1846.] ON THE MELANCHOLIC TEMPERAMENT. 165 ordinarily had recourse to. M. Parise cites several instances, in which the healing of wounds of various degrees of gravity, as regards the accompanying contusion of parts, seemed to have been much accelerated by the employment of this means. He suggests the following extension of the application. "I have not had the opportunity of employing this means after serious and important surgical operations, but I am disposed to believe in its utility in diminishing the intensity of the inflammation, and hastening cicatrization in these cases. Probability, which ordinarily foresees more than it sees, here is increased almost to a certainty, for the same causes produce the same effects. I am indeed convinced, that if, after the amputation of a large limb, the vessels being tied or submitted to torsion, a large cupping-pump were applied to the surface of the wound to remove the detritus, prior to dressing the stump, the subsequent inflammation and suppuration would be much diminished. Perhaps, too, purulent infection, that deplorable accident which carries off so many patients, might be thus prevented. Where would there be the danger in the experiment?" On the Melancholic Temperament. Notwithstanding the revolutions which medicine has undergone, the temperaments have remained much as the ancients described them, and so faithful to nature have the description of these been, that the efforts of Stahl, Cabanis, Hallé, and other celebrated modern physicians, have only succeeded in impressing certain modifications upon these. "The ancients founded their doctrines upon the condition of the fluids-the moderns have considered only the arteries, veins, and lymphatics: the one founding their doctrine upon the contents, and the other upon the containing parts: they were humorists, and we are solidists: and this is all the difference. We always must refer to their groups of the characteristics of temperaments, modified however by the progress of science." The melancholic temperament has been however among the moderns a subject of much controversy. The doctrine of Galen which prevailed in the schools for 16 centuries explained it by the existence of black bile, without, however, explaining what was to be understood by this. Cabanis and others look upon it as only a variety of the bilious temperament, without shewing in what it differs from this. Tissot and some others denied its existence altogether, while Broussais referred it to a chronic inflammation of the digestive organs. The author believes the characters of this temperament to be well. marked, and that the denial of its existence because its cause has not been ascertained, is a very unphilosophical procedure. He has frequently_met with it in Italy and Spain, and it is not uncommon in France and England; but, as a general rule, it most frequently occurs in hot and dry countries, as India, Spain, Arabia, &c. "Political and religious institutions may develop or exaggerate it, but they cannot produce it; for we must not confound melancholy with the melancholic temperament; the former may occur in every variety of organization, while the latter only predisposes to this singular neuralgia. "Slender forms; muscles slightly developed, their fibres being however dry and rigid; a narrow chest; a yellowish-brown skin covered with hairs, and generally brown ones; large veins coursing over the cutaneous surface: compact cellular tissue; a thin, bony, pale, or olive-coloured face; eyes sometimes blue, but usually black and deep-seated, having the conjunctiva of a yellowish colour; a timid, but sometimes sparkling look; slow, circumspect, and embarrassed movements are the external characteristics. The internal ones are marked by a quiet, small, contracted, and sometimes unequal pulse; feeble respiration, inactive hæmatosis, and scanty secretions, especially that of the skin. The digestion is very uncertain, while some epigastric tenderness is often present. “The cerebral system and intellectual faculties correspond to those conditions of the organism. The will is at first uncertain, then obstinate and inflexible; there is an extraordinary perseverance in habits, and a distrust which only increases by acquaintance with mankind; sometimes there is a great feebleness of intellect, and at others great power and depth of thought and observation. The imagination always runs to extremes, and, capable of producing chimeras and chefs-d'œuvre, it takes on a double aspect peculiar to this temperament. It is at once vivid and capricious, and yet able to strongly concentrate itself in objects submitted to meditation, so as to be able to follow a fixed idea to the extreme limits of reflection." As the sanguine temperament is the result of the predominance of the arterial or red-blood system, so is the melancholic produced by the predominance of the venous or black-blood system. Upon opening the body of a man of this last temperament we are struck with the brownish-yellow colour of his tissues, and the slight development of the various organs. Venous plethora is observed in the chest, but particularly in the abdomen, the portal system being especially loaded. The blood contained in these engorged vessels is also remarkably black. The physiological characters already given as those of this temperament, are readily explained by this predominance of the venous system, e, g., the colour and difficult transpiration of the skin, the defective hæmatosis, small and slow pulse, abdomi. nal uneasiness, &c. The predominance of the sanguine and lymphatic temperaments in women explain also the rarity with which the melancholic temperament is observed in them: so, too, in reference to age, none of the temperaments depend so much upon the influence of this in exhibiting. their characters; and where these are witnessed early, so are other signs of old age prematurely observed. Fernel fixes the 65th year as the period when the melancholic temperament is observed. Cullen believes that venous plethora commences between the 35th and 40th years. The period when it manifests itself doubtless differs according to original constitution. Its advent is announced, besides the external signs already adverted to, by two anatomical changes consequent on the progress of age, viz. the diminution of the capacity of the chest with ossification of its cartilages, and the diminution in the size, elasticity, and suppleness of the arterial system, the veins becoming at the same time enlarged and distended. All men, therefore, in the progress of age, acquire this temperament, but in very different degrees. The melancholic must not be confounded with the bilious temperament. "In the latter, the chest is broad and ample, giving rise to great development of the lungs, whence an active hæmatosis, a voluminous, active heart, and an ample arterial system. The muscles are thick and well defined. The secretion of fat increases abundantly with age in the bilious but not in the melancholic. The hepatico-gastric system always plays a large part in the former, while in the latter, there is rather an abdominal venous ingurgitation. In the one, there is 1846.] ON THE MELANCHOLIC TEMPERAMENT. 167 bilious vomiting and the class of diseases aftributed by Stohl to połycholia, while, in the other, hæmatemesis, melæna, hæmorrhoids, and passive hæmorrhages in general, are far more frequent. : "The moral contrast is as strong. The man of unmixed bilious temperament is prompt, active, decided, fiery and irascible, he can conceal nothing resistance is odious to him, and contradiction insupportable. He attacks obstacles with directness and hardihood. His language and manners announce the impetuosity and violence of his organic movements." It is equally distinct from the lymphatic. "The physiologico-anatomical considerations we have stated, show that the melancholic temp. is never allied with the lymphatic. The vascular system containing the white fluids is only very greatly developed in early life, its activity diminishing with age. It is completely and in everything the opposite of the venous system. We see lymphatico-sanguine and bilio-sanguine temp., but the characters of the melancholic and of the sanguine are never confounded. They are mutually exclusive; only one of the two great arterial and venous trees can predominate in the economy." M. Parise enters at some length into the modifications produced upon this melancholic or venous temperament by different degrees of development of the nervous system; and then proceeds to consider some of the corroborations of his views derived from pathology and clinical experience. The influence which the venous predominance exerts upon the vital actions must be, in some degree, extended to morbid affections; and thus we find in the melancholic temperament acute affections are less common and less severe, and chronic ones more common and more obstinate than in other constitutions. Inflammations are often latent, and may be attended by disorganizing processes not discoverable until after death. Melancholia, which is dependent on a certain condition of the nervous system, may occur in any temperament, but it is the melancholic which especially predisposes to it. The frequent connexion of this affection with the melancholic temperament is shown by the marked relief which frequently fol lows the disgorging the abdominal venous system by hæmorrhoidal flux or other discharges, either natural, or artificially induced by leeches or purgatives. "It is a remark made long since by practitioners, that each age has its hæmorrhages. In infancy and childhood they are manifested in the upper parts of the body, in manhood and old age in the lower parts. We see now how easily this is accounted for. We see also why hæmorrhoids are so salutary to a man predisposed to apoplexy. Whenever, in such a constitution, there is no varicose dilatation of the hæmorrhoidal vessels, the hæmorrhagic effort is concentrated upon the encephalon, instead of being directed towards the abdomen and lower portions of the body; hence apoplexy, partial paralysis, &c. Let us not forget that the impulsive force, acting upon the venous blood, is almost of no amount, and diminishes progressively. This is particularly the case in the brain, notwithstanding Nature's contrivances for facilitating the circulation of the venous blood by multiplying the sinuses; and thus cerebral sanguineous congestions are very frequent, especially in old age, whether on account of the abundance of black blood, or the weakness of the very extensible and dilatable venous tissue. Veins have a general tendency to become varicose, owing to the slight elasticity of their walls. When this occurs to the superficial veins, we apply appropriate measures, especially compression; but when such dilatations occur in the viscera, and especially the brain, where venous plethora may so easily arise, is so common and so dangerous in mature age, it is impossible but serious consequences must result. In this way we explain the occurrence of apoplexy in old men, and why thin, non-sanguineous looking persons sometimes are liable to cerebral congestions." The same condition of the venous system influences the diseases of the nervous system, and may give rise to hypochondriacism, monomania, &c. The venous temperament likewise predisposes to gangrena senilis, and the passive dropsies so common in advanced age. The author concludes his paper by a few observations upon the utility of the study of the Temperaments. "It contributes to the establishment of the foundations of clinical medicine. Temperaments are seldom mentioned in books, but much cared for in practice, for they must be considered in the diagnosis and treatment of every disease. Organic tendencies are in fact the primary conditions of diseases: they determine their nature and form, regulate their course, and augment or limit their intensity. It is upon these tendencies that the physician bases his estimate of probabilities of the progress and issue of the disease, and the effects and doses of appropriate medicine. All predisposing causes, i. e., those which it is most essential to be apprised of, originate in the different temperaments of the economy. How are we to oppose the development of these causes, if the very principle of the temperament is unknown to us? The important point is to arrive at the idiosyncracy by a practical and searching knowledge of the temperament. The practitioner who joins to the experience of things that of persons, possesses a safe basis for appreciating the unequal proportions of vital energy we remark among most men. The sagacity of judgment, the certainty of tact, the almost infallible experience of some practitioners, oftentimes only depend upon their precise knowledge of idiosyncracies and temperaments.” We regret that want of space will prevent our offering any analysis of the author's papers on Moral Medicine, and the Basis of the Progress of Medical Science. The former, however, was noticed by us on its first publication (M.-C. Rev., No. 70.) We will occupy the remainder of this notice with a few passages selected from the "Galerie Médicale," which contains some masterly sketches of the characteristics of several celebrated members of the profession, as Alibert, Desgenettes, Broussais, Marc, Richerand, Larrey, Corvisart, Boyer, Dupuytren, &c., &c. We should feel much pleasure if it were in our power to re-produce these in extensa, for they seem to have been very conscientiously written. "This gallery," says the author, “I make bold to say, is a true study of man, for in the lives of some celebrated practitioners of our epoch, I have sought less for details of interest than for lessons of profit and examples for instruction." The absence of a collection of biographies has always seemed to us a great and leading defect in our medical literature. Many of our practitioners know little or nothing of the lives and doctrines of their predecessors, and are unable to take encouragement or warning, as the case may be, by their example. A volume of well-written medical biographies would, we doubt not, prove an attractive as well as a useful work. Nothing worthy of the name has been attempted in this, or indeed in any country. Dupuytren. The determined and overbearing character of this celebrated surgeon manifested itself from the very commencement of his career. When, at 1846.] ' SKETCH OF DUPUYTREN. 169 17 years of age, he was appointed one of the Demonstrators at l'Ecole de Medicine; his poverty was so great that he was obliged to mend his own clothes. So far from despairing, however, he had such a complete conviction of his own superiority, and presentiment of its successful exertion, that he had already in view the surgical dictatorship which he afterwards attained. The renown of Bichat was a source of continual vexation to him, and upon hearing of his death, he exclaimed, "I begin to breathe." From this period, too, his reputation began to increase rapidly. "Knowledge, judgment, indefatigable industry, untiring patience, address, energy, and resolution, were all employed by him in the manner characteristic of a man who is determined to succeed-one who is never at ease but at the head of the crowd, who proceeds straight to the end in view, in spite of all the obstacles and difficulties of rivalry. This is in fact the period at which Dupuytren really worked, when he amassed most of his scientific labours, although it was long before he reached his eventual eminence. There was then to be observed in him the decided desire of increasing the riches of science, of extending its limits, united with that burning ambition which destroys rest, and which is the foundation of that strength which characterizes the man impatient of all control and jealous of every influence." * His avowed determination in 1812, to obtain the professorship held by Sabatier in l'Ecole de Medicine raised him numerous enemies and opponents; but he triumphed over all, in spite of an evident desire of the judges to favour some of these. Nothing now impeded his progress. "Arrived at the apogee of his renown, the genius of Dupuytren was quite equal to his position; and he was enabled to struggle with the torrent of occupations by which he was surrounded. There was indeed something really gigantic in that intelligence which provided for everything by its prodigious activity, indefatigable industry, determined ardour, and by a sort of ubiquity which allowed him to accomplish as well as to desire everything. For twenty years he was always one of the earliest at the Hôtel-Dieu, however inclement the season. He passed more than five hours there in the severest bodily and mental exertion. No sooner had he left these, than new duties and crowds of patients called him to all parts. Whoever wishes to give unrestricted praise to Dupuytren, must consider him in his professor's chair. There he triumphed— there he excelled. It was a remarkable thing to hear this illustrious surgeon delivering his beautiful lectures on Clinical Surgery, amidst three or four hundred silent and attentive pupils. With what order and method he enchained the attention of his auditors! how accomplished was he in instructing them, exhibiting the light of evidence with a skilful and vigorous logic, and inculcating good and sound information! His clear, calm, strong delivery, lucid and expressive, fluent, easy without prolixity, elegant without effort, always fortified by things and facts; the clearness of his views; his rare talent for exposition and deduction; his astonishing facility in defining, classifying, and expressing his ideas, in rendering objects sensible and evident, and in arresting, fixing, and directing the attention, gave to his lectures a singular attraction. No idle detail, declamation, or ornament was there: all was clear, precise, intelligible; all tended to fact, to its object, and to instruction. * * Nevertheless, the pupils sometimes reproached the professor with dwelling only with predilection upon those cases in which success had crowned his efforts, and disguising his reverses with skill. Another, and perhaps better-founded, reproach is, that this illustrious professor never quoted any one else, and French surgeons still less than any. To speak the truth, he had a marked and exclusive disdain for all that had not proceeded from himself; and this indifference, or rather scepticism * |