becomes more and more decided as the disease advances. We may confidently affirm that the change in the quality of the circulating fluid precedes, by a considerable period of time, any lesion of the intestinal mucous glands-the primary point de depart of all the phenomena of fevers, according to Broussais and his followers.

Let it be remembered that we do not mean to say that the change in the composition of the blood, although it is unquestionably anterior to the lesion of the Peyerian glands, is the cause of fevers; it is rather one of the earliest effects. We have not yet succeeded in detecting the primary link in the chain, and perhaps we never shall." (The doctrine of the old physicians, that the miasmatic poison of genuine fevers acts primarily on the nervous system, and subsequently on the blood, is probably the correct one.) "However important the study of the blood is, we must be careful not to separate it from the examination of the solids. Bichat's memorable saying, that every exclusive theory, whether of humorism or of solidism, is a pathological absurdity,' should never be forgotten. The great aim of the wise physician will be to strive to ascertain what share each of the two great elements of all organization takes in the production of diseases. Morbid anatomy has re vealed a numerous catalogue of lesions of the solids; but as it has omitted to examine the changes of the fluids, the aid of analysis should now be called in to lead us to the truth."

6

The Importance of the Microscope.-"The microscopic examination of the fluids and solids is a most valuable part of morbid anatomy, as well as of morbid chemistry. Already it has conferred great benefits on medical science, and still more important discoveries no doubt are yet to be made. The scalpel, the test-tube, and the microscope are the three equally necessary implements of pathological study,-and the right mode of using each of them should be well understood by every medical student. Hitherto the former has occupied an almost exclusive attention; but now a sounder method of examination has been introduced, and already has produced some valuable results."

The Old Humoral Pathology.-Before dismissing the subject of alterations of the blood, M. Monneret has very appropriately re-called to his reader's attention the opinions of one of the physicians of the last century, Dr. Huxham, on the influence which such alterations have in the production of fevers and other diseases, with the view of comparing them with the doctrines of the modern humoral pathology.

Huxham commences his account of fevers with a description of simple fever or synocha, which he says, is produced by an increase in the action of the solids on the fluids of the body, and by the subsequent re-action of these upon the former. He mentions three cases in which this morbid state may be induced. The first is that of a person who has taken any violent exercise; here the mere excess of the action and re-action of the solids and fluids on each other is sufficient to bring on the state of simple fever. In the second case, the quantity of the fluids is increased; as for example, by the sudden check of the perspiration, when this abundant: fever is the consequence, and nature makes an effort to get rid of the excess of the humors. The third, is that of a person who has drank a large quantity of wine or any other stimulating fluid: the excitement brings on a simple fever, which, however, will quickly yield to rest and abstinence.

Sometimes the blood is driven along with so much force that its globules penetrate into those minute vessels which do not usually admit them; hence the obstructions and congestions which so often occur in the course of some fevers. The chief remedial agent recommended by Huxham is bloodletting.

"which by diminishing the quantity of the red globules renders the moving force more feeble."

Now this idea, that the detraction of blood has the effect of diminishing the number of the red globules, has been found by the researches of MM. Andral and Gavarret to be quite correct; and it is curious to observe that the results of recent analyses are in perfect harmony with the assertions of the old pathologists,— assertions, too, based upon mere speculative theories. We have already stated that in plethora there is always an increase in the quantity of the red globules, and that bleeding is the appropriate remedy for this condition; seeing that it very quickly diminishes the quantity of these, and does not very sensibly affect the proportion of the fibrine for some time. At the period at which Huxham wrote, considerable attention was paid to the microscopic examination of the fluids, in consequence of the great interest that had been excited by the researches and discoveries of Leuwhoeck.

He admits three leading kinds of alteration of the blood; the two first are what he calls the constitutional states of the blood, and the third is that of its dissolution and putrefaction.

The first abnormal modification is that in which the red globules are increased in quantity, squeezed one against the other, and pressed too compact and dense; hence, he says, arises an over viseid state of the fluid, and an unusual tendeney to coagulate and solidify, when drawn from the body; at the same time the increased rapidity of the circulation causes an unusual degree of friction of the blood against the sides of the vessels, causing a greater development of heat. When such is the case, there is always a disposition to synochal fever, and to obstructions in the minute vessels. He attributes the buffy coat to the heat of the fever, which tends to coagulate the serous portion of the blood, and to convert it into a jelly.

We need not say that the theoretical edifice constructed by the English physician with so much ingenuity crumbles down before the recent analyses of the blood as to the notion of the greater friction of the globules against the walls causing a greater evolution of heat, we all know that it is quite conjectural, and far too mechanical to be true.

2. The second morbid constitution of the blood is characterised by the diminu tion in the quantity and in the density of the globules, and by an increase in that of the serum or watery portion. This condition is accompanied with pallor of the surface, great weakness, imperfection of the secretions, and a tendency to dropsical effusions. There is also a disposition to obstructions, not indeed of an inflammatory kind, as in the former case, but of a cold or torpid character from the diminished excitability of the vessels, in which the blood is apt to stagnate. Passive congestions too are liable to take place in this manner. The diminution in the proportion of the red globules, which Huxham had adopted on hypothetical grounds, has been demonstrated in the present day. This condition is observed in cases of anæmia, chlorosis, and of cachexia induced by long continued chronic diseases.

3. The dissolved state of the blood is observed in scurvy, which may be considered as the type of this alteration; ha norrhage and adynamia are the chief phenomena indicative of its existence. The coagula of the blood are soft, loose, diffluent, and without any buffy coat. The serum separate only imperfectly from the coagulum. The blood drawn from persons affected with petechie and ecchymoses often forms a uniform semi-coagulated mass of a darker colour than usual, and passes readily to putrefaction. Huxham believed that the hæmorrhages are generally owing to the acrimony of the fluids destroying the contexture of the blood itself and corroding the minute capillary vessels. He says that, if we examine the blood while within the vessels, we may observe the globules elongated to enable them to traverse the small tubes. He thence infers that they

become broken up in their passage and that their debris enters readily the excretory vessels and transudes from their extremities. He thus accounts for the hæmorrhage which not unfrequently occurs from the bowels and urinary passages, as well as for the petechiae and ecchymosed spots on the skin and some of the mucous surfaces. A dissolved state of the blood is not incompatible with the development of inflammation. Huxham describes particularly an epidemic pneumonia which was exceedingly fatal, especially among the inmates of prisons, ships, &c. and in which, although all the symptoms of the disease of the lungs were present, the blood drawn was soft and devoid of its normal consistence. The causes of this condition of the blood are, according to him, two fold. In some cases it is the result of spontaneous changes within the vessels, and in others it is induced by the introduction of poisonous matters into the system. Among these the poisonous matters-he enumerates alkaline salts, muriate of ammonia (which has the effect of destroying or dissolving the blood-globules very rapidly), cherry-laurel water, mercury, salt and decayed provisions, the virus of serpents, &c. An elevated temperature has been considered by some to be sufficient to induce a dissolved state of the blood. Boerhaave tells us that be confined a dog in a heated stove, and that, in proportion as the animal sweated profusely, he observed a tendency to hæmorrhage from various parts of the body. However we may view this experiment, it will be admitted by all that fevers, in which the blood is in a thin uncoagulable state, are more common in hot than in cold and temperate climates.

As to the intrinsic causes, or those which are generated within the system itself, we may allude first to the admixture of purulent and other septic matters with the blood. The recent experiments of Gaspard, confirmed as they have been by subsequent researches, have most satisfactorily demonstrated the striking changes which the blood undergoes by the contamination of such matters. They seem to act more especially by modifying the relative proportions of the fibrine and the red globules, either by diminishing the quantity of the former or by increasing the quantity of the latter.

In taking leave of Huxham, we cannot avoid expressing our admiration at finding in his writings such a multitude of curious facts which, far from having been overthrown by the discoveries of modern analysis, have been confirmed in a very striking manner by them; and our admiration is the greater when we remember that it was only by reasoning and hypothesis that he was led to the enunciation of such important truths.-Gazette Medicale.

ON GANGRENOUS AFFECTIONS IN THE PUERPERAL STATE.

The mode in which gangrene takes place, and the causes which give rise to it, are often exceedingly obscure, except indeed in those cases in which it can be attributed to a direct obstruction of the circulation, as from closure or disease of the bloodvessels, or from mechanical constriction of any of the tissues of the body. Formerly the difficulty was imagined to be at once explained by summarily saying that gangrene is one of the consequences of inflammation. In the present day, on the contrary, some authors have gone so far to the opposite extreme as to think that, even in those cases where inflammation precedes the occurrence of the death of a part, this latter lesion is not the necessary effect of the former; but that it is connected with it accidentally, either from some obstruction to the course of the blood produced indeed by the inflammatory action, or from the introduction into the system of some foreign substance, such as air or some poisonous matter, or lastly, from a peculiar morbid state of the constitution itself.

Struck with the frequency with which gangrene takes place in the course of

puerperal diseases, M. Reynaud, in his recently published memoir on this subject, has brought together many cases in illustration, and after pointing out the fluctuating and ill-supported opinions of most writers-opinions which are almost always based on the doctrine of gangrene being the result of inflammation or of putridity-he groupes them in two classes:-1, gangrenous affections attributable to inflammation, and 2, those attributable to infection.

As to the cases reported in the first class, we might have expected to find that in them there had been present all, or at least the most prominent, signs of inflammatory action, developing itself gradually with greater or less rapidity, and ultimately terminating in gangrene; and yet this is not the case, if we may judge from the details narrated in the reports. Thus, in the first case, which is headed puerperal peritonitis with gangrene of the abdominal parietes, peritoneum, and intestine, the gangrene appeared, on the eleventh day after accouchement, on the surface of the abdomen, without having been preceded by any redness or swelling of the part; and it is not stated in the dissection of the patient, who died at the end of the third week, that the gangrenous portion of the abdominal parietes exhibited any traces of pre-existing inflammation.

The author narrates among the same groupe several cases where death occurred a few days after laborious delivery, and in which the internal surface of the uterus exhibited a gangrenous eschar of some lines in thickness. In these cases he attributes the lesion to the violent manœuvres which the body of the womb had sustained. But, when the uterus has been in part disorganized by the efforts which a difficult labour has rendered necessary, should we attribute the gangrene in such cases to inflammatory action ? Is it not rather a result altogether mechanical, such as we observe to take place after severe contusions, in which inflammation has little or no part at all?

The author seems to have been himself aware how little the phenomena of inflammation can be supposed in such cases to have any thing to do with the development of gangrene; as he tells us that, in these circumstances, we must not forget to take into account the condition of the female system after labour, or, in other words, the puerperal state. On the whole, we are inclined to give it as our opinion, judging from the very cases which M. Reynaud has recorded in his first class, that inflammation has only a very doubtful part in the production of gangrene in puerperal women; at the same time we acknowledge that it often accompanies it, as if the two states, gangrene and inflammation, were the result of the same cause. This leads us to the consideration of the second set of cases, those of gangrenous affections induced by infection.

Puerperal diseases arising from infection differ from other diseases attributable to the same cause in this particular, that in the latter the infection usually proceeds from without, while in the former it is engendered in the bodies of the patients themselves: such is at least the opinion of the physicians of the French school, who entirely reject the doctrine of the transmission of puerperal affections by direct contact.

Whatever may be the origin of the infection, we must not the less keep in remembrance that, occasionally under the influence of certain changes in the fluids of the body, we observe gangrene taking place. It is true that if we try to push our inquiries further, and to discover what it is that constitutes infection, or how it acts in producing gangrene, we find ourselves quite at a loss; but it is one step, and that an important one, gained, to have ascertained that such cases are of too frequent occurrence to be regarded as merely the results of a simple oincidence.

In this point of view, the work of M. Reynaud is very interesting, atlhough many of his observations are far from being satisfactory. What connexion, for example, can be found between the external veins filled with pus, and pulmonary gangrene, or between even inflammation of the lymphatic glands and gangrene of the uterus? None, certainly, as far as we can trace; and yet we do

not deny positively that these different morbid states may not be connected with each other. We are disposed to attach more importance to another source in explaining some of the facts adduced by M. Reynaud, in illustration of the tendency in the female system after delivery to gangrenous affections we mean, the absorption of unhealthy secretions from the internal surface of the womb, and their introduction into the circulation, first of the uterus, and ultimately of the entire system.

The ingenious explanation given by M. Genest of the developement of pulmonary gangrene in cases of apoplexy of the lungs and of metastatic abscesses in their parenchymatous tissue, by the admixture of the external air with the blood or purulent matter, should certainly not be lost sight of in investigating the phenomena of certain puerperal diseases.

We are glad to observe, from a recent account of the different forms of puerperal fever observed at the Hôtel Dieu in Paris, during the year 1840, by M. Bourdon, that this intelligent physician has shaken off the trammels of the Broussaian school as to the proximate cause of the disease:

He says,

"The fever exhibited always the same characteristic symptoms, with a peculiar aspect and march truly remarkable; while the lesions found on dissection were very different in different cases. Several of the lesions might be attributed to the inflammation, which, in this disease, terminates with extraordinary rapidity and ease in the formation of purulent matter in different parts of the body, such as the posterior parts of the limbs, the sub-peritoneal cellular tissue, &c.; but we could not regard certain other serious lesions, as the consequence of this peculiar kind of inflammation."

If, at the same time, we call to mind the fluid state of the blood in the heart and large blood vessels, the softening of almost all the viscera, &c. are we not authorized to regard puerperal fever as a disease which is intimately connected with some change or poisoning of the blood?-Gazette Medicale.

Remarks. With many of the preceding observations we heartily concur; and rejoice to find that, in France, as well as in our own country, some of the most practical writers of the day are beginning to pay attention to the state of the fluids in disease, more especially in malignant fevers. The doctrine that puerperal fever is in all, or even in most cases, an essentially inflammatory disease, and, therefore, that it requires an active antiphlogistic treatment, is fraught with the most pernicious consequences. The capital error that has been committed by most writers arises from the opinion, that this fever is at all times and in all seasons of the same type; whereas, in truth, perhaps no two epidemics of the disease are alike; just in the same manner as the epidemics of typhous and of the exanthematous fevers are observed to vary exceedingly in different years. We have too long forgotten to take into our consideration of such diseases the influence of which Sydenham and many of the older writers have denominated the medical constitution of the season; and yet what practical physician can have failed to observe the striking difference in the general character, as well as in the mortality, of febrile disorders in different seasons? Take, for example, scarlatina; is it not sometimes so mild as scarcely to require any medical treatment at all? whereas during another year it is attended with high phlogistic symptoms, and in a third it exhibits the type of malignancy and putridity.

The same holds good of puerperal fever. It is quite true that in some epidemics, and, we may add, in some cases during all epidemics, the disease is essentially inflammatory; but it is equally true that in other cases the inflammatory symptoms, if they occur at all, are only added to, and, as it were, grafted upon a morbid state of the system, which is dependent upon a vitiated state of the fluids, and a consequent serious lesion of the entire nervous system. Now this is very nearly the doctrine of the older school; and, however humiliating to modern pride it may be to find that with all our improved methods of research