same complaint. In those cases in which amaurosis creeps on slowly and insidiously, as it is apt to do from various causes; and more particularly when it depends upon a low and chronic inflammation, engrafted upon habitual congestion of the vessels of the internal tunics of the eye; its approach is marked by sundry curious affections of the vision. The eye feels full or stiff, and sometimes there is pain of the head in its neighbour- hood. The patient complains that he sees things through a fog or mist, or as if a thick piece of gauze were interposed between his eye and the object he is looking at. In the daylight, the gauze or fog seems dull and murky, but in the dark it often ap- pears shining, reddish, and fiery; the flame of a candle is seen surrounded with a halo of prismatic colours. That amaurosis of this kind is often really dependent upon local congestion we are taught by the Icedentia, by the circumstances that aggravate 16 242 DISEASES OF THE EYE. [lect. xx. it: thus straining of any kind, which augments for the time the fulness of the ves- sels about the head, will make the mist appear more dense; the same effect may be produced by tying the neckcloth tight, or even by stooping. Boerhaave relates the qase of a man who, whenever he was intoxicated, laboured under complete amaurosis. It came on by degrees, increasing according to the quantity of wine he drank; and after the drunkenness went off, his vision returned. Surely these phenomena are very illustrative of the way in which nervous disorders may arise, or be made worse, from mere local plethora, in almost any part of the body. Sometimes the perfect amaurosis is preceded by a remarkable diminution of the ap- parent size of the objects looked at. A patient told Dr. Farre that a carriage, which happened to pass the window, seemed to him as small as a wneelbarrow, and the horses no bigger than dogs. More commonly ocular spectra become visible: that is, parts of the retina lose their power, or perhaps are eclipsed by turgid vessels: the patient sees flies in the air, musce volitantes, particles of soot, blacks, as we, who live in London, call them, which always float before his eyes, and seem to follow their motions; and which are especially plain and troublesome when he is looking upon a white surface. They multiply in number till the whole becomes dark. Do not, however, suppose that the appearance of these muscae volitantes, even when they are permanent, necessarily implies the approach of amaurosis. I should be sorry if it were so, for I see two of them every morning, when my eyes are directed towards a white basin, while I am washing my face. I can find them at other times if I look for them; else I am not sensible of their presence. They bode no further evil, if they are associated with no other defect, in function or in appearance, of the instru- ment of vision. You will infer from what I have been saying that there are two kinds of muscae volitantes,—the one a harmless kind, the other suggestive of further mischief. And it is so. And as patients will often be coming to you in a fright upon first perceiving these objects, you ought to be able to distinguish the innocent sort from the dan- gerous, so as to allay your client's alarm, or to direct his course of proceeding, as the case may be. The distinction is, in general, easy to be made; and it is well set forth in an interesting article in the North British Review for November, 1856. The paper is anonymous, but it bears internal evidence of having been written by Sir David Brewster. Whoever will look through a minute pinhole in a card at the clear sky, by daylight —or through a lens of short focal length at a candle, by night — may see floating be- fore his sight a number of translucent tubes or fibres, and many little beads, of which some are separate, some attached to the tubes, some apparently within them. The tubes or fibres are some straight, others looped or twisted, others again forked. All these objects are bright in the middle, and bounded by fine black lines. Beyond and parallel to the black lines which belong to the larger fibres, may be seen an appear- ance of coloured lines or fringes. The doublings and crossings of the knots or loops in the twisted fibres represent black points. Though the eye be fixed, these bodies are observed to change their position; some of them moving faster, some farther than others. Now, in ordinary light and vision, all these objects are imperceptible, except in certain cases the knots, and perhaps some of the fibres, when they happen to be large; and these knots and fibres, thus seen, constitute the harmless kind of muscae voli- tantes. They are described by several writers as resembling the knots in a deal board, with long fillets extending from them of irregular shape, and edged with black parallel threads. If the eye be fixed on a white surface after a sudden shake of the head, they appear to sink gradually downwards. Those among you who are versed in the science of optics will recognise the black lines and fringes that I have spoken of, as being phenomena of the inflexion or diffraction of light which are never seen but in divergent rays. All muscae volitantes having such fringes must be situated at a greater or less distance from the retina. In fact, there are conclusive reasons for be- lieving that they occupy the vitreous humour. They cannot, therefore, portend either amaurosis or cataract. Whereas those black specks which have no fringes, and which do not move, or which move only in correspondence with the motions of the eyeball, are flaws in the retina, insensible or eclipsed spots, and are therefore to be dreaded as probable harbingers of amaurosis. LECT. XX.] AMAUROSIS. 243 The simple and easy criterion, then, is this. The muscae which are motionless when the eye is at rest, and move with it when it is in motion, are signs of danger to vision. Those which sink gently downwards when the eye is fixed, are innocent. Let me add, however, that although these harmless muscae seem to descend, they must in reality be ascending; floating upwards in the vitreous humour as far as the partitions made by the hyaloid membrane will let them. It is obvious that no particular rules, no rules, that is, which will fit all cases, can be laid down for the treatment of so multiform a complaint as amaurosis. Wlien it manifestly results from disease of the brain, as when it accompanies hydrocephalus, or remains after a stroke of apoplexy, our attention must be directed to the disease from which it has sprung. When there is any reason to suppose that congestion or chronic inflammation of the internal tunics of the eye itself is concerned in the pro- duction of the amaurosis, we must adopt the measures that I have already described, as the most likely to remove the congestion; and especially the mercurial plan. When there is ground for suspecting that the blindness takes its rise in vascular exhaustion, or nervous debility, we must have recourse to tonics; bark, preparations of iron, nourishing diet, the cold bath. Aftep all, you will find too many cases, which will baffle your best-directed attempts, and in which you will be required and warranted to try other expedients. When what I may call rational measures have been expended in vain, you may have recourse to such as are empirical and tentative. There are various stimulants which have occasionally been found serviceable; but most of them, I believe, fail much oftener than they succeed. Electricity is one of these : it is applied by taking small sparks from the eyelids, and from the integuments round the orbit. The object of this is to rouse the dormant energies of the impassive nerve; and it appears sometimes to do this for the retina, as well as for the nerves supplying voluntary muscles. The same or a very similar agent may be conveniently administered by help of the electro- magnetic apparatus. Mr. Ware tells us that electricity is most beneficial in those cases in which amaurosis has succeeded a stroke of lightning. You must take great care not to apply this remedy when there is any inflammatory action at the bottom of the complaint: it should seldom be tried therefore when the affection is recent. Strychnia has, of late years, been used for the cure of amaurosis. I shall here- after take an opportunity of telling you the ordinary effects of that substance upon the body, when given in a certain dose — what is its poisonous operation, and what may sometimes be hoped from it as a remedy. In amaurosis it does good, when it is useful at all, by stimulating the exhausted or atonic nerve into action. With respect to this remedy also I may say—first endeavour to ascertain that it is not likely to do harm; as it will be if the blindness depend upon any condition akin to inflammation. Mr. Middlemore, of Birmingham, has probably given this remedy an ampler trial than any other person, and he speaks very favourably of its effects in certain cases: in others he found it to produce so much pain, and spasm, and distress, that he was obliged to discontinue its use. It is not given, in these cases, by the mouth, but applied locally, and Mr. Middlemore considers that it is most efficient when placed over the supra-orbitary nerve. He puts a narrow blister above the eyebrow; when it has risen he cuts off the cuticle, and applies a piece of linen, for half an hour, to absorb the serum that continues to ooze forth; then he sprinkles the strychnia, finely powdered, upon the raw part, and covers it with linen smeared with the unguentem cetacei. He repeats this every twenty-four hours, cautiously increasing the dose till the vision improves, or some sensible evidence of the agency of the strychnia becomes apparent. He commences with the sixth part of a grain. I must here leave the subject of diseases of the eye. In addition to the lessons which I pointed out before as capable of being learned by attending to the disorders of this small organ, I may now mention a few others, of no little moment, since we shall meet with their application again and again, as we proceed to investigate the morbid conditions of other parts. We have seen enough to convince us that mercury, properly administered, has the invaluable power of stopping adhesive inflammation; of arresting the effusion of coagulable lymph from the blood-vessels : that inflammation of a given part may be sensibly modified by the simultaneous agency of some specific poison upon the system, as that of syphilis; or 244 DISEASES OF THE BRAIN [l ECT. XXI. by the presence of constitutional tendencies to disease, such asare observable in gouty and rheumatic people. And we have seen that the functions of a nerve may be perverted, suspended, or abolished, in various ways: by pressure made upon it; by a plethoric state of its blood-vessels, or by an empty state of them; by inflammation of its texture, chronic or acute; and even, in some mysterious, or hitherto unex- plained manner, by mere irritation of a distant part; by worms, for example, in the alimentary canal; by poisonous substances introduced into the stomach; and by what, in our ignorance, we denominate the freaks and caprices of hysterical disorder. All these lessons we shall find repeated, as the course advances. LECTURE XXI. Diseases of the Brain and Nervous System. Difficulties of the subject. Short Review of some points in the Physiology of the Brain and Nerves. Peculiarity of the Cerebral Circulation. Pressure. Having considered some of the most important disorders of the eye, because they afforded me the means of illustrating many of the doctrines and principles, which I had previously endeavoured to lay before you, of general pathology, I go next to the diseases of that portion of the body, which, though it includes many distinct parts, is called, collectively, the head. I pass over the maladies to which the integuments of the head are liable, because they will fall more naturally and conveniently into the class of cutaneous disorders; and I come at once upon one of the most interesting, and at the same time most difficult and obscure subjects of special pathology — that which embraces the diseases of the brain and nerves. Though it will be a slight de- parture from the plan I have proposed of taking diseases as they affect different parts of the body from the head downwards in succession, I shall speak of the diseases of the spinal cord, and of the nervous system generally, in connexion with those of the brain. To disunite them would neither be easy nor useful. The study of the maladies and disordered conditions of the brain and nervous system, is surrounded with peculiar difficulties: and, accordingly, our knowledge of these diseases is less precise than of the diseases of most other parts of the body. 1. One source of difficulty lies in the circumstance, that the structure of the nervous system has no perceptible or understood subservience to its functions. We do not discover in the mechanism of this system that adaptation of means to an end which is so conspicuous in many other parts of the body: and consequently, though such adaptation doubtless exists, we are not able to trace the reason or the manner of its interruption. We find in the lungs an apparatus of tubes and cells fitted for the reception of air, upon the expansion of the chest by the contraction of certain muscles; of which muscles also we can see and understand the action. If we meet with any obstruction of those tubes, or any obvious impediment to the play of those muscles, we perceive at once how and why the function of respiration is deranged. But no alterations that become visible, after death, in the brain or spinal marrow, afford us any such explanation of the interruption of their proper functions; which are, in three words, sensation, thought, and motion. An apoplectic cell has no rela- tion, direct or inverse, that we are capable of appreciating, with a sentiment: nor a distended lateral ventricle with the exercise of the will. The morbid anatomy does not in any degree elucidate the disorder, simply because the natural structure throws no light upon the healthy office of the parts concerned. 2. It is a further source of difficulty, that physiologists have not yet been able to determine, with anything like precision or certainty, what share the several parts of the brain and spinal cord have in regulating, respectively, the functions which all physiologists acknowledge to belong to the nervous system in the aggregate. There LECT. XXI.] AND NERVOUS SYSTEM. 245 are many and convincing reasons, for believing that the brain is a complex organ; but we can seldom put our finger upon this or that portion of the nervous matter which composes it, and say, here resides the influence that governs this or that par- ticular function. 3. Again, the brain and cranio-spinal axis are so encased by their bony coverings, that, in the living body, we are unable to ascertain their physical conditions by means of any of our senses. Of many parts of the frame we ascertain the state by the sense of sight; and of many parts which we cannot see, we still may recognise the changes by the faculty of touch, or by the ear. The brain and spinal cord we can neither see, nor hear, nor handle. 4. Besides these obstacles to the acquisition of information by the exercise of our own senses, concerning the organs affected, the very disturbance of the functions of his brain cuts us off, in many cases, from that kind of information which we might otherwise derive from the statements of the patient himself. 5. There is a still greater cause of perplexity, with which we have to contend. The very same symptoms accompany alterations of the brain apparently of a very different, nay of the most opposite kind : and on the other hand, changes of structure, which, as far as we can perceive, are absolutely identical in their nature, are associated, in different cases, with totally different symptoms: and more frequently than not, nervous diseases are attended with no alterations of structure, appreciable by our senses. 6. And lastly, we are perpetually asking ourselves, when we find the proper func- tions of the nervous system disordered,—is this disorder the result of disease in the nervous matter itself? or is it merely sympathetic of disease in other parts ? for there are few diseases of any kind which do not, in some degree, modify or disturb the due exercise of the offices of the brain and nerves: and it is very difficult often, and sometimes it is impossible, to determine whether, and how far, the disturbance is primary or secondary. With all its difficulties, however, the pathology of the brain and nerves is always full of interest. How can it be otherwise when we reflect that the nervous system is the medium through which we hold communion with the world around us; the stage upon which all the phenomena of animal life are transacted; the instrument of the mind ? And with all its difficulties, there is also a good deal, in the pathology of the brain and nerves, that is fairly made out, and well understood; and we are at present in the right way for advancing our knowledge of this intricate and mysterious subject, by that careful collection of facts, and rigid induction of particulars, which will lead, at length, to a safe and useful generalization. I shall endeavour to point out to you what is known of the morbid conditions of the nervous system; I shall also state the conjectures and probabilities by which our judgment and practice must be guided, when absolute certainty is unattainable. With mere speculative questions, that have no practical bearing, I shall meddle as little as I can. Our knowledge, I say, of the exact functions of the different parts of the nervous apparatus is scanty and imperfect. Some certainties, however, we possess: and some strong probabilities which almost amount to certainties. Without first expounding my creed upon these matters, it would be impossible for me to explain, as it would be for you to understand, the notions I entertain respecting many of the diseases of the brain and nerves. Omitting the sympathetic nerve and its ramifications, (for we know but little of its office, and still less of its disorders,) the nervous system is made up of certain masses of nervous matter, called the nervous centres; and of nerves therewith connected. The nervous centres consist of the cerebrum and cerebellum, the medulla oblongata and the medulla spinalis. I shall include the cerebral hemispheres, and the lobes of the cerebellum, under the common term, the brain. So I shall speak of the oblong and of the spinal marrow, in the single phrase, the spinal cord, or the cranio-spinal axis ; their endowments appearing to differ more in relation and degree than in kind. I adopt the belief that the grey (which are much the more vascular) portions of these nervous centres, form the part in which their peculiar powers reside, or aro 246 DISEASES OF THE BRAIN [lect. xxi. generated: and that their white or fibrous portions are, like the white and fibrous nerves, mere conductors of the nervous influence. I incline also to the opinion (recollect, if you please, that I do not press these opinions of mine upon you as being necessarily correct), that the influence which originates in the grey matter, and is transmitted by the white, will at last be found analogous, if not identical, with some modification of electricity. We know that some of the effects of this influence may be very exactly imitated, in animals recently dead, by galvanism. The functions of the brain and nerves are sensation, thought, volition, and the power of originating motion. Other functions indeed there are; but these four are all that we need, at present, concern ourselves with. Now it is a part of my creed that the faculties of sensation, of thought, and of the will, belong to the brain : in all probability to the cerebrum alone. The precise office of the cerebellum is involved in some obscurity and dispute. Of the principal opinions that have been formed respecting it, I shall say something hereafter. The chief grounds for believing that the brain proper is, exclusively, the instru- ment of the mind, are these : — 1. Because this portion of the nervous centres is superadded to the cranio-spinal axis, in the greatest bulk and most complicated form, in man : and after him, in those of the inferior animals which show the largest share of reason. 2. Because injury or disease of the human brain does so often impair or abolish the mental powers. 3. Because in inferior animals which evince a certain amount of mental endow- ment, all manifestation of intellect ceases upon the gentle and gradual removal of the cerebrum and cerebellum: the animals continuing to live, for a long time, notwith- standing this mutilation. Again, it forms part of my creed on these subjects that the motive power resides in the spinal cord. The muscles furnish the instruments of motion. Now there is a certain class of muscles which contract without our willing their .contraction; and generally without our being conscious that they are contracting. Such are the heart, the muscular fibres of the alimentary canal, and of the bladder. These are, therefore, called involuntary muscles. There is another large class of muscles, which obey the bidding of the will, and serve the purposes of prehension, locomotion, and bodily effort. These are considered and called voluntary muscles. There is still another distinct set of muscles, of which the habitual action is invo- luntary, yet which submit also to the interposing control of the will. You will call to mind at once the muscles of respiration, which act while we are asleep, or other- wise unconscious; and the sphincters, which regulate the entrances and outlets of the body. Here, I say, the habit is involuntary, but the occasional action is prompted and governed by volition. But sometimes the involuntary action rebels against the willed action, and overcomes it. The muscle contracts in spite of the will. Nay, those muscles which, ordinarily, move only in obedience to volition, do some- times, under the influence of strong emotion, or of disease, contract independently of any effort of the will, and even in opposition to, and defiance of the voluntary power. Under certain circumstances the limbs move with much briskness and force in decapitated animals, in which sensation and volition are extinct. Some physiologists hold, indeed, that sensation and volition are properties of the spinal cord; and they would object to these cases, that no one is warranted in affirming the movements in question to be independent of the will. The animal has no means of informing us whether it feels or not, any more than the human head that has been severed by the axe or by the guillotine. This point, however, has been settled by certain phenomena which are observed to occur, in the human body, under disease. Limbs completely palsied as to voluntary motion, and quite dead as to sensation, do yet, under certain conditions, contract and move when the integuments are pinched; the rational patient neither feeling the pmch, nor being conscious of the movements. LECT. XXI.] AND NERVOUS SYSTEM. 247 Whence does the impulse that leads to motion in these cases proceed — how is the motive power awakened ? The answer to this physiological question has a most important bearing upon the pathology of the nervous system. It is no part of my purpose to enter into any history of the steps by which thia curious problem has been worked out. Its solution is an achievement of our own time; and I may add, of our own country. I profess no more than to sketch, in mere outline, the leading facts that have been ascertained; yet I must, in passing, pay the tribute due to one indefatigable labourer in this department of science, whose sagacity has enabled him to seize the clue, and in great measure to unfold the mazes, of the labyrinth in which this part of the physiology of the nervous system was so long entangled. Dim and uncertain glimmerings of the truth appear in the writings of bygone authors, but it was never clearly discerned, and plainly stated, and success- fully applied to the elucidation of a large class of disorders, until the publication, in 1832 or 1833, of Dr. Marshall Hall's ingenious and most interesting researches into " the functions of the medulla oblongata and spinal cord." Similar views appear to have suggested themselves, about the same time, to Professor Miiller of Berlin. I must recommend you to study the works of these authors; and I may also point out, as fit writings for your perusal (since the doctrines I am now speaking of are com- paratively new), Dr. Grainger's Observations on the Structure and Functions of the Spinal Cord; Dr. Carpenter's two works, Principles of General and Comparative Physiology, and Principles of Human Physiology; and a very able paper on the Pathology of the Spinal Cord, by Dr. William Budd, in the 22nd volume of the Medico- Chirurgical Transactions. If, on the other hand, you wish to see how nearly the idea, which has been so happily simplified into an intelligible principle by Dr. Hall, was reached by earlier observers, you may consult the writings of Dr. Whytt, upon nervous diseases. What, then, respecting this intricate subject, are the main facts and doctrines which modern research has made clearer ? It seems ascertained, that the movements of those muscles which acknowledge the empire of the will, depend essentially upon some momentary change in the condition of the spinal cord. This change (whatever may be its nature) is capable of being effected in three several ways. First, volition, or emotion, originating in the brain, may send down an influence, which travels with electrical rapidity to the spinal cord : whence, the requisite change having been instantly produced, the motive influence passes, with proportional speed, along the nerves which connect the cord with the muscles to be moved. Secondly, the change productive of motion may be wrought in the cord, whether the brain be attached to it or not, by mechanical, chemical, or electrical agencies, operating directly upon the cord itself. Thirdly, the change productive of motion may be wrought in the cord, by an in- fluence carried to the cord, not from the brain, but from the extremities of nerves dis- tributed upon the internal and external surfaces of the body. The action of this nervous circle, whereby, I say, an influence is first carried from the surfaces of the body, along nerves to the spinal cord—whence again an influence is transmitted, or reflected, as it were, to certain muscles along certain other nerves— has been called by Dr. Hall the reflex function of the spinal cord. The apparatus subservient to this function is named by him the excito-motory system ; the nerves which carry the impression to the cord are incident or excitor nerves; those which convey the motive impulse from the cord, reflex or motor nerves. Dr. Carpenter's terms (which I like better, except for their similarity in sound) are afferent and efferent nerves. Mr. Grainger believes that physiology indicates, and anatomy can exhibit, four seta of fibres belonging to the nerves and the nervous centres. Sensiferous, and volition nerves, connected with the grey substance of the cerebrum, and subordinate to the exercise of feeling and of the will; and incident and reflex nerves, connected with the grey matter of the cord, and belonging to the excito-motory system. Whether this be the true state of the case, or whether the efferent fibres be the same, while the afferent fibres are different; the latter coming to the spinal marrow both from the brain and from the various surfaces, just as two trains may arrive at 248 DISEASES OF THE BRAIN [lect. xxi. Euston Square ultimately by the same rail, although the one starts at Derby and the other at Birmingham; or (which is perhaps the better illustration) just as, in some houses, the same bell is made to ring in the servants' hall, by pulling, indifferently, the dining-room or the drawing-room rope : — which of these two hypotheses is the more correct, I am not competent to determine. This reflex action, independent of the will, and although attended often by con- sciousness and sensation, yet often also exercised when there is neither, governs the orifices by which air and food are introduced, and excrements are voided. The infant breathes and sucks by it; the adult uses his will for bringing nutriment into his mouth; in both, the act of deglutition, after the food has reached a certain point, is involuntary. The expulsion of the faeces, the urine, the semen, and the foetus, is regulated by the same function. Nevertheless, most of these muscular acts are capable of being moderated and directed by volition. The reflex power, on the other hand, extends, both in health and in disease, to the entire system of the strictly voluntary muscles; during health it is manifested only in the maintenance of what is called their tone, their natural tension and firmness : in disease, as we shall hereafter see, it sometimes acts upon them with terrific energy. Some of the difficulties which I enumerated in the beginning of the lecture, as impeding our researches into the diseases of the nervous centres, are insurmountable. One or two of them, however, appear to call for a more attentive consideration. I say we often fail to discover any deviation from the natural condition of these nervous centres, or of their appendages; even when the disorder of their functions has been broadly displayed. We are not to infer, from this, that no change has taken place in these parts. The only legitimate conclusion is, that the nervous functions are liable to be deranged impaired, or suspended, by altered conditions, not traceable by our senses, or at least not yet discovered by us, of the organs which minister to those functions. There may be only one such undiscovered disturbing cause, variable in decree in different cases; or (what is more probable) there may be several such conditions differing m kind. A blow or fall, which jars the brain; a sudden mental emotion; an electric shock; a teaspoonful of prussic acid; any one of these causes may destroy life, yet leave no vestige of its action in the nervous substance upon which it operates. It is probable that the fatal condition is not, in each case, the same. We may even form a reasonable conjecture of the manner in which the invisible changes are sometimes brought about. We can conceive, for example, that undue pressure upon the nervous pulp on the one hand, or insufficient pressure on the other, may constitute conditions of the kind we are in search of; and I shall be able, I think, to convince you that such is sometimes the case. Again, we can conceive that such conditions may be furnished by the varying state of the cerebral circulation. In point of fact, we know of some changes in the circulation through the brain which have the effect, invariably, first of modifying, and at length, if they are continued, of arresting, the cerebral functions. If no blood be sent through the arteries of the brain, death in the way of syncope ensues; if venous blood circulate in those vessels, it leads to death by coma. But whatever may be the nature of the unknown, and perhaps fuf pressure, occasioned the morbid phenomenon. LECT. XXII.] SYMPTOMS. 253 A gentleman, thirty years old, was reduced to a state of extreme weakness and emaciation by some complaint of his stomach. As the debility advanced, he became very deaf; and this symptom varied in the following instructive manner. He was very deaf while sitting erect or standing; but when he lay horizontally, with his head quite low, he could hear very well. If, when standing, he stooped forwards so as to produce flushing of the face, his hearing was perfect; and upon raising himself again into the erect posture, he continued to hear distinctly as long as the flushing contin- ued : as this went off the deafness returned. (Abercrombie.) An old clergyman, who was formerly my patient, was troubled by two grievances : deafness and an inter- mitting pulse. They were both always benefited by quina. Objections, I should tell you, have been raised against this theory of pressure affect- ing the functions of the nervous centres; but I think the objections are susceptible of a satisfactory answer. I must content myself, however, for the present, with having pointed out the main grounds upon which the theory rests. The difficulties that attend it, and the considerations which diminish the force of those difficulties, will come necessarily before us on a future occasion. LECTURE XXII. Symptoms of Cerebral Diseases. Inflammation of the Dura Mater and Arachnoid, from external injury ; from Disease of the Bones of the Ear, and of the Nose ; from the poison of Syphilis.—Inflammation of the Pia Mater. The functions of the brain, summarily expressed, being sensation, thought, and voluntary motion, we naturally look for disturbances of those functions whenever the organ suffers disorder or disease. And experience has made us familiar with various forms of disturbance to which these same cerebral functions are liable. Let us pass them shortly in review. 1. The faculty of sensation may be morbidly keen, or morbidly obtuse; or it may be perverted: in other words, it may deviate in degree, or in kind, from the healthy standard. The sensations referred to the several surfaces and structures of the body, and to the organs of sense, may (without any fault in those parts and organs) be preternatu- rally acute. Tenderness ascribed to different parts, their natural sensations being heightened into pain; a general state of irritability; intolerance of light, and of noise; are so many instances of this over-sensitiveness of the percipient organ. Under the head of diminished or defective sensation may be ranked, numbness in all its degrees, up to total loss of sensibility, or anesthesia ; dulness of hearing, deaf- ness ; dimness of sight, blindness; failure, or absolute extinction of the senses of taste and of smell. Perverted sensations, sensations unnatural in kind, or unprompted by their special excitements, are very numerous. To mention a few: giddiness; nausea; ringing sounds in the ears; ocular spectra; ill smells in the nostrils; false tastes on the palate; itching; and sundry uneasy feelings, many of which are indescribable. Various kinds of pain belong to this class; spirits violently high; causeless depression, anxiety, and dread. 2. Innumerable degrees and varieties of disturbance of the faculty of thought are met with. Delirium in all its shades; dulness and confusion of intellect; sundry defects of memory; incapacity of judgment; and every degree of stupor up to com- plete coma. 3. Of the function of voluntary motion there are also various kinds and gradations of derangement: twitchings of the muscles; tremors of the limbs; rigidity from spasm; irregular and involuntary jactitation; convulsions; muscular debility; palsy. 254 DISEASES OF THE BRAIN. [lect. xxii. Now, as I stated before, there is, and there can be no physical exploration of the living brain. We are limited, therefore, in studying its diseases, to the rational symptoms. It becomes our task to interpret the import of the multiform disturbances of function just enumerated, in every case in which more or fewer of them appear; and when you are told that these symptoms are apt to present themselves in almost every conceivable order and combination, and, moreover, that many of them may be sympathetic of diseases of other parts than the brain, you will scarcely need to be further informed, that the language they speak is often very hard to construe; that we frequently fail to reach and discover, by these outward signals, the inward things they denote. I am about to consider, in the first place, some of the inflammatory affections of the brain, and some which may easily be mistaken for inflammatory affections; and I warn you beforehand, that, in respect to exactness of diagnosis, we are sadly barren of certainties in these matters. Hints, sketches, approximations, are nearly all that I can promise concerning not a few of the many diseased conditions to which the brain and its appendages are obnoxious. In the brain, as in other composite organs, inflammation may be general or partial. It may attack certain tissues only: it may be seated in the substance of the cerebral mass; or in the membranes that envelope it. I need not tell any of you that the membranes which invest the brain are three in number; the fibrous dura mater, the serous arachnoid, and the pia mater, which is composed of blood-vessels held together by a web of areolar tissue. Speaking generally, inflammation of the cerebral substance alone, is perhaps more common than inflammation of the investing membranes alone. The central parts of the nervous mass may and do suffer inflammation, while the membranes escape. But it seems to me scarcely possible that inflammation of the pia mater should take place without implicating also the surface of the convolutions with which it has so close a relation, and a vascular connexion so intimate. Again, with respect to the membranes themselves, the dura mater may be inflamed while the pia mater remains unaffected. I believe also that the arachnoid may suffer inflammation, and leave the subjacent pia mater untouched. Whether the arachnoid ever escapes participating in the inflammation of the dura mater on the one side, or of the pia mater on the other, is to be doubted. Can we separate and distinguish these several inflammations by assigning to each its proper external phenomena ? Seldom; scarcely ever. Doubtless each has its peculiar symptoms; and if inflammation were often strictly limited to the one mem- brane or to the other, and if the course and events of the inflammation did not modify the condition of the brain itself, by causing variations of pressure, or by affecting the circulation of blood through it, then we might expect greater uniformity, and might hope by careful and repeated observation to seize upon the desired distinc- tions. But this simplicity is not exhibited by the inflammatory affections of the parts within the cranium. Inflammation commencing in one membrane is apt to spread readily and rapidly to the rest, and to the cerebral substance; and the complication of diseased conditions coexisting within the skull at the same time, throws confusion over the whole subject. This uncertainty of exact diagnosis is however of the less consequence, inasmuch as when we have learned that inflammation is going on in any part of the encephalon, we have learned enough to direct us as to the general plan of treatment to be adopted. After all, certain symptoms do present themselves more frequently when one part is inflamed, and certain other symptoms more frequently when another part is in- flamed ; and it will be proper and convenient to contemplate certain forms of menin- geal inflammation separately. Let us, first, then, consider inflammation as it is confined, occasionally, to the dura mater — or to the dura mater and arachnoid. This very rarely happens as an idiopathic or spontaneous disease; but it is not at all uncommon as a result of external injury. And we may advantageously trace its ordinary phenomena and consequences, by attending to these instances of traumatic inflammation of the dura mater. They were excellently well described, many years aS°; by Mr. Pott. A man receives a blow on the head; the blow stuns him perhaps lect. xxn.] DURA MATER AND ARACHNOID. 255 at the time, but he presently recovers himself, and remains for a certain period, ap- parently in perfect health. But after some days he begins to complain; he has pain of the head, is restless, cannot sleep, has a frequent and hard pulse, a hot and dry skin, his countenance becomes flushed, his eyes are red and ferrety; rigors, nausea, and vomiting supervene; and, towards the end, delirium, convulsions, or coma. Meanwhile the part which was struck becomes puffy, tumid, and somewhat tender; and if this tumid portion of the scalp be cut through, the pericranium beneath it is found to be separated from the bone; moreover, the bone itself is observed to be altered in colour, whiter and drier than the healthy bone; and if a piece of this bone be removed, it is also seen that the dura mater on the other side of it is detached from the cranium, and sometimes smeared with lymph or puriform matter. This is a form of disease very often met with by the surgeon. I have watched, with much interest, several such cases under the care of my hospital colleagues. One or two of them I will briefly describe. In the year 1833, during Christmas time, the coachman of a lady living in my neighbourhood fell, being intoxicated, into a cellar or area, struck in his fall one side of his head, and tore up the scalp over a considerable space. He was carried to the hospital, where the loose flap of integuments was cleansed and replaced. After some days erysipelas came on, and then a much larger portion of the scalp sloughed away, so that the bone was laid bare to a frightful extent, and looked, at a little distance, as he sat up in bed, like the tonsure of a monk. Nevertheless the man seemed wonderfully free from suffering or distress: his pulse, indeed, was frequent, but it was said to be so during health. His intellect was clear, and he had no head symp- toms ; or rather no brain symptoms. In the early part of February, 1834, he had a shivering fit, which was followed by convulsions of the right side of the body, and subsequently by paralysis of the right arm and leg, and by stupor, from which he could easily be roused. He would put out his tongue when desired to do so; but to every question he answered "yes." A portion of the left parietal bone was evidently dead. Here the trephine was applied; and a piece of bone being removed, the dura mater was exposed. It looked as if it also had lost its vitality. Some pus lay upon it. No relief followed the operation. On the 10th of February fluctuation was detected beneath the dura mater, which was then slit open. About three drachms of puriform fluid escaped. The patient died soon afterwards, having had no active delirium throughout. The surface of the dura mater was found to be nearly of its natural appearance, except where the trepanning had been performed. At that spot it was dry and sloughy. Over the whole of the anterior and lateral surface of the left hemisphere there lay, upon the arachnoid, a thick coating of coagulable lymph, smeared with pus : this extended down the posterior part of the hemisphere also, nearly to its base. There was no other morbid appearance; no fluid in the pia mater, nor in the ven- tricles. The substance of the brain was everywhere perfectly sound and healthy: it was divided in all directions in search of an abscess, but nothing unnatural could be detected. Another man came to the hospital to have a small incised wound of the scalp looked at. The injury appeared to be trivial; the cut was dressed, and the man made an out-patient. A few days afterwards he came again, incompletely paralytic on one side of his body. I saw this man's skull trepanned; he was perfectly calm and collected: that part of the dura mater which corresponded to the wound was found to be inflamed: and there was pus diffused over the arachnoid covering the cerebral convolutions on the same side. He sank quietly into a state of coma, and so died. Not the slightest incoherence or delirium had been manifested, there had been no convulsions, nor was there any other morbid appearance within the cranium. I mention these cases to show you the grounds of my own opinion that inflam- mation, beginning in the fibrous membrane, may affect the arachnoid, without neces- sarily extending to the pia mater; just as inflammation may overspread the pleura, or the pericardium, without touching the lung or heart which those serous membranes respectively clothe. Here no sensible traces of inflammation were discovered, deeper than the free surface of the arachnoid; and there had been no disturbance, till towards the end, of the proper functions of the brain. I conclude that the disease did not pass beyond the serous membrane; for I can scarcely conceive inflammation of the 256 DISEASES OF THE BRAIN. [lect. xxii. pia mater to exist without involving, in some degree, the surface of the brain; nor inflammation of the surface of the brain to exist without some manifest derangement of the cerebral functions. In the instances that I have been relating, the final stupor and palsy may reasonably be ascribed to pressure resulting from the events of the in- flammation of the arachnoid; from the effused pus and lymph. Inflammation of the dura mater is very rare as a simple and idiopathic affection. Dr. Abercrombie relates one instance of it, as the only one he had seen; and even that was not a pure case of inflammation of the dura mater. There was pus upon that membrane, which adhered to the cranium over a space as big as a crown-piece, and at that spot was ulcerated. But there was also found an adventitious membrane beneath the arachnoid where it covers the brain. Speaking generally, this complaint is marked by pain of the head, by fever, and by rigors which intermit; and so regular sometimes are the intermissions, that the prac- titioner may be tempted to believe that he has got an aguish patient, and to admin- ister bark. The intellectual faculties, especially at the outset of the disease, are but little affected; which is just what we might expect. The dura mater and the arachnoid lying apart from the sensorium, their inflammation can have no other than an indirect influence upon its functions. Although inflammation of the dura mater is very uncommon as an idiopathic or primary disorder, we very frequently meet with it as a secondary affection; and then there are few diseases more surely fatal, or less within the reach of remedies. It is as a consequence of what is called otitis, that physicians are chiefly accustomed to encounter inflammation of the dura mater. It results from disease of the internal ear, and of the petrous portion of the temporal bone. Sometimes acute inflammation arises within the tympanum, when there has been no previous disease: the patient has severe head-ache, and ear-ache; at length a gush of matter comes from the external meatus, but the pain does not, as it usually does in such cases, cease; it continues, or even increases in intensity: the patient begins to shiver; he becomes dull and drowsy; slight delirium perhaps occurs; and by degrees he sinks into stupor. In some instances no pus issues externally. More commonly symptoms of the same kind supervene upon a chronic discharge of purulent matter from the ear. It is scarcely possible to sketch an accurate general picture of this insidious, but most dangerous complaint. Next to seeing and watching actual cases of it, the best way of becoming acquainted with its phenomena is by attending to recorded instances. I will bring before you, therefore, some examples of inflammation of the dura mater, occurring in connexion with disease of the interior of the organ of hearing. A youth, sixteen years old, applied to the late Dr. Powell (who has related the case in the fifth volume of the Transactions of the College of Physicians) on account of an eruption, with an acrid discharge, behind the right ear. He had become deaf five years before, after scarlet fever, but no discharge took place at that time from the ear. In the following year, however, he had the measles, and then an abscess formed in the right ear; and after giving him much pain, it burst. He had again suffered, three days before Dr. Powell first saw him, a sudden attack of very severe pain in the same ear. The pain quite deprived him of rest: but he had no fever, nor delirium, nor coma. He slept, indeed, a great deal, but that was the effect of opiates, which he took to relieve the pain. This symptom was quieted by the opium; but it always returned with severity if the medicine were suspended. A foetid discharge came from the ear. On the tenth day of this attack, after a most violent paroxysm of pain, his strength rapidly declined, and he died. " When the head was examined, the structure of the dura mater was healthy and natural, but beneath this membrane the whole superior surface of the right hemisphere was covered with a layer of coagulable lymph and pus. The vessels of the substance of the brain were not more numerous or loaded than usual, and the brain itself was healthy in every part. In the base of the skull the dura mater adhered to the bone, except at one part, of about half an inch diameter, just over the petrous portion of the temporal bone, where it was black and sloughy. The subjacent portion of the bone itself was carious, black, and crumbling; and contained foetid pus." In this case, you will observe, there was no symptom to mark the extensive mischief within the head, except the pain: the pulse never exceeded 72; the skin was warm and moist; there was neither fever, nor delirium, nor convulsion, nor coma. lect. xxii.] DURA MATER AND ARACHNOID. 257 A girl, aged nine, (I take this case from Dr. Abercrombie, whose volume on the diseases of the brain is full of practically instructive examples,) had been liable to attacks of suppuration of the ear, which were usually preceded by severe pain, and some fever. She suffered one of these attacks in the left ear, in July, 1810. Upon the discharge of matter from the ear she did not obtain ease, as she had done on former occasions; but continued to be affected with pain, which extended over the forehead. When Dr. Abercrombie saw her, he found that, besides the pain, she had some vomiting, and impatience of light. Her look was oppressed; the pulse 84. Blood-letting, purging, blistering, and mercury, were employed without relief. Two days afterwards there was a slight and transient delirium, a degree of stupor, and slight convulsions. She lay constantly with both her hands pressed upon her fore- head, and moaning from pain, of which there had not been the least alleviation. On the fifth day from the commencement of the discharge, she continued sensible, and died suddenly in the afternoon, without either squinting, blindness, or coma, the pulse having been always under 90. A considerable quantity of colourless fluid was found in the ventricles of the brain, which, in other respects, was healthy. In the left lobe of the cerebellum there was an abscess of considerable extent, containing purulent matter of intolerable foetor. The dura mater, where it covered this part of the cerebellum, was thickened and spongy, and the bone corresponding to this portion was soft, and slightly carious on its inner surface; but there was no communication with the cavity of the ear. Here again pain was the most prominent symptom, and probably resulted from the partial inflammation of the dura mater. It is interesting to mark these two points: — that the disease in the bone imparted disease to the dura mater, although no passage was opened from the tjmpanum; and that this inflammatory state of the external membrane of the brain led (apparently) to deep-seated suppuration in the cerebellum; the parts lying between the abscess and the dura mater escaping. This last, and somewhat singular circumstance, might have been owing (so at least I conjecture), to the extension of the inflammation from the suppurating ear to some of the veins of the skull; and the consequent formation in the cerebellum of one of those secondary abscesses so commonly noticed in uncircumscribed phlebitis. Two very remarkable instances of diffused inflammation of veins, and of its terrible effects, occurring in connexion with purulent otorrhoea, have fallen under my own observa- tion : one of them in private practice, the other in the hospital. As I am not aware that such consequences as supervened in these cases upon otitis, have received much attention, I will briefly describe them. The first of these two patients was a boy, eleven years old, whom I attended with Dr. Maclntyre and Mr. Arnott. He had had a discharge of offensive purulent matter from the ear since the time when, four years before, he had gone through scarlet fever. In August, 1833, he went, for a walk, into Kensington Gardens, and there lay down, and slept upon the damp grass. The next day he was attacked with head- ache, shivering, and fever. Strong rigors, followed by heat and perspiration, occurred very regularly for two or three days in succession; suggesting the suspicion that his complaint might be ague: but then pain and swelling of some of the joints came on, and were, at first, thought to be rheumatic. However, the true and alarming nature of the case soon became apparent. Abscesses formed in and about the affected joints; and one of these fluctuating swellings was opened, and a considerable quantity of foul, grumous, dark-coloured matter let out. After about a fortnight the child sunk under the continued irritation of the disease. The hip-joint presented a frightful spe- cimen of disorganization; it was full of unhealthy sanious pus, the ligamentum teres was destroyed, the articular cartilages were gone, and matter had burrowed extensively among the surrounding muscles. The knee and ankle joints of the same limb were in a similar state. It is curious that the destructive disease of the joints was limited to those of the right lower extremity, while the primary suppuration was in the left ear. Unfortunately the head was not examined; but that the fatal disorder had penetrated from the ear to the dura mater, I entertain no doubt: in all probability the inflammation had involved the veins or sinuses of the head. The second case had many points of similarity with this. William Marriott, aged 19, was admitted under my care into the Middlesex Hos- pital on the 18th of October, 1834, having pain and tumefaction of the right shoulder, 258 DISEASES OF THE BRAIN. [lect. xxii. wrist, and foot, with redness of the latter. He complained also of headache, vertigo, drowsiness, and of an occasional feeling of stupor. His skin was hot and dry, his face flushed, his tongue furred, his pulse frequent (112), and his bowels were relaxed. A puriform discharge came from his right ear. He had been suddenly seized, a week before, with sharp pain in that ear, which lasted twenty-four hours, when the discharge commenced, and the pain was relieved. He then began also to have headache, which had never left him, and to be sometimes dizzy. Three days previously to his admission the rheumatism (as he supposed it to be) commenced in the foot. When this part was examined, the redness was found to be circumscribed, somewhat livid, and limited to the great toe. It had much the appearance of gout. He soon began to be troubled with shivering fits, which recurred regularly every morning about the same hour, and were followed by burning heat of the skin, but no sweating. An abscess formed near the toe, and was opened by Mr. Mayo, and some healthy-looking pus evacuated. Next, a large fluctuating tumour near the shoulder was punctured, and three ounces of pus, mixed with blood, came out. After this incision the rigors ceased; but the abscesses continued open, and the discharge had an offensive smell. On the 14th of November it was discovered that matter had col- lected in the left hip : this also was emptied by puncture. On the 1st of December, a very large quantity, not less than three pints, of unhealthy and grumous pus, was let out from a vast abscess which had formed in the loins: and pus was noticed in his stools. The discharge from the shoulder came at last to resemble the lees of port wine. During all this while the patient remained feverish, with a dry parched tongue, and a rapid and feeble pulse. The diarrhoea continued, more or less, throughout. For some time before his death, which happened about the middle of the month of De- cember, the left leg and thigh had been much enlarged by oedema. I was not able to be present at the inspection of the body; and I have to regret that in the report which I received of it, the condition of the brain, of its membranes, and of its veins, was not noted. The right shoulder-joint was extensively diseased; the cartilages were destroyed by ulceration over a considerable space. Those of the left hip were entire, but the synovial cavity was full of foul matter. The joint of the great toe was implicated also in the abscess which had formed there. The femoral vein, on the left side, was plugged up throughout its whole extent, by a coagulum, which was firm and of a red- dish-brown colour at the upper part of the vessel, loose and darker towards the ham. The saphena was pervious; the iliac was free from disease. The lungs had undergone partial disorganization. Several distinct portions of the pulmonary tissue were nearly solid, while the tissue immediately around them was crepitant and healthy. From these small solidified portions, purulent matter could be made to ooze by gentle pressure. The mastoid cells of the right temporal bone were filled with pus, and there was a slit-like opening in the membrana tympani. The small bones of the ear were sound. I much lament that in these instances, the direct link of connexion between the disease of the ear and the disorganization of the joints was not demonstrated: for seeing (they say) is believing. Yet the pain of the ear, the discharge of pus from the external meatus, the subsequent pain of the head, coining on with fever and rigors, and followed after a short interval by destructive suppuration in several distant parts, and, in the last case, the actual femoral phlebitis; these circumstances form a chain of presumptive evidence, amounting, in my judgment, to moral certainty, that the fatal mischief, in each case, found entrance through "the porches of the ear;" and that the dura mater underwent inflammation. The same evidence is scarcely less affirmative of the complication of cerebral phlebitis. Perhaps the veins of the diploe, which in the cranial bones are of considerable magnitude, were involved in the inflam- matory mischief; perhaps the large sinuses of the brain. The close vicinity of the lateral sinus to the diseased bone, and its formation by a duplicature of the dura mater, would seem to render such a complication highly probable. These views, which were brought forward in my first course of Lectures here, in 1836, have been confirmed by the publication more recently (1841), in the Medical Gazette, by Dr. Bruce of Liverpool, of two cases witnessed by himself, of " Phlebitis lect. xxii.] DURA MATER AND ARACHNOID. 259 of the cerebral sinuses as a result of purulent otorrhoea." He refers to several other instances of the same kind recorded by different authors. This combination of dis- ease is doubtless more common than had been heretofore supposed : and the important pathological considerations connected with it will probably receive further illustration, now that the attention of the profession has been called to the subject by Dr. Bruce's paper. Dr. Griffin has published, in the Dublin Journal of Science, two examples of otitis attended with symptoms exactly resembling those of intermittent fever. One of them is as follows:—A young man, previously healthy, was attacked with fits of shivering, accompanied by pain in the left side of the head. At first the paroxysms were rather irregular, but they soon assumed the form of tertian ague; coming on every other day, at about the same hour; the cold fit commencing at noon, and lasting about half an hour, followed by a hot stage of somewhat longer duration, and then a profuse sweat. In the intermissions the pain in the head was trifling: there was no thirst, nor heat of skin, but he did not sleep. A tumour formed over the mastoid process on the left side, and was opened, and a quantity of extremely offensive brownish pus sprang out with great force. This gave much relief. The bone was carious over a space as big as a shilling. After about ten days, the pain in the head and in the mastoid process became very severe; the patient had violent shivering fits many times in the day, great thirst, heat of skin, vomiting and delirium; his face was flushed, and his pulse hard; and he died within a few hours after the accession of these last symptoms. The most remarkable features in this case were the similarity of the fits of shivering to the paroxysms of ague, their regular recurrence at periods of forty-eight hours, and the circumstance that they seemed to be checked, for some time, by the treatment proper in ague; namely, the exhibition of bark. The occurrence of quotidian parox- ysms of the same kind has been noticed in relating some of the previous cases. I have related them to show you what different symptoms may result from inflam- mation of the dura mater; and to put you upon your guard against overlooking the cause from which such inflammation does frequently originate. The suppuration of the tympanum, and consequent disease of the bone, are more common in scrofulous persons than in others; and they are more apt to occur as a sequel of scarlet fever than in any other way. I conceive that the inflammation which affects the throat in that disorder, and which often constitutes all its danger, creeps along' the eustachian tube into the interior of the ear. In strumous subjects the fire thus lighted smoul- ders on, or if it ever go out, is readily rekindled; that part of the temporal bone, in which the organ of hearing is principally lodged, becomes carious; the membrana tympani is perforated; the little bones of the ear come away; more or less deafness ensues: and from time to time, or habitually it may be, there is a discharge of pus from the external orifice. At length the inner surface of the bone participates in the disease; and then the inflammation is apt to be propagated to the dura mater, or to the lateral sinus, in the manner of which I have given you some instances. It is in the first onset of the inflammation in the ear that remedies are most likely to be effi- cient in preventing this catastrophe. Leeches applied early and repeatedly to the mastoid process, especially when that part becomes tender, as it often does in such cases, and counter-irritation afterwards, are the best means in our possession. If symptoms of acute inflammation within the head supervene, the complaint may de- mand more active treatment, which I shall describe when I have spoken of inflam- mation of the other membranes of the brain. After what has been said, it is unne- cessary to point out to you that the prognosis in these cases is very unfavourable. But we are not to abandon them in despair. That inflammation of the dura mater may be recovered from, we know, by what happens in certain injuries of the head: and the following would seem to be an instance of recovery when the source of the mischief was situated in the ear. A young lady, after the usual symptoms in the head, lay for three or four days in a state of perfect coma, and her condition was thought utterly hopeless. Her medical attendants continued to visit her as a matter of form; and one day they were agreeably surprised to find her sitting up, and free frOm complaint: a copious discharge of matter had taken place from the ear, with immediate relief: and she continued in good health.—(Abehcrombik.) We cannot be sure in such a case that the matter came from the brain; but the symptoms made 260 DISEASES OF THE BRAIN. [lect. xxh. that supposition exceedingly probable. The case shows clearly one of two things; either that pus may thus escape from the skull, and the patient get well; or that pus shut up in the cavity of the tympanum, or in the mastoid cells, may produce the urgent symptoms that are known to result from cerebral pressure. [The frequency with which inflammation of the dura mater supervenes upon otitis, especially in children, should be kept constantly in mind; for it is only by a prompt, active, and judicious treatment, whilst the disease is confined to the internal ear, that we can have any hopes of saving the patient—when inflammation has extended to the membranes of the brain, the termination is very generally fatal. — C] Cases arc recorded of analogous disease communicated from the carious ethmoid bone to the dura mater; the patients having had pain in the forehead and purulent discharge from the nose, and becoming at last forgetful and delirious, and dying in a state of coma. I have never met with an instance .of this kind; nor of inflammation spreading inwards from the socket of the eye: but I make no doubt that each may occasionally happen. That part of the dura mater which is reflected over the inside of the skull may be regarded as its internal periosteum. Like the periosteum of the tibia, of the clavicles, of the bones composing the sternum, like the pericranium itself, this membrane is liable to a specific inflammation, one of the secondary effects of the poison of syphilis. In this form of disease you will often find the outer surface of the cranium painful, tender, knobby, embossed with smooth, round projections of considerable size: and there is good ground for believing that, under similar circumstances of contamination, similar prominences arise from its inner surface also. There may be nodes on either side of these bones; within no less than without. And such internal nodes, by the pressure, or by the irritation which they cause, may give rise to cerebral symptoms: pain in the head, convulsions, paralysis, coma. Whenever such symptoms present themselves, you must not allow this possible mode of their production to escape your attention and inquiry. This care is the more important because for chronic periostitis of syphilitic origin — if not for every form of chronic periostitis — we possess a spe- cific remedy in the iodide of potassium. To have discovered this curious and valuable truth should suffice to immortalize the name of the late Dr. Robert Williams. The effect of the iodide in these cases, when given in appropriate doses, is marvellously prompt and sure. The nodes cease to be painful, and begin at once to recede until they disappear. I should not prescribe less at first than five grains, three times daily; and I should not hesitate to carry the dose to ten or even fifteen grains, if the circum- stances of the case should seem to require that increase. I have never seen any of those ill consequences from full, but not excessive, doses of the iodide, which are apprehended by some physicians of eminence. The remedy should be continued for some time after the external nodes have departed, or the symptoms produced by the presumed internal nodes have ceased, and it should then be gradually withdrawn. These four then — idiopathic inflammation of the dura mater—very rare; inflam- mation of the dura mater by extension of disease from the aethmoid bone, or from the orbit — also infrequent; inflammation of the dura mater by extension of disease from the petrous portion of the temporal bone — very common; and syphilitic in- flammation of the dura mater — also common enough : these four constitute the forms of inflammation of the outermost tunic of the brain which the physician may be called upon to treat. The inflammation is not always — nay, perhaps it is seldom, if ever — restricted to that tunic; but it begins there; and the essence of the disease is inflammation of the dura mater. Acute arachnitis — by which I mean active and uncombined inflammation of the arachnoid membrane — is, I apprehend, a very uncommon disorder; although that term is of frequent occurrence in medical writings. I have shown you already that inflammation may pass from the fibrous dura mater to the serous membrane reflected over it; and thence (by what is sometimes called contiguous sympathy) to the oppo- * This interesting subject — the connexion between affections of the ear and disease in the brain or its membranes — has now been clearly and completely set forth by Mr. Toynbee, in a series of Clinical Lectures, published in the Medical Times and Gazette for 1855. LECT. XXII.] PIA MATER. 261 site portion of the same membrane spread over the surface of the brain. So, like- wise, inflammation may extend from the pia mater to the arachnoid. If simple arachnitis, of an acute kind, ever happen, it has not been my fortune to see or to recognise it; and I can tell you nothing about it. In truth, the authors who use the word arachnitis do not intend thereby to express unmixed inflammation of the arach- noid ; but include under that term inflammation of the pia mater also. Some apply the name meningitis to that compound affection; and the only objection to this nomenclature is, that the dura mater is as much one of the meninges of the brain as either of the two others. In the few remarks which I have to make upon inflammation of the pia mater (or, if you will, of the pia mater and arachnoid at once), I shall chiefly follow Dr. Abercrombie: because his observations are comparatively recent, and carefully made; because his veracity, and sobriety of judgment, and philosophical turn of mind, are well known; and because his cases (as regards this particular affection) are quite to the point, and his descriptions clear and concise. But I must premise a word or two respecting the anatomical characters of the disease. When the upper part of the skull, and the dura mater, have been removed, you may frequently see, on the surface of the exposed brain, what seems to be a thin layer of clear gelatinous substance : but this appearance is fallacious. Puncture here and there the transparent arachnoid, and a limpid fluid, like water, trickles out; and the jelly-like investment of the convolutions is gone. Now this thin serous liquid, thus collected in the meshes of the pia mater, may be the event of inflammation of that membrane : but it may also be produced, and it very often indeed is produced, by simple congestion and remora in the cerebral veins. Nay, a certain amount of serosity, in this situation, belongs to the condition of health. We cannot, therefore, with any certainty, infer, merely from seeing this serous effusion, that there has been inflammation : we judge of its import, by noting the co-existence, or the absence, of other traces of inflammation; and by the character of the symptoms that preceded death. On the other hand, we may be sure that there has been inflammation of one or both of these tunics of the brain when we find false membranes between them; layers, i. e., of coagulable lymph. In the effusion of this substance I conclude that the vessels of the pia mater play the main part; both because it is always, in such cases, excessively vascular, while the arachnoid is seldom found to be so in any remarkable degree, if at all: and also, because the false membrane commonly, though not always, sends down layers between those duplicatures of the pia mater which descend into the sulci formed by the convolutions; where, as you know, the arach- noid does not go. In fact, considering the arachnoid as the serous membrane of the brain, we should expect that, when inflamed, it would present the events or products of inflammation on its free surface; and we sometimes find them there; but this is very rare; and for my own part, I look upon those effusions which lie beneath the arachnoid, between it and the pia mater, as being furnished exclusively by the vessels of which the latter membrane is mainly composed. Now, the inflammation of these membranes (taking them together) commences and declares itself, by no fixed or uniform symptoms. The most common and striking phenomenon is a sudden and long-continued paroxysm of general convulsions. Some- times this is the first thing noticed. Sometimes it conies on after a few days of dis- comfort, slight headache, and vomiting. The convulsions recur, and at length end in coma. Sometimes, again, the first attack of convulsions is preceded by violent pain in the head, setting in quite suddenly, and attended with screaming. Consider- ing, on the one hand, the intimate connexion between the pia mater and the grey matter of the convolutions, and, on the other, the presumed functions of that grey matter, we might expect that inflammation of the pia mater would soon be attended with some manifest derangement of the mental faculties. Accordingly, delirium, often violent and continued, is stated by most authors to accompany and denote in- flammation of the membranes; and especially of the membranes where they invest the upper surface of the cerebral hemispheres. Yet I do not find that symptom men- tioned in any of the various examples of meningitis recorded by Dr. Abercrombie. He does give cases, indeed, in which there was much delirium; but they were not 262 DISEASES OF THE BRAIN. [lect. xxii. cases of meningitis of any kind. He relates them as instances "of a very dangerous modification of the disease, which shows only increased vascularity." ^ I venture with great humility to question or criticise any opinion of Dr. Abercrombie's : but I enter- tain no doubt about the nature of the cases which he so describes; and I hope to convince you by-and-by that they are not examples of inflammation at all. They neither show the anatomical characters of inflammation, nor yield to the remedies of inflammation. Excluding these cases, I do not find delirium specified as a symptom of uncombined meningitis. I shall abridge one or two of the well-marked examples of the disease. A girl, aged nine, woke suddenly in the middle of the night, screaming from violent headache, and exclaiming that some person had given her a blow on the head. For the next two days she complained of some, but not much pain in her forehead, and did not even remain constantly in bed : no alarm was felt about her. On the third day she was seized with violent and long-continued convulsions, and immediately after the convulsions she fell into a state of deep coma: she remained in this state, with a natural pulse, till she died on the sixth day of the disease. When the dura mater had been removed, the other membranes appeared highly vascular, except where this appearance was concealed by a layer of yellow adventitious membrane, spread out betwixt the arachnoid and the pia mater. This was distributed in irregular patches over various parts of the surface of the brain, but was most abun- dant on the upper part of the right hemisphere. It was as thick as a wafer, and in some places dipped down between the convolutions. A considerable quantity of it extended over the surface of the cerebellum also. A child two years old was suddenly attacked one morning with severe and long- continued convulsions. The convulsions recurred many times; in the intervals she was dull and torpid, in a state of partial coma, with occasional starting, and a frequent and feeble pulse. On the fourth day she sank. The surface of the brain, when the dura mater was removed, was covered in many places, betwixt the arachnoid and pia mater, by an adventitious membrane. It was chiefly found above the openings between the convolutions, and in some places appeared to descend a little way between them. The arachnoid when detached seemed to be healthy; but the pia mater was in the highest state of vascularity throughout; and when the brain was cut vertically, the spaces between the convolu- tions were most strikingly marked by a bright line of vivid redness, produced by the inflamed membrane. There was no effusion into the ventricles, and no other morbid appearance. In another example, the whole surface of the brain was covered by a continued stratum of yellow false membrane, lying between the arachnoid and pia mater, and in some parts following the course of the pia mater through the whole depth of the con- volutions. The pia mater and arachnoid adhered together everywhere, very firmly, by means of it. Not a trace of it could be found either on the outer surface of the arachnoid, or the inner surface of the pia mater. The arachnoid itself, when separated, presented no unusual appearance, but the pia mater was everywhere excessively vascular. There was no serous effusion, and the brain and cerebellum were perfectly healthy. Now in this dissection there was unequivocal evidence of acute and extensive in- flammation of these membranes, or I should say of the pia mater; yet the symptoms had been very obscure. The child in whom the disease occurred was convalescent from a mild attack of scarlet fever. One evening he became very feverish, and com- plained of his belly. Three days afterwards he had frequent vomiting, followed by stupor, and some convulsive movements of his face and arms, and death took place four days and a half after the feverishness began. We learn from this case, that general and severe inflammation of the innermost membrane may exist, and prove fatal, without giving rise to any violent symptoms at all. I must trouble you with one more history, because it affords another example of what I have mentioned as being rare; viz., the effusion of the products of inflamma- tory action upon the outer surface of the arachnoid, — marking therefore very dis- tinctly the inflammation of that membrane. It was evidently combined, however, with inflammation of the pia mater also. A child, eight months old, died after more than three weeks' illness; which began with fever, restlessness, and quick breathing; afterwards there were frequent convulsive affections, with much oppression; and at LECT. XXIII.] ENCEPHALITIS. 263 last severe convulsions, squinting, and coma. At an early period of the complaint, a remarkable prominence of the anterior fontanelle was noticed; in the second week this increased considerably; and in the third week it was elevated into a distinct cir- cumscribed tumour, which was soft and fluctuating, and pressure upon it occasioned convulsions. It was opened by a small puncture, and discharged at first some puru- lent matter, and then bloody serum. No change took place in the symptoms, and the child died four days afterwards. A deposit of thick flocculent matter mixed with pus was found covering the surface of the brain to a considerable extent, and lying upon the free surface of the arachnoid. There was a similar deposition also between the arachnoid and the pia mater, and considerable effusion into the ventricles. If the sketches I have been giving you afford a true outline of the phenomena which attend acute inflammation of the pia mater, or of the pia mater and arachnoid jointly, what, you may naturally ask, is the nature of those cases in which there is high excitement, and much fever, and great delirium, and which are sometimes spoken of as phrenitis or as brain fever? Why these are instances of acute inflammation of the whole contents of the cranium; of the brain and its membranes; of the encephalon in short; and, therefore, the disease has been called, not improperly, encephalitis. Of this formidable malady I shall give you some account to-morrow. Fio. 23. Fig. 24. Fig. 23.— Subarachnoid effusion on the upper surface of the anterior lobe, causing an apparent obliteration of the interstices between the convolutions, and accompanied by increased vascularity. * Enlarged Pacchionian bodies. Fig. 24. — Portion of upper cerebral hemisphere of a young woman, aged 27, with purulent effusion under the arachnoid: there were two yellow symmetrical patches, one on each parietal surface, concealing the subjacent convolutions. LECTURE XXIII. Acute and general Inflammation of the Encephalon. Period of Excitement. Modes in which the disease may commence. Period of Collapse. Treatment. Delirium tremens. Acute inflammation does sometimes appear to invade at once the whole of the parts that are lodged within the skull; or, beginning in one part, it extends rapidly to all the rest. As the contents of the cranium are called, collectively, the encephalon, so the disorder which I am about to consider has been named encephalitis. It is an 264 DISEASES OF THE BRAIN. [lect. xxm. uncouth appellation, but it will serve its purpose. Cullen, and many others, apply the term phrenitis to the same disease. You may choose between these names, taking care to remember what they signify. The malady is sometimes described as inflam- mation of the membranes of the brain. I believe this to have arisen from the circumstance that the effects of the inflammation which become visible after death, are often more striking and obvious on the surface of the brain, or in its ventricles, than in the cerebral substance itself. An abscess in the nervous mass can scarcely be overlooked: a softening of the cerebral pulp may escape the notice of a hasty or an inexpert observer: and those changes of colour which sometimes denote increased vascularity of the same part, may very easily be passed over without attracting much attention. Phrenitis, or encephalitis, or acute and general inflammation of the brain and its membranes, as it occurs in adults, presents two periods which are marked by different symptoms, and in most instances are very distinctly observable. In the first period what are called symptoms of excitement predominate : the functions of the organ are exaggerated as well as disordered; in the second period those symptoms appear which are comprised under the term collapse. Sometimes these two sets of symptoms, instead of following each other, are more or less mixed and confounded together. But the distinction is real, and requires to be attended to. The symptoms that characterize the period of excitement, are pain of the head, often intense and deeply seated, or extending over a large part of it; a sense of con- striction across the forehead ; throbbing of the temporal arteries; flushing of the face; injection of the eyes, which have a wild and brilliant look; contraction of the pupils; preternatural sensibility to external impressions, amounting frequently to impatience of light, and of sound; violent delirium; want of sleep; paroxysms of general convulsion; a parched and dry skin; a frequent and hard pulse; a white tongue; thirst; nausea and vomiting; constipation of the bowels. You are not to look for all these symptoms in every case; nor to conclude that your patient has not inflammation of the brain because the phenomena which I have been enumerating do not all present themselves, or do not take place in any regular order of succession. In fact, we find, in actual practice, that encephalitis is apt to come on, to commence I mean, so far as symptoms are concerned, in three or four different ways. Sometimes there is a sudden alteration of manner, and the patient, complaining probably of his head, becomes all at once and furiously delirious; and fever is lighted up. These are symptoms which cannot pass unnoticed, and which immediately direct one's attention to the head. They may, however, he fallacious, as we shall see by-and-by. In other cases the first thing remarked is nausea or vomiting: and these symptoms may soon cease; or they may continue several days, and even sometimes throughout the whole course of the disease. Bitter fluids are brought up, yellow, or green, and evidently containing a good deal of bile: and whatever is introduced into the stomach, even a small quantity of the most simple drink, is immediately rejected. With this state of matters there is generally much constipation, and the bowels refuse to act except under the stimulus of strong purgatives. It is important to attend to these symptoms; for occurring, as they usually do, with headache, they may easily deceive a person who is not previously aware of what they may portend. If the patient have not been previously subject to sick head- aches, and if the epigastrium and abdomen be natural, not tender, nor distended, as they are apt to be when the stomach itself is in fault, and especially if the tongue be at the same time clean, we have the more reason to look narrowly into the case, and to suspect that some serious mischief, of which the nausea is a token, may be going on in the brain. I would observe, by the way, that where there is much vomiting of bile, persons are apt, both patients and their doctors, to blame the liver, to set down the disorder as bilious; but you ought to be aware, that whenever vomiting is often repeated, or long continued, bile is to be expected in the matters brought up. The action of the duodenum, as well as that of the stomach, is inverted; and the bile passes in the wrong direction. If you have ever suffered from sea-sickness, you must know that after the puking has gone on for a little while, bile is constantly voided. LECT. XXIII.] ENCEPHALITIS. 265 Again, some cases of acute inflammation of the brain set in neither with sudden and °reat disturbance of the intellectual functions, nor with sickness and vomiting, but with a paroxysm of general convulsion, such as often ushers in an attack of meningitis. This symptom, according to Andral, is a much more certain sign of cerebral inflammation, than the occurrence of active delirium : and I quite agree with him in so thinking. It is probable (but I speak conjecturally only) that this diversity of symptoms, marking the onset of encephalitis, may depend upon the part in which the inflamma- tion begins: which is soon propagated from that part to the whole of the organ. I should suppose that when nausea and vomiting are the earliest symptoms, the inflam- mation has taken its point of departure in the cerebral pulp; in the substance of the brain: and that when the attack comes on with a sudden fit of convulsion, the in- flammation has commenced in the pia mater or arachnoid. This is consonant with what we know of inflammation of those parts, when they are separately affected. Again, it seems to me presumable that the cases which are characterized by early and fierce delirium are cases in which the inflammatory action has invaded the super- ficial parts of the cerebral hemispheres, the grey portions of the convolutions. I say I offer these as conjectures of my own : what it is of importance for you to remember is, that inflammation of the brain does commence in the three several ways that 1 have been describing. There are some cases, however, that cannot be brought within even this general rule. They begin in some irregular or obscure manner, or with some unusual pheno- menon. Andral states that he has seen a few striking instances of inflammation of the brain, of which the first sign was a sudden loss of the power of speech : and Dr. Abercrombie relates a very remarkable case in which the same thing happened. I call it remarkable, both on account of the singular manner in which the disease first showed itself, and because it furnishes an example of encephalitis produced by direct exposure to intense heat of the sun — insolation; an event very uncommon in our climate. It occured in the practice of a surgeon at Selkirk, in Scotland : — "A young man, aged 16, bathed twice, on the 5th of June, 1818, in the river Tweed. After coming out the second time he lay down on the bank, and fell asleep without his hat, and with his head exposed to the direct beams of a hot sun. On awaking, he was speechless; but walked home, and seemed to be otherwise in good health. He was bled and purged, and the next day recovered his speech, but lost it again at intervals several times during the three or four following days. He was forgetful, and his look was dull and heavy : he made little complaint, but when closely questioned said he had a dull uneasiness at the back of his head. In a few days more he had squinting and double vision, and a very obstinate state of bowels, and his pulse was 60. After further bleeding the pulse rose to 86; but he sank gradually into coma, and died on the 30th." The substance of the brain in general was found highly vascular, and a very considerable extent of it was in a state of softening mixed with suppuration. The ventricles were distended with fluid, and the membranes in many places were much thickened. One very curious circumstance (affording perhaps some explanation of the readiness with which the inflammation was produced) was that the cranium was of very unequal thickness at its upper part. In one spot, as big as a sixpence, it was as thin as writing paper, and transparent. However, the phenomena which I mentioned at first constitute the common and ordinary symptoms of acute inflammation of the brain and its membranes. They continue for a variable period; from twelve hours to two days, or more; and then they are succeeded by others, which characterize the second stage of the complaint, or the period of collapse, as it is called. These result, I apprehend, from the events and products of the inflammatory action; the violence of which is over, or abated. The patient ceases to complain of headache; instead of being excited or wildly delirious, he mutters indistinctly, and falls into a state of stupor, from which it is difficult, and at length impossible, to rouse him. His vision and hearing are no longer painfully acute, but dull, or perverted; strabismus and double vision are not uncommon; and the pupil from being contracted to the size of a pin's head, becomes first oscillating, then widely dilated, and ultimately motionless. The patient is not shaken, at this period, with violent convulsions; but twitchings of his muscles, and 266 DISEASES OF THE BRAIN. [lect. xxiii. startings of their tendons come on, and some of his limbs are agitated with tremors, or become powerless and palsied; the countenance is ghastly and cadaverous; cold sweats break out; the sphincters relax: at length the coma becomes profound, and life ceases. The disease, when it proves fatal, as it too often does, mostly runs a rapid course. It may kill in as short a time as twenty-four or even twelve hours; or the patient may struggle on for two or three weeks. The morbid appearances met with in the dead body are very various. Serous or puriform effusion into the ventricles, or into the meshes of the pia mater; layers of coagulable lymph between that membrane and the arachnoid; softening of the cerebral substance, with pus infiltered into the softened parts; or great vascularity, shown by a pink or purplish mottling of its cut surface, giving it a stained appearance. Let us next consider the treatment required for this frightful disorder. It is quite plain that for an organ so essential to life, and of such delicate organiza- tion as the brain, wherein changes so irreparable in their nature as many of those I have just enumerated, so readily take place under acute inflammation, we cannot hope to be of much service unless we see and treat the case at an early period. On this account it becomes exceedingly important to recognise the nature of the disease, at its very commencement; and, therefore, I have taken pains to point out to you the various forms which it may assume, while it is yet within the reach of remedial measures. The principal of those measures are blood-letting, purging, and the application of cold to the head. All the particulars of the antiphlogistic regimen are to be rigidly observed; the patient should be kept as much as possible in silence, and in darkness, with his head high, and on a firm pillow. And the antiphlogistic remedies are to be employed with decision and energy. With respect to bleeding I can only repeat what I have said before: the blood should be drawn in a full stream, and suffered to flow till some decided impression is made upon the pulse; or until syncope occurs, or is evidently at hand. After the patient has rallied a little, blood should be taken by cupping or leeches from the back of the neck, or the temples, or the mastoid processes; and these depletory measures must be repeated according to the violence or continuance of the symptoms which first demanded them. The application of cold to the head is a remedy of great importance in this disease. The head must be first shaved : and the mere removal of the hair is sometimes fol- lowed by a manifest abatement of some of the most urgent symptoms; of the pain, for example, and of the delirium. In cases such as I am now supposing, it will not be enough to apply wetted cloths to the head: the application must be colder than the ordinary temperature of cold water; and it may be made colder by ice; and one way of effecting a permanent reduction of the superficial heat is to put some pounded ice with a little water into a thin and flexible bladder, and to lay it on the patient's head: there should not be too much ice, or its weight may be injurious. This is generally very grateful and pleasant to the feelings of the patient; and we often have the satisfaction of perceiving that, with the abatement of the external heat of the head, there is also an evident mitigation of the violent symptoms; the agitation and delirium are calmed, and the patient isleeps, or recovers his senses. Another excellent and most powerful method of applying cold, is by pouring cold water in a slender stream upon the vertex of the head, until it produces some marked effect. Of course this, as well as all other strong measures, must be adopted with great caution, and its influence closely watched : I mean it is not to be left to the dis- cretion, or indiscretion, of domestics and nurses. Dr. Abercrombie tells us that he has seen a strong man, submitted to the operation of this cold douche, " thrown in a very few minutes into a state approaching to asphyxia, who immediately before had been in the highest state of maniacal excitement, with morbid increase of strength, defeating every attempt of four or five men to restrain him." Of the effect of this measure in a somewhat different morbid condition, he gives an instance, which I will quote, because it shows, in the first place, the striking power of the remedy; and, secondly, the simple mode of applying it. A strong plethoric child, five years old, after being for one day feverish, oppressed, and restless, fell rather suddenly into a state of perfect coma. She had been in that state about an hour when Dr. Aber- LECT. XXIII.] ENCEPHALITIS. 267 crombie saw her. She lay stretched on her back motionless, and completely insen- sible ; her face flushed and, turgid. She was raised into a sitting posture, and, a basin being held under her chin, a stream of cold water was directed against the crown of her head. In a few minutes, or rather seconds, she was completely reco- vered ; and the next day was in her usual health. This measure also is to be repeated, or not, according to the circumstances of the case. Some persons recommend that a constant dripping of cold water upon the patient's shaven head should be kept up. This may easily enough be managed by means of a sponge and funnel placed a little above the head. Andral mentions his attending with another physician (M. Recamier) a young man who laboured under all the symp- toms of acute inflammation of the brain. Cold water was made to drop slowly upon his head, and complete recovery took place, although no other active treatment of any kind was adopted. This remedy, potent as it is, fails often of its purpose from the difficulty of ensuring its proper employment. The nurse sleeps; or, if awake, forgets or neglects the per- petual change and renewal of the wetted cloths: the bladder of ice is imperfectly adapted, or shifts its place as the restless patient moves his head : the dripping sponge wets the whole bed. To do the good of which it is capable — nay, not to do harm, by exciting reaction, when applied only at intervals — the cold must operate steadily, uniformly, and over a definite space. These objects seem to be attainable through an apparatus which has been devised by Dr. James Arnott, whereby cold (or, where it is wanted, heat) may be applied, with a suitable degree of pressure*, or with scarcely any pressure, to any part of the body, for any required time. " A current of water of the appropriate temperature is made to flow through a thin waterproof cushion or bladder, in close contact with the body. The water runs into the cushion from a fountain reservoir raised above it, through a long flexible tube; and again, escaping from the cushion, it passes through another tube into the waste vessel. The cushion is of a size and form adapted to the part of the body on which the water is to act; and by a particular contrivance any pressure from its weight may be prevented. The part in contact with the cushion is kept moist, either by previously wetting the cushion, or by interposing a piece of wet lint, flannel, or other bibulous substance." If this apparatus—which I have not yet seen in action—prove easy manageable, it promises to be of essential service in many a sick room. In strongly recommending this efficient remedy, cold, to your adoption, you will not understand me to advise that it should supersede the use of adequate blood- letting. It is to be employed as auxiliary to the lancet or the cupping-glass; not as a substitute for either. The third remedy which I named, that is to say, purging, is also of great import- ance and efficacy. But it must be hard purging. There is a great tendency to ob- stinate constipation in most cases; and this must be overcome, and free and frequent evacuations from the bowels obtained: five grains of calomel and fifteen of jalap should be followed in three or four hours by a strong black dose; and after that I should give, in such cases, three or four grains of calomel every four hours, and repeat the black dose at least every morning, until the symptoms gave way. If the mercury thus exhibited affect the gums, so much the better; but we must not, in this disease, combine it with opium, to prevent its passing off by the bowels. Dr. Abercrombie uses this strong language in reference to the value of purgative medicines in acute inflammation of the brain : — "In all the forms of the disease, active purging appears to be the remedy from which we find the most satisfactory results; and although blood-letting is never to be neglected in the earlier stages of the disease, my own experience is that more recoveries from head affections of the most alarming aspect take place under the use of very strong purging, than under any other mode of treatment. In most of these cases, indeed, full and repeated bleedino* had been previously employed, but without any apparent effect in arresting the symptoms." He has found the croton oil the most convenient medicine for this purpose. Dr. Abercrombie is disposed to regard mercury as being useful in affections of the brain, chiefly in virtue of its purgative operation; and the opinions of a physician of his large experience and observing mind, must and ought to have great weight. But 268 DISEASES OF THE BRAIN. [lect. xxiii. I must not conceal from you my own persuasion that, in the early periods of acute inflammation of the encephalon (and it is of the early periods that I have hitherto been speaking), if the mercury come in a short time to produce its specific influence upon the gums, a great change for the better will often be perceived. Such is the result of my own observation. Recollect, however, that you are not to give calomel with the direct object of affecting the gums, but as part of the purgative plan, and you take the chance of its specific effect. You must not combine opium with it, for two reasons; first, you would thereby shut up the bowels, and deprive yourself of the use of one of your best weapons: and, secondly, you would incur the risk of aug- menting and perplexing your patient's head-symptoms, and of puzzling yourself^ since you would not be able to determine how much of the coma that ensued was owing to the progress of the disease, how much to your remedy. When the second order of symptoms has arrived, those which are included under the general phrase of collapse, and which commonly result, I believe, rather from the products of the inflammation than from the inflammation itself; from softening, that is, and from pressure exerted by effused serum, or lymph •, when symptoms of this order make their appearance, the time for doing good by active bleeding has generally gone by. If, however, blood-letting have not yet been employed, and especially if the pulse continue hard, whether blood has been already abstracted or not, it will be right to give the patient the chance of that remedy. Of the propriety of doing so, take the following illustration : — "A girl, aged eleven, had violent headache and vomiting, with great obstinacy of the bowels : and these symptoms were followed by dilated pupils, and a degree of stupor bordering upon perfect coma; pulse 130. She had been ill five or six days; purgatives, blistering, and mercury to salivation, had been employed without benefit. One bleeding from the arm gave an immediate turn to this case, the headache was relieved, the pulse came down, the vomiting ceased, the bowels were freely acted upon by the medicines which they had formerly resisted, and in a few days she was quite well." — (Abercrombie.) I must recite one other case — from among many which go to the same effect — to show the occasional influ- ence of hard purging. "A young man who had had cough and dyspnoea, and been bled for these symptoms, appeared convalescent. One evening he became affected with headache, and some vomiting. About midnight, having got out of bed to go to stool, he fell down in a state of violent and general convulsion. The convulsion re- turned during the night six or seven times with such violence that one of the pa- roxysms continued without intermission for an hour. The pulse, during the night, varied from 60 to 120." (I should have mentioned before, this great and rapid fluc- tuation of the pulse in respect to its frequency, as being a very common circumstance and sign, in inflammatory affections of the brain.) " At first it was found impossible to bleed him, on account of the violence of the convulsions; but about seven in the morning a full bleeding was obtained, after which the convulsions ceased, except some slighter attacks during the day, which appeared to be arrested by pouring cold water over his head. The next day he was oppressed with occasional tremors of the limbs, and some vomiting, and he had one or two threatenings of convulsion. He took re- peated doses of active purgatives with little effect; and on the following morning he appeared to be sinking into a state of perfect coma, with a pulse at 50. Croton oil was now given, which operated powerfully seven or eight times. He passed a good night; and the day afterwards was free from complaint." Having this evidence of the separate efficacy of the three remedies — blood-letting, strong purgatives, and the local application of cold to the head — we have much en- couragement to put them into combined operation in these very serious cases, especially when we have the opportunity of using them at an early period. Should the disorder happily yield to these measures, great care will long be required on your part, and great prudence on the part of the patient and his friends, lest the recent mischief should rekindle. A relapse is even more perilous than the first assault of the disease. Such prudence and care will consist chiefly in the avoidance and denial of all that might excite and disturb the brain; whether it be a premature return to animal food; or indiscreet and fatiguing interviews and conversations; or the too early resumption of the cares and concerns of business. Are we to employ blisters in this disease ? Not in the outset, during the period of excitement. They only add to the irritation, and make matters worse. And espe- lect. xxiii.] ENCEPHALITIS. 269 cially you should avoid putting them, as many are apt to do, upon the head itself, at that stage of the disease. We should not suppose, d priori, that they could then, and in that place, have any beneficial effect. They cannot divert the blood from the inflamed part; but they may attract it towards the encephalon. If they could be expected to do any good at all, it would be when they are placed upon the feet or le«;s. But this kind of revulsion is better accomplished by means of mustard poultices, or fomentations with hot water, which are often of much apparent service, in addition to the measures already spoken of. Experience confirms what reason teaches us to look for in this matter. When, however, the patient had sunk into a state of coma, he has sometimes, in my experience, emerged from that condition after a cap of blistering plaster has been put upon his head. It is only when the violent symptoms of excitement have abated that I can venture to advise you to employ blisters : they may then be applied to the nape of the neck, or behind the ears, or to the head itself. The symptoms which I enumerated as marking the period of collapse or sinking, are fearful symptoms; but the conditions on which they depend are not, necessarily, hopeless conditions. These symptoms do not always proceed from fatal disorganiza- tion of the brain, but sometimes (there is reason to believe) from simple exhaustion of the nervous power. And this is a point of critical importance. Patients appa- rently moribund are occasionally saved by the judicious administration of stimulants and restoratives; of ammonia, Hoffman's anodyne, beef-tea, and, it may be, of well- timed opiates. This plan of treatment you must therefore cautiously try, when an extreme degree of collapse occurs. If the structure of the brain be already seriously injured, and the disease irretrievably mortal, no harm can be done; while in doubtful cases, and when the symptoms result from mere depression of the vital powers, the patient may be rescued : and this chance in his favour must not be thrown away. Do you ask whether there be any mode of discriminating these opposite conditions, one of which is within, and the other beyond, the range of possible recovery ? I believe there is. If the tendency to death by coma be strong, the prospect is very discouraging: if, on the other hand, the symptoms that mark the mode of dying by asthenia predominate, you may hope to push the patient through. But to succeed, you must watch him hour by hour. Pallor, a feeble and flying pulse, extreme debility and tremors, coldness of the extremities, a want of power to respond to external impressions; these are alarming, but not absolutely desperate symptoms, especially if the mental faculties remain. Whereas profound stupor, partial palsy, profuse sweats, are of the worst omen; yet even these do not preclude the trial, together with blistering the head, of internal stimuli; and no other plan affords even a gleam of hope. There is just one caution that I wish to mention before I leave the subject of acute encephalitis; and it applies to all cases of coma and insensibility, and especially when there is any paralysis mixed with the coma: it is, that you should daily ascertain that the bladder is emptied. Always make the attendants show you the urine that has been passed; and lay your hand upon the hypogastric region, and try whether there is any undue hardness and prominence there, produced by the distended bladder. I shall revert to this matter more particularly at some future time : and I content myself with merely suggesting its importance to you now, in all cases of head affection. If the patient cannot or do not empty his bladder, of course it must be emptied for him, by means of a catheter. It would seem perhaps the most natural arrangement if I next proceeded to speak of such cerebral inflammations as are chronic, or partial. These forms of disease are more common, in adults, than acute and general encephalitis. I shall be obliged also to treat, separately, of inflammation of the brain as it is modified by its occurrence in strumous children,—of what is called acute hydrocephalus. But before I touch upon any of these, I am desirous to bring under your notice at once a very singular and extremely interesting complaint, which is not, I am persuaded, in its essential nature, inflammatory, but which may easily be mistaken, and has over and over again been mistaken, for acute inflammation of the brain and its membranes, with the considera- tion of which we have just been occupied. The mistake is the more serious, because the remedies that I have been recommending for encephalitis, and especially blood- 270 DELIRIUM TREMENS. [lect. x x 111. letting, not only are not required, but are in most cases positively injurious, in the disorder of which I am now about to speak; and which is best known under the appellation of delirium tremens. Nay, this affection of the nervous system may actually be brought on, in a predisposed subject, by the abstraction of blood. I go apparently out of my way in taking notice of this complaint now, but I do so that I may have the opportunity of contrasting it with encephalitis, while the phenomena of the latter disease are fresh in your memory. It certainty resembles it also in many respects : and it has been regarded as an inflammatory disorder by some excellent pathologists. The symptoms which mark a decided attack of delirium tremens, and which have sometimes been found so equivocal, are very striking. You will be summoned to a man who is supposed to be mad, or to have brain fever. You find him with a red face, perhaps, and injected eyes, talking wildly and incessantly, fidgeting with his hands, affected often with tremors of the limbs, having a rapid pulse, and bathed in sweat. Now it is very natural that a person not on his guard should interpret these symptoms as indicating inflammation within the head. But if you look closely into the matter you will find in the state of the patient, and in his history, some things very peculiar. The delirium you will generally find to be, not a fierce or mischievous delirium, but a busy delirium : he does whatever you desire him to do, but he does it in a hurried manner, with a sort of unsuccessful anxiety to perform it properly. During the approach of the malady, while he is yet able to go about, he manifests great impatience of any interference, or advice, or assistance, in his ordinary duties, which he sets about in a bustling and blundering manner. His loquacity is extreme, and he refers to matters that are not present before him. He is not altogether in- attentive to the objects and proceedings that are going on around him, but his mind wanders away to other subjects. There is an odd mixture of the real and the ideal in his thoughts and language. Sometimes he is very suspicious that those who are about him intend him some injury; or he fancies that he is surrounded by enemies. You will find also that he does not sleep; that he has not slept perhaps for several nights, but has been restless and rambling: and you will generally learn that he has been habitually intemperate, or subject to some great source of care, or anxiety, or excitement: and in many cases he has recently been somehow or other debarred from his customary stimulus. In addition to these points in his history, you will frequently be told that having been unwell, first he has been kept upon low diet, and then, as the delirium came on, he has been freely bled; and that he has been none the better, but commonly the worse, for the bleeding. When you gather such particulars as these from his friends (for upon his own statements you cannot place any reliance), and when you find the delirium to have the characters I have been attempting to de- scribe, and especially when there has been obstinate watchfulness, and the tongue is moist, and the skin is sweating, you may be pretty certain that your patient is affected, not with inflammation of the brain, but with delirium tremens; and that if you bleed him further you will harm, instead of helping him. But what are you to do under such a fearful state of things ? Why the jrreat indi- cation is to procure sleep; and the remedy which, in nine instances out of ten, you will find successful, is opium. The beneficial effects of this drug, in tolerably favour- able cases of delirium tremens, are really surprising. I will give you an example or two, which will be more instructive than any abstract description. In the year 1831, I was requested by a most respectable practitioner in this town, to visit a patient of his whom he reported to have had phrenitis, for which he had been freely bled, cupped from the back of the neck, and purged ; and who, he be- lieved, was now rapidly sinking, and not likely to survive many hours. I found the patient, a middle-aged man, with a red face, ferrety eyes, a frequent pulse, bathed in perspiration, busy with his hands, which trembled a little, and talking much and in- coherently. He was particularly anxious that his legs should not be scarified, told me he was willing to do anything I pleased, if I wouid not scarify his lees, nor let any one else scarify them. There was nothing the matter with his legs, nor had it entered anybody's head but his own, that they wanted scarifying. He had not slept for several nights. He had been intemperate, especially of late, drinking a good deal; and somewhat anxious about his affairs : he was a builder. His former history was not very promising. He had brought up a good deal of LECT. XXIV.] DELIRIUM TREMENS. 271 blood a few months before, and some years previously he had had jaundice • latterly he had been troubled with indigestion. I saw him in the afternoon, and prescribed one-third of a grain of morphia : in the evening he was just in the same state. I then directed half a drachm of laudanum to be given immediately, and twenty drops every two hours afterwards, till he slept. I said to the gentleman who had called me to the case, that I thought it very likely our patient might be well the next day; he smiled, and shook his head. I was obliged to leave London early the next morning, for two or three days : on my return I learned from the medical man that the patient took five doses of the laudanum, after which he fell asleep, and slept soundly, and for a long time, and then awoke (to his attendant's extreme surprise and satisfaction) sane and well. I was asked by the apothecary of the Middlesex Hospital to see a publican in that neighbourhood. I found a large strong man between 30 and 40 years of age. He had been without sleep for several nights, somewhat incoherent, and (what is not usual in such cases) violent; threatening and striking those about him because they refused him access to strong drink. He was joint proprietor with another in a gin- shop, and for some time previously he had been a sot, and daily muddled with drink. He told me he was quite well. There was not much tremor. I found that the object of his partner and relations in sending for me was that I might sanction his removal to St. Luke's, for his strength made him altogether unmanageable, and his insane and extraordinary conduct was hurting the business of the house. I declined to take any part in consigning him to a mad-house, and recommended morphia. After one full dose he soon slept; and the next day he was quite rational, and com- paratively well. These are the broad outlines of delirium tremens: there are many other features wanted to complete the portrait of the disease; which I shall endeavour to paint at our next meeting. LECTURE XXIV. Delirium Tremens, concluded. Chronic Inflammation of the Brain. Softening, Suppuration, Abscess, Induration, Tumours in the Brain. I DREW a rude outline yesterday, of that strange and interesting malady usually denominated delirium tremens. The disease is very common in this country; for its causes are in common and powerful operation. You will meet with it in every walk of life: and you will be almost sure to witness several examples of it during the course of every year, in any of our metropolitan hospitals. It is not a chronic or vague complaint, likely to be treated with placebos, or by waiting upon nature. Active measures are pretty certain to be adopted; and, in many cases, one plan of treatment, vigorously pursued, will hurry the patient to his grave; another plan will restore him to health with an almost magical celerity. It certainly bears a strong resemblance to that most formidable disease, inflammation of the brain and its mem- branes : but the great remedy for encephalitis acts like a poison in pure delirium tremens; and the drug, by the timely and careful administration of which we can often promise a speedy cure in delirium tremens, is one which we must carefully avoid, in the earlier treatment at least, of encephalitis. Accuracy of diagnosis, therefore, between these different disorders with similar outward signals, becomes of the very highest importance. Delirium — tremens. — There is delirium always; and there is generally, but not always, tremor. The name is a good enough name, in my humble opinion; yet it has been found fault with, because the trembling is not in all cases present: and some have, therefore, christened it delirium e pofu, or delirium ebriositatis. But these terms are open to just the same objection as the other; for though the disorder 272 DELIRIUM TREMENS. [lect. xxiv. is most commonly connected with intemperate habits, that is not always the case. One very curious fault has been discovered in the name: it is said that the delirium cannot tremble; and, therefore, that it is better to say, delirium cum tremore, or tremefaciens: and you would hardly suppose it, but there has been a sort of conten- tion for the honour of thus mending the nomenclature of this disease. But they who object to delirium tremens appear to see no harm in delirium ferox: whereas it is just as incorrect to say delirium is fierce, as to say that it trembles : It is the patient who is furious, even as it is the patient who trembles; and all this dispute about a name is mere trifling. It matters not what we call a disease, so that the name conveys no erroneous theory as to its nature or treatment. No such source of error attaches itself to the term delirium tremens; and, therefore, if it be only to avoid the incon- venience of change, we will adhere to that term. Recollect that the strong features of the complaint are sleeplessness; a busy, but not angry or violent delirium; constant chattering; a trembling of the hands, and an eager and fidgety employment of them. To these are added other symptoms which, though they are not so calculated to strike a looker-on, are of not less import- ance, inasmuch as they help to establish the diagnosis. The tongue is moist and creamy; the pulse, though frequent, is soft; the skin is perspiring, and most com- monly the patient is drenched in sweat. The sweat is usually described as having an offensive or a peculiar smell: I cannot say that I have observed it to be so. The face also is said to be pale; but that, I know, is not always the case, and therefore this point cannot be relied upon as a distinguishing circumstance. In one of the instances which I related in the last lecture, the face was flushed, and the eyes red and ferrety. Let me remind you, in a few words, of the peculiar characters of the delirium. If you question the patient about his disease, he answers quite to the purpose; de- scribes, in an agitated manner, his feelings, puts out his tongue, and does whatever you bid him : but immediately afterwards he is wandering from the scene around him to some other that exists only in his imagination. Generally his thoughts appear to be distressful and anxious; he is giving orders that relate to his business to persons who are absent; or he is devising plans to escape from some imaginary enemy. He is haunted by ocular spectra; fancies that rats, mice, or other reptiles, are running over his bed; sees spiders crawling on the ceiling, or a horse's head thrust through the wall of his room. He addresses remarks to strangers, whom he erroneously believes to be present. He looks suspiciously behind the curtain, or under his pillow, and he is perpetually wanting to get out of bed; but he is readily induced to lie down again. It is very seldom that he meditates harm, either to himself or to others : there is rather a mixture of cowardice and dread with the delirium. All the points that I have been mentioning require to be investigated in every case of this nature: and an inquiry into the previous history of the patient, into what the French call the commemorative symptoms, is equally important. In a large majority of instances you will find that he has been an habitual drunkard; and very frequently that from some cause or other this habitual stimulus has been diminished or taken away. Some accidental illness has befallen him, and he has been restricted to low diet, and, as a sailor would say, " his grog has been stopped." When, with symp- toms such as I have described just now, you hear a history of this kind, you may be satisfied that the disease is not inflammation of the brain, but delirium tremens. I believe that habitual intoxication of anj* sort may lead to this disorder; but distilled spirits more surely than wine: wine more than beer. I make no doubt either, that what is alleged of the habitual use of opium, in preparing a person to suffer in the same way upon its being withheld, is quite true, although I have had but few oppor- tunities of noticing such cases. But the disease is not confined to drunkards, although it is so commonly connected with that pitiable vice, as to have been called mania d potu. You meet with it occa- sionally in men who have overstrained their nervous system by other modes of strong excitement. Long-continued mental anxiety, that state of mind in which gamblers and great speculators (who indeed are gamblers) are accustomed to live, may cause it; anything by which the mind is over-wrought. A well-informed medical man, of tem- perate habits, told me a few days ago that he was on the brink of delirium tremens in the year 1825. He had foolishly entangled himself in some of the speculations LECT. XXIV.] DELIRIUM TREMENS. 273 which prevailed here like an epidemic at that period, and his mind was on the tenter- hooks of suspense and apprehension for some time. He could not sleep, and he found himself "everlastingly chattering." It comes on in the course of certain diseases; as sometimes, for example, in apoplexy : and it is a very common result of bodily inju- ries and accidents, and of surgical operations: or, I should rather say, that it often follows such diseases and casualties; for it is, even then, the consequence of the treatment and regimen to which the patients are subjected, rather than of the surgical or medical complaint. And it is certainly more apt to occu*, under these circum- stances, in old people; and in those who, being younger, are known to have been intemperate. So frequently does the delirium manifest itself upon the cessation of the accustomed spur, that the continually recurring stimulus has been regarded as the predisposing, and the privation of that stimulus the exciting cause of the affection. Sometimes, however, it comes on in men who are perpetually fuddled, even although they have not intermitted their usual indulgence in drink. We had a porter (an old soldier he had been) at the Middlesex Hospital, who was of great use to us as a sub- ject to practise upon, and to show to the pupils. I never saw him so drunk as to be unable to perform his duty: but I cannot conscientiously say that I ever saw him sober. Every three or four months we were sure to have him in the wards with deli- rium tremens. Sometimes he fell into the hands of one physician, and sometimes of another; but in one of his attacks he slipped through our fingers. I am not certain that he was not nominally my patient on that last and fatal occasion : but assuredly he never exemplified the coming on of the disease from the adoption of more tempo- rate habits. We often find that the malady shows itself immediately after an unu- sually severe debauch, which has disturbed the stomach and bowels, and left behind it a proportional degree of exhaustion and languor. Without knowing why it should be so, my own experience would lead me to the belief that delirium tremens is very uncommon among women. The number of beds for females in the physicians' wards of the Middlesex Hospital is somewhat greater than for males. On the men's side of the house cases of delirium tremens are very frequent: whereas I scarcely remember any on the women's. Yet each sex is obnox- ious to its main causes. The gin-shops of this town are said to draw a fearful crowd of votaresses. And we might expect that the more sensitive character of the female constitution would render them especially liable to this peculiar consequence of the abuse of alcohol. My experience, however, is such as I tell you. On the other hand, Dr. Roots thinks he has seen quite as many instances of delirium tremens attacking females as males. The result of M. Rayer's observation is more in accordance with my own. Of 176 patients seen by him, seven only (not one in twenty-five) were women. A still smaller ratio is recorded by Bang, ten in 456: less than one in forty-five. The disorder appears to be more common in the summer than in the winter months. The peculiar nature of the complaint, and the proper method of treating it, were first brought into general notice in 1813 by a little work of Dr. Sutton's, of Green- wich. He saw a good deal of the diseases of the smugglers, and of the customers of the smugglers, who frequented the coast of Kent; and he was struck by the different event of this disorder in the hands of different practitioners, according as bleedings, or narcotics, were adopted. It is the same disease which Dr. Abercrombie speaks of as " a dangerous modification of meningitis, which shows only increased vascularity." Dr. Bright also includes it among his cases of "Arachnitis." Both these eminent physicians had learned, however, that the complaint requires a particular method of treatment. Of late years many essays and papers on the same malady have appeared in this country, in France, and in the United States, where the disorder is common. But even now it is not so well understood, throughout the profession, as it ought to be. I apprized you, in the last lecture, that the great remedy in delirium tremens is sleep ; and that our most powerful means of inducing sleep are to be found in opium. The opium must be given in full doses; and it must be fearlessly repeated if its desired effect do not soon follow. If the patients pass many nights without sleep, they will die. I have tried various forms of opium; and I am quite satisfied with morphia. Some persons, however, have not found it so successful as solid opium, or as the common tincture, laudanum. You may try the one or the other, or the one 18 274 DELIRIUM TREMENS. [lect. xxit after the other, if you please. No particular rules can be laid down that will suit all cases. After clearing out the bowels by a moderate purgative, you may give three grains of solid opium; and if the patient show no inclination to sleep after two or three hours have elapsed, you may begin to give one grain every hour till he does sleep. Or you may prescribe corresponding quantities of the acetate or muriate of morphia: or of laudanum : or of the black drop : or of Battley's sedative liquor. His room, meanwhile, should be kept dark and quiet. If he sleep for some time he will awake calmer and more sensible; perhaps perfectly so: and you must withhold the remedy, or continue it in smaller or less frequent doses, according to the circumstances of the case. Dupuytren found opiate enemata of great efficacy in the cases of traumatic delirium which came under his care. That mode of administering the narcotic may properly be adopted, if there be any impediment to its reception or retention by the stomach. Now sometimes this opiate treatment alone is quite enough : sometimes it is not. You will meet with patients who resist very large doses of the drug; but who pre- sently sleep, or become composed, if you give some of their accustomed stimulus with it: "a hair (as the vulgar saying goes) of the dog that bit them :" if you put their opiate dose into a glass of gin, or a pint of porter. Nervous exhaustion goes along with and augments the nervous irritability. In such patients we commonly find the aspect pale and haggard, and the pulse small and weak. The disorder tends, then, to death by asthenia. You may obtain some clue to the particular cases which re- quire this treatment, by examining into the previous condition of the digestive func- tions. If you learn that, notwithstanding the intemperate habits of the patient, his appetite for food has continued unimpaired, and his digestion sound, you will, I believe, generally find that good nourishing diet, strong broths, for example, and the opium, will suffice for the cure. But if the powers and natural sensations of the sto- mach have been injured and perverted, as is too often the fact, then a temporary recurrence to the habitual stimulus will frequently be necessary : and it is well to ascertain in such cases, what the stimulus has been, whether spirits, or beer, or wine, and to order it accordingly. Of course this is not to be continued after the patient has recovered from his delirium; but the stimulus under these circumstances must be cautiously withdrawn. When the stomach retains its power of digestion, the bad habit of drinking ought to be broken off at once : and if, after sleep, you can get the patient to eat a meal of beef-steaks, or of mutton-chops, it will always be right to advise it. In hospital practice it sometimes becomes necessary to confine the patient to his bed by straps, or to muffle his limbs in a strait-waistcoat: but this is a most unfor- tunate necessity. Physical coercion, whether manual or mechanical, should never be resorted to, in delirium tremens, when by any means it can be avoided. The angry feeling and mental fret which it produces, and the exhausting bodily struggles to escape or resist the thraldom, are always highly injurious, and full of danger to the patient. A couple of strong and good-tempered attendants will not have much diffi- culty in persuading and managing the sick man, who is seldom either boisterous or obstinate : and if he be intractable by soft words, he will yield more patiently to their gentle restraint than to the force of manacles; while the appearance of coercion need not be continued a moment after his acquiescence. There are some things which I find it necessary to mention, for the sake of dis- commending them. I know persons who in treating these cases always combine calomel with the opium. And they say that they cure their patients so; and I make no doubt that they do; neither can I doubt that the same success would generally have followed the same quantity of opium without the calomel. In pure cases of delirium tremens I advise you not to give calomel. I know no possible good it can answer : it is itself a source of great irritation to the nervous system in many persons: and if it come to affect the mouth, you inflict upon your patient a superfluous dis- comfort; and, I believe, in many cases, a downright injury. You will be told also of digitalis, as a specific remedy for the disease; or you may read of it: but do not be led away from the standard remedies which reason recommends, and large expe- rience has sanctioned. Knowing what we do of the power of opium generally, and of its efficacy in this complaint in particular, I should consider myself guilty of a criminal trifling with human life if I made experiments with digitalis, upon the loose LECT. XXIV.] DELIRIUM TREMENS. 275 reports of some one or two persons, of whose credit or information I knew nothing; and whose dicta had been transferred perhaps from some foreign journal to fill a vacant corner in one of our own. The combination of opium and antimony, which has been much praised by physicians of great judgment and experience, seems to me chiefly appropriate to certain modifications of the disease. I have drawn the line between encephalitis and delirium tremens with sufficient clearness, because I have taken well-marked forms of each. But I am obliged to add that there are mixed cases, which are very puzzling when they occur, and exceed- ingly difficult to treat; and which require opiates on the one hand, and moderate antiphlogistic measures on the other. When the indications are uncertain, or equivocal, we must carefully weigh the different symptoms, and we must cautiously try the remedies. The circumstances that most distinguish the one form of the disease from the other are to be found in the pulse; which is hard and resisting in the earlier stages of inflammation of the encephalon, soft and compressible in delirium tremens : in the tongue ; which is mostly parched and rough in the former, moist and creamy in the latter: in the skin ; which is hot and dry in the one case, covered with sweat in the other: in the countenance; which is flushed in inflammation, and mostly (though not always) pale in delirium tremens : in the tremors ; which are not common in the primary periods of inflammation of the brain : in the usual absence of headache in delirium tremens: and in the peculiar characters, which I need not recount, of the delirium in the two cases. If these symptoms contradict each other, as they sometimes will, you had better act on the worst supposition, and presume that there is inflammation, and employ antiphlogistic remedies : but you must not do so with a strong hand; you must use them cautiously, and watch their effects, and guide thereby your subsequent treatment. Take a small quantity of blood from the arm; observe whether it has the buffy coat; and note the condition of the patient afterwards. It is in these mixed or ambiguous cases that it will be proper to combine calomel or antimony with the opium. You will sometimes find a state resembling delirium tremens left after the subsidence of acute inflammation of the parts within the cranium, and requiring the treatment of delirium tremens. The points of distinction just enumerated are obvious to the senses, and easy to note. Another, and probably a surer criterion than any or all of them, has lately been brought to light in some highly interesting researches of Dr. Bence Jones'; but, unfortunately, it is not self-evident, nor readily elicited. I allude to the contrast which Dr. Jones has shown to exist between the two diseases, in respect to the amount of earthy and alkaline phosphates excreted with the urine. In the severest cases of delirium tremens there is a marked diminution of these phosphates—in acute inflammation of the brain a considerable increase. Taking the average from three examples of each disease, the difference was in the proportion of 1 to 12. The ex- tremes presented the extraordinary ratio of 1 to 223. Dr. Jones concludes that the " excess of phosphates may be regarded as resulting from inflammatory action going on in the brain, while the diminution of the same phosphates in delirium tremens must be considered as caused by the positive hinderance of that process of formation of phosphoric acid which in the healthy state is continually taking place." I do not know that there is much good to be expected from counter-irritation in this disease. But after the more decided symptoms were gone by, I have sometimes thought that the recovery has been accelerated by the application of a blister to the nape of the neck. Inflammation of the brain, and delirium tremens, are distinct diseases. Hence, in the mixed cases, of which I just now spoke, we may expect after death to find, and we often do find, unquestionable traces of inflammatory action within the skull. But pure delirium tremens frequently leaves behind it no morbid appearance whatever in the brain or its membranes. In other cases there is serous liquid collected in the interstices of the pia mater, or in the cerebral ventricles; and I have on several oc- casions seen the arachnoid thicker and less transparent than is natural, and sprinkled over with little spots or streaks of a milk-white colour. Changes of this kind we be- lieve to be owing to chronic inflammation of the membrane. But, even in these cases, I see no reason for thinking that the fatal disorder had any connexion with the morbid state of the arachnoid. We meet continually with like appearances when there has been no delirium tremens; and we have delirium tremens without any such 276 DELIRIUM TREMENS. [lect. XXIV. appearances. The habitual abuse of ardent spirits leads to chronic inflammation in various parts and tissues of the body: in the blood-vessels, in the liver, in the kid- neys, and in the arachnoid. We need not be surprised at finding that membrane thickened and partially opaque in the victims of delirium tremens; since they are chiefly men who have run a long course of intemperance. I believe that disease to bear the same relation, and no other, to the chronic arachnitis in such persons, as to the chronic hepatitis to which they are equally subject. There is but one morbid condition which, since my attention was first directed to it, I have found constant in persons dead of delirium tremens, and that is, a remarkably soft, pale, and flabby state of the muscular tissue of the heart. Mr. Solly tells us that <| in all the cases which he has had the opportunity of examining after death, he has invariably found the hemispherical ganglion, or cortical substance, (of the brain,) pale and bloodless." The chemist may be more likely to detect altered conditions in the brain, in these cases, than the anatomist. Dr. Percy has obtained alcohol from the brain of a person who died from excessive drinking; and from those of various animals which had been killed by that poison. These facts are interesting, but they do not help us much in our attempts to explain the phenomena of the disorder. Cases such as I related in the last lecture, where violent symptoms are calmed at once, and the patient is rescued in a few hours from great apparent peril, make a strong impression upon those who witness them : and the practitioner gains amazing credit, and is spoken of to all their acquaintances as a wonderfully clever man. It is unfortunate that we are obliged to set off, against this advantage, a corresponding danger, when the disease ends ill, of being blamed without our deserving it. When these patients die (and they usually persist in their evil habits and die at last in one of the attacks of the disease,) when they so die, they are apt to die much in the same way as patients who are poisoned by opium; and if their friends are aware that we have been giving large and repeated doses of that drug, they sometimes have the cha- rity to lay the death at our door; and you ought to be prepared for this : and I will conclude what I have to say upon the subject of delirium tremens by relating a case, in which I have no doubt that I suffered (though quite unjustly) under that kind of imputation. Several years ago I was asked, one morning, by a general practitioner at the west end of the town, to see a patient with him : of whom he gave me this account. The man was about forty years old. He had been attacked some days before with sore throat, common cynanche tonsillaris. The tonsils and fauces were so much swelled that his deglutition was greatly impeded, and for four or five days he had scarcely been able to swallow anything. The night before I saw him he had become delirious, and then had been largely bled, and he was worse in the morning. His bowels had also been very much purged. I found him propped up in his bed, with a coronet of leeches round his head. He was pale; there was no headache, nor affection of his breathing; his pulse was not very frequent, and it was quite soft and compressible. He was sweating profusely. He answered the few questions I put to him readily and pertinently, and then went talking on in a rambling manner about his business. He was a hackney-man or stable- keeper, in a large way. He said (I remember) that the boys were all ready to start, that there were two pair of horses going down the road, and that he must go and see after them; and much more on the same subject. His mind was busy about the execution of imaginary orders. He had not slept at all for some nights. Upon my inquiring into his previous condition, his wife told me that without any turn for dissipation he had for some time been an habitual hard-drinker; that he had frequent dealings with the coachmen to the various families which he furnished with horses; and that he was obliged to drink something with each of them; so that every day he had many glasses of spirits, and a good deal of porter. She told me also that his mind had been anxious and uneasy; that the business was a large and harassing one; that he had embarked a considerable sum of money in it; and that it had not turned out so prosperously as he had expected. Putting all these things together, there could be no doubt, either as to the charac- ter of the complaint, or as to the treatment proper to be adopted. Here was a man who had been living a life of continued mental and physical excitement. Suddenly the stimulus to which he had been accustomed was taken away; he could not swallow LECT. XXIV.] DELIRIUM TREMENS. 277 even such nourishment as his case required or admitted. Then came on delirium — a symptom not belonging to the disease in his throat — and protracted watchfulness. He is largely bled, and profusely purged, andhe gets worse instead of better under these remedies. At the same time his skin is moist and perspiring, and there is no harduess in his pulse. I recommended that the leeches should be removed from his head; that he should take immediately (for he could swallow now) two grains of opium, and afterwards twenty drops of laudanum every two or three hours till he fell asleep. Somewhat unluckily, his wife's brother — a very young man — was the apprentice or assistant of a surgeon in the neighbourhood of town, and he came in to see his relative. After hearing what I had said, he went home, and probably consulted his books, and then came back again with doubts whether the complaint really was deli- rium tremens after all. Whether in consequence of these doubts I cannot tell, but for some reason or other only one or two doses of the medicine were taken. I had offered to see the patient again in the evening, but his friends said they would send for me if he did not get better. They did not send. The patient did not sleep. At night, therefore, at ten o'clock, three grains of opium were administered. The result of this was, that he passed a quiet but a sleepless night. Perhaps (but I cannot be sure of that) if the opium had been persisted with, the case might have terminated otherwise. About eight o'clock the next morning I was summoned to him in a great hurry: when I got there he was dying, perfectly comatose, breathing stertorously, with blue lips and contracted pupils. He had appeared so much better at seven, that he was, for the first time, left alone for a quarter of an hour; and when they went back to him he was changed in the manner I have described. The general practitioner with whom I had first seen the patient — a very sensible man — was much concerned at this issue of the case, and observed to me that doubt- less our patient had been poisoned by the three grains of opium. I was able, how- ever, to relieve his mind from this notion: and I have mentioned the case chiefly for the sake of guarding you against similar misgivings, under similar circumstances. The manner of dying was just such as opium will produce; but, then, death by coma is also frequently the termination of delirium tremens. Effusion at length is apt to take place into the ventricles, or into the meshes of the pia mater, and stupor comes on, and the patient sinks. But in this instance I was certain that his death had no- thing to do with the opium he had taken, for this reason; that so long a space of time had elapsed — nine hours — between his taking the opium and the coming on of the comatose symptoms. Dr. Christison, in his elaborate and valuable work on Toxicology, states it as the result of extensive inquiry into this subject, that when opium has been swallowed in a poisonous dose, it almost always begins to act as a poison within an hour; that very rarely indeed has its specific operation been post- poned much beyond the hour, except occasionally, when the person taking it was in- toxicated at the time. In one remarkable instance a drunken man took two ounces of laudanum, and no material stupor followed for five hours. I guess that I incurred the reproach of recommending a fatal plan of treatment in the particular case I have now related; but I am quite satisfied that the opium was innocent of the patient's death, and I even think that his chance might have been much mended if the opiate, in smaller dose3 perhaps, had been steadily continued. We may be content to bear occasionally these unfounded imputations, when we consider the other side of the account, and call to mind the far greater number of instances in which spontaneous recoveries are credited to us as cures; and the Doctor, like Belinda's Betty, is " praised for labours not his own." [The account given by the author, of the character, phenomena, causes, and treat- ment of delirium tremens, is, upon the whole, so very judicious, that it would scarcely appear to demand any other comment, than one of general approval. But as there exists a very decided difference of opinion among American practitioners in regard to the proper management of the disease, a few words upon this point may not be improper. Four different plans of treatment have been recommended, and the results of their extensive employment for a series of years, have been adduced, by their respective advocates, in evidence of the superior efficacy of each. One practitioner cures all or 278 DELIRIUM TREMENS. [lect. xxiv. nearly all his cases by repeated emetics, another, by the free exhibition of alcoholic drinks, and a third, by opiates in free doses, continued at short intervals, until sleep is procured — while a fourth considers that, neither excitants proper nor opiates are necessary, but simply a state of tranquillity in a quiet and darkened chamber — with perhaps an emetic to unload the stomach in the commencement of the attack, and some gentle cathartic to keep the bowels open — and when the stomach will retain it, a light, nutritious, and easily digested diet. The opiate practice is the one, in favour of the superior efficacy of which we have the most imposing weight of evidence —and it is unquestionably the one that will, in the majority of cases, when judiciously and cautiously managed, the most promptly and effectually remove the symptoms of the disease. That the opiate practice has been abused, we are perfectly aware. Under the supposition that opium to any extent that may be requisite to induce speedy sleep can be administered in delirium tremens with perfect safety, we have cause to fear that a state of coma has in more than one instance been induced from which the patient has never awoke. We have never been in the habit of administering large doses of opium, and have usually combined each dose with an equal quantity of camphor, and about half a grain of ipecacuanha. In young, robust, and plethoric subjects, we believe that the applica- tion of cups to the temples and nape of the neck, or even a moderate bleeding from the arm, is an important measure in the commencement of the attack, which should not be lost sight of. That there are many cases of delirium tremens in which a perfect recovery may be effected without the administration of opium or of any stimulant is very certain—but our experience has taught us, that when the disease occurs in confirmed inebriates, with a broken-down constitution, and in whom there is almost complete destruction of the proper functions of the digestive organs, almost the only means by which it can be certainly and promptly arrested is opium administered in moderate doses at short intervals. The treatment of delirium tremens by alcoholic drinks, while we can have no doubt of its very general efficacy, — is attended with an evil of too serious a character, to permit us to give to it, under any circumstances, our sanction. It cannot fail, we are persuaded, to confirm the patient in his intemperate habits — and thus render him liable to a renewal of the disease after a short interval. That it is not the only suc- cessful treatment we are convinced from ample experience. In the practice of our preceptor as well as in our own, which has extended now far beyond a quarter of a century, we have had sufficient opportunities for testing the value of the opiate prac- tice in this disease, and have seldom been disappointed in its effects. We do not say that the patient will invariably recover under it. There are cases, in which, from the condition of the patient's system — the complication of the tremulent delirium with serious disease of the brain or other important organs, death is inevitable under any plan of treatment: we believe, however, that in the general run of cases, the success of a properly conducted opiate treatment will equal that of any other; while in the old, broken down drunkard, it, or the stimulant practice, is the only one upon which any dependence can be placed. Of the emetic treatment, as recommended by Dr. Klapp, we cannot, it is true, speak from experience; in the very few cases in which we have tried it, we were disappointed in its effects. On the subject of the proper treatment of delirium tremens, the reader may consult with profit Dunglison's Practice of Medicine, 2d edition, vol. ii., page 274, and the able note by Dr. Gerhard in Tweedie's Library, American Edition, vol. ii., page 237. —C] I should wish to put you next in possession of what has been ascertained in respect to partial and to chronic inflammation of the brain, as these are met with in adults; for I must speak of some head affections of children separately. But I really do not know how to bring this part of the subject before you in a practical manner. If I were first to describe symptoms, and then to state what organic changes had been discovered after death preceded by them, I should have to tell you of different symp- toms with the same morbid conditions, and of the same symptoms with different morbid conditions, in various individuals. I believe the best method, upon the whole, will be to describe the several morbid appearances which the brain is found to present; LEOT. XXIV.] RAMOLLISSEMENT. 279 and then to mention the symptoms that have most commonly been observed to occur in association with such morbid conditions. I must premise, however, that the whole subject is full of uncertainty and apparent irregularity. Doubtless, there is some constant and uniform connexion of cause and effect between the altered physical States of the brain, and the altered manifestation of its functions: but we have not yet been successful in our search after those settled relations, or we have but partial and imperfect glimpses of them. One very remarkable condition of the brain has been several times mentioned in these lectures; viz. softening—ramollissement. A great deal of attention has been paid to this condition of late years, both in France and in this country: and some points in its pathology have been fairly made out. I will bring them together as concisely as I can. In the first place, the softening varies greatly in degree, from the consist- ence which naturally belongs to the cerebral substance, to that of thin cream. In its minor degrees it may be easily overlooked; and is more perceptible by the touch than by the eye. The cerebral matter is less coherent, but it is not yet discontinuous or broken down. It may be washed away, however, by letting a slender stream of water fall upon it; and the softened parts are thus easily distinguishable from those which retain their natural consistence. In the next stage of softening we recognise the complaint at once, for the softened parts undergo a change of form by their own weight: parts that are prominent in the healthy state, as the optic thalami, corpora striata, and convolutions, sink down, as it were, and are more or less flattened. If you make a horizontal section through a part thus diseased, a portion of the softened brain adheres to the knife, and is removed by it, and a depression is left. In a still more advanced degree, the natural texture of the organ in the softened part is entirely destroyed and confused by the change, diffluent: you may pour the softened matter out. The colour of the softened portions varies also considerably. Sometimes they are unchanged in colour: sometimes they are quite white, and present a strong contrast with the tint of the neighbouring parts: sometimes they are marked with various shades of redness, from a rosy pink to an orange, or deep red, or even a mahogany brown. Often there are red spots mixed irregularly with the softened cerebral pulp, and giving it very much the appearance of a mixture of raspberries and cream. In other cases we find the softened mass of a pale yellow, or straw colour, infiltered, as it were, with purulent matter: and sometimes it is mixed with serous fluid. Now, it is well established that softening of the brain is a common result of two very different morbid conditions. It is often caused by inflammation of the softened part: it is still more often caused by what I may call its starvation; by the diminished supply of arterial blood, in consequence of diseased blood-vessels. Can we distinguish these two forms of softening from each other simply by their physical characters ? Sometimes we can : and sometimes, it must be confessed, we cannot. Softening of the brain is usually partial: but this will not help us, for the partd that are most liable to have their consistence diminished through an inflammatory process, are the very parts that are most liable to be softened from defect of nutrition. The most vascular parts of the brain, in short: the grey matter of the convolutions, and the grey matter of the thalami, and corpora striata. It is stated, however, that softening of the septum lucidum, and of the fornix, very frequently accompanies an accumulation of serous fluid in the lateral ventricles, and very rarely results from disease of the cerebral arteries. If there be pus mixed with the softened brain, we know that there has been pre- ceding inflammation. Again, if we find the arteries impervious, or unsound, we conclude that the softening has not been inflammatory. Sir R. Carswell states that obliterated arteries may occupy the softened cerebral substance, and often be seen ramifying through it; and that when this substance is removed by pouring water upon it, the solidified vessels retain their situation, and feel sometimes as hard as fine wires. But a much more common condition is that fatty degeneration of the capillary blood-vessels which I spoke of in a former lecture; and this may often be detected by examining, under the microscope, the softened piece of brain. We come to the same conclusion if, no microscope being at hand, we find the larger vessels, the caro- tid, vertebral, or basilar arteries, obstructed by atheromatous or ossific deposit; and a large portion of the brain unnaturally soft. 280 DISEASES OF THE BRAIN. [lect. xxiv. We have no certain test of the nature of the softening in its being red. The redness may be the result of inflammatory congestion: but cerebral haemorrhage may occasion softening; and, on the other hand, softening may give rise to cerebral haemorrhage. This may be said, however: that when the softening extends much beyond the redness, or the effused blood; or when the redness occupies several small portions only of the softened pulp; we may presume that the blood was extravasated subsequently to, and in consequence of, the softening. On the other hand, when redness and vascularity can be traced into the brain, some way beyond the softened part, we may regard the softening as the consequence of inflammation. And we adopt the same belief with still greater confidence, when around the softened and dis- organized pulp we find the cerebral substance hardened, and of a uniform reddish colour. In attempting to make the diagnosis between these two forms of softening, we get some assistance by noticing the age of the patient. Degeneration of the arterial tissue is almost peculiar to the advanced periods of life; whereas inflammatory soften- ing may occur at any age ; in children, in adults, or in old persons. There are other points also in the history and circumstances of the patient, by which our judgment may be aided, and which will be brought under your notice in a future lecture. When you find the softened substance infiltered with purulent matter, you may call the case one of suppuration of the brain. But suppuration also occurs in another form; viz., in the form of abscess. The pus is contained in a regular well- defined cavity, surrounded by cerebral matter, in a healthy or in a hardened state. Now in suppuration occurring in the brain, there is the same puzzling diversity of symptoms as in cases of simple softening. Still, in the main, there seems an approach to the same order of symptoms; convulsions in the earlier period constituting the most prominent feature of the disease; paralysis in the later. I will take one of Dr. Abercrombie's cases in illustration of the formation of encysted abscess in the brain. A girl, aged eleven, thin and delicate, after having complained for some days of headache, was seized on the 11th of January with convulsions, which continued about half an hour: paralysis of the right arm followed the attack of convulsion. She was bled from the arm, and purged, and cold was applied to her head; and she was much benefited by this treatment. On the 13th the headache was much abated, and she had recovered a considerable degree of motion of the arm. On the 15th the headache increased again, and the arm became more paralytic, and she was again bled: and on the 16th and 17th the power of moving the arm was greatly improved. On the 18th, after being affected with increase of headache, and some vomiting, she became convulsed, the convulsion being confined entirely to the head, and to the right arm; the head was drawn towards the right side, with a rolling movement of the^ eyes ; the arm was in constant and violent motion. She was sensible, and com- plained of headache. Being bled to eight ounces, the convulsion ceased instantly, and the headache was relieved; but the right arm remained in a state of complete paralysis. Her pulse, during the five following days, fell from 100 to 60; some headache continued; she had occasional vomiting; and the convulsive attacks re- turned several times; they were entirely confined to the right arm, which after the 23rd, was left in a state of permanent palsy. Hitherto no other parts of the body had been affected by the convulsion; but on the 24th it attacked the right thigh and leg, and left them powerless. The former remedies were repeated without any effect. The thigh and leg went through a course precisely similar to that described in regard to the arm, and on the 29th were permanently incapable of motion. She was now, therefore, paralytic of the whole right side; she had no return of convulsion, was perfectly sensible, and made little complaint. Gradually she became dull and oppressed, and at length fell into a state of perfect coma, and died on the 14th of February, a little more than a month after the commencement of her illness. In the upper part of the left hemisphere of the brain there were two distinctly defined abscesses, containing together from six to eight ounces of very foetid pus. They were lined by a firm white membrane; and a thin septum of firm white matter separated them from each other. The one was in the anterior part of the hemisphere, **ery near the surface; and the other immediately behind it. In the posterior part >f the right hemisphere there was a small abscess containing about half an ounce of lect. xxiv.] TUMOURS IN THE BRAIN. 281 pus. There was no serous effusion in any part of the brain, and no other morbid appearance. In this very interesting case it is worth remarking how the convulsion preceded the paralysis, and how the palsy was more than once diminished by antiphlogistic measures. It is reasonable to conclude — it can hardly be called a conjecture — that in such cases of partial disease of the brain as I have hitherto mentioned, the occurrence of convulsion or of rigidity, marks the inflammatory stage; and the supervention of per- manent paralysis denotes the period of softening or suppuration, of complete disor- ganization, that is, of the texture of the brain in that part. Partial inflammation of the brain, especially when it is chronic, sometimes produces a totally different change from any that have yet been described. Instead of be- coming softer, or being converted into pus, the inflamed part is indurated ; comes to resemble in consistence portions of the brain that have been for a short time immersed in weak nitric acid. In this state it is often unusually vascular and injected with blood. When the induration is greater in degree, the hardened part assumes the appearance of wax, or of boiled white of egg, or (as Andral says) of Gruyere cheese, and contains but little blood, but is, on the contrary, distinguished by its pearly whiteness. That these changes are the result of slow inflammatory action is the more probable, because they are sometimes found to exist around an old apoplectic clot or cell; the blood effused having acted as a cause of inflammation of the neighbouring part, just as any foreign substance might do. In the progress of cases in which par- tial induration is effected, convulsive movements are common, but paralysis does not appear to be so frequently present. The symptoms may go on for months, and often remit, and are again aggravated by paroxysms. These cases are the more interesting, because they offer a greater probability of cure than those that are attended with an opposite condition of the cerebral mass. Besides these varieties of inflammation, and their consequences, the brain is often infested with tumours, which also give rise to a great diversity of symptoms. There are fibrous tumours which grow rather around the nervous matter than within it, and are connected with the dura mater. They have been found at almost all parts of the surface of the brain; at its base, at its sides, and towards its summit. Scrofulous tumours are also not uncommon : these are imbedded in the nervous substance, and assume a round form, for the reason formerly mentioned, viz., because the tubercular matter that is separated from the blood is not cast into any particular mould (as it is when it is effused into the small bronchial tubes), but is poured forth into the homo- geneous pulp, which exerts an equal degree of pressure upon it on all sides. These scrofulous tumours of the brain are much more frequent in children than in adults; and they are more commonly met with in the cerebral hemispheres than in any other part of the brain, occupying the cortical and medullary substance indifferently. They differ from pulmonary tubercles in this respect, that they are seldom numerous in the same brain. Sometimes one only is found. They vary in magnitude from the size of a large pin's head to that of a hen's egg; and they are sometimes even bigger than that. The substance of the brain immediately surrounding these tumours may be unchanged, in which case it is probable that the tumours themselves give rise to no particular symptoms, the cerebral matter of the spots which they occupy having been gradually absorbed to make room for them; but at length important alterations take place in the neighbouring texture; congestions of blood, or softening, or suppuration; or pressure is exercised upon parts that are essential to sense or motion; and then the ordinary consequences of these changes declare themselves outwardly. Of minute tubercular deposits upon or beneath the membranes of the brain, in strumous children, I shall have much to say in the next lecture. Cancerous tumours occur also in the substance of the brain. They usually occupy a large portion of it before they extinguish life. Hydatids are sometimes found there. Now of the occurrence of these various local maladies of the brain it is necessary that you should be aware, for you may expect to meet with them frequently in prac- tice. And it is right that you should also be aware that they do not disclose their precise nature by any peculiar symptoms, or succession of symptoms. They all, sooner or later, disturb the functions of the organ in which they are situated; and 282 DISEASES OF THE BRAIN. [LECT. XXV. they may all disturb them exactly after the same fashion. We may judge, some- times, from other circumstances, that the disease is of this or of that character. If we see scrofulous or cancerous disease in other parts of the body, we infer that the symptoms which denote disease of the brain are caused by scrofulous or cancerous tumours there situated; but from the symptoms themselves, we can only learn that there is some morbid condition of the brain. I attended, with Dr. Latham, a youth, whose symptoms led us to believe that he had tubercular disease of the peritoneum; a very formidable complaint, which I shall more particularly describe hereafter. We thought it probable also, although there were no physical signs of pulmonary disease, that his lungs contained crude tubercles. After some time, he went down to the coast; and was there attacked with a fit of general convulsions. Up to that period he had shown no symptoms whatever in- dicative of organic disease within the head. On being apprized of this seizure, we expressed in a letter to the physician then attending him, our opinion that it had re- sulted from the presence of scrofulous tumours in the patient's brain. The convul- sions returned a few days afterwards with great violence, and he died. It was as we had conjectured. The peritoneum was found studded with innumerable miliary tubercles: there were a few crude tubercles, of some size, around the roots of the lungs; and two large masses of the same sort in the brain. Here, you see, we were directed to a correct special diagnosis of the cerebral disease, simply by the evidence which had satisfied us that scrofulous tubercles existed in other parts of the body. In the case of specific tumours there is really nothing to be done by way of cure. We must then treat the symptoms, and seek to alleviate them as they arise. When it appears likely, or not unlikely, that the cerebral symptoms may be the result of cerebral inflammation, we must give the patient the chance of being benefited by some of the remedies of inflammation : we must treat the case in this instance upon the most favourable supposition. The class of remedies from which most may be hoped in equivocal cases, are local bleeding, counter-irritation, and especially the cautious and regulated employment of mercury. I have stated to you before, that I have known several obscure but threatening symptoms of brain disease clear entirely away, when the gums were made sore by mercury, and kept slightly tender for some little time. It is possible that we may sometimes do our patients harm by this mer- curial treatment. We may, now and then, accelerate the arrival of death in persons whom nothing could save; but we must not be deterred from giving them this chance of being rescued from a disorder which may be susceptible of cure, but which, if unchecked, will be inevitably fatal. LECTURE XXV. Hypertrophy of the Brain:—Atrophy. Acute Hydrocephalus: its Anatomical Characters; its Scrofulous Nature; Premonitory Signs; different Modes of Attack ; Stages of the Disease ; Causes. There is a very curious morbid condition of the brain, to which I shall advert before I take up the consideration of certain cerebral diseases as they occur in children. The condition of which I am about to speak I was totally ignorant of till I had been for some years in practice. In the spring of 1833 I admitted a young woman, 19 years old, into the Middlesex Hospital. Her countenance was sallow, and her lips pale. She complained of pain in her chest and limbs; of great and increasing debility, and wasting; and of nightly perspirations. She had some cough, and a frequent pulse; and although no morbid sounds were audible in her lungs, I suspected that they might contain small or scattered tubercles. She had been in the hospital (Scarcely a week, when she had a violent fit of epilepsy; and after recovering from it, LECT. XXV.] HYPERTROPHY. 283 she told us, for the first time, that she was subject to such attacks. The convulsions recurred on the same day, and she became insensible, and remained so during the whole of the next day, and till the evening of the day after, when she died. During this period of insensibility she had many convulsive fits; the pupils were dilated, the pulse 100, small and feeble. Leeches were applied to the temples, a blister to the neck, and afterwards to the shaven head, and other measures were used, but in vain. When the surface of the brain was exposed by the removal of the skull-cap, and of the dura mater, it was observed that the convolutions were remarkably flattened, so that the little furrows between them were nearly effaced : and the surface of the arachnoid membrane was perfectly dry. These are not very unusual, though they are unnatural appearances. I had often seen such before : and I ventured to say that we should find some cause of strong pressure in the central part of the brain: effusion of serum into the ventricles, or a large extravasation of blood, or a growing tumour. Any such source of centrifugal pressure either prevents altogether the out- pouring of the natural sub-arachnoid moisture, or forces it away into the spinal canal. But to my great surprise, and much to the discredit of my prophecy, we found nothing of the kind. The ventricles were even smaller than natural, and contained scarcely any moisture. The skull-cap was afterwards examined, and the bone was found to be uncommonly thick, dense, and heavy; and its inner surface, without being rough, was very irregular. I regret that, in this examination, the state of the blood-vessels of the brain, and the consistence of the cerebral matter itself, were not particularly noticed. In the record made at the time by my clinical assistant, it is merely stated that the brain was otherwise healthy. There was no disease in the lungs. This dissection interested me much, for I had never seen, nor heard of, anything like it before. But upon looking into some modern authors, I discovered that the same phenomena had been noticed by several observers, who had very properly (as it seems to me) considered them as the result of hypertrophy of the brain. There is a very good memoir upon the subject, by M. Dance, published in the fifth volume of Breschet's Ripertoire d'Anatomie: and Andral gives an account of the disease in his Pathology. It appears that Morgagni had not overlooked it, for he speaks of instances in which the brain seemed too big for its bony enclosure. When, in these cases, the skull is sawn through, the upper loose portion of bone starts up, as if moved by a spring, and the edges of the bone remain widely apart. Laennec also, in Corvisart's Journal, states that upon opening the bodies of persons whom he had thought affected with hydrocephalus, he had been surprised at finding a very small quantity only of fluid in the ventricles, while the convolutions on the surface of the brain were strangely flattened; proving that the cerebral mass had undergone strong compression, which could only have arisen from its preternatural volume, and undue nutrition. Besides the characters I have mentioned, the hypertrophied and compressed brain is firmer and tougher than natural; it contains but little red blood; and sections of it are seen to be unusually dry and pale. In most of the cases of hypertrophy of the brain recorded by authors, the patients had suffered epileptic fits, or rather paroxysms of convulsion; and in some of them the convulsions terminated in paralysis. Andral states that the intellectual faculties have been observed, in some instances, to become dull and obtuse. Many of the patients were subject to severe headaches. All these symptoms are common to various cerebral complaints. The diagnosis of this rare disorder can be no better than con- jectural ; and its treatment we have still to seek. Andral remarks, what is very true, that hypertrophy of the brain, i. e., an unduo and disproportionate development of that organ, may, and does happen, without giving rise to any morbid phenomena at all. But, in such instances, the brain-case is equally enlarged in capacity; so that no pressure upon the cerebral mass results from its own preternatural growth. It is only when the brain increases faster than the bony sphere which contains it, that the hypertrophy becomes a disease. In my patient there was also, in one sense, hypertrophy of the skull; the bone was considerably thicker, and more compact and heavy, than is usual; but the capacity of the cavity had not undergone a proportional augmentation : nay, it might, for anything I know, be diminished in consequence of the increased thickness of the bone; the case may 284 DISEASES OF THE BRAIN. [lect. XXV. have been one of concentric hypertrophy of the bone, without any fault of the brain itself: but what makes this the less probable is, that in other cases the skull has been found of the ordinary thickness and density; but too small for its contents. It is of some importance for you to be aware that the brain, and its case, may be extravagantly developed without there being any disease, or any symptoms of disease. M. Scoutetten gives an instance of this which he observed in a child five years old. Its head was as large as that of a well-grown adult person. The skull was from a line and a half to two lines in thickness. The dura mater adhered firmly to the bone, and the cerebral mass exactly filled up the cranial cavity. The superior and posterior part of the brain was developed beyond measure, so that to reach the ventricles it was necessary to make an incision nearly three inches in depth. There was nothing unusual to be remarked in any of the cerebral functions of this child; it was just like other children of the same age in respect of intellect. It died of acute inflammation of the bowels. The late Dr. Sweatman met with just such another child a few years ago: and I refer to his description of it the rather, because cases that occur near home are always more interesting, and satisfactory, than those which we merely read of in foreign authors. Dr. Sweatman had never read of anything of the kind: but in August, 1834, a little boy, two years old, was brought to him on account of the size of his head. It had been gradually increasing from the age of six months, till it had become so large as by its weight to prevent the child from continuing long in the upright posture. The boy was active and lively, though thin. He never had had any fit or convulsion; but occasionally seemed uneasy, and then would relieve himself by laying his head upon a chair. He had never squinted, nor was he subject to drowsiness, or startings during sleep; and his pupils contracted naturally. His appetite was good, and all the animal functions were properly performed. Dr. Sweat- man got Mr. Mayo to see the child with him: they both set it down as a case of hydrocephalus, but agreed in thinking that in the absence of symptoms it would be wrong to risk disturbing his digestive organs by active medicines. In the early part of 1835 the child died of inflammation of the chest, and Dr. Sweatman and Mr. Mayo examined the head. I here show you a cast of it. It measured, from ear to ear, over the vertex, twelve inches; from the superciliary ridges to the occipital, thirteen inches; and in circumference twenty-one inches. The anterior fontanelle, which was quite flat, measured across its opposite angles two inches and a quarter by one and a half; the posterior fontanelle was completely closed, as was the frontal suture. There was no absorption of bone at any part; on the contrary it was becoming thicker. The dura mater adhered with great firmness to the skull; and a layer of false membrane, as big as a crown-piece, was found upon its upper and anterior part. Beneath the arachnoid at that part there was slight jelly-like effusion. In all other respects the organ was sound. The convolutions were perfectly distinct, and retained their proper rounded shape. All the ventricles were found empty, and not dilated. The surfaces, however, of the medullary matter, exposed by repeated sections, pre- sented very unusual vascularity. The lesson we learn from cases of this kind is, that we are not to regard every child thathas a very large head as a hydrocephalic child; and especially that we are not to inflict upon such a child a course of mercury, or other active remedies unless some morbid symptoms appear. The nimia cura Medici may in these, as in many other cases, destroy health; produce disease where none existed before. [The subject of Hypertrophy of the Brain would appear to demand a more extended notice than has been given to it in the text. There is reason to believe that the disease is of more frequent occurrence than is generally suspected, and that to it are to be ascribed many cases of convulsions, epileptic attacks, inflammation and softening of the brain, and even of idiocy, in which the connection has heretofore been entirely overlooked; we know that hypertrophy of the brain has, in more than one instance, been mistaken for chronic hydrocephalus, and that even the operation of tapping the brain has under such circumstances been proposed, nay, probably performed. Hypertrophy of the brain, or at least a condition of that organ predisposing it to undue and more or less rapid augmentation in bulk, is often congenital. Thus chil- dren are not unfrequently born with heads of dimensions far exceeding the usual LECT. XXV.] HYPERTROPHY. 285 standard—while, in other instances, the head soon after birth is found to augment rapidly in bulk, disproportionately to the growth of the rest of the body, and within a short period to attain an enormous magnitude. When the cranium is developed in the same ratio with the brain, at first no morbid symptoms are produced, or only slight ones. In almost every case, however, we have observed more or less apathy, dulness, and drowsiness, to accompany these cases of undue development of the brain, from a very early period. After, however, the disease has existed for some time, and particularly when there is a disproportion between the morbid development of the brain, and the expansion of the cranium, the patient becomes affected with apathy to external objects, a dispo- sition to somnolency — great irritability of temper, giddiness, habitual headache, attended with severe exacerbations at irregular intervals, and inordinate appetite. The intellect becomes more and more obtuse, verging occasionally upon complete idiocy. There is, usually, a debility of the muscles of the extremities, particularly of the inferior, which constantly increases, until, finally, complete paralysis results. The bowels are usually torpid, and the pulse remarkably slow. In many cases, the muscles are affected with convulsive twitchings, at first slight, and occurring at long irregular intervals, but gradually becoming more severe and frequent, until regular convulsive paroxysms ensue. The convulsions, not unfrequently, assume all the characteristics of epilepsy. In some cases there suddenly ensues a considerable reduction, and, occasionally, an entire abolition of sensibility. In other instances, the patient is suddenly attacked with acute delirium, quickly followed by complete coma and death. Mania was observed by Andral in one case. In the majority of cases that have fallen under our notice, the patients have been inclined to fat. The disease is divided by Andral into two stages : — 1st. The chronic, marked by few symptoms, or simply by slight obtuseness of intellect — more or less headache, either permanent or intermittent—vertigo, apathy, drowsiness, broken at irregular in- tervals by convulsive paroxysms. All of the foregoing symptoms may occur, simul- taneously or successively, in the same case, or only one or a part of them may be present. 2d. The acute stage, marked by sudden attacks of violent convulsions, idiocy, epileptic paroxysms, deep coma, or the ordinary symptoms of acute hydro- cephalus. The prognosis in cases of hypertrophy of the brain is not necessarily unfavourable. As Dr. Lees correctly remarks, the affection of the brain is rather an error of develop- ment than an actual disease, and the excess of nutrition will often cease, and the brain may even return to its normal state. Many patients who have laboured under cere- bral hypertrophy have entirely recovered, others will arrive at puberty, or even a more advanced age, with but little suffering or inconvenience, while others again die at an early age from the accidental occurrence of hyperaemia of the brain, convulsions, or meningeal inflammation. In some instances death occurs suddenly during an attack of convulsions — or, the patient becoming more and more comatose, death finally en- sues without a struggle. The chief danger arises from the very great susceptibility of the hypertrophied brain to disease, especially upon the occurrence of any acci- dental affection of one of the other organs, or of either of the affections incident to childhood. Upon dissection, the brain is found to be enlarged in size, the convolutions being flattened — the blood-vessels containing a diminished amount of blood, the cortical substance exhibiting in consequence a morbid paleness, with but little or no serum within the ventricles or beneath the membranes. The substance of the brain is in many cases increased in density. Sometimes, according to Sims, the hypertrophy is con- fined to one lobe, or to the corpora striata or thalami; in all cases, the hypertrophy is chiefly confined to the cerebrum, the cerebellum being seldom much, if at all affected. Instances occasionally occur in which the vessels of the brain are injected with blood; others where a slight amount of reddish serum is found at the base of the brain, — and others again with a clot of blood within the substance of the brain, and rupture of the fibres of its medullary portion; in all these cases, it will be found, upon an inquiry into their history, that death was preceded by symptoms of cerebral disease, in addition to those which properly belong to simple hypertrophy of the brain. 286 DISEASES OF THE BRAIN. [lect. XXV. It is important to distinguish the hypertrophied state of the brain from chronic hydrocephalus, to which, particularly in its advanced stages, its phenomena bear a strong resemblanee, so much so as to have caused the two to be not unfrequently con- founded. Drs. Lees and Muncmeyer point to a particular and very striking projec- tion of the parietal protuberances, in hypertrophy of the brain, as a valuable guide in our diagnosis, while Dr. Hennis Green suggests the difference in the sensation com- municated to the fingers when pressed upon the fontanelles in children affected with the two diseases, as a diagnostic sign. The sensation being that of a tense membrane filled with water in cases of hydrocephalus, and of a firm solid substance in cases of hypertrophy. Dr. Mauthner, in his work on Diseases of the Brain ( Vienna, 1844), lays down the following diagnosis between these two affections : — In hypertrophy, it is the posterior part of the skull which is first observed to become abnormally promi- nent, the projection of the forehead occurring subsequently; whereas, in chronic hydrocephalus, the enlargement of the forehead is one of its first results. The latter affection is usually associated with a general emaciated condition of the body; the former with a leucophlegmatic habit, and an increased deposition of fat. The consti- tutional symptoms likewise differ in the two affections — restlessness, convulsions, and sopor, mark the early stages of chronic hydrocephalus, while spasmodic affections of the respiratory organs are among the earliest indications of hypertrophy of the brain, but seldom occur until the advanced stage of hydrocephalus. (See Condie on Dis. eases of CIiildren} 4th edition.) — C] Having told you what I know of hypertrophy of the brain, it is proper that I should say a word or two respecting the opposite condition; of atrophy of the cerebral mass. There are two forms of this affection : one is congenital, and results from imperfect development, or from an arrest of development, of the brain in its foetal state. In the other the change appears to take place in consequence of disease, either in the mem- branes of the brain, or perhaps in its arteries; though the effect of disease in the arteries is usually softening, which is a species of atrophy. But in the atrophy to which I am now alluding, the volume of the atrophied part is diminished, not its consistence. And the diminution of size may extend only to a few convolutions: or it may be most manifest in the interior of the organ; in the optic thalami and cor- pora striata for example. There is still another alteration to which some have applied the term atrophy, though improperly, I think: I allude to those cases, which I shall speak of more particularly soon, in which the form and disposition of the cerebral substance is altered, the convolutions being unfolded, and the nervous matter spread out by a large collection of fluid in the interior cavities of the brain, constituting the disease called chronic-hydrocephalus. I have not much to say upon what may be styled atrophy proper of the brain: that it will give rise to symptoms we cannot doubt, but that it shows itself by any peculiar or characteristic symptoms is what I have not discovered. I shall content myself, on this subject, with showing you Cruveilhier's representa- tion of a strongly pronounced example of atrophy of the entire cerebrum on one side. The drawing from which this engraving was made, was painted from the body of a patient who died in the H6tel-Dieu, dropsical, in consequence of disease of the heart. He was forty-two years old. When you look at the engraving you will perceive that the left side of the cerebrum is diminutive compared with the right. It filled up, however', a larger space than it appears to do in the plate, for the lateral ventricle on that side was distended by a quantity of serous fluid, which ran out when the ventricle was punctured; and then the surface of that side of the brain sank down, and collapsed. Still the convolutions on that side, and all the dimensions, are re- markably less than on the other. The anterior lobe projects half an inch further on the right than on the left side. The frontal bone, you will observe, is much thicker; twice as thick on the atrophied as on the natural side; and the frontal sinus is very wide and open. The internal parts of the brain are all diminished in proportion. There was a large quantity of serous liquid filling and distending the subarachnoid areolar tissue. The nervous matter was whiter and harder on the atrophied side. One very curious thing is, that the left lobe of the cerebellum was the bigger of the two; but there was no such marked difference between them as between the two sides of the cerebrum. lect. xxv.] ACUTE HYDROCEPHALUS. 287 Now the patient in whom this singular disproportion between the two sides of his brain was met with, had been incompletely hemiplegic, as long as he could recollect, on the right side; and the imperfectly palsied limbs were shrunk and withered, and the fingers of the hand contracted. Yet he had managed to walk about with the help of a stick; and there was nothing remarkable, one way or the other, in the state of his intellectual faculties. The same condition has been seen on both sides of the brain : the organ itself existing in miniature as it were, and lying at the lower part of the vaulted cavity of the cranium : the intermediate space being filled up with water. This condition of the cerebrum is accompanied by idiotcy. In long-standing cases of this description you must not suppose that the nervous matter has been compressed into a smaller compass by the effused fluid; but that the fluid has been poured out to fill that part of the skull which is empty of brain, and which must be filled with something. I proceed in the next place to the consideration of that disease to which the name of acute hydrocephalus has been given. By that term I desire to signify inflamma- tion of the brain, as it frequently occurs in children, and especially in scrofulous children. The inflammatory character of the disorder, though not always very clearly expressed in its symptoms, is sufficiently attested, in many of the fatal cases, by the changes discovered within the cranium. I made some observations, in the last lecture, respecting the nomenclature of diseases, and said something in defence of the term delirium tremens. Now it must be confessed that the complaint we are about to consider was unfortunately named, when it was called hydrocephalus. I repeat that it matters not at all how we denomi- nate a disease, provided that its title does not involve any erroneous notion of its nature. I think hydrocephalus a bad name, because it reminds us of one circum- stance only of the malady, viz., the serous effusion, which so far from being the cause, or the essence, is only a frequent effect of the disease; nay, it is no uncommon effect of other morbid conditions also, besides inflammation. But hydrocephalus, or water in the head, is an appellation so established, both among ourselves and with the public, that I cannot venture to propose any change. In early life, simple encephalitis is not often seen; and when inflammation of the brain does befall a child of healthy frame and constitution, it resembles in its general course and features the same complaint, occurring in the adult patient. What we call acute hydrocephalus is always, I believe, associated with the scrofulous diathesis — always an instance of scrofulous disease. Allowing for diversities of structure and function, acute hydrocephalus, phthisis pulmonalis, and tabes mesenterica, may respectively be regarded as the ordinary results of the same morbid tendency, mani- festing itself in the three great cavities of the body, the cranium, the thorax, and the abdomen. If you have recourse to books for a knowledge of this disorder, you will meet with endless discussions, and most perplexing differences of opinion, respecting its true pathology, and its proper management. To check, or to verify, by individual obser- vation, the notions received from indiscriminate reading, requires peculiar opportu- nities, such as few enjoy save those who are largely engaged in the practice of mid- wifery, and familiar, as the natural consequence of that practice, with the diseases of children. By far the best exposition that I have seen of what is known upon the subject, is given by Dr. West, in his published "Lectures on the Diseases of Infancy and Childhood." Upon a careful selection of accredited facts from various writers who have preceded him, Dr. West has cast the clear light of his own well-used and large experience. In the first place, acute hydrocephalus is an inflammatory disease. We are led inevitably to this conclusion by its symptoms, which much resemble those that occur where undoubted inflammation has arisen from injuries of the head : by the appearances seen on dissection, which are always such as inflammation might have produced, as softening, and the effusion of serous fluid; and frequently such as nothing but inflammation could have produced, as suppuration, and the formation of adventitious membranes: and lastly, by the unequivocal relief afforded by blood- letting, and other evacuations, the blood drawn being also sometimes sizy. 2S8 DISEASES OF THE BRAIN. [lect. xxv. Let us take the least equivocal of these three kinds of evidence — the morbid ap- pearances presented after death. What are they ? In some cases we find traces of inflammation of the membranes of the brain; a firm attachment of the skull-cap to the dura mater; occasionally some adhesion of the opposite surfaces of the arachnoid to each other. Sometimes there is an effusion of serous fluid beneath the arachnoid, in the meshes of the pia-mater, and especially in the depressions between the convolutions. You would suppose, upon looking at this collected fluid through the arachnoid, that it had the consistence of jelly : but it is not so. If you divide the arachnoid by means of a sharp scalpel, a perfectly limpid fluid makes its escape. More commonly the arachnoid is drier than is natural, has a dull lack-lustre aspect, and feels sticky to the touch. Not unfrequently there are layers of coagulable lymph interspersed between the arachnoid and pia-mater: this is a most unquestionable evidence of foregone inflammation; and it is most often met with in the strongly marked cases. When portions of the cerebral mass are removed by slicing it, a great number of red points are frequently to be observed, speckling the cut surface. I mention this appearance just to say that, to the best of my belief, it does not warrant any conclusion in respect to the state of the brain before death. We find these red spots numerous in many cases, where there had been no cerebral affection manifested during life; and they are not always to be seen when we are cer- tain that there was inflammation. [The grey suostance of the convolutions, in cases in which the sub-arachnoid tissue is strongly injected, is usually of a pale rose, or bright red colour. The lining mem- brane of the ventricles is occasionally injected, opaque, or covered with a pseudo- membranous exudation, or with numerous white flocculi, which become very apparent when the membrane is immersed in water. It is often easily separated from the cerebral substance. The plexus choroides is very often injected, and thickened; sometimes, however, it is pale and discoloured, and lined with small hydatiform cysts; this latter appearance has, also, been found in the cellular texture of the pituitary gland. — C.] With respect to the nervous matter itself, it is said to be sometimes softer through- out than natural, and occasionally it has been found infiltered, as it were, with serous fluid; wet, and so rendered soft. Golis describes an instance of this kind, in which, he says, the fluid could be expressed from the cerebral substance as from a sponge. [In some cases the substance of the brain has been found of a firmer consistence than natural, and to a certain extent hypertrophied. A case is related by Gblis, in which, upon opening the skull, the whole brain expanded, so that it could not again be replaced within the cranium. The convolutions are sometimes flattened, apparently from pressure against the skull. —C.] A more common and characteristic change is softening of the central parts of the brain, with an effusion of serous fluid into the ventricles. Generally the effused fluid is thin and watery; serosity rather than serum. It contains less animal matter, per- haps, than any other animal production. Dr. Bostock found that of 100 parts, 986 consisted of water, 1 part of salt, and 0*4 only of animal matter. It is not, therefore, in common, coagulable by heat. The quantity effused is uncertain; speaking gene- rally, it varies from two to six ounces. In 38 out of 40 cases, in which death had taken place under the symptoms of acute hydrocephalus, Dr. West found an appreciable quantity of fluid in the ventricles; and in 34 of these cases the quantity was considerable, amounting to several ounces. [In many cases the amount of effused fluid is very trifling; in some scarcely a trace is to be discovered. The effusion may take place in the arachnoid or sub- arachnoid tissues, or in the ventricles, or in all these parts at the same time. The greatest amount is generally met with in the lateral ventricle—occasionally the quan- tity is so great as to enlarge the posterior cornea, elevate the fornix, rupture the sep- tum lucidum, and thus establish a free communication between all the ventricles. The cellular tissue of the choroid plexus may also be distended with serum. When LECT. XXV.] ACUTE HYDROCEPHALUS. 289 the serous effusion in the brain is considerable, it is often found also in the spinal canal. — C] The effused fluid is not always, however, clear and limpid: sometimes it is turbid, like whey, or even puriform, with flocculent shreds floating in it. These have been considered as flakes of coagulable lymph; but I question whether, in many cases, they are not mere fragments of the softened and broken down materials in the neigh- bourhood ; for the septum lucidum, the fornix, and other parts forming the walls of the ventricles, are very commonly found to be soft and pulpy, or entirely disorganized.1 The septum is perforated perhaps by a ragged irregular opening, the softened portion having fallen out: the fornix has lost its consistence, and often its figure, or falls asunder when the most gentle attempt is made to raise it. It was Dr. Abercrombie's opinion, not only that this softness is the result of inflammation, but that in very many cases of acute hydrocephalus, inflammation of these central white parts consti- tutes the essence of the disease. He relates two striking examples, in which this softened condition of the septum lucidum, fornix, and corpus callosum, without any effusion of serum, or any other morbid appearance, was found, after death, preceded by symptoms which are usually considered to indicate acute hydrocephalus. It has indeed been thought that the softening of these central parts may sometimes be the consequence of their maceration in the effused fluid. But this notion is dis- proved by the fact that the ventricles are often found full of fluid when there is no defect of consistence in the cerebral substance forming their walls. Among thirty- eight cases, carefully noted by Dr. West, there were thirteen in which no central softening existed, although the ventricles contained fluid in every case but one. He refers to the statements of a German, Herrich, who found central softening of the brain in forty-seven only out of seventy-one instances, in which the ventricles con- tained from three to eleven ounces of serum. Finally, M. Rokitansky has ascertained, by direct experiment, that slices of cerebral matter may be soaked, for hours, in serum, without undergoing any change of consistence. In most instances the membrane lining the ventricles exhibits distinct traces of inflammatory action; is seen to be vascular, opaque, even obviously thickened. [In the cells of the arachnoid membrane there is often deposited a concrete yel- lowish matter, either soft and inelastic, or somewhat firm, elastic, and of a shining appearance. It is deposited either in patches, or in lines bordering the blood-vessels; and, as is the case with all the indications of inflammation in this disease, it is more commonly met with at the base than at the summit of the brain. Granulations and miliary tubercles are often interspersed in its midst. The whole base of the brain is often covered with a continuous layer of the yellowish gelatinous deposit alluded to. This deposit differs from the matter effused in inflammation occurring in persons un- affected with tuberculous disease; the difference is thus traced by Barthez and Rilliet (Malad. des Enfants, torn. iii). The former is almost always solid, the latter almost always fluid; the former occurs more especially at the base of the brain, the latter upon its convex surface; the former is of limited extent, particularly when upon the surface of the hemispheres, the latter may spread over the greater portion of the surface of the brain; finally, the former is almost invariably found in the cells of the pia mater, while the latter occurs habitually in the great cavity of the arachnoid.—C] Dr. West gives an interesting account of the inflammatory changes presented by the superficial investing membranes. Upon the convexity of the brain these altera- tions are often comparatively slight; while at its base they are almost always con- spicuous. In thirty-four out of thirty-nine fatal cases he found the membranes of the base to be the seat of disease, more or less extensive, and always exceeding that which existed at the vertex. " The least considerable (he says) of the morbid changes in the membranes at the base (>f the brain consists in a milky or opaline condition of the arachnoid and pia mater, but chiefly of the former, sometimes extending over the whole lower surface of the cerebrum, but seldom being equally apparent in that part of the membrane which invests the cerebellum. But, besides this opacity, we usually observe much 1 [This is the opinion of Rilliet and Barthez.] 19 290 DISEASES OF THE BRAIN. [lect. xxv. more distinct evidence of inflammatory action in the effusion of yellow lymph beneath the arachnoid. This is generally found about the olfactory nerves, which are often completely imbedded in it; while a similar effusion extending across the longitudinal fissure unites the two hemispheres of the brain together. A deposit of the same kind likewise reaches up the fissure of Sylvius in many cases, and connects the ante- rior and middle lobes of the brain with each other; or if poured out in less abun- dance, it may be seen running up in narrow yellow lines by the side of the vessels as they pass from the base of the brain towards its convexity. It is in the neighbour- hood of the pons varolii, however, and about the optic nerves, that the most remark- able alterations are met with. The opacity of the arachnoid is here particularly evident, while the subjacent pia mater is opaque, much thickened, and often infiltrated with a peculiar semi-transparent gelatinous matter, sometimes of a dirty yellowish- green colour. This matter is sometimes so abundant as perfectly to conceal the third and fourth nerves, and at the same time to invest the optic nerves with a coating two or three lines in thickness; though, on its being dissected off, the substance of the nerves beneath appears quite healthy. When this morbid condition exists in a very considerable degree, it extends beyond the pons, and involves the membranes covering the medulla oblongata, especially at its anterior surface." Enough, I think, has been said, to convince you of the inflammatory character of this fearful malady. But, secondly, acute hydrocephalus is a tubercular disease. Occasionally, scrofulous tubercles, of considerable magnitude, are discovered in the substance of the brain ; and it is probable that these would have been more frequently met with, if they had always been carefully looked for. They consist of a cheesy kind of matter, like that of large tubercles in the lungs. Much more commonly the tubercular deposit manifests itself in the shape of small granules, scattered, many or few of them, upon or between the membranes of the brain. This fact has not hitherto received, in this country, that degree of notice which its great importance deserves. It has engaged the attention, for some years past, of several of the French physicians. The following clear summary is given by Dr. West of the result of their observations. " The conclusion to which we are led by their careful investigation of the subject is, that the peculiar granular appearance which various parts of the membranes of the brain often present in this disease, is not due to inflammation, as was once supposed, but is occasioned by the presence of minute tubercular deposits. These deposits often assume the form of minute flattened spherical bodies, of the size of a small pin's head, or smaller, and either of a yellowish colour, and rather friable under pressure, or greyish, semi-transparent, and resistant, almost exactly resembling the grey granu- lations which are sometimes seen in the lungs or pleurae of phthisical subjects. They are likewise sometimes met with in what would seem to be an earlier stage, when they appear like small opaque spots, of a dead white colour, much smaller than a pin s head, and communicating no perceptible roughness to the membrane. This appear- ance is often observed in the arachnoid covering the cerebellum, and those parts of the base of the brain where the arachnoid is stretched across from one portion of the organ to another. The flattened yellowish bodies are more frequently seen at the convexity of the brain, and on either side of the hemispheres. They generally follow the course of the vessels that ramify in the pia mater, and accordingly occupy the sulci between the convolutions much oftener than their summit. The firm grey bodies are mostly seen about the pons, or imbedded in the pia mater in the neigh- bourhood of the optic nerves, or projecting from the surface of the membranes that cover the medulla oblongata. They are also often deposited in the arachnoid lining the occipital bone, and are then sometimes collected in considerable numbers around the foramen magnum. These bodies, sometimes of a grey, at other times of a yellow colour, are likewise met with, though less frequently, in the substance of the velum interpositum, or imbedded in the choroid plexuses; and in both of these situations they are sometimes very abundant." " These bodies, however, do not always retain the appearance of distinct granules, but sometimes on separating two folds of the arachnoid, which had seemed to be glued together by an effusion of yellow lymph or concrete pus, we find that the matter which formed these adhesions is not homogeneous, but that it consists of an aggre- gation of minute granular bodies, connected together by the lymph or pus in which LECT. XXV.] ACUTE HYDROCEPHALUS. 291 they are imbedded? This appearance is often met with at the convexity of the brain, and close to the longitudinal fissure, and rather more towards its posterior than its anterior part; a strip of this yellow matter, half an inch long by two or three lines broad, con- necting together the two hemispheres of the brain, or the two surfaces of the arachnoid. Sometimes two or three deposits of this kind are observed at the convex surface of the brain, but they are generally more extensive at the base of the organ, where they occupy the longitudinal fissure and the fissure of Sylvius, and frequently connect opposite surfaces of the brain so closely together as to render their ,. • -Vi •.!.•• •, v Deposit of tubercular matter in the Sylvian separation impossible without injury to its sub- &ssJe of ^ brain of a chM> aged w J^^ Stance. ^ ^ wk0 ^e^ ^n l containing sixteen grains of iodide of potassium, and four grains of iodine to one ounce of water, given in the dose of a teaspoonful every four hours, at the same time that a weak ointment of the biniodide of mercury was rubbed upon the child's scalp. Dr. Woniger gave a solution of one drachm of iodide of potassium, dissolved in half an ounce of water, in the dose, at first, of forty, and subsequently of fifty drops every '■'"( two hours. In the case of Dr. Christie, the first indication of improvement occurred in thirty-six hours after the employment of the iodine was commenced with, but in Dr. Woniger's case, not until after the end of seventy-two hours. In both the reco- very is said to have been complete and permanent. — C.] Let me say a word in reference to the prevention of this disease : concerning which your advice will be sure to be asked again and again. In families, in which acute hydrocephalus has occurred, or which show decided marks of the scrofulous diathesis, the earliest attention should be paid to any deviation from the healthy condition of any of the functions. Weaned children in such families should be kept upon a nour- ishing but light and unstimulating diet; consisting of well-dressed vegetables, farina- ceous substances, and a moderate proportion of animal food. Particular care should be taken to keep the bowels regular; not that weakening purges should be given, but the bowels should be fairly relieved at least once every day. Any disturbance of the digestive organs should he immediately corrected; by antacids, laxatives, change of 'diet, and sometimes by mercurials, as the hydrargyrum cum crettt. Such children should also, if possible, be brought up in the country, and freely exposed to mild and dry air; and in winter great care should be taken to have them sufficiently clothed. Exposure to the contagion of small-pox, measles, scarlet fever, or hooping cough, should be scrupulously guarded against. During the hazardous period of dentition, the state of the teeth and gums must be sedulously watched. There is good reason for believing that a seton or an issue in the neck or arm has been very serviceable in warding off and preventing attacks of the disease. Dr. Cheyne mentions some striking instances of the good effect of establishing an artificial irritation at some dis- tance from the brain, when there has been a disposition to disease in that organ. There is another caution, too, which you will often find reason for suggesting: and that is, not to press or encourage the development of the mental faculties in children lect. xxvi.] SPURIOUS HYDROCEPHALUS. 303 who are quick and intelligent beyond their years. Parents are apt to be proud of the early acquirements of their little ones: they are not aware that such precocity of the mind implies danger to the health of the body; and they provide them with instruc- tors, and to a certain extent abridge their hours of exercise and amusement, that they may do justice to their cleverness. But it is our duty to admonish such parents of the risk they are thus running: to advise them to think only, for the present, of corroborating the corporal strength of the child; and to avoid over-cultivation of his intellect until this dangerous period of his existence is got over. There is still one point remaining, and one of the utmost importance, in relation to the acute hydrocephalus of children. I told you in the last lecture, that in general the diagnosis was not very difficult. But there is a form of disorder very apt to be mistaken and treated for acute hydrocephalus, by those who are not forwarned; and one which may be rendered fatal, if the remedies of acute hydrocephalus be directed against it. Encephalitis, whether it occur in the child or in the adult, has its spurious double. As, in morals, every virtue has its corresponding vice, which apes its actions and assumes its garb, so it is also with many opposite bodily disorders : and it is of great moment that we should be capable of discerning the essential difference of character that lurks beneath external similarity of feature. It is a most curious, but unquestionable fact, that anaemia of the brain, a diminution of its natural supply of red blood, and exhaustion of the nervous power, will produce symptoms very much resembling those which result from the diametrically opposite condition. To excess of pressure on the one hand, and to defect of pressure or support on the other, there are many phenomena in common. If you pay no regard to the state of the general circulation, as indicated by the temperature and by the pulse, you will find the actual symptoms of syncope, and of apoplectic fulness, to be identically the same. When a human being bleeds to death,—as many do from wounds, from uterine haemorrhage, and so on,—what do we see ? Why the patients may have nervous delirium, become convulsed, and then insensible, with a wide and fixed pupil. The outward visible signs of concussion and of compression of the brain are very much alike. The vulgar always confound them, and are clamorous that a vein should be opened: a measure which would be proper and useful in the one case, but murderous in the other. It is the same with the functions of other parts : we have palpitation of the heart when that organ is insufficiently supplied with blood; palpitation when it is over-loaded : dyspnoea, or hurried breathing, when the lungs are congested; hurried breathing, when blood does not arrive in them plentifully enough. You must see that the importance of distinguishing between the causes of these analogous pheno- mena is immense. Several -authors in modern times have noticed the condition of the brain to which I now wish you to attend, and which may be called spurious hy- drocephalus. Dr. Marshall Hall, Dr. Abercrombie, and the late Dr. Gooch, — each of these three physicians appears to have discriminated, for himself, the spurious from the genuine disease; but their several accounts of it were made public in the order of time in which I have here mentioned their names. Dr. Gooch's Essay is entitled—" Of some Symptoms in Children erroneously attributed to Congestion of the Brain." His description of the disorder in question is very graphic. It is chiefly indicated, he says, by heaviness of the head, and drowsiness. The age of the little patients whom he had seen so affected was from a few months to two or three years; they were generally small of their age, and of delicate health, or had been exposed to debilitating causes. The physician finds the child lying on its nurse's lap, unable or unwilling to raise its head: half asleep; one moment opening its eyes, and the next closing them again, with a remarkable expression of languor. The tongue is slightly white, the skin is not hot; at times the nurse remarks that it is colder than natural; in some instances there is now and then a slight and transient flush. In all the cases that Dr. Gooch saw, the bowels had been already disturbed by purgatives; the symptoms had invariably been attributed to congestion of the brain; and the remedies employed had been leeches and cold lotions to the head, and purgatives—especially calomel. Under this treatment the patients had gradually got worse, the languor had increased, the pulse become quicker and weaker, and at the end of a certain number of days the children had died. In two instances he had known coma to come on during the last few hours; stertorous breathing, and dilated and motionless pupils. 304 DISEASES OF THE BRAIN. [lect. xxvi. Dr. Hall describes a very similar set of symptoms : the face pale, the cheeks cool or cold, the eyelids half closed, the eyes unattracted by any object put before them, the pupils unmoved on the approach of light, the breathing irregular and suspirious, the voice husky. These symptoms are sometimes preceded by irritability, and a feeble attempt at reaction; in which case the diagnosis requires extreme care and circum- spection. He attributes the disorder, which he calls the " hydrocephaloid disease," principally to exhaustion. In early infancy the exhaustion owes its origin chiefly to diarrhoea, or catharsis; in the later periods of infancy, to the loss of blood, with or without a relaxed condition of the bowels. The diarrhoea is often produced by im- proper food, and frequently succeeds weaning; or it results from the ill-timed admin- istration of purgative medicine. The exhaustion from loss of blood generally follows the application of leeches, for some previous complaint—or for this very complaint itself, when incipient, and misunderstood. I will take one of Dr. Gooch's cases in illustration, and give it you in his own words. " I was going out of town (he says) one afternoon, when a gentleman drove up to my door in a coach, and entreated me to go and see his child, which he said had something the matter with its head, and that the medical attendant of the family was in the house, and was just going to apply leeches. I went with him immediately, and when I entered the nursery I found a child ten months old, lying in its nurse's lap, exactly in the state which I have already described; the same unwillingness to hold its head up, the same drowsiness, languor, absence of heat and all symptoms of fever. The child was not small of its age, and had not been weak; but it had been weaned about two months, since which it had never thriven. The leeches had not been put on. I took the medical gentleman into another room, related the foregoing case (i. e., a case in which a child had been leeched out of its life), and several simi- lar to it, which had been treated in the same way, and had died in the same way. Then I related to him a similar case which I had seen in the neighbouring square, which had been treated with ammonia and decoction of bark, and good diet, and which had recovered; not slowly, so as to make it doubtful whether the treatment was the cause of the recovery, but so speedily that at a third visit I took my leave. He consented to postpone the leeches, and to pursue the plan which I recommended. We directed the gruel diet to be left off, and no other to be given than ass's milk, of which the child was to take at least a pint and a half, and at most a quart, in the twenty-four hours. Its medicine was ten minims of the aromatic spirit of ammonia in a small draught every four hours. When we met the next day the appearance of the child proved that our measures had been right; the nurse was walking about the nursery with it upright in her arms. It looked happy and laughing. The same plan was continued another day; the next day it was so well that I took my leave, merely directing the ammonia to be given at longer intervals, and thus gradually withdrawn; the ass's milk to be continued, which kept the bowels sufficiently open without aperient medicine." This case contains both a picture of the morbid state, and a summary account of the treatment it requires. Instead of the sal volatile, you may occasion- ally substitute with advantage from five to ten drops of brandy mixed with arrowroot. You are to restrain diarrhoea, if it exist; give the child plain nourishing diet — there is none so good for it as that furnished from a healthy mother's breast; caution the nurse or mother against raising it into the upright position; keep its extremities warm with flannel; and, if the season permit, let a current of mild fresh air blow freely over it. Bear in mind, then, the distinctive characters of this spurious hydrocephalus — the pale, cool cheek; the half-shut, regardless eye; the insensible pupil; the inter- rupted, sighing respiration : and when the mere symptoms are more ambiguous, your judgment concerning the true nature of the case will be much aided by tracing the manner in which they came on, and the causes to which they seem to be attributable. In very young children — in respect to whom the question is most likely to arise — you may often determine between congestion and exhaustion, between fulness and emptiness, between too much and too little pressure, by a very simple and easy test, which is not adverted to, so far as I remember, by any of the three writers whom I have mentioned. I mean by taking notice of the state of the unclosed fontanelle. If the symptoms proceed from plethora, or inflammation, or an approach to inflamma- tion, you will find the surface of the fontanelle convex and prominent, and you may lect. xxvi.] CHRONIC HYDROCEPHALUS. 305 safely employ, and expect benefit from, depletion. If, on the other hand, the symp- toms originate in emptiness and want of support, the surface of the fontanelle will be concave and depressed; and in that case leeches, or other evacuants, will do harm, and you must prescribe better diet, ammonia, and so forth. All that has hitherto been said has reference to acute hydrocephalus, which is an inflammation. I have next to speak of chronic hydrocephalus, which is a dropsy. From some cause, not well understood, a watery fluid collects within the skull, most commonly in the ventricles of the brain; and this occurring at the earlier periods of life, before the whole of the brain-case has become solid, the containing parts yield to the increasing pressure, and the size of the head is augmented in various degrees; at the same time the cerebral functions are more or less deranged. This dropsy of the cranial cavity often commences before the period of intra-uterine life is completed, and the head of the foetus becomes so large that it cannot pass with safety into the world. Accordingly, many of these infants perish at the moment when their separate existence commences : — nascentes moriuntur. The pressure of the maternal pelvis is fatal to them; or the diseased head bursts; or it is crushed by the accoucheur, to preserve the life of the mother. The skull is emptied of its contents, and the shell, if I may so call it, collapsing, passes through the natural outlets. In many cases, however, the dropsical skull is expelled entire and unhurt, and the infant lives for a shorter or a longer period. Sometimes the fluid does not begin to accumulate till after birth: in a few days, however, or after some weeks, or some months even, the head is perceived to enlarge with a rapidity quite disproportioned to the growth of the other parts of the body; and enlarging, it becomes misshapen also. The intervention of the membranous partitions called fontanelles and open sutures, between the ununited bones, allows the centrifugal pressure of the gradually accumulating water to modify the shape of the head. These membranous interspaces are unnaturally wide, and more numerous than in healthy children. Nevertheless the process of ossification goes on, but the bones are extremely thin. We see little islands of bone in seas (as it were) of membrane. By degrees, if the child survive, the pro- portion of membrane to bone becomes less and less, and at length the whole brain- case is hard, and firmly closed up, its surface exhibiting an unusual number of join- ings ; there are many ossa triquetra. In the meantime the direction and relations of the loose and yielding bones are altered. The os frontis is tilted forwards, so that the forehead, instead of receding a little, rises perpendicularly, or even juts out at its upper part, and overhangs the brow. The orbitar plates of this bone are apt to be forced downwards, made to slant back- wards, and flattened; sometimes they are rendered even convex towards the orbits. The parietal bones bulge above towards the sides; the occiput is pushed back; and the head becomes long, broad, and deep, but flattened on the top. This, at least, is the most ordinary result. In some instances, however, the skull rises up in a conical form, like a sugar-loaf. Not unfrequently the whole head is irregularly deformed, the two sides being unsymmetrical. Some of these rarer varieties of form are fixed and connate; others are owing, probably, to the kind of external pressure to which the head has been subjected. While the skull may be rapidly enlarging, the bones of the face grow no faster than usual, perhaps not even so fast; and the disproportion that results gives an odd and peculiar physiognomy to the unhappy beings who are the subjects of this calamity. They have not the usual round or oval face of childhood. The forehead is broad, and the outline of the features tapers towards the chin. The visage is triangular. This great disproportion of size between the head and the face is diagnostic of the disease, and would serve to distinguish the skull of a hydrocephalic child from that of a giant. Heartless parents sometimes make a wretched profit of the deformity. A penny show of this kind existed very recently in the immediate vicinity of this College. When, after death, we explore the physical causes of these singular deviations from the natural figure and bulk of the cranium, we find that they proceed from the pressure of accumulated water: the complaint is manifestly a dropsy. But the situation of the water, and the condition of the brain itself, are subject to some curious varieties. 20 306 DISEASES OF THE BRAIN. [lect. XXVI. A hydrocephalic skull from a girl aged 11 years : the enlargement of the skull is effected by its elongation, and by the depression and hollow- ing of its base. An increase of width appears to have been prevented by the premature and com- plete closure of the sagittal suture. The coronal suture, and that between the frontal and parietal bones and the suture, also, of the sphenoid, are wide open. The superior walls of the orbits are pressed downwards. The bones generally are thin and light. St. Bartholomew's Museum. In a certain number of cases the brain is incompletely formed ; deficient in some of its parts, or even altogether wanting. That portion of the cranial cavity which should contain the nervous pulp is filled up by a thin pellucid fluid. From some unknown cause, operating during the period of intra- uterine life, the progressive formation of the brain has been arrested. Marks of imperfect development are often visible in other parts of the same infants; they have a hare-lip, a bifid spine, or a fissured palate. It is in cases of this kind generally that the skull, unnaturally small perhaps, is pinched up into a conical peak, and has considerable thickness. They are obviously hopeless cases. To the physiologist they are subjects of much interest; for the prac- tical physician they have none. But in the majority of instances, when the infants survive their birth, the liquid is contained in the central cavities or ven- tricles of the brain, which are expanded into one. The convolutions are unfolded, and the cerebral matter is spread out into a hollow sphere; the irregularities of the sur- face have disappeared; the whole of the brain is smoothly extended in a thin layer, immediately beneath the bones and the membranes that connect them, and surrounds the enclosed liquid like a bag. Less frequently a different state of matters is seen. The liquid, instead of being included within the cerebral substance, lies in the cavity of the arachnoid, close to the dura mater; while the brain, perfect in all its essential parts, is at the bottom of the cavity. The difference, however, is more apparent than real: the two conditions are substan- tially the same, only that, in the one case, the solid parts that lie around the ventricles gradually expand as the fluid slowly collects, much as an air-balloon dilates in propor- tion as gas is introduced within it; while in the other case the seams or commissures (as they are technically called), that unite the hemispheres of the brain, give way, or are deficient, so that the ventricles, and the general sac of the arachnoid form together one huge cavity; the hemispheres are turned aside, or folded back, the surfaces that naturally have a central aspect look upwards, and seem to constitute the summit of the cerebrum. This was the state of the parts within the immense skull from which the largest of the casts before you was taken. It belonged to a man named Cardinal, who died in Guy's Hospital, in 1825, and of whom Dr. Bright has given a very inte- resting account. Now some of the consequences of this distension of the brain and skull with watery fluid are simply mechanical. The child is top-heavy. His large unwieldy head is too much for the muscles of his neck to sustain without fatigue; or even, when they are unassisted, to sustain at all. He walks gently and carefully, like a person balancing a heavy load upon his head; or he holds and partly carries his head with his hands, as a milkmaid steadies and supports her pail; or he reclines the weight of his burden upon the chair, or table, as he sits. But far more important effects of the disease are those which relate to the three great functions of the brain. The child is soon found to be blind; or, what however is less common, deaf; or palsied in one or more of its limbs; or idiotic; or all these. In other words, the special senses, the power of voluntary motion, and the mental faculties, are apt to be defective or perverted. Instances, however, do occur, in which these functions are, for some time, but little deranged. The greater number of those who are afflicted with dropsy of the brain either recover, or die during their infancy. Still, a few survive, bearing their complaint to the adult period, and even to old age; and in some of these individuals, who, with excessively large heads, have yet numbered many years of existence, the intellect and the senses, if not entire and lect. xxvi.] CHRONIC HYDROCEPHALUS. 307 perfect, have been sufficiently effective to answer the common wants and purposes of social life: the moral emotions strong, the feelings lively and correct, the memory tolerably retentive, the reasoning powers respectable. Dr. David Monro relates the case of a hydrocephalic girl, six years old, whose head measured two feet four inches in circumference. She is described by him as being " as lively and sensible as most of her age," and as " having a strong memory." Dr. Bright's patient, Cardinal, was nearly thirty years of age when he died. He was born in 1795. At the time of his birth, his head was only a little larger than natural; but it had a pulpy feel, as if it were almost destitute of bony matter. A fortnight afterwards, it began to increase rapidly; and when he was five years old, it was but little less, according to his mother's account, than when he died. He could not walk alone until he was nearly six, and then only on level ground. If he attempted to run, or to stoop, he fell down. He was sent to school when he was about six, and soon learned to read well and to write tolerably; but writing he soon gave up, because, as he was near-sighted, it obliged him to stoop, which he could not conveniently do. When a candle was held behind his head, or when his head happened to be between a spectator and the sun, the cranium appeared semi-transparent; and this was more or less the case till ho was fourteen years old. About the age of twenty-three, epileptic fits began to occur; and after that his health, which previously had been very good, failed somewhat. The ossification of the skull was not complete till two years before his death, the anterior fontanelle being the last part that closed. It has been mentioned that he was near- sighted ; but he was very quick of hearing, his taste was perfect, and his digestion good. Dr. Bright states that his mental faculties were very fair, and his memory tolerable; but it was not retentive of dates. It was said that he was never known to dream. There was something childish and irritable in his manner, and he was easily provoked. He died, at last, of fever and diarrhoea. There were seven or eight pints of fluid within the cranium, in contact with the dura mater. On the base, or floor, of the skull lay the brain, with its hemispheres opened outwards, like the leaves of a book. How comes it that the cerebral functions are thus sometimes fulfilled, or go on so well, when the machinery through which the mental powers are manifested — the instrument whereon and whereby the immaterial principle mysteriously operates—is so palpably and greatly deranged ? How comes it that life, and especially the life of the mind, subsists at all ? These questions open very interesting considerations. It would appear, from such cases as I have been referring to, that the curious arrange- ment and collocation of the several parts of the brain are rather matters of convenient package than of necessary relation. The pulp which furnishes the medium of sense, and thought, and volition, is there, but it is disposed in an unusual shape. In neither of the two varieties of the malady that have been described as being compatible with prolonged existence, is there any necessary diminution of the cerebral mass. The brain itself, which forms a bag in the one case, and is split in halves in the other, has been found to weigh quite as much as a healthy brain at the same period of life. There has been no loss, therefore, of substance; the pressure has been gradual, and it has not been made to act injuriously by counter-pressure; no effectual resistance has been afforded by the rigidity of the brain-case: and thus the unopposed distend- ing force neither causes absorption of the cerebral pulp on the one hand, nor, on tht other, induces coma, or convulsions, or idiotcy, by its compression. Most commonly, however, the mental and voluntary functions are maimed or per- verted ; and these serious calamities make parents look at a large head in a young child with anxious solicitude. But you are aware, after what I stated on this subject in the last lecture, that the head may be extravagantly large without dropsy of the brain, and without disease. We have just seen, that while the brain itself is gradually unfolded, or its hemi spheres are parted and turned aside, by the liquid accumulating within the cranium, the functions of the organ may suffer but little, so long as the yielding brain-case permits the expansion or separation of the nervous substance, without inordinate pressure. But as soon as undue pressure begins to be exercised, then morbid symptoms arise, or the defects that have previously shown themselves are aggravated. Hence that period of life becomes a perilous period, at which the skull, by the closure of its fontanelles and sutures, loses its capability of further expansion. In some rare 308 DISEASES OF THE BRAIN. [lect. xxvi. cases the closed sutures re-open under the augmenting pressure, and a respite is thus obtained. Dr. Baillie has recorded an instance in which this happened in a boy seven years old. A similar case is mentioned in Dr. Yeats' work on hydrocephalus. The patient was a boy nine years of age. The sutures of his skull separated again after having been united; and it was remarked that the teeth in the jagged edges, whereby the bones interlock with each other, were much fewer than is usual. If this be always so when the sutures give way, it will serve to facilitate our understanding how such a separation can take place. The skull may, however, go on expanding, although the sutures are permanently closed; there still being left intervals between the several points of ossification, which intervals are covered by membrane only. The beautiful preparation on the table, showing this remarkable state of the cranium, I have borrowed for your inspection from Dr. Sweatman's museum. Indeed, although I have spoken of this complaint as being especially a disease of childhood, it does occasionally commence long after the skull has become a complete case of bone. Enlargement of the head, in these cases, is impossible; but this circumstance, and the symptoms it is apt mechanically to produce, form the only differences between the disorder as it affects the child and the adult. In both cases disturbance of the cerebral functions arises, and at length convulsions or coma close the scene. In both, a dropsical state of the ventricles of the brain constitutes, often, the only morbid change presented after death. A young and distinguished lawyer of my acquaintance had one or two attacks of rather sudden loss of consciousness, while engaged in the Court of Chancery; by degrees he became dull, stupid, forgetful, and, at length, insensible. In this condition he died. A large quantity of serous liquid was found distending the ventricles of his brain. No other alteration could be detected. Dr. Baillie describes a case of chronic hydrocephalus that occurred in a man fifty years old. Six ounces of fluid were contained in the lateral ventricles. He had been paralytic on the right side of the body; and for eleven months before his death had lost the recollection of his own language, with the exception of four or five words; which he employed, with different intonations, to express his various wants. The celebrated Dean of St. Patrick's afforded another instance of the same disease, attended with a similar interruption of the power of discoursing. The case, as re- lated in Sir Walter Scott's Life of Dean Swift, is curious, and contains an early suggestion of a piece of practice which in our own time has met with more favour. "A few days afterwards he sunk into a state of total insensibility, slept much, and could not without great difficulty be prevailed on to walk across the room. This was the effect of another bodily disease, his brain being loaded with water. Mr. Stevens, an ingenious clergyman of his chapter, pronounced this to be the case during his illness, and upon opening his head it appeared that he was not mistaken; but though he often entreated the Dean's friends and physicians that his skull might be tre- panned, and the water discharged, no regard was paid to his opinion or advice." He remained from October, 1742, to October, 1745, in a state of silence, with few and slight exceptions; and died in the 78th year of his age. Gblis also mentions three instances in which this disease began in advanced life; two of the patients were above seventy years old; the third, who was a physician at Vienna, likewise died in the decline of life, haying suffered under the disorder foi ten years. Now, what can we do in these wretched cases ? Seldom much good, I am afraid. Yet something we must try, for parents will flatter themselves with hopes of a cure: and to say the truth, there have been, under judicious management, a sufficient number of recoveries to forbid our despairing in any case, and to make it incumbent upon us to employ carefully all those measures which have occasionally brought the disease to a favourable termination. Gblis even affirms, that of the cases which began after birth, and which he saw and treated early, he was fortunate enough to nave the majority. lbct. xxvii.] CHRONIC HYDROCEPHALUS. 309 LECTURE XXVII. Treatment of Chronic Hydrocephalus ; Internal Remedies: Mechanical Expedients ; Bandages, Tapping. Symptoms of Spinal Disease. Inflammatory conditions of the Spinal Marrow. The cure of chronic hydrocephalus may be attempted by internal remedies, or by external mechanical expedients, or by both. The internal remedies by which most good appears to have been effected, and from which, therefore, most is to be hoped, are diuretics, purgatives, and above all, mer- cury, which is believed by many to have a special and powerful influence in pro- moting absorption. Conjointly with these, the abstraction of small quantities of blood from the head, by means of leeches, has been found beneficial. Gblis advises that calomel should be given in half-grain doses, twice a day; or, if that quantity should purge too much, in doses containing only one-fourth of a grain. At the same time he would rub a scruple or two of mercurial ointment, mixed with ointment of juniper berries, upon the scalp, every night. He recommends that the head should be kept constantly covered also by a woollen cap. Infants require, he says, no other nutriment than good breast-milk; while older patients should take a moderate quantity of meat. In mild weather they should be as much as possible in the open air. Under this plan of treatment he affirms that he has known the cir- cumference of the head decrease by half an inch or an inch, in a period of six weeks or three months; and that perseverance in this method has frequently, in his ex- perience, been followed by perfect recovery, both of the mental and of the bodily powers. If no improvement should be perceptible in two months, he advises that diuretics should be given, with the former remedies, the acetate of potash, or squills, or both : that an issue should be made in the neck, or in each arm, and be kept dis- charging for several months. And he thinks that when convalescence has once begun, it may often be much accelerated by minute doses of quina; the fourth of a grain, for example, thrice daily. In a disease so unpromising as chronic hydrocephalus, we are warranted in trying any plan that has been found, or supposed, to be useful. An apothecary of consider- able experience — now dead — once took the pains to write out and send me the par- ticulars of two cases in which he had seen a peculiar mode of administering mercury successful. I will give you them nearly in his own words. In the year 1817, he had under his care a lad, named Scott, labouring under chronic hydrocephalus. He had been ill two or three years, was nearly blind, had very little use of his lower extremities, and could not walk across the room without support. He suffered violent pains in his head, and was unable to bear the least pressure on his scalp. His bowels were constipated, and his pulse " oppressed." Cupping and blistering, the blue pill, drastic purgatives, and ordinary diuretics, tried in combination and succession, gave him temporary relief; but no permanent benefit was obtained. Dr. Gower then suggested a plan which he had himself found suc- cessful in such cases, and which had first been used by Dr. Carmichael Smith, who had recorded ten cases of recovery under its adoption. Dr. Gower's plan was to rub down ten grains of crude mercury with about a scruple of manna, and five grains of fresh squills : this was to be one dose : and it was to be repeated every eight hours. My informant rubbed the quicksilver down with conserve of roses, and then added the fresh squills, making the whole into the consistence proper for pills with liquorice powder. The patient took this dose three times a day, for nearly three weeks, with- out any ptyalism being produced. Its effects were great prostration of strength, and loss of flesh, with gradual relief of all the boy's sufferings. It operated profusely by the kidneys. The medicine was continued twice a day, and at length once, for another fortnight; when all the symptoms of the disease had disappeared. The boy was greatly emaciated. He was then ordered an ounce and a half of Griffith's mix- 310 DISEASES OF THE BRAIN. [lect. xxvii, ture thrice daily; and soon regained his health and strength, and got quite well. He remained well eight years afterwards. The success obtained in this case led to the pursuance of a similar course in that of the son of a well-known fish-monger in Old Bond Street. He was about twelve years old, and afflicted in nearly the same manner as Scott, except that the pain in his head was more acute, and caused violent screaming: relief had been repeatedly given, for a time, by cupping. The physician in attendance was unwilling to try the plan, when it was proposed to him, but said that he would give what was equivalent —small doses of blue pill, with squills in powder. The result was salivation in a few days, without any amendment. In about three weeks, the local effects of the mercury having subsided, and the patient then suffering extreme pain in the head, loss of sight, and want of power over the lower extremities, my informant was desired to adopt any measures he thought fitting. The medicine was given as in the former case, and with the same happy consequence. It acted, as before, without producing ptyalism, but with a great reduction of strength and flesh. Health was restored by steel, after the symptoms of hydrocephalus had disappeared. This cure also was permanent. I think you will give me credit for not being over fond of recommending what may be called conundrums, instead of well-tried and approved means of cure; but I say that in such a complaint as chronic hydrocephalus, we have generally the oppor- tunity of testing the virtues of many reputed remedies, one after another; and we are not to despise or neglect any measures that have been found beneficial, merely because they are out of the way, or because we cannot see in what manner they can excel the more common formulae. You will observe that these were cases in which the disease came on some time after the sutures of the skull had closed. [Dr. Hannay relates a case of chronic hydrocephalus, in the Edinburgh Med. and Surg. Journal, in which he attributes the recovery of the patient mainly to the ap- plication to the scalp of a liniment composed of powdered ipecacuanha and olive oil, each two drachms, and half an ounce of suet. Dr. Hannay remarks, that the appli- cation of this liniment, three or four times a day, is followed in about thirty-six hours, by a papular and vesicular eruption; and he is of the opinion, that as chronic hydrocephalus often succeeds to the suppression of eruptions on the scalp, the use of this counter-irritant will prove in many cases extremely useful — its effects are much more manageable than those of the tartar emetic ointment, which, in this disease, has been found advantageous. — C] The mechanical remedies of chronic hydrocephalus are two: and they have a totally opposite mode of action. By the one, the brain is compressed; by the other, it is lightened of its pressure : yet both of them have proved successful. What does this show ? what, but a confirmation of the doctrine that there are different states of the encephalon, very dissimilar in their essential character, yet having some symp- toms in common; and those the most likely of all to catch our attention ? Such common symptoms resemble an algebraical symbol, which derives its value from the plus or minus sign prefixed. Surely it is of vital importance to study, and if we can to settle, the differences whereby these inverse conditions, requiring contrary remedies, may be discriminated. Bandaging the head is one of these two expedients; puncturing it the other. Neither of them is practically applicable after the bones of the skull have united. Bandages appear to have been suggested by the notion that the increase of the fluid within the head, and probably some of the symptoms too, might depend, more or less, upon the want of firmness and proper resistance in the outer containing parts; in the feeble and half solid skull. A certain amount of support and pressure is requisite for the due exercise of the cerebral functions. Beyond this amount all increase of pressure is hurtful. The middle point of safety it may be hard to hit. It is certain that the easy yielding of the bony walls of the head, by reason of the membranous interspaces that exist in the early periods of life, proves oftentimes the safety of these patients. If the skull did not expand as the water gathered, morbid symptoms would ensue. Great nicety must therefore be requisite in the use of this lect. xxvii.] CHRONIC HYDROCEPHALUS. 311 remedy. While the head is palpably enlarging, compression by means of plasters or bandages would probably be mischievous. When the disease is stationary, and the unconnected bones of the skull are loose and fluctuating, and the child is pale and languid, much benefit may be expected from moderate and well-regulated support. The late Sir Gilbert Blane was the first, I believe, to suggest this mode of treatment; but its safety and efficacy have been more recently demonstrated by Mr. Barnard who has related several examples of complete success from the employment of band- ages. In these cases the children were pale, bloated, and feeble, with flabby muscles; the bones of their heads were moveable and floating, and the functions of the brain more or less impaired. Mr. Barnard applies strips of adhesive plaster, about three- quarters of an inch wide, completely round the head from before backwards; covering the forehead from the eyebrows to the hair of the head, as low down on the sides as the ears will permit, and lapping over each other behind. Then, cross-strips are carried from one side of the head to the other, over the crown; and lastly, one long slip, reaching from the forehead, within half an inch of the root of the nose, over the vertex to the nape of the neck. In his first trial of this plan, but never after- wards, Mr. Barnard laid pieces of linen, wetted with cold water, over the plasters. The only internal medicine given was castor-oil, to regulate the bowels. The effects, in all this gentleman's cases, were these: a gradual diminution of the size of the head; mitigation, and ultimate disappearance, of all head symptoms, such as strabis- mus, rolling of the eyes, starting of the muscles, and convulsions: and at the same time, increased tone of the muscular system, with an improved appearance of the skin, and of the secretions from the bowels. These are striking results. They show that, in certain conditions of chronic hydrocephalus, a part of the danger arises from a lack of due support and confinement of the brain; and they prove that compression alone may be equal to the cure. To such cases, Dr. Arnott's air-press would seem, from the facility with which its equable compressing force may be regulated, to be especially adapted. But in children who are not of this pale and feeble habit, and in whom ossification of the skull goes on, the period when the walls cease to yield is the period of danger. The water continuing to accumulate, inordinate pressure begins to take place. Under these circumstances, the application of bandages or plasters must, if nothing else be done, be insufficient or unsafe. The brain-case being no longer capable of expansion, there remains to be attempted a reduction of the quantity of the liquid which it contains. Now, any considerable diminution of the accumulated fluid, through the agency of mere absorption, is scarcely to be expected; even although we endeavour to aid that process by applying leeches and cold to the head, and by purgatives, or diuretics, or diaphoretics. Some mode, more certain and effectual, of emptying the distended cavity, has therefore been earnestly sought after; and the second mechanical expe- dient of which I have spoken offers a very sure method of attaining this object. He must have been a bold physician who first proposed to decant the water from the brain, by means of a perforation, made with a trocar, through the membrane of the fontanelle, through the membranes of the brain, and through even the expanded cerebral substance itself. But the success of the project has amply vindicated his happy audacity. It is not a very new suggestion, but it has received particular attention in this country of late years; and though tapping the brain in chronic hydrocephalus has been denounced as useless and cruel by some high continental authorities, by Gblis and Richter especially, it furnishes one of the best of the few chances of safety to the patient. Of course I mean ultimate safety, for the operation itself is attended with the present risk of accelerating the patient's death. Other means, however, failing, we are justified in advising that hazard. We have to consider, that by performing the operation, we incur the danger of abbreviating the existence of a being, whose life, without it, could scarcely be long continued, or capable of enjoyment: but then we afford some chance of a perfect cure. A speedy death, or an uncertain life of mental and bodily imbecility, or complete restoration : these are the three events to be looked at. Of the three, the second is, in my judg- ment, incomparably the worst; and if the case were my own, if I had to decide the painful question in reference to one of my own children, I would accept the alterna- tive of probable speedy death on the one hand; possible complete recovery on the other. 312 DISEASES OF THE BRAIN. [lect. xxvii To say the truth, the immediate danger is not so very great as you might suppose; provided that the operation be skilfully and cautiously performed, and only a moderate quantity of water drawn off at a time. That even a very rough operation is not necessarily fatal we learn from a singular case related by Mr. Greatwood. A child, fifteen months old, afflicted with chronic hydrocephalus, fell down, and struck the back part of its head against a nail, which penetrated the skull. _ Above three pints of water gradually flowed out at the orifice thus maue, and the child was cured. In some rare cases the imprisoned liquid has found a natural vent, and dribbled away, through foramina in the bones of the skull communicating with the nostrils. In this manner injurious pressure has been relieved, or for a while staved off. I will mention a few instances in which tapping the brain has been performed; for I know no better mode of showing you the manner in which the operation should be done, the cautions to be attended to in doing it, and what kind of success it has had. There is an account of the performance of this operation by Lecat, in the Philoso- phical Transactions for the year 1751 This date is subsequent to the period when the Rev. Mr. Stevens suggested the propriety of trepanning Dean Swift's cranium. In 1778, Dr. Remmet, of Plymouth, punctured the head of a hydrocephalic child on five several occasions, with a lancet, and took away, in all, no less than eighty ounces of fluid; five pints, as pints were measured in that day. The child died seventeen days after the last tapping. A very interesting case of the same kind is related by Dr. Vose, of Liverpool. His patient was an infant seven months old. Its head was more than twice the ordinary size. Three operations were performed; the first with a couching needle. Upwards of three ounces were on that occasion evacuated; and it was estimated that about the same quantity dribbled away afterwards. The child thereupon became very weak, but was presently revived by some cordial medicine. About six weeks afterwards, the liquid having collected again, an opening was made with a bistoury, and eight ounces were removed; and nine days after that, twelve ounces more, without any bad consequences. The head diminished in size, the patient got apparently well, and the case was published as a successful one. Unfor- tunately, however, upon the closure of the sutures by ossification, the complaint returned, and the child died of it. Mr. Lizars, of Edinburgh, operated upon a little patient of his twenty times in the course of three months; using a small trocar. Dilatation of the pupils, and squinting, which had previously existed, ceased immediately upon the escape of the water. The child recovered. But in this case also, as in Dr. Vose's, the success was temporary only. The head at the period of teething again enlarged, and again the tapping was performed; but the little patient sunk. Another very striking and instructive instance is recorded by Mr. Russell, of Edinburgh. The patient was an infant three months old, with an enormous head ; twenty-three inches in circumference, and fifteen inches and a half from one ear to the other. The child was affected with strabismus, and a perpetual rolling of the eyes. The usual routine measures, compression among the rest, had been employed without any success. By four operations, performed at intervals of about ten days, the size of the head was considerably reduced; but, the fluid continuing to collect, calomel was given in small and frequent doses, and the the gums became sore, and the child got well. At eight months old the dimensions of the head were less, by four inches in circumference, and by two inches and a half across the vertex, than they had been before the first tapping; and the sutures had entirely closed. But Dr. Conquest, of Finsbury Square, has, more than any other person, given authority to these operations. In a paper published in the Medical Gazette, in March, 1838, he tells us that he had then tapped the heads of nineteen children for this complaint, and in ten of the nineteen cases the children survived. Very little is known of the subsequent fate of these ten cases. Of the condition of three only, at a later period, is there any record. Not one of the three was in a very satisfactory state. Dr. Conquest introduces a small trocar through the coronal suture below the anterior fontanelle, and cautiously makes a pressure upon the head afterwards by means of strips of adhesive plaster; and he closes the wound in the integuments care- fully after each time of puncturing. The greatest quantity of liquid withdrawn by him, at any one time, has been twenty ounces and a half; and the greatest number of operations on any one child has been five, performed at intervals of from two to six lect. xxvii.] CHRONIC HYDROCEPHALUS. 313 weeks. The largest total quantity of water removed was fifty-seven or fifty-eight ounces, by five successive tappings. This expedient, though doubtless hazardous, must be deemed to possess a certain value. The rules relating to its performance may be briefly summed up. The opera- tion should scarcely be had recourse to until other means have failed. The trocar should be small, and it should be introduced perpendicularly to the surface, at the edge of the anterior fontanelle; so as to be as much as possible out of the way of the longitudinal sinus, and of the great veins that empty themselves therein. The fluid should be allowed to issue very slowly; and a part only of it should be evacuated at once. The instant that the pulse becomes weak, or the dilated pupil contracts, or the expression of the child's countenance manifestly alters, the canula should be with- drawn, and the aperture in the skull closed. Gentle compression should be carefully made to compensate, in some degree at least, the pressure that has been removed with the fluid. Should the infant become pale and faint, it must be placed in the hori- zontal posture; and a few drops of sal volatile, or of brandy, mixed with water, may be given. Sometimes slight inflammatory action comes on in the course of a day or two after the tapping. When this happens, we must apply cold lotions, or leeches, and use the other remedies which I mentioned before, as proper to subdue such inflammation. It has been thought that the operation is more likely to succeed in the rarer case of arachuoidean than in the more common case of ventricular hydrocephalus. But supposing this to be so (which, however, is very questionable) how are we to dis- criminate between these two conditions ? Partly, we are told, by the character of the accumulated fluid; and this may be ascertained by introducing a grooved needle through the membrane. Serous fluid in the cavity of the arachnoid is sometimes a consequence of a previous extravasation of blood in the same part; and, thus arising, it is apt to be tinged with blood and to contain a sensible proportion of albumen. Whereas in dropsy of the ventricles the liquid is almost as limpid as water, and holds little or no albumen in solution. This criterion cannot, however, be implicitly relied on. The liquid withdrawn from the cerebral ventricles is sometimes red and albuminous. Partly, again, we may judge by the depth to which the needle penetrates before reaching the fluid. But this, also, is an ambiguous test, for not seldom the liquid in the distended ventricles comes so near to the surface as to seem to be immediately beneath the dura mater. There is one positive indication, when it occurs, that the dropsy is ventricular, which I have learned from the comprehensive lectures on this subject, just delivered before the College of Surgeons by Professor Prescott Hewett. He points out, what I mentioned a few minutes since, the effect of the pressure of the fluid collected within the skull, in flattening or pushing outwards the orbitar plates of the frontal bone. This happens in ventricular hydrocephalus alone; but it does not always happen. Now this change in the orbitar plates narrows the dimensions of the orbits, thrusts the eyeballs more or less out of their sockets, and gives them a downward direction; so that a great part of the pupil is hidden behind the lower lid, and the white of the eye is more uncovered and visible than is usual. When this condition of the eyeballs is noticeable in a hydrocephalic patient, you may be sure that the dropsy is ventricular. But there may be ventricular hydrocephalus without this out- ward token of its situation. The orbitar plates are not always warped. Whether they are so or not will depend upon circumstances, and one of the determining cir- cumstances probably is the period at which the dropsical accumulation and pressure commence. I once got a surgeon to perform the operation of tapping upon the infant of a poor wcnian, after I had tried in vain all the other measures that I have spoken of. To our horror, when the trocar was withdrawn from the canula, instead of clear serosity, a fine stream of purple blood spouted forth. The opening was at a considerable dis- tance from the longitudinal sinus; but the trocar was not so delicate as it might have been, and I presume that one of the larger superficial veins had been pierced. I do not think, either, that the instrument was introduced in a sufficiently perpendicular direction. Of course the risk of hitting a vein is increased when the trocar is car- ried obliquely inwards: and a large portion of the cerebral mass is also wounded. 314 DISEASES OF THE BRAIN. [lect. xxvii. We naturally thought it was all over with the child, which presently became deadly pale and faint. A verdict of infanticide by misadventure stared us in the face. But under the use of stimulants the infant revived again; no haemorrhage went on inter- nally, as we apprehended it would; but the child, after a day or two, seemed very much the better for the loss of blood. This amendment, however, did not last; and the mother, who had been terrified by the immediate consequences of the operation, feared to come near me, lest I should wish to have it repeated; and at length our patient died. I was very desirous to examine the interior of the head; but this was not permitted. On one subsequent occasion I have witnessed the operation. The subject of it was an infant about eight months old. Four months after its birth, its head was ob- served to grow inordinately large. At the time of the operation the fontanelles were exceedingly tense; the- child screamed frequently, occasionally vomited, and was slightly convulsed; the features were pinched, and the eyeballs distorted downwards; but the pupils were not dilated. Four ounces of transparent liquid were let out by puncturing the anterior fontanelle. A few hours afterwards the child was'tranquil, and much improved in aspect; the distortion of the eyeballs had disappeared. Three ounces more were taken away the next day. For two days thereafter all the symp- toms appeared to be mitigated; but the skull was flaccid; yielding, like a broken egg, to the gentlest pressure. On the evening of the fourth day after the first tap- ping, the respiration became hurried, the child grew dull, and, before midnight, ex- pired. In this case it appeared to me that the chance of success was baulked by the want of external support subsequently to the tapping. [Dr. Whitney relates, in the Edinburgh Medical and Surgical Journal, an instance of the successful puncture of the brain in a case of chronic hydrocephalus. By the first operation nine ounces of fluid were drawn off, and in three weeks subsequently, by a second operation, five ounces more. Neither operation was succeeded by any bad symptom, and the recovery of the child appears to have been complete. Two cases are related by Professor Wutzer, and Dr. Butcher, in the Austrian Medical Journal, in which the puncture of the brain was unsuccessfully employed. In the first, a child seven months old, death occurred in six days after the first operation; in the second case, of a child sixteen months old, the operation was repeated, after an interval of four weeks, and, seven weeks after the second puncture, the child died in convulsions. Dr. West (Report for 1844-45) states that of sixty recorded cases in which puncture of the brain was performed, seventeen, or one in 8 J, had a favourable termination; or, in other words, the recoveries have been to the deaths in the propor- tion of 28 per cent. — C] You will not expect me to draw any comparison between the merits of compression and of paracentesis, as substantive remedies. They are opposite measures, and adapted to different and opposite conditions of the brain. The one repairs defect of pressure; the other relieves its excess. To hold the balance even requires much care, a steady and gentle hand, an accurate judgment, and incessant vigilance. Either expedient may suffice, alone. Both may be (and have been) profitably employed in the same case, in succession, according to its varying circumstances. If the walls of the head be tight and firm, the trocar should precede the bandage; if lax and move- able, compression should be cautiously tried, and followed, if need be, by the puncture. When adverting, in a previous lecture, to the radical cure of hydrocele, I remarked that in other forms of dropsy we scarcely dared to employ, with the same view, the injection of irritating substances into the emptied cavity: but, in so saying, I under- rated the hardihood of operative surgery. To cure chronic hydrocephalus in a radical manner, preparations of iodine have been thrown into the tapped skull. In one in- stance, not only was such fluid injected, but in order that it might be brought into contact with the whole internal surface, the poor child's head was shaken, as one might shake a phial. In another case no fewer than twenty-one injections were prac- tised; and from first to last, not less than a drachm and a-half of iodine, and four drachms and a-half of the iodide of potassium, were thrown in upon the brain. Both arachnoidean and ventricular hydrocephalus have been thus treated. It is very sur- lect. xxvii.] MENINGITIS ENCEPHALICA. 315 prising that these rude handlings of one of the most delicate textures of the body should have been apparently so harmless. If, however, they have hitherto inflicted no palpable injury, neither have they effected any permanent good. In one example the head was tympanitic after the operation; in more than one, the dimensions of the skull diminished somewhat for a time; in none did any signs of inflammation ensue. All this (as Mr. Hewett observed) merely shows what some children will bear. I have now done with the inflammatory affections of the brain: in conjunction with which I have also considered some other morbid conditions, that are either con- nected with inflammation of the contents of the cranium, or resemble it in some of their phenomena. Thus, I have spoken of delirium tremens, which is apt to be mis- taken for inflammation of the brain : of softening from disease of the cerebral arteries, which is liable to be confounded with inflammatory softening : of tumours of different kinds, which tend to produce inflammation, or symptoms like those belonging to in- flammation : and of chronic hydrocephalus, which sometimes is the sequel, sometimes the precursor, of acute hydrocephalus; and has other points of analogy with that disease, the encephalitis of strumous children. [Meningitis encephalica.—Under this name, Dr. Brockman has recently described a peculiar form of cerebral disease incidental to childhood, in which the membranes of the medulla oblongata and pons varolii are chiefly affected. Dr. B. has met with fourteen cases of this affection. It was, at first, observed by him as a sequel of scarlatina, but subsequently, he has seen it to occur most fre- quently as an idiopathic affection. It is sometimes associated with general disease of the brain; at others, it is uncom- plicated. Notwithstanding it is unattended, in its earlier stages, by any serious symptoms, it is an affection fully as dangerous as cerebral meningitis. The first stage, or that of simple hyperaemia, generally continues for one or two days. The child is dull and heavy, and the occiput is often hot; the bowels, however, are regular; there is no vomiting, no intolerance of light, nor any disturbance of sleep. The general dulness of the patient, and vague complaints of some uneasy sensation in the head, increase as the inflammatory stage sets in; the heat of the occiput is augmented; the head becomes retracted, as in the ordinary cases of acute hydrocephalus; and con- vulsive twitchings of the limbs occur, similar to the effects of light electric shocks, which recur every few minutes while the patient is awake, but cease during sleep. The general febrile symptoms continue during the third stage; the pulse, however, diminishes in frequency and fulness, but does not become either irregular or inter- mittent. The general disquietude of the child subsides, by degrees, into a comatose condition, in which the head becomes still more retracted, but unattended with stra- bismus, or any morbid condition of the pupil; the peculiar air of stupidity that characterizes hydrocephalic patients is wanting. Two pathognomonic symptoms, however, indicate the occurrence of the stage of effusion. One of these is deafness; the other difficult articulation, and difficulty in moving the tongue — both of which occur at the same time, probably from paralysis of the motor nerves of the tongue. The deafness and affection of the tongue usually occur suddenly; sometimes they are first observed upon the child awaking from a quiet sleep. They are, according to Dr. Brockman, the earliest and most certain indications of the occurrence of effusion. This stage continues, sometimes, for three, and sometimes for fourteen days. Its termination is in fatal paralysis, the occurrence of which is often pre- ceded by various singular nervous phenomena — as, sudden pauses in the respira- tion, or equally sudden syncope. In some cases, however, the paralysis does not follow, but the anomalous symptoms subside, and the patients gradually recover; until, indeed, the paralytic stage is fully established, the recovery of the patient is still possible. In the uncomplicated cases of the disease, upon examination after death, the cere- brum in general, presents an extremely pallid and anaemic condition, in striking contrast with the cerebellum, the vessels of which are turgid with blood, while its substance, also, is often in a state of marked hyperaemia. The hyperaemia increases in intensity towards the central portions of the encephalon; and the membranes covering the pons varolii and medulla oblongata are found in a most decided state of 316 DISEASES OF THE BRAIN [lect. xxvii. inflammation. The portion of inflamed membrane is perfectly isolated, and not more, nsually, than a square inch in extent—the membrane of the cerebellum being entirely free from any indications of inflammation. There is ordinarily an effusion of a serous fluid into the sub-arachnoidal tissue; sometimes to the extent of several ounces; occasionally a gelatinous matter is effused, and, in some cases, the effusion is of a purulent character. This form of the disease is most frequently observed in children from three to ten years of age, and who had previously enjoyed good health. The treatment recommended by Dr. Brockman is, in its first two stages, depletion, by leeches to the posterior part of the head, cold applications to the scalp, and the free administration of calomel, which latter may be continued during the stage of effusion. Here, however, it becomes necessary to support the strength of the patient; for this purpose ammonia is directed by Dr. B., but he remarks that, in some cases, the administration of wine may be required. According to his experience, powerful counter-irritants, as a large blister, or the actual cautery, prove, also, sometimes beneficial. — C] Before I take up the subject of apoplexy, and of palsy, I wish to direct your attention to the inflammatory conditions of the spinal cord. The whole pathology of this portion of the nervous system is extremely interesting; but it has not yet been so thoroughly made out as to enable any one to give a very systematic or satisfactory account of it. In addition to those numerous difficulties with which I showed you in a former lecture that the entire subject of the diseases of the nervous apparatus is beset, there is this further obstacle to our studying dili- gently the structural changes of the spinal marrow — that much labour and expense of time are required for exposing the interior of the vertebral canal; which is, there- fore, too often neglected in examining the dead body. There are certain points in the anatomy and physiology of the spinal cord which it is necessary that you should bear in mind, if you would have any clear notions even of what has been learned in respect to its pathology. 1. In the first place, the spinal cord (including the medulla oblongata) is the seat and centre of that remarkable property, the reflex function; by which so many of the automatic movements of the body are regulated. 2. In order that we may feel, or be conscious of, what occurs in any part of the trunk or limbs, and in order that our will to move any such part should be obeyed, it is necessary that there should be a continuity of nervous matter between the part in question and the brain. If the cord be cut across at any point, or so crushed as to be thoroughly disorganized at that point, a complete abolition of sensation and of voluntary motion ensues in all those parts of the body that receive their sentient and motor nerves from that portion of the cord which lies beyond the place of the injury, reckoning from the brain. What is true in this respect of the mechanical division of the cord, is equally true of such disease as pervades and spoils the nervous matter composing it. Now it follows from this, that the effects of disorganizing forms of disease — as well as the effects of injury — must vary greatly according to the part of the cord they occupy. Thus any such disease or injury affecting the whole thickness of that portion of the spinal marrow which is contained within the upper cervical vertebrae, is inevitably fatal at once; producing suffocation by paralysing those muscles through the play of which the motions of respiration are performed. You know that the intercostal mus- cles and the diaphragm have at all times the main share in carrying on the mechanical actions of respiration; and probably they execute the whole action in every case of ordinary breathing. Now the intercostal muscles are furnished with motor nerves from the spinal cord, all along the dorsal vertebrae; and the diaphragm is principally supplied by the phrenic nerves, which are chiefly derived from the third and fourth cervical nerves. These muscles obey the will; but they act also independently of the will. The pneumogastric and trifacial nerves, with respect to them, are excito-motory nerves, and call into play a reflex power which is transmitted from the medulla oblon- gata. Hence any profound injury of the spinal cord, above the origin of the phrenic nerves, stops both the voluntary and the involuntary movements of the respiratory LECT. xxvii.] AND SPINAL CORD. 317 muscles, and the individual perishes by apnoea, in as strict a sense, as though the access of air to the lungs had been suddenly prevented by a ligature drawn tightly round his wind-pipe. Again, when a segment of the cord, however small, is disorganized in its cervical part, between the origin of the phrenic and the origin of the upper intercostal nerves, the breathing is not instantly suspended; but is performed entirely by means of the diaphragm, the intercostal muscles having no share in it. The ribs cease to rise and fall; and the abdomen is alternately protruded, and sinks back again. In each case I suppose the disease of the cord to he such as suffices to paralyse the parts supplied with nerves from it, beyond the seat of the disease. If disease of this kind occur below the giving out of the intercostal nerves, the breathing is not affected; we have paraplegia only, palsy and loss of feeling in the lower extremities, and perhaps in the hips, or even higher. Now a person in this condition may live a long time. When the disease is situated between the origin of the intercostal nerves and the origin of the phrenic, he may live a few days, but he seldom lives a week, and never survives a month; and when the disease is higher still, in the very upper part of the cord, above the origin of the cervical nerves, he perishes outright. The kind and degree of disease, therefore, being the same, the character of the symptoms, and the amount of danger, differ remarkably according to the seat of the disease. 3. Although sense and voluntary motion cease upon the disruption of the commu- nication with the brain, the excito-motory functions of the separated portion of the cord are not necessarily suspended. On the contrary, they seem to acquire increased activity. The automatic power is apt to run riot, as it were, when the controlling in- fluence of the sensorium is withdrawn. All of you probably have seen the limbs of a recently decapitated frog thrown into violent action by the stimulus of galvanism. I have witnessed the same thing in the human body after death by hanging. What is still more curious, you may have unequivocal manifestations of similar phenomena in the living body. I have lately been informed, by Dr. William Budd, of a case in which a man was afflicted with paraplegia, in consequence of disease of the vertebral column. He was totally deprived of the power of moving his lower extremities. Sensation in them was almost, yet not entirely, extinct. A sharp pinch, or the prick of a pin, he could feel; but slight friction he was quite unconscious of: yet (as he himself said) his limbs were not; for when the inner edge of the foot was brushed or tickled by the hand of another person, the corresponding leg, over which he had no voluntary control, would start up, and be briskly convulsed. The same thing took place, in both limbs, whenever he passed his urine or faeces; so that he was obliged to have an apparatus of straps and ligatures to keep the legs down on such occasions. I have seen something like this myself, in several instances.1 4. Under the sagacious researches of Dr. Marshall Hall, the physiology, and with it the whole pathology, of the spinal cord is undergoing, at this very time, a com- plete reformation. I know of no modern discovery so fruitful of important practical consequences, or so likely to impfove our remedial management of nervous disorders, as the singularly interesting truths which he and others are even now engaged in de- monstrating and enforcing. I do not profess to teach you this new physiology. I touch only, as I pass along, upon some of its cardinal points, to which I may have occasion to refer in future. We are considering how the signs of spinal disease may vary according to the particular location of that disease; and I would have you re- mark", here, that inasmuch as all the acts of ingestion and expulsion, all the inlets and outlets of the body, are governed by the spinal marrow, with its corresponding apparatus of incident and motor nerves—it is to be expected that disease in the upper part of the true spinal system should affect the orifices which answer to that part, and which are principally inlets — the larynx, the gullet, the cardia: while disease in its lower portion will be likely to disturb the natural functions of the lower orifices — the rectum and anus, the bladder and urethra, the os uteri — which are chiefly outlets. 5. You must bear in mind also the grand discovery of Sir Charles Bell, that the two roots by which each spinal nerve arises have distinct and different functions; the anterior roots being composed of motor fibrils, the posterior of sensiferous. ' This very interesting case has since been published, in detail, with several others resembling it in the 22d volume of the Medico-Chirurgical Transactions. 318 DISEASES OF THE SPINAL CORD. [lect. xxvii. It was a natural inference, from this discovery, that the anterior columns of the spinal cord were subservient to the purposes of motion, and the posterior to the faculty of sensation. But this was an erroneous inference. _ Later anatomical researches, those especially of Mr. Lockhart Clarke; and experiments made upon living animals, especially the experiments of Dr. Brown Sequard, concur with the results of clinical observation to prove that the posterior white columns are not the channels of sensation. Sensibility has remained perfect when these columns were thoroughly disorganized. It is probable, from their relations with the cerebellum, that a part at least of their office concerns the co-ordination and regulation of the muscular movements of the body. The anterior, or the antero-lateral columns, with the grey matter of the cord, are doubtless the seat and channels of the motory power, while they also minister to the transmission of sensations. It is a curious fact, elicited by clinical experience, that in disease of the cord, not involving the roots of the nerves, the power of moving the limbs is commonly earlier diminished than their sensibility. Sometimes it happens that sensibility, or voluntary motion, or both, are impaired in the upper extremities, while the same functions remain perfect in the lower and more distant limbs. In explanation of this phenomenon it has been supposed that distinct and different filaments of the spinal cord, extending from its junction with the brain, connect themselves with or help to form the several nerves which emerge from the cerebrospinal axis; and that disease of the brain, or of the cord, has spared those strands and fibres which pass down to the nerves given off at the inferior part of the spine, while it has affected those strands only which belong to certain nerves from the superior part. But a similar limitation of paralysis to the upper limbs may result from the impli- cation of the roots of the spinal nerves, in disease of the upper segments of the cord itself or of its membranes. And it is a curious fact, worth remembering, and cer- tified both by physiological and pathological observation, that irritation or disease affecting the roots of the upper cervical nerves may cause inequality in the pupils of the eyes, and suggest suspicion of mischief within the head, when the disorder is purely spinal. 6. We must not forget that the brain, and the spinal cord, which are distinct from, but yet continuous with, each other, sympathize largely and mutually under disease. This circumstance throws an additional obscurity over the study of their morbid con- ditions. It is one, however, which we cannot avoid, but which we must estimate and allow for, in our observation of diseases, as we best may. 7. There are a few remarks made by Dr. Abercrombie, in relation to some of the anatomical dispositions of the cord and its investing membranes, which may help us to comprehend better some of their morbid contingencies. Thus, with respect to the dura mater of the cord, it is practically of importance to recollect " that it adheres very slightly to the canal of the vertebrae by a very loose cellular texture : and that it adheres very intimately to the margin of the foramen magnum. In this manner a cavity is produced betwixt the membrane and the inner surface of the spinal canal (external, i. e., to the membrane), which cavity may be the seat of effusion, and which has no communication with the cavity of the cranium. On the other hand, the space between the dura mater and the pia mater (or membrane immediately covering the cord) communicates freely with the cavity of the cranium; so that fluid may pass easily from one to the other, according to the position of the body." I shall pursue the same order, in speaking of the inflammatory affections of the spinal cord, as I followed in respect to the analogous conditions of the encephalon. And, first, let us inquire what has been noticed of inflammation of the membranes of the cord. They may undergo inflammation, independently of the substance of the cord, and independently of the brain; but this is not very common. Usually, when we have meningitis of the cord, we have the same disease also within the cranium: usually too, with meningitis of the cord, we have more or less inflammation of the nervous matter composing it. The commonest symptoms of inflammation of the me- ninges of the cord (for I do not pretend to speak of the several membranes sepa- rately) appear to be pains, often intense, extending along the spine, and stretching lect. xxvii.] DISEASES OF THE SPINAL CORD. 319 into the limbs, and aggravated usually by motion, and simulating therefore rheumatic pains: rigidity or tetanic contraction, and sometimes violent spasms, of the muscles of the back and neck, amounting in some instances to perfect opisthotonos : a similar affection of other muscles also, as those of the upper or lower extremities: a sense of constriction in various parts, in the neck, back, and abdomen, as if those parts were girt by a tight' string: feelings of suffocation : retention of urine: priapism: obstinate constipation : and with these symptoms, rigors often. You are not to expect in every case all the symptoms which I have been enume- rating : they will vary according to the seat and extent of the inflammation. We need not wonder at the spasmodic symptoms, when we recollect that the nerves which issue from the body of the cord receive a covering from its pia mater. The pain felt along the course of the spine itself is said to be aggravated by the percussion of the spine, but not by simple pressure; and this seems very likely. I know of no way in which I can so well hope to awaken an interest in you about these diseases, or to offer you instruction respecting them, as by instances. The fol- lowing I take, abridging it somewhat, from Dr. Abercrombie. A man, twenty-six years old, had for several years been subject to suppuration of the left ear; suffering occasional attacks of pain on that side of the head, which were followed by a more copious discharge from the ear. In the first week of April he became ill, with pain of the forehead and occiput, disturbed sleep, and loss of appetite; but no fever. At the end of the week he complained of pain extending along the neck. This pain gradually passed downwards in the course of the spine, and deserted the head; and at last, after many days, it fixed itself with intense severity at the lower part of the spine; shooting thence round the body towards the crests of the ilia. He became affected also with great uneasiness over the whole of the abdomen, and had much pain and difficulty in passing his urine. About the end of the second week in April his sufferings had become extreme. He could not lie in bed for five minutes at a time, but was generally walking about the house in a state of great agitation, grasping the lower part of his back with both his hands, and gnashing his teeth with the intensity of his pain. He had no interval of ease, and was sometimes incoherent and unmanageable. On the 16th, he went to take a warm bath, walking down three stairs, and into an adjoining street, with little assistance. His speech afterwards became somewhat affected: there were convulsive twitches of his face, and difficulty of swallowing. Some transient squinting also was observed. The pulse was now veiy frequent. On the 18th, while sitting in a chair, he suddenly threw his head backwards with great violence, fell immediately into a state of coma, in which he remained for two hours, and then died. During the whole disease, there had been no paralysis, except the slight affection of his speech; no difficulty of breathing; no vomiting; and no convulsion except the twitching of his face the day before his death. The pulse was small and irregular. The bowels were easily kept open, but the pain in his back was much increased by going to stool. Two days before his death he had several attacks of shivering; and much purulent matter was discharged from his left ear during his illness. Upon a very careful examination of his body, every part of the brain was found to be in a most healthy state. Some gelatinous deposit was found under the medulla oblongata; and purulent matter flowed, in considerable quantity, out of the spinal canal. The spine being entirely laid open, the cord was seen covered with a coating of purulent matter, which lay betwixt it and its membranes. The matter was most abundant in three places; at the upper part, near the foramen magnum — about the middle of the dorsal region — and at the top of the sacrum : but it was also distri- buted over the other parts with much uniformity. The substance of the cord was soft, and separated in some places into filaments. All the other viscera were healthy. You may find several interesting examples of this form of disease in Ollivier's Treatise on the Spinal Marrow. The prominent symptom was generally pain, referred to some part of the spine, and increased by motion ; and what is curious, sometimes little complained of except upon motion. In general, also, it extended along some of the limbs, and was accompanied by muscular rigidity, or tetanic spasms. Palsy oc- curred in one case; but this seemed to have been owing to softening of the cord itself. Constantly there was increased sensibility; a circumstance which Ollivier thinks cal- 320 DISEASES OF THE SPINAL CORD. [lect.xxvii. culated to distinguish inflammation of the membranes from inflammation of the sub- stance of the cord; the latter being usually attended with diminished sensibility. In the case that I have quoted from Dr. Abercrombie, the intense pain underwent no remission or abatement. In one of Ollivier's examples, there was, at the commence- ment of the disease, a striking intermittence of the pain; it came on with intense severity at ten at night, and lasted till three in the morning. The causes of spinal meningitis are not always to be discovered. It sometimes extends from within the cranium. It may be excited by external violence to the spine, of which a good specimen has been recorded by Sir Charles Bell:—A wagoner sitting on the shafts of his cart, was thrown off by a sudden jerk, and pitched upon the back of his neck and shoulders. He was taken to the Middlesex Hospital, where he lay for a week, without complaining of anything except stiffness of the back part of the neck. He could move all his limbs with freedom. On the eighth day after his admission he was seized with general convulsions and locked jaw. He then be- came affected with a singular convulsive motion of the jaw, which continued in violent and incessant movement for about five minutes. This was followed by maniacal de- lirium. He then sank into a state resembling typhus fever; and after four days was found to be palsied and insensible in his lower extremities. The day before his death he recovered sensation in his legs. On dissection, a great quantity of purulent matter was found within the spinal canal. It appeared to have formed about the last cervical and the first dorsal verte- brae, and to have dropped down, by its own gravity, to the lower part of the canal; where it produced palsy and anaesthesia of the inferior limbs by the pressure it oc- casioned. Inflammation of the substance of the spinal cord leads to the same changes in its texture which have been already spoken of .as being often the results, in the brain, of inflammation of the cerebral matter. Softening — induration — suppuration. I need not, therefore, again describe the physical characters of these alterations. The symptoms which flow from inflammation of the nervous pulp of which the spinal marrow is composed, are by no means uniform; nor can we expect that they should be so, when we call to mind what has been already stated of the different effects that must ensue according as different parts of the cord happen to be impli- cated. The phenomena will vary likewise, according as the inflammation is acute or chronic. If we recollect how many parts of the body depend for their power of motion, and for their sensibility, upon the integrity of the spinal cord, we shall not be surprised at the diversity and multiplicity of the symptoms produced by disease of the cord. Tracking inflammation and its events from the upper portion of the spinal marrow downwards, we should expect to find, and we actually do find, some such an arrangement of symptoms as the following : — Convulsive affections of the head and face, inarticulate speech, loss of voice, trismus, difficult deglutition, spas- modic breathing, irregular action of the heart, constriction of the chest, vomiting, pain of the belly, sensation of a cord tied round the abdomen, dysuria, retention of urine, incontinence of urine, constipation, tenesmus, involuntary stools: and with respect to the voluntary muscles corresponding to these parts of the spinal marrow, convulsions, or palsy; or palsy succeeding to convulsions. I must again have recourse to examples, to put you, more fully than any attempted abstract picture could put you, in possession of such forms of inflammation of the cord as you may expect to meet with in practice. A man, fifty-six years old, was exposed to severe cold, while travelling on the out- side of a coach. After this he was attacked with pain in the right arm and leg, most severe about the shoulder, but affecting the whole side, and he had also con- siderable headache. He soon perceived some loss of power in the affected limbs; and the progress of this was very curious. It began at the upper part of the arm, and extended downwards so gradually, that he was able to write distinctly, after he had lost the power of raising the arm, or bending the elbow. Then the leg became affected in the same gradual manner, and after ten or twelve days from the com- mencement of the disease, the whole leg and arm had become completely paralytic. Some pain continued in the parts, and it was occasionally severe, especially in the •eg. Repeated blood-letting, and purgatives, and blistering, were employed. His lect. xxvii.] DISEASES OF THE SPINAL CORD. 321 mind remained quite entire. His pulse was 84, and rather weak. After some time the left arm became paralytic, rather suddenly; but it was not so completely motion- less as the limb on the right side : the left leg was not at all affected. Slight de- lirium occurred, but passed off again. At the end of two months after the exposure to cold, he again became delirious, and his pulse got feebler and rapid : he then fell into a state of stupor, muttering incoherently, but answering questions distinctly when he was roused. He lost his speech a few hours before death. For the last eight or ten days there had been considerable sloughing of the sacrum. The brain was found to be healthy throughout. Much bloody fluid was discharged from the spinal canal into the cavity of the cranium before the spine was laid open. On displaying the spinal cavity itself, the cord was found in a state of complete softening, from the second to the last cervical vertebra. The portions above and below that part were quite healthy. (Abercrombie.) Comparing this case with the one I detailed of meningitis, we find that pain was present in both, but more severely so in the case of inflaramation of the membranes : we find also, that stiffness and spasm of the muscles marked the meningitis; palsy, the inflammation of the substance of the spinal cord. In neither of them were the intellectual functions disturbed till towards the last. I believe that the characters now pointed out belong to these forms of disease respectively. I borrow the following example (abbreviating it) from an interesting collection of Cases of Paraplegia, recently published by Dr. Gull. A healthy brickmaker, twenty years old, walked twenty-eight miles on the 18th of July, 1855, in search of work, and slept in a brickfield. On the next day, which was close and wet, he walked thirty-two miles, and allowed his wet clothes to dry upon his body. On the 20th his legs suddenly gave way under him, and he fell down; but he got up again, and walked from his garden into his house, and two hours after- wards up stairs to his bed, feeling all the time " pins and needles" from the thighs to the feet. Retention of urine then came on, and his bowels ceased to act. On the 26th there was complete paraplegia, with involuntary twitchings and spasms of the legs, and gradually increasing anaesthesia below the navel, but nowhere complete. The motions of the lower ribs were imperfect. He had no priapism, no sense of tightness round the waist, and scarcely any pain. Slight movements of the legs could be produced by tickling the soles of his feet, and these movements weio more readily excited as the case advanced. The retained urine became ammoniacal; sloughs formed over the sacrum; and he died exhausted, without any delirium, on the 20th of August. There was no adhesion between nor effusion of lymph upon the spinal membranes, which had an anaemic appearance. At the middle of the dorsal region there was marked softening of the cord with slight enlargement for two or three inches. The posterior columns were quite diffluent, and contained exudation granules, to an extent much greater than was indicated by the softening visible to the naked eye. The anterior columns were softened, but retained their form. Both columns were of an opaque white colour; the grey matter was mottled by injection of its vessels. Here again, the cord being affected and the membranes untouched, we have palsy, with scarcely any pain, and no disturbance of the mental functions. Much may be learned in regard to the effects of inflammation, or any other cause of disorganization, confined to a limited portion of the cord, by observing what takes place in those injuries in which the bones of the vertebral column are broken or dis- placed. Of course I do not dwell upon these accidents, for they belong to surgery: but I have seen a good many of them, and watched them with deep interest. The symptoms are much more uniform than when inflammation occurs within the vertebral canal independently of external injury; simply because the injury to the cord is more definite and local. But such cases are very valuable objects of study to the physician. I remember several that occurred when I was a dresser in St. Bartholomew's Hospital; and I will state very briefly the particulars of one as an exemplar. In the year 1820, a man was brought there who had been thrown out of a tilt cart, in consequence of a dray's running foul of it. He had pitched upon his head, which showed, how- ever, no trace of injury. When picked up he was found to be powerless, both in the upper and lower extremities. His stools passed from him without his being aware of it, and it was necessary to use the catheter to empty his bladder. He breathed 21 322 DISEASES OF THE SPINAL CORD. [lect. xxvii. entirely by the diaphragm — that is, his thorax was motionless, and his abdomen rose and fell with every alternate act of inspiration and expiration. These symptoms are perfectly distinctive of injury to the cord between the origins of the phrenic and inter- costal nerves. He suffered pain about the middle part of the neck behind. He went on exceedingly well for four or five days, and then the nurse very foolishly acceded to his request to be turned on his side, which caused his death in a very few minutes. This is not the only instance that I have known, in which life has been suddenly extinguished by similar imprudence. The lesson may be useful. There was another patient in the same hospital, who had fractured the cervical portion of the spinal column. Among other remedial measures, the surgeon had directed that his head should be shaved. The barber had performed half his task, and was turning, with his hands, the unfortunate man's head into a more convenient position for completing it, when he suddenly expired. The twist was fatal to him. On' the examination of the body of the patient whose case I was mentioning, a very remarkable -state of-.$e spinal column was found. The fifth and sixth cervical vertebrae" were dislocated from each other without any fracture; a thing which has sometimes been pronounced impossible. The articular processes were fairly separated; and the vertebrae were also forced asunder, by the detachment of one of them from the intervertebral substance. The nervous matter of the cord opposite the point of dislocation was quite soft. There is one very common and distressing consequence of such disease of the spinal marrow as produces paraplegia, not particularly noted in any of the cases which I have related, but always to be looked for. The muscles by means of which the blad- der empties itself, are liable to participate in the palsy; and then the bladder empties itself no longer. The urine accumulates in it, and distends it, and even the ureter becomes dilated; and in this way not only the present but the prospective danger is increased. For the foundation of future disease in the kidneys is often thus laid, even when such distension of the bladder by its retained contents occurs independently of any disease of the spine; as it may do from stricture; from enlargement of the prostate; or even from the voluntary retention of the urine beyond a certain period, through feelings of delicacy. You are to look out, I say, for this distension of the bladder, and relieve or prevent it by the introduction of a catheter through the urethra. You must not be deceived by being told that the patient passes plenty of water; that it even runs from him. Incontinence of urine is, in fact, in these cases, though it may sound paradoxical, a sign of retention of urine. The urine dribbles away because the bladder admits of no further distension; it overflows, and runs out at the natural orifice, but the bladder remains constantly full and stretched. You must make an examination, therefore, of the hypogastric region with your hand. If you find that part of the belly hard and resisting, and giving out a dull sound on per- cussion, you may be sure, in these cases (where there is paralysis of the lower extre- mities, and the water dribbles away), that the bladder is full, and has lost the power of expelling its contents. Sometimes you may recognise the fluctuation of the urine in the distended bladder, and ascertain the globular shape of that organ. It may rise even beyond the umbilicus. But what I chiefly wished to point out to you is the circumstance that the bladder becomes diseased, and the urine altered in quality, under this state of palsy. The urine grows alkaline, turbid, and ropy, and exhales a very offensive ammoniacal smell; and the inner surface of the bladder is found, after death, to be thickened, red, and smeared with adhesive puriform mucus — in a state of chronic inflammation, in short. lect. xxvm.] DISEASES OF THE SPINAL CORD. 323 LECTURE XXVIII. Inflammatory and Structural Diseases of the Spinal Cord, continued. Treatment. Apoplexy. Its General Symptoms and Diagnosis. Symptoms characterizing the Apoplectic State. Pressure the ordinary Physical Cause. Hemiplegia. The Palsied Muscles Rigid, or Limber. Allow me to repeat that the structural diseases of the spinal cord will reveal themselves, by their symptoms, most clearly to him who most distinctly perceives, and most accurately bears in mind, the physiology of that part of the nervous system. But to the best informed, and the most sagacious, they are too frequently obscure and perplexing. Disease occupying a portion only of the cord, but affecting the whole thickness of that portion, from centre to circumference, will be likely to disturb, or suspend, the functions of sensation and voluntary motion in all the parts supplied with motor or sentient nerves from that portion of the cord, and from the portions beyond it. So that a great variety of symptoms depend, when the amount of disease is the same, upon the place of the disease. A total interruption of the conducting function of the cord, in the neck, above the origin of the phrenic nerves, extinguishes life by stopping the actions of respiration. A similar interruption in the cervical part of the cord, above the origin of the intercostals, but below the origin of the phrenic nerves, destroys life as certainly, but not so rapidly, nor in exactly the same manner. We find the lungs loaded with frothy serous fluid in such cases; we find the bladder inflamed; and, often, sloughing of the integuments and muscles of the nates and hips. A similar interruption below the dorsal vertebrae is not necessarily fatal, even when it is attended with permanent paralysis : but it usually is so, sooner or later. When the interruption of function is not total and complete, disease of the cord will be likely to produce rigidity, convulsions, tremors, or simple weakness, of1 the corresponding muscles; pain, tingling, numbness, of the corresponding limbs' and surfaces. The spinal cord is a symmetrically double organ, and disease limited to one of its lateral halves will derange or abolish the power of movement in the corresponding muscles on the same side of the body alone; and perhaps disturb somewhat the sen- sations of that side. But the experiments of Dr. Brown Sequard appear to prove that there are sensiferous fibres proceeding upwards and downwards from the posterior roots of the nerves; and that these sensiferous fibres decussate each other within the cord. If this be admitted as an anatomical truth, it explains what was formerly a perplexity, namely, that paralysis of one side of the body is sometimes associated with anaesthesia of the other side. In this severance of palsy and defective sensi- bility, may we not find a clue to the special diagnosis of hemiplegia that is strictly spinal, from hemiplegia that is cerebral in its origin ? If you impress upon your recollection the facts thus summarily stated, you will find in them, I think, a key to many of the phenomena which accompany, and denote, more or less plainly, disease of the spinal marrow. Inflammation of the membranes of the spine is most apt to declare itself by pain, increased on motion, of the spine and of the limbs; and by rigidity and ■ spasm of the muscles of the neck and back. Inflammation of the cord itself, which readily passes into, or rather produces, softening of its substance, is most commonly marked, first, by convulsive movements of some parts of the body; secondly, by palsy of those parts, with or without anaesthesia. The same may be said of suppuration when it occurs as an event of inflammation; and the pus may be collected into an abscess in the nervous matter of the cord, or it may be diffused and mixed with softening. Now I need not dwell upon the treatment proper to be adopted in inflammation of the spinal cord and its membranes. Mutatis mutandis, it is the treatment already recommended in inflammation of the brain and its membranes. When the inflamma- tion is acute, we must take blood from the arm, or by cupping-glasses along the sides 324 DISEASES OF THE BRAIN. [lect. xxviii. of the spine. Blood enough may be taken by cupping along this tract to produce the effect of general bleeding as well as of local. Perfect rest in the horizontal pos- ture must be strictly enjoined. Mercury will generally be proper. In more chronic forms of inflammation within the spinal canal, we have still a capital remedy in cupping : and counter-irritation in various ways, butmore especially by means of issues made on one or both sides of the spinous ridge, is also, in many cases, of most essential and unquestionable service. Great care must be taken, when there is palsy of the bladder, not only (as I ad- monished you in the last lecture) that the urine be regularly drawn off, but also that the patient be kept dry and clean; for if great attention he^ not paid to this point, sores will form where the urine remains in contact with the skin, to the great increase of his suffering, and of his .danger. Indeed, take what pains we may, there is generally a strong disposition to the formation of sloughs upon the sacrum and hips in cases of paraplegia. They result from the perpetual pressure made upon those projecting points; from the feeble state of the circulation in the palsied parts; and (often) from the irritation of the urine and faeces, which are passed without the sufferer's consciousness. When the patient is kept clean and dry, and the surfaces on which the weight of his body has been supported begin to be red and angry, you may protect them by a plaster: or by rubbing them with brandy, you may sometimes prevent the skin from breaking : or what is best of all, you may put your patient upon one of Dr. Arnott's hydrostatic beds; and then the pressure will be equally distributed over all that portion of the body which comes in contact with the waterproof material of the bed. To bring this outline of the diseased states of the spinal cord up to that point in which we left those of the encephalon, I may state that, like the brain, the spinal marrow may become hardened by chronic inflammation; and, like the brain, it may be enoroached upon by tumours; fibrous, scrofulous, or malignant. With respect to these, all that I can now say likely to be of any practical benefit to you, is that the symptoms they occasion are those of slowly increasing paralysis, or of slowly increasing rigidity of the muscles, without fever or what is called reaction; and that the locality, and extent, and effects of the paralysis, or of the rigidity, will vary according to the part of the cord in which these morbid conditions occur, and the depth to which they affect it. [Cerebro spinal meningitis has, of late years, attracted considerable attention from the circumstance of its having occurred as an epidemic in different parts of Europe and the United States. According to M. Rollet, who describes the disease as it occurred at Nancy, (Bulle- tin de I'Acad. Roy. de Med., viii. 43,) it occurs under two forms; in the one, there are no signs of lesion of the nervous centres themselves, no affection of sensation or motion, though there are all the symptoms of inflammation of the membranes; at first, rigors, then maliase, tinnitus aurium, vertigo, violent pain in the head, extend- ing along the vertebral column; agitation or restlessness, slight delirium, and moderate fever, or absence of fever. In the second form there is affection of the intellectual faculties, and also of the functions of sensation and motion, with more or less complete abolition of all the senses. In this latter form the appearances upon dissection were, great vascularity of the cerebral arachnoid; a layer of plastic purulent matter cover- ing the whole inner surface of the pia mater and the brain, and a considerable collec- tion of the same matter at the base of the brain, about the pons varolii and medulla oblongata. The cerebrum was slightly punctated, but not softened. The choroid plexus was injected; the cerebellum softened; and the arbor vitae of a blood-red colour. Beneath the spinal arachnoid there was the same kind of purulent matter as beneath the cerebral arachnoid; and opposite the third dorsal vertebra, a considerable collection of pus, as well as opposite the last dorsal vertebra. The substance of the spinal cord appeared healthy. The lesions here described exactly correspond with those described by MM. Faure-Villar, Chauffard, and Forget, by whom accounts of the disease have been given as it prevailed in Versailles, Avignon, and Strasburg. Morbid changes from inflammation have also been noticed in the alimentary canal, but these M. Rollet regards as merely accidental coincidences. M. Forget, however, attaches great importance to them. lect. xxvni.] CEREBRO-SPINAL MENINGITIS. 325 The appearances alluded to are slight redness of different portions of the gastro- intestinal mucous membrane, in the form of patches, arborizations, or dots: in some instances a diseased condition of the follicles; in others, thickening, or softening, to a greater or less extent, of portions of the mucous membrane of the stomach and ileum; and in other cases, again, enlargement and even ulceration of the agminated and solitary glands of the lower portion of the ileum, with enlargement, reddening, or softening of the mesenteric glands. These lesions of the alimentary canal have almost invariably been observed in patients who survived the first few days of the attack, from which circumstance and their infrequency, they can be viewed only as the result of an accidental or secondary affection. M. Rollet remarks, that, in those cases in which the substance of the brain is affected, there is an almost continual tendency to intermission, or, at least, remission, which alternates about every three hours with an exacerbation; this he regards as merely characteristic of the encephalo-meningitis, and not as an evidence of the dis- ease partaking of the nature of remittent fever, which is the view taken by M. Gassaud. According to Dr. Mayne, by whom an interesting account is given of the disease as it occurred in Ireland during the year 1846, (Dublin Quarterly Journal of Medi- cal Sciences, for August, 1846,) its general pathological characters were nearly uni- formly the same wherever examined. The serous membrane covering the brain and spinal marrow was invariably found to be the seat of extensive inflammation, and unlike the more ordinary forms of arachnitis, the spinal arachnoid always suffered much more severely than the cerebral. In the post-mortem examinations made by Dr. Mayne, the scalp and dura mater exhibited but little undue vascularity; the pia mater covering the hemispheres of the brain was congested, and the large veins, in their way to the several sinuses, appeared remarkably turgid. The free surface of the cranial arachnoid felt dry and clammy, and had lost its transparency in many places, particularly at the base of the brain, but there was no lymph or other inflammatory effusion in the sac of the arachnoid. Lymph of a yellowish or greenish hue appeared on the surface of the encephalon, beneath the serous tunic: this occurred sparingly on the upper surface of the hemispheres, and there only along the sulci; but at the base of the brain it was found in greater quantities, especially in the sub-arachnoid space corresponding to the circle of Willis, where many of the cerebral nerves at their origin were fairly imbedded in it. In the spinal canal, a similar exudation filled the sub-arachnoidal space; it there existed in sufficient abundance to envelop the cord completely; it also extended down to the lowest extremity of the cauda equina, in- vesting each of the spinal nerves at its source; but in the vertebral canal, as in the cranium, the cavity of the arachnoid contained none of this morbid secretion. The substance of the brain and spinal marrow appeared remarkably free from lesion; there was no unusual vascularity, induration, or softening apparent, nor did the ventricles betray any evidence of inflammation. In many of the cases reported, however, the brain and spinal marrow are stated to have been occasionally implicated; in some, the ventricles of the brain contained in- flammatory effusions, and the choroid plexus appeared unusually vascular; in others, more or less of the substance of the brain and spinal marrow was found in a state of softening; in a certain number, sero-purulent effusion was detected at the base of the brain, and in the theca vertebralis; but in every instance the serous membrane was the part essentially engaged, whilst the nervous material seldom suffered, and when affected it was only accidentally involved, the disease having been, in such cases, evidently propagated to the substance of the cerebro-spinal axis from its membranous investments. In the post mortem examinations made at Versailles, in 1839, the left cavities of the heart were found to be almost entirely empty, while those of the right side were filled with large fibrinous coagula, of a yellow colour and some consistence. The same thing was observed by the physicians in other parts of France, especially in cases in which the blood drawn during the lifetime of the patient was buffy and con- tained but little serosity. Dr. Ames, of Alabama, found the blood drawn from the arm, and by cups, to form large, loose coagula, in which all the red globules were rarely included. The serum separated slowly, and in small quantity. The colour was in general bright—in a few cases approaching to that of arterial blood. In four only, 326 DISEASES OF THE BRAIN. [lect. xxviii. out of thirty cases, it was buffed. It presented indications of an excess of fibrine. In four analyses of the blood, procured, in two cases, at the first venesection, in one at the second, and in another at the third, M. Tourdes states, that the principal altera- tion detected was an increase of the red globules and of the fibrine, but especially of the former. The symptoms by which the disease commences are, in general, of a very formida- ble character, and its accession is often sudden and quite unexpected; in a large number of cases the patient is in his ordinary health and spirits up to the very mo- ment of the seizure, and experiencing no premonitory symptoms to warn him of his danger. In four of the cases at the South Dublin Union, the boys had eaten a hearty dinner, and retired to bed in apparent health, when the disease, all at once, declared itself. Very generally, however, the attack is preceded by more or less pain of the head, especially of the forehead, temples, or occiput. The pain is usually constant, but sometimes remittent, or even intermittent. Pain is, also, sometimes experienced in the back of the neck and along the course of the spine, with a sense of soreness in the limbs and joints. In a few cases the attack is preceded by a sense of giddiness, with or without dimness of vision. Occasionally, the attack commences with a feeling of chilliness, succeeded by a slight increase of the heat of the surface, and pain, extending from between the shoulders to the occiput, with stiffness, to a greater or less extent, of the posterior cer- vical muscles. In other cases, the patient may be attacked by chilliness, pallor of coun- tenance, coldness of the extremities, low moaning, or muttering delirium, quickly suc- ceeded by restlessness, flushing of the face, a frequent pulse, a wild expression of the eyes, and a hot and dry skin. In other cases, again, the disease may be ushered in by a sense of lassitude and uneasiness, considerable prostration, and a dull heavy pain of the head, with more or less vertigo, especially when an attempt is made to assume the erect position; the eyes are languid and half closed, the speech laborious and in- distinct. Occasionally the patient is suddenly attacked with deep coma, or with more or less stupor, attended by a sense of extreme debility, giddiness, dimness of sight, or double vision. Or, finally, the attack may commence with severe pain of the ab- domen, immediately succeeded by nausea, and perhaps vomiting. In violent attacks of this character, the extremities become, at the same time, cold and of a bluish colour, and the pulse is reduced to a mere thread. After a few hours, reaction, more or less complete, generally ensues. Whatever may be the character of the initiatory symptoms, they are replaced, sooner or later, by a state of violent agitation, or by a state of stupor more or less de- cided, with a slow, occasionally full, pulse, and dilated and immovable pupils. When in this condition, touching any portion of the patient's body will sometimes cause him to emit a short plaintive cry; at others, the patient utters, from time to time, acute cries, and carries his hand frequently to his head. When spoken to, he will, in general, exhibit a degree of consciousness by a motion of the head, by an attempt to articulate, or by opening his eyes for a moment. Pain, more or less intense, of tl|e head, and along the spine, is present in the early stage of nearly all cases. Pressure applied to the cervical portion of the spine will often produce pain of the head, darting to the forehead, eyes, and temples, as well as pain at the top of the sternum; while pressure on the dorsal vertebrae will cause pain at the middle of the sternum, or about the umbilicus, according as it is made higher or lower. The pain is frequently severe, and continues for some time after the pres- sure is removed. Delirium is very commonly present from an early period of the attack. It is often attended with contraction of the pupils; occasionally with dilatation of one pupil and contraction of the other; sometimes with ptosis of the eyelids, and ecchymosis under the eyes. The delirium ordinarily lasts only a short period, but quickly returns. In most cases, the mind of the patient is desponding and apprehensive. In the majority of cases there is more or less intolerance of light and sound; in some, to such an extent, that the slightest ray of light, or the least unusual sound, is apt to excite convulsive movements. Imperfect vision has been occasionally noticed in the first period of the attack — the patient seeing objects double, or only one half of them, or they appear to him as if enveloped in a mist. The conjunctivae are often lect. xxvni.] CEREBRO-SPINAL MENINGITIS. 327 injected, and the eyes of a glittering and watery aspect. The insensibility of the eyes to light, and complete blindness of one or both eyes, are noticed as having been pre- sent in many cases. Violent inflammation of one or other eye is described as being of frequent occurrence in some epidemics. In some cases there is partial or complete deafness; in others a constant ringing in the ears is complained of from an early period of the attack. An exalted sensibility of the entire surface of the body is very generally present. The patient winces upon the slightest touch, even of the bed-clothing, and refuses to change his position, from the pain consequent upon every attempt at motion. This exalted sensibility of the cutaneous surface is often manifested only towards the close of fatal cases. Diminution of tactile sensibility and confirmed stupor, when they occur, are always indications of imminent danger. In very violent cases, petechiae occur upon the extremities and over the eyelids, within a few hours after the attack. An exanthematous eruption, also, occasionally makes its appearance. The respiration is sometimes irregular and laboured — a difficulty would appear to be experienced in some cases in expanding the lungs — with respiration chiefly through the nostrils. Stertorous respiration is not a frequent symptom. There is often continued irritability of the stomach, with insatiable thirst,, and ten- derness of the epigastrium upon pressure. These symptoms are entirely independent of disease of the abdominal viscera. In two cases in which they persisted in a very marked degree to the close, Dr. Mayne, upon examining the abdomen after death, found the stomach, intestines, and other organs, without any appreciable lesion. Constipation and suspended secretions are common symptoms of the disease. The tongue is usually more or less coated with a pale ash, white, or yellowish fur. In the more grave and malignant forms of the disease, it has been observed to be broad and flabby—sometimes so enlarged as to impede articulation, and indented around its edges by pressing upon the teeth. An increased flow of saliva is commonly present. The pulse, during the period of excitement, is usually full and frequent—from 120 to 140 in a minute—often, however, it is very slow—sinking, sometimes, to 48 or 50 in the minute. The pulse has been observed to vary in the number of its beats at different periods of the day. The most striking characteristic of cerebro-spinal meningitis is that presented by the condition of the muscular system. The muscles of the neck, in particular, become rigidly contracted, drawing back the head upon the vertebral column, and firmly fixing it in that position, so that the patient is unable to move it forwards; neither can this be done by the attendants with the employment of any justifiable degree of force. The countenance, at the same time, assumes very much the tetanic expression. In some cases, the contraction is confined to the sterno-mastoid muscle of one or both sides; in others, again, it is the extensors that are principally affected, the head being retained permanently in its natural erect position. Rigidity is very com- monly observed, also, in the muscles of the extremities. The patient loses the power of moving his limbs and of assuming the erect posture. In some instances there is a quivering motion of the muscles of the face, with tremors of the hands, and embarrassment of the movements of the extremities, or spasmodic twitchings in the flexors of the limbs, with a disposition to a constant movement of the legs from side to side, alternately. In some epidemics, rigidity of all the spinal muscles was a common symptom — occasionally, the whole spine, from the occiput to the sacrum, being bent forcibly backwards, like a well-strung bow, so as to prevent the patient from lying flat upon his back. Contraction of the recti muscles of the abdomen is often present. In many cases there is a difficulty of prehension, it being with great difficulty that the patient can take and drink water from any vessel without assistance. In some cases involuntary twitchings of the muscles are produced whenever the patient attempts to move or seize any thing, as if he were under the influence of strychnia. In others, violent convulsions are induced the moment the inferior extremities are raised up, or merely touched. There is great irrregularity as to the period when the tetanic symptoms occur. They may set in as early as the first day of the attack, oi not until after the lapse of several days. Cerebro-spinal meningitis, although it is generally marked by pain in the head, 328 DISEASES OF THE BRAIN. [lect. xxviii. more or less intense, rachialgia, heat of the scalp, congestion of the conjunctivae, some degree of intolerance of light and noise, exalted sensibility of the cutaneous surface generally, tendency to coma, and a tetanic affection of the muscles of the neck, and perhaps extremities, may, nevertheless, in many instances present no symptoms of so decided a character as to lead us to suspect the existence of serious disease of the brain and spinal marrow, until the labored pulse, the dilated pupil, the profound coma, or the severe spasmodic or convulsive attacks indicate but too plainly the near approach of death. In other cases, again, and those by no means of rare occurrence, symptoms of a most formidable character may present themselves at the very outset of the dis- ease. Thus, the patient may be attacked at once with violent paroxysms of general convulsions, requiring manual restraint to protect him from injury; or, he may sud- denly, without any striking premonitory symptoms, sink into a state of coma almost apoplectic in its character, or, into a half-unconscious condition, with constant moaning or plaintive cries, and grinding of the teeth. Intermissions of a periodic character are not uncommon in the course of the disease. So complete are these, in some cases, as to lead to the hope of a speedy recovery of the patient, the fallacy of which is shown by the return of the symptoms, in perhaps an aggravated degree, on the following day. When death is not early induced by the violence of the attack, the patient sinks, more or less rapidly, into a state of profound coma, his pulse becomes slow and laboring, his powers of speech and deglutition entirely fail, his tongue becomes dry, and, together with his lips, encrusted with dark sordes; his stools are passed involun- tarily, while his bladder becomes distended with urine, or allows it constantly to dribble away: death finally closes the scene, often preceded by paralysis of one side of the body, or of one or other extremity. The duration of the disease is very variable. Death may occur within a few hours from the commencement of the attack. The generality of cases terminate about the fourth day, some, however, are protracted to over fourteen, twenty, or even fifty days. Convalescence is usually slow and lingering. Even after an apparently perfect recovery, secondary diseases are apt to occur, and sooner or later destroy the patient. The diagnosis in cerebro-spinal meningitis is somewhat obscure. There is no symptom or series of symptoms which can be considered as strictly pathognomonic. The disease is in general characterized by acute and fixed pain of the head, rachialgia, aversion from light, injection of the conjunctivae, increased sensibility of the surface, acute cries, low, muttering delirium, or coma, pain, and stiffness of the posterior- cervical muscles, with permanent retraction of the head, often rigidity of the large extensors of the spine, spasmodic tremors or twitchings of the muscles, particularly of the face, and tetanic convulsions of the limbs. When a disease, marked by several or all of the above symptoms, occurs, especially as an epidemic, we may pretty confi- dently pronounce it to be cerebro-spinal meningitis. The prognosis is for the most part unfavourable—sporadic cases, it is true, frequently do well under an appropriate treatment, but in its epidemic form, it has been found to terminate fatally in the great majority of cases. When the attack commences with great prostration, coma, and general symptoms of collapse, death often ensues very speedily without the occurrence of reaction. Few cases recover after severe tetanic symptoms make their appearance. Irregularity of respiration, difficulty of swallowing, great enlargement of the tongue, extensive petechiae, violent general convulsions, and deep persistent coma, are all unfavourable symptoms. As already remarked, it is chiefly from the occurrence of cerebro-spinal meningitis as an epidemic, that the disease has of late years attracted the attention of physicians. These epidemic visitations are occasionally confined within very narrow limits, while, at others, as was the case in France, between the years 1837 and 1842, they spread successively over extensive regions. Their occurrence would appear to be altogether independent of any morbific agency referable to peculiarities of climate, season, or locality. Age, and to a certain extent sex, would appear to rank as predisposing causes of the disease, whatever may be the nature of the epidemic agent by which it is produced. Its subjects, wherever it has occurred, have been young persons, gene- rally of the male sex. In Ireland, boys under twelve years of age were those almost exclusively attacked. In Gibraltar, in the great majority of cases, it occurred in males between two and fifteen years' of age. In Tennessee, its principal victims were iect. xxviii.] CEREBRO-SPINAL MENINGITIS. 329 children between the ages of six and fifteen years. In Missouri, between ten and fifteen years. In St. Augustine, Texas, the patients were generally under fifteen years; in but two or three instances did the disease attack those over eighteen years of age, and not in a single instance a female. In Alabama, however, the majority of those attacked — over fifty per cent —were beyond twenty years of age. Fifty-four per cent, were males. In Texas there was not an instance of the disease occurring among the negroes, who were probably more exposed to morbific agencies than the whites. In France, the disease occurred, for the most part, among the young con- scripts who had lately joined their regiments. With respect to the treatment of cerebro-spinal meningitis but little can be said of a very positive or satisfactory character. The rapid march of the disease in the larger number of cases, allows but a short interval for the application of appropriate remedies. At the height of the epidemic, especially in cases where the attack commences with symptoms of extreme violence, or in which a state of extreme collapse is present from the very onset, the most judicious and best directed treatment will very generally fail to arrest a fatal termination. In the commencement of the attack, when symptoms of prostration and of deep stupor are absent, as well as during the early period of the stage of excitement, there can be no doubt of the propriety and efficacy of direct depletion. The amount of blood to be drawn is to be measured by the age and condition of the patient and the effect produced. If a weak pulse rise, or a strong one retain its character during the flow of blood, this may be allowed to continue; but if the pulse becomes weak, a moisture breaks out upon the surface, and the face becomes pallid, indicating approaching syncope, the flow of blood should be instantly arrested, even though we may find it necessary, from the rising of the pulse, and the renewed flushing of the face, to re-open the vein a few hours afterwards. The extent of our bleeding should never be proportionate to the degree of restlessness and delirium with which the patient may be affected : these states of violent nervous erethism quickly exhaust the powers of life, and when present, a too copious venesection would be liable to induce a sudden and speedily fatal collapse. Subsequent to general bleeding, cups should be applied to the back of the neck, and along the spine, and leeches to the temples and neck, and behind the ears, and repeated at short intervals, so long as any indication for direct depletion remains. After the first bleeding an active mercurial purgative should be administered, and cold applied to the shaved scalp, by means of a bladder half filled with powdered ice, or cloths wet with iced water, or iced water and vinegar. At the same time the feet and legs should be immersed in hot water, followed by sinapisms to the feet and ankles. In conjunction with direct depletion by the lancet, active purgation cannot fail to prove an important remedy, by producing a determination from the diseased organs. There will scarcely be met with a case in which the presence of gastro-enteric inflam- mation will contraindicate its employment. Tartar emetic in divided doses, combined with some one of the saline diaphoretics, will no doubt prove beneficial in the early period of the stage of excitement. In the epidemic which occurred at Vicksburg, Miss., Dr. Hicks gave it, in combination with camphor, in the following prescription, and, as he states, with the best effects: R. Antimon. tart. gr. ij, Pulv. camphor, ^ij., Mucilag. g. acaeiae Jvj. Mix. Dose, a tablespoonful every two hours. After direct depletion has been carried as far as, under the circumstances of the case, is judged advisable, especially if the patient falls into a state of coma, with feeble pulse and deficient reaction, sinapisms or blisters along the whole course of the spine will often be found of advantage. Blisters to the upper portion of the spine very generally had the effect, Dr. Ames informs us, of removing or greatly relieving the cephalalgia, even when bleeding had failed to do so. The relief afforded by them in the malignant forms of the disease is, we are informed, very decided. Blisters to the scalp have been advised; we much doubt, however, the propriety of their appli- cation to this part. When the attack commences with symptoms of collapse, or when a state of collapse ensues after a short and imperfect reaction, the most powerful excitants — mustard, ammonia, or turpentine — aided by heat and friction, should, without delay, be ap- 330 DISEASES OF THE BRAIN. [lect. xxviii. plied externally along the spine and to the extremities, and perseveringly continued, at short intervals, until the torpid sensibility is aroused. It is probable that, in such cases, the actual cautery, as employed by M. Rollet, will be found of advantage. This gentleman passes the iron, at a white heat, six, eight, or more times, upon as many different points, along each side of the spinal processes. He states that, in the worst cases, the first application of the actual cautery does not elicit from the patient any indication of sensibility; it is only at the third, fourth, or even fifth application that a slight muscular movement proves that pain is experienced. Some patients utter cries during the last applications, but immediately relapse again into a comatose condition. Should we succeed in establishing permanent reaction, the patient must be carefully watched, and if the reaction transcend the proper grade, resort should be immediately had to general and local blood-letting, to an extent proportioned to the violence of the symptoms, and the age and strength of the patient; at the same time, cold applica- tions should be made to the head, and the other means of keeping down excessive reaction employed. The early and free exhibition of mercury, both by the skin and mouth, with the view of producing promptly its specific action, is favourably spoken of by several of the American writers on the disease. Dr. Ames, of Alabama, considers it a more efficient remedy than blood-letting, as well in the promptness as in the permanence of its beneficial effects. The French physicians condemn mercurial frictions ; more, however, we suspect, from theoretical views, than from any actual experience of their bad effects. It is proper to remark that, in many cases, mercury, even when its specific effects have been induced early in the attack, has failed to exert any percep- tible influence in retarding the fatal march of the disease. The same is true, how- ever, in reference to every other remedy that has been resorted to in this disease. Subsequent to the employment of venesection and the other antiphlogistic reme- dies, the administration of opium has been recommended by several of the French physicians. Forget commenced its use between the fifth and seventh days of the disease, in the form of a syrup containing half a grain of opium as a dose for an adult. This he found to relieve the pain of the head, and to calm the delirium and muscular spasms. M. Chaufard states that the early employment of the most energetic anti- phlogistic means failed in his hands to cure the disease, but he found it to be promplj arrested by opium given in large doses: in many cases it was advantageously com- bined with quinine. It is stated that before this plan was adopted, only one case was cured out of thirty, but subsequently the disease was even less fatal than in its spo- radic form. M. Tourdes admits the in efficacy of the usual antiphlogistic remedies, but cannot agree with all M. Chaufard has asserted in favour of the curative effects of opium. Dr. Ames, of Alabama, does not consider opium as generally a safe remedy in the more violent inflammatory cases, or as beneficial in the congestive malignant cases. In other forms of the disease, he speaks of it as a safe and very valuable remedy. We are informed by Dr. Roberts that, at St. Augustine, Texas, opium and morphia were tried in a few cases, but without any good result; they appeared rather to increase the stupor, without relieving the pain and restlessness. The water of the cherry laurel and of valerian, combined with mucilage, were employed by some of the French practitioners with a view to their sedative operation, subsequent to antiphlo- gistics and revulsives. The distilled water of bitter almonds is preferred by M. Maihle, as furnishing more definite proportions of hydrocyanic acid. By certain of the French army physicians quinine is recommended as a most effi- cacious remedy in cerebro-spinal meningitis; by the majority of them, however, it is denounced as positively injurious. Dr. Ames employed it frequently in the graver forms of the disease, and sometimes with partial success. He found it occasionally to arrest the paroxysms when the disease was attended by fever of a regular remittent character. In other forms of the disease, if not absolutely injurious, its effects were not such as to encourage a continuance in its use. Dr. Ames speaks highly of the effects of potass in this disease. It was given to children in doses of from three to five grains, every two hours. He states that no case proved fatal, so far as he could learn, in which the potass was freely and con- tinuously employed. Under the use of the remedy, in many cases unattended with true febrile symptoms, the cephalalgia was speedily and permanently relieved, and in lect. xxviii.] APOPLEXY. 381 others, its use was followed by a prompt reduction of arterial excitement, delirium, and the intense pain of the head. Etherial inspiration, it is said, was practised, with the best effects, by M. Basseron, physician-in-chief to the Military Hospital of Mustapha, in Algeria. During the period of excitement, cooling drinks should be allowed, and a strictly antiphlogistic diet enjoined. Absolute rest and quiet, with the seclusion of light, as far as it is consistent with due ventilation, are all-important. In the comatose cases, and during the stage of collapse, care should be taken to prevent an accumulation of urine in the bladder. Convalescence from epidemic cerebro-spinal meningitis is usually protracted, and relapses are liable to occur from slight errors in diet and regimen, hence the greatest watchfulness is to be observed until the general health and strength of the patient are fully re-established. Dr. Hicks found the annexed prescription to act as a most admirable tonic, after the violence of the disease had been subdued, for relieving the inertia of the nervous system that remained in every instance in which recovery took place : R. Iod. ferri, 9j; iod. potass, gij ; iodini, gr. viij; syr.'sarsaparil. §iv. Mix. Given in teaspoonful doses every four hours, in an equal quantity of pure water. — C] I proceed, in the next place, to a perfectly distinct class of diseases of the brain and spinal cord; to the apoplectic and the paralytic affections, arising independently of inflammation. It will be convenient to consider these disorders together. Apoplexy may indeed occur without paralysis, paralysis without apoplexy; but the two so fre- quently coexist, or happen in such immediate sequence and connexion, and in their history and pathology they have so much in common, that we shall best understand the whole subject by comprehending them in the same review. When a person falls down suddenly, and lies without sense or motion, except that his pulse keeps beating, and his breathing continues, he is said to have been attacked with apoplexy. He appears to be in a deep sleep; but this is not all, for you cannot awaken him by the same means which would rouse a healthy man. He is not in a state of syncope, for his pulse beats, perhaps with unnatural force; and often his face, instead of being pale, is flushed and turgid, and his respiration goes on, though it may be laboured and stertorous. What I now denominate apoplexy, is the very same state which has so frequently been mentioned already in these lectures; it is coma occurring suddenly, or coming on (at least) with rapidity. What is coma ? It is that condition in which the functions of animal life are suspended, with the excep- tion of the mixed function of respiration; while the functions of organic life, and especially of the circulation, continue in action. There is neither thought, nor the power of voluntary motion, nor sensation: but the pulmonary branches of the par vagum continue to excite, through the medulla oblongata, the involuntary movements of the thorax. When this upper part of the cranio-spinal axis becomes involved in the disease, and its reflex power ceases, the breathing ceases also, and the patient is presently dead. It is a common question—how would you distinguish apoplexy from the effects of a narcotic poison ? If you were summoned to a person in the state I have been de- scribing, how could you tell whether he was afflicted with apoplexy, or stupefied by a large dose of opium, or merely dead drunk ? Why, so far as the condition of the cerebral functions is concerned, you cannot discriminate the one from the other. In each case there is profound coma: but the cause of the coma is different in each, and you must seek to ascertain that cause in the history and other circumstances of the patient: you inquire whether he isknown to have been drinking, you try if you can perceive the odour of alcohol, or of wine, in his breath; or you endeavour to make out whether he has been low-spirited, or in known difficulties; in short, whether it is likely that he may have swallowed poison. But from the actual condition of his sensorial functions, you cannot solve the question. Yet let me say, thus in the outset of our remarks upon apoplexy, that it is often of great importance that the diagnosis should be determined. A man was found lying in Smithfield in a state of total insensibility, and motionless, except that he still breathed. He was carried into St. Bartholomew's Hospital. The house-surgeon thought he smelt the smell of gin in his mouth; and thereupon very properly made 332 DISEASES OF THE BRAIN. [lect. xxviii. use of the stomach-pump. By means of it he discharged a large quantity of ardent spirit; and in the course of a few minutes the man revived, shook his ears, and walked away. If the gin had been suffered to remain in the stomach, and if the remedies of apoplexy had been vigorously put in force, the absorption of the poison would have been thereby accelerated; and the debauch would probably have had a fatal termination. The same remarks apply still more urgently to the case in which opium, or any other strong narcotic poison, is lying in the stomach. Even when there is no great danger, either in the person's condition, or in the remedies used for it, it is not a very pleasant or creditable thing to make a false point of this kind. If we do err, however, we had better err on the safe side. The father of the late Pro- fessor James Gregory, of Edinburgh, (who used to relate the case in his lectures), was once called out very late in the evening to visit an old gentleman of that city. He found him in a completely comatose state; his wife crying, and all his household plunged in grief and distress. They told him that the patient, whom he now saw in a fit, had come home, and upon the servant's opening the door to him, had fallen into the passage, on his back, in a state of insensibility. Dr. Gregory learned, however, that he had been at the " Club," and he knew well enough that this club was com- posed of choice spirits, fond of their cups; although the gentleman's wife did not know so much. Therefore he ventured to express his "hopes" to the wife that her husband was drunk: a charitable view of the case, at which she was extremely affronted and indignant. He persisted, however, in his opinion, and not long after- wards the patient began to recover his senses. It turned out that he had partaken more liberally than the rest of the club, and was the first to be intoxicated. Two of his companions carried him home quite incapable of motion ; but not liking to intro- duce him themselves to his wife in that predicament, they placed him with his back against the door, rang the bell, and decamped. Of course when the servant came to open the door, his master tumbled senseless on the floor. I need not point out to you what ridicule the physician would have brought upon himself, and what damage he might have inflicted upon his patient, had he busily applied, in this case, the ordinary remedies of apoplexy. The state of coma, such as I have described as being characteristic of apoplexy, may terminate in one of three ways. It may cease, more or less rapidly, and leave the patient to all appearance in perfect health. What may be the exact condition of the encephalon during the continuance of the coma, in such cases, no one can positively tell. But the occurrence of temporary coma, under the influence of a narcotic poison, and the perfect disappearance of the coma as the effects of the drug pass off, teach us that the functions of the brain may be almost totally suspended for a time by causes which do not injure its texture. I think it probable that, when there is no poison at work, a temporary stress upon the cerebral blood-vessels (pro- duced by a determination of blood towards the head, through the arteries, or by a detention of blood in the obstructed veins) may exercise a sufficient degree of pressure upon the central parts of the brain to cause transient coma. But often there is poison at work, an inbred poison, of which the agency was not recognised until a recent period; the poison of unpurified blood. When speaking of the general pathology of dropsy, I mentioned a peculiar renal disease — first detected and described by our distinguished countryman, Dr. Richard Bright — which unfits the kidney for what is probably its most important office; that of removing urea from the system. When this excrement, thus retained, accumulates in the blood beyond a certain amount, it is very apt, among other injurious tendencies, to cause death in the way of coma. The retention of bile, or of some of its principles, has occasionally, as it would seem, a similar consequence. In all cases, therefore, of apoplectic stupor, you must not omit to search for evidence of this source of the coma. In the second place, the apoplectic coma may terminate, more or less quickly, in death. And on examining the brain we may find a large quantity of extravasated blood spread over its surface, or lying within its broken substance : or a considerable effusion of serous fluid collected within its ventricles : or we may detect no deviation whatever from the healthy structure and natural appearance of the organ. The. con- gestive pressure (if it indeed existed) has left no prints of its action. Dr. Abercrombie has given to that form of apoplexy, which destroying life, leaves no traces behind it, the name of simple apoplexy. And this name, for its conve- LECT. XXVIII.] APOPLEXY. 333 nience, I shall retain. Of the other two kinds of quickly fatal apoplexy, that in which blood is found extravasated is more common than that in which there is effusion of serum only. The one has been called sanguinous apoplexy ; a better term is cerebral hemorrhage: the other has been named serous apoplexy. Thirdly, the apoplectic coma may terminate in partial or imperfect recovery. One, or all of the cerebral functions may be left impaired; the mind enfeebled; the power of motion limited, or lost, in some parts of the frame; the faculty of sensation be- numbed or extinguished: the unhappy subject of the attack remaining more or less crippled in body, and more or less maimed in intellect. In these cases, when at length we have an opportunity of examining the brain, we almost always find traces of damage inflicted upon its texture at the period of the attack. A part of this damage has usually consisted in the extravasation of blood to a small or moderate amount: sometimes, with or without extravasated blood, there is softening or disrup- tion of the nervous substance. I shall return to these points presently. The attack of apoplexy does not always occur in the same manner; and Dr. Aber- crombie has pointed out three several ways in which it is apt to come on. I am con- fident, from the result of my own observation, that the distinctions laid down by Dr. Abercrombie are just and true: and it is of importance that you should be aware of them. "In the first form of the attack, the patient falls down suddenly, deprived of sense and motion, and lies like a person in deep sleep; his face generally flushed, his breathing stertorous, his pulse full and not frequent, sometimes below the natural standard. In some of these cases, convulsions occur; in others rigidity and contrac- tion of the muscles of the limbs, sometimes on one side only." Now respecting persons seen in this condition, the immediate prognosis is uncer- tain. Some die in a short time, and much blood is found extravasated within the cranium. Some die after a rather longer interval, and then we often find serous effusion only. And in some that die early, no effusion either of blood or of serum can be detected. Some recover altogether, without any ill effect of the attack remaining. Others recover from the coma, but are left paralytic of one side, and with some imperfection of speech, or of one or more of the senses. And this paralysis and imperfection may disappear in a few days, or gradually depart, or remain for life. In the second form of attack, the coma is not the earliest symptom. The disease generally begins with sudden and sharp pain in the head. The patient becomes pale, faint, and sick, .and usually vomits; and sometimes, but not always, falls down in a state of syncope, or resembling syncope, with a bloodless and cold skin, and a feeble pulse. This also is occasionally accompanied by some degree of convulsion. Some- times he does not fall down, the sudden attack of pain being accompanied only by slight and transient confusion. In either case he commonly recovers in a short time from these symptoms, and is quite sensible, and able to walk; but the headache does not leave him. After a certain interval, which may vary from a few minutes to several hours — and Dr. Abercrombie records cases in which it was even much longer—the patient becomes heavy, forgetful, incoherent, and sinks into coma, from which he never rises again. In some instances, paralysis of one side occurs; but perhaps more often, there is no palsy observed. The disease, when it comes on in this way, is much more uniform, and of much worse omen, than when it commences after the former fashion. It'is of great use to know this; for to an inexperienced eye the cases do not seem so terrible as those in which the patient becomes profoundly comatose from the very first. The apparent amendment is fallacious, and apt to lead one into giving a false prognosis. Very few persons come out of the coma, and a large quantity of blood is usually found extra- vasated in the brain. These cases are not, as Dr. Abercrombie well observes, apoplectic in the outset. They differ remarkably from the first set of cases. If there be at the very beginning some loss of sense or motion, it goes off again in a very few minutes, or perhaps in a few seconds: the prominent symptom, at the commence- ment, is sudden and violent pain of the head, with faintness, sickness, and often with vomiting. The pain continues, and is sometimes confined to one side of the head; the face is pale and ghastly, the pulse weak, and often frequent or irregular; but the patient is quite conscious, and in full possession of his intellect. At length he recovers his natural temperature, his countenance improves, and the pulse becomes stronger and steadier: then his face gets flushed, he feels oppressed, answers questions 334 DISEASES OF THE BRAIN. [lect. xxviii. slowly, and at last sinks into stupor and fatal coma. The period between the first attack and the commencement of the coma is variable. Sometimes the stupor suc- ceeds the pain and faintness so rapidly, that the case comes greatly to resemble those in which coma is the first symptom, and takes place suddenly; but still a short period of sense, commonly with complaint of great pain, may be observed. But the interval may be a quarter of an hour, or many hours, or even two or three days. " Upon inspection," says Dr. Abercrombie, "we find none of those varieties and ambiguities, which occur in the apoplectic cases, but uniform and extensive extravasation of blood." [I should state that he calls the first class of cases apoplectic cases, the coma being present from the first: and the second class, which we are now considering, he calls cases not primarily apoplectic.'] The symptoms in this form of attack depend, no doubt, upon the giving way of some one of the cerebral vessels. At the moment when the vessel is ruptured, a shock is given to the brain; a temporary derangement of its functions occurs; but this passes off. The circulation then goes on as before, until such a quantity of blood has escaped from the ruptured vessel as is sufficient to produce coma. There is no part of Dr. Abercrombie's book more admirable, and clearly put, than that which is occupied with these important distinctions, which I give you very much in his own words. He points out the close analogy which exists between this variety of apoplexy, and the result of external injuries, when they occa- sion extravasation of blood on the surface of the brain. The hurt person recovers from the immediate effects of the accident, walks home perhaps, and after some time becomes stupid, and at last comatose. The surgeon trephines the skull, and disco- vers blood upon the dura mater; and the blood being removed, the coma goes off. We cannot help our patients by a similar expedient; though the opinion has been broached that trepanning the skull will, at some future period, be a common practice in apoplexy. Dr. Abercrombie conjectures that after the rupture has taken place, the haemorrhage is sometimes stopped by the formation of a clot at the orifice in the vessel, but at length the blood bursts out again, and proves fatal. He relates two cases in which this probably happened; in one of them an interval of three days, and in the other an interval of a fortnight, elapsed between the first attack, and the super- vention of coma. ^ The portions of blood extravasated at the two separate periods may sometimes be distinguished by their appearance — their colour and consistence. The third form of attack described by Dr. Abercrombie can scarcely be said to be an apoplectic attack at all; indeed he himself includes this form in the class of para- lytic cases. It is characterized by sudden loss of power on one side of the body, and frequently by loss or impairment of speech, without loss of consciousness. The patient is sensible, listens to and comprehends your questions, and answers them as well as he is able, either by words, which in most cases he articulates imperfectly, or by gestures. The further progress of the cases that commence in this way is marked by considerable variety. Sometimes the hemiplegia passes gradually in a short time into apoplexy. Sometimes the patient soon gets well, the palsy leaving him entirely. Or a gradual recovery takes place, which is not complete for some weeks or months. Or the patient rallies up to a certain point, and there the improvement stops; he regains the power of moving his leg, but it drags somewhat after him; or the leg recovers, but the arm remains feeble, or his speech continues to be inarticulate. And in another variety of this form the patient neither improves on the one hand, nor becomes apoplectic on the other, but is eonfined to his bed, paralytic, and perhaps speechless, though in possession of his faculties in other respects, and dies at last worn out and exhausted, some weeks, or months it may be, after the attack. In the outset of these cases there is not always complete hemiplegia, sometimes the arm only is affected, sometimes (but much more rarely) the leg only. Or some other voluntary muscles are the first to lose their power. Dr. Abercrombie speaks of the conditions discovered after death in cases that have thus commenced, as being inconstant; but I believe that in a vast majority of in- stances they will be found to consist of softening of the brain and its consequences, whereby the communication between the centre of volition and the paralysed muscles has been suddenly cut off. With this softening there may, or there may not, be ex- travasation of blood. You will find, I think, that most cases of apoplexy, or of palsy akin to apoplexy, range themselves with more or less exactness in one or the other of the three classes LEOT. xxviii.] APOPLEXY. 335 which I have been describing. Let me briefly recapitulate them. In the first, the coma is sudden and deep; the condition of the patient thus struck in an instant senseless and motionless, warranting those epithets which the ancients applied to the victims of this disease, of attoniti and siderati, as if they were thunder-smitten, or planet-struck. In the second form of the attack, the earliest symptom is acute pain of the head, with sickness and faintness; coma supervening usually in no long time. The third form is ushered in by sudden hemiplegia, which may or may not lead to loss of consciousness, or stupor. These broad lines of distinction, being kept in mind, will both furnish assistance towards the diagnosis and the prognosis of this multiform disorder, and also give "to your study of it, as it occurs to you in practice, a higher degree of interest than it would possess if all the forms of attack had been jumbled together in one common description. When the apoplectic state is fully formed, in what manner soever the attack may have commenced, it is marked by most or all of the following circumstances. The patient lies totally unconscious of all that may be going on about him. He replies to no questions, he is unmoved by the cries and lamentations of his family; in fact, he does not hear them. His pulse is infrequent, often full, perhaps intermitting. His breathing is peculiar, being slow, sometimes interrupted or irregular, attended with snoring or stertor during Aspiration, and a puffing out of the cheeks, like the action of one who smokes a pipe, during expiration. Both these peculiarities are referable to the same principle, and both denote a profound insensibility to all external impressions. There is no longer any voluntary attempt to breathe, yet the involun- tary movements of respiration subsist: the medulla oblongata still responds to the impressions which reach it from the lungs and from the skin, still prompts contrac- tion of the muscles that enlarge the capacity of the thorax; but the loose curtain of the palate, and the lips and cheeks, are passive. By the vibrations of the one the stertor is occasioned; the mouth is closed by the mere elasticity of the others, and the flaccid cheeks flap outwards with the explosion of the air, as it escapes when the chest again collapses. The countenance is frequently turgid, and livid; the blood which tinges it is already but half arterialized; the pupils are commonly contracted; sometimes they are of unequal size. The limbs lie motionless : either they are all absolutely palsied; or (what probably is often the case) the capacity of motion re- maining, the will to move them is wanting. If you raise one of them it falls pas- sively down again, when you leave hold of it, like a dead limb. Sometimes, how- ever, they are rigid and sriff. Sometimes one is stiff, and the others limber. And sometimes one or more of them, or those of one side, tremble, or are distinctly con- vulsed. You find perhaps that the patient is unable to swallow. If you put fluids into his mouth, they appear to choke him, or they run out again at the corners of his lips. His bowels are usually torpid; but if they act, the evacuations are passed in the bed without his knowledge or concern. His urine also flows involuntarily; or is retained in the distended bladder until it fairly overflows, and dribbles away perpetually. When the attack terminates in death, that event is preceded, I believe in almost every case, by profuse perspiration, which bursts forth from every part of the sur- face, and is often cold and clammy. The pupils are sometimes at this period dilated, one perhaps more so than the other. The pulse becomes more frequent, the breathing more rare, and at last it ceases altogether. In this description you will perceive that something more is included than pure coma. The absence of consciousness — implying the suspension of thought, of sen- sation, and of volition—marks plainly the affection of the cerebrum. The symptoms which diversify the apoplectic state, and distinguish one case of the disease from another, proceed from an associated or consecutive affection of the spinal cord There may, indeed, be merely coma; profound and invincible sopor only. In this condition a morsel of food, or a spoonful of drink, passed far back into the pharynx, is instantly carried onwards by an act of deglutition : the excrements are duly re- tained, and duly voided: the limbs are simply passive and motionless; neither stiff, nor convulsed. But in the severe cases, inability to swallow, laxity of the sphincters, spasms, rigidity, tremors of the voluntary muscles—more or fewer of these adjuncts to the coma—are very apt to present themselves: and they denote, I say, the direct 336 DISEASES OF THE BRAIN. [lect. xxviii. or indirect oxtension of the morbid influence on which the apoplexy depends, to the cranio-spinal axis. An easy and interesting criterion of the degree in which the reflex^ apparatus may be concerned has been pointed out by Dr. Hall. The orbicularis is the sphincter muscle of the eyelid. Touch the eye-lashes, and the lids involuntarily close; even during sleep the movements of the shut lids are apparent. If, in apoplexy, they do not respond to this mechanical stimulus, we know that the true spinal functions are gravely implicated. On the other hand, many of the morbid phenomena just mentioned may occur, without any affection, from first to last, of the intelligence. But to these forms of disease, although their nature and essence may be the same, the term apoplexy cannot properly be applied. This state, so appalling and painful to look upon, but fortunately so devoid of suffering for the patient — this suspension of the functions of animal life — depends, we have reason to believe, upon pressure applied to the brain, the organ subservient to those functions. That excess of pressure is a vera causa is obvious, and that it is adequate to the production of coma is capable of demonstrative proof. It is not enough to show that they often exist together, for the coincidence might be casual. Neither does their occasional disjunction, real or apparent, furnish any conclusive argument against the general proposition, that coma, in many and in most cases, is the result of pressure upon the encephalon. Coma may exist without pressure. In other words, coma acknowledges other causes also, besides pressure. It is produced by many narcotic poisons; by the circu- lation of venous blood through the arteries. In these cases we have no proof of any compression of the cerebral substance. The other disjunctive condition is much more puzzling, and has led some persons to question or deny the general proposition. Can there be unnatural pressure, yet no coma ? It would seem so. Serum, pus, blood, have been met with in the brain, foreign matters have penetrated the cranium, and coma has not ensued. The force of this difficulty is lessened by the consideration that foreign substances may be present within the skull, without occasioning any preternatural degree of pressure. We read of bullets being carried about for some time in the brain. In such instances it is probable that a portion of the contents of the skull was forced out at the time of the injury : or that coma has come on, and gone off again, in con- sequence of the gradual absorption of the cerebral matter to make room for the foreign body. The same explanation may be applied to the chronic accumulation of water within the cranium, and to the slow growth of tumours. Further, there is reason to believe that it is not on every part of the brain that the same degree of pressure made will produce the effect ascribed to it. It is stated in Mr. Mayo's Physiology, as the result of actual experiments on animals, that lateral pressure against the hemispheres of the brain produces no observable ill consequence; but that vertical pressure, pressure downwards, occasions stupor; which is probably attributable to compression of the central or deep-seated ganglia. Now it is obvious that some injuries of the brain may tend more than others to cause pressure in that direction. The difficulty may not be wholly relieved by these considerations. But it is a difficulty which cannot invalidate the evidence of numerous facts that attest the agency of pressure, as, at least, one cause of coma. The presumption of such agency arises whenever coma immediately succeeds to pressure; and it is converted into certainty if, upon the removal of the pressure, the coma immediately departs. Now the annals of physic are full of instances of that 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 remitting 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. lect. xxvni.] APOPLEXY. 337 A most remarkable example of the concurrence of coma from pressure upon the brain, and of the removal of the ccma by removing the pressure, was afforded by a patient who was in St. Thomas's Hospital under the care of Mr. Cline. Mr. Green, who was Mr. Cline's nephew, was in the habit of relating the case in his lectures here. It is quite pertinent to my present purpose. One of Mr. Cline's apprentices was visiting the depot at Deptford, and discovered there a man who had been for some time in a state of unconsciousness : and he had him removed to St. Thomas's. His main symptoms were apparent insensibility to all surrounding objects, and a total incapacity to make any communication to those about him; except that his at- tendants learned to infer, from certain instinctive movements or gestures, that he felt hunger, or thirst, or a want to relieve his bowels. His fingers were permanently bent towards the palm of the hand, and his eyes were turned upwards, so that the corneae were completely concealed beneath the upper lids. Upon examining this man's head, Mr. Cline found that there had been fracture with depression of one of the parietal bones. He trepanned that part, and elevated the bone. The patient seemed to feel the operation; and as soon as it was concluded, his eyes and fingers were restored to their natural position. On the evening of the same day he sat up in bed, and though at first stupid and incoherent, soon became rational and well. When he had entirely recovered his senses, it was ascertained that the last thing he remembered was his serving on board a vessel which made a capture off Minorca. He was wounded in the engagement, and carried afterwards to the hospital at Gibral- tar. All this happened upwards of twelve months before the operation. So that one whole year of this patient's life was a complete blank, because, during that period, a little piece of bone was pressing upon his brain. Cases of this kind show, very convincingly, the connexion that subsists between pressure on the brain and coma, and their relation to each other as cause and effect. The pressure and the coma begin together; the coma continues as long as the pres- sure continues; and it ceases when the pressure is removed. The old definition of the cause of a morbid condition is completely satisfied: " Praesens morbum facit, mutata mutat, sublata tollit." Observe, in passing, that in the case just described there was not only coma, but a permanent contraction also of certain muscles ; that these muscles did not through that long period of time become unfit for the exercise of their proper function; and that the pressure was applied to the periphery of the brain. From this digression — not altogether foreign to our subject—I return to the con- sideration of the pathology of apoplexy. If the patient recover from the coma, he may live a few hours, or days, or he may live for many years. Sometimes, as the coma departs, all the natural functions are gradually restored; but much more commonly paralysis remains. You already know that it is apt to affect one moiety of the body only. If a line be drawn from the vertex to the perinaeum, dividing the body into two halves, which, so far as the exterior is concerned, are symmetrical, all the voluntary muscles that lie on one side will be found powerless; or if they are not all so, those which are palsied are situated on the same side of the line. And this state of things is called hemiplegia. Paraplegia, that condition in which all the parts below a transverse line are palsied, though it sometimes results from cerebral disease, is much more commonly the consequence of mischief in the spine. Hemiplegia, I say, may remain after the coma of apoplexy has passed away. But I have already told you that hemiplegia may occur without antecedent coma, and as a primary affection. The actual phenomena are the same in either case; and a careful study of these phenomena you will find to abound with interest. Hemiplegia, then, may be complete or incomplete. By complete hemiplegia I mean total palsy of most of the voluntary muscles on one side of the body, and espe- cially of the muscles of the limbs of one side. The patient may will the motion of his leg, or arm, but they no longer obey the act of volition; if they are lifted by another, and then let go, they drop down like logs of wood. You will find that, in well-marked cases, the intercostal muscles of the palsied side do not contract. Dr Todd makes this remark concerning the muscles of the thorax and abdomen, that they are seldom palsied in hemiplegia depending on disease of the brain; but almost 338 DISEASES OF THE BRAIN. [lect. xxviii. always so in the rarer form of hemiplegia which sometimes results from mischief in the upper part of the spinal cord. The muscles of the face, also, are some of them inert on the same side. I have known many persons who have thought that the muscles of the face, in hemiplegia, when they were affected at all, were affected on the opposite side of the body from that to which the palsied limbs belonged. But they never could have examined actual cases of hemiplegia with any attention. How the error arose I cannot tell, but I have known a professed anatomist make it. I guess that it may have arisen from one of two causes. An anatomist who had not looked closely upon disease, would expect, and not unnaturally, that the face and limbs would be affected on opposite sides of the body; seeing that the nerves which supply the muscles of the face are given off above the place where those fasciculi of nervous matter which are called the anterior pyramids, decussate each other. And a common observer, who was not an anatomist, would be apt to conclude that the side towards which the mouth was drawn was the affected side: whereas it is just the reverse. The face is drawn to the healthy side, because the muscles on that side are no longer counteracted and balanced by the corresponding muscles of the palsied side. The blank half of the face is that which answers to the paralysed limbs The muscles which cease to obey the will are generally those that are supplied by the third, or by motor branches of the fifth nerve : and the rule in hemiplegia is that these muscles are palsied on the same side with the muscles of the leg and arm. But there is no rule, they say, without an exception : certainly the exceptions to this rule are very uncommon. I have not had leisure to look over the records of the very many cases of this disease which my position as physician to a hospital has brought under my observation; but I do not recollect more than two exceptions; and one of them, as it happens, is now exhibited in the person of one of my patients in the Middlesex Hos- pital. Some of you have seen the woman. It is a well-marked exception : but in this instance the hemiplegia followed a blow on the head, and I suspect that a double injury was inflicted; that the palsy of the face results from mischief on one side of the brain, and the palsy of the limbs from mischief on the other. This I only con- jecture, because the phenomenon is so rare.1 Then, again, with respect to the tongue: when put out beyond the lips, its point is commonly turned to one side. To which side ? Why towards the palsied side. For what reason ? Clearly because the muscles that protrude the tongue are powerless on that side, and in full vigour on the other. That half of the tongue which corresponds with the sound side is pushed further out than the other half, and therefore the tongue bends to the palsied side. Such is the usual fact, and such the explanation of it. But there are more numerous exceptions to this than to the correspondence of the paralysis in the external facial muscles. Gaps in the row of teeth may regulate the direction of the protruded tongue. Sometimes it comes out straight; sometimes the patient cannot thrust it forth at all; and sometimes, even, it deviates towards the sound side. But the rule is as I have stated it. This also has been noticed of the tongue in such cases; that the patient has been able, after some effort, to thrust it suddenly out, and then has required a certain interval of time before he could do so again; as if the spent nervous power were slowly regenerated. With these different affections of the tongue, the patient's speech is variously altered. His voice is thick, muttering, inarticulate, or unintelligible. Some- times, even though he may be quite conscious and rational, he is unable to utter a syllable: or his efforts result in the constant use and repetition of some one inappro- priate word or phrase; and he seems vexed at finding that his attempts to converse are fruitless. Supposing the patient to recover, wholly or partially, from the paralysis, the leg, the face, and the tongue, in nine cases out of ten, ay, and in a much larger propor- tion than that, recover first and fastest: sooner and quicker I mean than the arm. And another fact, quite analogous with this, is that when one of the extremities alone is affected with paralysis, it is, in nineteen cases out of twenty, the arm that is so affected. I give you again the rules; they are liable to occasional exceptions. It is stated by Romberg that hemiplegic paralysis dependent upon spinal, and not upon cerebral mischief, is more persistent in the leg than in the arm. i This patient died afterwards, at her own home; and no opportunity was given of inspecting LECT. xxviii.] APOPLEXY. 339 This, then, is one way in which the hemiplegia may become, or be from the first, incomplete : viz., in extent. One limb may be powerless and the other strong. But the palsy may also be incomplete in degree. The patient may be able to move and use his limbs, but they are feeble. Such movements as he is capable of are com- menced slowly; as though the effort of volition were not obeyed, as it is in health, on the instant. He cannot bend his fist firmly; nor lift his arm beyond a certain height. Or his leg feels heavy to him, and trails a little behind as he walks; he is unable to stand upon that limb; or to plant his foot securely, or with the usual precision. In short, there are innumerable gradations of paralysis, from slight weakness of the affected muscles to perfect immobility. I have stated that the actual condition of the palsied muscles differs in different cases. Sometimes the limbs are loose and supple; bending backwards or forwards readily when moved by the hand of another, or by the sound hand of the patient him- self. Sometimes, on the contrary, they are more or less stiff and contracted. They resist the attempted movement. You cannot extend or bend them much; and your endeavour to do so gives the patient pain. The rigidity may affect both the flexor and the extensor muscles, but it is principally seen in the flexor. It may present itself in both limbs, but it is most often manifest in the arm. These facts have long been recognised. The light which they shed on the pathology of brain disease, and the guidance which they furnish in its treatment, have been but recently pointed out. We owe this valuable addition to our knowledge on these subjects, to your distinguished teacher, Dr. Todd. His doctrines are fully expounded in his volume of Clinical Lectures on Paralysis, Disease of the Brain, and other Affections of the Nervous System ; from which I gather very much of what I am now about to tell you. Rigidity of the limbs in hemiplegia may occur simultaneously with, or presently after, the palsy; and then it indicates "irritative disease" within the cranium. It may come on slowly, late in the course of the disorder, after perfect resolution and flaccidity of the muscles in the first instance; and then it shows that there has been " loss of substance of the brain, and that a cicatrix is undergoing contraction." The rigidity that happens early in the disease may be slight and partial, one or two only of the palsied muscles being stiff while the others are flaccid; or it may be con- siderable, and affect nearly all the muscles. If you try to extend the patient's arm, or to straighten his fingers, you find that the biceps in the one case, and the flexores digitorum in the other, are, or at once become, stiff, and resist your efforts: and in like manner, though less strikingly, the triceps of the arm may forbid its flexion The same may be said, mutatis mutandis, of the leg, when it presents similar phe- nomena. Sometimes, but not often, the muscles concerned in mastication are impli- cated. The patient, though insensible, resists powerfully any attempt to pull open his mouth. This early rigidity is occasionally preceded or accompanied by convulsive move- ments. It is attended with little or no wasting of the affected muscles. The rigidity that remains late in the disease, may follow either of the two earlier conditions — the lax or the stiff condition — of the palsied muscles. Like the former rigid state, it is sometimes slightly marked; while sometimes it is extreme in extent and in degree, the hand being carried up to the shoulder, the fingers bent into the palm, which is hurt by the growth of the nails, and even the heel fixed firmly against the buttock. Whatever its degree, this form of rigidity impermanent; and the rigid muscles, and the limbs to which they belong, gradually dwindle. Inaction of the muscles, according to the principle which I explained to you in a very early part of these lectures, leads to lessened nutrition, and a consequent diminution of bulk; in one word, to atrophy. Sometimes, however, the size of the helpless limb is main- tained, or even augmented, by the supervention of oedema. The motion of the blood in its veins not being aided by the play of its muscles, the areolar tissue becomes infiltered with serous liquid. When in the outset of hemiplegia the palsied limbs are lax and flabby, there is both early and rapid wasting of their muscles. Dr. Todd's theory, I repeat, with respect to the early rigidity, occurring with or without convulsive movements, is that it is connected with irritation within the cra- nium : with laceration of the brain, for instance, by a clot of extravasated blood — 340 DISEASES OF THE BRAIN. [lect. xxviii. with an inflammatory condition of its hurt, or around its softened, substance — with the mechanical irritation produced by depressed bone in fracture of the skull. And the occurrence of this early rigidity warrants the opinion that the cerebral mischief or irritation lies on, or not far beneath, the surface of the brain. The late rigidity he believes to accompany a gradual shrinking and contraction of the cerebral matter, during the process of repair set up in the torn or otherwise injured brain. There is another mode of discriminating different conditions of hemiplegia, which Dr. Todd has, to the best of my belief, put upon its right footing. It is furnished by the results of the application of the stimulus of electricity to the paralysed mus- cles. He makes three classes of cases. In the first, and vastly most numerous class, he found the palsied limb to be affected slightly, or not at all, and always less than the sound limb. In the second there was no perceptible difference in the effect of electricity upon the two limbs. These were " cases of recent paralysis, the cause of which was not of a very depressing nature." In the third class the electricity had a greater influence (yet never a much greater) upon the palsied than upon the sound limb. In nearly all these last cases the paralysis was accompanied by early rigidity of the muscles. Dr. Todd's conclusions on this matter, which I give you in his own words, are " that when the paralysed limbs exhibit an early spastic or rigid state of the muscles, they will be more excitable by electricity than the sound limbs; but if the paralysis be accompanied by a state of complete resolution of the muscles, the sound limb is most excitable to the galvanic stimulus, and the paralysed limb is sometimes scarcely at all to be excited. In the latter case, the nerves of the paralytic limb are in a de- pressed condition; in the former they are in an irritated condition; and the different effects of electricity in the two cases will depend on the difference of cause of the paralysis. If the paralysing lesion be irritative, the paralytic limb will be more ex- citable by the galvanic stimulus; if, on the other hand, it be depressing, the paralytic limb will be less excitable; and thus this difference in the effect of electricity on the two limbs may serve to guide us in our diagnosis, and we may conclude that the lesion is irritative or depressing, according as the paralytic limb is more or less excitable by the galvanic stimulus." Besides the palsy, there is often anaesthesia also. But this is by no means so con- stant a symptom as the paralysis. The function of sensation (wherefore I cannot tell) is less frequently abolished or perverted than the function of voluntary motion. When the sensibility is lost, or blunted, or any how modified, it is so, commonly, in the same parts that are affected with paralysis. But sometimes there is anaesthesia, and no palsy; and, more strange still, there has been sometimes anaesthesia of one side and palsy of the other. As a general rule, the anaesthesia is less common, and less intense than the palsy; and is much sooner recovered from. Tracing these cases onwards — such cases, I mean, as do not perfectly recover,— we find that the palsied limbs are usually colder than their fellows. This probably is owing to the diminished circulation of blood through the capillaries : there is not so much blood converted into venous from arterial; and less animal heat is developed. This has been observed even when the main artery of the part has beat as forcibly as in the corresponding part on the other side. It is necessary to be aware that these palsied parts do not resist the influence of cold or of heat so well as the sound parts. When the sensibility is blunted, we can readily understand how the limb may become burned, from the absence of any warn- ing pain that an injurious degree of heat is applied : but this is not all. A lower degree of temperature than would injure a sound part has often been found prejudicial to a palsied part: and if these palsied parts get chilled by frost, they more readily vesicate and inflame, on the return of heat, than other parts: merely warm water will sometimes act upon them like scalding water. I say a knowledge of this fact is of practical moment. That degree of warmth which the palsied limb fails to generate for itself, we must accumulate for it by warm clothing; and we must take care that it is never exposed to any artificial temperature which exceeds a certain point. We sometimes see mischief done by applying hot bottles or bricks — too hot — to such limbs. The mental faculties are, in some few instances, quite unhurt by the attack: too frequently, however, they suffer irreparable damage. Of many persons, a striking LECT. XXIX.] APOPLEXY. 341 alteration is evident in the whole character and temper. The brave man has become timid; the prudent man foolish; the calm and cheerful man peevish and impatient. There is no longer the same power of attention, the same capacity for business, the same clearness and comprehension of thought. And whatever other changes may be observable, there are two ways, especially, in which the patient, after he has emerged from the coma, is very apt to be affected: viz., by a defection of memory, more or less partial; and by a peculiar tendency to emotion, particularly the emotion of grief: he will weep for very slight causes, sometimes long after the attack of apoplexy has passed over. This is very curious. I may tell you that the same readiness to shed tears, and to be immoderately affected by trifling causes of emotion, is sometimes no- ticed among the precursory symptoms of apoplexy. LECTURE XXIX. Apoplexy and Palsy, continued. Conditions of the Brain left visible after Death. Cerebral Hemorrhage. Changes of and around the extravasated Blood. White Softening of the Brain. How produced. Parts of the Brain most commonly implicated. We were engaged with the subject of apoplexy. I requested your particular attention to the threefold mode in which that fearful disorder has been observed to make its attack. I described the apoplectic state itself, and endeavoured to elucidate the manner of its production. Lastly, I brought under your notice the varied pheno- mena of hemiplegia, and pointed out to you the inferences which have recently been drawn from the pliant or the stiff condition of the paralysed limbs. Let us next inquire what morbid conditions have been disclosed by dissection of the brain after death from apoplexy and cerebral palsy; and what relations these con- ditions bear to the different outward manifestations of disease which were recounted in the last lecture. I shall pass over those cases in which no morbid condition is detected, simply reminding you that a determination of blood towards the head, or a detention of blood within the head, sufficient, by tightening the full vessels, to occasion extraordinary pressure upon the nervous pulp, may account for the symptoms, and for the extinc- tion of life : or the presence of some poisonous substance in the circulating blood (such as urea) may account for them. I pass over likewise those cases in which serum only is found effused within the cerebral ventricles. A moderate quantity of serous fluid poured out rapidly during life would certainly exert a degree of pressure adequate to the production of fatal coma. How the serum comes to be so effused, it is not always easy to say. Yet there is one condition of the blood-vessels of the brain which, when it can be proved to exist in a given case, is sufficient to account for the effusion. Any real or virtual retardation of the blood in the cerebral veins would lead to what is tantamount to dropsy, there, as well as in any other part of the body; and intelligible causes of such retar- dation are known sometimes to be in operation. A very common morbid condition in these cases is a quantity of extravasated blood — cerebral hemorrhage. The amount, as well as the situation of the blood, varies greatly. Sometimes it is spread over the surface of the brain, on or between the membranes. Sometimes it is collected in one or more of the ventricles : but much more often it occupies the broken substance of the brain itself; and then, if its quantity be considerable, it generally forces its way either into the ventricles, or (less frequently) to the surface, or even in both these directions at once. In such cases, apoplectic symptoms, and death, are the invariable consequences of the haemorrhage. But when blood effused into the substance of the brain does not break a passage 342 DISEASES OF THE BRAIN. [lect. xxix, out, either in the one direction or the other, its pressure is not necessarily or imme- diately mortal. The patient may survive for weeks, or months, or y-ears; and the clot of blood may, in the meantime, undergo remarkable changes. Fio. 27. Apoplectic effusion upon the left side of the pons varolii. Of course the cavity in which it lies varies in magnitude in different cases. It may be barely big enough to receive a large pea : it may be capable of containing a hen's egg. When examined not long after its formation, the clot is soft and of a dark colour; much like black-currant jelly. The sides of the cavity are irregular and Fig. 28. Hemorrhage into the right lateral ventrical and right hemisphere, in a man aged 65. He was brought into St. Mary's Hospital in a state of profound coma, and died two hours after admission. There was a large ragged cavity in the hemisphere, communicating with the ventricle, from which ahout 4 oz. of black fluid blood escaped. The corpus striatum and thalamus opticus of right side were much softened. There was no apparent disease of the arteries. ragged; and the cerebral substance of which they are formed is generally, to the depth of a line or two, moist, soft, and as if stained of a reddish or yellowish colour, which is fainter in proportion as it is more distant from the coagulum, and gradually loses itself in the natural tint of the surrounding parts. By degrees this stain disap- pears. The clot becomes more and more firm; assumes first a brownish, and subse- quently a pale red, or even yellowish hue; diminishes continually in bulk; and at length may, I believe, be entirely re-absorbed. Meanwhile the walls of the cavity become less uneven, and clothe themselves by degrees, as they contract upon the shrinking coagulum, with a distinct membrane of a yellowish colour, sometimes of extreme delicacy, and resembling the serous membranes; sometimes thick and appa- rently fibrous. It is said that these cysts arc capable of being obliterated by a pro- cess of cicatrization. This I have never myself seen. But they often remain filled LECT. XXIX.] APOPLEXY. 343 with a gelatinous or serous liquid; or traversed by threads, more or less numerous, of areolar tissue; or containing a small residue of the original clot of blood. It is impossible to assign the precise period within which these remarkable changes may be accomplished. Dr. Abercrombie has detailed an instance in which a coagu- lum, that must have been of very considerable size, had entirely disappeared in less than five months. In another of his cases it was seen to be partially absorbed at the end of three months. " On the other hand, Moulin found a small coagulum not quite gone at the end of a year; and Riobe observed some of the blood still remaining in a cavity of small extent after twenty months. In two cases Serres found a hard coagu- lum of blood remaining; in one at the end of two, and in the other at the end of three years." It frequently happens that a patient has suffered, during life, several distinct attacks of apoplexy or of cerebral haemorrhage; and that as many cells are met with after death, exhibiting respectively various stages of that process of repair which has just been described. These are the changes that mostly take place in the coagulum, and its containing cell, when the haemorrhage does not prove fatal, and the patient recovers more or less completely. But the same changes do not always, or necessarily, occur. Instead of being gradually removed by absorption, the extravasated blood appears occasionally to become a solid, organized, and consequently living mass, deriving its nourishment from the arteries of the brain. A man, whose case is related by Andral, was smitten with apoplexy, and remained thenceforward, for many years, hemiplegic. At length he died, of some other complaint, in the wards of La Charite. When his brain was examined there was found, in one of the hemispheres, a mass of a pale red colour and fibrous appearance, traversed by numerous small blood-vessels which anastomosed with those of the brain : the surrounding nervous matter retained its natural aspect; and there was no appearance of any cyst. I have yet to mention another, and a fatal consequence of haemorrhage into the substance of the brain. It is not, I think, a very frequent consequence; yet it de- serves attention the more, because the risk of its occurrence may perhaps be lessened by judicious treatment in the outset. The clot sometimes provokes suppurative in- flammation of the cerebral matter around it: or it may be that the nervous pulp, being bruised or torn by the first violent irruption of the blood, suppurates sponta- neously afterwards. It is affirmed (by what French author I forget) that the patient cannot be considered secure against this consecutive mischief until eight days of safety have elapsed from the period of the apoplectic seizure. Instances of this result of cerebral haemorrhage, according to my experience, are not, I say, very common. I have before me some memoranda of the last case of it that I saw. I received, on the 3d of September, a note, written in a remarkably clear and neat hand, desiring that I would call upon the writer, as he had had a severe attack of apoplexy a day or two before. I concluded that the note had been penned by some member of the patient's family, and I expected to see him in his bed, paralytic, probably, or manifestly ill. But ^ I found a stout, active gentleman, walking about in his drawing-room, apparently in perfect health, and declaring that he felt so. He showed me, however, a paper writ- ten by a surgeon who on the previous day had brought him to town from a distance, and who had been obliged to return immediately. The paper stated that Mr.---- had suffered a sudden and decided fit of apoplexy on the 30th of August; that he was then freely bled; that perfect consciousness was not restored, nor the force of the pulse subdued, till twenty ounces of blood had issued from his arm; and that on the evening of the same day sixteen ounces more were drawn. My patient spoke of going down to his country-house, where he had, he said, " a good deal of shooting to do." I dissuaded him from this, and enjoined perfect quiet for at least a fortnight to come. The next day, after a long and imprudent conversation with a friend, he suddenly .ost the thread of his discourse, and could not recover it. Then he became confused and misapplied words. I asked him how he felt. He answered, " Not quite right," and this he repeated very many times, abbreviating it first into "not right," and at length into " n'ight." Wishing to mention "camphor," he called it ''pamphlet." 344 DISEASES OF THE BRAIN. [lect. xxix I mention these as specimens. On the fifth it was evident that his right arm and leg were weak in comparison with the others; but their sensibility was unimpaired. By slow degrees the weakness degenerated into complete palsy, and the right side of the face became motionless. Gradually also he grew heavy, stupid, comatose, unable to swallow, with a fixed pupil; and so, on the morning of the 15th of September, he died. We examined his head the next day. On the left side, the dura mater adhered to the skull-cap with morbid firmness. During the endeavours made to detach it, a table-spoonful, or more, of a dirty-looking, greenish, very offensive pus spurted forth. This was found to have proceeded from an abscess, which must have contained two ounces of pus, and which was situated in the upper part of the left hemisphere of the cerebrum. The walls of the abscess looked as if they were coated with a layer of yel- lowish plaster. In the centre of this cavity was a small, fibrous, tough mass of a dull red colour; the coagulum, doubtless, of blood effused on the 30th of August. In front of the abscess, the brain seemed natural, but its consistence was that of liquid custard. Another very common condition met with after death, is that which is called white softening of the brain. The physical characters of such softening I have already described. Its causes remain to be considered. They may all be summed up under the head of defective nutrition : and in a great majority of instances the deficient nutrition is owing to disease in the cerebral arteries — to that fatty degeneration of which I spoke in a former lecture, and which begins, most probably, in the muscular element of those vessels. The change is not limited, in general, to the capillary vessels of the brain: but is distributed, under the shape of atheromatous patches, throughout various of the larger arteries of the body; in the aorta, in the iliacs, in the radial artery, where it may occasionally he felt in the living patient, in the carotid, vertebral, and basilar arteries, and in their ramifications. In consequence of these changes, parts of the brain are supplied insufficiently with nutrient blood, grow soft, and at length become utterly disorganized. The transmission of the nervous power is cut off by a breaking up of the road along which impressions leading to sensation travel in the one direction, and the mandates of the will in the other. Paralysis occurs: paralysis without loss of consciousness, for there is no necessary pressure. This then is one mode in which white softening of the cerebral substance may happen, and give rise to palsy, and especially to hemiplegia. It is a gradual process, yet the palsy may be sudden. Degeneration of the cerebral substance precedes the final disruption of its fibres: and there are often symptoms of such gradual degenera- tion of the blood-vessels, and of the brain — premonitory symptoms of the palsy. Of these I shall say more as I go on. But there is another way in which white softening of the brain, and its conse- quences, may be more rapidly produced. One or more of the larger cerebral blood- vessels may be plugged, or compressed, and the supply of blood to the corresponding portion of the brain suddenly shut off; and then that portion soon loses its consistency, and its organic structure, and liquefies into a mere pulp. Dr. Todd has recorded in the Medico-Chirurgical Transactions a case of this kind which I saw in consultation with him at Norwood. The common carotid on the right side was closed, and its channel rendered impervious, by blood which had dissected its way between the layers of the middle coat of the aorta, after passing through a transverse rent in that vessel. Paralysis of the left side of the body followed three days afterwards, with white softening of a large portion of the cerebral substance on the same side with the shut carotid. Similar mischief in the brain sometimes results from ligature of that artery for the cure of aneurism. And a very curious source of obstruction to the cerebral (or other) arteries, in consequence of disease existing in a distant organ, has recently been discovered and explained by Dr. Kirkes. I shall hereafter describe to you certain fibrinous excrescences to which the valves of the heart are liable. These are some- times so soft that portions of them are broken off, and washed away by the circulating blood: and so may be carried in any direction till they enter some blood-vessel which they cannot pass through, and which they thus seal up. When this happens in one of the principal arteries of the brain, the necessary results are white softening and paralysis. The anatomical distribution of the arteries at the base of the brain explains why it is that a solid mass coming through the internal carotid is more frequently LECT. XXIX.] APOPLEXY. 345 arrested in the middle cerebral artery than elsewhere; and why the obstruction of that vessel at its origin shuts off nearly all their nutrient blood from those portions of the brain which are supplied by its branches. For reasons to be given hereafter, this accident is more likely to take place in the early periods of life: white softening from dilapidation of the blood-vessels in the later. Haemorrhage into the brain may occur with little or no previous alteration of the cerebral substance, which the blood then ploughs up and crushes; but it seldom does so occur except under external violence, or from the sudden spontaneous rupture of a large blood-vessel. I just now told you that the larger blood-vessels as well as the smaller are very subject to disease, and especially to that fatty and calcareous degene- ration of their inner coats which is sometimes called atheroma, or, popularly, ossifica- tion. The disease shows itself in whitish patches of a round or oblong shape, which render the bore of the affected artery unequal in capacity, and its inner surface uneven. This variation of calibre impedes the free passage of the blood, and tends indirectly to increase its pressure upon the sides of the vessel. At the same time the coats of the artery lose their natural elasticity, become weak and frangible, and at length incapable of sustaining the impulse of the blood, and sudden haemorrhage ensues. The arteries at the base of the brain are liable to aneurism also, and to consequent rupture. Morgagni has reported cases of aneurism affecting the internal carotid and basilar arteries. Serres has described a case of apoplexy resulting from perforation of the basilar artery, which was dilated, not far from its superior bifurcation, into an aneurismal pouch as big as a hen's egg. Dr. Baillie records an instance where both the internal carotids, on the side of the sella turcica, were distended into little aneu- risms, one of the aneurisms being about the size of a cherry, the other somewhat smaller: and similar examples are related by other writers. I have seen two such myself: a beautiful preparation of one of them is preserved in the museum of the College of Physicians. Again, white softening may take place without cerebral haemorrhage: but neither is this very common, except from the sudden plugging or obstruction of a considerable blood-vessel. You will easily perceive how it is that the two conditions, the effusion of blood and the softening, are so commonly found co-existing. The softening, which is caused by the degeneration of the blood-vessels, combines with that degeneration in facilitating their rupture. The support which the healthy nervous substance afforded them is lessened and ultimately lost, till at length those fibres of the brain which hitherto had sufficed to convey, though perhaps imperfectly, its peculiar influ- ences, either give way of themselves, or are broken down by a gush of blood from the fracture of minute blood-vessels. The character of the attack — the presence or ab- sence of pressure upon the central parts of the brain, and of coma, the result of such pressure — depends much, as I have said before, upon the amount of blood poured out, and upon the place where it is shed. No doubt softening of the brain may be produced by inflammation of its tissue: but the concomitant symptoms will generally enable you to discriminate between such cases and those of atrophic softening, which ensues from the defective supply of nutri- tive blood to portions of the brain. It has long been known that haemorrhage does not occur in all parts of the sub- stance of the brain indifferently. Morgagni had remarked the frequency of san- guineous effusions in or near the corpora striata and optic thalami; and more extensive subsequent research has amply verified the general correctness of his observation. The same parts are also, I believe, more frequently than any others, the seat of atrophic softening. The explanation is that tnese are the most vascular parts of the brain. It has been noticed that the corpora striata are especially subject to laceration and sanguine effusion, while the surrounding parts remain unhurt, in violent concussions of the brain. And when injections are forced into the cerebral blood-vessels in the dead body, it is in the very same parts, the corpora striata above all others, that a sort of factitious haemorrhage is produced by the rupture of vessels, and the escape of their contents. 346 DISEASES OF THE BRAIN. [i.ect. xxx. LECTURE XXX. Apoplexy continued. Relations between the Symptoms and the Appearances found in the Brain after Death. Special Diagnosis and Prognosis. Relations between Cerebral and Cardiac Disease. Predisposition to Apoplexy and Palsy—natural and accidental. Precursory Symptoms. Exciting Causes. Treatment. I left off in the last lecture, after having described the appearances which ordi- narily present themselves within the skull, after attacks of apoplexy, and of cerebral palsy. In this description some account has been already given by anticipation of the connexion traceable between the physical injury sustained by the brain in such cases, and the outward symptoms. I proceed to touch upon certain points, relative to that connexion, which have not yet been noticed. One of the most remarkable circumstances which dissection teaches us, when there has been partial palsy, is, that the palsy is on the one side of the body, and the haemorrhage of the brain on the other. This is a very general law. But exceptions to it are said to have been observed. Morgagni mentions such. Dr. Bright has re- corded a somewhat doubtful case of exception. I have never met with any: and I cannot help suspecting that in some of those which are said to have occurred, mis- takes have been made: that either they have been incorrectly observed, or inaccu- rately described. You may consider the rule as almost, if not altogether, universal. This crossing over of the morbid effect of the extravasated blood, or of any other diseased state, has long been attributed to that crossing over of nervous fibres which takes place at the upper part of the spinal cord. Just where the medulla oblongata and the medulla spinalis unite, the anterior pyramids decussate each other, and send their fibres mutually to the opposite side of the body. All this of course you know. The right anterior pyramid is continued into the centre of the left half of the spinal cord; and the left anterior pyramid into the centre of the right half of the cord. Now supposing, as we have every reason to suppose, that the nervous influence, what- ever may be its nature, travels in the course of the fibres of the brain, we see in this decussation of the anterior pyramids an easy and pleasing solution of the phenomena in question. And Mr. Mayo, in his Outlines of Pathology, has made a happy use of two facts previously ascertained, which, taken together, afford a very neat proof that the transference of the morbid influence, or privation of influence, from one side to the other, actually takes place in that very part of the nervous system where the decussating fibres meet. The facts are stated by Dr. Yelloly, in the Medico-Chi- rurgical Transactions. Sir Astley Cooper divided the right half of the spinal cord of a dog, in the space between the occiput and the atlas; immediately, that is, after the cord has emerged from the skull through the foramen magnum: the result of this division of the cord was hemiplegia, paralysis of the limbs, on the same side with the injury. The bridge by which the morbid effect crosses over must therefore be above that point. We have got a limit on one side. And a case observed by Dr. Yelloly gives us a limit on the other. He examined the head of a man who had died hemiplegic; and he found a tumour, as big as a filbert, imbedded in and pres- sing upon the right side of the annular protuberance. The palsy had existed on the left side. The bridge of communication must consequently lie below that point. It must lie, therefore, between the two points now indicated; i.e., it must be either in the medulla oblongata, or just at the junction of the medulla oblongata with the medulla spinalis. Now in this very interval, and here alone, a decussation of the nervous filaments is found to exist. There can be no doubt that the decussating fibres form the channel of communication. But here we are met by a serious difficulty. How does it happen that the muscles of the face, and of the tongue — which are supplied by nerves that arise from the nervous centres above the place of decussation — how does it come to pass that these muscles sustain the same cross injury, and are paralysed on the same side on which the limbs are paralysed ? And again, how does it happen (as it certainly does), that LECT. XXX.] APOPLEXY. 347 haemorrhage into the cerebellum should have a similar cross influence ? These seem- ing anomalies have never been satisfactorily explained : but you must not forget that they exist. The complex structure of the brain, and the dissimilar consequences that ensue, in different cases, from its injury or disease, lead directly to the belief not only that the organ subserves several distinct functions, but also that separate parts or sections of it hold peculiar and definite relations with other portions of the body. Ingenious men have even attempted to settle these points experimentally. By wounding or re- moving various portions in succession of the cerebral mass in living animals, and comparing the results, they have endeavoured to assign to each portion its particular province and function. But to say nothing of the remarkable differences which exist between the cerebral functions in man and in the inferior animals, there is an un- avoidable source of fallacy common to all such experiments. We cannot reach the particular spot in the brain upon which the contrived injury is to be inflicted, with- out penetrating and hurting various other parts: and from these combined injuries (dangerous, indeed, and often fatal in themselves) arise symptoms which the experi- menter may erroneously conclude to be characteristic of the lesion originally in his contemplation. Much more accurate and satisfactory data for the determination of this interesting class of questions, would seem to be furnished by the spontaneous operation of disease, and especially of the diseases we are now considering. The injury done to the cerebral substance by the irruption of blood is often not less sudden, nor less mechani- cal, than in the experiments or contrived observations to which I have alluded. It is capable also, in many instances, of exact appreciation in regard to its extent; the parts which lie round the seat of the effusion remain undisturbed; and above all, the organ that is the subject of our observation is the human brain itself. Attempts have accordingly been made to connect particular symptoms with the disorganization of particular parts of the brain. These attempts can boast, as yet, it must be confessed, but little success. Very few, if any, of the conclusions hitherto advanced upon this intricate subject can be relied on. Yet it is proper that you should be informed of them. Because palsy of the arm is, in general, more complete, and more persistent, than palsy of the leg, it has been maintained that the former, the paralysis of the arm, is to be ascribed to haemorrhage of the corpus striatum, which seems to be more common than any other; and upon similar grounds haemorrhage of the opuc thalamus has been supposed to determine paralysis of the leg. So much have these distinctions been confided in, that the honour of having first pointed them out has actually, in France, been made a subject of dispute. Now it is plain that one example of the contrary effect of these particular lesions, would suffice to upset the whole theory: but many such exceptions have, in fact, been noticed. With the view of settling this question, Andral collected and collated seventy-five cases of cerebral haemorrhage, in each of which the clot of blood was sufficiently limited to allow of that case being applied towards the solution of the controverted points. In forty of the seventy-five, both the leg and the arm were paralysed together. And where was the place of the haemorrhage in these forty cases ? Why, in twenty- one of them the corpus striatum was the only part injured; and in nineteen of them the optic thalamus was the only part injured. Thus you see, according to the theory just explained, in about one-half of the cases the arm alone should have been palsied; and in about half, the leg alone : whereas both leg and arm were palsied in them all. Again, in twenty-three of the seventy-five cases the palsy was confined to the arm. Therefore, according to the theory, the injury should have been confined to the corpus striatum. What was the fact ? Why, in this class of cases also there was as nearly as possible an equal sharing of the injury between the two parts. In eleven of the twenty-three the corpus striatum alone suffered; in ten the optic thalamus alone; in two the space between them. Once more : there were twelve out of the seventy-five cases in which the leg alone was palsied. Consequently, in all of these twelve, if the theory were sound, there should have been damage of the optic thalamus only. But in ten of them the mis- chief was confined to the corpus striatum; in two only to the optic thalamus. 348 DISEASES OF THE BRAIN. [leot.xxx. Gall had conjectured that the faculty of speech was placed under the governance of the anterior lobe of the brain: and Bouillaud has endeavoured to support that opinion by a number of facts observed in connexion with cerebral haemorrhage; but Cruveilhier has brought forward several curious instances in which the loss of speech was a prominent symptom, while the disease was not found in the anterior lobe, but in some other part of the brain. Andral, with his accustomed industry, has accumulated evidence upon this point also. In thirty-seven cases of cerebral haemorrhage observed by himself or by others, in which the morbid condition occupied one or both of the_ anterior lobes, the power of speech was abolished twenty-one times, and unaffected sixteen times. On the other hand, he has collected fourteen cases, in which the power of speech was lost, yet no alteration had taken place in the anterior lobes. In seven of these fourteen cases the lesion was situated in the middle lobes; and in the other seven in the posterior lobes of the brain. There can be no doubt that there are certain distinct parts of the brain which influence respectively the upper and lower limbs; inasmuch as they are often separately palsied: and since the loss of speech is occasionally the only, or the most prominent symptom, while in other cases the speech is not affected at all, we cannot but believe that this faculty is under the special guidance of some definite part within the cranium. But the facts that I have just been quoting, show, in the most convincing manner, that we are not able, as yet, to allot these separate functions to their proper spots in the cerebral mass. In the account which I have endeavoured to give you of the symptoms of apoplexy, and of cerebral palsy, of the different modes in which the attack may commence, and of the various morbid appearances discovered within the cranium in the fatal cases, I have already embodied almost all that can be stated, with any confidence, respecting the special diagnosis and the prognosis of the disease. The one of these follows the other: the exact diagnosis being known, the prognosis is seldom difficult. By the diagnosis, however, I do not now mean simply the recognition of the disease as a case of apoplexy, or of hemiplegia. Of that general diagnosis, of the means of distin- guishing the coma of apoplexy from the coma caused by opium or alcohol, I told you all that I know in a former lecture. Hemiplegia, when it exists, is incontestably evi- dent to our senses. But I use the term diagnosis now in a stricter sense, and in reference to the distinctions that exist between one case and another ; and I say that, in proportion to the accuracy with which we may be capable of determining the pre- cise condition of the contents of the skull, will be the facility of predicting the issue of the complaint. Let me remind you, then, that when a patient suddenly becomes apoplectic, we cannot tell whether there be effusion of blood, or effusion of serum, or no effusion at all within the cranium : and therefore the prognosis must be precarious and uncertain. If, after the use of suitable remedies, the coma persist for many hours, the prognosis becomes worse. In those cases which begin with pain of head, faintness, and nausea, and which pass on to coma, the prognosis is positively bad; for the diagnosis is easy, and we are tolerably certain that a blood-vessel has given way, and that a large quantity of blood has ploughed up or compressed the substance of the brain. In the paralytic cases also, if coma supervene, the prognosis is gloomy: but frequently coma does not supervene, and then our prognosis, so far as life is con- cerned, may he pronounced favourable. Among the symptoms that belong to the apoplectic condition itself, there are some which experience has selected as being most especially of evil omen; and it is well worth your while to remark that these discouraging signs relate, almost all of them, to the automatic functions of the cranio-spinal axis. The open, fixed, unwinking eye; the explosive flapping of the cheeks in expiration; the inability to swallow; the slow, sighing, interrupted breathing; the loosening of the sphincter muscles of the bladder and anus : these are fearful, and too often fatal symptoms, and they all belong to the excito-motory portion of the nervous system. Perhaps the profuse sweat that so often attends the process of dissolution may be referred to the same source; the whole tone of the various tissues being lost or relaxed. I would not say that no one of these LECT. XXX.] APOPLEXY. 349 symptoms is ever recovered from : but I may say that of twenty patients in whom such phenomena occur, nineteen will die. Now symptoms of this kind may be expected to arise, if there be hEemorrhao-e in or near the medulla oblongata; or if there be mischief so extensive in the brain as to cause pressure upon the medulla oblongata. We should reason out the likelihood that such symptoms would be of bad augury. But the fact that they are so was ascertained long before the theory which accounts for them was devised. The fact is independent of the theory, and for that reason helps wonderfully to confirm it. You cannot have failed to observe how closely, in the diseases which we have been considering, the pathology of the brain is interwoven with the pathology of the heart and blood-vessels. You must perceive how necessary it is, in every instance of apoplexy or of hemiplegia, to inquire into the condition of the apparatus of the circulation. When sudden hemiplegia, with or without coma, occurs in advanced life—say after the age of fifty—in all probability evidence will present itself of disease in the heart, in the arteries, or in both. You may sometimes feel that the radial artery is unduly rigid, or of unequal calibre, in your living patient. If such evidence appears, you may conclude that there has been softening of the brain. Should there be early rigidity of some of the palsied muscles, you may infer that some irritative cause is in operation within the skull: and if the rigidity be extensive, and especially if it be attended with convulsive movements, the further inference will be warrantable that the cerebral mischief is not far from the surface. Again, in the early periods of life, the sudden occurrence of hemiplegia or of apoplectic symptoms should suggest the suspicion of valvular disease in the heart; and you would search accordingly for signs of such disease. Do not fall into the mis- take, which has been made by pathologists of eminence, of assigning to apoplexy and hypertrophy of the left ventricle of the heart, when they meet in the same person, as they frequently do, the relation of effect and cause. It has been held that the power- ful contractions of a ventricle thus morbidly strong may drive forwards the blood with such unusual force, as to strain and burst the cerebral arteries. Dr. Hope, in his elaborate work upon Diseases of the Heart, uses these words : — " Instances of apo- plexy supervening upon hypertrophy have been so frequently noticed, that the rela- tion of the two, as cause and effect, is one of the best established doctrines of modern pathology." Similar opinions have been expressed by the most distinguished of the French writers on this subject; Andral, Bouillaud, Cruveilhier. I believe them to be entirely erroneous. 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 of that organ : changes which imply some impediment to the circulation : changes which involve or influence its right chambers also. In fact, disease of the right heart is not very often seen, without disease of the left: and one of the commonest forms of alteration to which the left side is liable, is hypertrophy of its ventricle. Now I have already pointed out to you the connexion which sometimes subsists between cerebral haemor- rhage and such disease of the heart as obstructs the ready and regular descent of the blood from the head through the veins. Many of the cases of apoplexy occurring in persons who have previously had cardiac hypertrophy are, I really believe, cases of this~kind. The brain affection is dependent, in part, upon disease of the heart, but not upon the preternatural strength of its left ventricle. The heart acts morbidly upon the brain through the veins, and not through the arteries. But there is another reason for the coincidence; and here the arteries are concerned. No one can doubt that the momentum, with which the blood reaches the cerebral arteries, in healthy persons, under violent bodily exercise or mental excitement, must often exceed the momentum produced by a hypertrophic heart in the cerebral arteries of persons who are tranquil and at rest. But apoplectic seizures are frequent under the latter circumstances, infrequent under the former. We must look, therefore, for something more than the mere hypertrophy to explain the coincidence. Now (sup- posing the absence of any check to the flow of blood from the head through the veins) that something is to be found in disease of the arterial system. When the arteries of the brain are ossified, or changed, and rendered brittle in the way I yesterday described, the commencement of the aorta also is found, in a great 350 DISEASES OF THE BRAIN. [lect. xxx. majority of cases, to be the seat of similar alterations; and, often, to be sensibly dilated. Now the fatty or calcareous deposit beneath its inner tunic must seriously impair the elasticity of the vessel; and in this way the free passage of the blood out of the heart will be impeded. Dilatation of the aorta at that part will produce the same hinderance more certainly and in a greater measure. Still more effectually and obviously will any narrowing of the outlet prove an impediment. It is in consequence of these mechanical obstacles to the free exit of the blood from the left ventricle, that the walls of that chamber, urged to more vigorous contraction, become thicker and more powerful. The hypertrophy is the natural compensation for the morbid state of the aorta; without it the heart would much sooner become unable to propel its con- tents at all: and the hypertrophy does not often, I fancy, become greater than is needful for its purpose. The strength of the left ventricle, therefore, in such cases, is not a true measure of the force with which the blood is driven into the distant arteries. Quite the contrary. It is a measure of the difficulty with which the blood is circulated through the primary branches, and therefore through the entire system of the arteries. It indicates the diminished force with which the blood is likely to reach the cerebral vessels. And in point of fact, you will find in many cases of hypertrophy of the left ventricle — I do not say in all, but certainly in very many — you will find the pulse at the wrist to be disproportionately small and feeble. So that, in these cases, instead of regarding the cerebral haemorrhage as the effect of the hyper- trophy (acknowledging, as I do, the frequent coexistence of these morbid conditions), I have been accustomed to look upon the apoplexy and the hypertrophy as concomi- tant effects of the same cause; viz., of disease pervading the arterial tree. The hypertrophy of the left ventricle is a consequence of the diseased condition of the aorta at its mouth; the cerebral haemorrhage is a consequence of the same diseased condition of the arteries in the brain. When you find each of these lesions, and nothing to retard the venous current, you may, I believe, safely apply this explanation of the occurrence of apoplexy. If you suspect, from the age and other circumstances of your patient, that he may be the subject of fatty degeneration of the blood-vessels, that suspicion will be strengthened by your finding, on inspection of his cornea, that it presents the arcus senilis. The classes of persons in whom, caeteris paribus, attacks of apoplexy are especially to be apprehended, are those whose ancestors have suffered the same disease; those who possess a particular conformation of body; and, above all, those who have reached a certain period of life. No doubt apoplexy may and does occur in persons whose progenitors have escaped it; in persons of every conceivable shape and make; and in persons of all ages. But it is much more frequent in the classes I have specified, than it is among persons not comprehended in those classes. The first and the'second class sometimes concur, i. e., a particular conformation of the body is transmitted from parent to child, and with it is transmitted a proclivity to apoplectic disease. But even when there is nothing particular in their bodily form, or in their habits of life, old experience has clearly ascertained that they who come of an apoplectic stock are themselves more than ordinarly liable to apoplexy. The pattern of body which is most prone to apoplexy is denoted by a large head and red face, shortness and thickness of the neck, and a short, stout, squat build. This remark is as old as the time of Hippocrates. However, apoplexy is common enough in men and women who are thin, and pale, and tall. Caeteris paribus, cor- pulent people are more in danger of apoplexy than spare people; but it attacks both the one and the other. Advanced life is certainly a very strong predisposing cause, and the reason of thia must be evident to you after what I have said respecting the dependence of these diseases of the brain upon previous disease of the blood-vessels. Earthy concretions in the coats of the arteries are so frequent in the later periods of existence, that they are met with, according to Bichat, in seven individuals out of ten who die beyond the age of 60; and Dr. Baillie considered ossification to be much more common in old persons than a healthy state of the arteries. Apoplexy and cerebral paralysis begin to be common after 50: but they do sometimes occur even in young children. All these three kinds of predisposition are beyond our power. We cannot exter- minate the hereditary tendency; nor remodel the plan upon which the body is con- LECT. XXX.] APOPLEXY. 351 structed; nor arrest, or put back, the clockwork of human life. But we may guard and caution persons, thus predisposed by nature towards apoplexy, against many of its exciting causes. A strong predisposition to apoplexy is, moreover, engendered by certain other diseased conditions; and over some of these conditions our art enables us to exercise more or less control. One of these I referred to just now—the kidney disease discovered by Dr. Bright. Diseases of the chest influence very materially and injuriously the circulation within the head. Without going into detail respecting complaints with which I am obliged to suppose that you are as yet unacquainted, I may state, by anticipation, that impediments to the free transmission of blood through the heart and lungs con- stitute the mode in which thoracic disorders predispose to apoplexy. The plethora. capitis produced by such impediments is frequently visible in the turgid and livid features, and in the distended jugular veins. The cessation of habitual discharges, of the catamenia, of bleeding piles; the drying up of old sores; the healing of long established issues and setons; all have an unquestionable tendency, by causing or augmenting plethora, to generate a predispo- sition to apoplexy. And large observation of the habits of those who fall victims to this terrible malady, leaves no room for doubting that intemperance often paves the way for its invasion. The continued abuse of ardent spirits, in particular, lays the foundation of many of those morbid conditions of the sanguiferous system, and of the viscera, which constitute the predisposition we are now considering. Among the premonitory symptoms headache is of frequent occurrence: but the same symptom is abundantly common in persons who are in no danger of apoplexy; it derives its minatory character from the concurrent circumstances. Headaches awaken our fears when they begin to be troublesome in advanced life. They are, then, still more formidable if they are accompanied by vertigo; or, without any other evidence of gastric derangement, by nausea and retching. Sometimes, as I just now told you, severe headache ushers in, and almost forms a part of, the apoplectic attack. Vertigo itself, even without headache, is a very common precursor or warning of an approaching seizure. It is sometimes slight and transient; sometimes almost habitual. Although vertigo may depend upon other causes than mischief within the head, we cannot regard it without apprehension when it often occurs in old persons. It should teach us to obviate as entirely as we can all the known exciting causes of apoplexy. The principal of these I shall by-and-by describe to you. Transient deafness, or transient blindness, blindness or deafness for a few seconds or minutes, is another of these warning symptoms. The late Dr. Gregory, of Edin- burgh, used always to mention in his lectures the case of Dr. Adam Ferguson, the celebrated historian, as affording one of the strongest illustrations he ever met with of the benefit that may be derived from timely attention to the avoidance of those circumstances which tend to produce plethora and apoplexy. It is, perhaps, the most striking case of the kind on record. Dr. Ferguson experienced several attacks of temporary blindness some time before he had a stroke of palsy; and he did not take these hints so readily as he should have done. He observed that while he was de- livering a lecture, his class, and the papers before him, would disappear, vanish from his sight, and reappear again in a few seconds. He was a man of full habit; at one time corpulent and very ruddy, and, though by no means intemperate, he lived fully. I say he did not attend to these admonitions: and at length, in the sixtieth year of his age, he suffered a decided shock of paralysis. He recovered, however, and from that period, under the advice of his friend, Dr. Black, became a strict Py thagorean in his diet, eating nothing but vegetables, and drinking only water or milk He got rid of every paralytic symptom, became even robust and muscular for a man of his time of life, and died in full possession of his mental faculties at the ad- vanced age of ninety-three; upwards of thirty years after his first attack. Sir Walter Scott describes him as having been, " long after his eightieth year, one of the most striking old men it was possible to look at. His firm step and ruddy cheek contrasted agreeably and unexpectedly with his silver locks; and the dress which he usually wore, much resembling that of the Flemish peasant, gave an air of peculiarity to his 352 DISEASES OF THE BRAIN. [lect. xxx. whole figure. In his conversation, the mixture of original thinking with high moral feeling and extensive learning, his love of country, contempt of luxury, and especially the strong subjection of his passions and feelings to the dominion of his reason, made him, perhaps, the most striking example of the Stoic philosopher which could be seen in modern days." This anecdote, which I have made use of as a wrapper for some medical instruction, will not be the less acceptable to you when I add that the remarkable man to whom it relates was the great-uncle of my friend and present colleague in this school, Dr. Robert Ferguson. Very frequently slight and partial paralysis is the forerunner of an attack of apo- plexy. Double vision is one form in which such limited palsy is apt to show itself. It is evidently connected with some degree of squinting; i. e., some one or more of the muscles that move the eyeball are paralysed; the person cannot direct each eye to the same object at the same time. This is a very suspicious symptom. Dr. Gre- gory was acquainted with a sportsman who one day, when out shooting, disputed with his gamekeeper as to the number of dogs they had in the field. He asked how he came to bring so many as eight dogs with him. The servant assured him there were but four; and then the gentleman became at once aware of his situation, mounted his horse, and rode home. He had not been long in the house when he was attacked with apoplexy, and died. Sometimes the slight and local paralysis shows itself in a faltering or inarticulate mode of speaking. The rapidity of the movements of the tongue requisite for distinct utterance is so great, that the slightest weakness of any one of its muscles is rendered obvious. We see this in one very common form of what may in truth be considered a kind of apoplexy ; viz., in drunkenness. In many persons the very first symptom of their becoming intoxicated is their inability to speak plainly. " Clipping the King's English," is the slang expression for it; and the same thing often takes place in respect to the more proper forms of apoplexy. It is a curious circumstance, by the way, and one which is illustrative of what we meet with in disease, that different sets of muscles are chiefly affected by inebriation in different persons; the same set being always the first affected in the same person. Thus some men, when drunk, lose (as I have just stated) the proper command over the muscles of the tongue, and falter in speech, while they can walk very well: others reel and stagger, having lost, in a greater or less degree, the power of moving and governing their limbs, and of balancing themselves, who yet can speak quite fluently and plainly: and in a few cases, drunken persons become delirious, who still retain the power of distinct articulation, and of directing their steps aright. This being so, we need the less wonder at the variety in the nature of the warnings that precede the apoplectic attack. In many instances there is numbness or debility, or total palsy of one limb, or of a single finger, or even of a solitary muscle, as of the levator palpebrae. The patient cannot grasp your hand with firmness, or sign his name in his usual way, or pick up a pin, or snuff a candle, or manage an obstinate button, or tie a knot in a thread cleverly: or, perhaps, one of his eyelids droops, and the eye is half closed. Some- times, on the contrary, the patient stares at you frightfully, with one eye, which he eannot shut. The numbness also assumes various characters, according to its place and degree. One patient will tell you that he feels as if one of his limbs were muffled in flanuel; another, that he is uncertain whether, in walking, his foot has reached the ground or no. A gentleman, since dead of apoplexy, assured me that, when sitting, he did not know how far his breech covered the seat of the chair. With the numbness there is often associated a degree of tingling : that familiar sensation of " pins and needles," in a part which is recovering after being " asleep," from pressure upon the trunk of its ministering nerve. All these symptoms are modifications of the function of voluntary motion; or of the function of sensation. Nor are manifestations wanting, among these precursory circumstances, of a derangement of the other and nobler function, of which the brain and nervous system form the material instrument. I mean the function of thought. Thus one very deplorable warning is the loss of memory. All persons find, as they grow older, that they do not retain so tenaciously in their recollection things LECT. XXX.] APOPLEXY. 353 which have recently occurred, as things which happened when they were youn"-. This partly depends upon the degree of attention which we pay to different circum- stances. Those events which strongly excite the curiosity, and rivet the attention of the boy, become familiar to the man, and he gives them but little notice, and is very apt to forget them. But the loss of memory that threatens apoplexy is something more than this. It is sometimes partial, and extends to certain sets of things only. For example, some persons entirely forget certain words, while they recollect others perfectly. Common words are often thus forgotten, while unusual or remarkable words are remembered; or a wrong word is chosen. One word is used for another that sounds something like it. Thus one of my patients, meaning to accuse a certain individual of perjury, always called it purging: and many other words he changed after the same fashion. But in truth the modifications of a partial loss of memory that have been known to precede apoplexy are both odd and endless: some people forget their own names, or the names of their children. Dr. Gregory, who had paid particular attention to these precursory symptoms, and who had a large practice for a great number of years to furnish them, used to mention a case of this kind. After some efforts his patient could recall to his recollection what his christian name was, but he could not think of his surname. About twelve months after his memory began to fail in this strange manner he was found dead in his bed. Another gentle- man for some time before his death could never recollect the name of the street in which he lived. Upon one occasion of his visiting Edinburgh, he called on Dr. Gregory, and partook of a hearty breakfast, having forgotten that he had breakfasted before he came out. On the same day he attended, with Dr. Gregory, the funeral of a young lady who had been his ward; the funeral took place in the country; and when they returned together in the carriage it was evident that he had forgotten all that he had been doing. Next day he met the doctor in the street, and saluted him with all the kindness of an old acquaintance at first meeting; saying he was happy to have fallen in with him now that he was in town, and totally forgetful of their recent interviews. Connected with this failure of memory, there is often an unnatural degree of drowsiness. Sometimes without any permanent affection of the memory, there is a temporary confusion or suspension of thought; the patient suddenly loses the train of ideas with which his mind had been occupied; stops short in the middle of a sentence, and endeavours in vain to recover the broken thread of his discourse. Among the mental conditions that bespeak a tendency to apoplectic disease, I have several times noticed a strange and vague dread, of which the person can give no reasonable explanation; a sense of apprehension and insecurity not accounted for by the apparent state of his general powers and functions; a painful degree of indecision and irritability; with a dislike and fear of being left alone. One patient of mine described his " nervousness" of this kind, by telling me that in descending a stair- case, especially a winding one, he was obliged to turn round, and come down back- wards, as one descends a ladder; or even to sit down, and so slip, stair by stair, from the top to the bottom. Yet with the assurance given him by a friend's arm, or by a convenient baluster, he could walk down stairs without difficulty. He had no actual vertigo. All these, and many other signs that are apt to precede and herald an attack of apoplexy, are well worth your study. They show that, even before the stroke de- scends, there is some morbid process going on within the head. The great use of being acquainted with these warning circumstances, and of looking out for them, consists in the opportunity and the authority which they furnish, for enforcing upon the person in whom they manifest themselves, the absolute necessity of avoiding all the avoidable exciting causes of the disease. But our means of advising him will be very imperfect if we have not carefully considered what these exciting causes are. 1 propose to devote a few minutes, therefore, to the consideration of the circumstances that are apt to bring on the attack. There are many cases of apoplexy and of cere- bral hemiplegia, in which we cannot trace the operation of any such causes: but in many other cases their influence is decidedly marked; and the avoidance of them, while it is important to all who show a disposition to such diseases, is especially so to those who, having once suffered an attack, have reason to dread a repetition of it. In the first place, anything which is calculated to hurry the circulation, and to 23 354 DISEASES OF THE BRAIN. [lect. xxx. increase the force of the heart's action, is likely to operate as an exciting cause of apoplexy, or of cerebral palsy: simply by augmenting the momentum of the blood against the sides of the cerebral vessels, which in advanced life are so often diseased and weak. Strong bodily exercise, therefore, is a thing to be avoided by all persons in whom the predisposition to these disorders has declared itself. It is of much im- portance to make patients aware of this; for many persons think, when they labour under uncomfortable bodily feelings of any kind, they may get rid of them by a brisk walk; or by galloping some miles over the country on horseback. Another dangerous state for such persons arises whenever the free escape of the blood from the head is suddenly obstructed. I have adverted to this before. Certain diseases, chiefly thoracic, which tend to keep the veins of the head inordinately full, rank among the predisposing causes of apoplexy. But, upon the very same prin- ciple, various conditions, which are temporary only, may operate as exciting causes. By what is called " holding the breath," whether upon an inspiration or an expiration, the transit of the blood through the lungs is impeded: and the check is felt (through the pulmonary artery, right chambers of the heart, and great veins) in the vessels of the head. And this effect is increased when straining is at the same time performed; that is, when a deep breath is taken and retained, while some muscular forcing effort is made. Under this principle fall a number of bodily acts, which, however harmless in a healthy frame, are not without peril to a person having a predisposition to apoplexy. The motion of the blood in the lungs, and therefore in the head, is checked in the acts of coughing, vomiting, sneezing, laughing, crying, shouting, and so forth. You cannot have looked at a person in a violent paroxysm of coughing without seeing that it produced a determination of blood to the head, or rather a congested state of the veins of the head. The jarring pain in the head which is apt to follow each succus- sion of the cough depends upon this principle : which is often strikingly illustrated in young children labouring under hooping-cough. They turn purple in the face, and become giddy; and not uncommonly ecchymosis of the conjunctiva occurs, giving fearful intimation of what might just as readily take place within the cranium. It is not very unusual for the whole of the white part of the eye to become suddenly bloodshotten in these violent fits of coughing; and convulsions even have happened under the like circumstances. Straining at stool is a common exciting cause of apoplexy in those who are pre- disposed to it. And this is one of the worst dangers attending costiveness of the bowels in old people: but it is one which it is often in our power effectually to ob- viate. It is more within our control than a bad cough could be. Any kind of straining indeed is equally perilous. A very good proof of this danger was recently afforded by a patient of my own. He was attacked with apoplexy on his way to Ascot races; and upon recovering somewhat, was found to be paralytic on one side of the body. He was brought back to town, where I saw him. After some time he regained the power of using the affected limbs to a very considerable extent; so as to be able to walk about, and follow his business, which was that of a job-master, or proprietor of a livery stable. I cautioned him seriously, inter alia, against straining: but I suppose he forgot my caution. For, while dressing one morning, he tugged violently in attempts to pull on a damp boot, and in the midst of his efforts fell back insensible : and from this relapse he never fairly recovered. To the same principle are to be referred a variety of things from which a patient, in danger of this disease, must most carefully abstain. Lifting heavy weights; leap- ing ; striking a hard blow; playing on wind instruments; even long and loud talk- ing. Dr. Abercrombie relates two instances of fatal apoplexy brought on (as it would seem) by a sustained exertion of the voice: one of the attacks happened to a clergy- man during the delivery of his sermon; the other to a literary man while speaking in a public assembly. In both cases a large quantity of blood was found extravasated within and upon the brain. Dr. James Gregory used to mention a patient of his, an officer in the army, who had apoplexy, and in whom the attack had been preceded by pains of the head, and giddiness, upon his giving the word of command, and par- ticularly when dwelling upon the last sound; that is, when he made a long expira- tion. Precisely of the same kind is a case told by Van Swieten, of a singer who was obliged at length to abandon her vocation by reason of gradually increasing vertigo LECT. XXX.] APOPLEXY. 355 whenever she had to hold a high note. Violent emotion is another exciting cause, Large fires, crowded rooms, the heat even of the sun, favour the access of apoplexy, and therefore ought to be shunned by those who have a tendency to that disease. The warm bath is not without hazard to such persons. This is so well known, I un- derstand, at Bath, that the physicians there will not allow paralytic patients, in whom the paralysis has been connected with apoplexy — hemiplegic patients, for example — to go into their hot baths. The excitement of drunkenness, and the venereal excite- ment, are not uncommon causes of apoplexy, especially in old persons. I had a man of middle age under my care during the spring of 1837, in whom a most awful attack of apoplexy came on under circumstances such as I have just referred to. He had dined at a large festive party, and afterwards accompanied a woman with whom he was acquainted to a brothel; and he was struck with palsy during the act of inter- course. He was long unable to speak; and he still remains, and probably will ever remain, a cripple : incompletely hemiplegic. I have been since consulted upon the case of an old gentleman residing in France, in whom an attempt at sexual connexion was attended with similar consequences: " The Gods are just, and of our pleasant vices Make instruments to scourge us." Posture again has no small effect upon apoplectic people. Giddiness, and some degree of confusion of thought, are apt to be occasioned, in most persons, by long stooping. There is one peculiar posture or position mentioned by Dr. Fothergill as being very unsafe, especially for short-necked persons — viz., that position which is assumed when we turn the head to look backwards for any length of time without turning the rest of the body; in fact, a twisting of the neck. In this attitude the jugular veins are more or less obstructed. He gives an account of a man who was seized with apo- plexy as he was crossing the Thames in an open boat: he having kept his eye fixed upon a particular ship until, and after, he had been rowed past her. On the very same principle tight ligatures worn about the neck, and compressing the jugular veins, may bring on apoplexy; the wearing a tight neckcloth, for example. A continental writer informs us that a Swedish officer, who was desirous that his men should look well in the face, required them to wear tight stocks; and the consequence was that in a short time a great many in that regiment died of apoplexy. A similar unwise re- quirement in our own army regulations bfts of late, I believe, been abolished. Dr. Abercrombie quotes from Zitzilius the case of a boy who had drawn his neckcloth very tight, and was whipping a top, stooping and rising alternately. After a short time he fell down apoplectic. The neckcloth being loosened, and blood drawn from the jugular vein, he speedily recovered. There is one very powerful exciting cause of apoplexy, in those predisposed to it, which I need only refer to now, because the facts that have been observed in proof of its agency were fully detailed in a former part of the course; I mean exposure to cold. You~will recollect my telling you that the number of deaths in London from apoplexy and palsy in the month of January, 1795, which was a bitterly cold month, very much exceeded the number in the month of January, 1796, which was a remarkably mild month. The cold operates in two ways, in the production of apoplexy, In the first place, it drives the blood from the surface, and accumulates it in the large vessels of the interior of the body, and so increases the stress upon the cerebral arteries. And in the second place, the cold has a great influence in causing or aggravating affections of the chest; and the return of the venous blood from the head is impeded, in the manner just now explained, by fits of coughing and obstructed respiration. This influence of external cold, and probably certain barometric conditions also of the atmosphere, help to explain, what I am sure I have several times had experience of, namely, the epidemic prevalence, now and then, of apoplectic seizures. The older writers entertained some very false notions in respect to the distinction between sanguineous and serous apoplexy. They laid it down that apoplexy resulting from extravasation of blood within the cranium was denoted by flushing of the face, and strength of the pulse; and that it was a disease of persons in the vigour of life : while apoplexy resulting from the effusion of serum was marked by paleness of the countenance, and weakness of the pulse; and occurred in the old and infirm : and 356 DISEASES OF THE BRAIN. [lect. xxx. they directed their practice according to this distinction. After what has already been said, I need not tell you that this classification of apoplexies could not have been founded upon the actual observation of disease : and that our treatment, now-a-days, is not regulated by any such erroneous theory. Nevertheless, I do not mean altogether to praise the modern practice in apoplexy; for it is often one of mere routine. Practitioners are too apt, in this as in other in- stances, to be guided in their choice of remedies by the name of the disease, and to treat all cases of apoplexy alike. I remember being much amused by the perplexity which a friend of mine once told me he had felt on being summoned by letter many miles into the country to see a gentleman who had been struck with apoplexy. As he posted down he earnestly revolved in his mind what he might be able to advise when he should reach the house of sickness. He felt confident that the patient must already have been copiously bled; cupped, or leeched; blistered; and thoroughly dosed with calomel, senna, and croton-oil. Mustard poultices had doubtless been applied to his legs. My friend was distressed to think that while much would be expected, nothing would be left for him to do worthy of so long a journey, and so heavy an expense to his client. A clyster of turpentine might yet, perhaps, be an untried expedient. His cogitations were cut short, however, and his cares relieved, by an express which met him half-way on the road, to announce that the patient was dead. Now this is the routine of which I speak : most proper in some cases; unne cessary in others; pernicious in many. There are persons who seem to think that they have not done their patient justice if any part of this active intermeddling have been omitted. Others regard depletion as being always worse than useless, and trust entirely to stimulants and cordials. These are quite as dangerous routiniers as the others ; but they are fewer in number. Our practice would indeed be much easier than it is, if we could thus make one plan fit all cases which are, nominally, the same. But I need not, now, tell you that diseases alike in name — aye, and alike in their essential nature — are often widely different in their circumstances. I formerly explained to you that certain symptoms tell us what the disease is; but that we are often obliged to look to other symptoms, which may inform us what we are to do. I know of no rule so likely to guide you aright as that laid down generally by Cullen, of obviating the tendency to death. You must examine and judge to which of the several modes of dying there may be any manifest approach. If the tendency be, as in cases of apoplexy it mostly is, to death by coma, then blood-letting and the evacuating plan will often be requisite. If, on the other hand, the tendency be to death by syncope, you must withhold the lancet, and even have recourse to stimulating and restorative measures. The question is of the last importance; involving often (as Celsus taught) the alternative of life and death: "sanguinis detractio vel occidit, vel liberat." Now the distinction between these modes of dying is to be made by attending to the state, not so much of the ner- vous, as of the sanguiferous system. Insensibility and unconsciousness are common both to syncope and to coma: and cases which fall under the class of apoplexies, and which we cannot separate from that class, are sometimes really more like cases of con- cussion than anything else; the shock having been of internal instead of external origin. If the pulse be full, or hard, or thrilling (sometimes it feels like a tense vibrating rope), or if there be obvious external signs of plethora of the head, you must abstract blood. You are not to refrain from bleeding the patient, because he is pale, if his pulse warrant it; nor may you omit taking blood if the head and face be turgid, although the pulse be small; for that smallness may depend upon organic dis- ease of the heart. On the contrary, if his skin be pale and cold, and his pulse feeble and flickering, you would probably ensure your patient's death, or determine the accession of palsy, if _ you withdrew from the failing heart and blood-vessels a portion of their natural stimulus. I can only invite your attention to these broad features of distinction. Being once taught to look for and attend to them, your own judgment must instruct you as to what may be needful in particular cases. To this, as to most other diseases, the remark of Boerhaave is strictly applicable, who declares that he knows of nothing which can be called a remedy, " quin solo tempestivo usu tale fiat." Having made up your mind as to the general indications of treatment, you will pursue them steadily in detail. If the patient to whom you are summoned be stupid lect. xxx.] APOPLEXY. 357 and drowsy rather than faint, and his pulse and appearance warrant the conclusion of plethora capitis, the first thing to be done is to place him in a semi-recumbent position, with his head and shoulders raised; to loosen any tight parts of his dress, especially his neckcloth and shirt-collar, and whatever might press upon the neck; and then as quickly as possible to bleed him from the arm. We know that in some cases the apoplectic state occurs, when as yet no injury has been done to the brain; no effusion, no laceration of its texture ; and we may hope, by timely and active mea- sures, to prevent these terrible evils. We never can be sure that there is blood extra- vasated in such cases, and we must act, in the first instance, upon the presumption that there is not. We are especially encouraged to take away a considerable quantity of blood by venaesection when we perceive external signs that the vessels of the head are full: redness and turgescence of the face, throbbing and prominence of the tem- poral arteries, distension of the superficial veins of the neck and forehead. Our object is to take off the strain upon the internal vessels by bleeding in such a manner and to such an amount as shall produce a decided effect upon the general circulation. Some- times the good consequence of the bleeding is very marked indeed, so that no doubt of its propriety can be entertained; the patient being so insensible as not to feel the puncture of the lancet, and yet emerging from his coma while the blood is still flow- ing. It is seldom, however, that we can expect such immediate and manifest meliora- tion as this. After one sufficient bleeding from the arm, the vessels of the head may be further relieved by cupping the nape of the neck, or the temples; and venaesection may be repeated if the condition of the pulse, and the symptoms generally, should require its repetition. It is seldomer, however, in cases of apoplexy than in cases of acute inflammation, that a second or third recourse to the lancet becomes advisable, unless, indeed, the first blood-letting has been mismanaged. Enough blood must be taken, in the first instance, to produce some evident effect; and therefore no precise rules can be laid down respecting the absolute quantity to be drawn; nor can we make any sure estimate beforehand as to the whole amount of blood which it may be necessary to remove. Even if we could be certain that a blood-vessel had given way, and that blood was already poured out upon the brain, there are good reasons why (no adverse circum- stances withstanding) we ought at once to bleed our patient. I will enumerate briefly the benefits we seek to obtain by the abstraction of blood in such cases. 1. The effusion from the ruptured artery may be slowly going on. Bleeding from a vein, so as to make a sensible impression on the general circulation, will diminish the stress upon the cerebral blood-vessels, and so tend to put a stop to the haemor- rhage. Both of these two objects are of primary importance. 2. By early and free bleeding we lessen the hazard of inflammation supervening upon the mechanical injury done to the brain by the sudden tearing and contusion of its texture by the effused blood; and 3. We thereby bring the system into the most favourable condition for the rapid absorption of the extravasated blood, and for expediting the patient's recovery from those symptoms which depend upon the presence of the clot in the brain. But although, in that form of disease which we are now considering, bleeding is our sheet-anchor, it may be carried too far, or repeated too often. We must not lose sight of the fact that many of these patients are old, and will not survive undue depletion; and that if they survive at all, they will need all the strength that we dare suffer them to retain, for carrying on the vital actions, when the chief instrument of the most important of the animal functions is so greatly damaged: nor of the fact that if there be blood extravasated, we cannot touch it, except indirectly, by the abstraction of more blood from the arm : nor of the fact that a patient may be bled into convulsions, and fatal syncope. In short, after the first bleeding, you must be guided by the special circumstances of the case, and particularly by the pulse. The woman at present in the Middlesex Hospital, with paralysis of the limbs on one side, and of the face on the other, attributes her palsy (erroneously most likely) to her having been cupped. She had had a blow some weeks before, and suffered head- ache from that time. At length she was cupped, from the neighbourhood of the head : and the next morning she was paralytic. This might have been an accidental coinci- dence. But I remember being sent for a few years ago to see a patient at Greenwich, 358 DISEASES OF THE BRAIN. [lect. xxx. who had already three physicians about him, and was apparently in danger of apoplexy, of which he had for some time experienced distinct warnings. The three physicians had agreed that .he ought to be cupped from the back of the neck; to which I assented; and while blood was being rapidly extracted in that manner, he became all at once hemiplegic. Similar cases "have been noticed by other persons. Therefore we are not to bleed without measure or discretion. The pulse may be small, and the arterial action feeble, while yet the veins are turgid, and the capillaries of the head and face loaded with blood. _ Changes may have occurred in the heart, such as to obstruct the stream which it is its healthy- office to transmit. These are cases to which the local abstraction of blood from the head by leeches and cupping-glasses is peculiarly adapted. Again, the whole state of the patient may approximate more or less nearly to the state of syncope; the pulse being weak, the aspect pinched and bloodless, and the skin cool. In this condition, no good, but the contrary, is to be expected from blood- letting of any kind. You will do better to apply warmth, cautiously, to the surface, and cautiously to administer what are called diffusible stimuli, of which the prepara- tions, of ammonia afford the most eligible forms. Five grains of the sesquicarbonate, or half a drachm of sal volatile, mixed with camphor julep, are ordinary doses. Stand by till the first stunning effect of the internal shock passes off; and carefully watch meanwhile for symptoms of reaction. When hemiplegia happens without loss of consciousness or coma, it is most proba- bly the result of white softening and disruption of the fibres of the brain, with or without a small effusion of blood. In such cases I quite agree with Dr. Todd, that abstraction of blood from the arm is requisite and justifiable only when there is also early rigidity of the palsied muscles, betokening irritation, and threatening therefore inflammation of the cerebral substance. In more ambiguous cases, when you scarcely can tell which way the balance inclines, I would advise you to wait the effect of the next remedies I have to men- tion ; viz. purgatives, about giving which you need not entertain the same doubt and hesitation. Purgative medicines are of signal service in apoplexy. They empty the intestines, which are oftentimes loaded, and which by distending the abdomen have occasioned, perhaps, undue pressure against the diaphragm, embarrassed the breathing, and through it the cerebral circulation. Another very important purpose of hard purg- ing, which I have frequently pointed out before, is the producing of copious watery discharges from the bowels; whereby the blood-vessels are drained, and the tendency of blood to the head especially relieved. If the patient can still swallow, you may give him half a scruple of calomel, and follow it up by a black dose. If the power of deglutition be lost, the croton oil becomes a most valuable remedy. Dr. Aber- crombie suggests that it may be conveniently introduced into the stomach, suspended in thick gruel or mucilage, by means of an elastic gum tube. But really this is not necessary. If two or three drops of the oil be put upon the tongue, as far back as is possible, it will produce its specific effect very readily and well. But we are not to wait for the operation of aperients given by the mouth. Strong purgative and stimu- lating enemata must be thrown into the rectum : half an ounce, or six drachms, of turpentine, suspended, by the help of the yolk of an e^, in gruel or warm water. We very often witness decided signs of amendment upon the free operation of a pur- gative. I may mention one instance of this while it is fresh in my recollection. I was asked a few evenings ago by a medical friend, to see an old general, a patient of his. I found him in bed, comatose, though capable of being roused when loudly spoken to; but he presently fell off again into stupor. His respiration was peculiar. For a minute or two he would breathe, snoring strongly; then the breathing would cease altogether for half a minute or thereabouts; and then the stertorous respiration recommenced : and so on alternately. He had been found by his servant on the floor, nearly insensible, in the morning, having fallen either out of, or upon rising from, his bed. He had very properly been cupped; and calomel and aperient medicine had been given : but the coma had been growing more profound all the afternoon. His bowels had been but scantily moved; and the faeces and urine were passed as he lay. His extremities were coldish. The pulse was neither full nor strong. LECT. XXX.] APOPLEXY. 359 I learned that for four or five years he had had some very significant warnings * and within that period had suffered one or two slight apoplectic seizures, which had left him with impaired mind and memory. I recommended blisters behind the ears, and two drops of croton oil with two drachms of castor oil, in a draught. The next morning I expected to hear that he was dead; but I found him quite conscious, speaking somewhat inarticulately, with the right side of his face chopfallen and inexpressive. There seemed no particular weakness of the corresponding extremities. The oils had been followed by copious evacuations from the bowels. The day afterwards he was sitting up, and so well, that I took my leave. In combination with blood-letting and purgatives, cold lotions to the head are often found useful in this disease, especially if its surface be hot. I need not trouble you by rehearsing the modes in which the application of this remedy may be managed. Blisters near or upon the head, are also frequently of service, after due abstraction of blood, in rousing the patient from his state of coma. Formerly, at the suggestion, I fancy, of Dr. Fothergill, it was much the fashion to give an emetic in the outset of the treatment of apoplexy. But this also is a tick- lish remedy, capable of doing good or harm according as it is well or ill timed. If there be already extravasation of blood, or even plethora capitis, the act of vomitin^ will be likely to increase the existing mischief, and to enhance the danger. On the other hand, it may rouse and rally the nervous power when the patient is pale, and cold, and faint. Yet this can never be regarded as a legitimate purpose of emetics in apoplexy. They can safely be recommended in those cases only, in which the coma may appear to depend, wholly or in part, upon a loaded stomach. Hence the propriety of giving an emetic will deserve consideration whenever an attack of apoplexy follows close upon a heavy meal. When the immediate danger has passed by, and paralysis remains, or when hemi- plegia alone has befallen the patient, we are not to be over busy. If the palsy is to get gradually well, it must be by virtue of time, and the resources of nature. To young and strong persons I should, under such circumstances, give small and re- peated doses of mercury: and in all cases I should prescribe aperient medicines, so as to keep the bowels freely open once or twice a day; enjoin perfect quiet; and put the patient upon very short commons. Diuretics are also proper when the urine is not plentiful without them. You will often have to contend against the ignorance and impatience of the sick, or of their friends, on these occasions. They think that iveakness is to be remedied by strengthening food; by meat and drink, and tonic medicines; or if they are not so foolish as this, they will want to be electrified, or to be put into a warm bath. Certainly in the earlier states of the palsy that remains after apoplexy, none of those measures ought to be permitted. Attempts to urge the hurt brain into action by such means, would be both vain and unsafe. But a secondary evil is apt to ensue, which may in some degree be obviated. During the period in which the moving power is dormant, the machinery of motion may fall from disuse into decay. Muscles that remain long unexercised, wither; and wither for that reason. They undergo the one, or the other, or both, of the two species of atrophy so well described by Mr. Paget. Either they simply dwindle in size, or dwindling they degenerate also in texture. This last is the more common change. The muscle is then spoiled for its purpose; and no longer capable of resuming its contractions, upon the restoration of the nervous influence. It is probable, as Mr. Paget ingeniously suggests, that in some, at least, of the cases in which the paralysis abides after every other indication of disease in the nervous centres has passed away, the residual fault is really in the instruments of motion, the muscles. He adverts to the experiments of Dr. John Reid, which show that the loss of contractile power in a palsied muscle is owing, directly, to its imper- fect nutrition, and only indirectly to the severance of its connexion with the nervous centres. Dr. Reid divided the nerves of a frog's hind legs — and leaving one limb inactive gave the muscles of the other frequent exercise by galvanizing the lower end of its nerve. The result was, that at the end of two months the exercised muscles retained their weight and texture and their capacity of contraction; while the inactive ones had lost half their bulk, were degenerated in texture, and had also lost some of their power of contracting. In other cases also he found, that degeneration of texture 360 SPINAL HAEMORRHAGE. [lect. XXXI, in the unused muscles always preceded the loss of their contractile power. It will be proper, therefore, in cases of protracted paralysis, to promote, and if possible main- tain, the nutrition of the idle muscles, by friction and pressure, by shampooing, by calling them repeatedly into artificial exercise through the stimulus of galvanism or of electricity. Our aim must be to preserve the muscular part of the locomotive apparatus in a state of health and readiness, until, peradventure — that portion of the brain from which volition proceeds having recovered its functions, or the road by which its messages travel having been repaired — the influedce of the will shall again reach and reanimate the palsied limbs. If, however, no such repair or recovery should ensue, then, at length (as Mr. Paget tells us, on the authority of Dr. Turck), " those tracts or columns of the cerebro-spinal axis through which in health impressions were habitually conveyed from the diseased part" will themselves slowly and gradually undergo a softening, as by atrophy. In the more chronic cases we may sometimes benefit our patient's general condition by the cautious exhibition of some of the preparations of iron. LECTURE XXXI. Spinal Haemorrhage. Paraplegia. Facial Palsy and Facial Anaesthesia; their Symptoms, Prognosis, and Treatment. Other Forms of Local Paralysis, and Local Anaesthesia. I have done with apoplexy as it respects the brain; which is the same thing as to say that I have done with apoplexy. You will find the same thing applied, indeed, to effusions of blood in other organs of the body; but this use of the word is a per- version of language. Apoplexy, as I have frequently observed before, is the abolition of the functions proper to the brain; of sensation, voluntary motion, and thought. In short, it is coma, coming on under certain circumstances. I shall not speak therefore of spinal apoplexy (though that would be less improper than pulmonary apoplexy, or hepatic apoplexy), but of spinal hemorrhage. Of this I really have little to say, except that it is well known occasionally to occur; and that the symptoms to which it gives rise are by no means peculiar or distinctive. They consist of pain in some part of the spine; convulsions; palsy: that is, they are the very same symptoms which inflammation, softening, mechanical injury, and other dis- orders of the same part may produce. Spinal haemorrhage is much more rare than cerebral haemorrhage. Dr. Abercrombie had met with only one case of it. He gives the heads of seven others which have been recorded by different authors. Dr. Bright has never seen it: but he publishes the particulars of one case, which were commu- nicated to him by Dr. Stroud. _ I will read you one or two short examples of spinal haemorrhage, as specimens. A girl, fourteen years old, was attacked with headache, pain in the back, and a tendency to sickness when in the erect posture. At the end of a week the pain in the back became suddenly and very greatly aggravated; and this was followed by general con- vulsions, which proved fatal in five or six hours. The spinal canal was found filled with extravasated blood, in the lumbar region, where she had felt the pain. The brain and all the other viscera were sound. The case is detailed by Mr. Chevalier in the third volume of the Medico-Chirurgical Transactions. Take one more instance from Ollivier, whose work on the spinal marrow you may read hereafter, when you have leisure, with advantage. A gentjeman, aged sixty-one, had just arrived in Paris after a long journey, when he was seized with pain in the back, all the way down from the cervical vertebrae to the sacrum. ^ In the course of a few hours he became paraplegic, and was unable to retain his urine or faeces. He then sent for a physician, and died while talking to him. A very extensive extravasation of blood was found in the spinal canal, beneath the membranes of the cord. The lower part of the canal was filled with a bloody LECT. XXXI.] PARAPLEGIA. 361 mass, in which the substance of the cord could not be distinguished. Above the third dorsal vertebra the cord was entire, but of a deep-red colour, and very soft. The suddenness of the symptoms may lead you to suspect the true nature of these cases; but I cannot pretend to point out any other feature by which they may be distinguished from other morbid conditions of the spine, already spoken of. I show you one preparation; of which, however, I do not know the history. I have nothing to add, to what I have already said, respecting that species of palsy which is called hemiplegia: and I have only a very few further observations to make in regard to paraplegia. The cause of this kind of palsy is sometimes obvious; sometimes most obscure. If we find, in the spinal canal, blood effused, softening of the substance of the cord, traces of inflammation of its investing membranes, tumours occupying it or pressing upon it, pressure from disease or displacement of the bones, we have a sufficient ex- planation of the paralysis of those parts of the body, the nerves of which come from the spinal marrow at or below the place of the disease. There are three preparations on the table, of tumours that pressed upon the cord; scrofulous tumours I believe they are : each of the three persons from whose bodies they were respectively taken was more or less completely paraplegic. But in very many cases we detect no alteration that seems adequate to explain the paraplegia. The palsy creeps on slowly and insidiously, without any particular pain, or violent symptoms : there is no tenderness or bending of the vertebrae. The weak- ness commences mostly in the legs, which appear to the patient heavier than usual, and of which the healthy sensations arc often perverted. The toes tingle, or are numb: he experiences a feeling in them as if a number of ants were crawling on the skin. This is so common a circumstance as to have given a name to the symptom, formication. The patient straddles as he walks. His legs are lifted awkwardly, the toes being often the last part to quit the ground : they are then flung obliquely for- wards and outwards, and the feet flap down heavily and uncertainly at every step. By degrees the weakness of the lower limbs increases: the palsy creeps upwards, affects the bladder and rectum, and the muscles of the abdomen, at length invades the arms, and ultimately the patient dies : yet very faint traces of disease, or no traces at all, may be visible, by the naked eye at least, upon inspecting the brain and spinal cord. The commonest morbid condition is softening of some portion of the cord; and this is also the condition which is the most liable to be overlooked. Dr. Gull describes a case of paraplegia, and it is probably a sample of many more, in which it was only by the exercise of great patience and after repeated examination, that even the microscope discovered traces of inflammatory exudation in the cord; but these, though slight in amount, were distinct and decisive. It is in these cases of paraplegia that you may expect to witness the very remark- able phenomena which I mentioned before as evincing the separate existence of a " true spinal marrow," distinct from the brain and its prolongations into the spinal canal, endowed with special and peculiar properties, and performing functions that are independent of sensation, of consciousness, and of the will. If you pinch or tickle the surface of the paralytic members, or apply a hot spoon to the sole of one foot, the limbs will, in many cases, start up and move strongly, not only without any voluntary effort on the part of the patient, but in spite of him; or even (in those instances in which there is anaesthesia as well as palsy) without his knowing it. The legs often spring up of their own accord as it seems; but, no doubt, the apparently spontaneous movement is frequently an excited movement, and takes place in obe- dience to the laws that govern the automatic motions of the body. Some impression, made first upon the peripheral extremities of afferent nerves, runs through the ner- vous arc of communication, and exhibits its ultimate effect at the extremities of the corresponding efferent motor nerves. We can imagine many such accidental and un- suspected sources of excitement; a casual touch, the varying contact of the bed- clothes, the bite of a flea for aught I know to the contrary, may suffice. Even the passage of faeces or of flatus along the lower bowel, or of urine through the urinary passages, may be enough (as we are taught by unquestionable facts) to produce these movements. They are more readily excited, caeteris paribus, in proportion as the interfering influence of the will is more completely cut off. 362 PARAPLEGIA. [LECT. XXXI I knew a gentleman, who had retired from the medical profession, and who, though not paraplegic, laboured, I believe, under some morbid condition of the spine. He had been, in early life, a hard drinker, and had suffered delirium tremens. Every night, sometimes more than once or twice, the trunk of his body, and all his limbs, became for a while fixed and stiff, from rigidity of the muscles. A few days before his death, he told me this curious fact. Whenever he scraped his shoes on the scraper at the door, his leg flew up, with a spasmodic suddenness, from the iron, not- withstanding his endeavour to prevent it. He died suddenly. I believe he was found dead in his bed. In some cases of paraplegia involuntary retractions of the palsied limbs can be excited; in some cases they cannot. When the influence of the cerebrum is quite excluded by the operation of disease affecting the spinal cord itself, then is the sus- ceptibility of excited movements the most lively. But the increased susceptibility, which has this inverse relation to the voluntary power, is limited to that portion of the body, the nervous arcs belonging to which lie beyond the seat of the disease; more distant, I mean, from the brain. Hence it follows that we may determine, ap- proximately, the place of the disease, by the test of these reflex actions. The mis- chief may be situated, or may extend, so low down, that there are no uninterrupted nervous arcs below it. Supposing it to lie as low as, or to reach, the commencement of the cauda equina, we should have no involuntary movements. Conversely, when no involuntary movements can be excited, the spinal disease is, at least, as low as the upper lumbar vertebrae. Thus, I say, we have another mode, in addition to those pointed out in a former lecture, of determining, in a given case of spinal palsy, where- abouts, or to what extent, the cord is implicated in the disease. We do not so often observe these reflex movements in cases of hemiplegia; appa- rently for this reason, that in hemiplegia the sensorial influence is not, usually, so completely shut out as it is apt to be in paraplegia. Yet I have seen some of these phenomena in several hemiplegic patients. One of them, for example, whose right hand and arm were quite passive under the strongest efforts of his will to stir them, took notice himself, as did his nurse, that whenever he yawned and stretched himself, the fingers of the palsied hand participated in the action, and were thoroughly ex- tended : and I could, by tickling the sole of his foot, excite some starting of the leg long before any power of voluntary movement returned. Emotion has sometimes the same singular effect upon limbs and muscles over which volition has no dominion whatever. An artist with whom I am acquainted, and whose arm was almost completely powerless after a recent attack of paralysis, so that no exertion of his will sufficed to raise it from his side — was one day startled, as he was hobbling across a road, by the unexpected approach of a carriage. He noticed, with wonder, that during his attempts to get out of the way, the palsied arm was suddenly jerked up above his head. But he could not again lift it there after the fright was over. With the loss of power there is usually more or less of anaesthesia: the limbs are numb; or feel as if they were swathed in bandages. Sometimes they are totally devoid of sensibility, so that the patient, lying in bed, does not know, till he lifts up the bed-clothes, whereabouts or in what position his legs are lying. Do not forget the important fact that, in many, nay in most cases of paraplegia, the urine at length becomes ropy, stinking, ammoniacal; and that the bladder, after death, presents appearances such as chronic inflammation might produce; roughness and redness of its inner surface, and thickening of its coats. What is the order of these changes, and in what relation do they stand to each other ? Is the quality of the urine first altered, and does the bladder then suffer from the perpetual contact of this unnatural secretion ? or does the bladder become diseased in consequence of the palsy, and pour forth unhealthy mucus, whereby the quality of the urine is affected ? The truth I believe to be implied in the latter of these questions. In support of that view I have heard the following facts affirmed. The urine voided being alkalescent, the bladder was washed out by the injection and withdrawal of warm water. Then the next portions of urine that descended from the kidneys were immediately re- moved, and tested, and found to be acid. So also, after death, the urine has proved to be alkaline and mucous in the bladder, acid in the pelvis of the kidney. Dr. Bence Jones, in the Philosophical Transactions for 1845, has some excellent obser- LECT. XXXI.] PARAPLEGIA. 363 vations on this subject. He finds that, in such cases as I have been speaking of, the alkalescence of the urine is always due to the presence of carbonate of ammonia. It arises from the decomposition of urea by altered mucus. The urine makes reddened litmus paper blue, but the red colour returns as the paper dries. The blue would be permanent if produced by a fixed alkali in the urine. Moreover, pus globules are always to be detected by the microscope in the secretion, before it becomes animoniacal and ropy. While the urine continues acid, any pus which may be mixed with it re- tains its natural appearance, and fluid condition. Its globules remain distinct, and do not adhere to each other. But whenever the urine becomes alkalescent, the car- bonate of ammonia, acting upon the pus globules as the liquor potassae might do, causes them to stick together: so that a stringy viscid matter is formed which in- cludes epithelium, ammoniaco-magnesian phosphate, and granules of phosphate of lime. "All these together constitute the ropy mucus seen in cases of diseased bladder." There seems to be some connexion between an inflamed condition of the mucous membrane of the bladder, and the state of the spinal cord. Dr. Bence Jones calls attention to the fact, that sloughing of the external integuments is common in the palsied parts; and suggests that the internal integument of the bladder suffers some analogous change, whereby the urine is at length rendered ammoniacal. It is said, however, that in some instances of paraplegia, the urine has been secreted alka- lescent. If these cases have been accurately noted, disease may perhaps have been propagated from the bladder, backwards. Or the disorganization of the bladder, and the alkaline quality of the urine, may both have been common results of the inter- ruption of the nervous influence. We have reason to believe that the defect in some of these cases of paraplegia is merely functional: independent, I mean, of any such change in the nervous matter as is cognizable by our senses. It may be brought on by various causes : by cold; by intemperance in drinking; by excessive sexual intercourse; or, still more surely, by self-abuse. I have had the last cause assigned to me voluntarily by patients them- selves. In such cases we may presume that the loss of function is confined to the spinal marrow. But there is another way in which paraplegia may be accounted for, although its physical cause is very liable to be overlooked. It may result from serous effusion into the spinal canal; which effusion may have originated there, or what seems sometimes to be more probable, may have been poured out within the cranium, and descended by the force of gravity to the lower part of the cavity of the spine. Dr. Baillie read a paper on this subject before the College of Physicians : it is con- tained in the sixth volume of the Medical Transactions. He was not the first person to whom this mode of explaining certain obscure cases of paraplegia suggested itself; but he was the first I believe who published upon it. This effusion may very readily be overlooked. Commonly the brain is examined first; and no great attention is paid to the escape of fluid from the vertebral canal. It would be better to lay opcu the spinal cavity first, at its lowest part, and to puncture the theca, and then to ob- serve what quantity of fluid runs out when the body is placed upright. There should be a certain quantity; but if much serum so escaped, we might conclude that it had existed in hurtful abundance during life, and had caused the paraplegia. In most of these obscure cases you may trace some head symptoms; giddiness, transient con- fusion of thought, loss of memory; and it really will be worth your while to make the examination in the way I have pointed out, whenever you have occasion to in- spect the body of a patient who has died paraplegic. Paraplegia has been ascribed to some primary morbid condition of the nerves which belong to the spinal cord. That the functions of the efferent, or motor, nerves may be impaired, and even arrested, by exposure to cold, and by other injurious influences, is both possible and probable. But a diseased or disordered state of the afferent nerves has been assigned as a cause of the palsy. This is less clearly conceivable. Coexist- ing disease of the kidneys, and coexisting enteritis, have been thought sufficient to produce and keep up a paralytic condition of the lower limbs. The extremities of certain incident nerves being affected, a morbid impression is transmitted to the cord, suspensive of its central function. The efforts even of volition, which come from the brain, are no longer successful. Such is the theory. I do not say it is an erroneous theory; but I am bound to tell you that I think it unproven. My own experience has furnished me with no facts which go to support it. 364 PARAPLEGIA. [lect. xxxi. I have met with three or four instances of paraplegia, in which the palsy appeared to result from the immersion of the lower part of the body, for some time, in cold water. Thus, in one of them, the patient had been in the habit of wading for hours together, in a river, while fly-fishing. We may reasonably suppose that, under these circumstances, the motor nerves, rather than the spinal cord, would be likely to suffer. A remarkable example of the effect of cold so applied, in benumbing the sensations of the parts exposed to it, fell under my notice in the spring of 1846. A lady, between 20 and 30 years of age, suffering from slight leucorrhoea, was directed by her physician to use the cold hip bath. Mistaking, I believe, his instructions, she sat in the cold water for twenty-five minutes, on twelve successive mornings, in the month of February. On each occasion she came out of the bath benumbed. At first the numbness was transient; but at length it became permanent. When I saw her the sensibility was nearly extinct, from that level of her body which the cold water reached, downwards. The parts were not quite destitute of feeling, but seemed to her as if muffled. She scarcely knew when her legs touched each other —nor whereabouts they were when she was lying in bed. She walked in an awkward manner, and said that her legs felt large and heavy; and if one of her shoes slipped off, she was not conscious of it. The inclination to make water came suddenly, and with hurry, and the urine sometimes escaped from her unawares, and she had no sensation that it was passing. Her bowels were never relieved without the aid of purgatives, and then with similar haste. The pulse was plainly to be felt in the tibial artery. There were no head symptoms. I have related this case chiefly for the sake of mentioning the remedy to which it ultimately yielded. When warm baths, friction, blisters, and stimulants of various kinds had been tried in vain, Mr. Christophers, who had called me to see the patient with him, had recourse to electro-magnetism. After the second application, improve- ment became manifest; and in about three weeks the sensibility was completely restored, and the lady well. Cases of paraplegia, such as I have been describing, are by no means uncommon. They are usually slow and tedious; and you will be called upon to administer to their relief. I need not repeat the caution which I have several times given, in respect to the condition of the bladder; you must-take care that it does not become over-dis- tended with urine; and you must enjoin strict attention on the part of the nurse to keeping the patient clean and dry. Friction along the course of the spine; blisters to the loins or sacrum, frequently repeated; issues; and electricity: all these means you will generally have opportunity enough for trying, and for regretting their inutility. In such cases it may sometimes be warrantable and proper to employ strychnia: a poison which mainly affects the spinal cord; causing, when given in a sufficient dose, tetanic spasms of the limbs, with very little or no affection of the sensorium. I have heard of some striking instances of recovery from paraplegia under the exhibition of this drug. I wish I could tell you that I had ever seen such. Let me caution you against its indiscriminate use; or rather its abuse. No good can reasonably be expected from it, but much harm, unless the cord be free from organic disease. Even then I would not advise you to begin with a stronger dose of strychnia, or of the sulphate or the acetate of strychnia, than the twelfth part of a grain every six hours: this may be gradually and cautiously increased, until it gives rise to twitching of the limbs, or to some other obvious effect. The twitching is usually confined to the palsied limbs.* This shows that it results from the agency of the remedy upon the excito- motory system, or true spinal marrow; of which the reflex function is always more readily excited when the cerebrum has lost its customary controlling power. When this symptom occurs, you had better go on with the same dose; it would be unsafe to increase it: and the progress of the case will soon inform you whether any benefit is likely to accrue from a continuance of the medicine. A paraplegic out-patient now attending the hospital has taken the strychnia. It made his palsied limbs start and extend themselves; but no permanent power has been gained. There is one other drug which I should recommend you to try in such cases; viz., the tincture of cantharides. It certainly has sometimes a very beneficial effect. Generally, when it does good, it acts as a diuretic; and Dr. Seymour has throw-out the suggestion that it is most likely to be useful in those cases of serous effusion into the spinal cavity, of spinal dropsy, which I just now described. He recommends LECT. XXXI.] FACIAL PALSY. 365 the tincture as a good diuretic in several forms of dropsy; and supposes that it benefits paraplegia by tending to produce absorption of the serum effused within tho vertebral canal. Moreover, there is another principle upon which this medicine may be sometimes advisable. Cantharides are well known to have a peculiar effect upon the bladder; which effect is doubtless produced through the corresponding part of the spinal cord. If, by means of the Spanish fly, we can excite, though but from time to time, the function of that part, we may obviate, in a great degree, the distressing consequences of incontinence of urine, arising from paralysis of the sphincter vesicae. Dr. Mar- shall Hall relates a very interesting fact, bearing directly upon this point. A young lady had a tumour within the tenth and eleventh dorsal vertebrae. It gradually, but completely, severed the spinal marrow, and induced perfect paraplegia. The bladder lost its power of retention. But on giving a dose of the tincture of cantharides the power of retaining the urine was always restored for the time. That power would cease, and again be restored, on suspending and repeating the medicine. Dr. Hall remarks that the cantharides obviously acted through the segment of the excito-motory system left below the division of the spinal marrow. The tincture may be given in half-drachm doses. The forms of paralysis that have hitherto been noticed are forms of partia, para- lysis. When the palsy is still more limited, although the epithet partial would be equally applicable, the term local palsy is more commonly used. There is one of these local palsies which is exceedingly interesting, and of much importance: I mean palsy as it affects exclusively one side of the visage; facial palsy. It is sometimes called, not very correctly, paralysis of the portio dura of the seventh nerve. The most common kind of facial palsy is indeed paralysis of the muscles supplied by that nerve. But the word paralysis is misused when it is intended to express any other loss of function than that of the faculty of motion in muscular parts. It is incorrect to speak, as some authors do, of palsy of the kidney; it is equally inexact to speak of palsy of a nerve. I say that facial palsy, and facial anaesthesia (for the two should be considered together), are very interesting affections, because they elucidate, in the human subject, some of the most curious discoveries of modern physiology : and they are important affections for you to study and understand, inasmuch as, though always distressful and alarming to the patient and his friends, and sometimes indeed indica- tive of extreme danger, they often are merely inconvenient and disfiguring, and bespeak no peril at all. Let us first consider that affection in which the majority of the muscles on one side of the face alone are palsied. I have already briefly touched upon this form of palsy when it constitutes a part of hemiplegia. But it is of more consequence to attend to it when it occurs without any similiar affection of the limbs. If the arm, or leg, or both, are paralysed at the same time with one side of the face, we know that the whole results from disease in the brain, or in the upper end of the spinal cord. But it is not necessarily so when the face alone is palsied; and it is often of great moment to the comfort and the safety of the patient, that we should be able to tell whether the palsy does imply disease within the skull, or not. The appearance presented by patients affected with facial palsy is peculiar, and very striking. From one half of the countenance all power of expression is gone; the features are blank, still, and unmeaning; the eyelids apart, and motionless. The other half retains its natural cast, except that, in some cases, the angle of the mouth on that side seems drawn a little awry. This is apt to be mistaken for proof of a spasmodic condition of that part; but it is owing simply, as I stated before, to the want of the usual balance or counterpoise from the corresponding muscular fibres of the palsied side. The patient cannot laugh, or weep, or frown, or express any feeling or emotion with one side of his face, while the features of the other may be in full play. One half of the aspect, with its unwinking eye, its fixed and solemn stare, might be that of a dead person; the other half is alive and merry. Tho incongruity would be ludicrously droll, were it not so pitiable also, and distressing. To the vulgar, who do not comprehend the possible extent of the misfortune, the whimsical appearance of such a patient is always a matter of mirth and laughter. On the 366 FACIAL ANESTHESIA. [lect. XXXI. other hand, his friends and relations imagine that he has had a stroke, and are in great alarm for his life. In the majority of these cases there is not, however, any real danger of that kind to be apprehended; a circumstance which, of itself, would render the exact diagnosis of the complaint peculiarly interesting: and the exact diagnosis you may at once determine by noticing the condition of the eye. Dr. Todd has well remarked that inability to close the eyelids—paralysis of the orbicularis palpebrarum — is the pathognomonic sign of facial palsy from suspended function of the portio dura: and that this nerve is seldom affected in cases of hemiplegia depending on disease of the brain. In general there is no deficiency of sensation. And, vice versa, we sometimes have loss of sensibility in the same parts, without any diminution of the power of motion. The best way, I believe, to place the phenomena of these curious affections plainly before you, will be by examples. A house-maid, Jane Smith by name, twenty-eight years old, became one of my out- patients at the Middlesex Hospital, with the following symptoms. She had lost all power of moving the right side of her face. When she endeavoured to raise her eye- brows, the right side of the forehead remained smooth, and the left was wrinkled. When she attempted to close her eyes, the right eye was but partially covered, the eye-ball rolling upwards, and carrying the cornea within the curtain of the upper lid, which descended a little to meet it. When she tried to snuff in air through the nose, not being able to keep the right nostril stiff and open, its sides came together, and no air passed up on that side. When she smiled, the right side of the face remained perfectly still, like a mask; and it wore at all times a vacant and inanimate character. When she was told to perform the action of blowing, her right cheek was puffed out like a loose bag, and the breath issued, whether she would or no, at the right angle of her mouth. The same thing happened with her food and drink; she could not prevent their escaping at the right corner of her mouth; nor could she convey mor- sels of food from the right to the left jaw, without the aid of her hand applied exter- nally in support of the paralysed cheek. The masseter and temporal muscles, how- ever, acted as strongly on the one side as on the other; she could chew perfectly wel! on the palsied side, and the sensation of the palsied parts remained perfect; and there was no paralysis of any other part of the body. All these phenomena are invariably met with in all complete cases of this kind. I will contrast them with the phenomena presented by another of my patients, who was in the hospital, and whose name was Ann Church. I give their names, that I may the more readily distinguish the one from the other. When this woman, Church, applied for admission, she complained of intense pain, with some swelling, in the right temple, and extending thence generally over the right side of the face and head. It was soon discovered, however, that although she complained of most severe pain in these parts, theyhad entirely lost their ordinary sensibility to external impressions. She felt nothing when her forehead, or cheek, or nose, or chin, was touched on that side. In short, there was complete anaesthesia, of the right half of the face; just as in Smith's case there was complete palsy. The insensibility was very exactly limited to the right half, and terminated abruptly at the middle line. It was remarkably evident in a part in respect to which the bystanders could scarcely be deceived, even if there had been any reason (which there was not) for distrusting the patient's own state- ment. The surface of the eyeball is proverbially sensitive, even to slight impressions. But you might place your finger upon this woman's right eye, or you might brush it with a feather, without giving her the smallest pain, or producing any sensation at all: whereas, on the left side, the lightest touch caused involuntary shrinking, and closure of the eyelids, and a gush of tears. She declared also that she had no feeling in the right half of her mouth; she neither tasted sapid substances, nor was she at all conscious, from any sensation produced by them, that they were placed there. Her lips on the same side were equally destitute of sensibility; so that when she drank, haying no perception of the contact of the cup with her lips beyond their middle point, she felt as if she were drinking from a vessel with a broken rim. This is a circumstance which all persons who are thus affected are much struck with: and it almost always forms a part of their voluntary account of themselves. Besides this defect of sensibility, the power of contracting the masseter and tempo- ral muscles on the right side was entirely abolished in this patient. You may deceive lect. xxxi.] FACIAL PALSY. 357 yourselves on this point, if you do not investigate it carefully, and with certain pre- cautions. At least I have known persons doubt, because, having directed the patient to open and shut his mouth, they have confounded the movement of the whole jaw with the action of the masseter muscle. But if you tell the patient first to close his mouth, and then to perform the action of grinding with his teeth, placing your fingers at the same time on the corresponding muscles on each side, the difference, when it exists, will be very striking. In the woman of whom I speak, no swelling of the masseter or temporal muscle on the affected side took place when she forcibly closed her jaws. There was no other paralysis. Now we cannot separate the physiology from the pathology of such affections as these. Nor ought we. The morbid conditions of which the two cases just described furnish samples, illustrate in a very beautiful manner the modern doctrine respecting the special uses of particular nerves. In the first of the two cases the palsy resulted from suppression of the function of the hard portion of the seventh pair of cerebral nerves; and the anaesthesia, in the last of the cases, depended upon suspension of the function of the fifth pair. You know that experiments performed upon living ani- mals have proved that the division, by the scalpel, of the portio dura, before it spreads out into that remarkable nervous network on the side of the face, paralyses all the muscles, the combined play of which gives variety and significant expression to the countenance; and that, on the other hand, the division of the fifth nerve deprives the same parts of their sensibility. In these two cases, and in such as these, for they are by no means infrequent, a similar set of experiments upon the same nerves, in the human living body, is performed before our eyes by the agency of disease, or accident: and the result justifies most completely those conclusions which had been deduced in the first instance, from contrived observations made upon the lowei animals. There is one point in the history of these cases upon which I must dwell a moment longer; for it is a most interesting point. That the condition of the temporal and masseter muscles should be reversed in two patients so oppositely situated, was no more than might have been expected. But in each these muscles were affected in a manner the very contrary of that which the general circumstances of the case would, d priori, have prepared us to anticipate. Where the superficial muscles were para- lysed, and the principal movements of the face suspended, there the masseter and temporal muscles were in full power and action; and where the loss of sensation was the predominant phenomenon, and the ordinary motion and expression of the counte- nance remained, there these muscles were in a state of complete palsy. A few years only ago, this difference and apparent inconsistency would have been quite inexplicable. The progress of modern science has removed the difficulty, by establishing a general agreement between the functions of different nerves, and cer- tain observed peculiarities in their anatomical relations and arrangements. Suffer me to remind you (for I know that these interesting points of physiology must have already been taught you) that the nerves which proceed from the spinal column on each side are connected with it by two fasciculi of nervous fibrils — two roots, as they are metaphorically called—of unequal size; that when the larger of these, which is situated posteriorly, and is furnished with a ganglion, is divided in a living animal, the parts to which the nerve is distributed lose the faculty of sensation, while the power of voluntary motion remains unimpaired; and that when the smaller and ante- rior, which has no ganglion, is alone cut, the same parts are instantly palsied, but retain their sensibility. In other words, the posterior fasciculi minister to the faculty of sensation, the anterior to that of motion. Now the fifth pair of nerves was observed to have a similar origin ; to be composed, that is to say, of two fasciculi or roots, one larger than the other, and invested with a ganglion; the other smaller, and having no ganglion. It was natural to infer that the functions of these roots would be analogous to those of the corresponding portions of the spinal nerves; that the ganglionic fasciculus would relate to sensation, and the other to motion. And such is found to be the case; and the arrangement here is really very curious. The smaller portion of the fifth nerve is exclusively expended upon a very few muscles; viz., the masseter, the temporal, the two pterygoid mus- cles, the circumflexus palati, and the tensor tympani. The action of the two first of these, of the masseter and temporal muscles, is obvious to common observation; and 368 FACIAL PALSY. [lect. xxxi. therefore their condition is noticed in such cases as I have related^ Again, these very same muscles have been shown, by careful dissection, to receive no nervous branches from the seventh nerve, which is a motor nerve, and which ramifies so abundantly upon the superficial muscles of the face. It was to be expected, therefore, that any diseased state confined to the portio dura of the seventh nerve, would leave the temporal and masseter muscles fully effective: and that disease involving the fifth nerve, but leaving the seventh untouched, would destroy, not only the general sensibility of the face on that side, but also the power of contracting these particular muscles. And this was thoroughly exemplified in the two cases that I have detailed. The girl Smith had total palsy of the superficial muscles; but sensation, and the action of the deeper-seated muscles, continued per- fect : while in the woman Church there was default of sensibility, and paralysis of the temporal and masseter muscles; but the movements of the superficial muscles were unimpeded. Total interruption of the function of the portio dura will paralyse these superficial muscles of the face : and such interruption may be occasioned either by sudden injury done to the trunk of the nerve; or by disease affecting its proper structure; or by pressure, the consequence of disease in parts contiguous to it. And it is of great importance to observe that the morbid condition which causes the interruption may be situated at any point in the course of the trunk of the nerve: while it is yet within the cranium; or during its passage through the petrous portion of the tem- poral bone; or after it emerges upon the face, through the stylo-mastoid foramen, to be ultimately spread in meshes over the cheek and temple. The nerve may be com- pressed or hurt while still within the skull; but in most cases of this kind other por- tions also of the nervous matter are involved in the mischief, and other sets of volun- tary muscles testify this by their immobility or their irregular action. This is sometimes the case when facial palsy occurs as a part of hemiplegia. In most instances, however, of hemiplegia, there is but slight distortion of the countenance, a mere hanging of the cheek, with no paralysis of the orbicularis muscle of the eye: motor branches of the fifth nerve only being affected. When the facial muscles alone are paralysed, it happens in a great majority of instances that the nervous func- tion is interrupted in that part of the portio dura which lies incased in the bone, or in the more exposed part which issues in front of the ear: and hence it arises that this particular form of palsy is, in general, unattended with any danger to life. The physical cause of this remarkable disfigurement, and the true explanation of its prevailing immunity from danger, were first pointed out by Sir Charles Bell: but both the existence of the malady as a distinct form of disease, and its comparative harmlessness of character, had been observed and described some years previously: although the reason neither of the one nor of the other was at that time understood. Dr. Powell had narrated, in the fifth volume of the Transactions of the College of Physieians, three marked instances of this form of local palsy; and had noticed at the same time its apparent independence of any apoplectic tendency, or cerebral disease. The exciting causes of the complaint are various. Sometimes it is the consequence of mechanical violence, by which it is plain that the nerve has been lacerated, or otherwise injured. Sir Charles Bell, to whom we are indebted for much information on the subject, mentions several examples of this kind. In one a man was shot by a pistol-ball, which entered the ear and tore the portio dura across at its root. In an- other, the patient was gored by an ox; the horn of the animal entered beneath the angle of the jaw, and came out in front of the ear, tearing the nerve across. In a third, the nerve was divided by a surgeon's scalpel, in an operation for the removal of a tumour which lay above and around its course. I have myself known the same disaster to result from the unlucky incision of an abscess near the ear. In all these cases the injury was external and obvious. In a fourth the palsy followed a blow on the ear which caused haemorrhage from that part: here probably the nerve was hurt in its passage through the bone. Some time ago, a man was brought into the Mid- dlesex Hospital who had fallen from a height, upon his head. The muscles of the left side of the face were paralysed. He died in a few days; and examination of the head showed a fracture in the base of the skull, passing through the petrous portion of the temporal bone, and rendiug the seventh nerve at its entrance into the meatus LECT. XXXI.] FACIAL PALSY. 369 auditorius internus. In the year 1832 I had a patient (Richard Hills) in the hos- pital with the same kind of paralysis, which seemed, in him, to have been occasioned by a mere shock or jar. He was a coachman, and one day, when he was off his box, his horses started away, and he ran to their heads to stop them, but was thrown down in the attempt, striking his hip and elbow. He received no blow on the head at all. Three hours afterwards he found that he could not spit properly. The affection is not unfrequently discovered bjp that circumstance. He could not avoid spitting on his clothes on one side; and he could not whistle. Another circumstance worthy of notice took place in this man, which often, though not always, happens in these cases, and which I did not mention before. He remained for about two months in the hos- pital; and regained during that time in some degree the power of exercising the affected muscles; but he still was unable to bring the right eyelids together. The eye itself was unharmed. After he was made an out-patient he resumed his func- tions on the coach-box; and his eye, permanently half-open and unprotected, was more exposed to dust and to currents of wind than it had been when he was an in- patient. Moreover he got drunk; and he soon presented himself again with uni- versal redness and inflammation of the conjunctiva. Sometimes the inflammation in such cases produces opacity of the cornea and a total loss of vision. This is one of the worst consequences of facial palsy. Fortunately it is only an occasional conse- quence : and it will occur or not, according to the quantity of motion which remains to the eyelids, and the degree of exposure to the ordinary causes of inflammation. I have noticed that — either from differences in the completeness of the palsy, or from peculiarities of the features—the speech is more embarrassed in some of these patients than in others. Labial sounds, and words that require the explosive pressure of the buccinator muscle, are uttered imperfectly; and the patient soon learns to assist his defective articulation, by supporting the palsied cheek, and so affording a fulcrum to the lips, with his hand. Sometimes the palsy depends upon manifest external disease ; sometimes upon dis- ease which is hidden, and probably internal; in the bony canal. Sir C. Bell describes an instance in which it accompanied the disorder called the mumps. Dr. Maiden, of Worcester, witnessed another in which a fixed, hard, indolent tumour, had formed between the ramus of the lower jaw and the mastoid process of the temporal bone. As this tumour gradually subsided, the palsy disappeared. In each of Dr. Powell's three cases the affection was apparently caused by exposure of the side of the head for some time to a stream of cold air. A medical acquaintance of mine residing in London, had a patient at Greenwich, whom he visited daily. It was cold weather; and on one occasion, as he was returning in the cabin of a steamboat, he was sensibly incommoded by a keen east wind, which blew through an open window directly upon his ear. The next day he presented himself to me with that side of his face fixed in the manner I have been describing. Exactly the same mishap befel a Scottish physician while travelling to London by a coach : and sent him in great alarm to Sir 0. Bell. Some years ago a marked example of facial palsy occurred in one of my hospital patients; it appeared to be owing to his having been constantly in the streets for some days without shoes or stockings, during a cold thaw. It may be presumed that in these instances some swelling was produced in the soft parts around the nerve, compressing it where it lies within the unyielding bone. Exposure to cold in this way is the commonest of all the exciting causes of the complaint, and cases thus arising are more obedient to treatment than most others. Probably some of you saw a female patient who came under my care in the hospital in May last (1838), in whom facial palsy had existed on one side for eighteen years. When about three years old she had the measles; and a scrofulous tumour formed behind the ear, and broke: and after some time, a portion of carious bone came away. Then the wound healed (of which deep traces are still visible); and the peculiarity of her features was observed. There are still other cases in which we fail to discover any direct explanation of the paralysis, either in the history of the patient, or in his physical condition. In the girl Smith, whose symptoms I stated in detail as an example of the appearances uniformly present, the malady came on without any obvious cause, and it resisted all the means employed for its removal. That the greater number of cases of this kind are free from serious peril, is a fact of great practical importance. It enables us to quiet the alarm of the patient and of 370 FACIAL PALSY. [lect. xxxi. his family: and it regulates in many instances the treatment; rendering it less active than it might and perhaps ought to be, if the palsy were really the harbinger of apoplexy. At the same time you should not be ignorant that a similar limitation of paralysis to the particular muscles supplied by the portio dura is sometimes (though rarely) observed, when the disease has a more inward origin; when it affects and involves the brain itself. The following case caused me much anxiety, for the subject of it was a personal friend of mine. — I was summoned to his house in the autumn of 1829, and found him with complete palsy of the left side of the face. It had existed a day or two. I shall not describe the appearances and symptoms that resulted from the paralysis: for they were precisely the same as were presented by the girl Smith; and they are always, and necessarily, very much alike. But though the palsy was strictly limited to this set of muscles, there were other symptoms present which indicated that the interruption of the functions of the portio dura was connected with some morbid condition within the cranium: nausea and vomiting, twitching of the muscles of the other side of the face, great drowsiness, and a slow pulse, 48 only in the minute. He lurched also, and staggered as he walked; but he distinguished this from the reeling of vertigo, and denied the latter sensation altogether. He was deaf, too, on the affected side. His previous history did not tend to diminish the fears which his actual state excited. In the preceding February, he had been attacked, rather suddenly, with intense pain just above the right eyebrow, and became extremely drowsy. Being desirous, on account of these feelings, to excuse himself from a dinner engagement, he found that he was unable to write a proper note : he could not remember how he ought to express himself. All these symptoms soon passed off; after the operation, I believe, of an emetic. But he had another attack of the same kind in the subsequent May: the same severe pain over the right brow, with great drowsiness and confusion of mind. He could not recollect the first line of the .ZEneid. He wished a friend to look at the signatures of some letters that had arrived : and though he knew the root, he could not tell how the word he wished to use was formed: whether it was signition, or signation, or signature. The digestive organs on this occasion were made the object of treatment, and he soon got well. Another part of his history was instructive; and therefore I mention it. Before these attacks he was in the habit of eating and drinking freely: and his power of digestion was supposed to be enormous. After the attack in May he commenced a strict course of temperance. He drank no wine till three or four days before the occurrence of the facial palsy: he had then taken it again ; about four glasses daily: and on one of the days he drank two glasses of champagne. It was of some moment to this gentleman, not only that he should recover, but that he should recover quickly. He had been appointed by Government to a mission in Ceylon, and all his equipment was already on board a vessel which would sail in a fortnight. Cupping behind the ears, blistering, purgatives, and small doses of calomel continued till the gums were slightly sore, removed the paralysis, and all the other symptoms, in about ten days. He went to Ceylon, and accomplished his mission so ably that after his return the Government appointed him to one of far greater importance in India. He has remained perfectly well; and possesses one of the clearest and strongest intellects that I am acquainted with. I must trouble you with one more case, to complete the history of this disease: a case in which the cause of the facial palsy was situated within the cranium and proved fatal, and became visible after death. Samuel Dovey, a tailor, fifty-seven years old, was admitted under my care into the hospital, in February, 1833, with complete palsy of the muscles supplied by the portio dura on the right side, and of no others. There were symptoms enough, however, to show that some serious mischief was going on within the skull. He suffered intense headache, more on the left than the right side; was dizzy and staggering; and could not get to the ward without being led. The palsy had come on about ten days before, in the night. He found when he came down stairs the next morning that he could not spit as usual; and his friends LECT. XXXI.] FACIAL PALSY. 371 observed the unnatural state of his features. He had had no fit, nor loss of conscious- ness ; but he thought his memory was failing. At the time when the paralysis was first noticed, he had some numbness and tingling of the right arm, extending to the last two fingers. He was quite deaf in the right ear. This is a point deserving attention in such cases. The deafness, when it occurs, marks an affection of both the portions of the seventh nerve: and therefore indicates the probability of an in- ternal cause. The whole progress of this case was very interesting; but I must confine myself to those circumstances which bear upon our present topic. He lived about a month after his admission, and during that interval he suffered great pain in the head, was delirious at times, and at other times in a state of coma: at one period he suddenly presented the ordinary symptoms of apoplexy, from which he partly recovered. I found a cancerous tumour occupying the right hemisphere of the brain; and at its under part was an apoplectic clot, as big as a hazel-nut. I found also a very satis- factory explanation of the deafness and of the' facial palsy which had been noticed during his life-time. The portio dura and the portio mollis, where they emerge as distinct cords from the medulla oblongata on the right side, were adherent to each other. The portio dura was both harder and larger than the corresponding nerve on the opposite side, while the portio mollis was wasted and diffluent. The same change was traced up to their entrance into the petrous portion of the temporal bone. Im- mediately over the medulla oblongata, and in a vertical line above the point of emer- gence of the seventh pair of nerves, a nipple-like portion of brain projected down- wards, and had apparently communicated pressure to these nerves; and this projection from the lower surface of the brain seemed to have been produced by the general pressure resulting from the growth of the tumour. The remarks which I have been applying to palsy of these parts hold true also in respect to their loss of sensibility. The anaesthesia may or may not portend danger to life, according as the interruption of nervous function on which it depends is situated more or less near to the origin of the fifth pair of nerves in the brain. The patient, Church, whose case I have several times referred to in this lecture, left the hospital with the sensibility of her face nearly as perfect as ever. The treatment consisted in local blood-letting and counter-irritation. She had erysipelas of the head while in the hospital, and was in some danger from that complaint, which was attended with a good deal of fever and delirium. With the exception of the delirium, which belonged no doubt to the erysipelas, there was no reason to suspect any affec- tion of her brain. I have incidentally adverted to the plan of treatment to be pursued in these cases of facial palsy. When the complaint is recent, and has an obvious cause, the appro- priate remedies will readily suggest themselves. When, for example, it has come on after exposure to a current of cold air, or after a blow, or any circumstance likely to give rise to inflammation, you must treat the case as you would treat inflammation; hearing always in mind that a small amount of disorganization, a little thickening or induration of the parts around the nerve, may render the deformity and the incon- venience permanent. If there be inflammatory fever, bleed from the arm : if there be not, take blood from the neighbourhood of the affected nerve by cupping: apply fomentations; or, what is better in these cases, conduct the steam of hot water against and into the ear: and administer mercury so as just to touch the gums. I should always take this latter precaution, lest any effusion of lymph should cause abiding pressure on the nerve. If the palsy give way before the gums become tender, the mercury need not be pressed further. The iodide of potassium is often an eligible remedy in these cases. Where there is any ground to suspect that the brain is implicated, the treatment just described must be pursued with greater diligence, and with such modifications as the nature of the case may require. If there be evidence of chronic disease in the petrous portion of the temporal bone, such as tenderness of the mastoid process, deafness, a protracted discharge from the ear, and an imperfect state of the membrana tympani, we can scarcely expect much good from very active treatment. We must then have recourse to counter-irritation, and such other measures as I spoke of when the subject of otitis was briefly considered. The examples which are met with of local palsy, and local anaesthesia, are number- 372 REMARKABLE CASES. [lect. xxxi. less; but those which I have mentioned are the most common and the most impor- tant. They are always deserving of attention; but more so when any suspicion arises that they may be connected with cerebral disease. Sometimes they evidently have no such connexion. In the month of November, 1834, a coachman became my patient in the hospital with incomplete paralysis affecting some of the muscles of the right leg alone, with numbness of the foot. He could both stand and walk; but on advancing that leg, his foot flapped suddenly down, and he could not deliberately direct and plant it like the other. His general health was quite good; he had no headache, nor giddiness, nor palsy of any other part. But a month ago he had been sitting with the right leg thrown over the opposite knee; and he continued in that position until the foot felt numb, and tingling, and was (what is called) asleep; and it had remained in the same condition from that time. After some general treatment (cupping and purgatives) before he came to the hospital—treatment which was quite proper in the way of precaution, but which was probably, in truth, unnecessary — I had his leg electrified; and in about ten days .the sensation and the power of the limb were almost restored. Mr. Swan mentions a somewhat similar case, in which anaesthesia of the hand was produced by strong pressure made upon the wrist. There are some very curious facts connected with anaesthesia, showing that the voluntary exercise of the muscles is regulated in some measure by the sensations of the limb that is employed. The sense of resistance prompts to such contraction of the muscles as is required to balance that resistance; reminding the will (so to speak) of the necessity that exists for its perpetual and vigilant operation. Continued volition is essential to the continuance of the muscular tension. Thus Dr. Yelloly describes a woman who had no power of feeling in her hand and fingers, although the power of moving them, and of grasping substances, was perfect. This woman found that she could carry glasses or plates in that hand very well and safely, if she con- tinued to look at and attend to them; but if her eyes were turned another way, as she did not feel what she held, she was very apt to drop it. Dr. Ley met with just such another case. A woman had defective sensibility on one side of the body : she could hold her child in the arm of that side so long as her attention was directed to it; but if surrounding objects diverted her from taking notice of the state of her arm, the flexor muscles soon began to slacken, and the child was in danger of falling. All this is exceedingly curious. Andral has recorded a most singular example of local anaesthesia, which preceded an attack of apoplexy. The patient lost, from time to time, all sensation in certain isolated parts of the skin upon the thorax : there were five or six of these insensible spots, each about the size of a five-franc piece. You might pinch the skin in these places without producing the slightest feeling in the patient. In all other parts the sensibility was perfect and lively. There are other cases also on record, more remarkable still; in which the patients have lost both the power of motion and the faculty of sensation in almost every part of the body, and yet have survived for a considerable time. Thus one person (whose case is related in the Bulletin des Sciences Medicates for January, 1828,) became first amaurotic, then deaf, and then by degrees lost all power of sensation and motion except in the tongue and in the muscles of deglutition and respiration. His speech and intellects were unimpaired. It was accidentally discovered that a small patch on the right cheek retained its sensibility; and by tracing letters on this sensible spot, his wife and children were enabled to interchange ideas with him. He died at length, and his body was not examined. I shall finish what I have to say on this head, by relating a case of the same kind, which occurred under Dr. Abercrombie's notice; and which we are sure, therefore, would be observed with care, and recorded with fidelity. A servant girl, about 20 years old, sprained her back in lifting some heavy article of furniture. She felt no great inconvenience at the time; but some little while after, weakness of the legs came on, and gradually increased to complete paraplegia. After an interval, the affection extended to her arms, and she then had not a vestige of motion of any of the parts below the head, except a very slight movement of one of the fingers; but the internal functions were all perfect, and her utterance was distinct, except that in speaking she was sometimes seized with spasmodic twitches of the lips and lower jaw. She lived in that state, without any change of the symp- LECT. XXXII.] TETANUS. 373 toms, and her general health continuing good, for about twenty years. In the morn- ing she was taken out of bed, and placed in a chair, so contrived as to support her in a sitting posture. Her arms rested on a cross board which passed before her; and if by any accident one of them slipped from this support, she had no resource but to call for the assistance of another person to replace it. Having been on one occasion left alone for about two hours after one of her arms had thus slipped down, the hand had become extensively oedematous. In the same manner, if her head fell forward upon her thorax, it remained in that position until raised by an attendant. Her mind was entire. She died after four days' illness with symptoms of low typhus fever. You may suppose that Dr. Abercrombie looked with the greatest interest for the cause of these most remarkable symptoms. " I examined the body with the utmost care, (says he,) along with Dr. Pitcairn, who had been in the habit of seeing her for several years: and we could not discover any disease either in the brain or in the spinal cord." It is much to be regretted that when this case was under observation, the excito- motory functions were not understood, nor attended to. I shall next proceed to consider those diseases (and there are several of them) which are marked by definite symptoms, which consist essentially in some disturbance or disorder of the nervous system, but which are not accounted for by any physical changes that we can appreciate in any part of that system. After some of these dis- eases we do, to be sure, sometimes meet with morbid appearances in the nervous centres; but none that are constant, or uniform. LECTURE XXXII. Tetanus. Its Symptoms and Varieties. Causes. Diagnosis. Pathology. Treat- ment : Opium; Blood-letting; the Warm Bath; the Cold Bath. In those diseases of the nervous system which have hitherto engaged our attention, the function of voluntary motion, when it has been affected at all, has mostly suffered in the way of diminution, or suspension; the power of moving has been impaired, or lost; there has been complete or incomplete palsy. Sometimes, indeed, convulsion, or an irregular and involuntary action of the muscles, has also occurred. But, distinct from the paralytic affections, there is a class of spasmodic diseases, of which it is the main and leading feature, that the function of voluntary motion is (not mor- bidly heightened, as in the preternatural strength of a madman; nor lowered, as in palsy; but) perverted: performed in an irregular and unnatural manner. There are two sorts of spasm. One of these is marked by a long-continued con- traction of the affected muscles, not rapidly alternating with relaxation : the relaxation taking place slowly, after some time : and then, perhaps, the contraction, after another interval, coming on again. This is called tonic spasm; and, by Cullen, spastic rigidity. A very familiar example of it is the common cramp of the leg. In the other form of spasm, the contractions of the affected muscles take place repeatedly, forcibly, and in quick succession; and the relaxation is, of course, as sudden and frequent. This has been named clonic spasm. We find illustrations of it in con- vulsions. Sometimes the two are mixed together in the same disease; certain muscles under- going convulsions or clonic spasm, and certain other muscles being affected with rigidity or tonic spasm. But it is convenient to keep the distinction in mind. We recognise these disorders by the unnatural conditions of the muscles: but you will please to remember that the fault lies in the nervous system. With regard to spasmodic diseases generally, I may say that some of them constitute the most appalling and fatal maladies to which the human body is liable; and some 374 TETANUS. [LECT. XXXII. of them, though frightful to look upon, and productive of extreme distress to patients and their friends, are trivial in their consequences, and scarcely ever attended with any peril to life. I propose first of all to consider one of the most formidable and worst of these spasmodic diseases, viz., tetanus: of which tonic spasm is essentially characteristic. Its name is derived from tslva, to stretch. In respect to all those diseases concerning the exact or full pathology of which we are ignorant, and which we identify by the group of symptoms they present, rather than by any organic changes of structure in any part of the body, the most convenient mode of proceeding will be, first to describe the distinctive symptoms. Tetanus, then, is characterized by an involuntary, long-continued, violent, and painful contraction—in one word, by cramp — of the voluntary muscles of various parts, or of nearly the whole body. There is no difficulty in recognising the disease when it is fully formed. But it is of much importance to be aware of the marks of its approach, and of its earliest symptoms; in respect of the treatment to be then adopted. The muscles that seem, in general, to be the earliest affected are those of the neck, jaws, and throat. The patient feels a difficulty and uneasiness in bending or turning his head; and supposes that he has got what is called a stiff neck. He finds also that he is unable to open his mouth with the customary facility. At length the jaws close: sometimes gradually, but with great firmness; sometimes (it is said) suddenly, and with a snap. In four cases, perhaps, out of five, the disease begins in this way, with trismus, or locked jaw: so that this last is the vulgar name for the complaint. Along with this symptom, or very soon after it, the muscles concerned in swallowing become affected; and in a short time there comes on, what is often the most distressing part of the disorder, an acute pain at the lower part of the sternum, piercing through to the back. This depends, it can scarcely be doubted, upon cramp of the diaphragm. The pain is subject to aggravation in paroxysms; and each paroxysm of pain is attended with increased contraction of the other parts also that are implicated. The spasm extends to the muscles of the trunk: to the large muscles of the extremities: the muscles of the face: and last of all, in general, to the muscles of the tongue, and of the hands and fingers, which often remain moveable at the will of the patient, after all the other voluntary muscles of the body have become fixed; and frequently the muscles of the wrists and hands escape altogether. With respect to all the muscles involved, from the time when they are first affected to the time when the disease is relieved, or the patient dies, they continue in a state of contraction, and are swelled and hard in their centres. The jaw, for instance, can never be completely opened, and the muscles of the abdomen are so rigid as to make it hard, like a board. But, besides this, they are all subject to aggravations or exacerbations of the spasm, which occur perhaps every ten minutes, or quarter of an hour, and last for two or three minutes at a time; and then the muscles fall back into the minor degree of contraction in which they were prior to the exacerbation. In a very few instances only has a perfect remission of the spasm been observed. The exacerbations usually begin by an increase of the pain felt at the sternum. Some- times there is no obvious exciting cause of their occurrence; but frequently it is evident that they are brought on by exertions of the body; even by slight movements, such as belong to a change of posture, to the attempt at swallowing or speaking. As the disease advances, these paroxysms of aggravation become more frequent, and a rapid increase in the frequency of their recurrence is one of the most unequivocal signs that the case is severe and dangerous. The more speedily the intervals between the paroxysms shorten, the worse. It is a curious thing, that the spasm is observed to give way, sometimes at least, and the muscles to be relaxed, during sleep. To be sure, in the severer cases, the patient is seldom able to sleep; and it may be that in the less violent instances, the spasm abates or ceases, and the exhausted sufferer sinks into repose in consequence of this abatement. However, a similar phenomenon occurs in at least another of these spasmodic diseases, as we shall see hereafter. Mr. Mayo had a boy afflicted with tetanus, in the Middlesex Hospital. On visiting him one day, he found him asleep, and remarked that he lay perfectly relaxed. The abdominal muscles were soft and yielding, and had not the least tension. The boy was awakened, and at the LECT. XXXII.] TETANUS. 375 instant the full tension of the muscles returned. Not being further disturbed, he fell asleep again in a few minutes, when the muscles again slackened; and again, upon his being a second time roused, resumed the state of spasm. In most cases the strong muscles of the back are the most affected, and they over- come those on the anterior part of the body; so that sometimes the patient during the paroxysm rests only upon his head and his heels, while his body is raised into the shape of an arch. This form of the complaint is called opisthotonos, a bending back- wards. The sterno-mastoid muscles of the neck have been so stretched and misplaced as to become powerful extensors of the head. In a few instances the body is bent forwards, so that the head and knees are in contact, and the patient is rolled together like a ball. This is called emprosthotonos. In the only example of emprosthotonos which I ever saw, these two conditions alternated with one another. The patient was a girl, in Edinburgh, under the care of a friend of mine, who took me to see her. It was a case of hysteria rather than of tetanus; but all at once she would be drawn into a position such, that the top of her head, and her feet, were alone supported on the bed, while her body was bent backwards, like a bow; then, after a time, with equal suddenness, the opposite posture was assumed, her forehead and knees being brought together. Still more rarely the body is bent to one side. This is pleuros- thotonos, or tetanus lateralis ; and this I never saw. Sometimes again, in the height of the spasm, the antagonist muscles counteract each other exactly; and the head and trunk are rigidly extended: and the term tetanus is by some writers confined to this form of the disease. It is called trismus when the jaw only is affected. It is well to know that these varieties occur, and may be looked for; but in all of them — trismus, opisthotonos, emprosthotonos, or pleurosthotonos — it is the same disease; and the prognosis is not altered any more than the diagnosis, by the variety that happens. During the fits of exacerbation, the aspect of the sufferer is often frightful. The forehead is corrugated and the brow knit, the orbicularis muscle of the eye rigid, the eyeball motionless and staring, the nostril spread, the corners of the mouth are drawn back, the set teeth exposed, and all the features fixed in a ghastly grin — the true risus sardonicus. The tongue is apt to get between the teeth, and to be severely bitten. All the contractions are attended with intense pain. You may form some notion of the severity of this pain, if you have ever been troubled by spasm of the gastroc- nemius, or cramp of the leg, and if you can bring your mind to conceive that the same sensation which you then felt in the calf, involves nearly all the voluntary muscles of the body. The pain is worst during the exacerbations, and that which is experienced at the sternum is commonly the most complained of. Even to this, however, there are occasional, though very rare, exceptions. Sir Gilbert Blane has described a case of tetanus, which ran the usual course, and terminated fatally, yet the patient suffered no pain : the sensation excited by the violent muscular contrac- tions was a sort of tingling, of rather a pleasurable kind. So violent are the contractions sometimes, that the teeth have been broken by them. There is one case related in which the thigh bones were fractured by the forcible action of the femoral muscles; and another in which the psoas muscles were found, after death, to have been torn across. Dr. Latham tells me that he once saw one of the recti muscles, in front of the abdomen, thus rent asunder. With all this disturbance of the muscular system, there is commonly very little derangement of the other functions of the body. The disorder is almost always attended with obstinate costiveness; partly, perhaps, from the spasmodic closure of the anus, partly, perhaps, in some cases, from the medicines that are given. When stools are obtained, they are usually very offensive and unnatural. There is no fever. The pulse and respiration are quickened, and a sweat frequently breaks out during the exacerbations, from the pain and anxiety then experienced: but this does not occur during the intervals between the paroxysms. In the last stages of the fatal cases, the pulse becomes quick and feeble, and the sweat is cold, as in other instances of approaching dissolution. What is still more worthy of observation is that the mental functions are unaffected. There is seldom any delirium, or coma, or disturbance of the intellect. These symp- 376 TETANUS. [LECT. XXXII. toms only appear (if they appear at all) when other indications of the failure of the powers of life come on. The mode of death in this disease seems to be of a mixed nature. Partly it ap- pears to result from apnoea; the thorax being held as in a vice by the spasm of the muscles, and the breathing for a time suspended, or much embarrassed: partly, and chiefly, it occurs from asthenia; the power of the heart flags and is exhausted by the continuance of the suffering, by the fatigue and expenditure consequent upon the muscular action, and by the patient's inability, in many cases, to take sufficient nou- rishment. When death happens suddenly, as it sometimes does, in a paroxysm, it is owing, in all probability, to spasm of the respiratory muscles, and perhaps of those of the glottis among the rest. Most cases of tetanus may be traced to one of two causes: which are, exposure to cold, especially to sudden alternations of temperature, and bodily injuries. In many instances both these causes co-operate in producing the disease. When it supervenes upon some bodily hurt, it is called traumatic tetanus : when it arises spontaneously, or after exposure to cold, it is held to be idiopathic. In this country, and I believe in every other, the traumatic variety of the disease is much more common than the spontaneous. But in what manner soever it may originate, tetanus is far more fre- quent in hot than in temperate climates and seasons. In this case, however, as in so many others, the heat appears to act as a predisposing cause only; the exciting cause, in addition to the wound in the traumatic species, being the application of cold (par- ticularly, according to Hennen, of cold air in motion) after the heat, or during the prevalence of hot weather. Thus it is stated that after the battle of Muskau, in the midst of great heats, very few of the French troops were affected with tetanus; whereas those who were wounded in the battle of Dresden, when the weather was cold and wet, just after a very hot season, were decimated by that complaint; which did not spare even those who underwent immediate amputation. Idiopathic tetanus is extremely rare in this country. Dr. Gregory, of Edinburgh, used to mention in his lectures the case, seen and treated by himself, of a man who, having fallen asleep in moist grass, awoke with a stiff neck, which afterwards went on into regular tetanus. A good example of well-marked tetanus, arising from ex- posure to cold, is narrated in the Edinburgh Medical and Surgical Journal, by Dr. Hall, of Berwick. The history of that species of tetanus which occurs in connexion with wounds and injuries, presents nothing constant or uniform. The disease is liable to follow hurts of any parts of the body, and of every kind, degree, and extent; from a slight cut or scratch, to a compound fracture, or a severe surgical operation. It comes on also in various stages and conditions of the injury. Sir James M'Grigor tells us (in the sixth volume of the Medico- Chirurgical Transactions) that in the Peninsular war the complaint supervened " in every description, and in every stage of wounds, from the slightest to the most formidable; the healthy and the sloughing; the incised and the lacerated; the most simple and the most complicated." Sometimes, however, the discharge from the wound has been observed to be remarkably diminished, or sup- pressed, at the coming on of the tetanic symptoms; and sometimes the wound has healed completely before the commencement of the attack of tetanus. To show you how very trivial the injury may be, how various in kind and in place, I may mention a few instances that have been collected, in illustration of the manner in which this terrible disorder may originate. It has been known to arise from the sticking of a fish-bone in the fauces; from a slight wound of the ear by a musket-shot; from the mere stroke of a whip-lash under the eye, although the skin was not broken; from cutting a corn; from a bite on the finger by a tame sparrow; from the blow of a stick on the neck and on the hand; from the insertion of a seton; from the extraction of a tooth; from the injection of a hydrocele; from the operation of cupping. Nevertheless there are some sorts of injury, and some parts of the body, more fre- quently than others concerned in the pathogeny of tetanus. The disorder more often supervenes upon injuries of the extremities, than of the trunk, head or neck; and upon wounds made by puncture than upon most other hurts. Penetrating wounds in the sole of the foot, such as are not seldom inflicted by treading upon a nail, or a splinter; and laceration, or other violence done to the muscles that constitute the ball of the thumb, are very apt to be followed by tetanic spasm. Some have supposed LECT. XXXII.] TETANUS. that the disease has some special connexion with injuries of tendinous parts; but there can be no doubt that it is essentially a malady of the nervous tissue. The tetanic symptoms occur at no fixed period after the reception of the injury. Professor Robinson, of Edinburgh, was once at table, when a negro servant lacerated his thumb by the fracture of a china dish. He was seized with convulsions almost instantly, and died with tetanic symptoms in a quarter of an hour. Such rapid pro- gress as this, however, is quite out of the usual course of the disease : probably fright had something to do with it. Hennen, in his work on Military Surgery, states that terror is frequently the immediate antecedent of the attack. In general the tetanus supervenes between the fourth and the fourteenth day after the infliction of the injury: some time in the second week is the most common period of all. In the Peninsular war it did not commence later than the twenty-second day. In some rare instances, its accession is still longer deferred. " Of the nature of the changes that take place in the interval (justly remarks Dr. Alison) we have no information what- ever." The longer, however, that the disease delays its assaults in these traumatic cases, after the reception of the local injury, the milder, in general, does it prove, and the more room is there for hoping that it will end favourably. When the disorder arises from exposure to cold and damp, it comes on much ear- lier; often in a few hours. If, for example, the exposure take place during the night, the complaint may begin to declare itself the next morning. Although tetanus may be excited by a wound, independently of any exposure to cold, or by cold without any bodily injury, there is good reason for thinking that, in many instances, one of these causes alone would fail to produce it, while both together call it forth. After the disease has set in, its rate of progress is various. Almost all writers divide it into acute and chronic tetanus. But the difference is merely in the degree of severity. When the spasms come on suddenly, recur often from the beginning, and increase in frequency and violence, the chance of recovery is but small. The patient, in these cases, sometimes dies on the second, and generally before the fifth day. If he live to the ninth day of the disease, his prospect is somewhat better, and the spasmodic symptoms may gradually abate and disappear. Some, however, have died as late as the sixteenth, the twentieth, and even the thirty-fifth day: but this last is very rare. The idiopathic tetanus, or that which is produced by cold, although it commences earlier, is more generally of a chronic character than the traumatic: that is to say, the spasmodic contractions take place more slowly, and the paroxysms do not increase in violence, and in rapidity of recurrence, as they are apt to do in the symptomatic variety: and accordingly this form of the malady is much oftener, I dare not say cured, but recovered from, than the other. With respect to the diagnosis of tetanus, there is only one point in which it is at all ambiguous or important. There is no other disease that is likely to be confounded with it, except perhaps that extraordinary disease, hysteria, which sometimes mimics its phenomena. I have already alluded to one example of this kind that I myself saw. But there is a form of poisoning that may easily be mistaken for tetanus. The symptoms produced by a poisonous dose of strychnia, or its salts, or the vegetables from which it is procured, are the symptoms of tetanus. And as this drug is now readily obtained, and its noxious qualities are well known, it is not unlikely to be made an instrument of suicide, or of murder. It is necessary, therefore, that you should be acquainted with the effects of this poison, which constitutes the active prin- ciple of the nux vomica, the faba S" Ignatii, and the upas tieute. Dr. Christison has excellently well described these effects as they are observable in brutes; and I have once, by accident,* had an opportunity of witnessing them in the human body. I shall not be wandering from our present subject if I enumerate the symptoms to be expected from a large dose of strychnia; especially as I have lately been advising you to make trial of it as a remedy in certain forms of disease. Dr. Christison, who had made ex- periments with it upon animals, tells us that the creature " becomes agitated, and trembles, and is then seized with stiffness and starting of the limbs. These symptoms increase, until at length it is attacked with a fit of general spasm, in which the head is bent back, and the spine stiffened, the limbs extended and rigid, and the respira- tion checked by the fixing of the chest. The fit is then succeeded by an interval of 378 TETANUS. [LECT. XXXII. calm, during which the senses are quite entire, or unnaturally acute. But another paroxysm soon sets in, and then another and another, till at length a fit takes place more violent than any before it, and the animal perishes suffocated." Some time ago I had occasion to prescribe the strychnia for two patients in the Middlesex Hospital, both of whom had paraplegia. I directed one grain to be inti- mately mixed with crumb of bread, so that it might be divided into twelve pills : and one of these pills, or one-twelfth of a grain of strychnia, was to be taken by each patient every six hours. Unluckily, through mistake or negligence of the person who was at that time the dispenser, a grain of the poison was administered at once, to each patient. It was given about seven in the evening. At half-past seven it began to produce its characteristic effect upon one of the patients. He was suddenly seized with tetanic spasms; his legs were separated widely from each other, and rigidly extended : and his head and trunk bent backwards. He was, in fact, in a state of opisthotonos. His abdomen was quite hard, and his limbs were stiff, even when the violence of the paroxysms abated. He cried out with the pain at the coming on of these spasms. Any attempt at movement, even the touching him by another person, brought them on. This is just what happens in the disease. The opening of a door, a sudden current of air, a shake of the floor, or bed, the smallest bodily effort, the act of swallowing, nay, even the imagination of these influences, may be sufficient to renew the spasmodic tightening of the affected muscles. My patient spoke of a particular sense of constriction all over the abdomen, as if it were drawn in. His intellect was quite unaffected. He had two extremely violent attacks of the kind I have been de- scribing, in which he thought he should have died : and to say the truth I was myself horribly afraid of the same catastrophe. Afterwards, from half-past eight o'clock to between eleven and twelve, he had several slighter and shorter fits. He was left weak and exhausted by them: but he soon recovered. I may as well tell you that his paraplegia was not a whit benefited by this violent action of the remedy. You may suppose that when I found one of my patients in this alarming state, I became very anxious to ascertain the condition of the other, who had taken the same quantity of the strychnia, and lay in another ward. He told me that he had been for a short period very dizzy, and had trembled all over; and at the time when I saw him, he had a weight or uneasy sensation at the nape of his neck, which drew his head backwards; and he experienced some difficulty in opening his mouth, and in articulating his words. But he thought these symptoms were diminishing rather than increasing. He was perspiring profusely. It is stated by Dr. Christison that if the spasms do not come on within two hours after the poison was swallowed, the patient is safe. It was more than two hours since this patient had taken the strychnine. I gave him a full dose of purgative medicine, which acted as an emetic : and, after he had vomited, the unpleasant sensations about his head and neck left him. I scarcely knew what to do with the other patient, in whom the spasms had com- menced. There is nothing satisfactorily made out, that I know of, concerning the mode of treating such cases. Of course, if one saw the patient early, and knew what he had swallowed, the first thing to be done would be to procure its evacuation from the stomach. But here it had had full time to get into the circulation : and no emetic could have withdrawn that part of it at least, which had already found its way into the blood-vessels. When I reached him, though the spasms were strong, they were less violent than they had been, and their violence seemed upon the wane : but they were brought on by any, almost the slightest, muscular effort, or change of position. I hoped therefore that the most dangerous period was passing off (and so it turned out), and I was fearful of doing harm by exciting those movements of the body which accompany the act of vomiting. I recollected, too, that another patient in the hos- pital, under the care of one of my colleagues, had once been attacked with opistho- tonos after taking half a grain of strychnia; and that brandy and water had been given to him; and that he got well from that time, without having another paroxysm. So I gave my patient some brandy and water; and he seemed the better for it: but whether or no it contributed much to his recovery I cannot be sure. Now how are we to tell, when we meet with such symptoms as these, whether they are the result of disease, or of poisoning? The symptoms are the symptoms of tetanus; I know of no test whereby to distinguish them from the symptoms of tetanus caused by exposure to cold, or supervening upon a wound, except the period of time LECT. XXXII.] TETANUS. 379 over which they are spread. Dr. Christison states that " the disease never proves so quickly fatal as the rapid cases of poisoning with nux vomica." " Besides, the fits of natural tetanus are almost always slow in being formed, while nux vomica brings on perfect fits in an hour or less." If indeed the case related by Professor Robinson, in which the negro was dead in fifteen minutes, could be relied on as having been a genuine instance of tetanus, this distinction, drawn from the rapidity with which the poison kills, would scarcely hold. But that case is unique, and of such doubtful value that it need not disturb our estimate. Again, persons who have taken an over- dose of strychnia sometimes survive the tetanic symptoms, but die afterwards from the irritant effects of the poison upon the mucous membrane of the alimentary canal. This we do not observe in the disease. " It is right to remember, however (adds Dr. Christison), that nux vomica (or its poisonous element, strychnine), may be given in small doses, frequently repeated and gradually increased, so as to imitate exactly the phenomena of tetanus from natural causes." In suspicious or questionable cases, we must look into the history of the patient; inquire whether he were likely to destroy himself, or to be murdered by others; what he last swallowed, and when it was taken; whether he have lately been exposed to the injurious influence of cold, especially to a stream of cold air while he was perspiring; and whether he have recently received any bodily hurt. By a careful investigation of all the circum- stances, we shall generally be enabled to decide the true nature of the case; but it is clearly necessary that our eyes should be open to the possibility of a case of poisoning, by some of the preparations of strychnia, being palmed upon us for a case of natural disease.1 The pathology of tetanus is undoubtedly obscure: but not more so, I conceive, than that of those nervous diseases in general which produce violent symptoms, and even death itself, without leaving any traces of their operation inscribed upon the dead materials of the body. Nay, it is not so obscure as several others. I think we may fairly come to the conclusion that the symptoms result from some peculiar con- dition of the spinal cord, produced and kept up by irritation of its substance, or of its afferent nerves ; and that the brain is not involved in the disease. The French (at least some of the most modern writers on tetanus) hold that it is always an in- flammatory complaint; and that it consists essentially in inflammation of the spinal marrow: and some of them have sought to remedy it by enormous blood-lettings; from fourteen to fifteen pounds of blood being taken in the course of a few days by one practitioner; and another bleeding his patient eight times, and applying 792 leeches along the course of the spine, and to the epigastrium. But this doctrine of inflammation being at the bottom of every case of tetanus is contradicted by the plainest facts; and the practice founded upon it has been pushed to a most extra- vagant and absurd extent. Numberless instances occur of inflammation of the spinal cord and its membranes without any tetanus; and equally numerous examples of tetanus have been met with, when no unnatural appearance at all could be discovered within the vertebral canal. I say we must content ourselves with referring the phenomena of the disease to irritation, direct or indirect, of the spinal cord; or of its nervous appendages. It is conjectured by Dr. Todd and Mr. Bowman that the changes which take place in the nerves, and in the nervous centres, whereby sensa- tions and muscular contractions are produced, are molecular changes, rapidly propa- gated from the point where the stimulus is applied; and analogous with "that re- markable change in the particles of a piece of soft iron, in virtue of which it acquires the properties of a magnet so long as it is maintained in a certain relation to a galvanic current; these properties being instantaneously communicated when the cir- cuit is completed, and as instantaneously removed when it is broken. A state of polarity is induced in the particles of the nerve by the action of the stimulus, which is capable of exciting an analogous change in other particles, whether muscular or nervous; whence results the peculiar effect of the nerve's influence." 1 This warning, suggested in the first delivery of these lectures, has been terribly justified by subsequent events. The names of Palmer and of Dove will ever retain an infamous celebrity in the annals of our criminal jurisprudence, for cold-blooded murderings by the poison of strychnia. Wainewright's case, which was less notorious, but of precisely the same character with Palmer's, had occurred previously. It forms the basis of Sir E. Bulwer Lytton's well- known novel Lucretia. 1 380 TETANUS. [LECT. XXXII. In accordance with this theory these authors hold, with great show of reason, that in tetanic spasm, the natural polar force of the spinal cord is greatly exalted, and kept so, by the constant irritation applied directly to the cord itself, or propagated to it by the nerves of the injured part. If you irritate, mechanically, by means of a pair of forceps, the exposed spinal cord of a recently decapitated animal, a turtle for example, you produce spasmodic contraction of the limbs. What difficulty is there in supposing that some mechanical irritation existing within the spinal canal of a living man may have a similar effect ? It may be, and probably is, sometimes, the mechanical irritation caused by the altered state of the blood-vessels under inflammation; for sometimes we do find traces of such inflammation in the spinal marrow after death by tetanus. Again, if you irritate, by pinching, one of the spinal nerves of a turtle whose head has just been cut off—if you thus irritate one of these nerves in any part of its course, what happens? why the muscles of the limbs contract spasmodically; those on the side to which that nerve belongs become rigid, and those on the other side also. That property of the cord comes into play which I have so often mentioned: a pro- perty which it possesses independently of the brain; which it evinces when all com- munication with the brain is cut off; a property, therefore, which may be manifested without any exercise of volition, and even in spite of efforts made by the will to restrain its manifestation: I mean, of course, the property whereby it is capable of receiving impressions through the medium of its afferent nerves, from parts at a dis- tance, and of originating motion in the muscles of the trunk and limbs through the medium of its efferent nerves. By the courtesy of Dr. Marshall Hall I have been afforded the opportunity of witnessing, in the headless turtle, the phenomena that I have been describing to you. Surely they throw a broad light upon the pathology of tetanus, and of sundry other affections. We infer from them, most legitimately as it seems to me, that the tonic spasm which characterizes the disease we are considering, may be caused by a morbid condition of the spinal marrow itself; or of the nerves that belong to it. In the latter case, irritation is set up at the free extremity, or somewhere in the course, of incident nerves; along these nerves an influence is con- ducted to the cranio-spinal axis, in which a process or change takes place, whereby an answering influence is reflected to the muscles along motor nerves : and the whole circle of action and reaction is run through with the suddenness and swiftness of lightning, or of thought. You cannot expect that visible marks of the irritating cause should, in all cases, be left upon the body; any more than you could discern the pinch made by the forceps after they were withdrawn. When, in the experiments to which I have referred, Dr. Hall plucked at, or com- pressed, one of the denuded spinal nerves, spasmodic motions were excited in the muscles of both sides; and above, as well as below, the junction of that nerve with the cord. This shows that the change (whatever it be) that is wrought in the cord by impressions made upon one of its afferent nerves, is not necessarily confined to the corresponding segment of the cord; but may be instantly communicated, in both directions, throughout its entire course : the whole of this centre of the excito-motory system responding to the influence conveyed by a single nerve, as completely as a tight string vibrates from end to end, when struck at any one point. We frequently, indeed, find that the excited motions are more limited; but it is important to mark this ready consent of the whole cord, under sufficient excitement. Dr. Hall has given certain distinguishing epithets to tetanus, according to the supposed source and locality of the irritation. When the irritating cause operates directly upon the spinal cord itself, he calls the disease centric tetanus; when it resides in some part of the body distant from the spinal cord, he calls the disease eccentric tetanus. These are good and intelligible names; and I shall take leave to adopt them. Observe now how well this explanation meets the facts of the case. We sometimes find the spinal cord or its membranes inflamed, when there has been tetanic spasm. We then refer the spasm to the centric irritation. But in a far greater number of cases we can detect no marks whatever of disease in the spinal canal, while we know that an irritating cause has been applied to parts at a distance. Often we have evidence which is visible, that a nerve has been injured, torn across perhaps, or half torn, or compressed in some way or other; just as we might compress a nerve, with a pair of forceps, in a decapitated turtle. That experiment shows us that very slight LECT. XXXII.] TETANUS. 381 irritation may be enough to produce the spasmodic action; and we find that slight injuries, as well as severe, will bring on the disease, when, by the operation of certain injurious agencies, the frame has been predisposed, and rendered morbidly susceptible. There is no part of the trunk or limbs which is not supplied with nerves from the spinal cord; and we find that injuries of various parts, or of almost any part, in an individual predisposed to take on the disordered action, may produce it. The exciting cause may he a wound irritating a particular nerve : it may be exposure to cold, acting upon the extremities of various nerves that proceed from the surface: it may be a bundle of worms, irritating the nerves spread upon the mucous tissue of the alimentary canal; for I omitted to state before that some writers, especially MM. Laurent and Lombard, have maintained that tetanus is almost always, even when it supervenes after wounds, the result of the presence of worms in the digestive organs. They have founded this opinion upon the fact, that worms have been very frequently indeed discovered in the stomachs or intestines of persons dead of this disorder. I think this is a point well worth attending to. It is objected that worms infest the human body without causing tetanus: but the very same thing may be said of the operation of cold; and of external injuries. Any of these may probably excite the disorder, when the body is preternaturally susceptible of it. The real mystery lies in this predisposition. We have reason to suppose that a high atmospheric temperature, continued for some time, is one predisposing cause; but how it operates, or what is that state of system in which the increased susceptibility consists, these are points concerning which we are really in the dark. The disease is common enough in brutes: and it is frequently eccentric in them ; brought on by injuries, mostly of the extremities. Locked-jaw is a familiar term in the nosology of farriers. It is not uncommon in the horse after castration. I re- member a mare belonging to my father dying of that disease a few days after foaling. It often results, in these animals, from a prick in the foot, by a nail, in shoeing. Dr. Parry noticed eccentric tetanus in lambs. "I have often seen lambs," says he, " whose ears, for the purpose of marking them, have been bored with a red-hot iron too near the root, so-rigid all over with tetanus, alternating with convulsions, that their bodies would project in a right line with their hind legs, when one held them out horizontally by the hind feet." Dr. Mason Good tells us that parrots also are frequently affected with trismus : a calamity which, supposing the bird to be within ear-shot, it would be difficult to commiserate. We are not advancing any wild theory, then, respecting the controverted pathology of this disease, when we lay down the following propositions; that it is essentially a disorder of the excito-motory apparatus; that it results from irritation of a peculiar kind, affecting that part of the nervous system; that the irritating cause may be centric,—within the spinal canal itself; that, again, it may be, and often is, eccentric, — situated at the extremity, or somewhere in the course, of one or more of the afferent spinal nerves; and that a certain predisposition is for the most part neces- sary, to render the body susceptible of the disease under the operation of the exciting irritation. At one time it was supposed that the physical cause of the disorder had been de- tected, in the presence of more or fewer thin scales of bony or earthy matter, lying in or upon the arachnoid of the cord. I have myself seen these after death preceded by tetanic symptoms. But tetanus often happens and proves fatal without them : and they are often met with when there has been no tetanus. If, therefore, there be any connexion between these thin plates of ossification and the occurrence of tetanus (which may well be questioned), it must be of this kind; that the scales of earthy matter predispose the spinal cord, somehow, to be affected by the exciting causes of the disease. The doctrines recently propounded by Dr. Marshall Hall, of which the importance becomes daily more apparent, and by which his name will be enduringly connected with the physiology of the nervous system, receive a strong confirmation from the phenomena of tetanus. They furnish a key to many problems which had previously perplexed the pathologist; and they do this simply by distinguishing the proper functions of the two distinct nervous centres; the brain and the spinal cord. But the practical application of these new views is yet in its infancy. The treatment of tetanus is a mortifying subject. The disease is and has always 382 TETANUS. [lect. xxxii. been a lamentably fatal one. Hippocrates says, trtt, tpufiati oftatnos sfttyt-vopivof, ^tavaaifiov, tetanus supervening on a wound, is mortal: and the aphorism holds true, with very few exceptions, in the present day. Almost all the acute and severe traumatic cases are fatal. Hennen declares that he never saw a case of "acute symptomatic tetanus" recover. Dr. Dickson found all curative measures followed by " unqualified disappointment." Mr. Morgan uses these words : " I have never yet seen or heard of an instance of recovery from acute tetanus." Another of Hippo- crates' aphorisms is, oxosoi vrio tttavov a%v$xovtai tx tsaaapatv tipcpnow artoXXvvtat, they who are seized with tetanus die within four days; but he adds, nv Ss tavtai 8t,a$vyu>oiv iyt,sci ywovtai; if they get over this period they recover. And to this we can only add now, that those who survive the first few days, and ultimately get well, recover in a variety of different ways, and under various modes of treatment. But as to the mode of treatment which is to be preferred, or even as to the real efficacy of any mode, there is much room for doubt. Under every plan of management a vast majority die. Let us briefly pass in review the principal remedies that have been tried, and in- quire what degree of success has followed their employment. One drug from which much benefit has been hoped for, is opium. In some spas- modic disorders it is of unquestionable service. Very large doses of it have been given and borne in tetanus; and some have recovered under its use, and more have died. It is well known that pain fortifies the nervous system against the peculiar influence of narcotic substances. We need not, therefore, be surprised that opium, administered in enormous quantities, in this painful disease, has had but little effect. I was assured by a physician, with whom I formed an acquaintance in Edinburgh some years ago, and who is known, I find, to a student now present, that his own wife, while labour- ing under a tetanic affection, swallowed, in twenty successive days, upwards of 40,000 drops of laudanum, which is at the rate of more than four ounces a day; in all, more than two imperial quarts. The lady recovered. A case is recorded in the second volume of the Medico-Chirurgical Transactions, in which an ounce of solid opium was taken, in divided doses, every day, for twenty-two days. This appears a more astounding instance than the former; but I am not sure that it was so; for, in this complaint, solid opium does not always dissolve in the stomach. I have heard the late Mr. Abernethy say that he had found enough undissolved pills of opium in the stomach after death, to poison a dozen healthy persons. This fact should teach you, if you resolve on trying opium at all, to exhibit it in a liquid form; laudanum, or a solution of the acetate or of the muriate of morphia. And with the internal admin- istration of opium, it would be well, perhaps, to combine its external use; to apply a broad strip of opiate plaster along the whole length of the spinal column. It is sometimes a difficult matter to introduce medicine by the mouth, so strong is the spasmodic contraction of the muscles that close the jaws. You cannot get the mouth open. Some persons set to work to heave it open, by levers; and it has been proposed, and I believe practised, to break off or extract a tooth or two, to make a passage for the introduction of medicine and of nourishment; but I hope you will never be guilty of such clumsy barbarity as this. Food and physic may be carried into the fauces and into the stomach by means of a flexible tube: and this may be inserted through the nostril; or through the mouth, by passing it between the jaws, behind the back teeth, where there is always an aperture that will admit a tube suffi- ciently large. After all, in respect to the cures that have been ascribed to the opiate treatment, they have all (so far as I know) occurred in cases of the milder or more chronic tetanus; and mostly in the idiopathic form of the disease; and this circumstance makes it a question whether they were cures at all; whether they were not simply recoveries. Dr. William Budd (in the paper already referred to) challenges, on physiological principles, the propriety of giving any opium in this disease. He says, " It has been ascertained that the effect of that drug is to excite, and not to quiet, the motor func- tion of the spinal cord: indeed, it is well known that the motor acts of the cord may be rendered much more active and powerful, by giving, before decapitation, opium to animals that are to be subjects of experiment." He considers " these objections, LECT. XXXII.] TETANUS. 383 furnished by theory, to be motives sufficient for the future exclusion of opium from the treatment of tetanus." I had long been aware that the effect of opium upon frogs was to produce tetanic spasms. But in no case of poisoning by opium in the human subject (and I have seen a great many) have I ever witnessed any approach to tetanus: and I much ques- tion the safety of arguing, in such matters, from what we know to happen in the in- ferior animals, to what we suppose would happen in man. The failure, however, of opium in the severer forms of the malady, and its equivo- cal utility in any, taken together with these theoretical objections, prevent my recom- mending opium as a remedy for tetanus. What is the result of experience in regard to blood-letting in tetanus ? I am afraid that, as a curative agent, it has very little power over the disease. Yet it may be, in certain cases, of use, as an auxiliary to other measures. When the disorder bears any aspect of inflammation—when, for instance, fever is lighted up, and pain is felt along the course of the spine, or when the approach of the spasm is marked by the super- vention or the increase of pain in the wound — then our chance of doing good by venaesection is the greatest. Some of the cases that happened in the Peninsular war, were decidedly benefited by blood-letting practised under such circumstances. I need scarcely say that though the bleeding, when adopted, should be early, free, and full, so as to produce some sensible impression upon the system, yet we must always use this remedy with caution. The tendency of the disease is to exhaust the power of the heart; and if by one over-bleeding we bring that organ to a stand-still, it may refuse to begin again. In a complaint which depends so much on irritation, and so often on manifest irri- tation of external parts, we look naturally to the warm bath for help. And it has been fairly tried : and some persons have found it useful; and others have found it useless, doing neither good nor harm; and some have condemned it as actually hurtful. The cold bath has been extolled as a much more powerful agent than the warm; and so, doubtless, it is. But it is more potent for harm as well as for good. For example: a tetanic patient, in St. Thomas's Hospital, was plunged into a cold bath, at his own request. " All the symptoms disappeared (says Mr. Morgan) in a moment; and he was almost immediately taken out of the bath; but he was taken out lifeless." Sir James M'Grigor says that, during the campaign in Spain, "the warm bath gave only momentary relief; and the cold bath was worse than useless." However, the application of cold water to the surface has, in many recorded instances, been of at least temporary benefit and comfort: and in the West Indies, where the disease is common, the cold affusion still continues, I believe to be the most favourite expedient. After it, the patient is rubbed dry, put to bed, and has laudanum administered. I have again to observe, of this remedy also, that it is chiefly service- able in the idiopathic form of tetanus. It has been tried upon animals. Dr. Parry says that it was quite unavailing in the case of certain lambs that had the disease. In a note, which I made at the time, of Mr. Abernethy's lecture on tetanus, I find the following statement. " The effect of cold in diminishing excessive muscular action was strikingly shown in the case of a horse belonging to Professor Coleman, which had tetanus. The animal was slung, and carried out of the stable, and laid on the snow, which was then on the ground: and he was covered over with snow also. A horse affected with tetanus is a curious sight. His legs straddle, and become stiff; his ears are pricked up; and his tail sticks out. In this case, on the application of the snow, his ears sank, his tail became pliant, and the rigidity of his muscles was removed. He was again taken into the stable, and the spasms returned." Mr. Abernethy said, that were he himself the subject of tetanus, he would desire to have the cold affusion tried. If you are willing to assay the same remedy, do not plunge your patient into a cold bath, but take him out of his bed on an extended sheet, pour cold water over his body, wipe him dry, and place him in another dry bed. This will often, for a time at least, diminish the spasmodic action; and the patient will sometimes sleep comfortably after it. Dr. Todd has suggested to me the application of ice to the spine ; a measure which he has found eminently beneficial in convulsions. This mode of employing cold as a remedy in tetanus seems well worthy of trial. It would have the advantage of not inflicting any shock which might excite or disturb the reflex function of the cord, through its incident nerves. 884 TETANUS. [LEOT. XXXIII. LECTURE XXXIII. Treatment of Tetanus, continued. Wine ; Mercury ; Purgatives ; Digitalis ; Tobacco ; Musk; Prussic Acid; Belladonna; Carbonate of Iron; Oil of Turpentine; Strychnia ; Surgical Expedients; General Rules. Hydrophobia. In the last lecture we considered the symptoms, the nature, the causes, and to a certain extent the treatment, of that terrible malady, tetanus. There is good reason for believing that it is essentially a disorder of the excito-motory apparatus : that it is caused by irritation of a peculiar kind, affecting that part of the nervous system, and producing tonic spasm of the voluntary muscles: that the irritating cause may be centric, situated within the spinal canal, and applied directly to the cord; or eccentric, situated out of the spinal canal, applied to some part of one or more of its afferent nerves directly, and thus influencing indirectly the cord itself, and through it the reflex motor nerves : that a certain ill-understood state of the system is necessary, a certain aptitude to take on the disease, before the exciting cause can be efficient; and that one circumstance which has been ascertained to tend to the production of such an aptitude, is a long-continued high temperature of the atmosphere. I mentioned several remedies and plans of treatment which have been fairly tried, and mostly tried in vain, for the removal of this disease. The severe cases, and especially the severe traumatic cases, almost all prove fatal; the less severe cases, those in which the paroxysms are less violent and less frequent, and which run on for several days, sometimes terminate in health: whether in consequence of the measures employed, or whether in spite of them, it is not easy to say. The idiopathic cases, as they are called, those which appear to be produced by exposure to cold and wet, are usually the less severe, and the more hopeful. The remedies that have been tried, and which were mentioned in the last lecture, are opium; blood-letting; the warm- bath; the cold-bath. I showed you that, under each of these remedies, a great number of patients died, and some recovered; and that the recoveries had been almost exclusively amongst those patients in whom the disease appeared originally in its milder form. So that whether the complaint was actually cured in any of these cases, whether, i. e., any single patient recovered, or recovered sooner, from using any of these remedies, who would have died, or in whom the disease would have been pro- tracted, if he had not used them, is a matter of uncertainty. The celebrated American physician, Dr. Rush, regarding the disease as essentially a disease of debility, and looking, probably, at its common tendency to death by asthenia, wrote a paper to recommend the employment of bark, and wine, and spirits, in full doses. It is curious enough, but quite in agreement with what has been already stated of opium, that how much wine soever may be swallowed by the patient, nothing like intoxication is produced by it. The system resists the ordinary influence of the alcohol. In one instance related by Dr. Currie, the disease lasted six weeks, and in that space of time the patient drank 110 bottles of port wine. The same author mentions a remarkable case, in which a horse, which was attacked by tetanus, and happened to be a great favourite with its master, was treated with wine, and got well, after swallowing more portwine than he was worth. Whenever this plan has appeared to do good, it has been in the more chronic variety of the complaint. Mercury, you may be sure, has not been left untried. It is said that the system is slow in submitting to its influence, in this malady. The specific effect of mercury upon the gums is not, however, so strongly resisted as that of wine or opium upon the nerves. Nor can we be surprised^ at this, when we consider that in tetanus the functions of organic life are, comparatively, but little involved. It is clear that there is not time for any effectual exhibition of mercury in those severe cases that are early fatal. In its more chronic form the disorder has been known to yield upon the mouth becoming affected. This happened, if I mistake not, in Mr. Mayo's patient, mentioned in the last lecture. Tetanus has sometimes, however, commenced while the patient was in a state of salivation. Dr. Wells has recorded three instances of LBCT. XXXIII.] TETANUS. 385 that kind. The experience of the military surgeons who were in Spain, is, upon the whole, against the reputed efficacy of mercury. We must take care not to conclude too hastily, that because a patient uses a certain remedy and recovers, he recovers through the operation of that remedy: any more than we should conclude, if he re- covered during a general election, that the election had cured him. Yet this absurd and unsafe mode of reasoning is for ever employed in respect to disease, by the public; and too often, I fear, by ourselves. Purgatives have been much given in tetanus; and often with manifest advantage: I mean in the less severe cases. But very large doses are commonly required to pro- cure evacuations from the bowels. Whether the torpor of the intestines be always the effect of the disease, or whether it may not sometimes be, in part at least, a con- sequence of the opium that is given, I am not sure. When they do act, very unna- tural motions are frequently produced. Mr. Abernethy tells us of a hospital patient of his who recovered under the use of purgatives; they were long before they had any effect, and when they did at last operate, such foetid stuff came from him, that no one who could crawl out of the ward would remain in it. He says also that the nurses, in other cases, have reported the stools to be more like sloughs than faeces. Enormous quantities of drastic purgatives have been given. You may read an in- stance of this in the second volume of the Medico-Chirurgical Transactions. It is related by Mr. Harkness. There is a still more extraordinary case detailed by Dr. Briggs, in the fifth volume of the Edinburgh Medical and Surgical Journal. In little more than 48 hours, the patient in triaT case took 210 grains of scammony, 89 of gamboge, 80 of cajomel, an ounce and four scruples of jalap, and 2| pints of what we call black dose, the infusion and tincture of senna: and all this without either sickness or griping; but on the contrary, with the most decided benefit. In the first week of his disease, the patient swallowed — of calomel, 280 grains; scammony, 260; gamboge, 110; jalap, 3 ounces and 10 grains; infusion of senna, 5| pints. And altogether in the first 25 days — of calomel, 320 grains; scammony, 340; gamboge, 126; jalap, 5 ounces and 7f drachms; infusion of senna, lOf pints; besides an ounce and a half and 35 grains of the colocynth pill. I mention all this to show what the system will bear, under the bondage of the disease; not as an encouragement to you to prescribe such doses. It is certainly proper and necessary to clear out the bowels, and to endeavour to correct unhealthy secretions; yet numerous evacuations, the act of going to stool, often repeated, should be avoided. Under such obstinacy of the bowels, the croton oil would perhaps be the most eligible purgative. Foxglove and tobacco are two medicines, or rather poisons, which have been used; both, probably, upon the same principle. Their effects, when full doses have been given, are much alike: sickness, faintness, feebleness and fluttering of the pulse, coldness of the surface, with that slack and passive state of the muscles which belongs to syncope. But if we consider that the influence of these substances upon the in- voluntary muscles, especially upon the heart, is more certain and decided than upon the muscles of voluntary motion, which are the muscles involved in the tetanic spasm, and if we take also into account the strong disposition observable in tetanus towards death by asthenia, we shall scarcely be prepared to expect any good, but the contrary, from digitalis, or tobacco; especially in the latter periods, when, so far from obviating the tendency to death, they would seem to co-operate with the disease in extinguish- ing life. However, if the result of experience were clearly in their favour, we should not be warranted, by mere theoretical views, in withholding these drugs. The army sur- geons, some of them, have fancied digitalis useful. Sir James M'Grigor mentions a case in which it caused a relaxation of the spasms; but the man died afterwards, ap- parently from the effects of the remedy. And this is just what I find with digitalis. When given in large doses (and small ones here must be useless) it becomes unman- ageable. Certainly we have no such accounts of its sanative power as would induce me to give it with much expectation of success, or to give it at all. The tobacco is not given by the mouth, but thrown up into the rectum : either the smoke of its burning leaves, or (what is probably as efficacious, and I should think more uniform and less unsafe) an infusion of them in water. Mr. Curling, after analysing a large number of cases of tetanus, thinks tobacco the best remedy we at present possess. Mr. Travers is of the same opinion. However, I should re- 386 TETANUS. [lect. XXXIII. commend great caution in the use of this ticklish remedy. You ought to know that, when injected in other emergencies, in strangulated hernia, for example, mortal syncope has followed such enemata. Musk, in large doses, has been strongly recommended by a Frenchman, Fournier- Pescay, who has written on this disease. He gave ten or twenty grains at intervals; so that a drachm, or even two drachms, were taken in the course of the day; and he declares that he found it more efficacious than anything else that he had tried. Prussic acid and belladonna are said by Dr. Elliotson to have been freely pre- scribed, and to have failed; whether in his own hands, or in those of others, I do not know. There is another remedy which the same physician has employed; and employed not without success : the carbonate of iron. Reflecting, he tells us, upon the effects of this medicine in another complaint which has some points of analogy with tetanus, viz. chorea, of which I shall soon speak, and considering how miserably narcotics had failed, he determined to give the'carbonate of iron a fair trial upon the first oppor- tunity. He has published some account of its effects, in tetanus, in the Medico- Chirurgical Transactions. In the first case in which he used it, the tetanus super- vened upon a compound dislocation of the great toe. The method in which the remedy was administered was this. The carbonate was made into an electuary by mixing it with twice its weight of treacle. The electuary thus made was well stirred in beef-tea just as the patient was about to drink it. He took this every two hours, as much as he could swallow: and he go*? well. The next case is described as being a very severe one; it resulted from a contusion of the thumb. Dr. Elliotson says that he never saw a case, which did well, that was more severe. This patient also took the carbonate of iron, as much as could be got down; and that was about two pounds a day. He had injections twice daily, to keep the bowels unloaded: and the iron is described as having come away in large red lumps, in shape like horse-dung. This man recovered. In a third case, where a chilblain above the heel was the ex- citing cause, the boy died within twenty-four hours of the time when the remedy was first prescribed. To produce its influence upon the system (Dr. Elliotson observes, very truly) iron must be given for a few days: nay, he holds that months sometimes elapse before it has any effect. So that if it really be useful in tetanus, we cannot expect much good from it in the more acute cases: and these are the cases for which we want a remedy. Oil of turpentine is one of the many substances that have been praised as useful in tetanus. Now, bearing in mind its power (which I shall hereafter describe, but which you must at present take for granted) as a worm-killer, and also the frequency with which worms are met with in the stomach and bowels after death by tetanus, this is one of the drugs which I should employ as a, purgative, taking my chance of whatever good might possibly arise from its specific or anthelmintic qualities. It may be given in such cases either by the mouth, or in an enema, or at both ends together: but it must be given in large doses, not less than an ounce at a time; and it may be mixed with an equal quantity of castor oil. The one oil dissolves, or becomes incorporated, in the other. Strychnia has been suggested as a remedy for severe tetanus; not in infinitesimal doses, as Hahnemann would, I suppose, prescribe it, but in sufficient quantity to produce a sensible effect. The principle upon which this has been recommended is the same with that on which the nitrate of silver ointment is applied to the inflamed conjunctiva in purulent ophthalmia. We know that strychnia acts upon the spinal cord, affecting apparently those parts and those functions of the cord which are affected in tetanus; and in so fatal a malady, it would be justifiable, I conceive, to give the strychnia, in the hope that it might occasion a morbid action which would supersede the morbid action of the disease, and yet be less perilous and more manage- able than it. But it would be right to try such a remedy as this, in the first instance, in corpore vili; upon one of the lower animals. This, were it successful, would be a cure, according to the Hahnemannic doctrine—similia similibus curantur—a doc- trine much older, however, than Hahnemann. But the opposite maxim, contraria contrariis, has been suggested. Mr. Morgan proposes to give such poisons as are known to cause paralysis, with the view of countervailing the undue action of the •nuscles in tetanus. He produces artificial tetanus by inserting a poison brought LBCT. XXXIII.] TETANUS. 387 from Java, called " chatic," into a wound, and then relieves the tetanic symptoms by a North American poison, the ticunas. Professor Sewell, of the Veterinary College, has tried this principle in one case at least, where the tetanus was the result, not of any poison, but of disease. Not having had an opportunity of getting the particulars of this case from Mr. Sewell himself, I give you Mr. Mayo's account of it. "A horse, suffering from a severe attack of tetanus and locked-jaw, the mouth being too firmly closed to admit the introduction of either food or medicine, was inoculated on the fleshy part of the shoulder with an arrow point coated with the wourali poison. In ten minutes apparent death was produced. Artificial respiration was immediately commenced, and kept up about four hours, when reanimation took place. The animal rose up, apparently perfectly recovered, and eagerly partook of corn and hay. He was unluckily too abundantly supplied with food during the night. The conse- quence was over-distension of the stomach, of which the animal died the following day, without, however, having the slightest recurrence of tetanic symptoms." I had fancied that the death had resulted from some injurious effect upon the lungs, pro- duced by the artificial breathing. But I have little doubt that Mr. Mayo derived his statement from Mr. Sewell himself. The experiment deserves to be carefully repeated. The virtue of the vapour of aether, or of the newer substance, chloroform, will doubtless be put to the proof in these diseases of painful spasm. Nay, I read in the newspapers and medical journals that this remedy has already been tried in tetanus; and not without marked relief of suffering. That it will prove equal to the cure of the severer cases, which would end fatally without it, is, in my mind, a matter of hope rather than of expectation. I have but little to say concerning what may be called the surgical treatment of traumatic tetanus. It was a natural thing, the source of the irritation being supposed to be the wound, to expect relief from amputation of the limb. But that will not arrest the morbid action after it has once been fairly established. Dr. Elliotson says he has searched scores of books, and found only one case in which the limb and the disease were lopped away together. However, Mr. Blizard Curling, in his Essay on Tetanus, refers to seven instances of recovery, after the injured part had been ampu- tated. Yet he states that " it is almost impossible to ascertain with certainty how far the amputation, in these cases, was of service." I believe I cannot offer you better advice on this subject than may be gathered from the concluding remarks of a very distinguished and philosophical surgeon, in his lectures on this disease. I allude to the late Mr. Abernethy, whose pupil I had the good fortune to be. He said, " The state of the part injured is not the sole cause of tetanus. In cases of tetanus I have often amputated injured fingers; and though I did not thereby save my patients, yet I think that the symptoms were mitigated after such amputations. In such cases, then, I would not amputate any considerable member; nor even a small one, unless I thought that, from the injury sustained, it would prove useless to its possessor, even though the case should terminate favourably." The tourniquet has been applied to the hurt limb; but not, so far as I know, with any good effect. The most promising expedient which surgery offers is the division of the principal nerve proceeding to, or rather from, the seat of the injury. This, supposing the nerve to be known and accessible, is less formidable, less severe, less hazardous, less maiming, and, if we may judge from past experience, more effectual too, than amputation of the part. Dr. Murray has recorded (in the eleventh volume of the Medical Gazette,) a very interesting case in which the operation was followed by most decided and instant relief. The patient was a young midshipman, who, having trodden on a rusty nail, which pierced the sole of his left foot, had kept watch the same night upon deck, the weather being very cold. The disease began the next day, and the symptoms ran high. It was a case, therefore, of severe or acute tetanus. Without loss of time the posterior tibial nerve was divided. The limb was previously cold and as the patient said, dead, and he had little power of moving it. He could not articulate distinctly, on account of the closed state of his jaws. The nerve was cut through by one stroke of the scalpel; and "immediately (says Dr. Murray) he opened his mouth with an exclamation; and on looking at his countenance I was astonished at the striking improvement in it. I asked him how he felt, and he said he was already much better, and that his leg had come to life again." Some stiffness 388 TETANUS. [lect. XXXIII. of the jaws and neck remained for a day or two; but he soon recovered. Dr. Murray refers to another case mentioned by Baron Larrey, in which division of the nerve had a similar result. Probably, to be successful, the operation must be early; before the morbid condi- tion peculiar to the disorder has had time to root itself in the nervous system. Although, in the present state of our knowledge, there is no one remedy or plan on which we can rely for the cure of this fearful malady, we may with much confidence lay down certain general rules, the observance of which will secure to the patient the best chance of a favourable result. Since any, the smallest, movement or impression made upon the surface, or upon the senses, will bring on the severer degrees of spasm, it is of primary importance to protect the patient against these sources of trouble, so sure to aggravate his sufferings, and so likely to augment his danger. Hence if blood-letting should be thought advisable, it should be done early, sufficiently, and once for all. There should be no repetition of venaesection, or of cupping, or of leeches, unless the circumstances and progress of the case plainly demand them. The same remark applies to the frequent use of purgatives. The bowels should be well cleared in the outset, and then let alone. The patient should lie in a darkened room; from which noise also should, as much as possible, be excluded. He should not be surrounded by a multitude of friends or attendants. He should be enjoined to speak, to move, to swallow, as seldom as he can. In the severe traumatic cases, the nerve, in my judgment, should be promptly divided. And in all cases, there being no special indications to the contrary, I should be more inclined to administer wine in large doses, and nutriment, than any particular drug. If the tendency to mortal asthenia can be staved off, the disturbance of the excito-motory apparatus may, perchance, subside or pass away. There is a form of this complaint called trismus nascentium. As the name implies, it occurs in newly-born children. It is very frequent and very fatal in the West Indies; coming on usually in the second week after birth. Hence it has been called " the ninth-day disease." Another of its names in the British settlements there, is " the jaw-fall;" from the circumstance that shortly before death the lower jaw, which had previously been firmly pressed against the upper, drops on the breast. It has been said that a fourth of the infant negroes in Jamaica used to die of this disorder. Some persons refer it to the irritation produced by the retention of the meconium in the intestines; others to irritation from the wound made by dividing the navel string. A dose of purgative medicine appears to be the most hopeful remedy. The complaint is common, I am told, in ill-ventilated lying-in hospitals. Pure air must therefore be desirable as an adjuvant. Tetanic symptoms sometimes occur (but I should think very rarely) in ague. Or paroxysms of tetanus return at regular intervals, and terminate by profuse perspira- tion : the patient being well during the intermissions. When such phenomena arise, the treatment proper in severe forms of ague must be adopted : what that treat- ment is, I shall in no long time be able, I hope, to lay before you. Again, tetanus is occasionally a symptum in hysteria; and then the treatment applicable to hysteria must be had recourse to; especially enemata containing oil of turpentine, or the same medicine given by the mouth; and the cold affusion. If the disease of which I have been speaking be dangerous, and very often fatal, in spite of all remedial measures, that which I propose to bring next under your attention is still more appalling; for I believe that hitherto it has been uniformly mortal. I know not that any one has ever been rescued by art, or saved by the efforts of nature, from Hydrophobia, after that frightful disease has once declared itself by its characteristic symptoms. The nature of those symptoms, and the absence of all definite or constant traces of organic change in the dead body, sufficiently mark the disease as belonging essentially to the nervous system, and as being essentially a spas- modic disease also. What are the symptoms, stated in broad outline ? These. Excessive nervous irritability and apprehension; spasmodic contractions of the muscles of the fauces, excited by various external influences, and especially by the sight or sound of liquids, and by attempts to swallow them; and extreme difficulty, amounting sometimes to impossibility, of drinking. LECT. XXXIII.] HYDROPHOBIA. 389 This is one of the diseases which are produced by animal poisons ; and its course will be most conveniently traced if we include in our description of it the very first step towards its production, — the application of the specific poison to the body. A man is bitten by a dog. After a time the symptoms proper to hydrophobia come on. After another, but much shorter, interval, the man is dead. Before we advert to the many very interesting points of inquiry which arise out of the contemplation of this malady, let us follow the tragedy from its commencement to its closing scene. A person is bitten, then, by a mad dog. Does the existence of rabies in the animal modify in any way the injury thus inflicted? No; the wound that is made behaves just the same to all appearance, as it would have behaved if the dog had not been rabid; and it gradually heals. After an uncertain interval — which lies, for the most part, between six weeks and eighteen months, and which has been called the period of incubation — the following symptoms begin to be noticeable. The patient expe- riences pain, or some uneasy or unnatural sensation, in the situation of the bite. If it have healed up, the cicatrix tingles, or aches, or feels cold, or stiff, or numb; sometimes it becomes visibly red, swelled, or livid; on one occasion a papular eruption took place around it; sometimes it opens afresh, and discharges a peculiar ichor. The pain or uneasiness extends from the sore or scar towards the central parts of the body : i. e. if the bite have been inflicted on a limb, the morbid sensations extend towards the trunk. All this gives fearful notice of what is about to happen. This period is called the period of recrudescence. I believe it seldom fails to occur, although it sometimes is not noticed; the attention of the patient, and of his medical advisers, being absorbed by the horrible sequel. Very soon after this renewal of local irritation — within a few hours perhaps, but certainly within a very few days, during which the patient feels uncomfortable and ill — the specific constitutional symptoms begin : he is hurried and irritable; speaks of pain and stiffness, perhaps, about his neck and throat; unexpectedly he finds himself unable to swallow fluids, and every attempt to do so brings on a paroxysm of choking and sobbing, of a very distressful kind to behold; and this continues for two or three days, till the patient dies exhausted; in the way of asthenia. I have seen three, perhaps four examples of this terrific malady. As they consti- tute the whole of my personal experience in the matter, I shall relate these cases. The first occurred in the year 1826, in the person of a coachman, the back of whose right hand had been struck, ten weeks previously, by the teeth of a terrier dog : but, as both the patient and his fellow-servants declared, there was no wound made, no blood drawn, no breach or lifting of the skin; but merely an indentation, showing where the animal's teeth had pressed. He was brought to St. Bartholomew's Hos- pital on a Tuesday. On the preceding Thursday his hand had become painful, and swelled a little. On Friday the pain extended into the arm, and became more severe. His wife stated that he had been in the habit of sponging his head and body every morning with cold water, but that, on this morning, he refrained from doing so, on account of some feeling of spasm about the throat. His own remark on this was, that " he could not think how he could be so silly." On Saturday the extent and the severity of the pain had still further increased. On this and the preceding night he got no sleep. He felt ill and drowsy on the Sunday, but drove a carriage to Kensington Gardens : he was, however, obliged to hold both whip and reins in his left hand. The pain extended to the shoulder. He was then bled. A slop-basin full of blood was taken, with much relief to the pain; and purgative medicine was given, which operated well. The next day he complained of "feeling very ill all over," and he told his medical attendant that he could not take his draughts, because of the spasm in his throat. That gentleman (Mr. Macdonald), concealing his own suspicions as to the true nature of the disease, said, " Oh, you don't like the taste of your physic ! drink some water. But he declared he had the same difficulty with water. The next day he came to the hospital. When there, water was brought and placed before him m a basin, for the alleged purpose of allowing him to wash his hands. It did not seem to disturb him, nor to excite any particular attention. Water was then offered him to drink, which he took, and carried to his mouth, but drew his head from it with a convulsive shudder. After this, on the same morning, he was much questioned by several persons about the supposed cause of his illness; and water was again brought him, 390 HYDROPHOBIA. [lect. xxxiii. which agitated him, and he became exceedingly distressed and unquiet, complaining of the air which blew upon him. I first saw him myself soon after this. He was then, to all outward appearance, well; lying on his back, without spasm, without anxiety; his face somewhat flushed. He said he had a little headache, but no pain in the arm. His pulse was 132, full, and strong; his tongue moist, and slightly furred. He appeared to be a very quiet, good-tempered man; and smiled generally when he was spoken to. I was naturally much interested by this case, and at nine in the evening I visited the patient again. He was composed and tranquil. Gruel was mentioned, and then he sighed two or three times deeply; then sat up, and, after a moment's look of serious terror took half a spoonful of the gruel in a hurried gasping manner; and said he would not take more at a time, lest the sensation should come on. He was desired to drink the last portion of the gruel from the basin. He accordingly seized it with hurry, carried it to his mouth with an air of determination, and then a violent choking spasm of the muscles about the throat ensued, the sterno-mastoidei starting strongly forwards. Most of the gruel was spilled over his chin; and ,he observed that he had been too much in a hurry, or he should have managed it. The treatment consisted in full doses of opium, repeated at frequent intervals. On this visit to him I noticed, that while attempting to take some of the gruel with a spoon, he seemed inclined to doze as he sat. Otherwise there were no signs of his being overwhelmed, or even sensibly affected by the opium, unless indeed his general quietness was the consequence of it. He was quite rational and calm, except when attempting to take fluids. On the Wednesday, at noon, he was nearly in the same state, but said he was better. In the course of the night some morsels of ice had been given him : with considerable effort he swallowed two or three of these; the third or fourth caused so much spasm, however, that he was obliged to throw it out of his mouth : but so great was his re- solution that he seized it again, and, by a strong exertion, succeeded in swallowing it. He complained now that his mouth was and had been clammy; and he champed much, and spat out a good deal of tough mucus. At his own request, and (as he said) that he might injure no one, a strait-waistcoat was brought, which he assisted in putting on. But he was perfectly tranquil then. I now had an opportunity of seeing him take some arrow-root. He sat up in bed to eat it; and before attempting to do so, he made hurried inspirations, and sobbings precisely resembling those which occur when one wades gradually into cold water. He swallowed small quantities of arrow-root eight or nine times, with hurry and diffi- culty, and with sighs that succeeded each other rapidly. He said that he felt the upper part of his throat narrower than it should be. He continued to take laudanum mixed with sugar and bread into a kind of pulp. By the evening of that day the disease had not made much further progress. He again sat up and tried to eat some thinnish gruel. While taking the basin into his hand, he drew back his head to a distance from it, apparently involuntarily. He took one half-spoonful with effort and distress, then sighed deeply and rapidly, or rather his breathing consisted of a succession of sighs at short intervals: he gave up the basin, and sank back on his pillow still sighing. In the course of that night he ceased to take the laudanum; he could no longer attempt it. The next day he was still composed, though more easily irritated; and it was found that he had lost the power of moving the left arm. His pulse was 140, and much weaker than before, and his mental powers were failing. He gradually sank, and died in the evening, having repeated the Lord's prayer an hour previously. During the last hours of life he had been moaning, and tossing from side to side: his bowels were purged; fluid stools ran from him, and distressed him greatly. His lower extremities first became cold, and the coldness extended by degrees up to his chest. He hawked up in the course of the day a considerable quantity of ropy mucus, and much frothy saliva came from his mouth towards the close. As his wife was wiping this away, his teeth, whether by convulsive accident or otherwise, came in contact with her finger, and drew blood. The part was cut out; and no bad consequence followed that I know of. The examination of his body threw no satisfactory light upon the essential nature of the disease. Blood and serous fluid escaped on the removal of the calvarium. The vessels of the membranes were full, and the brain itself was mottled somewhat LECT. XXXIII.] HYDROPHOBIA. 391 by its vascularity. There were a few spots of ecchymosis on the heart. The back part of the tongue was very vascular. The stomach presented the most notable ap- pearance. There was a quantity of brownish-coloured mucus on its inner surface, and the mucous membrane had disappeared from a space about four inches in diame- ter at its left and larger end. That space alone was diaphanous; its edges sloped inwards; and a segment of this thin place looked exactly like a piece of china. On a white ground, there were inosculating vessels, some of them blue, and some of them of a coffee-coloured brown. I conclude that this appearance was produced by the action of the gastric juice after death. This was in some respects a remarkable case. It was remarkable for its duration. Dr. Bardsley, in the article on Hydrophobia in the Cyclopaedia of Practical Medicine, states that the patients " invariably go on from bad to worse, and finally die before the sixth day." Now if we reckon that stage of the complaint here referred to by Dr. Bardsley to have begun on the morning of Friday, when he was obliged to omit his sponging because of the spasm about his throat, this patient did not die till the middle of the seventh day. In fact it was a very protracted case; and the symptoms were less violent than usual. Whether this was owing to the opium he took or not, it would be difficult to determine. In the second of the cases which it has been my lot to witness, the characteristic symptoms of hydrophobia were more faintly pronounced than is usual. On my arrival at the Middlesex Hospital, on Thursday, the 5th of October, 1837, I was told that a patient had been admitted (under one of my colleagues) labouring probably under hydrophobia. He had applied at the hospital in the middle of the ni On the first day of the year, 1855, a lady, 32 years old, residing at a short distance from London, was bitten on the ulnar side of the middle finger of her right hand, in the furrow between the skin and the nail, by a white cat, belonging to the stables of the house. The young lady's brother had seen the cat quarrelling with a terrier the day before; and afterwards struggling and fighting with another cat. Supposing that the animal might be ill, or hurt, the lady desired to have it brought to her, and placed it on her lap, when it bit her. The cat was killed the same day, but not before it had scratched the gardener's child, flown furiously at another man, and seized and bitten a whip with which the coachman had attacked it. On Wednesday, the 14th of March, Miss L. began to feel generally unwell. On the 16th, pain ran from the bitten finger along the ulnar aspect of the right arm into the axilla, and across the chest about the level of the fifth rib. No redness nor swelling was visible about the scar, but she spoke of a sensation there as if the skin were hin. This pain did not last long, nor did it recur. On Saturday, the 17th, she found a difficulty in swallowing medicine. Dr. Todd visited her in the evening, with Dr. Garrett, and prescribed enemata, containing each ten drops of laudanum. Some puffiness in the right axilla was noticed, but it soon disappeared. On Sunday morning I met those physicians in consultation. I found Miss L. in bed, with a wildish expression about her eyes. Her tongue was dry and furred; her pulse eighty, soft, with occasional accelerations for a few beats only. There was a slight systolic murmur of the heart, which was beating noisily. Her bowels had acted during the night. She had twice passed urine into the bed, and she said that she had done so inevitably, and that " it showed how weak she was." The debility was indeed very great, as we perceived upon raising and sustaining her in a sitting position. A morsel of ice was given to her. She put it hastily into her mouth, then drew back her head, and stretched out her arm with a repelling gesture, and sighed many times; but she failed to swallow the ice. Afterwards she succeeded better with some tea, which she took in spoonfuls, yet with a strange hurry, and with sighing gasps, and a rolling upwards of the eyes. It was remarkable that this patient was not agitated, nor apparently distressed, by the sound of liquids poured from one vessel into another, nor by the access of light upon the sudden withdrawing of the window-blinds, nor by currents of air, for she even bore to be fanned. I conclude that she knew, or at least suspected, what was the matter with her, for she said that to drink some tea would be a test. She then, without much difficulty, ate a boiled egg; and under encouragement, and our expression of hopes that she was better, and exhortations to be careful and not to hurry, she swallowed, with seeming ease, a glass of wine in successive tea-spoonfuls— until the last spoonful, from which she recoiled with a look . of terror, exclaiming, despondently, " It is no better." We were to visit her again together the next day, though I had my misgivings as to her surviving the night. I learned from Dr. Garrett that she swallowed more wine in the afternoon, and fancied it did her harm. She had then paroxysms of sighing respiration, with intervals of comparative calm. At seven in the evening Dr. Garrett noticed that she began to eject, in a gulping manner, saliva and viscid mucus from her mouth. This increased in quantity, and was attended with a sort of chewing, or champing. At ten o'clock she desired that the servants should, one by one, bo r94 HYDROPHOBIA. [lect. XXXIII. brought to her bedside, and exhorted them severally to the observance of their religious duties. She expired at a quarter past seven o'clock on the Monday morning, her mind having continued clear to the end. The fourth case to which I have alluded was, in my judgment, a genuine instance of hydrophobia, although some, who witnessed it, doubted. I am indebted for the opportunity of seeing it to the kindness of Dr. Sibson, under whose care the patient, a female child five years of age, was lying in St. Mary's Hospital. She had been bitten by a spaniel on the 3d of May, in the right leg, just above the calf, where the scars of the injury were visible. The dog was killed the same after- noon. The child began to be unwell on the 4th of June. The symptoms reported were shudderings whenever a stream of wind passed over her, and spasms, and gasping dysphagia upon her attempting to drink. I saw her on the 9th of that month. Her countenance was tranquil, but now and then assumed a sort of idiotic smile. When a current of air was directed upon her by blowing, she made a sighing start, cried for a few seconds, and was again quiet. She took from a spoon some wine and beef-tea readily, and seemed to like them, for she opened her mouth always as she saw the spoon approach her lips. When the cup was offered her, she clutched it with her hands, and drank a little, with obvious distress. A mirror waved before her face did not appear to affect her. She had dozed a little in the night. Occasionally she closed her eyes, which could then be seen to quiver or vibrate beneath the shut lids. I thought she squinted slightly. She did not utter any articulate words, but she had talked a good deal the day before. She was very weak; unable to stand. Though I observed no mucus about her mouth, she was said to have spat out viscid frothy saliva, and frequently to have grinded her teeth. She particularly disliked to have her abdomen touched, or uncovered. On repeating my visit to the hospital later in the day I found her weaker. She had voided urine into the bed, and had vomited several times. She made frequent little backward jerks of the head—which was held back rather rigidly by the muscles of the neck, while her shoulders were firmly hunched up. Swallowing could still be effected, but with increased difficulty. She was less sensible to currents of air. Her pulse was very rapid. Afterwards sickness and hiccup came on, and she died early the next morning. A careful examination of the dead body disclosed nothing remarkable, or illustrative of the disorder. The symptoms had been attributed to worms; but the intestines were slit up through their whole length, and no worms were found. Generally, the disease, when it has once set in, and shown the peculiar hydrophobic symptoms, runs a short and fierce course. The nervous irritability becomes extreme. The peculiar paroxysms of choking spasm, and sobbing, are excited, not only by attempts to swallow liquids, but by the very sight or sound of them. Dr. Elliotson mentions a boy who was thrown into a state of violent agitation by hearing a dresser who sat up with him make water. The passage of a gust of wind across his face, the waving of a polished surface, as of a mirror, before his eyes, the crawling of an insect over his skin, is often sufficient to excite great irritation, and the peculiar strangling sensation about the fauces, in a hydrophobic patient. These circumstances were but little observable in the patients whose cases I have related. The first of them indeed was remarkably calm and tranquil under the disease. In general the patient is dreadfully irritable, and apprehensive, and suspicious; and in most cases there is a degree of mania or delirium mixed up with the irritability; the sufferer is very garrulous and excited. In this respect there is a marked difference between hydrophobia and tetanus. In the latter disorder the mental faculties are clear, and the patients serene, and what is called heart-whole, to the last. The two diseases differ in another striking particular: the spasm in the one case is tonic, in the other clonic. In tetanus, again, there is no thirst, and seldom any accumulation of tough and stringy mucus in the fauces and about the angles of the mouth: in hydrophobia both these symptoms are always, I believe, present. So probably is vomiting; but vomiting in tetanus is rare. The nervous irritability in hydrophobia is doubtless a part of the disease, and is very seldom absent even now-a-days. Some time ago it might perhaps have been plausibly attributed to the" treatment adopted. I allude to that period in which it was believed that these miserable persons had both the power, LEOT. XXXIII.] HYDROPHOBIA. 395 and the inclination, to impart the disease to others by biting them; and when, under pretence of shortening his sufferings, but really, I am afraid, with the cowardly view of protecting themselves, his friends were accustomed to smother the unhappy patient between two feather-beds, or to open a vein, and to leave him to bleed to death. Any person suspecting what was the matter, and foreseeing such a termination to his dis- ease, might well be nervous and irritable. But now that this barbarous practice has been exploded, and the dread of being smothered does not occur to the mind of the patient, he is still found to be exquisitely irritable and timorous. The foam and sticky mucus that gather in the throat and mouth, these patients make great efforts, by spitting and blowing, to get rid of; and the sounds they thus produce have been exaggerated by ignorance and credulity into the barking and foaming of a dog. In the same way the paraplegia which sometimes takes place, rendering the patient unable to stand upright, has been misconstrued into a desire on his part to go on all fours like a dog. The pulse, though it may be strong and hard at the outset, becomes, in a short time, frequent and feeble, and the general strength declines with great rapidity. Death occasionally takes place within twenty-four hours after the commence- ment of the specific symptoms. Most commonly of all it happens on the second or third day; now and then it is postponed to the fifth day; and in still rarer instances, of which my first case was one, death does not occur till the seventh, or eighth, or ninth day. In most cases the paroxysms, becoming more violent and frequent, exhaust the patient; but occasionally the symptoms undergo a marked alteration before death. The paroxysms cease, the nervous irritability disappears, the patient is able to eat and drink and converse with ease; those sights and sounds which so annoyed and distressed him before, no longer cause him any disquiet. In this state he often sinks into a sleep, and suddenly wakes from it to die: sometimes his exist- ence is put an end to by a sudden and violent convulsion. It is needless for me to go into a minute account of the morbid appearances that have been met with in persons dead of hydrophobia. They are various, uncertain, unsatisfactory. Decomposition of the tissues, and of the blood, is said to take place rapidly. In some bodies the most careful examination has discovered nothing amiss. In others, vascularity of the brain, or of the spinal cord, has been noticed. And in not a few instances the mucous membrane of the fauces, oesophagus, and stomach — or of the larynx and trachea — or of both these tracts — has been found red, and covered with adhesive mucus. But we must take care not to attribute undue im- portance to these last appearances—not to conclude that they have been the cause of the symptoms, when, in truth, they may have been the effect of the disease. That we should find the parts in the throat red and congested is what we might naturally expect, when we consider the violent straining spasmodic action of these parts for some time before death. The morbid anatomy of this disease throws but little light upon its nature, or upon its proper treatment. Many interesting questions present themselves relative to hydrophobia. I will state the principal of these as shortly as I can. 1. You will be surprised when I tell you that some persons have made it a question whether there is any such disease at all. I have known such. The late Sir Isaac Pennington, who was Regius Professor of Physic at Cambridge, had never seen a case of hydrophobia, and nothing could persuade him that any one else had seen anything more than a nervous complaint produced by the alarmed imagination of the patient, who, having been bitten by a dog reputed to be mad, and having the fear of feather-beds before his eyes, was frightened into a belief that he had hydrophobia, and ultimately scared out of his very existence. Now if you meet with such in- credulous persons, and think it worth your while to argue the point with them, you may object to their unbelief, the improbability that so many persons who have been bitten by mad dogs should have suffered so precisely the same train of symptoms, and at last have died, from the mere force of a morbid imagination. You may urge them with the fact that many of these persons have been under no apprehension at all until the disease has seized upon them; that many also have been men of naturally strong and firm minds, not at all likely to be frightened into believing that they were seriously ill unless they really were so, and still less likely to be terrified into their graves. And if this have no weight with such reasoners, you may bring forward the conclusive facts that the disease has befallen infants, and idiots, who had never heard 396 HYDROPHOBIA. [lect. XXXIII. or understood a word about mad dogs or hydrophobia, and in whom the imagination could have had no power in calling forth the complaint. And if they are proof against this, you must give them up : I can suggest nothing more. ^ 2. Allowing that the disease exists as a real, and not merely imaginary disease, and also that it is caused by the bite of a rabid animal: this important question arises — has it any other cause ? Sitting aside that quibbling application of the term hydrophobia, which some writers have chosen to make, to diseases in which, from some painful affection of the throat, the patients have been unwilling to attempt to swallow fluids, there are cases recorded, exactly resembling hydrophobia in their symptoms, and occurring in persons who were never known to have been bitten by, or even to have been in the presence of, a rabid animal. The celebrated and accurate Pinel has given the history of such a case. There is another by Savirotte, in the Journal des Savans (August 1757). Now it is just possible that this disease may sometimes develop itself in the human body without any contagion having been applied : and it is also possible, and much more probable, in my judgment, that the poison may have been applied without the person's being aware of it. We shall see, by and by, some very possible ways in which that might happen. All that we need concern ourselves with practically, is this—that in 999 cases out of 1000 the disease in the human body is derived from a rabid animal. If it ever be spontaneous, we cannot reckon upon meeting with such a case: indeed, many medical men pass through life without witnessing the disorder at all. [Many well authenticated cases are on record, in which disease having all the pathognomonic symptoms of hydrophobia, occurred without the slightest evidence of its being the result of the bite or scratch of a rabid animal, or its having been pro- duced by a virus accidentally introduced into the system from any possible source. We met ourselves, a few years ago, with precisely such a case, in which the most cautious investigation convinced us, that the disease had been produced independently of any specific contagion from without. — C.] 3. Granting, then, that the disease in man is the result of an animal poison, the next question is, from what animals may he receive the infection ? We are sure that the disease, by the inoculation of which hydrophobia may be produced in man, is common in the dog, and that it has been communicated to the human animal by the fox also, the wolf, the jackal, the raccoon, and the cat. Mr. Youatt says that the saliva of the badger, the horse, the human being, have un- doubtedly produced rabies, and some affirm that it has been propagated even by the hen and the duck. The same author mentions a case in which a groom became affected with hydrophobia through a scratch which he received from the tooth of a horse that was labouring under the disease. All animals, even fowls, are susceptible of the disorder when bitten by the rabid dog. Of course it is an important question to have resolved, whether the saliva of all these is capable of conveying the malady. The case just now mentioned on Mr. Youatt's authority would seem to settle the question as respects the horse; but as horses, cows, turkeys, &c, do not generally bite, we have not many opportunities of supplying a positive answer to the general question: there can be no doubt about the cat, the fox, the wolf, and the jackal. The late Duke of Richmond died in Canada of hydrophobia, communicated, it was thought, by a tame fox. In the 13th volume of the Medico-Chirurgical Trans- actions, an account is given by Mr. Hewitt, of several cases of fatal hydrophobia from the bite of a wild and rabid jackal. Many examples are on record of the pro- duction of the disease by the bites of mad cats and wolves. The first case which I have spoken of, as having been seen by myself, would seem to prove, if all the facts were correctly stated at the time, that the saliva of the dog may be sufficient to produce the disease, when it is merely applied to the unbroken skin. It was affirmed by various persons that the teeth of the terrier did not break the cuticle. But we must take care not to draw a hasty general inference from a single case. The late Mr. Youatt, who had seen more of the disease probably both in man and in other animals, than any other person in this country, did not think that the saliva of a rabid animal could communicate the disorder through the un- lect. xxxiv.] HYDROPHOBIA. 397 broken cuticle: he believed that there must be some abrasion or breach of surface. He held, however, that it might be communicated by mere contact with the mucous membranes. Of its harmlessness on the sound integument, he offered this presumption — that his own hands had many times, with perfect impunity, been covered with the saliva of the mad dog. He records some singular instances in which the disease was trans- mitted by contact of the saliva with the mucous membranes. "A man endeavoured to untie with his teeth a knot that had been firmly drawn in a cord. Eight weeks afterwards he expired, undeniably rabid. It was then recollected that with this cord a mad dog had been confined. A woman was attacked by a rabid dog, and escaped with the laceration of her gown. In the act of mending it she thoughtlessly pressed down the seam with her teeth. She died." If these cases be authentic, they are conclusive of this question; unless, indeed, the lips of those who perished happened to have been chapped or abraded. But Mr. Youatt's own opinion was that the virus could not be received on a mucous surface without imminent danger. The disease is said to have been caused by the scratch of a cat. But as we know that cats as well as dogs frequently apply their paws to their mouths, especially when the latter part is uneasy, (as it clearly is in mad dogs,) this fact of the production of the disease by a scratch, if thoroughly made out, would not prove that the disease can be introduced into the system in any other way than by means of the saliva. LECTURE XXXIV. Hydrophobia, concluded. Various Questions considered respecting the Disease as it appears in the Human Subject, and respecting Rabies in the Dog. Pathology of the Disorder. Treatment. Preventive Measures. After giving you some account of the phenomena of hydrophobia, or rabies canina, I began to notice, in the last lecture, the chief of the interesting questions which naturally present themselves to the minds of most men, and especially of medical men, in respect to that shocking disorder. In the first place, there is such a disorder. It appears, too, secondly, from state- ments made upon credible authority, that the same group and succession of symptoms as characterize the disease when it is produced by the bite of a rabid animal, have been observed to occur in persons who were never known to have been bitten. In my own opinion it is more probable that these persons had been exposed to the virus without being aware of it, than that the disease was spontaneously engendered in their bodies. I would make the same remark with regard to an instance which is said to have happened of hydrophobia in a lad who had been bitten five weeks before by a healthy dog : the dog remaining well at the time of his seizure and death. Mr. Youatt holds, indeed, that however the disease originated, it never occurs now, not even in the dog, except as a consequence of the application of the specific contagion. It is certain, in the third place, that (besides the dog) the wolf, the fox, the jackal, and the cat, have communicated the disorder to the human animal. The death from hydrophobia of a boy after being bitten by a raccoon, is recorded by Dr. Russel, of Lincoln, Massachusetts, in a report contained in the Transactions of the American Medical Association for 1856. Mr. Youatt affirms, in his pamphlet on this disorder, that the saliva of the badger, of the horse, and of the human being, has caused rabies; and I mentioned, on his authority, a case in which a groom contracted the disease through a scratch which he received while administering a ball to a rabid horse. But I feel much less certain about these latter animals. Respecting the dog, the fox, the wolf, the jackal, the cat, there can be no question. The result of certain experiments made at the Veterinary School, at Alfort, is opposed to Mr. Youatt's statement. Pro- fessor Dupuy made wounds in cows and sheep, and rubbed upon these wounds sponges 398 HYDROPHOBIA. [lect. xxxiv. which had been chewed by rabid animals of the same species : yet he never succeeded in communicating the disorder in this way; but when he used a sponge that had been mumbled by a mad dog, then the disease occurred in the sheep and cows. It is still more interesting to inquire, whether the saliva of a human being, labour- ing under hydrophobia, be capable of inoculating another human being with the same complaint ? Mr. Youatt says, yes: that the disease has undoubtedly been so pro- duced. If this be so, the fact will teach us — not to desert or neglect these unhappy patients, still less to murder them by smothering—but to minister to their wants with certain precautions : so as not to suffer their saliva to come in contact with any sore or abraded surface; nor, if it can be avoided, with any mucous surface. On the other hand, all carefulness of that kind will be unnecessary, if the disease cannot be propa- gated by the human saliva. Certainly, many experimenters have tried in vain to inoculate dogs with the spittle of a hydrophobic man; but there is one authentic experiment on record, which makes it too probable that the disease, though it may not be communicated often, or easily, is yet communica&Ze. The experiment is said to have been made by MM. Magendie and Breschet, at the Hotel-Dieu, and to have been witnessed by a great number of medical men and students. Two healthy dogs were inoculated, on the 19th of June, 1813, with the saliva of a patient, named Surlu, who died of hydrophobia the same day in that hospital. One of these dogs became mad on the 27th of the following month. They caused this dog to bite others, which, in their turn, became rabid also: and in this way they propagated the malady, among dogs, during the whole summer. Now this is a very striking fact, yet it ought not to be considered conclusive: for it is possible that the dog might have gone mad at that time, whether he had been so inoculated, or not. It may have been a mere coincidence. We want repetitions of such experiments to settle the point: nevertheless, we have enough in this one experiment to make us use all neces- sary caution when engaged in attending upon a hydrophobic patient. I just touched upon the question, whether the saliva of a rabid dog could produce the disease if it fell upon the sound skin ? The first of the cases which I related as having been witnessed by myself, would appear to give an affirmative answer to this question. Mr. Youatt thinks the disease would not follow such an application of the virus; but that it cannot be received upon even the unbroken surface of a mucous membrane without the greatest danger. Horses are said to have died, mad, after eating straw upon which rabid pigs had died. Portal was assured that two dogs, which had licked the mouth of another dog that was rabid, were attacked with rabies seven or eight days afterwards. Mr. Gil man, of Highgate, in a little pamphlet on Hydrophobia, quotes an instance from Dr. Percival, in which a mad dog licked the face of a sleeping man, near his mouth, and the man died of hydrophobia, although the strictest search failed to discover the smallest scratch or abrasion on any part of his skin. At the very close of the lecture I observed, that even should it be clearly proved that hydrophobia has ever resulted from the scratch of a rabid animal's claws — the claws of a cat, for example—we are not to set it down as a sure thing that the disease can be introduced into the system independently of the saliva of the diseased animal. As we know that dogs and cats are in the habit of putting their paws to their mouths when they feel uneasy there, we may readily understand how the poisonous saliva may be introduced by a mere scratch with the creature's nails. Mr. Youatt believes that the saliva only is capable of conveying the disease. 4. Supposing the virus to have been inserted into the part bitten, what becomes of it ? Is it immediately taken into the system, and does it, like the poison of small- pox, in some mysterious way, multiply and diffuse or mature itself in the body, until the disease explodes ? Or does it remain imprisoned in the wound, or in the cicatrix, for a time ? This is an important practical question. For if the poison lurk for some weeks in the place where it was originally deposited, we might successfully remove it at any time between the infliction of the bite and the period of recrudescence. Now the facts, that at this period of recrudescence the wound or scar is re-inflamed often, and almost always becomes the seat of some fresh morbid phenomena, pain, swelling, numbness, and the like, spreading towards the trunk — and that, soon after this, the peculiar paroxysmal symptoms begin — these facts are strong in favour of the belief that the poison does lie inert in the place of the original hurt, for some time. Dr. lECT. XXXIV.] HYDROPHOBIA. 399 Bardsley states that the recrudescent pains seem always to follow the course of the nerves, and do certainly never inflame or irritate the lymphatic glands in the vicinity, though passing in a parallel course towards the trunk. He affirms the entire absence of any fact contrary to this observation in the works of the numerous authors who have written on the subject. I mention this statement, because it certainly is not correct. Mr. Mayo says, " in one case which I witnessed and examined after death, the inner part of the cicatrix was bloodshot; and a gland in the axilla had swelled at the coming on of the hydrophobic symptoms." And I find among my notes of Mr. Abernethy's lectures, another striking case, still more to the point. "A very intelligent boy had been bitten by a dog in the finger: he was brought into St. Bartholomew's Hospital. Caustic had been liberally used, affecting the sinewy parts, and producing a terrible sore: yet the boy was recovering himself, and the sore was healing. One day, as Mr. Abernethy was going round the hospital, he saw and spoke to the boy, who said he thought himself getting well, but that he had that day an odd sensation in his fingers, stretching upwards into his hand and arm. Going up the arm, Mr. Aber- nethy saw two red lines, like inflamed absorbents: they doubtless were so. He affected to make light of the matter, ordered a poultice, and recommended the boy to take some medicine. Early the next morning Mr. Abernethy visited the ward, pre- tending he had some other patient there, whom he wished particularly to see : and, when going out again, he asked the boy, in a careless tone, how he was. He said that he had lost the pain, but that he was very unwell, and had not slept all night. Mr. Abernethy felt his pulse, told him he was a little feverish, as might be expected, and asked him if he were not thirsty, and would like some toast and water. The boy said he was thirsty, and that he should like some drink: when, however, the cup was brought, he pushed it from him; he could not drink. In forty-eight hours he was dead." Facts such as these would lead to the conclusion that, in cases in which excision had not been performed in the first instance, the scar, or the sore, might be cut out with propriety at any time before the period of recrudescence: and if the case hap- pened to be my own, I would have this done even at that period, the moment any new sensation manifested itself in the seat of the injury. Mr. Mayo on the same grounds, advocates the removal of the cicatrix, even although the hydrophobic symp- toms may have appeared. I do not mean to say that the facts, now referred to, show with any certainty that the poison remains in the place where it was first deposited until the phenomena of recrudescence take place : but they afford some presumption in favour of that notion: and in such a disease as hydrophobia, we are bound to act upon the very lowest presumption that affords a chance for our patient's life. The poison may he absorbed into the general system at the period of recrudescence, although no affection of the absorbing vessels or glands should be manifest: through the veins, namely. Poisons that find entrance into the blood do not remain inoperative there for an indefinite time, and then begin to manifest their poisonous influence. They lodge in this organ or in that, and presently disturb its functions: or they are, more or less rapidly, eliminated from the body through one or more of its natural emunctories; or they produce specific and constant results after periods of incubation, which are also definite and constant — as we see in cases of small-pox and measles. But there is no instance known that I am aware of (unless indeed it be so in this disease of hydro- phobia) in which a poison circulates in the blood for an indefinite and long period, to give rise at last to symptoms that are strictly specific. Looking at the matter theo- retically or practically, I should recommend, under the circumstances already stated, the excision of the cicatrix. The poison of hydrophobia may be detained in tempo- rary and precarious union with some one of the animal tissues, just as I shall here- after show you the poison of lead may be.1 5. Another important question is this. Is a man who has been bitten by a mad 1 The following curious statement, bearing upon this obscure but interesting question, I find in the Monthly Journal of Medical Science for November, 1853, quoted by Mr. Grove from the Medico-Chirurgical Review:—"A girl, aged 14 years, was seized with influenza. She complained of pain in each arm at the spots where, when an infant, she had been vaccinated; and, in fact, in these localities vaccine vesicles now became perfectly developed. An elder sister was re- vaccinated with the lymph hence obtained; beautiful vesicles formed, and ran a normal course." 400 HYDROPHOBIA. [lect. XXXIV. dog, and in whose case no precautions have been taken, a doomed man ? will he be sure to have the disease, and therefore to die of it ? By no means. But few, upon the whole, of those who are so bitten, become affected with hydrophobia. It is curious that different species of animals appear to be susceptible of hydro- phobia in different degrees. Thus, according to Mr. Youatt, two dogs out of three, bitten by one that is rabid, become rabid. The majority of horses inoculated with the virus, perish. Cattle have a better chance : perhaps because in them the skin is looser and less easily penetrated. A full half (he thinks) of those that were seized by a mad dog, would escape. With sheep the bite is still less dangerous. He reckons that not more than one in three would be affected. The tooth, perhaps, has been wiped clean in its passage through the wool. The human being is least of all in danger. John Hunter states that he knew an instance in which, of twenty-one persons bitten, one alone fell a victim to hydrophobia. Dr. Hamilton estimates the proportion to be one in twenty-five. But I fear these computations are much too low. In 1780, a mad dog, in the neighbourhood of Senlis, took his course within a small circle, and bit fifteen persons before he was killed; three of these died of hy- drophobia. The saliva of a rabid wolf would seem to be highly virulent and effective. These beasts fly always, I believe, at a naked part. Hence, probably, the fatality of their bites. The following statement applies exclusively to the wolf. In December, 1774, twenty persons were bitten in the neighbourhood of Troyes; nine of them died. Of seventeen persons similarly bitten in 1784, near Brive, ten died rabid. In May, 1817, twenty-three persons were bitten, and fourteen perished. Four died out of eleven that were bitten near Dijon : and eighteen of twenty-four bitten near Rochelle. At Bar-sur-Ornain, nineteen were bitten, of whom twelve died of hydrophobia within two months. Here we have one hundred and fourteen persons bitten by rabid wolves, and among them no less than sixty-seven victims; considerably more than one-half. There is no doubt, however, that the majority of persons who are bitten by a mad dog escape the disease. This may partly be owing to an inherent inaptitude for accepting it. We see some persons who, though often in the way of it, do not contract syphilis: there are others upon whom the contagion of small-pox has no influence. This dif- ference exists, apparently, even among dogs. There was one dog, at Charenton, that did not become rabid after being bitten by a rabid dog; and it was so managed that, at different times, he was bitten by thirty different mad dogs; but he outlived it all. Much will depend also upon the circumstances and manner in which the bite is inflicted. If it be made through clothes, and especially through thick woollen gar- ments, or through leather, the saliva may be wiped clean away from the tooth before it reaches the flesh. In the fifth volume of the Edinburgh Medical and, Surgical Journal, there is a case described by Mr. Oldknow, of Nottingham, in which a man was bitten in three different places by the same dog, viz.—in the scrotum, the thigh, and the left hand; the bite on the hand was the last. Now it seems not improbable that, but for this last bite, on a naked part, he might have escaped. At least it was a remarkable circumstance that the phenomena of recrudescence occurred only in the hand and arm. The dog is supposed to have closed his mouth after inflicting the first two bites, and thus to have charged his teeth afresh with the poisonous saliva. In the American report, to which I just now referred, it is stated, that of seventy-five cases, the injury was inflicted on the hand in forty instances, on the face in fifteen, on the leg in eleven, on the arm in nine. It is this frequent immunity from the disease in persons who have been bitten, that has tended to confer reputation upon so many vaunted methods of prevention. Igno- rant persons, and knavish persons, have not failed to take advantage of this. They announce that they are in possession of some secret remedy which will prevent the virus from operating: they persuade the friends of those who die that the remedy was not rightly employed, or not resorted to sufficiently early: and they persuade those who escape that they escape by virtue of the preventive remedy. If the plunder they reap from the foolish and the frightened were all, this would be of less conse- quence ; but unfortunately the hope of security without undergoing a painful opera- tion leads many to neglect the only sure mode of obtaining safety. Mr. Youatt is of opinion that the power of the virus ceases with the life of the ani- mal. He states, that in many dissections of the dog, the saliva, in spite of all care, must have come in abundant contact with his hands, and they were not always sound. LECT. XXXIV.] HYDROPHOBIA. 401 I should strongly recommend you not to act upon this opinion : but to use the same precautions, in dissecting a rabid animal, as you would use if you were persuaded that the disease might be communicated with equal certainty before and after the death of the animal. 6. A still more anxious inquiry next arises. Whoever has been bitten by a rabid, or a suspected animal, must be considered, and will generally consider himself, as being in more or less danger of hydrophobia. This dread is not entirely removed, even by the adoption of the best means of prevention. Now, how long does this state of hazard continue ? When is the peril fairly over ? After what period may the person who has received the injury lay aside all apprehension of the disease ? To this inquiry no satisfactory reply can be given. In a vast majority of instances, indeed, the disorder has broken out within two months from the infliction of the bite. But the exceptions to this rule are too numerous to permit us to put firm trust in the im- munity afforded by that interval. Cases are recorded in which five, six, eleven, nine- teen months, have intervened, between the insertion of the poison and the eruption of the consequent malady. Nay, in one instance, three years are said to have elapsed, and in another the enormous period of twelve years. In these cases one cannot help supposing that some unsuspected re-inoculation, some fresh application of the peculiar virus, may have taken place. If not, then we must conclude that the poison really lies imprisoned in the part; and only becomes destructive when, under certain obscure conditions, and at indefinite periods, it is set afloat in the circulating blood.1 It is interesting to know that the same uncertainty of access has been noticed among infected dogs. On the night of the 8th of June, 1791, the man in charge of Lord Fitzwilliam's kennel was much disturbed by fightings among the hounds; and got up several times to quiet them. On each occasion he found the same dog quarrelling; at last, therefore, he shut that dog up by himself, and then there was no further disturbance. On the third day afterwards, the quarrelsome hound became unequivocally rabid; and on the fifth day he died. The whole pack were thereupon separately confined, and watched. Six of the dogs became subsequently mad; and at the following widely different intervals from the 8th of June, viz. — 23 days, 56, 67, 88, 155, and 183 days. There are some considerations respecting this disease, which relate to both the biter and the bitten; the canine and the human being. And there are some which relate exclusively to the dog, yet concerning which we, as medical philosophers, ought not to be ignorant. I shall advert to a few of these. One question I have already glanced at; viz., whether the disease maybe produced by a healthy, though angry dog or cat. I referred to one instance in which this was supposed to have been the case; and I repeat that I should be more inclined to think, unless we had other examples of the same kind, that the person had been inoculated in some way that he was not aware of. But I have heard Mr. Youatt describe cases in which there had been no symptoms of rabies observed in the dog at the time the injury was inflicted, though soon afterwards the animal became decidedly rabid. It is much to be regretted that the dog is so often destroyed. When a person has been bitten by a dog or cat suspected to be rabid, the beast ought by no means to be killed, but to be secured, and kept under surveillance, and suffered, if it shall so happen, to die of the disease. If he do not die, in other words, if he be really not rabid, that will soon appear; and the mind of the patient will then be relieved from a very pain- ful state of suspense and uncertainty, which might otherwise have haunted him for months or years. Should the dog die mad, the injured person will be no worse off than if the animal had been killed in the first instance : nay, in one respect he will be better off, inasmuch as certainty of evil is preferable to perpetual and uneasy doubt. "Give a dog a bad name (says the proverb), and hang him:" and it is literally so with the imputation of madness. A wretched dog is perhaps ill, or weary, or cross, or he may have been worried already by mischievous boys: the cry of mad dog is raised; and then he can expect no mercy. There are gross errors prevalent with regard to the signs of madness in the dog. If a dog be seen in a fit-in the street, some person charitably offers a conjecture that perhaps he may be mad ; the i Romberg states that an analysis of 60 authentic observations has shown that the shortest period is 15 days, the longest from 7 to 9 months; and that the average period is from 4 to 7 weeks —Diseases of the Nervous System. Sydenham Society's Translation. Vol. n. p. 144. 402 HYDROPHOBIA. [lect. xxxiv. next person has no doubt of it; and then, woe to that dog ! But Mr. Youatt assures us that the rabid dog never has fits : that the existence of epilepsy is a clear proof that there is no rabies. Again, it is a very common belief that a rabid dog, like a hydrophobic man, will shun water; and if he take to a river, that is thought to be conclusive evidence against his being mad. But the truth is, that the disease, in the quadruped, cannot be called hydrophobia: there is no dread of water, but an un- quenchable thirst; no spasm attending the effort to swallow, but sometimes in dogs an inability to swallow, from paralysis of the muscles about the jaws and throat. They will stand lap, lapping, without getting any of the liquid down. They fly eagerly to the water; and Mr. Youatt states that all other quadrupeds, with perhaps an occasional exception in the horse, drink with ease, and with increased avidity. This erroneous impression is not confined to the vulgar. In the case which I have more than once alluded to, and which is mentioned in Hufeland's Journal, of a lad who died of hydrophobia after having been bitten by a dog that had not been and was not then mad, one circumstance stated in evidence of the animal's freedom from rabies is, that he drank without difficulty a large quantity of water. There is another superstitious opinion not at all uncommon, viz.—that healthy dogs recognise one that is mad, and fear him, and run away from his presence, in obedience to some mysterious and wonderful instinct, warning them of danger. This is quite unfounded. Equally mistaken are the notions that the mad dog exhales a peculiar and offensive smell, and that he may be known by his running with his tail between his legs; except, as Mr. Youatt says, when, weary and exhausted, he is seeking his home. It will not be out of place to state what are the symptoms of rabies as observed in the dog, and as described by Mr. Youatt. The earliest symptoms of madness in the dog (he says), are sullenness, fidgettiness, continual shifting of posture, a steadfast gaze expressive of suspicion, an earnest licking of some part, on which a scar may generally be found. If the ear be the affected part, the dog is incesantly and violently scratching it. If it be the foot, he gnaws it till the integuments are destroyed. Occasional vomiting and a depraved appetite are very early noticeable. The dog will pick up and swallow bits of thread or silk from the carpet, hair, straw, even dung: and frequently he will lap his own urine, and devour his own excrement. Then the animal becomes irascible; flies fiercely at strangers; is impatient of correc- tion ; seizes the whip or stick; quarrels with his own companions; eagerly hunts and worries cats; demolishes his bed; and if chained up, makes violent efforts to escape, tearing his kennel to pieces with his teeth. If he be at large he usually attacks only those dogs that come in his way; but if he be naturally ferocious he will diligently and perseveringly seek his enemy. According to Mr. Youatt, the disease is princi- pally propagated by the fighting dog in towns; and by the cur or lurcher in the country: by those dogs, therefore, which minister to the vices of the lower classes in town and country respectively. He maintains that if a well-enforced quarantine could be established, and every dog in the kingdom confined separately for seven months, the disease might be extirpated. This opinion is founded of course upon the belief that rabies never originates at present, any more than small-pox does, spontaneously; but is always propagated by the specific virus. And it is corroborated by the fact that rabies and hydrophobia are unknown in some countries : in the Isle of Cyprus, for example, and in Egypt. I fancy that South America is, or was, a stranger to it. It appears to have been imported into Jamaica, after that island had enjoyed an im- munity from the disease for at least fifty years previously; and Dr. Heineken states that curs of the most wretched description abound in the island of Madeira; that they are afflicted with almost every disease, tormented by flies, and heat, and thirst, and famine, yet no rabid dog was ever seen there. On the contrary, 1666 deaths from hydrophobia, in the human subject, are stated to have occurred in Prussia in the space of ten years. Very early in the disease, as it appears in the dog, the expression of countenance is remarkably changed; the eyes glisten, and there is slight strabismus. Twitchings of the face come on. About the second day a considerable discharge of saliva com- mences ; but this does not continue more than ten or twelve hours, and is succeeded by insatiable thirst: the dog is incessantly drinking, or attempting to drink: he LECT. XXXIV.J HYDROPHOBIA. 403 plunges his muzzle into the water. When the flow of saliva has ceased he appears to be annoyed by some viscid matter in his fauces; and in the most eager and extraor- dinary manner he works with his paws at the corners of his mouth to get rid of it: and while thus employed he frequently loses his balance and rolls over. A loss of power over the voluntary muscles is next observed. It begins with the lower jaw, which hangs down, and the mouth is partially open; but by a sudden effort the dog can sometimes close it, though occasionally the paralysis is complete. The tongue is affected in a less degree. The dog is able to use it in the act of lapping: but the mouth is not sufficiently closed to retain the water. Therefore, while he hangs over the fluid, eagerly lapping for several minutes, it is very little or not at all dimin- ished. The paralysis often attacks the loins and extremities also. The animal staggers about, and frequently falls. Previously to this he is in almost incessant action. Mr. Youatt fancies that the dog is subject to what we call spectral illusions. He says he starts up and gazes eagerly at some real or imaginary object. He appears to be tracing the path of something floating around him, or he fixes his eye intently upon some spot in the wall, and suddenly plunges at it; then his eyes close, and his head droops. Frequently, with his head erect, the dog utters a short and very peculiar howl: or if he bark, it is in a hoarse inward sound, altogether dissimilar from his usual tone, and generally terminating with this characteristic howl. Respiration is always affected; often the breathing is very laborious; and the inspiration is attended with a very singular grating, choking noise. On the fourth, fifth, or sixth day of the disease, he dies : occasionally in slight convulsions; but oftener without a struggle. Mr. Youatt gives a detailed account of the appearances met with after death in the carcases of these rabid dogs. They are not very constant or distinctive. The most curious and uniform consist in the presence of unnatural ingesta in the stomach: straw, hay, hair, horse-dung, earth. Sometimes the stomach is perfectly distended with these substances; and when it contains none of them, there is a fluid of the deepest chocolate colour mixed with olive; or still darker, like coffee: and when neither the unnatural ingesta nor the dark fluid appear, it will be found, Mr. Youatt says, upon careful inquiry, that the dog has vomited much hair, hay, straw, or the like. In 1837, a few days after the case of hydrophobia occurred in the Middlesex Hos- pital, I saw the carcass of a dog, that had died rabid, examined by Mr. Ainslie at his and Mr. Youatt's Infirmary. The most remarkable morbid appearances were in the stomach, which contained some bits of straw and stick, and a considerable quantity of a dark fluid like thin treacle. In various parts of the stomach there were spots, almost black, of considerable size; apparently produced by dark blood partly extra- vasated beneath, and partly incorporated with, the mucous membrane. I believe that Mr. Youatt's opinion, already mentioned, of the cause of rabies in dogs, and in all creatures — viz., that it always results from the introduction of a specific virus into the system —I believe that this opinion is not commonly enter- tained. Most people think that the disease is generated, de novo, in the dog at least; and causes have been assigned for it which certainly are not the true or the sole causes. Thus hydrophobia in the dog has been ascribed to extreme heat of the weather. It is thought by many to be particularly likely to occur in the dog-days ; and to be, as Mr. Mayo observes, "a sort of dog-lunacy, having the same relation to Sirius that insanity has to the moon: which, indeed, in another sense, is probably true " Many cautions are annually put forth, about that period, for muzzling dogs, and so on : very good and proper advice, but, if those who have noted the statistics of the disease may be depended upon, it would be as appropriate at one period ot the year as at another. Rabies occurs nearly as often in the spring, in the autumn, and even in winter, as it does in summer. M. Trolliet, who has written an interesting essav on rabies, states that January, which is the coldest, and August, which is the hottest month in the year, are the very months which furnish the fewest examples of the disease The disorder has often been ascribed to want of water in hot weather and sometimes to want of food. But MM. Dupuytren, Breschet, and Maeendie have caused both dogs and cats to perish with hunger and thirst, without producing the smallest approach to a state of rabies. At the Veterinary School at Alfort three dogs were subjected to some very cruel but decisive experiments. It 404 HYDROPHOBIA. [lect. XXXIV. was during the heat of summer, and they were all chained in the full blaze of the sun. To one salted meat was given; to the second water only; and to the third neither food nor drink. They all died; but none of them became rabid. Nor does the supposition that the disorder has some connexion with the period of sexual heat in these animals appear to have any better foundation. If you are desirous of knowing what my own opinion on this matter is, I must say that I think Mr. Youatt's doctrine by far the most probable one; that rabies never occurs except from inoculation of the specific virus. It has not been proved, and indeed it would scarcely be susceptible of proof, that the disease ever breaks out spontaneously; large tracts of country are totally free from it; and in nineteen cases out of twenty, perhaps, we trace the bite or the fray in which the inoculation has been effected. If I were asked to define the seat of this terrible disease, I should place it, with- out hesitation, in that division of the nervous system which comprises the excito- motory apparatus; the true spinal marrow, with its appendages of afferent and efferent nerves. Nay, I should go further, and say that it is the upper part of this apparatus, of which the functions are primarily and chiefly deranged: that the poison acts mainly upon the nervous arcs which pertain to the throat, and with which the eighth pair of nerves in particular is connected. There is nothing singular in this localiza- tion of the influence of a specific poison. The ergot of rye affects principally those arcs which belong to the uterus; cantharides those which govern the muscular fibres of the bladder. It is true that the mental functions are remarkably modified, and that paralysis of the lower extremities occurs, in most instances of the disease. But neither of these phenomena is constant; and they simply illustrate, when they do happen, the facility with which any morbid state of the spinal cord may propagate its influence in either direction. Whether in hydrophobia the essental change be centric or eccentric, cannot be determined with anything like certainty: but it seems to me to be most probable that the sensibility of the afferent nerves of the fauces, of the skin, and of the air-passages, is altered or morbidly exalted; whence, upon the application of the exciting stimulus, the peculiar sighing dyspnoea, and the strang- ling dysphagia, are produced by a reflected influence through the ^central axis upon the muscles concerned in these actions. But, as I said before, the pathology of the excito-motory apparatus is as yet in its new birth. What can I say of the treatment in hydrophobia; or in rabies? There is no well- authenticated case on record, that I am aware of, in which a hydrophobic person has recovered. As it has been, so it is still, Ia-fpoj la/fat ^ava-toi. The physician that cures is death. There can be no ground therefore for the recommendation of any especial drug, or form of medicine, nor even for any general plan of treatment, after the peculiar symptoms of the disease have once set in. Of course those powerful remedial agencies that are in common use among medical men, have been fairly tried: copious blood-letting, mercury, opium, arsenic, sugar of lead, oil of turpentine, the cold affusion even : and not only those, but the strong poisons that are sometimes, but not so generally, employed for other diseases : bella- donna, stramonium, prussic acid, white hellebore, strychnia, cantharides, the nitrous oxide gas: and no end of less gigantic remedies; such as alkalies, and especially am- monia, carbonate of iron, electricity and galvanism, tobacco-juice, and the guaco (which was introduced into this country a few years ago with high encomiums for its power over the disease), the mineral acids, violent exercise: and if we take into account the substances administered likewise to the brute, we may increase this list by the alisma plantago, Scutellaria, box, and rue, all of which, at one time or another, have been vaunted as successful remedies; veratrum sabadilla also, and ticunas poison. The difficulty of swallowing fluids, and in some cases of swallowing at all, is a serious obstacle to the fair trial of almost every form of internal remedy. It has been proposed to introduce powerful medicines into the rectum, in clysters; but to this also the patients have been found to make great resistance. The injection of medi- cines into the veins has been tried. Magendie hoped that he had discovered a cure, in first largely bleeding the patient, and then injecting his veins with a correspond- ing quantity of warm water: but it has always happened with this, and with other promising experiments, that just as the patient seemed to be about to recover, he has LECT. XXXIV.] HYDROPHOBIA. 405 died. The nervous irritability has in one instance or two been much calmed by the injection of a solution of a salt of morphia into the veins. In a case treated by Pro- fessor Todd, the symptoms appeared to be greatly mitigated, for a time, by applying ice to the cervical portion of the spine, and to the fauces. When I last addressed you on this subject, I ventured to predict that the vapour of chloroform would be tried, and tried in vain, in this untractable malady. I can now inform you that it has been tried, and found as useless, except for the purposes of quieting fierce excitement, and of promoting the euthanasia, as every other remedial measure. Mr. Mayo suggested bronchotomy : upon this ground (to use his own words), " that the principal character of the disease, and the rapid exhaustion which attends it, appear to depend in a great part upon the fits of spasm and closure of the glottis, brought on, not merely by the attempt or the idea of drinking, but by any sudden impression upon the senses. Now it is clear (he adds) that as far as the distressing feelings in the throat consist in a sense of suffocation, they would be put an end to or relieved by the establishment of a free opening in the windpipe." Dr. Marshall Hall would use, in combination with tracheotomy, the hydrocyanic acid. Now I should be sorry to say anything to damp your reasonable hope of benefit from any experi- ment ; but I am bound to confess to you that I should not expect the smallest advan- tage from tracheotomy in this disease. The mode of death offers no encouragement to its use. There may be spasm of the glottis, but I doubt it. At any rate, the patients do not die of suffocation. The death is not death by apnoea, but by asthenia. We see persons labouring grievously for their breath for hours together, who yet sur- vive, and are presently themselves again ; persons, for instance, who are affected with severe spasmodic asthma. I have seen a man sitting up in bed a whole night long, inspiring with such difficulty that, if I had not been aware of his having, scores of times, been as bad before, I should have thought he could not exist five minutes longer. Now we have nothing of this dyspnoea in hydrophobia: and, as I said already, I am sorry, and diffident too, when I differ from great authorities on practical points, but I see no hope of cure, nor even of sufficient benefit to counterbalance the inconvenience and hazard of the operation, from the performance of bronchotomy. The principle is that of suffering the parts gradually to recover themselves, and of allowing the patient in the meanwhile to breathe through another channel. The principle is excellent (as I shall show you by and by), where there is a permanent obstacle to the admission of air to the lungs through the larynx ; but in hydrophobia there is no such permanent obstacle to surmount. Though your patient, in laryngitis, should be at the point of death, yet open his windpipe, and he breathes again and is safe; but it is not at all uncommon for a hydrophobic patient to lose his spasms, to swallow well, and to breathe easily, yet he does not recover. This amendment is the prelude of death, the last flicker of the expiring lamp. Since I lectured upon this subject before, Dr. Latham has told me the following circumstance respecting a pa- tient whom he treated for hydrophobia, in the Middlesex Hospital. He went one day to the ward, fully expecting to hear that the patient was dead. But he found him sitting up in his bed, quite calm, and free from spasm; and he had just drunk a large jug of porter. " Lawk, sir (said a nurse who stood by), what a wonderful cure !" The man himself seemed surprised at the change. But he had no pulse ; his surface was cold as marble. In half an hour he sank back, and expired. Fur- thermore the experiment in question has been tried, and it has been tried by its pro- poser, Mr. Mayo, upon the dog, without affording, as Mr. Youatt assures us, the slightest relief. In the matter of cure, surgery, I fear, is as impotent as physic. Not so, however, in the matter of prevention : this is the most important part of the practice. The early and complete excision of the bitten part is the only measure in which we can put any confidence: and even here we are met with a source of fallacy. In the majority of cases, no hydrophobia would ensue, though nothing at all were done to the wound. How can we know, then, that the disease is ever pre- vented by its excision ? No doubt many persons go through the pain of the operation needlessly. But in no given case can we be sure of this. They get at any rate re lief from the most harassing suspense, with which they would probably have been tortured for months. And if a large number of bitten persons, who had suffered the wound to heal as it would, could be compared with an equal number who had had the 406 HYDROPHOBIA. [LECT. XXXIV. bitten part cut out, hydrophobia would be found a frequent consequence of the bite in the first class — a very rare consequence of it in the second. Mr. Youatt, who trusted to caustic, and who had himself been bitten seven times, tells us that he had operated, with the caustic, on more than four hundred persons, all bitten by dogs respecting the nature of whose disease there could be no question; and that he had not lost a case. One man died of fright, but not one of hydrophobia. Moreover, a surgeon of St. George's Hospital told him that ten times that number had undergone the operation of excision there, after being bitten by dogs (all of which might not, however, have been rabid), and that it was not known that any one had been lost. Mr. Youatt, I say, trusted to caustic; and the caustic he used was the nitrate of silver. But I advise you to trust to nothing but the knife, if the situation of the bite will allow you to employ it effectually. If the injury be so deep or extensive, or so situated, that you cannot remove the whole surface of the wound, cut away what you can; then wash the wound thoroughly, and for some hours together, by means of a stream of warm water, which may be poured from a tea-kettle; place an ex- hausted cupping-glass from time to time over the exposed wound; and finally apply to every point of it a pencil of lunar caustic. If you cannot bring the solid caustic into contact with every part, you had better make use of some liquid escharotic; the nitric acid, for example. In my own case — and what I should choose for myself I should advise for another — if I had received a bite from a decidedly rabid animal upon my arm or leg, and the bite was of such a kind that the whole wound could not be excised, my reason would teach me to desire, and I hope I should have fortitude enough to endure, amputation of the limb above the place of the injury. But if the wound he of such a size, and in such a part, that it can be excised, what is the proper way of cutting it out ? Were I to give you any opinion, as from myself, upon that point, you might think, perhaps, that I was stepping beyond my proper province. I shall, therefore, again retail to you the advice of my old master, Mr. Abernethy. " The cell (he says) into which a penetrating tooth has gone, must be cut out. Let a skewer be shaped, as nearly as may be, into the form of the tooth, and then be placed in the cavity formed by the tooth; and next let the skewer, and the whole cell containing it, be removed together by an elliptical incision. We may examine the removed cell, to see if every portion with which the tooth might have come in contact has been taken away: the cell may even be filled with quicksilver, to see if a globule will escape. The efficient performance of the excision does not depend upon the extent, but upon the accuracy, of the operation." Mr. Abernethy was of opinion that when once the poison had been imbibed into the system, nothing ever had done good, and nothing, probably, ever would. I should be sorry to be so absolutely despairing in respect to a disorder from which dissection after death dis- closes no reason why the patient might not recover. He used to add, that as bleed- ing had been much extolled, had he hydrophobia he would allow a surgeon to bleed him even to death. Like Seneca, he would be willing to have his veins opened, though his disease might not permit him to indulge at the same time, like Seneca, in the luxury of a warm-bath. I say early excision is the only sure preventive; but let me repeat that it will, in all suspicious cases, be advisable (if, for any reason, the operation have been omitted in the first instance,) to cut out the wound, or the cicatrix, within the first two months, or at any time before the symptoms of recrudescence have appeared. One would do it, though with less hope, as soon as possible after they had appeared; but I do not expect to hear of excision being successful then in stopping the disease. Dr. Bright has recorded a case in which the arm was amputated upon the supervention of tingling, and other symptoms, in the hand, in which the patient had been bitten some time before; but the amputation did not save him. It has been proposed to fill the wound with ink, and then to wash it until every trace of the ink is gone; in this way, it is conceived, the complete ablution of the poison also will be ensured. With a timid or an obstinate patient, who would .no* submit to the knife or the caustic, some such expedient ought to be diligently tried; but it would be better to try it after excision, or after the application of the escharotic substance. It is impossible to take superfluous pains to obviate so fearful a disease as hydrophobia. After the wound has been excised or cauterized, it has been recommended that it LECT. XXXIV,] HYDROPHOBIA. 40'< should be prevented from healing, and made to discharge for a long time, by means of irritative dressings. This may be advisable when thorough excision, or complete cauterization, cannot be effected; but I should think it quite useless as auxiliary to those expedients, and only likely to keep up, or to produce, a hurtful irritability of the system. The new power which we have happily obtained of suspending sensation by the inspiration of certain vapours will contribute to the prevention at least of hydrophobia, by divesting the process of excision of its pain, and therefore of its terrors. I should perhaps have mentioned before, a theory, and a plan of preventive treat- ment, which made a great figure in all the journals, foreign and domestic, a few years ago. It was pretended by a Russian physician, Dr. Marochetti, that sometime between the third and the ninth day after a person has been inoculated with the hydrophobic poison, by the bite of a rabid dog, little pustules appear on or about the fraenum of the tongue, containing a small quantity of sanious fluid, of a yellow or greenish colour. Pustules of the same kind were declared to exist also under the tongues of the mad dogs themselves. Now Dr. Marochetti pretended further, that if, from the very time of the bite, you gave the patient large doses of the decoction of broom tops, and looked out for the eruption of these pustules, which seldom lasted more than twenty-four hours, you might infallibly prevent the disease by opening and emptying the pustules, and then cauterizing them with a red hot iron; and afterwards causing the patient to gargle his mouth with that same decoction of broom. He held that the poison was deposited there for a short time, and then re-absorbed into the system ; and he proposed to prevent such re-absorption. This was a very pretty theory; and took mightily in the medical world. But it has turned out a sort of hoax. I do not mean a wilful hoax on the part of Dr. Marochetti; for I have no doubt that he contrived to hoax himself. These pustules have been looked for again and again; but they have never been discovered in Englishmen affected with hydrophobia; nor in English mad dogs. The truth seems to be that the mucous follicles of the mouth, generally, and those at the base of the tongue, and those beneath the tongue, in particular, are com- monly enlarged and exaggerated in the dog, and in the human animal, labouring under the disease; and these enlarged and altered follicles were regarded by the Russian physician as a specific eruption, which furnished the virus and pabulum of the complaint. As almost every drug that has ever been included in any Pharmacopoeia has been administered with the hope of checking the disease, so a great number of medicines and measures have been praised as preventives. Some people have great faith in sea-bathing; and they go to the coast to be ducked and half-drowned every day"for six weeks; and if they escape hydrophobia they conclude that the immersion in salt water has saved them. Some of the specifics, as you may suppose, are great secrets; and they who possess them — whether they believe in them or not is another matter — sell them at no cheap rate to those who having been bitten by the dog, are weak enough to be bitten again by the quack. The composition of several of them has transpired; and they are found to consist either of ingredients the most insignificant and worthless, or of poisons of which the inefficacy had already been ascertained. The celebrated pulvis antilyssus, which was introduced by no less a person than Dr. Mead, into the London Pharmacopoeia, was a mixture of ash-coloured liverwort and black pepper. The Ormskirk medicine, long famous, and scarcely obsolete yet in the north of England, was made up of bole armeniac, alum, chalk, elecampane, and oil of aniseed. The Tonquin medicine was composed of cinnabar and musk: and the Tanjore pills were a combination of mercury and arsenic. Even now scarce a year elapses but some correspondent of the newspapers, whose philanthropy is more con- spicuous than his judgment or his knowledge, recommends a new and infallible pre- ventive. I confess to you that I have not the slightest faith in any one of them; but as I had a great respect for Mr. Youatt's judgment, and as he was not quite so sceptical as I am on this point, and as patients or their friends will insist upon the adoption of protective measures sometimes, when the local means of prevention have been omitted or imperfect, I will tell you the result of his inquiries respecting these prophylactic dru°"s. In the first place he never succeeded in curing the disease in the dog with anything that he had ever tried. In the way of prophylaxis, he experimented with a great number of substances. 408 EPILEPSY. [lect. XXXV. He thought that the box-wood, which is the basis of some celebrated preventive drinks in Hertfordshire and Kent, had some effect. He tried the alisma plantago, the boasted efficacy of which had been strictly inquired into by the magistracy of Toula, and the receipt purchased by the Russian Government at an immense price. But he had no success with it. He then put the belladonna to the test, beginning with two grains, and increasing the dose to a scruple twice every day, and continuing this for six weeks: and he says he is confident that he saved several dogs; but he lost almost as many. They all became debilitated and most rapidly emaciated. Then, in the year 1820, his attention was directed to the Scutellaria lateriflora, which Dr. Spalding, an American physician, had found highly successful as a pre- ventive of rabies : and upon trial of it, he soon was brought to regard it as really valuable: and (not to tire you with a detail of his proceedings in the interim) he at length combined it with belladonna: "and the result" (I here quote his own lan- guage) " has been a medicine which I cannot, dare not, call a specific; for it has failed : but the use of which, in the cases of doubt and fear to which I have alluded, I would most earnestly recommend." He relates two experiments, which seem to have made a great impression upon his mind. They are as follows : — " Three pieces of tape were thoroughly moistened with the saliva of a rabid dog, and inserted as rowels in the polls of three other dogs. To two the Scutellaria and belladonna were given : the third, a fox-hound bitch, was abandoned to her fate. On the 29th day after the inoculation she became rabid." The others, at the time this was written, i. e., some months subsequently, were living and well. He afterwards took the same two dogs, and a third. He moistened two pieces of tape with the saliva of a rabid dog, and inserted them in the polls of one of the old dogs, and of the third dog. Another piece of tape, dragged repeatedly through the mouth of the same rabid dog twenty-four hours after its death, was inserted in the poll of the second of the old dogs. This dog and the new one were suffered to take their chance. To the other old dog the medicine was given. In the fourth week the new dog died undeniably rabid. The other two survived. I repeat that I have no faith in these preventives. But sometimes some of them must be tried; and I would prefer those which are thus sanctioned by Mr. Youatt's good opinion to any others. And with respect to the established disease, I think that if I were the unhappy subject of it, I should wish to be put into a hot air bath, and thoroughly sweated, and to take opiates; not so much in the hope of recovering as with a view to the euthanasia. But with all respect to those gentlemen who advocate that practice, no one, if I could help it, should make a hole in my windpipe. LECTURE XXXV. Epilepsy. Its symptoms and varieties; duration and recurrence of the paroxysms; periods of life at which they commence ; warnings. Effects of the paroxysms, im- mediate and ultimate. Pathology. Anatomical characters. Causes. The great functions of which the brain is the material instrument are sensation, thought, and voluntary motion. The influence of the will is a cerebral influence : it reaches and acts upon the muscles through the interposition of the spinal cord. Mo- tions that are involuntary belong more exclusively to the system of the true spinal marrow. Yet cerebral changes, morbid states of the brain, may excite them. I have shown you that all these functions are liable, under disease, to be separately affected, and each in various ways and degrees. The number of combinations capable of arising out of disordered conditions of two, or three, or all of these functions, is very great. Yet the symptoms proper to the nervous system do arrange themselves LECT. XXXV.] EPILEPSY. 409 into groups sufficiently definite and constant to allow of our giving them distinctive names, and making them separate objects of inquiry. At the same time, as might indeed be expected, these several groups have strong resemblances to each other. They are obviously of the same family: " facies non omnibus una, nee diversa tamen; qualis debet esse sororum." Occasionally the features are so nearly alike, that we find it somewhat puzzling to determine with which of the sisters we are conversing; but usually there is some mark or other by which the individual may be identified. Of these essentially nervous diseases, there are several in which the most prominent and obvious of the phenomena relate to the muscular system; irregular, violent, and involuntary contractions occurring of muscles which, in the healthy state of the body, . are subject to the control of the will. I have spoken of two very frightful disorders belonging to this head: — of tetanus, namely, in which the muscles of voluntary motion present the most striking changes, being affected with tonic spasm; while the sensibility undergoes no other alteration than what is a consequence of that spasm, pain I mean in the muscles themselves; and the intellectual functions continue undis- turbed:— and of hydrophobia, in which the natural sensibility suffers much, and the mental functions some derangement; yet still the characteristic features of the malady depend upon the irregular and uncontrollable action of muscles usually obedient to volition. The disease which I am next to consider is scarcely less terrible to look upon, when it occurs in its severer forms, than tetanus or hydrophobia; but it is not attended with the same urgent and immediate peril to life. Yet it is, upon the whole, productive of even more distress and misery; and is liable to terminate in worse than death. You will understand that I am alluding to Epilepsy: a disease not painful probably in itself; seldom immediately fatal; often recovered from altogether: yet apt, in many cases, to end in insanity or fatuity; and carrying perpetual anxiety and dismay into those families which it has once visited. The leading symptoms of epilepsy are, a temporary suspension of consciousness, with clonic spasm; recurring at intervals. It is impossible to frame a perfect definition of epilepsy; nay, so various are its shapes, so numerous its modifications, that no general description even of it can be given. It will be necessary for me, therefore, here (as it has been before) to describe first the most ordinary form of the disease, as a standard; and then to note the several variations from that standard which are known to occur in practice. A man, then, in the apparent enjoyment of perfect health, shall suddenly utter a loud cry, and fall instantly to the ground, senseless and convulsed. He strains and struggles violently. His breathing is embarrassed or suspended; his face becomes turgid and livid; he foams at the mouth; a choking sound is heard in his windpipe; he appears to be at the point of death by apncea. But presently,_ and by degrees, these alarming phenomena diminish, and at length cease; the patient is left exhausted, heavy, stupid, comatose: but his life is no longer threatened. And in a short time he is once more, to all appearance, perfectly well. The same train of morbid pheno- mena recur however, again and again, at different, and mostly at irregular intervals. ' This is a brief description of the most ordinary form of epilepsy. The suddenness of the attack is remarkable: in an instant, when it is least expected by himself or by those around him, in the middle of a sentence or of a gesture, the change may take place; and the miserable sufferer is stretched foaming, struggling, and insensible upon the earth. This fearful suddenness is expressed in the name of the disease, im%s\ia., a seizure, an abrupt invasion. The ancients, among whom the complaint was well known, superstitiously ascribed it to the malice of demons, or to the anger of their offended deities. If a person were seized with epilepsy in the forum, it was considered an ill omen, and the meeting was at once dissolved, and all public business suspended for that day. Hence the disease was called morbus comi- tialis. Morbus qui sputatur was another of its names, because those present were accustomed to spit upon the epileptic man, or into their own bosoms; either to express their abomination, or to avert the evil omen from themselves. In this country its common designation is the falling sickness: or, more vaguely, fits. The cry which is frequently, though by no means always, uttered, is generally a piercing and terrifying scream. Women have often been thrown into hysterics upon hearing it. It is said 410 EPILEPSY. [lect. XXXV. to have caused pregnant females to miscarry. Even the lower animals appear to be sometimes startled and alarmed by a note so harsh and unnatural. Dr. Cheyne informs us that, upon one occasion, "a parrot, himself no mean performer in discords, dropt from his perch, seemingly frightened to death by the appalling sound." The muscular convulsions are strong, irregular, and often universal. In most of the fits of which I have happened to see the commencement, the first effect of the spasm has been a twisting of the neck, the chin being raised, and brought round by a succession of jerks, towards one shoulder: and one side of the body is, usually, more strongly agitated than the other. The features are always greatly distorted. The brows are knit; the eyes sometimes quiver and roll about, sometimes are fixed and staring, sometimes are turned up beneath the lids, so that the cornea cannot be seen, and the white sclerotica alone is visible; the mouth is twisted awry; the tongue, thrust between . the teeth, and caught by the violent closure of the jaws, is bitten, often severely; and the foam which issues from the mouth is reddened by blood. The hands are firmly clenched, and the thumbs bent inwards upon the palms: the arms are thrown about, striking the chest of the patient with great force, or bruising themselves against sur- rounding objects, or inflicting hard knocks upon the friends and neighbours who have hastened to the patient's assistance. It frequently happens that the urine and excre- ment are expelled during the violence of the spasm : and seminal emission sometimes takes place. The spasmodic contraction of the muscles is occasionally so powerful as to dislocate the bones to which they are attached: the joints of the jaw, and of the shoulder, have been thus put out; and the teeth are sometimes fractured. When the convulsive paroxysm is over, the patient falls into a deep sleep. You might imagine that he slept from exhaustion, like a man worn out by great fatigue; but there is something more than this; the patient passes into a state of incomplete coma, or rather the insensibility continues after the convulsions have ceased. When he wakes he is often confused and incoherent for a time; by degrees, however, he resumes his ordinary appearance and condition; but he remembers nothing of what passed during the fit. You may suppose that so much irregular contraction of the muscles of voluntary motion is not likely to occur without some derangement or modification of the func- tions of the circulation. The breathing is irregular, gasping, or arrested. The heart palpitates violently against the ribs during the paroxysm; the pulse becomes frequent and feeble; and sometimes it ceases to be tangible at the wrist during the height of the fit, and begins to be felt again as the spasms subside. The turgescence of the face indicates obstruction of the venous circulation; the cheeks and lips become purplish and livid, and the veins of the neck and forehead are visibly distended. This, then, is one form, the most severe and the most common, as well as the best marked form, in which an epileptic attack occurs. But there is a large class of cases, in which the symptoms are much more mild. There is very slight and transient, or even no convulsion at all; no turgescence of the face; no foaming at the mouth; no cry; but a sudden suspension of consciousness, a short period of insensibility, a fixed gaze, a totter perhaps, a look of confusion; but the patient does not fall. This is momentary; consciousness presently returns; the patient resumes the. action in which he had been previously engaged, and is not always aware that it has been interrupted. Sometimes, with this temporary abeyance of the mental functions, there is some slight evidence of convulsion or involuntary action; the fingers of one hand, or less commonly of both, are moved irregularly, and without any object; or the eyes roll or are turned upwards; or the muscles of the face are twitched. Sometimes the patient is himself aware of what has been his con- dition, but shows some cunning in endeavouring to conceal it. This slighter attack is called by the French, petit mal; while the severer form is named, grand mal. The former is spoken of also as epileptic vertigo, and distin- guished by that appellation from the epileptic fit. Of affections so different in degree, and in some respects so dissimilar in kind, you may be disposed to ask whether they really constitute the same disease. That they are essentially of the same stamp, we have this evidence; that both forms of attack occur in the same individuals. Sometimes a patient will suffer many recurrences of the epileptic vertigo, and at length will become affected with violent epileptic fits. Or the two forms will intermingle, sometimes the milder happening, sometimes the LECT. XXXV.] EPILEPSY. 411 severer. In such cases we cannot doubt that the attacks are in their nature the same, though different in their form and degree. And when (as sometimes happens) we meet with the slighter disease alone, we cannot refuse to assign to it the character and the name of epilepsy. Between the two extremes, there are many links of gradation. Sometimes the sufferer sinks or slides down quietly, and without noise, is pale, is not convulsed at all, but insensible; much like one in a state of syncope. After recovering, he re- mains sick, languid, and confused, during the remainder of the day. You will perceive, from what I have now said, the difficulty of giving any single description of epilepsy, which will include all its varieties. It is of course still more difficult to offer a strict definition of the disease. Cullen defines it to be " muscu- lorum convulsio, cum sopore." Dr. Copland furnishes a larger and more compre- hensive definition: " Sudden loss of sensation and consciousness, with spasmodic contraction of the voluntary muscles, quickly passing into violent convulsive distor- tions, attended and followed by sopor, recurring in paroxysms often more or less regular." But almost every one of these circumstances may, in its turn, be wanting. There may be no convulsion; there may even be very slight and transient interruption of consciousness; there may be no subsequent coma or sopor; there may be no recur- rence of the attack. Yet I trust that you now have obtained some general notion of what is meant by an epileptic seizure. And I go on to inquire into several most important points con- nected with the paroxysms. In the first place, they vary considerably in duration. Sometimes, as I have already stated, the seizure is slight, and does not occupy more than a moment or two of time. But even the severer attacks are often over in a few minutes. They sel- dom continue longer than half an hour, and probably the average duration may safely be laid at between five and ten minutes. Attacks that are spread over three or four, or more hours, generally consist of a succession of paroxysms, with indistinct inter- vals of comatose exhaustion. In the long-continued fits, or in the protracted succes- sion of fits, the patients often die. The periods at which the paroxysms return are also extremely variable. Occa- sionally the patient expires in the first paroxysm; occasionally, though he recovers from it, he never has another. Both of these occurrences are rare. Rather more frequently the fits recur at very long intervals; at the distance, I mean, of many years. Most commonly of all, they revisit the sufferer at irregular periods of a few days: sometimes every day, or every night: and not very unfrequently they take place many times in the twenty-four hours. This extreme frequency of repetition belongs principally to the slighter imperfect seizure, the petit mal. Sometimes the fits observe a strictly regular period of return; but, for the most part, they are quite uncertain and zYregular. The time of life at which the fits commence, and the circumstances attending their commencement, are deserving of notice. They not uncommonly begin in infancy. Those fits of convulsion to which young children are subject during the first dentition, and which sometimes appear to depend upon the irritation of teething, and sometimes upon manifest disorder of stomach and bowels — these fits are not distinguishable in their phenomena from genuine epilepsy, and we must reckon them as instances of epi- lepsy. It has been remarked by some one, that if you can trace the early history of an adult epileptic, you will almost always find that he or she suffered infantile convulsions. [This is true. Epileptics, it will very generally be found, were affected with re- peated attacks of convulsions during the period of infancy. In many subjects, how- ever, we have known the disease to commence immediately subsequent to puberty, or even late in life. In the majority of these latter cases the disease appeared to be the result of a life of intemperance---O] To what extent this is true I do not know, but I recommend it to you as a point worth attending to in your future opportunities of observation. The epileptic attack may come on, for the first time, at any age. According to Dr. Bright (whose account of the disease, though short, is particularly perspicuous), 412 EPILEPSY. [lect. xxxv. the most common periods are about the age of seven or eight years, probably about the time of the second dentition; and from fourteen to sixteen, shortly before the age of puberty. And the disease (he says) is very apt to occur for a few years subse- quently to this. But sometimes the first fit has taken place between the ages of thirty and forty; in not a few cases, after sixty; and occasionally quite in the decline of life. Dr. Bright offers a little piece of theory in respect to the periods at which epilepsy is apt to begin. It is a reasonable piece of theory, and serves to tie the alleged facts to one's memory, even if it be not yet proved to be true. Doubtless in many cases the circumstances that determine the first attack are quite accidental. But setting aside these casualties, he says, " there are leading periods in the evolution of the frame, and peculiar circumstances connected with certain periods, which may well be considered as influential in the production of the disease. In infancy, the nervous system is delicate, and easily acted upon by various causes of irritation. Then fol- lows the trying period of teething. In a few years the second dentition occurs. In a few years later, all the great changes connected with the age of puberty. To this follow the excesses and exposures of manhood; and after the lapse of years, the vigour of the system fails, and many causes act to derange the nice balance of the constitution; the bowels often become sluggish; changes more or less serious take place in the structure of the arterial and venous systems; and many causes, organic or functional, which had before been unable to exert an influence on the vigorous frame, acquire power from its relative weakness." The first accession of the disease takes place more commonly before than after puberty. Of sixty-six epileptic women, in whom the outset of that disease and the first period of menstruation were carefully noted, thirty-eight had epilectic fits before, and twenty-eight not till after that period. The attacks are very apt to come on during the night; in the commencement of the disease they frequently are confined to the night. They are said chiefly to occur at the moment when the patient is sinking into sleep, or awaking from sleep. How far this is true I cannot tell. When the disease is yielding, the fits often happen in the night only; so that after they have, for a certain period, taken place in the day- time, or during the day and the night indiscriminately, it is reckoned a good prognostic sign if they begin to restrict themselves to the night. Some patients, under these circumstances, suppose that the physician has particular remedies that will make the fits happen in the night rather than in the day; and they ask for these remedies. Sometimes each paroxysm arrives unannounced and unexpected; sometimes distinct warnings of its approach are given. The latter is less frequent than the former. Georget affirms that premonitory symptoms do not occur more than four or five times in a hundred cases. I am sure that this is much understated. When warning symptoms do happen, they are sometimes spread over a considerable period; several hours, or a whole day: sometimes they last just long enough to enable the patient to remove from a situation in which a fall would be attended with unusual danger: to dismount from horseback, to lie down in a boat, to get away from the fire-place, from the edge of a precipice, from the vicinity of water, to assume the horizontal position of his own free will and in his own manner, or to give notice to those about him of what is going to befall him. In some cases the warning is too short and sudden even for this. The kind of notice that he receives is very variable indeed. Often it con- sists in some unnatural state of the mind, the feelings, the temper; the patient is fidgety, irritable, low-spirited, timid, sullen; or, on the other hand, he feels unusually strong, and hearty, and cheerful. Sometimes there is a notable change in some one or more of the natural functions, or of the bodily sensations; the patient loses his appetite, or his appetite becomes voracious; a great flow of urine takes place; he smells an ill smell, is aware of a strange taste, hears extraordinary noises, or sees spectral illusions; not mere specks floating before him — muscae volitantes — but distinct forms of persons and things not present. This is not very common, but it certainly happens. The late Dr. Gregory, of Edinburgh, was assured by a patient of undoubted veracity, that always, when he had a fit of epilepsy approaching, he fancied that he saw a little old woman in a red cloak, who came up to him, and struck him a blow on the head, and then he immediately lost all recollection, and fell down. Headache, giddiness, dim or dazzled vision, are all of them common symptoms LECT. xxxv.] EPILEPSY. 413 among those which have been observed to be precursory of epilepsy. Sometimes there are circumstances which are obvious to a by-stander : a flushing of the face, or lividity, or, perhaps, pallor : delirium ; difficult articulation; vomiting. Of twenty-one epileptics treated in the hospital at Wilna, by Joseph Frank, vomiting announced the paroxysm in seven. Some of the uneasy feelings are apt to come on and to continue even for several days previously to the attack; restlessness in particular, disturbed sleep, dis- tressful dreams, a peculiar and sudden coldness of the extremities. An internal working is a phrase often used by such persons to express a sensation which is probably indescribable. But the most curious precursory symptom of all, if we except the spectral illusions, is what is called the epileptic aura. This is a sensation which is likened by different patients to different things; to a stream of warm or cold air, to the trickling of water, to the creeping of a spider. The sensation proceeds commonly from some distant part of the body, — from one of the extremities, from a thumb, or finger, or toe, or from some spot on the trunk — and runs along the skin towards the head : occasionally it gets no further than the pit of the stomach: as soon as it reaches the head, or stops at the epigastrium, or elsewhere, the patient's consciousness forsakes him, and the paroxysm declares itself. There seems to be some analogy between this epileptic aura and the well-known sensation, to be spoken of hereafter, of a ball rising from the stomach to the throat, and constituting the globus hystericus; except that in cases of epilepsy the sensation commonly begins in an extremity, and not in the stomach : and the fit comes on when it reaches the head, and not the throat. Sometimes, I think, these two sensa- tions are blended. In some instances, spasms of the muscles of the part whence the aura proceeds are observed to take place prior to the more general state of spasm. This aura is certainly a very curious phenomenon. It has been thought to depend upon some change propagated along the nerve upwards to the brain, and to be some- times connected with some injury done to, or some morbid impression made upon, an afferent nerve. I think that this explanation may apply to some cases. Dr. John Thomson, of Edinburgh, used to state in his lectures, that he had known epilepsy to begin with an aura proceeding from an old cicatrix in the side. In a patient of my own, who was subject to epilepsy, the warning sensation commenced in one of his thumbs, which presently after began to be twisted inwards; but by tying his handkerchief tightly round the thumb, he could prevent the fit. Dr. Sey- mour mentions the case of an epileptic boy, who had learned to protect himself against a threatened paroxysm by biting his tongue. In other cases the aura probably originates in some change within the head, and is analogous to the numbness or tingling that is often felt in some part of the body or extremities immediately before an attack of palsy or apoplexy. There is no real in- consistency in this twofold explanation: the source of the aura may be centric or eccentric; so also may the exciting cause of the paroxysm; as, in due time, I shall explain to you. A knowledge of these warning circumstances is clearly of importance, always so far as respects the comparative security of the patient during the attack; sometimes as affording us the opportunity of staving off the fit altogether. And it is necessary to remark, that they sometimes give, as it were, a, false alarm ; they occur, and yet, although no measures of prevention are taken, no paroxysm follows. The phenomena that succeed the paroxysm are also of great interest and moment. I have already apprized you that the convulsions generally terminate before the in- sensibility is over: the patient draws, perhaps, two or three gasping sighs, and ceases to struggle. Some few persons are quite themselves again in a moment or two; some appear to recover consciousness, and then fall into a deep and prolonged slumber; but many do not regain their consciousness at all upon the cessation of the convul- sions, remaining in a state of profound stupor, from which, however, they can generally be roused for a time. This state of coma (for it is nothing else) has been known to last a week. After the patient emerges from it, he is sometimes merely languid and inert; sometimes he is like a person stunned, or in a state approaching to idiotcy, which gradually clears up; sometimes he is furiously delirious for awhile; not unfrequently there is a degree of partial paralysis, which also usually soon goes 414 EPILEPSY. [lect. xxxv. off, though occasionally it is permanent; his eyes are fixed, or he squints, or his pupils are dilated, or he drags a leg, or he falters in speech. Sometimes he is com- pletely hemiplegic. Most commonly he speaks of headache, or discomfort of some kind. It is very seldom that the patients have any recollection whatever of what has passed during the fit. Many of them are not aware that they have had a fit: and those who do know it, discover the fact by finding themselves wet or dirty; by the injuries they have received during the convulsions; by the soreness of the bitten tongue; by their blood-shorten eyes; by the bruises of their limbs; or by the con- fused or painful sensations which they subsequently experience, and which they have learned to associate with the conviction that a fit has happened, from having been in- formed on previous occasions, when they felt the same sensations, that they had suffered a paroxysm of insensibility and convulsions. Upon the whole, it is seldom that any permanent ill effect can be noticed as having been left behind it by any one single fit; but, unhappily, this cannot often be said of their repetition. Doubtless a single paroxysm does often leave the patient in a worse condition than that in which it found him; but this does not become perceptible to an ordinary observer, until after the alteration has been magnified and made apparent by repeated fits, and repeated small additions to the permanent injury. The friends of the patient remark that his memory is enfeebled in proportion to the number of the attacks; that his mental power and intelligence decline. His features even assume, by degrees, a peculiar character; he becomes subject to insane delusions, and too often he sinks at last into utter and hopeless fatuity. It is this tendency which renders epilepsy so sad and fearful a disease. Foville affirms, that the intellectual degeneration is more constant, and comes on more early, in persons who are principally afflicted with the epileptic vertigo, the petit mal, the imperfect seizure, than in persons in whom the grand mal, the violent and decided paroxysm, takes place. Dr. Copland, on the other hand, is of opinion, that " the more severe the fits, the more is that result to be dreaded." This is a point which can only be settled by statistical facts. And as we all have the oppor- tunity of collecting some such facts, and of adding them to the general stock, I men- tion this, and some other points that are still uncertain or disputed, as worth bearing in mind. More, probably, depends upon the repetition of the fits, than upon their precise nature or severity. Cases do occur in which epileptic persons preserve their faculties to a good old age; but those who are early epileptic do not often attain old age; and whenever the disease comes on, if it repeat itself frequently, it is followed much more often than not by impairment of the mind, or by some apoplectic or para- lytic affection, which implies and accompanies the mental change. You will some- times hear the cases of Julius Caesar, of Mahomet, and of Bonaparte quoted, as examples of high intellectual power, existing and remaining in spite of epilepsy: — and it is allowable, perhaps, to make use of such cases for comforting the friends of epileptic persons : or for giving the advantage of sustained hope to the patient himself. But, in truth, these cases are not worth much. Napoleon is said, I know not upon what authority, however, to have suffered something like epilepsy during sexual intercourse. This is not very uncommon in persons subject to that disease. And, with respect to Julius Caesar, we learn from Suetonius, that it was only in the latter part of his life that he laboured under epilepsy; and that he had two attacks while engaged in business. Having now described the phenomena of epilepsy; the periods of life at which it is most apt to commence; its varieties; and its tendency and most common termina- tion : let us next inquire what is known respecting the real seat and nature of this strange and melancholy complaint. The functions that are affected are clearly functions of the brain. Sensation, thought, and motion regulated by the will, are the natural functions of that organ. The temporary abeyance of sensibility, thought, and volition; and violent and irregular action of the muscles which are thus withdrawn from the government of the will; constitute a paroxysm of epilepsy. We have, in this malady, another illustra- tion of the fact, that when the controlling influence of the cerebrum is suspended, lect. xxxv.] EPILEPSY. 415 the peculiar functions of the spinal marrow are exercised, not only in a disorderly, but also in an unusually energetic manner. That the brain and the spinal marrow, though physiologically distinct, are yet intimately connected with, and dependent upon, each other, a thousand familiar facts assure us; and there are good reasons for believing that the change, whatever it is, which is the immediate precursor and cause of the epileptic fit, may sometimes originate in the spinal cord, and thence extend to the brain; and sometimes originate in the brain, and communicate itself to the spinal cord. Dr. Marshall Hall's doctrine, that all convulsive diseases are diseases of the spinal marrow, cannot be properly applied to this convulsive disease of epilepsy. It is true that the spinal cord is concerned whenever there is convulsion; but it is con- cerned in every voluntary movement also, through the instrumentality of the brain itself; and it may be, and often is, irregularly influenced by a disordered and unnatu- ral state of the brain. Tetanus may fairly be regarded as a disease of the cord and its proper appendages. The spasms arise and reach their height, while the powers of thought and sensation are undisturbed, and while volition remains, although the morbid condition of the cord renders it ineffectual. In epilepsy these cerebral functions are always implicated. There is always a loss of consciousness : and in the epileptic vertigo, the petit mal, there is frequently a suspension of consciousness only, without any convulsion at all. The brain, therefore, we must consider to be essen- tially concerned in this disorder. What the precise state of the nervous matter may be, which determines the loss of consciousness and the spasms, we can only conjecture. A derangement in the rela- tion between the arterial and venous circulation within the head; a temporary pres- sure somehow arising; a determination of blood towards the head; a diminution of the natural quantity of blood sent thither from the heart; all these have been assigned as possible causes of the paroxysms. Plausible reasons might be given in favour of the operation of each of them; but the speculation is more curious than useful. We have not yet penetrated the mystery of these remarkable phenomena, and it will be more profitable to turn to another question, which admits of a somewhat more definite answer, viz.: — what is the morbid anatomy of epilepsy ? Suppose that a person who has had epileptic fits, but in whom they have not been followed by any durable affection of the intellectual or locomotive functions, dies of some other malady; and that you have the opportunity of minutely examining the condition of his nervous system. Often you will find nothing at all which can throw any light upon the occurrence of the epileptic paroxysms; no appreciable alteration whatever in any part, either of the brain or of the spinal cord. In other cases you may discover some organic disease within the head : a scrofulous tubercle, a spiculum of bone projecting from the skull. Have you then detected the cause of the disease? All that can be said is, that the piece of bone or the tubercle was probably a predis- posing cause of that derangement of the nervous substance which determined the paroxysms; the derangement itself, if, indeed, it were of such a nature as to be cog- nizable by our senses, has gone, with the symptoms; the tubercle or bone having in the mean time remained, without any sign which could betray its presence. M. Foville, whose testimony in this matter is entitled to much weight, affirms that, in persons who have been subject to epilepsy, uncomplicated as yet with any perma- nent disorder of the intellect, or of the faculty of voluntary motion, and who have died in the fit, constant alterations are observable within the head; viz., a strong injection of the vessels of the encephalon. The membranes, the brain, and the cere- bellum, are gorged, he asserts, with livid blood. But he goes on to say that this is to be ascribed to the mode of death; that we see the same appearances in persons who have died by hanging, or by any form of apnoea; that they are not peculiar to epilepsy, and do not explain the attack, but only point out the way in which it has been fatal. It is I fancy, a very common notion, both that such congestion does take place, and that it is the cause of the paroxysm : and it may be worth while shortly to state the reasons which are opposed to the conclusion, that the congestion (granting for the moment that it always happens) is a sufficient explanation of the attack. In the first place it is not easy to conceive that the congestion could so suddenly arise and subside again, as it must sometimes do, if it be the immediate determining cause of the fit: within the space of a single minute, for example. 116 EPILEPSY. [lect. xxxv. And in the second place, the signs of external congestion and plethora, by which signs we measure the amount of the internal, are most marked just when the symp- toms of the paroxysm begin to subside and disappear. The congestion, which is the result of obstructed venous circulation, which again is a consequence of the muscular spasms, cannot be regarded as the cause of the convulsive symptoms. Let us go a step further, and inquire into the state of the encephalon in those per- sons who, having suffered epilepsy, had, before death arrived, been affected with some permanent impairment of the mental functions, or (what often goes along with such impairment) with some degree or other of muscular paralysis or debility. The most common alterations met with in the brain in such cases are the following Induration of the white matter of the brain, which presents a dull appearance; sometimes, besides the hardening, a general injection of the white matter; and in the majority of cases a marked dilatation of the blood-vessels. In some instances the consistence of the white matter is diminished, it is soft and flabby; but there is the same dilatation of the blood-vessels. These changes pervade the whole of the white matter in every part of the brain. At the same time the grey matter is found irre- gular on its surface, marbled or of a rosy colour in its substance, and sometimes altered in consistence. And in many cases the membranes are found to be adherent in some parts to the convolutions with which they lie in contact. Such are the results of the experience of careful observers in respect to the morbid. anatomy of epilepsy; of Morgagni, of Foville, and of MM. Bouchet and Casauvielh. The changes last described are such as are produced by chronic inflammation of the brain and its membranes. They are the consequences (I imagine) of repeated pa- roxysms of epilepsy; they are the very same as are frequently met with in cases of insanity complicated with paralysis, and they elucidate, therefore, the connexion of these affections; but they certainly teach us little or nothing of that actual condition of the nervous mass upon which the epileptic paroxysms depend. And, in truth, to expect to find in the brain the traces of convulsions that have passed away, would be as unreasonable as to expect to find there the traces of former voluntary movements. Of those organic changes which may be regarded as strong predisposing causes of the paroxysms, my own experience accords with that of Dr. Bright; who states, that most frequently they are such as affect the surface, rather than the deeper-seated parts of the brain: tumours external to the cerebral matter; alterations in the mem- branes that envelope the organ, or in its bony case; the skull being very often unna- turally thick, heavy, and uneven. Various altered states of the spinal marrow have also been recorded. But besides the morbid appearances that are sometimes only visible in the nervous centres themselves, there are others, which it is of great importance to attend to, situated in other parts of the body, and at a distance from those centres: diseased states of the liver; biliary concretions; granular kidneys; renal calculi; stones in the bladder; worms in the alimentary canal; diseases of the uterus; and of various other parts. And these morbid conditions have often, no doubt, an intimate connex- ion with the epileptic paroxysms. Accordingly some authors make almost as many varieties of epilepsy as there are organs of the body; they specify the cerebral, the spinal, the cardiac, hepatic, gastric, intestinal, renal, genital uterine, and so on. It will be sufficient, however, to consider two species only : that, namely, in which the disease originates in the nervous centres themselves, and especially in the brain; and that in which it originates in some other part. Most persons who have written on epilepsy make this distinction, although they employ different terms to express it: cerebral and occasional; primary and secondary; idiopathic and sympathetic; centric and eccentric. The last two terms are the best. But let us clearly understand them. The disease may, in one sense, be considered eccentric, even when it is situated in the brain; eccentric, i. e., in respect to the true spinal marrow. But I apply the epithet centric to epilepsy when its cause lies in either of the two great nervous centres; the brain, or the cranio-spinal axis. In the eccentric species a morbid influ- ence is conveyed by afferent nerves from the seat of the local disease to the spinal cord, and the convulsions mark its responsive action. This distinction we shall find to be an important one, both as regards the prognosis and the treatment. Let me, however, first say a word respecting the causes and the diagnosis of epilepsy. There is no doubt that a tendency to epileptic disease is frequently hereditary. It lect. xxxvi.J EPILEPSY. 417 may be derived from parent to child; or it may skip over a generation or two, and appear in the grandchild or great-grandchild; or it may be traceable only in the col- lateral branches of the ancestry. This is just what takes place in other hereditary maladies. You may often notice also that other forms of nervous disorder prevail in the same families. MM. Bouchet and Casauvielh found that among 110 instances of epilepsy, 31 were ^hereditary. Of 321 persons afflicted with epileptic insanity, and seen by Esquirol, 105 were descended from insane or epileptic parents. Again, a tendency to epilepsy is very often found to go along with an unnatural form of the head, which is pinched up like a sugar-loaf; or misshapen and unsym- metrical, one half being unlike the other; or in some way or other oddly configurated. Epilepsy is no uncommon attendant of chronic hydrocephalus. And thirdly, the scrofulous diathesis is a strong predisposing cause of epilepsy. Dr. Cheyne even holds that epilepsy is as certain a manifestation of the strumous dis- position, as tubercular consumption, or psoas abscess. Now, of the two predisposing circumstances last mentioned, it may be observed, that they commonly merge in that which preceded them : the strumous diathesis, and a particular conformation of the head, are both very likely to descend from parents to their progeny. Whether the sex has any influence in determining a predisposition to epilepsy, is a question that remains to be settled. Foville thinks it is most common in females; Dr. Elliotson, in males. I have certainly seen more epileptic boys and men, than girls and women. But the casual experience of a single observer is not enough to deter- mine the point. We want numerical statements on a large scale. At the close of the year 1813 there were 162 male epileptics in the Bicetre; 289 female cases in the Salpetriere. Jos. Frank observed that, of 75 patients, 40 were females. LECTURE XXXVI. Epilepsy, continued. Recapitulation. Exciting causes. Simulated Epilepsy. Diagnosis. Prognosis. Treatment: during the fit ; during the intervals; during the warnings. At our last meeting I began to speak of epilepsy. Let me rapidly retrace the ground we then passed over. An epileptic seizure may be very severe; or very slight. The very severe attacks are characterized by a sudden cry, immediate loss of consciousness, general and violent convulsions, and subsequent coma or heavy sleep. The very slight attacks consist in a momentary abeyance of the mental faculties, sometimes with and some- times without slight and partial convulsion. These extreme forms of epilepsy we judge to differ only in degree, inasmuch as they both attack the same persons at dif- ferent times; or the one form conducts to the other. Between these the gradations are innumerable. We call the extremes the epileptic fit, and the epileptic vertigo ; the French name them the grand mal and the petit mal. These fits may last from a few seconds to half an hour. Paroxysms apparently longer than this commonly consist of a succession of fits. The average duration is from five to ten minutes. The fits recur at variable intervals; which are sometimes periodic, mostly irregular. There may be many in a single day; there may be only one for many years. They are commonly more severe in proportion as they are less frequent. The epileptic seizures sometimes begin in early infancy : another period at which they often commence is about the age of seven or eight: another about fourteen or sixteen, or for some few years after that age. They more frequently begin before than after it. Sometimes the first fit takes place in the middle period of puberty 418 EPILEPSY. [lect. XXXVI, life: sometimes even in declining age. They often occur in the night, especially in the outset and towards the close of the disease; usually when the patient is between asleep and awake; i. e., at the commencement or at the termination of his slumber. In the majority, perhaps, of cases, the fit is unexpected, and preceded by no warn- ing. But in other instances there is some alteration perceptible by the patient him- self, or by his friends, giving notice of its approach; some change in the temper, feelings, appearance; some disturbance of the senses; ocular spectra; or what is called the epileptic aura, a creeping sensation arising in some part of the surface, generally of the extremities, and gliding towards the head. Some of these warnings precede the paroxysm by a day or two, or by a few hours; some by two or three seconds only. Sometimes the blow is threatened by their appearance, but it does not fall. The fit is almost always, in its severer forms, attended and followed by coma; sometimes, after the coma, by temporary confusion of mind; deafness; slight para- lysis ; delirium; inarticulate speech. There is seldom any appreciable permanent damage effected by a single fit. A repetition of the fits leads, in a large majority of instances, first, to a defect of the memory, and of the general intelligence; and at length to a peculiar expression of countenance, to decided imbecility of mind, t# complete fatuity; and with this there is often associated some paralysis or muscular debility. The convulsions take place, necessarily, through the medium of the spinal cord and nerves—just as voluntary movements do; but the suspension of sensation, thought, and volition (which suspension is seldom absent, while the irregular mus- cular action often is wanting) shows that the brain is essentially involved in the disease. Accidental organic lesions are sometimes (and sometimes only) found in the encephalon, or in the spinal cord, of persons who have suffered epilepsy uncomplicated with any permanent mental or paralytic affection; tubercles, for example, or bony growths from the interior of the skull; but as these are constant, while the paroxysms are occasional, and as in the intervals they give no signal of their presence, we can only regard them as being probably predisposing causes of the seizures. When the epilepsy has been complicated with permanent alienation of mind, or with some degree of paralysis, evidence of chronic inflammation of the brain and ita membranes is generally discovered. This has been the consequence of the repetition of the paroxysms. This explains the frequent connexion of fatuity and palsy with epilepsy of long standing. The diseased condition which excites the paroxysms maybe situated in the nervous centres themselves, or in some other part of the body. In the one case we call the disorder centric, or idiopathic; in the other, eccentric, or sympathetic. We cannot always be sure with which species of the disease, the centric, or the eccentric, we have to deal; but the distinction, when it can be made, is of considerable importance, in respect to the prognosis, and in respect to the management of the case. The predisposition to this fearful complaint is often hereditary. Malformation, or defect of symmetry in the two sides of the head, is a frequent predisposing cause. So, pre-eminently, is the scrofulous diathesis. And these two, viz., the scrofulous diathesis, and a peculiar conformation of the head, are both liable and likely to be propagated from parents to children. But the predisposition is found to be hereditary even when the shape and structure of the body is, to all appearance, quite perfect and natural; and when no outward indication of the strumous diathesis is perceptible. At the very close of the lecture I informed you that it is an unsettled question — and it is not a question of very great importance — whether the disease be more common in females or in males : whether the sex have anything to do with the pre- disposition. Taking epileptic people as a class, you will find them to be generally characterized by weakness and irritability of mind and body, and not by steadfastness and vigour; by a lack rather than an excess of vitality. They are much more commonly pale than florid, anaemic than plethoric, feeble than robust, melancholic than sanguine, timid than bold. And these indications of defective vitality become still more manifest in those who have been long or frequently subject to the disorder. The inherent debility of the system augments as the paroxysms multiply in number. LECT. xxxvi.] EPILEPSY. 419 There are certain vices, which are justly considered as influential in aggravating, and even in creating, a disposition to epilepsy: debauchery of all kinds; the habitual indulgence in intoxicating liquors; and, above all, the most powerful predisposing cause of any, not congenital, is masturbation — a vice which it is painful and difficult even to allude to in this manner, and still more difficult to make the subject of inquiry with a patient. But there is too much reason to be certain that many cases of epilepsy owe their origin to this wretched and degrading habit: and more than one or two patients have voluntarily confessed to me their conviction that they had thus brought upon themselves the epileptic paroxysms for which they sought my advice. Among the exciting causes of epilepsy, fright is conspicuous. And any strong mental emotion is apt to produce the fit, in a person who is already subject to the disease. This fact alone would be enough, I conceive, to forbid our ascribing the paroxysms exclusively to an affection of the spinal cord. Bodily pain; manifest and great disturbance of almost any of the principal functions of the body; may act also as exciting causes. Sometimes the cause is obvious, sometimes it is quite inscrutable. If the attack occur every night, Dr. Bright thinks it may be attributed to the " con- gestion" of sleep: if it take place at monthly intervals in women, we may " often trace it to nervous irritation in sympathy with the uterus: and when long periods have intervened we may usually trace each distant paroxysm to the repetition of some excess, or to a neglected state of the bowels." In these latter cases, the epilepsy is of the sympathetic, or eccentric kind; the irritation being seated in some part at a distance from the nervous masses, in the stomach, or intestines, or uterus. Now I would suggest the expediency of observing what muscles or sets of muscles are first affected by the spasm in such cases, and in what part the warning aura (if there be any) arises: because by accurately noting these particulars, we may, perhaps, be led to a knowledge of the part or organ in which the irritation operates : and if we know the seat of the irritation, we shall be more likely to know its nature, and its cure. [M. Lamonthe relates, in the Journ. de Me'd. de Bourdeaux, a case in which the epilepsy was caused by a foreign body in the ear, and ceased upon its removal. The patient was a man thirty years of age, in whose external meatus a pebble had been accidentally introduced. He at first experienced only a slight diminution of hearing, afterwards suppuration occurred, and finally epileptic attacks supervened; from which he had suffered for two years before he consulted M. Lamonthe. This gentleman, being informed of the probable existence of a foreign body in the ear, made an examination, and detecting it, by proper means, succeeded in removing from the meatus a rough pebble of nearly a triangular shape, and from that period the patient had no more attacks of epilepsy. In the same Journal, another case of the same kind is related by M. Roussilhe. —C-] Among the exciting causes of epileptic fits are also enumerated — and I believe, from what I have myself noticed, with great justness — the repulsion of eruptions, and especially of eruptions about the head, when proper artificial evacuations are not at the same time obtained; the cessation of habitual discharges; and, on the other hand, profuse and unusual discharges. Haemorrhage certainly does often bring on convulsions and a state of insensibility, exactly like certain forms of epilepsy. Persons who are bled till they actually faint, are sometimes, while fainting, convulsed also. And animals that are killed by loss of blood, are always affected with convulsions before they expire. There is yet another very singular occasional cause of epilepsy that deserves to be mentioned, viz., the sight of a person in a fit of that disease. This has been noticed over and over again. Not only will a patient who has already suffered such attacks often fall into one upon seeing another so affected; but people will even sometimes do so who have never before shown any symptom of epilepsy. In this way the disease will now and then run through a boarding-school; or through a ward in a hospital. There is a very good example of this recorded in the 11th volume of the Medical Gazette, by Dr. Hardy, of Bath. A strong healthy young man was hired to take care of an older patient, who suffered frequent and exceedingly violent paroxysms of epilepsy. He remained with the patient night and day; and at the end of seven weeks became himself epileptic in a very high degree. An acquaintance of his, of 420 EPILEPSY. [lect. xxxvi. equally robust make, but some years older, occasionally visited the two. In a fort- night from his first visit he also was seized with similarly violent attacks. Dr. Hardy quotes the following short case also from Baglivi: — "Vidimus, anno 1690, in Dal- matic juvenem gravissimis correptum convulsionibus, propterea quod inspexerat solummodo alium juvenem dum epilepsia humi contorquebatur." [M. Meyer has recently given an account of a number of the pupils in a female school that were attacked with epilepsy, in consequence of seeing one of their number under the influence of the disease. Most of the subjects were approaching the period of puberty; whilst they were all of a highly excitable temperament---C.] Dr. Cullen, who, as well as many others, had noticed the same thing, starts the question whether this mode of propagation of the disease be imputable to dread and horror; or to the mere force of imitation, which is often so strong, in health as well as in disease: and he decides in favour of the force of imitation. In fact, there are many other sights equally horrifying with that of a person in convulsions; yet there is no spectacle of horror so efficacious in producing a fit of epilepsy in others, as that of a person suffering under epilepsy. This principle of imitation holds good in many of the spasmodic diseases: and in some of them, especially in hysteria, its influence is more remarkably seen than in epilepsy: I shall therefore have to recur to it again. There is one very curious fact, however, which relates to epilepsy in particular. You are aware that this disease is often feigned by impostors. Now I believe it is ascertained, beyond the possibility of doubt, that fits and actions which were at first, in these pretenders, strictly volun- tary, have at length become involuntary and uncontrollable, and have passed into paroxysms of real epilepsy. The rogue is caught in his own trap. [The following statistics are presented by M. Leuret, in an interesting paper on Epilepsy in the Archives GSndrales for May, 1843. Among 106 epileptics, in 24, or nearly one-fourth, the disease commenced between the tenth and fourteenth years of their age; in 18, or nearly one-sixth, between the fifteenth and nineteenth years, and in 16, between the fourteenth and twenty-fourth years. Thus 58 patients, or more than one-half, were first attacked between their fourteenth and twenty-fourth years. Of the whole number of cases, in six only was it ascertained that the disease existed in one or other parent, and in but eight was it found that one of the parents had died of any disease of the brain, namely, three of insanity, two of apoplexy, one of paralysis, one of suicide, and one of meningo-cephalitis. Of the 106 patients, thirty had been drunkards, twenty-four masturbaters, and fifteen addicted to women. In fifteen cases, the actual or presumed cause of the first attack of epilepsy was ascribed to terror; in twelve to onanism; in six to drunkenness; in two to anger; in two to distress; in two to falls; in one to libertinage, &c. Thirty of the patients had an attack very regularly once a fortnight: 17 suffered attacks once a month; 13 once a week; 9 every three or four days: 4 almost every day; 2 every day; 1 every two months; 3 every three months; and 24 at very irregular intervals. In 35, the attacks took place in the night especially; in 29, they were as frequent in the day as in the night; in 12, they frequently occurred in the day; in 8, they occurred during the day only; in 8, during the night only; in 3, in the morning only; in 3 others generally in the morning; and in 4, in the evening only___C.] And the mention of these impostors leads me to consider the diagnosis of epilepsy. First, how are we to distinguish the feigned disease from the true ? Secondly, are there any other real diseases which may be mistaken for epilepsy, or for which epilepsy may be mistaken ? In the number of feigned diseases epilepsy is one of the most common. Soldiers and sailors pretend to have epileptic fits, in the hope of obtaining their discharge from the service. Cases of simulated epilepsy occur also continually in our streets among mendicants and impostors, who think to excite the compassion and pecuniary charity of the credulous; and are even sometimes actuated, I believe, by a desire to obtain admission into hospitals, where they live tolerably well, and quite idly. It is easy enough, they think, to throw their less and arms about, and to grin; and many of LECT. XXXVI.] EPILEPSY. 421 them get up a capital show of foaming at the mouth, by placing a bit of soap between the gums and cheek. The means of detecting these vagabonds are of some import- ance to us all; and it is more particularly necessary that they should be well known to those who are likely to join the medical department of our fleets or armies. It is of course desirable, in questionable cases, to witness a fit. But pretenders are not very willing to perform when they know that a medical man is looking on. You may sometimes convict them, in the absence of the fits, by cross-examination. A cheat will seldom be consistent in the account which he gives of his fits; as to whether they are regular or irregular; and as to the times and places in which he has suffered them. An impostor chooses such situations for his exhibition as are most suitable to his own purposes; a crowded street, or a well-frequented public walk. True epileptics almost always select retired places to take exercise in; especially if they have any warning or expectation of the approach of a paroxysm. You will find also that the impostor is not attacked at his own home; but always fixes upon some spot in which he is not only sure to be seen by others, but in which he is not likely to sustain any injury by tumbling down. True epileptics are often seriously hurt by their falls; feigned ones generally come off without much bodily damage. However, when the fits are alleged to be frequent, and when also they occur regularly, you may soon expect one, and must make a point of being present; and then you will seldom fail to remove or to verify your suspicions. In the first place, the muscular power of epileptics is far beyond what is natural. It will sometimes take four or five stout men to hold a weak emaciated lad, in a fit of epilepsy. Of course no impostor can command more than his natural strength. In the second place, a real epileptic fit, if it last long, is seldom violent; whereas impostors, for obvious reasons, make their fits both long and violent. You may often get much information from the state of the eyes, which usually in true epilepsy are partly open, with the eye-ball visibly rolling and distorted. In feigned epilepsy the actor almost always prefers to shut his eyes completely. Sometimes, if he be closely watched, and no suspicion be ex- pressed, he will be seen to open his eyes occasionally, to ascertain the effect of his exhibition upon the bystanders. In real epilepsy, too, the pupils are often con- siderably dilated, and do not contract when stimulated by light. This is a very sure criterion; for no impostor can prevent his iris from acting on exposure to vivid light. The pulse, in true epilepsy, is not only frequent, but often irregular also; a circumstance which never can be imitated. The skin of an epileptic, during the fit, is commonly cold; but that of an exhibitor is hot, and covered with sweat, obviously the consequence of his violent and voluntary exertions. In this respect, also, it is scarcely possible for him to deceive us. Again, an impostor will not bite his tongue, as epileptics often do; nor very willingly void (like them) his excrements and urine during the fit; indeed, it would not be very easy for him to do so, and at the same time to carry on the necessary pretence of convulsions. Besides, epileptics, during a fit, are quite insensible to external impressions; and hence the vulgar modes of detection, though harsh and not to be recommended, are often effectual ones; such as dropping melted sealing-wax upon the patient; putting some gin into his eye; burning him with a hot poker; or (what I believe is more fashionable among beadles and police constables, when they have to administer to such patients) the pressing your thumb-nail violently under that of the supposed impostor. This causes exquisite pain, yet inflicts no lasting or serious injury; and I believe that few pretenders stand out against this expedient. It is astonishing, how- ever, how much torture some of them will bear before they can be brought to confess their imposition. If we speak of having recourse to some of these painful tests in the hearing of the pretender, we shall find that the fit will soon come to an end. Dr. Cheyne mentions an instance in which one table was placed upon another, and a soldier, who was supposed to be shamming, was laid upon the upper one, while his paroxysm was on him; and the fear of falling from such a height soon stopped the convulsions. Mr. Hutchinson relates the case of a sailor who was suspected to be a cheat, in whom the convulsions were instantly removed by blowing some fine Scotch snuff up his nostrils through a quill. This brought on another kind of fit, viz., a fit of sneezing, which lasted nearly half an hour; and there was no return of the epilepsy so long as Mr. Hutchinson remained in that ship. He tried the same expedient in cases of real epilepsy, but never could produce any similar effects, although the 422 EPILEPSY. [lect. XXXVI. patients were not snuff-takers. There was a beggar in Paris, who often fell into epileptic fits in the streets; one day some compassionate spectators, fearing that he might injure himself in his struggles, got a truss of straw and placed him upon it: but when he was in the height of his paroxysm, and performing remarkably well they set fire to the straw; and he presently took to his heels. There is another ingenious plan, very likely, I should think, to detect an impostor and yet not calculated, like the one last mentioned, to injure a real sufferer; which is to propose gravely, in his hearing, to pour boiling water upon his legs, and then to proceed actually to pour cold water upon them. Of the real diseases which are apt to be confounded with epilepsy, hysteria is the chief. The question whether a given case be one of epilepsy, or of hysteria, very often arises. By a careful attention to several circumstances, the discrimination is generally to be made. In the first place, the total suspension of consciousness, which is so constant an accompaniment of the epileptic paroxysm, does not take place in the hysterical. In epilepsy there is no globus hystericus, no alternations of laughter and tears. The solitary cry which ushers in the epileptic attack so frequently, and which is so characteristic, is not heard in hysteria. Not that hysterical girls do not scream, for they often do; but then it is repeatedly and continuously. The heavy comatose sleep that succeeds epilepsy is not common in hysteria. Hysterical patients contrive also to avoid hurting themselves by their contortions: they do not bite their tongues nor foam at the mouth. Dr. M. Hall teaches that, in epilepsy, there is a forcible closure of the larynx, and expiratory efforts which suffuse the countenance, and pro- bably congest the brain, with venous blood. In hysteria the respiration, on the contrary, is rapid and sobbing. It is interesting to remark how early and how strongly the muscles that lie about the throat are implicated, in each of the three terrible spasmodic disorders which we have been contemplating. Tetanus begins with cramp in the muscles of the back part of the neck, and of the lower jaw. The pharyngeal muscles, as well as those subservient to respiration, are intimately concerned in the paroxysms of hydrophobia. In epilepsy it is Dr. Hall's belief that the platysma myoides plays an important part, preceding often, in spasmodic contraction, the muscles that shut up the larynx, com- pressing the jugular and other veins of the neck, and so producing congestion of the parts within the cranium. In all three the stress of the malady is first visible in muscles which obey the influence of the medulla oblongata, or of the upper portion of the spinal cord. Observe that I have been speaking, all along, of what has been sometimes called habitual epilepsy. It is not every attack of convulsions with insensibility which ought to be so named. Such attacks are apt to follow sudden injuries done to the brain; stunning blows on the head, fractures of the skull, the eruption of blood in sanguineous apoplexy, and even overwhelming emotions of the mind. The retention of urea in the unpurified blood, occurring in connexion with a peculiar renal disease which I have frequently alluded to already, and which I shall hereafter describe, appears to be a frequent cause of similar seizures. They happen also in parturient women, in persons poisoned with lead, in hydrocephalic patients, in persons affected with hypertrophy of the brain, and in the outburst of some of the eruptive fevers. With these casual occurrences of epileptiform convulsion I do not here meddle. Epilepsy is one of those complaints concerning the probable issue of which the patient, and still more the patient's friends, are sure to make repeated and anxious inquiries. It is seldom that we can pronounce with any confidence a favourable prognosis; but there are some cases in which the prospect is much worse than in others. If we have reason to believe that the disease is centric, and connected with any organic derangement of the nervous centres themselves, the prognosis must be bad. Caeteris paribus, it is rendered worse by the coexistence of any sign of scrofulous dis- ease, or of the well-known bodily characteristics of the scrofulous diathesis : it is ren- dered worse, also, when the disease has happened in the parents, or among the more immediate ancestors, of the patient; whenever, in short, there is reason to think the disposition to it is inherited. The prognosis is bad when the complaint occurs in per- sons who have slanting foreheads and misshapen skulls; and when the epileptic phy- siognomy has become established. The prognosis is always the more unfavourable LECT. XXXVI.] EPILEPSY. 423 the longer the disorder has lasted; the oftener the fits have been repeated; and the more habitual they have become. And when the memory is permanently enfeebled, or fatuity has come on, or the disease is complicated with any form or degree of paralysis, the case is hopeless; so far, at least, as a perfect cure is concerned. On the other hand, the prognosis is better when the disease is eccentric: i. e., when there is any obvious exciting cause of the paroxysms, manifest in structural or func- tional disorder of some part of the body other than the nervous matter. And when this eccentric cause is removeable—a stone in the bladder, for instance, worms in the intestines — then the prognosis still further improves. On this account the prognosis is better in children than in older persons, for the exciting cause is often clearly eccentric, and likely to be transitory; the irritation of teething for example; and be- sides this, it is stated by many practical writers that even repeated and habitual attacks of epilepsy in children often go off as the patients grow older, and especially at the age of puberty. The experience of Heberden, however, was against this. He says that he had known several persons become epileptic at that time; but that he had never met with one who had then got rid of the disease. He had seen a few who had recovered before, and soon after, the age of puberty. Dr. Elliotson mentions a case in which a girl had epilepsy prior to the first period of menstruation : then the fits stopped; and she remained free from them until in advanced life the catamenia ceased to recur; and then the epilepsy returned. In all those cases in which we can assign some evident cause for the fit — such as the use of improper food, uterine irri- tation, mental emotion, and so on — the prognosis is somewhat better than usual. [In the predisposed, one of the most frequent causes by which the paroxysm is brought on, is errors in diet, either in regard to the quality or quantity of the food taken. We have known cases in which the patients remained free from an attack so long as they abstained from a particular article of food, but invariably experienced one on partaking of it. —C] " The eccentric epilepsy (says Dr. Hall) is to be viewed as curable, however diffi- cult of cure." And however unfavourable the prognosis may be, there is nothing that can excuse any apathy or neglect on the part of the practitioner. Though few cases of habitual epilepsy admit of a cure under any treatment, yet there are few which may not be relieved by treatment, so far as regards the frequency or the violence of the fits, or both. The treatment of epilepsy resolves itself into the measures to be adopted during the fit; and the measures to be adopted during the intervals between the fits. In the paroxysm itself we have to provide against the risk of injury from the strug- gles and contortions of the patient; and, if possible, to mitigate the violence, and to shorten the duration of the fit. The patient should be placed in the centre of a large bed; his neckcloth, and any ligatures about his person, should be loosened; his head should be somewhat elevated. When the risk of his hurting himself cannot be avoided in any other way, his limbs should be restrained by the bystanders, or secured in a waistcoat. Some persons have advised that a piece of cork or soft wood should be placed between his teeth, to prevent him from biting his tongue, or breaking his teeth. But it is not easy to manage this expedient cleverly. If the head be visibly congested and hot, cold wet cloths may be applied to it with propriety; and if, at the same time, the extremities be cold, means of restoring warmth to them should be adopted. I do not know whether art can abbreviate the paroxysm. Some years ago the late Barry O'Meara sent a letter to one of the newspapers, saying that he fancied he had seen a popular remedy useful in such cases; that, namely, of cramming salt into the patient's mouth : he thought he had succeeded in bringing the patient about by that expedient. In the epileptic patients that come into hospitals, the physician, not being always on the spot, does not see all, nor even many of the paroxysms; but after read- ing that letter, I desired the nurses to treat all my patients who might be seized with epilepsy in the wards upon that plan : and on comparing the length of the paroxysms when the salt was used, with their ordinary duration as reported by the friends of the patient, or as previously observed in the hospital during some of the earlier fits, it certainly did seem to curtail the convulsions. Probably it is more calculated to relieve 424 EPILEPSY. [LECT. XXXVI. a hysterical than an epileptic fit. In the epileptic fits of children much benefit often results from immersing them in warm water: particularly if there be any coldness of the extremities. It is very much the fashion to bleed persons who are seen in a fit, of whatever kind; and to bleed them largely. I have already given you my opinion respecting the indiscriminate use of this strenuous measure in apoplectic attacks. If it be clear, from the phenomena, or from the known history of the patient, that the case is one of epilepsy, bleeding, during the fit, will seldom be necessary or proper; unless, in- deed, the evidence of cerebral plethora is very strongly marked: and even then I would advise you not to do more than take a moderate quantity of blood, by cupping, from the neck or temples. The convulsions and the sopor may be expected soon to pass off; as soon, probably, and as completely, without, as with, any abstraction of blood. Whereas the difference of the alternative is not trifling, in respect to the condition in which the patient may be left when the fit is over. The injurious effect of excessive blood-letting upon the system at large, is manifest, sometimes, for months afterwards. During the intervals between the attacks we seek to prevent their recurrence; and this end is to be attained, when it is attainable at all, by getting rid of the predispo- sition to the disease on the one hand, and by protecting the patient against its exciting causes on the other. Now there are certain kinds and causes of predispo- sition which we cannot get rid of; such are the tendency that is inherited; the strumous diathesis; malformation of the head; the presence of some organic lesion in the brain or spinal cord. Vicious and dissolute habits are also difficult, but not impossible, to eradicate. It will be our duty when such are discovered, to set strongly before the unhappy patient the dreadful end towards which he is hastening; the certain loss of reason to which, when once the disease has shown itself, the continu- ance of his baneful indulgences will drive him; and to urge upon him the necessity for a short and sudden turn on his part, if he would expect any aid from medicine. Where no physical cause of the proclivity exists, or can be detected, it is of much importance to ascertain whether there be any deviation from the standard condition of health; towards general plethora in the one direction, or towards emptiness and asthenia in the other. The first of these unnatural states may be redressed by regi- men and exercise; by abstinence from stimulating food and drink; by a slender diet also; and, if need be, by direct depletion. The second, which is the most common of the two, and which often leads (as I have explained before) to local plethora, may be removed or lessened by a tonic treatment. The object in both cases is to give stability and firmness to the nervous system; to diminish that mobility, or readiness to be impressed, which is so strong a characteristic of the class of patients affected with epilepsy, although it may not be very apparent in some few individuals among them. It is upon this principle, that mineral tonics sometimes do good in epilepsy, and not by any specific virtue which they possess in restraining the fits. It is owing, perhaps, to a neglect of these two somewhat opposite conditions of general plethora and general debility, or to the difficulty which sometimes is met with in distinguishing them, that such a variety of opinions have been expressed con- cerning the proper treatment of habitual epilepsy. Plethora is to be reduced without causing hurtful debility : tone is to be given without inducing dangerous fulness. It requires some nicety to carry the balance even; to attain the hoped-for good, and at the same time to avoid the evil that is apt to wait upon it. In very many cases the requisite extent and measure of the tonic plan on the one hand, or of the lowering system on the other, can only be learned by careful trials. But sometimes the indi- cations of treatment are more plain. When the patient is young and strong, and full of blood, and not of a particularly moveable temperament; when he has a hard pulse, and any degree of feverishness; when the disorder has supervened upon the suspen- sion of some customary discharge, so that there is an obvious cause of plethora; and when the disease is in its early stage, and the recurrence of the fits has not yet been established by habit: in any or all of these circumstances it may often be proper to abstract blood from the patient, and it will always be right to purge him actively, and to insist upon an abstinent regimen. When former paroxysms have been preceded by signs of fulness of the vessels of the head — by headache for instance, throbbing of the temporal arteries, distension of the superficial veins, a flushed or loaded coun- LECT. XXXVI.] EPILEPSY. 425 tenance — you may sometimes, by a timely use of the lancet or the cupping-oiass avert an attack that was apparently impending. On the other hand, if the patient be pale and weak; or unduly susceptible; or if his malady have been fastened upon him through many repetitions of the fit; you will generally find that any form of active depletion is injurious, and learn to place your best hope in measures which are calculated to invigorate the frame. One of the most useful of the particular remedies employed for strengthening the body, is the cold shower-bath. This tends, more perhaps than any single measure, to give permanent firmness and steadiness to the system. The best test, in all cases, of the tonic and bracing effect of this remedy, is the occurrence of a pleasant and general glow after each application of it. It is the only safe mode in which the cold bath can be used by an epileptic person. You will find, in books, a great many tonic medicines recommended for this disease, which medicines you will have opportunity and ample time for trying. Of the mineral tonics, the salts of silver, zinc, copper, and iron, have been chiefly praised. The nitrate of silver used to be highly thought of; but there is one very serious objec- tion to it which must never be forgotten : viz. that it is apt to produce a permanent discolouration of the skin, a frightful lead-colour. There is a footman in a house near Cavendish Square who has been thus blackened : and there is a gentleman of property resident at Brighton, in the same predicament; his face looks as if it had been tho- roughly and carefully pencilled over with plumbago. A barrister, a friend of my own, had a narrow escape from a similar misfortune: in fact, his skin has acquired a just perceptible tinge of gray. Now, if the remedy were sure to cure the disease, I am not certain that every one would accept of a cure on such terms. It would be proper, even on that supposition, to tell the patient that though he (or, a fortiori, she) would get rid of the epilepsy, there was a likelihood that this unamiable complexion might ensue. But the truth is, that, in giving this nitrate of silver, we run a great risk of obtaining its disfiguring effect, for the sake of a very small chance of curing the epilepsy. I have been assured, hy one of his friends, that the Brighton gentle- man has carried a dark outside for a quarter of a century at least; and that he is as subject to epileptic fits now as ever he was. To do good, the lunar caustic must be given for some time together, and the probability is that it will not do good even then : and if it be given for some time together, there is great danger of its changing the colour of the skin. For these reasons I never give it myself, and therefore I cannot recommend it to you. If you wish to try it, or if you have a patient who insists on trying it, as some will, you may begin with half a grain in a pill three times a day; and the dose has sometimes been carried as high as fifteen grains. And it is worth observing that, in the larger doses, this drug proves purgative. It is possible that its good effect, when it has any, may be attributable to its operation in that way. There is no danger of spoiling the beauty of your patient by administering the oxide or the sulphate of zinc, or the cuprum ammoniatum. The liquor arsenicalis has been thought useful, but it requires to be exhibited with great caution. Of all the metallic remedies, I prefer some preparation of zinc, or of iron. They appear to do good by giving what is called tone to the nervous system, and rendering it less prone to be affected by the slighter exciting causes of the disease. The salts of iron probably do this by improving the condition of the blood. I cannot pretend to weigh the merits of the long list of substances which have been lauded as efficacious in keeping off and curing the disease; and which, when they have been useful at all, have operated, I conclude, in diminishing the disposition to epilepsy, by corroborating the nervous system. The most renowned of them are valerian, assafcctida, wormwood, the mistletoe of the oak, the cardamine pratensis, rue, the cotyledon umbilicus, the sedum acre, indigo; narcotic vegetable preparations, stramonium, belladonna, hemlock, lettuce; animal substances, musk, castor, ox-gall; and the number might be many times multiplied. This long array of drugs, all of which have been known, or sup- posed, to accomplish a cure, affords, in truth, one of the strongest evidences of the intractability of the disease under any plan of treatment. There is a shrewd remark of Esquirol's, which I believe to be quite true, however difficult it may be to account for the fact, and which is, that epileptics are apt to improve for a time under every new plan of treatment. Whatever drug you may see reason to select (and the patients will have drugs, and 426 EPILEPSY. [LECT. XXXVI. you must be prepared to ring the changes upon them), there are certain other points in the management of the disease which are of essential importance. The patient who is subject to epilepsy should live by rule, and be temperate in all things.^ His diet should be simple, nutritious, but not stimulating. Except under special circum- stances, he should renounce all strong liquor, and become, in the new-fangled and vulgar phrase, a tee-totaller. He should rise early, and take regular exercise in the open air; keeping his head cool, and his extremities warm. He should avoid all mental excitement, and the fatiguing pursuit of what is called pleasure; all probable sources of sudden anger, surprise, alarm, or deep emotion of any kind; all striving and contention of the intellect. The student, of whatever age and sort, in whom epi- lepsy has declared itself, should shut his books; the man of business, abandon or abridge his professional toil: at least they must be instructed to abstain habitually, in their respective callings, from such application as would task and strain their powers, whether mental or bodily; and endeavours should be made to engage their thoughts, and to interest their minds in less engrossing objects of attention. No minute rules can be laid down on these points, but, keeping the general indication in view, it will seldom be difficult to follow it up in practice. When the fits appear to have been brought on by a species of moral contagion, or by imitation of the same disease seen in others, care should be taken to exclude as much as possible those objects or trains of thought which produce the mental emotion or the morbid propensity. In these cases, and, indeed, I may say in almost all cases, it is more rational to expect benefit from such measures as tend to calm the mind and fortify the nerves, than from this or that substance thrown at random into the stomach. There is ground for believing that epileptic fits sometimes depend upon a syphilitic affection of the bones of the skull; I am much mistaken if I have not seen such cases. When that suspicion arises, it may be proper to give mercury a full and fair trial. Such a plan has been followed by success. I should always premise, however, in such cases, the iodide of potassium; the specific efficacy of which in dispersing syphilitic nodes is unquestionable. I am accustomed to recommend a gentle and long-continued course of mercury whenever organic disease of the brain is suspected; the influence of that remedy being carefully watched. It will be right and proper also to try the effect of counter-irritation; of blisters, a seton in the neck, or the croton-oil liniment. But I must confess to you that, often as this expedient is em- ployed, I have seldom witnessed any such result from it as would encourage me to expect benefit from repeating it in another case. There is one form of counter-irri- tation which I have never seen put to the test, but which has of late been strongly recommended by a very able and observing physician, Dr. Pritchard; and of which I have heard very good accounts from a gentleman who had seen it extensively employed in Bristol; I mean the making a long issue in the head itself, dividing the integu- ments down to the bone by means of a scalpel in the direction of the sagittal suture, and keeping the incision open and discharging for some time, by means of issue peas. The formation of the issue is said to be not so painful as one might suppose. Dr. Quain, in his edition of Martinet's Pathology, relates the following case: •— " Some years ago I saw a boy who was epileptic from infancy, and who, in one of his usual fits, fell over a cliff by the sea side, and received a very severe lacerated wound of the scalp, which healed slowly and with a copious suppuration. While the dis- charge continued he was free from any epileptic attack; but as soon as the wound healed, the fits returned as before." Twice I have seen similar good effects from the insertion of a seton in the neck. Twenty times that measure has disappointed my hopes. When the disease is ascertained or believed to be of the eccentric kind, we must search diligently to find the seat of the distant irritation, in some disturbance of func- tion ; and apply our remedies accordingly. The irritation may be found, as I have already intimated, in almost any organ of the body. Painful or irregular dentition is perhaps one of the commonest of the eccentric sources of epilepsy. Sometimes the attacks are attended with symptoms of disease in the liver; slight yellowness of the skin, uneasiness and tenderness in the right hypochondrium, and lowness of spirits. In such a case we must rectify that state of the liver, by such means as 1 shall have to specify hereafter. If the disorder depend on a stono in the bladder, the LECT. XXXVI.] EPILEPSY. 427 cure must be committed to the surgeon. I long had a patient under my occasional inspection, who from time to time suffered slight fits of epilepsy; on most occasions he passed about the same time a small calculus by the urethra. I make no doubt that in his case the exciting cause of the epilepsy lay in the kidney. You will find that most persons, in respect to such diseases as that which we are now considering, have some favourite or usual mode of treatment; and if I were called upon to name any single drug, from which, in ordinary cases of epilepsy, I should most hope for relief, I should say it was the oil of turpentine. And I find that other physicians have come to the same conclusion. Dr. Latham the elder was, I believe, the first person who made known its efficacy in this disorder. Foville states that he has seen excellent effects from it. It is highly spoken of by Dr. Per- cival, in the Dublin Hospital Reports. It is not to be given in large doses, but in smaller ones, frequently repeated; from half a drachm to a drachm every six hours. You are aware that it sometimes produces strangury, and therefore the patient must be forewarned of this, or carefully watched. Occasionally turpentine has done good in virtue of its anthelmintic properties. I know that a physician of my acquaintance cured a case of epilepsy in this way, somewhat to his own surprise. Without having in his mind any notion of worms, he thought it might be well to purge his patient, who had laboured under epilepsy for some time, with the oleum terebinthinae. The patient, who is the brother of a person holding at present a high office in this country, was residing two or three miles out of town. In the middle of the night the doctor was summoned to him in a great hurry; the messenger said he was supposed to be dying. He was only intoxicated, however, by the free dose of turpentine he had swallowed: the next morning he voided into the close-stool a large tape-worm; and he has never had epilepsy since. A nobleman residing in Cambridgeshire was long epileptic; and he too got rid of his epilepsy and of a worm at the same time. I believe that the cure was effected by turpentine in his instance also; but I am not certain of that. Such cases are remarkably interesting: they show that irritation of the sto- mach or intestines may be sufficient to cause the fits; they illustrate excellently well the eccentric form of the disease; and they deserve to be always borne in mind when we are asked to prescribe for an epileptic patient. A cure from so dreadful a com- plaint, by such simple means — the cause of his malady, and the certainty of his having got rid of that cause, being both so obvious and intelligible to the patient — may be enough, sometimes, to make a practitioner's fortune. But I think you will sometimes find the oil of turpentine very useful, even though it expels no worm, and when there is no worm to expel. If the bowels should be costive, the oil of turpen- tine and castor oil, in equal proportions, go exceedingly well together. When the patient has a distinct warning of an approaching paroxysm, can anything be done to ward it off? Why, in some cases, by interrupting the precursory symp- toms, it certainly may be prevented. A pupil of the class informs me that a brother of his, twelve or thirteen years old, has been subject to epileptic fits for two years. They occur in the night, especially if he be waked, even though the awakening cause may have no tendency to startle him. He often is dull and drowsy the evening be- fore, and if his friends rouse him from this lethargic state by conversation or amuse- ments, the attack expected that night sometimes does not happen. Another student knows a young girl, in whom the occurrence of very high spirits is always precursory of the paroxysm. When this extreme vivacity is moderated by those about her, the threatened fit is sometimes averted. I mentioned before an instance in which the aura, proceeding from one of the thumbs, was frequently checked by tying a ligature tightly round the thumb. Other examples of exactly the same kind are on record. Mr. Wardrop cured a case beginning with an aura in one finger, by amputating a joint of the finger. Dr. M. Hall states that the immediate accession of the paroxysm' may sometimes be prevented by dashing cold water on the face, or by exciting the nostrils by snuff. In this manner the disposition to closure of the larynx, and to expiratory efforts is exchanged for sudden acts of inspiration. Another patient of my own, an old college friend indeed, who is afflicted with epilepsy, feels convinced that he some- times staves off a fit by applying smelling-salts to his nose : and he always carries a bottle about with him for that purpose; but unfortunately the warning (which con- sists chiefly in giddiness) is often so short, that he has not time to have recourse to his preventive before he falls down. It is a question whether the fit may not be ob- 428 CHOREA. [LECT. XXXVII. viated by a strong mental effort in some cases. I make no doubt that it may, espe- cially in the imitative form of the disease, which originates in, and depends upon, mental and moral causes. It is scarcely necessary that I should do more than advert generally to those pre- cautions which every one who is subject to epilepsy ought to observe, and which it is the business of his medical adviser to enforce, both upon the patient himself, and upon his friends. His bed should be large, and low; or if not large, it should be enclosed with some netting or other defence against his falling out of it. If he sleep in a room by himself, care should be taken that in the winter a proper temperature is kept up, for should he get out of bed in an attack, and remain upon the floor, he may be seriously injured by cold. He should not, however, be left alone if it can be helped. Guards should be placed over every fire-grate near which the patient may come. He should avoid ascending and descending stairs as much as he can. He should not ride on horseback; nor on the outside of a coach; nor even in a gig; nor go about, especially in solitary places, without an attendant. A patient of Dr. Cheyne's, a young man of twenty, was drowned in his own garden by falling forwards into a little runnel of water, which was not four inches deep. Neither, on the other hand, will it be proper or safe for him to frequent crowded or hot rooms; or the streets of a populous town, in which the multiplicity and distraction of objects are apt to produce, even in a healthy person who is not accustomed to them, a degree of vertigo and confusion. Dr. Cheyne advises that when the patient's circumstances will admit of his having a constant attendant with him, the latter should be provided with some diffusible stimulus : a potion, for example, composed of camphor mixture and aither, by the swallowing of which the impending paroxysm may sometimes be repelled. LECTURE XXXVII. Chorea. Symptoms; Pathology; Complications; Causes; Treatment. Chronic Chorea. Other nervous Disorders to which the same name has been applied. Another disease of a spasmodic kind, and essentially belonging to the nervous system, is Chorea — St. Vitus's dance. This, in its ordinary .form, is far less serious than the complaints which we have recently been considering ; but it is always a very unpleasant disorder to suffer, and occasionally it assumes a very frightful and even a fatal form. It has several points of analogy with the other nervous and spasmodic ailments. Its prominent symptom is an irregular and involuntary clonic contraction of some of the voluntary muscles, which, however, are not wholly or constantly with- drawn from the government of the will. In tetanus we had rigid spasm, while the mind was clear and free; volition was unaffected, but the muscles which should have obeyed the effort of the will, were seized upon and mastered by some stronger over- ruling power. In epilepsy, with convulsive spasm, there was suspension of the mental functions : a temporary interruption of consciousness, and therefore of volition. But in Chorea we have a different state from either of these. There is no loss of con- sciousness; no defect of volition. The ordinary movements of the body can be per- formed in some degree, or sometimes, under the direction of the will; but it would seem as if some other power, thwarting the will, wantonly interfered to excite them when they are not needed, to render their action unsteady and imperfect, to arrest the natural movement, and give a new direction to the limbs, and to cause the patient to gesticulate and grimace like a Merry-Andrew. Moreover, these apparently absurd motions do not occur in paroxysms, but continue throughout the day, sometimes for weeks together; but they generally cease during sleep: for the most part, but not always, the agitated limbs are still, while the senses are shut up in slumber. The complaint is not attended with fever. This disorder was first distinctly described by Sydenham, whose account of it is LECT. XXXVII.J CHOREA. 429 very graphic and excellent, and has been copied by most subsequent writers. With- out reference, however, to the portrait which he has left us, I will sketch the disease, as it has occurred under my own observation. It usually begins with slight twitches of a few muscles in the face, or in one of the upper extremities; and by degrees the spasmodic action becomes more decided and more general. All the voluntary muscles are liable to be affected by it. Those of the face seldom escape. The features are twisted into all sorts of ridiculous forms; you might suppose that the patient was what is called pulling a face, or making mouths at you: but there is neither mirth nor mockery in the contortion ; it is a little convulsion. It is succeeded by a vacant look, and then it begins afresh. The disease occurs much oftener in young girls than in any other persons. If you ask the patient to put out her tongue, she makes sundry attempts to do so before she can accomplish it; and then the tongue is suddenly thrust out, and as suddenly withdrawn, and the jaws snap together as if she were resolved that you should have as short a glimpse of it as possible. She writhes "and contorts her shoulders. She cannot keep her hand or arm for half a minute in the same position. Alternating movements are common. The hand is turned palm up- wards upon her lap, and presently reversed ; the fingers are extended, and again bent; the mouth and eyes are opened and closed without apparent purpose. When, at meals, she desires to carry her hand to her mouth, it is arrested midway, and suddenly pulled back again, or pushed off in some other direction; and it is only after many deviations and fruitless efforts that she succeeds. The lower extremities are apt to be similarly affected. When the patient intends to sit or stand still, her feet scrape and shuffle on the floor, or one of them is suddenly everted and then twisted inwards, or perhaps is thrown across the other; and if she endeavour to walk, her progress is most uncertain; she halts and drags her leg rather than lifts it up, and advances in a rushing or jumping manner by fits and starts. In short, the voluntary muscles are moved in that capricious and fantastic way in which we might fancy they would be moved if some invisible mischievous being, some Puck or Robin Goodfellow, were behind the patient, and prompted the discordant gestures. With all this the articu- lation is impeded: there is the same perverse interference with some of the muscles concerned in the utterance of the voice. By a strong figure of speech, the disorder has been called " insanity of the muscles." Such is a picture of the main symptoms of this strange malady, as they have pre- sented themselves to me; and such, I venture to say, you will often see in your future practice. You will find, moreover, that the jactitations are usually more marked and general on one side of the body than on the other: and sometimes they are confined to the muscles of one side. Here, therefore, we have a trait of resemblance to epi- lepsy and to hemiplegia. Again, the irregular movements always appear first, and are most decided in the upper extremities. Sometimes the lower limbs are not affected at all: they are never exclusively affected. Generally speaking, the disease is the more severe, and the more difficult of cure, in proportion to its extent, to the number of muscles implicated. I believe that in every fatal case hitherto recorded, the mus- cles of the whole body have been involved. [Two cases of Chorea are referred to by Romberg (Diseases of the Nervous System, vol. ii. p. 55), and they were the only ones he had ever met with, in which the mus- cles of the external and internal respiratory apparatus were involved. In one of these cases, a child eight years of age, the choreic movements of the right half of the body were associated with dyspnoea, whistling inspiration, and palpitation. In the second case, a boy of eight years, only the muscles of the extremities, the face, and the eyes, were at first attacked; subsequently, the choreic movements ceased in these parts, and the muscles of respiration became affected. — C] It is a curious fact, but one which I have often ascertained, that when one limb alone happens to be thus agitated, if that limb be laid hold of, and kept still by main force some other limb or part will take on the spasmodic action. The persons who are subject to chorea are always inordinately sensitive, and what is popularly called " nervous." They are easily stirred by new ideas and sudden feelings, and pass rea- dily, and upon slight occasions, from' one mood of mind to another. The mind is affected, as Dr. Cullen remarks, in the same way, and often shows the same varied, 430 CHOREA. [LECT. XXXVII. desultory, and causeless emotions, as in hysteria. You see the indication of this ner- vousness in the fact that the fidgetty catching of the muscles increases when the patient is spoken to, especially by a stranger — by the physician, for example. Tho nurses of the hospital constantly tell me that such or such a patient, who has chorea, is much more composed at other times than she is during my visits, when she is sur- rounded by students, and made the object of their attention. In most cases the jac- titations are partly and in some degree under the influence of the will. Sometimes the patient seems to give way to them, indulges in or exaggerates them: at other times she can, by making an effort, control them. Many of the patients, especially such as are old and intelligent enough to understand our directions, and to make the trial fairly, can suspend for some seconds the convulsive movements, by taking a deep inspiration, and resting upon it, without expiring, for a little while. Like other spas- modic diseases occurring in moveable constitutions, chorea is liable to be propagated also by a species of contagion, or rather of involuntary imitation. These diseases con- stantly approximate, and touch each other, in some of their characters. Chorea, in this its standard form, is essentially a disease of youth. Sydenham and Cullen, who closely follows him, state that for the most part it attacks boys and girls, who have not reached the time of puberty; between the tenth and fourteenth years of their age. These limits are, however, too narrow. It is very common between the eighth and sixteenth years; a period which corresponds pretty accurately with that included between the second dentition and puberty. The disorder sometimes comes on as early as four or five; and now and then it begins in adult life, or in old age: the instances, however, in which a first attack occurs before the age of eight, or after the age of twenty, are comparatively few in number. I have already intimated that chorea is much more frequent in girls than in boys. Dr. Hughes has published, in the Guy's Hospital Reports, two instructive digests of cases treated at that hospi- tal during a long series of years, and amounting in all to 309. Taking the aggregate of his lists, and of six others recorded by various observers, I find that among 1029 patients affected with this malady, 733 were females. This gives a proportion of nearly five to two. Yet, according to the tabular statements of Dr. Hughes and of others, the two sexes are equally liable to chorea before the age of nine. [In 429 cases referred to by Dufosse and Rufz, 130 occurred in boys, and 299 in girls. —C] If I may trust to my own experience, it is much more common in children having dark hair and eyes, than in those of a light complexion; and I think I have seen the same remark in some book, but I forget where. [According to Mr. W. H. Bell—(Diet, des Etudes Medicales) Dufosse' (ibid.), and Rufz (Archives Generates de Mid., iv. 239) — the subjects of chorea have chiefly light hair.—C.] Temperature appears to influence its development. Dr. Hughes found it to be more frequent in the six winter months (reckoning October as the first) than in the six summer months, in the ratio of three to two. This tallies with Romberg's re- mark, that the disease becomes rarer as we approach the equator, and is almost un- known in the tropics. When the disease is strongly marked, or lasts long, there is usually some imbecility of mind manifested; a slight degree of fatuity, and a foolish expression of the features. But this goes off with the other symptoms. The child generally recovers, but the malady is apt to recur, and that more than once. In this respect we may trace a distant resemblance to epilepsy: if we regard each attack as a long and mild paroxysm, then these paroxysms are liable to repetition. No doubt the duration of the disorder is often abbreviated by proper treatment: there are cures in this disease as well as recoveries. In its milder form, which fortunately is by much the most frequent form also, the grimaces and gesticulations of the patient are apt to be regarded by thoughtless lookers-on as objects of mirth and amusement; but in its severer and fatal form there are few diseases more terrible to witness. Sleep is obtained with difficulty; and in LECT. XXXVII.] CHOREA. 431 the waking state no intervals of calm arrive, such as divide the fearful paroxysms of tetanus or of hydrophobia. In spite of all care and protective contrivance, the loins, hips, and elbows of the unhappy patient are chafed and inflamed under unceasing friction with the bed-clothes; the limbs, in their perpetual contortions, are bruised and wounded; the bitten lips bleed; the countenance Dr. Hughes describes as wear- ing a piteous and imploring expression ; occasionally an involuntary cry or squeak is heard, until at length the vital power is exhausted, and death comes to the sufferer's relief. It is my good fortune never to have had a fatal case of chorea to treat, and I have seen but one. The subject of it was the patient of one of my colleagues, in the Middlesex Hospital. Under any circumstances, death from this disorder is uncom- mon : it is still more uncommon during childhood. Of 16 deaths attributable to the disease itself, and occurring among Dr. Hughes's 309 cases, 12 were of patients who were near, or had reached, or had passed the period of puberty; their ages varying from 15 years in the female, up to 25 in the male. Inspection of the dead body, in the cases that have proved fatal, has thrown no light upon the pathology of the disease. We shall seek in vain, I believe, to dis- cover the nature of chorea through the revelations of morbid anatomy. In the patient who died in our hospital, great vascularity of the uterus was noticed; there were earthy concretions in the pancreas, omentum, and mesentery, and tubercles in the lungs. In a fatal case that fell under Dr. Bright's observation, the uterus and jts appendages were diseased. Dr. Hughes informs us that, of 14 cases examined after death from chorea, disease of some kind was observed within the cranium in 10, while the brain and its membranes appeared quite healthy in 4. In 6 of these 14, the spine was not opened ; the cord was found healthy in 2 ; and softened in 2; and otherwise diseased in itself or its membranes in the remaining 4. Of 16 cases examined after death during the existence of chorea, the organs within the thorax were not mentioned in 2; were reported healthy in 2; and were more or less dis- eased in 12. In 11 of these 12, the sigmoid or the auriculo-ventricular valves of the heart were in a diseased condition. In 5, if not in 6, of these cases, the disease con- sisted in vegetations upon the edge of the mitral valve; and in 1, similar vegetations were present upon the tricuspid valve. The abdominal organs were healthy in 4 of the 16 cases; the liver was said to be large, or congested, in 6; the kidneys to have been congested in 4; and the stomach to have been ulcerated in 2. Of 7 females who had arrived at or near the age of puberty, the organs of gene- ration were not noticed in 3 ; the ovaries were turgid, or congested, or evidence of undue uterine excitement existed, in 4. What inferences may fairly be drawn from statements such as these? Some of the morbid conditions revealed by dissection had probably no connexion with the chorea at all. Some may have aided its accession by increasing that irritability and mobility of the nervous system, which subjects it readily to the exciting causes of various nervous ailments: or (as I most incline to believe) they may have operated upon afferent nerves of the spinal cord as eccentric exciters of the irregular movements, in constitutions already predisposed to chorea. This last supposition derives support from the fact that chorea affects some women during their pregnancy, and ceases spontaneously after parturition. Dr. Lever has recorded five instances of this kind; and Dr. Hughes refers to two others. A very remarkable part of the summary which I have just quoted from Dr. Hughes is that which concerns the heart. It has long been observed that some occasional but obscure relation subsists between chorea and acute rheumatism. During the presence of the latter disease, the lining (as well as the investing) membrane of the heart is very liable to inflammation, by which its valves are permanently injured \ and such valvular injury almost always gives rise, in the living patient, to some cardiac murmur. Now valvular disease of the heart was found to exist in eleven of the twelve cases (the whole number being but sixteen) in which the heart was any way implicated: and in another part of his report, Dr. Hughes says that " out of 104 cases in which special inquiries were made respecting rheumatism and heart affections, there were only 1;"> in which the patients were both free from cardiac murmur, and had not suffered from a previous attack of rheumatism." 432 CHOREA. [lect. XXXVII. Making large allowance for the possibility that, in some instances, the cardiac murmur may have been due simply to the anaemia which is so common in chorea, there is convincing evidence in these statements, of a frequent though not a necessary connexion between that disease and acute rheumatism. On former occasions, I have been in the habit of mentioning two conjectures which had occurred to me on this subject. Rheumatism (as we shall see by-and-by) is especially a disease of fibrous structures, and it usually invades various fibrous parts at the same time. I deemed it, therefore, not improbable that in the cases in question, some morbid condition of the membranes of the spinal cord might have arisen simul- taneously with the cardiac inflammation. Of this, however, we find no evidence in the teachings of morbid anatomy. Again, the cardiac injury might, I thought, like some other structural diseases, be an eccentric exciting cause of the spasmodic disorder of the muscles : and this appears to be Dr. Hughes's opinion. But the most probable theory is that suggested by Dr. Todd and by Dr. Begbie. Acute rheumatism is a blood-disease; and it is most likely that the unhealthy blood, circulating through the several organs, is the common source and cause of the articular, the cardiac, and the spinal symptoms; and the bond of connexion between them. This theory explains also the occurrence, which Dr. Begbie has noticed and recorded, of chorea in some, and of acute rheumatism in others of the same family. From an analysis of 36 cases in which chorea was observed in connexion with articular rheumatism alone, with acute cardiac disease alone, or with these two dis- orders in combination, Dr. Kirkes deduces the following conclusions. That choreal symptoms are oftener associated with endocardial than with pericardial disease; and that they are more likely to arise when articular rheumatism and disease of the heart exist together, than when either of those affections occurs separately There is a speculation of some of the French writers respecting the seat and nature of chorea so ingenious, that I cannot refrain from mentioning it. It is held by modern physiologists, as you probably know, that one of the functions, the principal office indeed, of the cerebellum, is to preside over and regulate the faculty of locomotion; to keep the muscles in due subordination, as it were, to the will. No voluntary movement, almost, can be executed without the combined and consenting action of many muscles: it is the business of the cerebellum, they say, to maintain this consent and community of purpose; to prevent any mutiny of individual muscles, and to make them unanimously co-operate in producing an intended move- ment. How far this doctrine may be true I do not now inquire; but supposing it well founded, then they very ingeniously assign the cerebellum as the seat of that change, whatever it is, which gives rise to the phenomena of chorea. And it is most certain that the irregular movements by which chorea is characterized can neither be con- sidered as the effects of imperfect paralysis, as some have stated, nor of convulsion, in the proper sense of that word, as others have asserted; but rather as consequences of the want of due harmony and agreement between the various muscles, which should combine to produce the desired state either of rest or of motion. There is a defect of the requisite association in the actions of the different muscles; and it is in this sense that chorea has been denominated insanity of the muscles. There is a certain portion of the brain which ministers to the intellectual functions; there are certain altered states of that portion, which lead to mental aberration; the persons so affected form false judgments; cannot associate their ideas aright. So also there is a certain portion of the encephalon which presides over the locomotive functions; and there are altered states of that portion, which lead to a loss of the due association of the muscular contractions. That portion is the cerebellum. Such is their theory; and it is a very plausible and pleasant, but withal an unsatisfying theory. The disorder really belongs, I apprehend, to the excito-motory department of the nervous system. From some infirm or unnatural state, either of the cord or of the incident nerves that convey impressions to it, its reflex function is called into irregular play, and voluntary muscles contract independently of volition. Sometimes, at the same instant, the patient wills certain definite movements through the instrumentality of the very same muscles. But the authority of the will is impaired, and the automatic motions are proportionally strong and unruly. The consequence is, that the same muscles, receiving at the same time contradictory orders from these two sources, obey neither LECT. XXXVII.] CHOREA. 433 mandate completely, but give rise, by their discordant action, to the grotesque and seemingly antic gestures which these patients exhibit. But to leave these seductive theories, and to return to duller matters of fact. Chorea is a complaint that is seldom attended with any bodily pain. I have in several instances, however, known it to be accompanied by pain of the head; and in some of them, with pain on that side only of the head which was opposite to the agitated limbs. I mention this as being of some practical importance; for I have found the disease to become sensibly less severe, and very soon to cease, upon drawing blood by leeches, or cupping, from the painful side of the head. In a greater number of eases, however, no such pain is experienced. Sometimes you will find that in all respects, excepting the nervousness, and the irregular movements, the patient is in the enjoyment of perfect health. But neither is this very common : generally there is something manifestly wrong in the state of the stomach and bowels, either before or during the complaint; a capricious appetite, costiveness, a tumid abdomen, offen- sive breath, a foul tongue : or irregular menstruation. Probably anything which makes a forcible impression upon tho nervous system may act as an exciting cause of chorea. Strong mental emotion, or a sudden mental shock, is very likely to bring it on, in those of a moveable constitution who are pre- disposed to it. Of its ascertained or alleged exciting causes, fright is beyond all comparison the commonest. And, what is very curious, fright has been known to effect its cure. Dr. Hughes tells of a girl who having recovered from chorea, and suffered a relapse, was on her way to Guy's Hospital, for the purpose of seeking re- admission there. As she passed over London Bridge, she wis terrified by seeing a person knocked down and run over. Before she reached the waiting-room of the hospital, her malady was gone. The disease has been observed to follow blows and falls on the head; but even in these cases the alarm may have had a greater share in producing it than the blow itself. It sometimes seems to depend upon irritation of the stomach or bowels, by improper diet, by accumulated faeces, or by worms; and it is found to be connected, in not a few cases, with difficult and painful menstruation. It frequently begins about the period of the second dentition : the late Dr. Gregory, of Edinburgh, was in the habit of relating instances of that kind. In one case, the old teeth were remaining while the new ones were appearing by their sides. The old teeth were drawn, and the removal of the chorea was complete. This Dr. M. Hall would justly call eccentric chorea. But even in such cases the state of the gums cannot be re- garded as the sole cause of the chorea: there must be the predisposition, as well as the accidental exciting cause; for the complaint is apt to recur under the agency of some new irritation, and may then be removed by other means. [We have not found the disease to be much influenced by the season of the year or the condition of the atmosphere. Duges, Rufz, Spangenburg and Blache state that it occurs most frequently in summer. According to the statements of Rochoux, Chervin, and Danste, it is a rare affection in the southern hemisphere. It is not a very frequent disease in Philadelphia. — C] Chorea, such as I have been describing it, may last from a week or two to some months. The disorder often terminates — at any rate much more often than epilepsy does—at the period of puberty; especially upon the first coming on of the menstrual discharge in the female. [Chorea, like epilepsy, according to Andral, may be excited by irritation; the fact, however, is denied by Rufz and Blache.—C] I had occasion, in the last lecture, to remark, that when a vast number of different drugs are recommended as specifics in any given disease, we may sometimes infer from that very circumstance that the disease is difficult of cure, and generally intract- able under all plans of management. But there is another class of diseases which a variety of drugs are supposed capable of curing,—those, namely, which tend to termi- nate in health. I believe that many cases of chorea — most cases — would at length get well without any aid from physic: I believe also that many of the boasted spe- 434 CHOREA. [lect. xxxvii. cifics have been quite innocent of any share in the recovery of the patients to whom they were administered; at the same time I am quite certain that treatment has a great influence over the disease. It was Sydenham's practice first to bleed and purge his patients, and then to ad- minister bitters, aromatics, and antispasmodics, with the view of strengthening the nerves. After his time the blood-letting and purgatives fell into disuse, until the publication of Dr. Hamilton's well-known work again brought the latter deservedly into favour. The treatment of chorea embraces two definite objects. The first, and chief, is to give stability to the unduly moveable nervous centres. The second is to remove or avert whatever may be likely to produce unnatural excitement of the incident nerves. Now the complaint in its genuine form is seldom dependent upon any organic or inflammatory change. The instrument is not broken anywhere; but slackened, jangling, and out of tune: and (to pursue the metaphor) we often can restore its harmony by bracing it up again. I can confidently recommend you to abstract blood locally in those cases in which there is a fixed pain in the head; but with this exception, blood-letting is neither useful, nor even (in my opinion) justifiable. There is oftener a deficiency than a re- dundance of red blood in the system. I shall not attempt to distract your attention by discussing the various remedies that have been vaunted against chorea; but shall take the liberty of referring you to books (to Dr. Copland's Dictionary, for example) for further information on that subject, and content myself with telling you what modes of treatment I have been in the habit of employing, with very satisfactory results. I think, then, setting aside the complication with headache just mentioned, you will be able to deal successfully with most of the cases of chorea which you may have to treat, if you have at your command purgative medicines, the shower-bath, preparations of iron and of arsenic, and the oil of turpentine. It will be right, in all cases, to begin by clearing out the bowels with calomel and jalap, or some active aperient; and you should persist in the regulated use of purga- tive medicines, if they continue to bring away much or foul faecal matter. You are to be guided less by the amount of the doses than by the effects they produce; at any rate one full evacuation of the bowels should take place every day. But though purgatives are good auxiliaries, we cannot trust to them alone for the cure of the complaint. One of the most effectual of the tonic remedies is the cold shower-bath. If the patient be of a feeble constitution, the water may at first be used tepid; by degrees it should be used cold. This remedy should be employed every morning, or every other morning, early, as soon as the patient gets out of bed. Of the best indications of the propriety of its continuance I spoke in the last lecture only; I need not tire you, therefore, by repeating the observations I then made. With this external tonic it will be right to combine some internal one; and for the most part, the best for the purpose is some preparation of iron. The carbonate of iron is an exceedingly good form, and it may be given in the way recommended by Dr. Elliotson, one of whose pets it is—namely, mixed with twice its weight of treacle, so as to form an electuary. You may begin with it in half-drachm doses, and pre- sently increase the quantity to a drachm, or a drachm and a half, or two drachms. Much larger quantities indeed have been given, and that for a long time together; but I am not in the habit of so pushing this drug. Patients do not like to swallow from half an ounce to an ounce of the powder and twice as much treacle three or four times a day; and some of them cannot get so much down. And I mentioned on a former occasion that the iron is apt to accumulate in the large intestines, and to be expelled at last, often with difficulty and pain, in large, hard, red masses, like what is called, I fancy, slag, or the dross of iron ore from a furnace. The treacle may be dispensed with if you employ the Ferri carbonas cum saccharo which has been introduced of late into the London pharmacopoeia. When one or at most two drachms of the carbonate given three or four times a day, make no impression on the disease, you had better change the form of the medicine. Give two or three grains of the sulphate of iron for a dose, or half a scruple of the citrate, or an ounce and LECT. XXXVII.] CHOREA. 435 half of Griffith's mixture (mistura ferri composita), or twenty or thirty minims of the tinctura ferri muriatis. [We have seen the best effects result from the use of the ammoniated tartrate of iron in five grain doses, repeated three or four times a day or oftener, according to the age of the patient and the extent of the choreic symptoms. — C. ] Dr. Bright says he has found the sulphate of zinc answer when the carbonate of iron had failed, and the iron succeed when the zinc had done no good. One most severe case, about which I was consulted, and which had resisted other remedies, got well under the use of the sulphate of zinc; the dose of which was gradually in- creased to ten grains, given three times a day. Whenever the medicine was pushed beyond this point it became emetic. This seems to be the favourite remedy in Guy's Hospital, where the dose has sometimes been carried, Dr. Hughes informs us, as high as half a drachm, two scruples, and even in one instance forty-two grains, thrice daily. It cured forty-five out of sixty-three cases; five in every seven. [The valerianate of zinc, in doses of from three to five grains, according to cir- cumstances, will often arrest the disease with great promptness. — C]. Certainly the disease is often very obedient to arsenic; but, for plain reasons, it is better to effect a cure, when we can, by less hazardous substances. The gravest case I ever had to treat occurred in one of my hospital patients. I tried the carbonate of iron in vain. The shower-bath so terrified and agitated the girl that I could not persist with it. I then gave her arsenic, under which she improved at first, but it ultimately was very injurious; her bowels were greatly irritated by it, she became paralytic in her lower extremities, and sank into a typhoid state; and I really was afraid that I should lose her. But she recovered from this condition, which I could not but ascribe to the arsenic; and as soon as I dared venture, I began to give her the muriated tincture of iron, twenty drops at a time, every six hours. Under this treatment she steadily and rapidly improved, and was soon quite well. Dr. Begbie, in an experience of nearly thirty years, has never known arsenic fail. He gives five drops of the liquor potassae arsenitis twice a-day, an hour after meals, adding one drop every third day, until the specific effects of the mineral upon the system begin to be observable: when he withdraws it for a while. " The earliest manifestation of these effects are itching and swelling of the eyelids, redness of the conjunctiva, nausea, and uneasiness at the pit of the stomach, and particularly a peculiar white silvery appearance of the tongue, seldom accompanied with tenderness." The oil of turpentine also is certainly a valuable medicine in this disease; whether there be worms at the bottom of it or not. When the bowels are torpid and the girl is of that age when menstruation may be conjectured to be at hand, its arrival seems sometimes to be accelerated, and great relief to be produced, by the turpentine. The best way of exhibiting it in such cases is in combination with an equal quantity of castor oil; two drachms or half an ounce of the mixture may be given every morning, or every other morning, according to its effect upon the bowels; and when they are very sluggish, or the stools are unnatural, it" will often be serviceable to give a couple of grains of calomel also, twice or thrice a week, at bed-time. [Very decided testimony has been presented by Young, of Pennsylvania, Lindsly, of Washington, Hildbreth, of Ohio, Kirkbride and Professor Wood, of Philadelphia, Beadle of New York, and other American physicians, in favour of theefficacy of the cimicifuga, or black snake-root, in cases of chorea. It may be given in the dose of half a teaspoonful of the powdered root three times a day; or from one to two drachms of the saturated tincture, or a wineglassful of the decoction. The cyanuret of iron, in the dose of three grains three times a day, in the form of a pill, has been strongly recommended by Dr. Zollickoffcr, of Maryland. The cyanuret of zinc, in the dose of one-third of a grain, twice a day, gradually increased to fourteen grains in the twenty-four hours, has recently been highly spoken of by the physicians of Berlin and elsewhere. See Condie on Diseases of Children. The nux vomica, 436 CHOREA. [LECT. XXXVII. either in the form of extract or tincture, in as large doses as can be safely given has in our hands proved a valuable tonic in cases of chorea. — C] It is scarcely necessary for me to say that due attention must be paid to the diet. This ought to be plain and simple, but at the same time nourishing, and even generous. Exercise, short of that which produces fatigue, in the open air, in fine and dry weather, will also conduce much to the patient's recovery. And all kinds of immoderate emotion should be guarded against: for the contest often seems to lie between the emotional and the voluntary impulses to action. The stillness of the muscles during sleep is in accordance with this belief. There is an affection (it scarcely deserves to be spoken of as a disease) which is sometimes called chorea, of a chronic nature, and resembling the disorder I have just been speaking of, inasmuch as it commonly is met with in nervous persons, and con- sists in the irregular, unmeaning, and involuntary contraction of certain muscles, especially in the limbs, neck, or face: but differing from it in this, that the same muscles are always affected, and in the same way; that it lasts long, almost always for life, and implies no accompanying derangement of the general health. In its slighter form the irregular movements are rather awkward tricks than spasms : little shakes of the head, or rapid and repeated elevations of the eyebrows, or corrugations of the nose, or sniffings and snortings through the nostrils, or shrugs of the shoulders — movements of which the person seems scarcely conscious. At other times, how- ever, the motions are more extensive; a limb starts out, or the head is turned awry; and the individual who performs these evolutions is quite aware that he does so, and vexed and annoyed at the ridiculous figure he makes, but he cannot help performing them; or if he can prevent it, the necessary effort is worse than the disease. One young man who was subject to this infirmity told a friend that he could stop the movement by a strong exertion of the will; but that exertion was extremely painful, and was followed by languor and much discomfort. In some instances I make no doubt that the continuance of the affection is the result of a long-established habit. It occurs more frequently in men than in women. I had for a long time, as an out- patient at the hospital, a girl about seventeen years old, in all other respects the picture of health, but who was annoyed by an involuntary shake of the head, which took place two or three times in a minute. She received no benefit from medicine. A lad in my own service was affected in a similar manner. He seemed to be giving me, and my friends, from time to time, a familiar nod: and I was obliged to part with him. Others are subject to twitchings of the face. I am acquainted with one gentleman who is perpetually wrinkling his nose; and he has assured me that he was subject, when young, to an involuntary shake of the head, like the two persons just mentioned; but a blister having once been applied to his throat for some disorder in his air-passages, the shaking of the head was thereby rendered painful and difficult, and the movement there ceased : but (as he expressed it) it broke out in his nose, where it triumphs to this day. This chronic chorea, as it has been called, I merely mention to prevent your confounding together two affections which, though they have received the same name, and are in some respects analogous, yet differ in still more points, and those points of more importance. I believe that medicine has no power oyer any of these tricks. They are distressing and unsightly; but in no way dangerous. The word chorea, which you know signifies a dance — and the trivial term, St. Vitus's dance — are not very appropriate to either of the modifications of the nervous affeotion which I have been noticing. In fact that term was originally applied, and much more suitably, to another set of symptoms of a most singular kind, concerning the real occurrence of which we might well be sceptical, if we had not authentic nar- ratives of many instances of such disorder from different persons of credit, as well in this country as in others. What has happened many times before, may happen again; and you ought not to be in ignorance of the histories to which I allude. They relate to an affection characterized by movements that cannot be called spasmodic, but are rather owing to an irresistible propensity to muscular action, increased sometimes to a sort of mania by the force of imitation, or by the sound of music. It is the toll- LECT. XXXVII.] CHOREA. 437 tion that, in these cases, is morbid and perverse. You might fancy the patient to be possessed and coerced by an evil spirit, like the Saifiov^opsvoc of the Gospel history. Some of the subjects of these extraordinary affections, impelled by a strange and unintelligible necessity, execute measured and regular movements with surprising energy, rapidity, and perseverance. When music is performed in their hearing, the movements become an actual dance; and where crowds are collected together, the dancing mania is apt to spread from person to person by a sort of imitative infection; realizing the fable of Orpheus, and giving origin (it may be presumed) to those ro- mantic legends met with in the literature of most ages and countries, of universal, involuntary, and unceasing saltation, at the sound of a magic pipe. To these feats the term chorea is apposite enough. Indeed I have seen it somewhere suggested that the phrase chorea Sancti Viti is but a vulgar corruption of chorea Sancti inviti; and took its rise in the misfortune of some holy person who chanced to be afflicted with one of these unwilling but invincible impulses to caper. The common explanation makes this holy person to have been a certain German Saint Weit, to whom a chapel is said (I know not with how much truth) to be dedicated at Ulm, in Suabia. Sometimes, instead of dancing on their feet, these patients drum and beat with their hands, either upon their own knees, or upon the objects near them. This variety has received the bombastic title of " malleation." Sometimes they circuni- volve with great rapidity; or they turn their heads repeatedly from side to side with great velocity : this is " rotation." When they are irresistibly impelled to move in a given direction, the term " propulsion " is employed. The very invention of these names attests the reality of the disorder. You will find one of these singular cases related by Mr. Kinder Wood in the seventh volume of the Medico-Chirurgical Transactions. The patient was a young married woman. After having suffered severe pain in one side of her face, she began to be troubled with involuntary movements. They commenced in the eyelids, which were opened and shut with excessive rapidity. Then the muscles of the extremities became affected. The palms of the hands were beat rapidly upon the thighs, and the feet upon the floor. The motions soon extended to the trunk and pelvis. The patient was suddenly half raised from her chair, and instantly reseated. This was repeated as quickly as one action could possibly suc- ceed another. Sometimes she had a propensity to leap upwards, and strike the ceil- ing with the palm of her hand; or to touch little spots or holes in the furniture of the room. Or she would dance on one leg, holding the other in her hand. These attacks were accompanied by headache, sickness, and vomiting. At last she took to making steps about the room, regulated by an air, or by a series of strokes on the furniture as she passed, her lips moving as if words were articulated, but no sound escaping them. A person thinking he recognised the tune which she beat on the furniture, began to sing it; and she danced directly up to him, and continued dancing till he was out of breath. A drum and a fife were now procured, and the same air played upon them. She immediately danced up to the drum, and as close to it as possible, till she missed the step, when the motions instantly ceased: and this was found always to be the case. The motions stopped also when the measure was changed; or was increased in rapidity beyond her power to keep pace with it. A continued roll on the drum had likewise the effect of putting an end to her movements. This being discovered, their approach was watched; and by always rolling the drum as soon as they threatened to begin, the chain of association which seemed to constitute the disease was at length broken. The bowels were in an unnatural state during the complaint; and the men- strual discharge appeared on the evening of the day on which it ceased. One might conceive the conduct here described was an indication of folly or of insanity; but Mr. Wood declares that the patient's spirits were good, and her perception and judgment accurate and just; that during the absence of the paroxysms she went about her household affairs as usual; and that she had a correct knowledge of her situation, and of the advantage she derived from the drum, with an anxious desire to continue its use. She stated " that there always was a tune dwelling upon her mind, which at times becoming more pressing, irresistibly compelled her to commence the involuntary motions." In a lady, whom Dr. Abercrombie saw, the following symptoms, among others, 438 CHOREA. [lect. XXXVII. occurred : — After she had been ill with various nervous affections for two years, she began to suffer convulsive action of the muscles of the back, and involuntary twitches of the legs and arms, producing a variety of movements of the whole body very difficult to describe. These were much increased by touching her, especially on any part of her back. This is a symptom quite in conformity with Dr. Hall's doctrine of eccentric irritation. At one time there was difficulty of deglutition, so that attempts to swallow produced spasms, resembling those of tetanus. At other times, after lying for a long while quiet, she would in an instant throw her whole body into a kind of convulsive spring, by which she was jerked entirely out of bed : and in the same manner, while sitting or lying on the floor, she would fling herself into bed, or would leap, as a fish might do, upon the top of a wardrobe fully five feet high. These are feats that surpass the powers of a person in health: and I say we should hesitate to believe them if they were not related by a physician of such sober judgment and unquestionable veracity as Dr. Abercrombie. He tells us that during the whole of these symptoms her mind continued entire : and the only account she could give of her extravagance was, a secret impulse which she could not resist. But, after a time, motions still more wonderful commenced, affecting the muscles of the upper part of the back and neck, and producing a constant semi-rotatory motion of the head. This sometimes continued without interruption night and day for several weeks together: and if the head or neck were touched, the motion was increased to a most extraordinary degree of rapidity. These paroxysms were relieved by nothing but cupping on the temples to the amount of ten or twelve ounces, when the affection suddenly ceased, with a general convulsive start of the whole body. She was then immediately well, got up, and was able to walk about in good health for several weeks, when the same symptoms returned, and required a repetition of the same treatment. All this went on, at intervals, for four years; the menstruation during that time being irregular and scanty, and the bowels torpid. She was pale and bloodless from the frequent bleedings, but not reduced in flesh. At last, in the spring of 1829, she had a severe paroxysm of the rotatory motion of the head; and it was then determined to allow the attack to take its course, and to direct the treatment entirely to the menstruation. Sulphate of iron, and Barbadoes aloes, were prescribed. She went on for three weeks, the convulsive motion of the head continuing without intermission night and day. At length, in the middle of the night, the paroxysm ceased in an instant, with the same kind of convulsive start of the whole body with which it used to cease after cupping. At the same instant menstruation took place in a more full and healthy manner than it had done for many years. From that time she remained well; at least up to the period when Dr. Abercrombie wrote the account. The alternating rotatory motion of the head is by no means an uncommon feature of these singular cases. It occurred in a patient of Dr. Conolly's; in whom the menstruation was irregular, and about to cease altogether. It came on in paroxysms which were repeated many times a day, and it was attended with inordinate loquacity. The head was turned from side to side about eight times in a second, and each paroxysm lasted three or four minutes. The patient got well after being cupped and leeched, and thoroughly purged. I have seen precisely the same thing in a hospital patient. Dr. Crawford met with an instance of involuntary rotation of the head, without pain, but attended with intolerance of light. And there is a striking example of it described in the twenty-third volume of the Edinburgh Medical and Surgical Journal, by Mr. Hunter, of Glasgow, who speaks of it under the name of " rotatio or chorea." The motions are said to have been furious and alarming: they were executed with such extreme rapidity, that it was difficult even for the eye to follow them. She appeared, Mi*. Hunter says, absolutely to be looking backwards and for- wards, and in every direction, at the same moment. This woman had sometimes fifty paroxysms of this kind in a day: they greatly exhausted her; but she was perfectly rational in the intervals. A modification of the same kind of affection took place in a most extraordinary case recorded by Dr. AYatt, of Glasgow, in the fifth volume of the Medico-Chirurgical Transactions. His patient was a girl ten years old. First she had headache, accompanied by vomiting, and increased by the slightest deviation of the body from the erect posture, either backwards, or forwards, or to one side. These symptoms lasted about a month; and during that time she lost the power of speech and of walking. At the end of that period she was seized with a propensity LECT. XXXVII.] CHOREA. 439 to twirl round on her feet, like a top, with great velocity, always in one direction; and was pleased when those about her assisted in increasing the rapidity of her move- ments. After continuing nearly a month, these motions ceased, the headache returned, and she became unable to move her neck, or support her head. Soon after she was visited with a new kind of motion : she would lay herself across the bed, and turning over like a roller, move rapidly from one end of it to the other. At first the fits of this kind lasted two hours; but they gradually extended to six or seven hours every day. On being carried into the garden she rolled rapidly from one end of a gravel walk to the other; and even when laid in the shallow part of a river, though appa- rently on the point of being drowned, she began to turn round as usual. The rota- tions were about sixty in a minute. She made little or no use of her arms in revolving. In about another month or six weeks an entirely new set of movements began. She lay upon her back, and by drawing her head and heels together, bent herself like a bow, and then allowing her head and heels to separate, her buttocks fell with con- siderable force upon the bed. She repeated these movements ten or twelve times in a minute, first for six hours daily, and at length for fourteen. After another space of about five weeks had elapsed, the most singular freak of all ensued; she became possessed with a propensity to stand upon her head with her feet perpendicularly upwards. As soon as the feet were elevated in this manner, all muscular exertion seemed to be withheld, and the body fell down as if dead; her knees striking the bed first. This was no sooner done than she instantly mounted up as before; and continued to do so from twelve to fifteen times in a minute, for fifteen hours a day. After a variety of fruitless treatment, a spontaneous diarrhoea came on, and she recovered. The spinning motions observed during a part of this case have been observed in other instances. In Magendie's Journal de Physiologie, the two following singular forms of disease are referred to. A man, after some other symptoms of cerebral disorder, was seized with an irresistible inclination to move forwards, stopping only when exhausted. He would sally forth into the streets, and continue walking straight forward until he dropped down from fatigue, and was obliged to be brought home in some conveyance. This man at length died, and several tubercles were found in the anterior hemispheres of his brain. Dr. Laurent, of Versailles, exhibited to the Academy of Medicine a young girl, labouring under the exactly opposite necessity. In the attacks of a ner- vous disease she was irresistibly propelled backwards, and with some rapidity: being unable to avoid obstacles or hollows, she received many falls and bruises in her course. I say that histories such as I have been giving you some samples of, and those mostly in an abridged form, would sound very like romances, if they were met with in the old authors alone, or if they were not attested by unimpeachable authority. They resemble chorea in this respect, that they are examples of muscular actions performed by persons in possession of consciousness, and performed in spite of them- selves. But in most other respects they differ from what we now-a-days mean when we speak of chorea. Perhaps they may rank among hysterical vagaries. It is re- markable that the majority of them occur in young women, in whom the menstrual function is suspended or irregularly performed. Some persons may consider them as varieties of insanity. The patients certainly did not feign to be ill, for the feats of strength and agility which many of them enacted were much beyond their natural power and endurance. The truth seems to be, that there are innumerable modifica- tions of the nervous functions, and that some of them are more common and more capable of being arranged into groups than others; but that they all offer points of resemblance, like (as I observed before) the different members of a large family, in which the individuals have the same general cast of features, and yet preserve each his particular identity. I advert to these odd forms of disease with the view of directing your attention to such of them as may come in your way. We are yet terribly in the dark about mor- bid affections of the nerves, both organic and functional. Hereafter some medical Newton will arise, and reduce all these apparently complicated phenomena under one simpler law. At present all that we can do is to collect, and, as far as we may, to arrange facts, in the hope that at length some better light will be shed upon the subject. And it must be observed that some of the modern researches into physi- 440 CHOREA. "[lect. XXXVII. ology do throw a little glimmerinp: of illumination into these dark corners of pathology. In certain of M. Magendie's experiments on animals the following curious facts were ascertained:—When a vertical section of the cerebellum of a rabbit was made, leaving one-fourth of the whole adhering to the crus of the right side, and three- fourths to that of the left, the animal rolled over and over incessantly, turning itself towards the injured side. The same phenomenon occurred upon the division of the crus cerebelli. The animal lived for eight days, and continued during the whole of that time to revolve upon its long axis, unless stopped by coming in contact with some obstacle. How like is this to the symptoms exhibited at one period in the girl whose case is related by Dr. Watt! Nor is Dr. Watt's case a singular one; M. Serres has described another much resembling it. A shoemaker, sixty-eight years old, of intemperate habits, after one of his debauches exhibited a kind of drunkenness which surprised his friends. Instead of seeing objects turn round him, as a drunken person is apt to do, he thought he was himself turning, and soon began to revolve; and this lasted till he died : and when his head was examined, extensive mischief was found in one of the peduncles of his cerebellum. Again, M. Magendie noticed that when the upper part of the cerebrum is gently removed in birds and mammalia, they become blind; but no affection of the locomo- tive powers is produced. No further result is occasioned by the removal of a portion of the grey matter of the corpora striata: but when the striated part is cut away, the animal immediately darts forward with rapidity, and continues to advance as if im- pelled by some irresistible force, until stopped by an obstacle; and even then it retains the attitude of one advancing. The experiment was tried with the same result upon various species of animals — dogs, cats, hedgehogs, rabbits, Guinea-pigs, and squirrels. It seems that there are horses that cannot back; although they make good progress enough in a straightforward direction. Now Magendie says that he has opened the heads of such horses; and has always found, in the lateral ventricles of their brains, a collection of water, which must have compressed and even disorga- nized the corpora striata. It has been further ascertained, by the same experimenter and by others, that certain injuries of the cerebellum cause animals to move back- wards contrarily to their will. If the tail of the animal so mutilated be pinched, he still persists in his retrograde course. Injuries of the medulla oblongata had the same effect. Pigeons into which he forced a pin through that part, constantly re- ceded for more than a month, and even flew backwards. A section of the medulla oblongata, where it approaches the anterior pyramid, gives rise to a movement in a circle, like that of a horse in a mill; the animal, in its walk or its flight, bearing round continually to the injured side. Surely we have, in these facts, supplied by experiments on living animals, and by observation of the phenomena of disease in the living human body, some of the materials for a more exact knowledge, both of the physiology and of the pathology of the nervous system, than we have yet reached. M. Magendie supposes that different portions of the encephalon are endowed with energies which tend to cause motion in various directions; that in the healthy state these balance each other, and that a preponderating impulse can be given to any one of these forces by the will; but that when the equilibrium is destroyed by disease, the will is not sufficient to counteract the tendencies which are then brought into play. Mr. Mayo offers a different explanation of the phenomena. He supposes that the injuries inflicted on the nervous matter produce a sensation analogous to vertigo; and that the animal conceives itself either to be hurried forward, and makes an exertion to repel the imaginary force; or to be moving backward, or turning round in one direction, and endeavours to correct this by moving the corresponding muscles. Whatever may be the true explanation, the facts themselves are abundantly curious and interesting, and I recommend them to your attention. Some of the affections that I have been describing, fall, perhaps, under the cate- gory of those to which the appellation of the leaping ague has been given in some parts of Scotland. There is a class also of convulsive spasmodic affections which resemble epilepsy on the one hand, and chorea on the other, or rather form a link of alliance between the two, and which are especially remarkable for this, that they are capable of being propagated by that kind of imitative contagion of which I have several times spoken. This point might be well illustrated by the history of various lect. xxxvin.] PARALYSIS AGITANS. 441 sects of religious enthusiasts. One or two of those enthusiasts have apparently at first worked themselves up into a state approaching to epilepsy, accompanied even by insensibility sometimes; and then this state has been communicated by sympathy to the more susceptible of their auditors. I must not, however, go into any further details on this subject; and perhaps I have prosecuted it too far already. Those among you who are inclined to pursue it further may find some curious accounts of an epidemic which occurred in Lanarkshire, in Sir John Sinclair's Statistical Account of Scotland, under the head of the " Conversions of Cambuslang;" and in one of the early volumes of the Edinburgh Medical and Surgical Journal. Dr. Robertson has described in an inaugural dissertation De Chared Sancti Viti, a similar epidemic, which occurred in the States of Tenessee and Kentucky, in the western districts of America. This is also referred to in the same volume of the journal. Among other things Dr. Robertson says, that while extravagant sounds, and actions, and gesticulations, were in the first instance wilful, the actors "at length, to their own astonishment, and the diversion of many of the spectators, continued to act from necessity the curious character which they had commenced from choice." I will only remark further of such forms of nervous disease, that as they spring often from moral causes, so they admit, in a great degree, of moral remedies. The pranks played by the Scotch enthusiasts were brought to an end by threatening to duck every one who should thereafter be attacked; and, I believe, a few of them were horse-ponded, by way of example. AYith respect to the solitary instances of perverted locomotion, our business must be to correct whatever is wrong in the state of the bowels; in women, to amend the disordered uterine functions; to invigorate and confirm the system generally; and, in addition to the measures proper to effect these objects, I suspect that the cold sousing would in many cases be found of most material service. LECTURE XXXVIII. Paralysis Agitans. Mercurial Tremor. Hysteria: Two Forms of Hysteric Parox- ysm ; Diagnosis from Epilepsy; Class of Persons most liable to Hysteria; Dis- eases apt to be simulated by Hysteria ; Treatment: Prevention. In the last lecture I spoke of chorea, and of some singular forms of disorder that have sometimes been included under the same appellation; and I shall begin the pre- sent with a few observations concerning a disease very closely allied to some of those which we were then considering, and yet distinct enough to deserve and require a separate notice. I refer to what has been called the shaking palsy—paralysis agi- tans. Allusions to this form of disease are to be found in many of the older syste- matic writers on physic; but it never was much attended to in this country until Mr. Parkinson published an essay upon it in the year 1817; and a very interesting little pamphlet it is. He defines the disease thus : — " Involuntary tremulous motion, with lessened muscular power, in parts not in action, and even when supported: with a propensity to bend the trunk forwards, and to pass from a walking to a running pace : the senses and intellects being uninjured." The latter symptoms constitute the scelo- tyrbe festinans of Sauvages; and the former symptoms of the definition are not always attended by the latter. In old persons you may often observe incessant and involun- tary nodding and shaking of the head, without any tendency to run forwards. There is an old woman whom I see regularly sitting in the aisle at church every Sunday: she walks to her seat slowly and steadily enough, and sufficiently upright; but her head never ceases to nod, and wag, and tremble in various directions. It may be that she is in the less advanced stage of the malady; but I have remarked her for three or four or more years, and I see no change. Mr. Parkinson's notice was first called to the disease during his professional attend- 442 MERCURIAL TREMOR. [lect. xxxviii. ance upon a person affected by it. From observation of that case, and of several others that he subsequently met with, his account of the disorder was drawn up. He states that its first approach is insidious, and its progress often so slow and impercep- tible that the patient cannot recollect precisely when it began. A sense of weakness, and a disposition to trembling, fastens on some particular part: sometimes it is the head, but more commonly it is one of the hands or arms. These symptoms gradually become more decided; and at length the morbid influence is felt in some other part. At a still more advanced period the patient is found to be less strict than usual in preserving an upright posture, even when standing or sitting, but especially when walking. By degrees he finds a difficulty in making the hand obey the dictates of the will when he is engaged in any delicate manipulation — in writing, for example; and he is obliged to walk with circumspection and care: his legs are not raised to that height, nor with that promptitude, which the will directs; so that much atten- tion is necessary to prevent frequent falls. Then, as the malady proceeds, the pro- pensity to lean forward becomes more strong—the patient is forced to step on his toes and forepart of his feet, while the upper part of his body is thrown so far forward as to render it difficult for him to avoid falling on his face: in some cases he is irresisti- bly impelled to take much quicker and shorter steps than common, and thereby to adopt unwillingly a running pace. AAThen once this state has been pointed out, I make no doubt that some of you may recognise it, in old persons, whom you may have seen walking about. But the disorder does not stop here; the unhappy patient becomes unable to feed himself; or to walk at all without an attendant, who steps backwards before him, and prevents his falling forwards by the pressure of his hands against the forepart of the patient's shoulders : his powers of speech and deglutition fail; and the saliva dribbles from his mouth: he can no longer retain his urine or faeces; and at length death closes the miserable scene. Mr. Parkinson conjectures that this complaint results from some chronic change of the upper part of the spinal cord, or of the medulla oblongata; but dissections aie wanting to support or to refute that conjecture. Some of the patients whose cases he has given had been intemperate livers; hard drinkers : others had not been guilty of any such excesses: several had suffered a good deal from rheumatism, which he thought might have laid the foundation of their lamentable disease. But a more exact pathology of the shaking palsy is still needed. Dr. M. Hall observes that the symptoms have, in several particulars, a marked resemblance to the effects observed by M. Serres (and related in his Anatomie du Cerveau) of disease of the tuber annulare, or of the tubercula quadrigemina. Nor have we any ascertained means of curing this disease; or rather, this state of decay. Dr. Elliotson indeed says that he succeeded in one instance (of which, how- ever, the particulars are not given), with the carbonate of iron; but that he had tried the same medicine in vain in several other cases. We must administer to symptoms, and endeavour to set those functions right which may be obviously wrong: to regulate the bowels, to procure sleep, to nourish and uphold the patient without unduly stimulating him : and this is all that I can tell you of the shaking palsy. Another analogous disorder, meriting a moment's notice, is that peculiar kind of trembling which is apt to occur in persons who are much exposed to the poisonous fumes of mercury: mercurial tremor it is called; and popularly, the trembles. It consists in a sort of convulsive agitation of the voluntary muscles, which is most violent whenever efforts are made to move the limbs by the help of those muscles; whenever, in fact, volition is brought to bear upon them. It differs therefore from the shaking palsy, inasmuch as the tremor ceases when the muscles are supported, or are not called into action. It is also more susceptible of relief by medicine. The last person in whom I have witnessed this curious affection has been twice my patient in the Middlesex Hospital, and has twice got well there. John Chattin, 33 years old, was first admitted in August, 1837. He was led into the room, walking with uncertain steps, his limbs trembling and dancing as though they had been hung upon wires. While sitting on a chair he was comparatively quiet; you would not have supposed that he ailed anything; but as soon as he attempted to rise, and to walk, his legs began to shake violently with a rapid, incessant, and irregular motion. He could neither hold them steady, nor direct them with precision. Indeed without lect. xxxvni.] MERCURIAL TREMOR. 443 support he must have fallen down. His arms were agitated with similar involuntary movements. His tongue was tremulous, and he spoke in a hurried, abrupt, inter- rupted, staccato manner, not natural to him. He had no fever. His pulse was 66, and soft; his skin was natural; his bowels were costive. He complained of slight nausea. At the end of six weeks he went out well, or with very slight remaining weakness of his knees, and a little occasional tremor upon unusual exertion. In June, 1839, he again presented himself, in a similar state of agitation and helpless- ness. This man was a water-gilder; and had been employed in that business for 18 years. Till somewhat more than a twelvemonth prior to his first appearance at the hospital, he had been free from disease. Then he began to tremble a little; but for a fort- night before his admission the shaking had become so much worse that he could not go up stairs, nor even walk upon uneven ground. The trembling, when once brought on by efforts to move, did not cease until he sat down, or got one of his fellow-work- men to grasp his limbs tightly. This singular disorder is produced by the agency of mercury as a poison upon the body; and especially by the absorption of that metal when raised into vapour by heat, and inhaled in breathing. It is accordingly very common among water-gilders. AYater-gilding is the gilding of metals, and of silver in particular, by means of fire. It is called wafer-gilding, I believe, to distinguish it from other kinds of gilding, called gilding in oil. The silver to he gilded is covered with an amalgam of gold and mercury, and then is placed over a charcoal fire, by which the mercury is raised in fumes, and driven off, and the gold alone is left adhering. To these fumes the work- men are necessarily exposed; and numbers of them become affected with this tremor, which is not a common result of mercury applied to the system in other ways. The same complaint is frequent among the workmen in the quicksilver mines of Friuli and of Almaden, where the crude ore is purified by the aid of heat. Dr. Bateman relates, in the Sth volume of the Medico-Chirurgical Transactions, some cases like that which I have been describing. But the best account of the disorder that I have seen is given by Merat, in an appendix to his book on the Colique Metallique. The malady comes on sometimes suddenly, more often by degrees. The patient is loss sure of his arms than usual; they become tremulous, and at last shake, and, if he continue to pursue his employment, the force of the trembling goes on increasing, till at length it is so general and violent that he can persist no longer. His power of locomotion is impaired; his mastication, his speech, all his manual operations, are interfered with; he becomes unable to convey food to his mouth, and is obliged to be attended to and fed, like an infant; and by and by, if he do not quit the poisonous atmosphere, graver symptoms supervene — wakefulness, delirium, loss of memory, loss of consciousness. As the tremor increases, the digestive organs become disordered : the appetite falls off, nausea is felt, the tongue becomes furred, and gas collects in the intestines. The patients acquire a remarkable, brown, hue; and their teeth turn black. The pulse is generally full and slow. The time required for the production of these effects varies much in different cases; from two years to five and twenty. Something depends, no doubt, upon the quantity and intensity of the fumes. Chattin told us that the workmen became ill whenever they had a large job on hand. In both his severe attacks (and very often besides, both in him and in his companions) the mercury produced salivation. This was unfrequent in the patients observed by Merat. The duration of the complaint is considerable : it may last two or three months, or longer; and sometimes it is not completely recovered from at all. Yet it is not a fatal disorder. Although the visible affection is of the muscles, the mischievous operation of the poison is really upon the nervous centres, weakening and interrupting their natural influence. AVhen the will is directed upon the muscles, they contract unsteadily, and with frequent remissions; their action is not sustained; and it is a general observation by all who have written upon the disease, that it is aggravated by all kinds of mental emotion, by alarm, anger, surprise. My patient's shaking was, at first, augmented by the shock of the shower-bath: and always became excessive in thundery weather. So, on the other hand, it has been noticed that whatever tends to stimulate and fortify the nervous power, does temporary good: a glass of wine for example. Chattin 444 MERCURIAL TREMOR. [lect. xxxvin. informed us that, while the malady was coming on, he could not get up stairs to his work without first swallowing half a quartern of gin: and that he was obliged to drink porter two or three times a day. Tremor is always a token of debility. What is called tone of the muscular system is a sustained state of gentle contraction, due probably to the reflex power of the spinal cord. It is believed to be maintained by a continuous stream of nervous force; or by a succession of nervous impulses so rapidly repeated that their effect appears to be uninterrupted. AYhen the stream fails to be continuous, or when the impulses no longer succeed each other with the requisite rapidity, the muscular fibres relax and contract alternately and briefly, and the phenomena of tremor are presented. Some of the German physiologists have illustrated this view of the matter by experiments performed upon living animals. If a motor nerve be divided, the muscles supplied by it become flaccid and lax. A strong electric force applied to the separated nerve produces convulsive contractions of those muscles: but their natural tension and firmness may be restored by a weak current of electro-magnetism. AVhen the rotatory movement of the machine is sufficiently rapid, the stimuli follow each other so closely as to leave no perceptible interval between them, and the palsied muscles resume and retain their tone. But if the revolutions of the instrument are performed more slowly, so that the successive stimuli are separated by appreciable intervals, the mus- cular fibres relax in accordance with those intervals, and trembling occurs. The treatment, then, of tremor, considered generally, must consist in the adapta- tion to the particular case, of those natural agencies which tend to restore the lost tone of the body — well-chosen food, fresh air, regular exercise, and the like—and in the administration of tonic drugs, such as steel or quinine. I should expect—indeed I may say that I have witnessed in such cases — beneficial results from very small closes of strychnia. But when the tremor depends upon some known exciting cause, as in the mercurial tremor which is now before us, there is something preliminary to be done. AVe must, if we can, remove the patient from the further operation of the poison, and remove the poison already imbibed from the body of the patient. The first of these objects is secured by withdrawing him from the injurious atmosphere. The second may, I believe, be greatly facilitated and made complete by giving him suitable quantities of the iodide of potassium. This is comparatively new doctrine. It was put forth in 1849 by M. Melsens in a paper in the Annates de Chimie et de Physique, of which paper a translation, with some valuable prefatory remarks, was published by Dr. AVilliam Budd, in the British and Foreign Medical Review for January, 1853. " In all cases (says Dr. Budd) of mercurial and saturnine poisoning (for the paper comprehends slow poisoning by lead, as well as by quicksilver), M. Melsens assumes, and no doubt rightly, that the metallic substance is in actual union with the affected part or parts, and is retained there in the form of some insoluble compound. "According to his view, the iodide of potassium, after its absorption into the blood, combines with the metallic poison, and forms with it a new and soluble salt; liberates the poison from its union with the injured part; dissolves it out, so to speak, from the damaged fibre, and sets it once more afloat in the circulation. " The new compound thus set at liberty (under the form, it is presumed, of a double iodide of mercury and potassium) he supposes to be eliminated through the kidney almost as soon as formed, in combination with any excess of iodide of potas- sium that may happen to be present. So that poison and remedy being both cast out together, the cure may be said, in a peculiar sense, to be radical and complete." 31. Melsens gives some striking examples of the rapid cure of mercurial tremor by this specific treatment. In one of these cases mercury was sought for, and found, in the patient's urine, while he was taking the iodide. It is remarkable, too, that this man recovered perfectly, although he continued all the while to work at his trade as a gilder. Surely facts of this kind, if future experience shall authenticate them, are pregnant with important suggestions. In all probability it is in the very same way that the iodide of potassium combines with and carries off the syphilitic poison, and removes, often with a rapidity almost marvellous, large venereal nodes. There is one possible source of peril to be guarded against in this sort of cure. The poison, again set afloat, is no less a poison : and if it be suddenly reconveyed into the LECT. XXXVIII.] HYSTERIA. 445 blood in large quantity, it may compromise the patient's safety by converting his chronic disorder into a case of acute poisoning. Dr. Budd relates an instance of what I suspect to be a not very uncommon event. A patient of his in the Bristol Infirm- ary, was put under treatment by the iodide of potassium in free doses, for the cure of secondary syphilis. He had taken mercury largely some time before, but none for several months. In a few days he presented all the well known symptoms of severe mercurial ptyalism, although not a grain of mercury had been given after his admission. The caution required is that of carefully adjusting the dose, and carefully watching the effects of the remedy. You must begin with small quantities of the iodide, and gradually feel your way to larger. AVhen all the poison has been expelled, it may be necessary to give tonics. Even without the previous employment of the iodide of potassium, quinine has been found useful. But I have most faith in preparations of iron. My patient Chattin mended decidedly and rapidly when he began to take steel. It was not the mere avoidance of the cause of the complaint that produced the improvement, for he had been away from his work for a fortnight before he applied for admission. To prevent this effect of mercury, the workmen should be instructed to avoid, as much as possible, inhaling the poisonous fumes, to ventilate the room thoroughly, and to pay great attention to cleanliness. I believe the furnaces may be so built that the metallic vapour shall not reach the operator. If he cannot avoid being involved in it, perhaps some sort of respirator might afford protection. [A very peculiar form of convulsive disease has recently been described. It is characterized by repeated bobbings of the head forward, at first slight and occasional, but becoming, in process of time, so frequent and powerful, as to cause a heaving of the head forwards, towards the knees, succeeded by an immediate return to the up- right position, somewhat similar to the attacks of emprosthotonos. In one case, re- lated by J. AV. AA7est, these bobbings were repeated at intervals of a few seconds, teii, twenty, or more times, in each attack, which continued from two to three minutes, and recurred twice, thrice or oftener in the day; the attack occurring whether the patient was sitting or lying. During the attack, the child retained his consciousness. The other cases that have been since recorded by Drs. Barton and Bennett, in their general symptoms, differ in no degree from that of Mr. AArest, with the exception of that of Dr. Bennett, in which the disease was of a more aggravated character. Sir Charles Clarke has seen four cases of the disease, and from the peculiar bobbing of the head, has named it the Salaam Convulsion; Dr. Locock has seen two cases. One of Sir Charles Clarke's patients recovered perfectly, the other became paralytic and idiotic, and died at the age of seventeen. Mr. AVest has heard of two other cases — one of the patients lived to the age of seventeen; the other to ninetean, — both became idiotic. Faber (Scmidt's Jarbuch. vol. lxvii.,) relates two cases; one in a girl of three, and the other in a boy of six years of age. The patients whose cases are on record, were chiefly boys; their ages varied from three to six years — death did not occur in either; in some the disease appears to have ceased spontaneously. Of this strange form of convulsions, the pathology is still a subject for future in- vestigation, and until that is ascertained, its treatment must be tentative and experi- mental. — C] I proceed to the subject of hysteria: a subject highly interesting and important, as well as obscure and difficult. I scarcely know how to arrange what I have to say, so as to present the disorder to your notice in the most intelligible manner. Hysteria has characters peculiar to itself: but it is apt also to assume the form, and mimic the symptoms, of various other diseases of a much graver nature. If we are not capable of distinguishing the true malady from that which is its double, we shall be con- stantly committing most serious mistakes in the prognosis, to our own damage and discredit; and in the treatment, to the injury of our patient. I shall first attempt to describe to you the phenomena which are peculiar to hysteria; and then to point out the class of persons who are most subject to it; and afterwards I shall briefly advert to the imitative freaks which we are almost daily witnessing in hysterical constitutions, and to some other points connected with this extraordinary complaint. 446 HYSTERIA. [LECT. XXXVIII. I need not tell you that the hysterical paroxysm is almost, though not exclusively, confined to women. [AVe have repeatedly seen all the phenomena characteristic of hysteria in the male subject. The fact of their frequent occurrence in males is also stated by Sydenham, Louyr Villermay, Georget, Ferriar, Frotten, Conolly and others. See also the admissions of Dr. AVatson towards the close of his remarks on the pathology of the disease. — C.] It occurs under a great variety of forms, but they may all be reduced, for conveni- ence of description, to two. The first of these has a general resemblance to an epi- leptic fit. The trunk and limbs of the patient are agitated with strong convulsive moments: she struggles violently, like a person contending; rises into a sitting posture, and then throws herself back again; forcibly retracts and extends her legs, while her body is twisted from side to side: and so powerful are these muscular con- tortions that it often is all that three or four strong persons can do to restrain a slight girl, and prevent her from injuring herself or others. The head is generally thrown backwards, and the throat projects; the face is flushed; the eyelids are closed and tremulous; the nostrils distended; the jaws often firmly shut; but there is no distor- tion of the countenance; the cheeks are at rest, unless when, as often happens, the patient is uttering screams or exclamations. If the hands are left at liberty, she will often strike her breast repeatedly ami quickly, or carry her fingers to her throat, as if to remove some oppression there; or she will sometimes tear her hair, or rend her clothes, or attempt to bite those about her. With all this, her breathing is deep, labouring, irregular; and the heart palpitates. After a short time this violent agita- tion is calmed: but the patient lies panting and trembling, and starting at the slightest noise or the gentlest touch; or sometimes she remains motionless during the remissions, with a fixed eye; till all at once the convulsive movements are renewed : and this alternation of spasm and quiet will go on for a space of time that varies con- siderably in different cases; and the whole attack frequently terminates in an explo- sion of tears, and sobs, and convulsive laughter. There is a variety of this form of hysterical paroxysm, in which the patient suddenly sinks down insensible, and without convulsions : with slow and interrupted breathing, a turgid neck and flushed cheeks; and she recovers from that condition, depressed in spirits, fatigued, and crying. You will observe that the symptoms I have been enumerating belong to the nervous system; and indicate great derangement in the functions of animal life. In the other of the two forms to which all the various modifications of the attack may be reduced, the principal marks of disturbance are referrible to some of the viscera. The patient experiences a sense of uneasiness in some part of the abdomen, frequently towards the left flank; a ball appears to roll about, and to rise first to the situation of the stomach, and then to the throat, where the patient feels a choking sensation; the action of swallowing is frequently repeated; the abdomen becomes distended with wind, loud rumblings and sudden eructations take place; there is much palpitation of the heart, the patient is sad and sorrowful, and prone to shed tears. After the paroxysms, these patients commonly void a large quantity of limpid, pale urine, looking almost like water; and this is sometimes expelled during the fit. Such is a brief, and, I am aware, incomplete account of the hysterical paroxysm. It sets forth, however, in outline, tho two principal varieties of the attack : and you are to observe that the last, the quieter form, is often the prelude to the convulsive; but it not seldom also occurs alone, and then is as indicative of hysteria, as the petit mal, to which it is somewhat analogous, is of epilepsy. And before I go any further, let us again inquire into the circumstances which distinguish the paroxysms of those two diseases, epilepsy and hysteria. I have shortly adverted to these discriminative circumstances before; but we shall be better able to appreciate them, now that the main features of each diseased state have been under our consideration. It is of great importance to be able to render the diagnosis certain and accurate. It is a dreadful announcement to have to make to a father or a mother that their child is epileptic; whereas, hysteria, though it is sufficiently dis- tressing, is attended, in nine hundred and ninety-nine cases out of a thousand, with LECT. XXXVIII.] HYSTERIA. 447 no ultimate peril, either to mind or body. In some instances the diagnosis is per- fectly easy : in others it is dubious and full of anxiety. AVhenever you°fail to satisfy yourselves completely as to the nature of a given case, you will do well in lc<^al phrase, to give your patient the benefit of your doubt, and acquit her of epilepsy; or pronounce her guilty of the minor offence of hysteria., The points of resemblance, and the points of distinction, belonging to the hyste- rical and the epileptic paroxysm respectively, have been very clearly summed up by Foville. There are two principal forms of each disorder. In each, one of these forms is convulsive, and the other is not. The non-convulsive form of epilepsy relates exclu- sively to the sensorium : it is characterized by vertigo, and by a suspension (however brief and transitory) of the mental powers. The non-convulsive form of hysteria has little apparent connexion with the animal functions : its palpable phenomena consist in derangement of the organic functions of the thorax and abdomen. It is the ganglionic portion of the nervous system that seems chiefly disturbed. In the epileptic fit there is an entire loss of consciousness. The patient, on emerging from the paroxysm, recollects nothing of what has been going on during its continuance. It is not so in the hysterical fit. The loss of consciousness is very seldom complete : and it never occurs at the outset of the attack. The patient often is able to repeat (though she may not always choose to confess it) what has been said by the bystanders during the period when she seemed insensible. This is a point of distinction well worth remembering, for more reasons than one. It not only helps the diagnosis when the fact comes out; but it suggests certain cautions to ourselves. AVe must take care not to say anything by the bed-side of a hysterical patient, which we do not wish her to hear: and we may take advantage of her apparent uncon- sciousness, and pretend to believe in it, and speak of certain modes of treatment which she will not much approve of, but the very mention of which may serve to bring her out of the fit. In the epileptic paroxysm the face is usually livid; and foam, which is frothy with air, or red with blood, escapes from the patient's mouth. These are symptoms which we do not see in the fits of hysteria. The convulsive movements even, offer some characteristic shades of distinction. In epilepsy they are often more marked on one side of the body than on the other, and less irregular : the same movements are rapidly repeated : there is a strangling rattle in the breathing: while in hysteria the forcible flexion and extension of the limbs, and the contortions of the trunk, are more sudden, and, as it were, capricious; the respiration is deep, sighing, mixed with cries, and sobs, and often with laughter. But, perhaps, the convulsive motions differ most in the face. The epileptic expression is usually frightful: the eyelids half open, the eyeballs rolling, the mouth drawn to one side, the teeth grinding, the gums exposed by the retraction of the lips, the tongue protruded and bleeding, the complexion leaden; while in hysteria the cheeks are red, but at rest; the eyelids are closed and trembling; if you raise the upper one, you will see the eye fixed, perhaps, but it is bright, and very different from that of the epileptic, which, if it be not rolling, is dull, projecting, and the pupil usually dilated. Foville states that when, besides a sudden loss of consciousness with convulsive movements, there are also lividity of the face, and an escape of frothy saliva from between the lips, and the convulsions are more pronounced on the one side of the body than on the other, the disease is epilepsy, and not hysteria: and I think he is right. By Dr. Marshall Hall the grand distinction between the two diseases is affirmed to be this :—that in hysteria, much as the larynx may be affected, it is never closed; in epilepsy, it is closed. Accordingly in the former we have heaving, sighing inspira- tion ; in the latter, violent ineffectual efforts at expiration. In the very outset of the epileptic paroxysm the respiration, I believe, is thus suspended. The hysterical seizure may be over in a quarter of an hour, or in less time than that; or it may last many hours, or even several days. The hysterical seizure is almost peculiar to women : and it seldom occurs in them except during that period of their lives in which the menstrual function of the uterus is or ought to be, in activity. In this country it is most apt to occur between the a^es of fifteen and forty; and in the vast majority of patients who do suffer it, you 448 HYSTERIA. [lect. xxxriu. will find some marked derangement of that particular function. These facts alone afford a strong corroboration of the ancient theory, which ascribed the whole of the phenomena to uterine disorder; and named the disease accordingly. You will hear or read of disputes as to whether the womb, with its appendages, or the nervous system, is the seat of hysteria. But such disputes are merely verbal, I conceive. No doubt the convulsive movements, and the mental affection, and the unnatural sensa- tions, depend upon some altered condition of the brain and nerves; but it does not follow that the disease originates in that altered condition. AA"e know that the uterus, or the ovaries, cannot of themselves determine the muscles to contract; but if they be in an unhealthy state they may act upon the muscles through the medium of the nervous system : and such I take to be the fact. How they do so we no more know than we know how the little finger is bent when we resolve to bend it. But, say some, we every day meet with diseased conditions of the uterus and ovaries — amenorrhoea, dysrnenorrhcea, menorrhagia, even disorganization — without any of these nervous symptoms. True; and we cannot always fathom the mystery of this. But one thing is certain, that there exists in some persons a much greater readiness to take on the disease, upon the application of the exciting cause, than in others. This predisposition I have had occasion to advert to again and again, since I began to speak of the spasmodic diseases of the nervous system. Such diseases occur in certain individuals only; and in these individuals there pre-exists a peculiar condition of the nervous system, "for which," says Dr. Alison, "we have no more precise or definite expression than nervous irritability, or mobility ; a condition which is more common in women and children than in men; and more common in all per- sons when in a state of weakness, than when in the full enjoyment of muscular strength; in women, particularly, more common about the menstrual periods, and immediately after delivery, than at other times; more common likewise in those in whom the monthly discharge is habitually excessive, or altered, as in leucorrhoea, or suddenly suppressed, or more gradually obstructed in the different forms of amenor- rhoea, than in others. In this condition of mobility, both sensations and emotions are intensely felt; and their agency on the body is stronger and more lasting than usual; continued voluntary efforts of mind, and steady or sustained exertions of the voluntary muscles, are difficult, or impossible; the muscular motions are usually rapid and irregular, and the ' animus, nee sponte, varius et mutabilis.' " In persons of this moveable temperament, spasmodic complaints are easily excited: and the tendency to their recurrence is increased by each repetition of them. Now the persons who suffer hysteria are of this class. They are commonly young women, in whom the process of menstruation is in some way or other disordered; and who either are naturally of a feeble constitution, or have been debilitated by dis- ease, or by their habits of life. Often they are pale; have cold hands and feet; are subject to chilblains; eat but little, and do not fancy meat, which they sometimes absolutely dislike and refuse; or their taste is depraved and capricious; they will devour wax candles, wafers, chalk, sealing-wax, slate pencil, and such trash. And what is very curious and characteristic, although they often abstain almost entirely from animal food for weeks or months together, and take very little nourishment of any kind, they do not in general emaciate. You might expect that, under such a mode of life, they would waste away; but they continue round, and plump, and smooth. Some of them are even ruddy. And belonging to women of this peculiar constitution there is one other very re- markable character, which it behoves us to make ourselves thoroughly acquainted with. Almost any part of the nervous system, in these persons, is liable, under the influence of slight causes, and even without any obvious cause, to fall into a disordered state of action and suffering, more or less resembling that which inflammation or organic disease might excite in the same part. This is a most important fact; because if we erroneously ascribe symptoms which really result from inflammation to mere nervous or hysterical disorder, we may suffer the patient to perish for want of active measures that might have saved her; and on the other hand, if we apply to these nervous, imitative, hysteric complaints, the treat- ment proper for inflammation, we shall generally, indeed, relieve our patient for the time; but we shall leave her more prone to the nervous affection than before, and permanently damaged by our mischievous activity. LTBCT. XXXVII1.] HYSTERIA. 449 [On the subject of the pathology of hysteria the reader is referred to the very judicious paper of Dr. Conolly in the 2d vol. of the Cyclopaedia of Practical Medi- cine, Philadelphia edition, 562, et seq.—C] I say that almost every kind of serious disease may be mimicked by what we must call hysteria. And your skill will sometimes be severely tasked to determine the true import of the symptoms, and the real nature of the case. One of the diseases which is most often copied by hysteria, is inflammation of the peritoneum. You will find a patient complaining of acute pain of the abdomen, aggravated by the slightest pressure; and she shall have, perhaps, a hot skin, a quick pulse, and a furred tongue. When you meet with such symptoms in a young female, in whom there is any derangement or irregularity of the uterine functions, you will do well, before you bleed her to syncope, and cover her abdomen with leeches, to ask yourselves whether all this suffering may not be simply nervous. Search into her previous history as narrowly as you can. If you find that she has had similar attacks before; if she have been known to suffer hysterical fits; and if the tenderness be excessive, and, as it were, superficial, felt upon the slightest touch as much as when firmer pressure is made, you may generally spare the blood-letting, purge the patient well, and cause an asafoetida enema to be thrown into the rectum; and in a few hours you will find that the peritonitis has vanished. Among the pains which infest females of the hysteric constitution, and which are apt to be erroneously ascribed to inflammation, stitches and pains in the hypochondria are probably the most common. They are oftener complained of in the left hypo- chondrium than in the right. These things are much more generally understood now than they used to be even a few years ago. I cannot tell you how many persons I have seen who had been diligently treated with leeches, and blisters, and blue pill, for supposed chronic inflammation of the liver or spleen, or still more actively deple- ted for presumed pleurisy or pericarditis, when no such inflammation existed, and when the treatment, by reducing the strength, tended to rivet that mobility of system which was the chief predisposing cause of the pains. You would scarcely suppose that palsy — decided hemiplegia or paraplegia—could be simulated by hysteria: yet this certainly is the case; and I have seen instances of it even among hospital patients. They are difficult and perplexing cases. The sud- den occurrence of the paralysis, with no corresponding affection of the face or tongue, and without any of the other symptoms which commonly mark the real disease, its sudden disappearance, and, above all, the supervention of a hysterical paroxysm, will often disclose the true nature of the disorder. Dr. Todd asserts that in hysterical hemiplegia (which is generally incomplete) the patient drags the palsied leg along the floor after her as if it were dead, without endeavouring to lift it, and without that swinging-round movement of the limb observable in those who are hemiplegic from organic disease of the brain. Paraplegia, again, coming and departing with like sud- denness and caprice, is no unfrequent shape assumed by this changeful malady. The sensibility of the lower limbs is often impaired in these cases as much as, or even more than their muscular power. And having thus been led to toueh again on the subject of paraplegia, let me take the opportunity of repairing, parenthetically, an oversight and omission of which I was guilty when that disease was more directly under our consideration. I ought to have made you acquainted with a useful classi- fication of the phenomena of paraplegic disorders, suggested by Dr. Gull. Dealing with acknowledged facts, and referring to a large number of recorded examples, he remarks that when paraplegia results from local injury or local disease of the cord, the motor functions are always more involved than the sensitive; the palsy is always more decided, and more abiding, than the anaesthesia; and frequently there is no loss of sensibility at all. No circumscribed or segmentary affection of the spinal cord ever produces loss of sensation only, without loss of motion also. On the other hand, there are many cases of paraplegic disorder in which the anaes- thesia preponderates, or even sometimes exists alone. Experience teaches us not to expect to find, in these cases, after death, any local or limited disease of the cord. There are, in fact, two forms of paraplegic malady in which the loss of sensibility thus occurs alone; or precedes, or surpasses in degree, the loss of muscular power. In one of these the affection is primarily peripheral. Its causes (exposure of the sur- 29 450 HYSTERIA. [lect. XXXVIII. face to cold and wet being one of the commonest causes) act upon the sentient extre- mities of the nerves themselves, the muscular movements of the limbs being subse- quently impaired, if they are impaired at all. Of this I gave you some remarkable instances. In the other form the paraplegia and the diminished sensibility seem to have an encephalic origin; and its apparent causes are such as operate upon the ner- vous system generally — mental and moral causes — influences which tend to lower the nervous energy. No definite or appreciable change presents itself in the spinal cord; but sub-arachnoid effusions, collections of fluid in the cerebral ventricles, with general wasting, perhaps, or general softness, or general induration, of the nervous substance, are frequent concomitants of this condition. This disorder appears, I say, to be fre- quently the result of mental anxiety, of depressing circumstances, reverses of fortune, overmuch study, irregular habits of life, and similar exhausting agencies, long con- tinued. I am desirous of placing this classification before you, even thus irregularly, because I think it calculated to enhance the interest of every fresh instance of paraplegia; to facilitate our future study of that very difficult and obscure disorder; and to conduce to greater exactness in the framing of its natural history. To return from this digression to our current theme of mimic disease. Hysterical affections referred to the throat are very common. Aphonia, for example : the voice being lost on a sudden, and recovered as suddenly. Mock laryngitis. I remember being asked by Sir Charles Bell some years ago, to see a young woman in the Mid- dlesex Hospital under his care. She had recently arrived, and was breathing with the stridulous noise peculiar to inflammation of the larynx. She had twice before, in the country, had tracheotomy performed for similar attacks; and there were the scars of the operations on her neck : but both Sir Charles and myself were satisfied, upon considering all the circumstances of the case, that the difficult inspirations were spas- modic and hysterical; and she recovered under the remedies which do good in hys- teria. Inability to swallow, dysphagia, is another of the hysterical vagaries relating to the parts about the throat. Dr. Bright has a very instructive case of that kind. A patient was sent to Guy's Hospital for stricture of the oesophagus. It was stated that the difficulty of deglutition had existed for several weeks, and was increasing. The surgeon under whose care she was admitted was instantly struck by certain cir- cumstances which did not seem to consist very well with the notion that there was organic disease. Her appearance belied it, and her age. But he thought it right to examine the oesophagus by means of a probang; and no sooner was the instrument introduced, than the patient went into a hysterical fit, which was followed imme- diately by hysteria in several females in the same ward. The complaint turned out to be nothing but a hysteric constriction, and was soon completely removed. Surgeons are familiar with the " hysterical breast." The mamma becomes painful, tender, enlarges somewhat perhaps. The girl fears that a cancer is breeding. She communicates her alarm to her friends, and a medical man is consulted. If he hap- pen to be timid and inexperienced, he makes matters infinitely worse by applying leeches and fomentations; by examining the breast at every visit; and by keeping the patient's attention anxiously fixed upon it. Whereas the treatment ought to be directed to the state of the general system; and the local uneasiness spoken lightly of, or disregarded. Among the hysteric affections of the air-passages, there is a peculiar kind of cough which you ought to be acquainted with. It is loud, harsh, dry, more like a bark than a cough. Sometimes it is incessant, sometimes it occurs in paroxysms which, I verily believe, are more annoying to hear than to suffer. Hysterical affections of the diaphragm, again, are by no means rare. I had a very obstinate case of that sort in one of my hospital patients. She would sit in her bed all day long, uttering every eight or ten seconds a loud and most discordant hiccup. And I remember an out- patient, who presented a picture of perfect health, and who came week after week, to be cured of what I could consider nothing but a hysterical eructation: it was con- tinual and distressing, and prevented her from obtaining any employment as a servant. Hysterical vomiting is also frequent, simulating cancer of the stomach. Nay, hyste rical haematemesis. A romantic girl was for some months under my care in the hos- pital with that complaint. She vomited such quantities of dark blood (which did not coagulate, however), as I would not have believed if I had not seen them. Day aftei LECT. XXXVIII.] HYSTERIA. 451 day there were potfuls of this stuff: yet she did not lose flesh, and she menstruated regularly; and what was very curious, the vomiting was always suspended during the menstrual period, and recurred again so soon as the natural discharge ceased. I said she was romantic; but I should rather have said that she had that peculiar mental constitution which belongs to hysterical females. She used to write me long letters of thanks for my attention, though I was heartily tired of her; and these were couched in all the fine language of the Minerva press. At last I sent her away : just as bad as when she came into the hospital. This was five or six years ago; and last year she called at my house with a present of some game, and told me she had got married to a hair-dresser, and was quite recovered. There is a kind of sanguineous expectoration belonging to females of this class, and very likely to mislead the unwary. I meet with two or three instances of it every year. The patient exscreates daily, or at irregular intervals, a thinnish fluid some- thing like saliva, more or less tinged and streaked with brown or florid blood. A young hand investigates diligently the source of the bleeding, and puzzles himself to determine whether the case be one of haematemesis or of haemoptysis. Nine times out of ten it is neither the one nor the other. The blood comes from the mouth, or the fauces. Hysterical affections of the joints are common also. A young girl became my patient in the hospital for some trifling ailment, and after a short time she began to complain of great pain in her knee and hip; she could not stand upon the limb, nor bear to have it moved or touched. I got Sir Charles Bell to see her: he was so satisfied of the nature of the case — so convinced that it was a genuine example of inflammation and ulceration of the hip-joint — that he gave a little lecture to the pupils who stood round the bed, upon the characteristic position in which the patient lay; and he took her into one of the surgical wards to be under his own care. Some time afterwards I had occasion to go into that ward, and there I found my former patient with her heel drawn tight up against her buttock. It turned out that she had had no serious disease of the hip at all: both it, and the rigid contraction, gave way under measures which could have done no good to an ulcerated joint. I think the first clue to the real nature of her malady was the occurrence of a fit of hysteria. Sir Benjamin Brodie says, that among the higher classes of society, at least four- fifths of the female patients who are commonly supposed to labour under diseases of the joints, labour under hysteria, and nothing else. Another prank belonging to hysteria, and one which it is very necessary that you should be on your guard against, is that of mimicking disease of the bones of the spine. The patient complains of pain and tenderness in her back, and of weakness probably in her lower extremities; and it is now become notorious that scores of young women have been unnecessarily confined for months or years to a horizontal position, and have had their backs seamed with issues, for supposed disease of the bodies of the vertebrae, who had really nothing the matter with them but hysteria, and who would probably have soon ceased to complain if, instead of being restricted to that unnatural imprisonment and posture, they had taken a daily gallop on horse- back. It is curious enough to notice how the mind is apt to become affected in some of these cases. After the patient has been lying supine for some weeks, she is unable to stand or walk, simply because she thinks she is unable. The instant she makes a fair effort to use her limbs again, she can and does use them. Her condition is at once reversed. Potest quia posse videtur. Dr. Corfe, the present apothecary to the Middlesex Hospital, has no little trouble with patients of this kind; but he generally succeeds in making them walk, and in convincing them, as well as himself, that they may do so with impunity. Sometimes, though the authority of the Doctor may not be efficacious in this respect, some stronger influence prevails. A lady told me not very long ago that an acquaintance of hers, a member of a family of distinction, had been lying I know not how long on her back; that position having been prescribed to her by some medical man for a presumed disease of the spine. She lost all power of using her legs; but she got quite fat, as, indeed, well she might, for her appetite was remarkably sharp, and she lived chiefly upon chicken; and the number of chickens she devoured was incredible. She lived at some little distance from town, and at last Sir Benjamin Brodie was sent for to her. Now Sir Benjamin, to use a 452 HYSTERIA. [LECT. XXXVIII. vulgar phrase, is up to these cases; and he wished to see her try to walk: but she declared that the attempt to do so would kill her. He was resolute, however, and had her got out of bed; and in a few days time she was walking about quite well, and very grateful to him for his judgment and decision. A medical man of less name, or of less determination, would probably have failed. Dr. Bright has a good example of a somewhat similar kind; showing the power of another form of influence. He was asked to see a young lady who had been confined to her bed for nine months. If she attempted to move she was thrown into a paroxysm of agitation, and of excru- ciating agony, affecting more particularly her abdomen. She had almost lost the use of the lower extremities; and she and her friends seemed to have given up all hope of her restoration. But she presented no appearance of important disease; her countenance bore no marks of visceral mischief; nor was it possible to discover any proof of organic change. Dr. Bright set the case down in his own mind as one of hysteria. She was thought to have derived relief from some stimulating injection, and from certain pills. As her friends were in moderate circumstances, Dr. Bright talked seriously to the mother, and recommended that simple water should be em- ployed for the injection, and that bread pills should be substituted for those the girl had been taking. The mother soon perceived that these means produced the same tranquillizing effects on her daughter which had hitherto been ascribed to the medicine. " My visits," he says, "became less frequent; I was absent a fortnight: on my renewing my visit, no change had taken place. I attempted to get her shifted gently from the bed to the sofa, but it was impossible; the paroxysm almost overcame her. Once (after having, attended altogether about nine months) I called after an absence of nearly a month; her sister met me at the street-door with a smiling face to tell me that our patient was quite well: and on inquiry, she related how, three mornings before, under a deep religious impression, she had completely recovered all her powers; and I found her sitting up, working and amusing herself as if she were completely convalescent from some ordinary illness." Southey, in one of his published letters, speaking of his mother, says — " While she was a mere child she had a paralytic affection, which deadened one side from the hip downward, and crippled her for about twelve months. Some person advised that she should be placed out of doors in the sunshine as much as possible; and one day, when she had been carried out as usual into the forecourt, in her little arm-chair, and left there to see her brothers at play, she rose from her seat, to the astonishment of the family, and walked into the house. The recovery from that time was complete." These are the cases which suit the purposes of miracle-mongers. A few years ago all the journals belonging to a certain party in the religious world were full of an instance of miraculous cure. The patient was a young woman; her legs had been paralytic, or contracted, I forget which; some enthusiastic preacher had influence enough with her to make her believe that if on a certain day she prayed for recovery with a strong faith, her prayer would be successful, she would recover at once; and she did so. No one can doubt that it was just such a case as those I have now been mentioning. Many of these pseudo-diseases terminate suddenly under some strong moral emotion. A fall—a fire in the house — any overwhelming terror, will sometimes put an end to them. And where the joints have been the parts affected, several patients have declared that they felt a sensation as if something had snapped or given way in the part, immediately before the sudden recovery took place. Some of the shapes assumed by this pathological Proteus are hideous and disgusting. Paralysis of the muscular fibres of the bladder, or spasm of its sphincter, sometimes really occurs, sometimes is only aped, in hysteria. It is a common trick with these patients to pretend that they labour under retention of urine ; and that, although the bladder is full, they cannot make water. The daily introduction of the catheter by a dresser or apprentice appears to gratify their morbid and prurient feelings. Some- times, no doubt, the difficulty is real; but it is oftener feigned or exaggerated. I have again and again known it disappear upon the patient's being left, without pity, to her own resources. But girls have been known to drink their urine, in order to conceal the fact of their having been obliged and able to void it. The state of mind evinced by many of these hysterical young persons is such as to entitle them to our deepest commiseration. The deceptive appearances displayed in the bodily functions and LECT. XXXVIII.] HYSTERIA. 453 feelings, find their counterpart in the mental. The patients are deceitful, perverse, and obstinate: practising, or attempting to practise, the most aimless and unnatural impositions. They will produce fragments of common gravel, and assert that these were voided with the urine: or they will secrete cinders and stones in the vagina, and pretend to be suffering under some calculous disease. A young woman contrived, in one of our hospitals, to make the surgeons believe that she had stone in the bladder: and she actually submitted to be placed upon the operating table, and to be tied up in the posture for lithotomy, before a theatre-full of students; and then the imposture was detected. Sometimes they simulate suppression of urine, and after swallowing what they have passed, vomit it up again, to induce the belief that the secretion has taken place through the new and unnatural channel. It is impossible, I say, not to pity the unhappy victims of this wretched disorder, when their morbid propensities drive them to such acts as these. I mention them because you must expect to meet with such cases; and because while you take care not to express your suspicions prematurely, or on light evidence, you should be upon your guard against the mortification of being deceived, by the false signals held out, into active and ill-directed measures of treatment. There is another very common hysterical pain which I ought to have mentioned, viz., a pain occupying some one point in the head; the patient speaks of it as a sen- sation like that which would be caused by driving a nail into the part; and the afff > tion has therefore been called the clavus hystericus. It is often situated just above one eye-brow; and it sometimes comes on every day, at the same hour. Now in these cases it imitates very closely the hemicrania, which constitutes no uncommon form of an intermittent, and is called, accordingly, the brow ague. The distinction between the two — whether the affection, I mean, be hysterical or aguish — is not of any great consequence: but in many of the previous examples of hysterical pain mimicking organic or inflammatory disease, the diagnosis is obviously of the greatest moment. How, then, is it to be made ? You may, generally, I believe, be led to a right judgment if you look to the several points that I have incidentally touched already. You may guess that the affection is hysterical if the patient be a young unmarried woman; if there be any disorder or irregularity in the uterine functions; if you can gather any history of former hysterical disease; and especially if she be subject to fits of hysteria. The suspicious symptoms may often be traced back, and found to spread themselves over a considerable previous period of time; yet there is no such wasting, or commensurate deterioration of the general health and strength, as might be expected in organic disease. When the complaint simulated is some acute local inflammation, and there is pain, increased upon your pressing the part, you will find that the pain is aggravated by the gentlest touch; it is more felt if you brush your hand over the surface, or slightly pinch up the integuments, than when firm pressure is made: and you will find also that this exquisite tenderness is not limited to the part complained of. Suppose it to be the abdomen, the patient will shrink and exclaim if you suddenly put your finger on her neck, or her arm. The suspicion that the disorder is nervous or hysterical will also be corroborated if the symptoms which resemble the symptoms of inflammation arise and subside rapidly, without obvious cause for such fluctuation; and if various organs appear to be attacked in succession. Between the several symptoms that mark real disease there is always (as we learn by experience) a certain congruity and relation; but in the simulative displays of hysteria the symptoms are apt to be irregular, inconsistent, contradictory. When, after the most careful inves- tigation of the case, you still doubt, it will be right either to pause, or to treat it upon the most tmfavourable supposition. The consequences of suffering active inflammation to go on unchecked would be far worse than the temporary and slight and remediable injury to the system, which might result from once applying the remedies of inflam- mation to a case of mere hysteria. There is another hazard also which you must be aware of, and seek to avoid; that of overlooking real disease, when it is mixed with, and masked by, hysterical symptoms. It is not easy to lay down positive rules of action for all these supposable cases; but I trust that I have said enough to convince you of the importance of making the diagnosis of hysteric complaints a careful object of your future study. I have hitherto spoken of hysteria as if it were exclusively a malady of females. Etymologically, to apply that term to the diseases of males would oe absurd. But 454 HYSTERIA. [lect. XXXVIII. that peculiar modification of the nervous system which is observed in hysteric girls does certainly present itself, though rarely, in £bung men. I have seen two or three instances of what I could give no other name to than hysteria, in males. One of them was in the person of a young surgeon who had been house-surgeon to the Middlesex Hospital. I believe he applied to not less than a dozen medical men for advice: and in that batch I happened to have my turn. He had some of the symptoms that are ascribed to hypochondriasis; i. e., he was exceedingly attentive to his own sensations, and fancied that he laboured under a number of diseases which had no existence but in his own imagination; he showed great unsteadiness and infirmity of purpose; was what is called "very nervous;" and had occasional bursts of choking, and tears, and laughter, exactly resembling those which we so often witness in the other sex. Many cases of hysteria in the male have been recorded by different writers. The same moveable state of the nervous system, and the same symptoms referrible to that sys- tem, may exist in both sexes. In females, in nine cases out of ten, or in a much larger proportion, the exciting cause of the hysteria is connected with the sexual functions; and that is all that can be meant when it is asserted that, for the female, the complaint is not badly named, but has an intimate dependence upon the uterine sympathies. At the same time it is quite true that the " uterus is not the only organ of which the irritation may so affect the nervous system as to produce hysteria." As in epilepsy, so also in hysteria, the treatment to be adopted regards, first, the paroxysm itself; secondly, the condition of the patient during the absence of the paroxysm. One object, during the paroxysm, is to prevent the patient from injuring herself, by her hands, or by her teeth, or in her convulsive movements. Her dress should be loosened; but it may be necessary to confine her hands and arms. The next thing to be aimed at, is the putting an end to the fit. Various measures are found more or less useful for that purpose. The patient should be surrounded, as far as that is pos- sible, with cool fresh air. If she be able to swallow, you may sometimes shorten the attack by administering a couple of ounces of the mistura asafoctidae; or half a drachm of aather, with fifteen or twenty minims of laudanum in camphor julep; or a draught containing a drachm of the ammoniated tincture of valerian. When the patient can- not or will not swallow, she may sometimes be brought about by stimulating volatile substances offered to the nostrils. Signal good may also be effected by foetid or stimu- lant enemata: the enema asafcetidae, for example, made by mixing two drachms of asafoetida, with half a pint of water, by means of the yolk of an egg; or the turpen- tine injection, made in the same manner, and containing half an ounce of turpentine; or the same quantity of ice-cold water thrown into the rectum, or applied to the pudenda, will often bring the fit to a speedy termination. Indeed I believe there is more virtue in cold water, in hysterical diseases, than in any other single remedy. In the paroxysm it may be freely and repeatedly sprinkled, or dashed with some force, upon the face and chest. Active purges are beneficial and requisite in almost all these cases. There is commonly a costive, sometimes an obstinate, and'always an unnatural, state of the bowels. In those long paroxysms — if they may be so called — in which some other disease is simulated by hysteria, the cold affusion is a most valuable resource: especially in those forms of the disorder in which a limb is permanently bent, or incapable of motion. In several instances, in which such contraction had existed for a long time, it has yielded in the Middlesex Hospital, to a few minutes' application of the cold douche. Dr. Corfe, as I stated before, takes much pains with these cases. He pours cold water from a tea-kettle, or any other convenient vessel, in a small stream, from a moderate height, upon the contracted limb. It has been bent up for weeks perhaps; no power that you are able to exert can extend it; and any very forcible attempts to straighten it give the patient extreme pain. After the stream of water has been kept up for a short time, the patient complains of it very much; but Dr. Corfe is inflexi- ble — more so than the culprit limb — he goes on. Presently the limb begins to tremble, the tight state of the muscles is evidently on the point of yielding, and in no long time they are entirely relaxed and manageable, and the member becomes as lithe and moveable as ever. It often happens that the state of contraction recurs; but a repetition of the douche has always the same good effect, and by degrees the habit is proken, and the patient set free. It requires some determination to put this expe- LECT. XXXVIII.] HYSTERIA. 455 dient in practice. The patient looks upon you as a monster of cruelty: and, in pri- vate, the friends will not always allow such " rough " treatment, as they consider it. Sir Charles Clarke, who necessarily saw a great number of these cases—they are more common in the upper than in the lower classes of society—is a great advocate of this ducking system. A paper of his upon the subject was read before the College of Physicians a few years ago. He recommends a " sudden and lavish " application of water to the face; or the immersion of the whole body. He describes the class of patients, in whom the hysterical affection which is curable by that method occurs, as being generally females of a pasty complexion, fat, pale, and weak; or such as evince the ordinary signs of debility, a feeble pulse, cold extremities, and purpleness of parts distant from the centre of circulation. The age of the patients varied from ten to thirty years; in many of them menstruation was imperfect, or absent. A medical practitioner whom I met lately at a patient's house, told me he had just come from another patient, upon whom he had seen a surprising cure performed. A young lady, for many days, had been affected with trismus. She was unable to open her jaws, and therefore could neither speak nor eat. At last Sir C. Clarke was called in to see her. He presently comprehended the nature of her ailment, had her placed with her head hanging over a tub by the side of the bed; and proceeded to pour pitchers of water on her face. Before he had emptied the second, the patient began to scream and complain, giving very audible indications that she could open her mouth. I say although these patients get great relief by the treatment, they do not like it; and if they are convinced that it will be put in force, they will generally contrive not to require it. Of all the spasmodic affections, hysteria is that which is most readily propagable by what may be called moral contagion. When, in a large ward, one girl goes off in a fit, half a dozen others perhaps, all who chance to possess the hysteric diathesis, will experience a strong inclination to follow her example. But this chorus, as it were, of hysteria, is much more common in some wards than in others. A stern nurse, or a general order that the cold affusion shall at once be employed in every instance of a hysterical fit, will keep the complaint wonderfully in check : and on the other hand, great sympathy with such patients has a striking effect in encouraging the paroxysms. These facts show that the symptoms are, to a certain degree, under the patient's control. The fits are not wholly wilful; neither are they wholly unconquerable. I have but little to say respecting the medical management of such patients in the intervals between the paroxysms. The objects to be aimed at are, to restore the ner- vous system to the requisite degree of stability: and to correct the disordered func- tions of the uterine system. Now much the same plan of treatment is applicable to both these objects; and I spoke of the remedies that are found most beneficial for giving tone and firmness to the system, when I was upon the subject of epilepsy, and other nervous spasmodic ailments. The following points must be kept in view. The regulation of the bowels, which are mostly sluggish, by aloetic aperients; the exhi- bition of some form or other of steel; the steady employment of the shower-bath; regulated exercise both on foot and on horseback; the avoidance of hot rooms and of late hours, both in respect of going to bed, and of rising from it; the avoidance also of strong moral emotions, of novel reading, and of all the other thousand modes of dissipation, mental and bodily, which always accompany, and abate the blessings of, a high state of civilization. Marriage often proves a cure : sometimes it does not. The disposition to hysterical disorder may be more easily prevented than cured; but upon this point medical men are not consulted. Parents do not foresee the misery they are often laying up for their daughters by the unnatural mode of life to which they are subjected, for the sake of filling them with fashionable accomplish- ments. I cannot close this subject, and this lecture, better than by quoting Sir Ben- jamin Brodie's remarks on the same point, as I find them in a little work recently published by him, and containing many highly valuable observations and instructions in respect to local hysterical affections. " You can render (he says) no more essential service to the more affluent classes of society, than by availing yourselves of every opportunity of explaining to those among them who are parents, how much the ordinary system of education tends to engender the disposition to these diseases among their female children. If you would go further, so as to make them understand in what their error consists, what the/ 456 CATALEPSY. [lect. XXXIX. ought to do, and what they ought to leave undone, you need only point out the difference between the plans usually pursued in the bringing up of the two sexes. The boys are sent at an early age to school, where a large portion of their time is passed in taking exercise in the open air; while their sisters are confined to heated rooms, taking little exercise out of doors, and often none at all, except in a carriage. Then, for the most part, the latter spend much more of their time in actual study than the former. The mind is over-educated at the expense of the physical structure : and, after all with little advantage to the mind itself: for who can doubt that the principal object of this part of education ought to be, not so much to fill the mind with knowledge, as to train it to a right exercise of its intellectual and moral faculties; or that, other things being the same, this is more easily accomplished in those whose animal functions are preserved in a healthy state, than it is in others ?" LECTURE XXXIX. Catalepsy. Ecstasy. Neuralgia: Tic-douloureux; Sciatica; Hemicrania. There are yet some strange forms of nervous disorder which require to be men- tioned; but upon which I do not intend to dwell. Catalepsy is one of these; and what is called ecstasy another. These affections are very rare as well as very wonder- ful : so wonderful and rare, that weak and superstitious persons have referred them to the interposition of supernatural agents in human affairs; and stronger-minded persons, who happen never to have witnessed such diseases, deny their occurrence as fabulous, or laugh at them as the tricks and cheatings of imposture. They certainly do happen, however; and they happen mostly in the same class of persons in whom hysterical and nervous complaints of all kinds are most common. They often appear to be produced by similar causes with these: they resemble hysteria in being seldom attended with any danger to life: their pathology is, if possible, still more obscure than that of hysteria: and if I were to speak of the treatment which would seem to be most suitable for their cure or prevention, I should merely have to repeat what I said, upon the treatment and prevention of hysteria, in yesterday's lecture. I shall content myself, therefore, with a short description of these two affections, that you may be aware of their characteristic phenomena, and not be taken by surprise in case either of them should occur to you in your practice. A fit of catalepsy implies a sudden suspension of thought, of sensibility, and of voluntary motion; the patient remaining, during the paroxysm, in the position 1l> which she (for it is almost always a female) happened to be at the instant of tho attack, or in the position in which she may be placed during its continuance; and all this without any notable affection of the functions of organic life. This is certainly a very curious state, and one different from any that we have yet contemplated. We have had the muscles rigidly contracted with tonic spasm, while the powers of the mind, and the sensibility of the body, were unimpaired. We have had the same muscles shaken with clonic convulsions; both with and without coexistent disorder of the intellectual functions. But here we have a new phenomenon: the mental faculties are in abeyance, and the sensibility is abolished, and so also is the function of voluntary motion ; but the limbs are not tied down by spasm : nor agitated by successive contraction and relaxation of their muscles; nor yet left, like portions of dead matter, passively obedient to the laws of gravity: they assume any posture in which they may be placed, and that posture, however absurd, however (to all appearance) inconvenient and fatiguing, they retain, until some new force from without is applied to them, or until the paroxysm is at an end. The patient so affected, with open staring eyes often, and outstretched limbs, looks like a waxen figure; or an in- animate statue; or a frozen corpse. Indeed, Hoffman seems to have formed the strange lect. xxxix.] CATALEPSY. 457 conclusion that, as catalepsy, so far as he knew, occurred most frequently in winter, it must depend on congelation of the nervous fluid. These singular attacks occur in paroxysms; and they have been known to alternate with well-marked hysteria; and to take place in connexion with insanity. I have never seen an instance of perfect catalepsy, which I now regret, as I once had an op- portunity of doing so, of which I did not avail myself. Dr. Gooch has described a case of it, as he witnessed the disease in a patient who suffered puerperal mania. She had long been subject to the common forms of hysteria. This is illustrative of what I have often stated respecting the consanguinity of these nervous disorders. It had become necessary to confine this patient in a strait-waistcoat; she was attended by Dr. Gooch and Dr. Sutherland. I will quote Dr. Gooch's account of the cataleptic state, for it is authentic and modern. He says, "A few days after our first visit we were summoned to observe a remarkable change in her symptoms: the attendants said she was dying or in a trance. She was lying in bed, motionless, and apparently senseless. It had been said that the pupils were dilated, and motionless, and some apprehensions of effusion on the brain had been entertained; but on coming to examine them closely, it was found that they readily contracted when the light fell upon them; her eyes were open, but no rising of the chest, no movements of the nostrils, no appearance of respiration, could be seen; the only signs of life were her warmth and pulse; the latter was, as we had hitherto observed it, weak, and about 120. " The trunk of the body was now lifted, so as to form rather an obtuse angle with the limbs (a most uncomfortable posture); and there left with nothing to support it; there she continued sitting while we were asking questions and conversing ; so that many minutes must have passed. One arm was now raised, then the other; and where they were left, there they remained. It was now a curious sight to see her, sitting up in bed, her eyes open, staring lifelessly, her arms outstretched, yet without any visible sign-of animation. She was very thin and pallid, and looked like a corpse that had been propped up, and had stiffened in this attitude. We now took her out of bed, placed her upright, and endeavoured to rouse her by calling loudly in her ears; but in vain. She stood up, but as inanimate as a statue. The slightest push put her off her balance. No exertion was made to regain it. She would have fallen if I had not caught her. " She went into this state three several times. The first time it lasted fourteen hours, the second time twelve hours, and the third time nine hours; with waking intervals of two days after the first fit, and one day after the second. After this the disease resumed the ordinary form of melancholia; and three months from the time of her delivery she was well enough to resume her domestic duties." There is a minor form of this affection described, in which the patient is incapable of moving or speaking, but is conscious of all that goes on around him at the time. I saw a lady last year, who was subject to these attacks of imperfect catalepsy: which have been whimsically, but very expressively, called also attacks of daymare. From her time of life, her habits, and some other points in the history of the disease, I concluded that in her case these seizures, of temporary loss of muscular power with- out loss of consciousness, were dependent upon a diseased state of the blood-vessels of the brain. She afterwards consulted Dr. Chambers; and he told me that he had formed the same opinion of the nature and cause of the symptoms. In what is called ecstasy, the state is different. The patient is lost to all external impressions; but wrapt and absorbed in some object of the imagination. The muscles are sometimes relaxed; sometimes rigid as in slight tetanus; but the loss of volun- tary power over them is not complete or universal, for these patients often speak in a very earnest manner, or sing. They are, as the term txo-taai j imports, out of the body at the time, wholly engrossed in some high contemplation. This state is not uncom- mon as forming a part of religious insanity; and sometimes it runs into ordinary hysteria. Nervous and susceptible persons are apt to be thrown into these trances under the influence, whatever it be, of mesmerism : and grave authors assure us that the intelligence which then deserts the brain, concentrates itself in the epigastrium; or at the tips of the fingers: that people in that state read letters which are placed: upon their stomach, or applied to the soles of their feet; answer, oracularly, enig- matical questions; discover and declare their own and other persons' internal org*»m