congestion of the liver produce the hæmorrhages we have just described. I have recently witnessed a case, wherein the piles alternated with spitting of blood, and both were evidently dependent on congestion of the liver.

Congestion of the liver, by impeding in its course the volume of blood that is distributed to the abdominal viscera, is also, as we have remarked already, productive of diseases in remote parts of the system. Pulmonary diseases are often seen in connexion with congestion of the liver; and the commonest form it assumes is bronchitis chronica, a disease admirably described by Dr. Armstrong *. This connexion has also been pointed out by Drs. Philip and Hastings. As might be expected, pulmonary consumption is no infrequent consequence. In his lectures, Mr. Abernethy relates a striking example, which occurred in his coachman's wife, who was apparently in the last stage of phthisis, and who recovered by the use of medicines which produced tar-like evacuations from the bowels. The case of Mr. C. is one in point. After a tremendous inflammation of the lungs and pericardium, his recovery was retarded by congestion of the liver. The disease put on the aspect of phthisis, and his stools manifested no secretion of bile. Eventually a diarrhoea of tar-like offensive matter came on, the function by the liver returned, and his recovery was then rapid and complete. All observers have pointed out the connexion of gout with a morbid condition of the liver, of which indeed it may be regarded as the natural cure. These vicarious diseases vary with the predisposition of the individual: accordingly we sometimes see the head, the organ that is soonest called into sympathetic action; and the consequences are hypochondriasis, or apoplexy. Of the former disease, I have witnessed several examples, where the mental affection was strongly marked. The abdominal

* Armstrong on Consumption, p. 178.

excretions being black, or dark green, denoted the condition of the liver; and the affection of the head, in addition to the mental disturbance, was denoted by headache, heat of the head, and flushing of the face. There was, however, no distinctly formed pyrexia. In one example a discharge of black matter from the bowels was preceded by a rigor which resembled an ague-fit. Cases of melæna combined with apoplexy are not uncommon. In two cases which fell under my observation, in addition to coma, the face was flushed, the head burning hot, and the blood and pulse indicated fever.

4. As the treatment of many of the diseases we have enumerated has been long settled on the sure basis of experience, our remarks on this part of the subject will be very general. Indeed, in the present state of medical practice, there is more room for showing the rationale of many of the practices which have been handed down to us by our fathers, than for the addition of any new ones. It is, however, an indirect proof of the soundness of pathological speculations when they square with the established methods of cure. The fatal examples of Cullen and Brown should deter us from deviations in practice on theoretical grounds.

We have remarked that the remora occasioned by venous congestion of the larger organs, as the brain and liver, gives rise to an increased action of the arteries; and hence it is, that this condition of the organ is in no long time complicated with inflammation. Indeed, a state of venous congestion precedes and alternates with all pyrexial diseases, and is characterized by coldness, paleness, and shiverings. It is called by nosologists the cold stage, to distinguish it from the reaction which ensues. It is worthy of remark, that sometimes, from constitutional debility, the stage of reaction is never established; and the patient dies with all the symptoms of venous congestion. In typhus and scarlatina this is not uncommon.-In hot climates, it is in this primary stage, and this only, that remedies are availing in fevers and inflamma

tions. During this short prelude to the storm, copious bloodletting, the warm bath, &c. moderate the reaction, the violent efforts of the heart and arteries to restore the equilibrium of the system; otherwise the squall, as Dr. Rush emphatically calls it, lays the system prostrate, and disorganizes some of the vital organs. On this principle, then, the necessity of bloodletting in venous congestions of the graver kinds is obvious. At the same time, such is the state of what we will call debility, for want of a better term, that unless cordials are previously administered, and the patient put into a warm bath, a sufficiency of blood cannot be abstracted. In this climate, in such diseases, a succession of smaller bleedings is safer than one full evacuation by the lancet. In all the cases which have occurred to me, every succeeding venesection has been borne better, and has been larger than the one that preceded it; accurately noting in the phraseology of pathologists the decrease of debility, but in correcter language the diminished oppression of the venous system.

Although in the minor forms of venous congestion, cordials are sufficient for their removal, in the graver forms they are quite inadequate. The lever is not long enough to lift the load, and it cannot be lengthened, inasmuch as stimulants excite only in certain quantities; beyond this limit they act as debilitants. In the illustration of the lever and the load to be removed, if we cannot lengthen the one, we must lighten the other; so in these diseases our only resource is, to relieve the oppression of the veins by a careful abstraction of a portion of their contents.

We have seen, that in cases of venous congestion, the extreme vessels, the exhalants as they are called, are in an atonic state, and hence it is that the skin is supple and bedewed with a clammy sweat, the stomach nauseated with vitiated secretions; that there is often watery diarrhoea, and always an excessive flow of pale urine. Even the secretion of the liver is changed, and sometimes the effect upon the salivary glands

produces a salivation. The indications arising from these symptoms are obvious: the warm bath; frictions of the surface; purgatives; mercury sometimes, and medicines which tranquillize the stomach, complete the catalogue of remedies for venous congestion.

NARRATIVE

OF AN

UNUSUAL CASE OF UTERO-GESTATION;

IN WHICH

THE PREMATURE EXPULSION OF ONE FETUS PRECEDED
BY TWO MONTHS THE BIRTH OF A TWIN FETUS
AT THE FULL TERM.

BY W. NEWNHAM, ESQ.,
Surgeon, of Farnham, Surry.

On the 16th of November 1822, the wife of Benjamin Binfield, labourer, residing at Long Bottom, in the parish of Farnham, was confined prematurely with a still-born foetus. For two days previously she had suffered from irregular uterine action, which had induced her to send for her midwife unnecessarily; but on the present recurrence of effective pain she was speedily delivered, and in a few minutes afterwards the placenta was expelled.

The midwife now discovered that there was a second fœtus in utero, and was a little disconcerted by not finding a return of pain. However, she took the resolution of waiting, and when her patience was exhausted, sent for me. It was four o'clock in the afternoon of the 17th of November (about twenty-two hours after the birth of the above-mentioned stillborn fœtus), when I first saw this patient.

According to her own calculation she did not expect to be confined until Christmas; and upon a more particular inquiry,