"Medical writers afford numerous instances of a large effusion of bloody lymph into the cavities of the pleura, from diseases of the lungs, and in cases of violent death with long struggling......... A skilful and learned physician informed the editor that in cases of violent and painful death there is usually an effusion of lymph, or of lymph mixed with blood, into the cavities of the chest and abdomen. ...It is, however, reasonable to acquiesce with those who are of opinion that the evangelist here intended to express more than a pathological fact.'-The physician meant in this passage was no doubt the late Dr. Willan, who-in his History of the Ministry of Jesus Christ,'-makes a similar remark, equally indicative of doubt and uncertainty. We have instances of watery effusion into the cavities of the pleura to a considerable amount, in cases of violent death with long struggling.... . The phenomenon here men

tioned by the evangelist is generally looked upon as miraculous.'"* P. 135.

Some have supposed that the blood came from the heart and the water from the pericardium, both being pierced by the thrust of the spear. The elder Gruner thus comments upon the subject:

"It was doubtless the left side that was pierced by the soldier's spear. According to the testimony of John, immediately after the infliction of this wound there flowed out blood and water. Such an effusion could scarcely have taken place, except on the left side, under which, besides the lung, lies the pericardium full of water when a person dies after extreme anxiety, as likewise the heart, connected with the arch of the aorta. The lung slightly wounded might have yielded a little blood, but certainly not water. That conjecture is, therefore, the most probable, and the most in accordance with forensic medicine, which derives the blood from the [left] ventricle of the heart, and the water from the pericardium." P. 136.

In a special treatise on the cross and crucifixion, Kipping draws the same conclusion, with the exception of regarding the water poured out on this occasion as naturally contained in the pericardium. Bishop Watson too, in his Apology for the Bible, has adopted the same view. But then, as Dr. Stroud very justly remarks, the quantity of serum usually found in the pericardium after death is so small that, "in a case like that under consideration, it would have been absolutely imperceptible." Haller states that a small quantity, not exceeding a few drachms, has frequently been found in the pericardium of executed persons; and John and Charles Bell deny the occurrence altogether, except under very peculiar circumstances: "If," these eminent anatomists observe, a person have laboured under a continued weakness, or have been long diseased, if a person have lain long on his death-bed, if the body have been long kept after death, there is both a condensation of the natural halitus in all the parts of the body, and an exudation of thin lymph from every vessel, there is water found in every cavity from the ventricles of the brain to the cavity of the anklejoint, and so in the pericardium amongst the rest. But, if you open a living animal, as a dog, or if you open suddenly the body of suicides, or if you have brought to the dissecting-room the body of a criminal who has just been hanged, there is not in the pericardium one single particle of water to be found."

In the natural state, the quantity of the pericardial fluid is certainly very

* Hewlet's Bible, &c.; Notes on John, chap. 19, v. 34, and Acts, chap. 1, v. 18; Dr. Willan, History of the Ministry of Jesus Christ, &c. p. 195.

1847]

Its Physical Cause explained.

475

small; but after some forms of violent death, more especially when this has been attended with obstructed respiration, there is often rather more; and then it is either pure or tinged with blood. "An effusion of the latter kind is said to have been noticed in stags killed after a hard chase; and in some rare instances of sudden death, occasioned by strong mental emotion, the pericardium has been found distended with blood, owing probably, as Morgagni suspected, to organic disease, and the rupture of vessels; but for the statement of the Grüners that, after death accompanied with anxiety, the pericardium is full of water, there is no evidence."* Besides, if such an effusion take place slowly and gradually, the fatal result will be not sudden or unexpected, but lingering, and preceded by symptoms of oppression and suffocation. But this pathological objection has little weight, compared with that derived from the simple narrative of the sacred text; for is it not obvious that the discharge of blood and water must have been considerable, and the distinction between the two well marked, to have been clearly observed and so emphatically mentioned by St. John? Dr. Stroud remarks upon this point :

"Bloody serum, whether originally effused in that state, or resulting from subsequent mixture, would not have presented this character; for it would neither have issued rapidly, nor in sufficient quantity, nor would its distinction from ordinary blood have been so striking as to have attracted the attention of an uninformed, and somewhat distant spectator. Moreover, unless blood has been previously extravasated, little or none can by any kind of wound be extracted from a dead body, except by the action of gravity, the heart being usually empty, or, if otherwise, devoid of power to expel its contents. This important fact, overlooked by most other writers, was perceived and acknowledged by the Grüners, who nevertheless failed to discover the true explanation, and were induced to adopt the inadmissible opinion, that Christ was not actually dead when pierced by the soldier's spear, but merely in a faint and languid condition, which allowed the heart to act feebly, and, on being wounded, to pour forth its blood, preceded by the water, which they suppose had previously collected in the pericardium." P. 141.

The conclusion which our author deduces from the whole inquiry, of which we have given an abstract in the preceding pages, is given in the following words:

"It may, therefore with certainty be affirmed that, between the agony of mind which the Saviour endured in the garden of Gethsemane and the profuse sweat mixed with clotted blood which so rapidly followed it, violent palpitation of the heart must necessarily have intervened; this being the only known condition which could have been at once the effect of the former occurrence, and the cause of the latter. In like manner, when on the cross this agony was renewed, and by the addition of bodily suffering was increased to the utmost intensity, no other known condition could have formed the connecting link between that mental anguish and His sudden death,-preceded by loud exclamations, and followed by an effusion of blood and water from His side when afterwards pierced with a spear-than the aggravation even to rupture of the same violent action of the heart, of which the previous palpitation and bloody sweat were but a lower degree and a natural prelude. If, whilst every other explanation hitherto offered has been shewn to be untenable, the cause now assigned for the death of Christ, -namely, Rupture of the Heart from Agony of Mind-has been proved to be the result of an actual power in nature, fully adequate to the effect, really present without counteraction, minutely agreeing with all the facts of the case, and neces

sarily implied by them, this cause must according to the principles of inductive reasoning be regarded as demonstrated."

It is not without interest to learn that some of the commentators, ancient as well as modern, on the Gospels, had adopted views which, with the exception of certain extravagant expressions and errors of detail in their exposition, will be found to be in strict accordance with our author's ideas. Want of space, however, utterly precludes our giving any quotations.

But what is of much greater importance than any merely human corroborative testimony is the circumstance of there appearing to be a distinct allusion, in several prophecies in the Scriptures of the Old Testament, to the more remarkable of the physical effects of the Saviour's sufferings, including the bloody sweat, the intense thirst, and finally the mortal rupture of the heart. In the 22nd Psalm it is said,—" I am poured out like water; my heart is like wax; it is melted in the midst of my bowels: my tongue cleaveth to my jaws;" and, in the 69th, we read that "reproach hath broken my heart." There is a still more striking intimation of the cause of death in that memorable prediction in the 53rd ch. of Isaiah, where we are told that "He poured out His soul (or, as Michaelis and some other distinguished Hebraists render it, His life's blood) unto death." When too we remember that, in all the types in the patriarchal and Mosaic dispensations pre-figurative of the death of the Messiah, the shedding of blood was a necessary accompaniment of expiatory sufferings, and when we think of the symbols of the bread broken and the wine poured out in the rite of the last supper, not to mention the rending of the veil of the temple, the cleaving of the rocks, and the opening of the graves at the very moment of the mortal struggle, does not Dr. Stroud's explanation gain more and more upon our convictions? and do we not feel that he is justified in saying that, "the peculiar cause of the death of Christ, which by a regular induction from the evangelical narrative has been ascertained as a fact, remarkably illustrates the entire series of types and prophecies relating to that solemn event, which could not indeed in any other manner have been completely fulfilled? These in turn, by their minute and perfect correspondence with the circumstances, afford, if that were necessary, an additional confirmation of the fact itself; and the whole transaction demonstrates with irresistable evidence the special interposition and superintendence of the Deity."

And now we must take leave of our author, but not without again expressing our high admiration of his character and attainments, and saying at the same time that, in drawing to a close the present series of this Journal—and with it the Medico-Chirurgical Review itself as a separate and independent publication-it gives us very sincere gratification to have it in our power to recommend such a volume as the present to the thoughtful perusal of all our readers.

1847]

Levy on Measles in the Adult.

477

MEMOIRE SUR LA ROUGEOLE DES ADULtes. Par le Docteur Michel Lévy.

An Essay on Measles in the Adult. By M. Levy, M.D ; Chief Physician and Senior Professor of the Hospital of Instruction at Metz; late Professor at the Val-de-Grâce, &c. Octavo, pp. 48. Paris, 1847.

THIS brochure from the pen of Professor Levy, details the particulars of an epidemic of Measles in the Adult, which he has recently had the opportunity of witnessing at the Clinical Hospital at Metz, over which he so ably presides. The conclusions he has arrived at upon several interesting circumstances connected with the disease are well worthy the notice of our readers.

"The measles," he observes, "though manifesting itself less frequently among adults than children, is far from sparing these former to the extent supposed by several pathologists who have drawn the elements of their statistics exclusively from hospitals. In the most recent analytical work on medicine, the Compendium of MM. Monneret and Fleury, we find the statement-' After fifteen years the measles become rare.' This does not agree with the clinical observations at the military hospitals, which receive a large proportion of patients between the ages of 18 and 30. In these we are constantly meeting with cases of measles. In the east, south, and north of France, in Corsica, and the Morea, wherever, indeed, the vicissitudes of our career have taken us, we have seen young soldiers seized with measles, and frequently the affection attains in our garrisons the magnitude of an epidemic. During the siege of Antwerp, the ambulance at Boom, the surgical service of which was under my direction, received a certain number of cases of measles; and ten years' experience at Val-de-Grâce enabled me to observe these cases occurring periodically, and almost always proportionally to the extent the disease prevailed in the town. In 1837, the e were 60 cases alone in the service under my charge, the disease prevailing at the same time epidemically at Paris, Versailles, and other places. The foundation of the present work is constituted by the facts I have observed in the hospital at Metz during thirteen months, from the 1st Jan. 1846 to 28th Feb. 1847. It is first necessary to make the remark that the distinction which is judiciously drawn between the diseases of civil life and those of garrisons, is not applicable in respect to our subject. During the period embraced in our observation, the progress of measles has been precisely the same in these two groups of the population. Absent or sporadic in the town it has been equally wanting in the hospital, or was only seen there now and then: the attacks becoming multiplied in the city, it soon became epidemic in the garrison. The parallel was constant."

The number of cases observed during these 13 months amounted to 120, three patients only were less than 18 years of age, the oldest being 34.

Form of the Eruption.-Generally this was confluent, the face being almost always vultuous. In 10 cases the confluence was excessive. The papular form (boutonneuse) was observed in four cases. In four others the eruption was anormal, being scarcely observable on the body, while the limbs were covered with large numbers of bright red spots. Two patients had a violaceous suffusion of the face, and a discrete eruption over the body.

NEW SERIES, NO. XII.—VI.

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Progress of the Eruption.-In 99 out of the 120 cases this went through its regular stages. Delitescence took place in 21-10 times on the second, and 16 times on the third day. In 7 cases cold seemed to be the cause of the sudden disappearance of the eruption, and in 3 the delitescence coincided with intense diarrhoea; but diarrhoea manifested itself in many other cases without deranging the course of the eruption. As to the consequences of the suppression of the eruption there were none remarked in 14 patients, who were as promptly cured as if the eruption had pursued its usual course. Two were seized with diarrhoea and one with vomiting, but soon recovered. In another, varicella supervened, and in another, signs of phthisis. In six, severe bronchitis followed; and two died subsequently to the retrocession, one having succumbed to an assemblage of thoracic complications, and the other to severe capillary bronchitis and acute dysentery supervening upon the administration of tartar-emetic. Of these pulmonary complications M. Levy thus speaks :

"Dyspnoea, oppression, intense cough, bright coloration of the face, and even anxiety, are not certain indications of an inflammatory complication of the small bronchi or the pulmonary parenchyma. We have seen these symptoms carried to a high degree in measles with slight catarrh as fugacious as the exanthem; and then they disappeared as if by enchantment when the eruption had entirely come out. They are only the expression of a general labouring of the organism, resolving itself in the eruption. When they subsist after the complete evolution of this, they announce the co-existence, not of an ordinary bronchitis, but of a suffocative catarrh (capillary bronchitis), or of an inflammation (almost always lobular) of the lung itself."

Concomitants.-(1.) As a precursory symptom Epistaxis was of fequent occurrence, and in 11 patients appeared during the course of the eruption, and generally on several occasions. (2.) Vomiting, which is seldomer a precursory symptom than in small-pox, was observed in seven after the appearance of the rash. (3.) The precursory Diarrhea did not derange the course of the eruption in any of the cases in which it appeared, and probably may be considered as a mere effect of the morbillous hyperæmia of the intestinal mucous membrane, just as weeping is of the ocular, or coryza of the pituitary. It is to be distinguished from that which is induced by a real complication, as from enteritis, &c., from which it may be distinguished by its coincidence with the other precursory symptoms, its mucous character, the comparative infrequency of the stools-these seldom exceeding 6 or 8 in the 24 hours-the absence of abdominal pain, and its non-perturbatory power over the cutaneous eruption. In 30 patients this diarrhoea appeared. It was not interfered with, and it is to be remarked that the subjects of it suffered less from the morbillous bronchitis. (4.) Constipation was observed only in three patients. (5.) With four exceptions, all the patients offered the symptoms of bronchial catarrh.

"These symptoms are those of bronchitis, but is the modification which measles impresses upon the air-passages identical with phlegmasia of this membrane? If it is true that in this pyrexia the amount of fibrine continues stationary, or even in severe cases falls below the normal mean, we may, from this alone, conclude that the bronchial lesion, which nineteen out of twenty times accompanies measles, is not inflammatory, or at all events cannot be classed with the pure phlegmasia of the respiratory organs. The above-named symptoms