a year past; and the same may be said of pleurisy, though to a less extent, as we think idiopathic pleurisy is more common; but even here the large majority of pleurisies are occurring in patients suffering from chronic disease. We will add to this bronchitis, and maintain that acute idiopathic bronchitis is a rare disease. In reference to the pericardium, we may remind the reader that acute idiopathic inflammation of this structure is almost unknown. If then, acute pneumonia and pleurisy occurring in healthy persons constitute the exceptional cases in which such forms of maladies occur, and other acute affections are still more rare, how remarkable it appears for some of our older writers to speak of acute inflammations in healthy persons as typical forms of disease, and those in which the action of remedies is to be studied. In considering the abdomen, nearly all the affections, as witnessed in this country, are chronic; and acute peritonitis, which might be called idiopathic, we have never yet seen. Hepatitis and dysentery are acute in tropical climates, but the changes in the liver, kidney, intestine, &c., as we in our country witness them, are mostly slow. Acute peritonitis in nearly all cases results from some lesion which is chronic in one of the organs which is covered by it, and arises from abscesses bursting into it, or perforations of the hollow organs, or from a local inflammation commencing in an ovary or other part propagating itself throughout the abdomen.

Should acute inflammations arise without a chronic change in this part, there is some constitutional affection implicating the fluids in the body; such as disease of kidney, which is often suddenly fatal by a pericarditis or peritonitis. The disposition for disease to commence slowly and end rapidly or acutely, is nowhere better seen than in a phthisical lung; towards the apex, where the disease commenced, we see a vomica surrounded by dense tissue, showing the organization and slow process which characterized the commencement of the disease; as we proceed lower down we find deposit of a softer character; still lower down, this resembles the material of gray hepatization, and below this again we often find an acute pneumonia which has carried off the patient.

We do not, of course, in thus speaking cursorily on this subject, refer to diseases dependent on some specific cause or poison which may lay hold of any healthy person, as the exanthemata, but we allude rather to local inflammations, which, according to some of the older systematic writers, were regarded as the most common forms of affections, and might occur in any person; they thought that an arachnitis or pericarditis, or a peritonitis, might from such a cause as exposure to cold, be suddenly lit up in a previously healthy person. Now, we are not aware that we have ever witnessed such a case, these acute affections being merely parts of some more general malady affecting the whole system, or attacking an organ previously diseased. This, as before said, is not altogether true of pneumonia, nor of pleurisy, which are constantly occurring from causes above named, although even these affections arise far more frequently in diseased persons. We may state, then, in general terms, that disease of the various parts of the body is, as a rule, chronic, and that the acute affections are merely terminations of these, or are set up by them. We are quite aware of the objection that observation in the wards and in the post-mortem room is of a different kind, and that the very fact of these remarks having been made on the dead, is sufficient to show that such organic changes could not have existed in those who have recovered. A discussion on this point would too greatly prolong this paper, and, therefore, we will merely state that the proofs of the existence of various diseases during life are slight compared with ocular inspection after death; and therefore if, for example, in every case of fatal peritonitis a prior cause is found to have produced it, we think the arguments are equally in favor of such cause existing in the cases which recover, as that the inflammation is altogether idiopathic. We should have liked, had space allowed, to have entered upon this subject more in detail, and illustrated it by examples; this we hope to do at a future time; at present merely pointing out to those who have not the opportunities of making necroscopic examinations, the result of our observations.

ART. 16.-On the Changes in the Constitution of Fever and Inflammation in Edinburgh during the last forty years. By PROFESSOR CHRISTISON.

(Edin. Med. Journal, July, 1858.)

During the last forty years, Dr. Christison maintains, there has been a change in the character of the symptomatic fever attendant on acute local inflammation, which will account for so great a change in the treatment as the abandonment of bloodletting.

"Unfortunately," he says, "I am not able to refer to any recorded facts in support of this proposition. But I can conscientiously say, that many years have elapsed since I have made allusion to it in my lectures on Clinical Medicine' in this university. And I can, with equal confidence, pledge myself to have formed my present opinion long prior to the first germs of the present controversy, and quite irrespectively of controversial bias of any kind.

"The local inflammations, in which the change in the form of the concomitant fever has principally attracted my attention, have been erysipelas, acute rheumatism, pleurisy, and pneumonia. In all of these diseases, during the earlier period between 1817 and 1830, or a little later, it was customary to find the pulse not merely frequent but also either full, hard, and difficult to extinguish by pressure, or small, wiry, and equally hard to compress. This state of the pulse was likewise attended with more heat of the skin and febrile restlessness than I have been accustomed to observe for many years past. In correspondence with these peculiarities, it was not uncommon to observe the blood issue from the vein, opened for the purpose of bloodletting, with great force, and of an unusually florid color, and occasionally with a certain jerk contemporaneous with the pulse. I have repeatedly seen, at the time now referred to, hospital dressers or other young medical men so much alarmed at these appearances, as to fear that they had cut the subjacent artery, and only relieved upon finding the flow of blood averted by firm pressure of the vein beyond the wound. In no disease was the force of reaction more remarkably demonstrated by these phenomena than in acute rheumatism. I well remember that in my experiments on the changes produced by the air in the blood, performed in 1830 (See Edinburgh Medical and Surgical Journal,' xxxv, 94), I was repeatedly unable to use for my purpose venous blood taken from rheumatic patients, on account of its color being too little removed from that of arterial blood, to show the change of hue caused by agitation with air.

"The character of the pulse, which I principally miss in the present time, is its incompressibility, which was a constant object of attention and interest during the fashion of bloodletting, and by which, far more than by the mere frequency or fulness of the pulse, the question of bloodletting and its amount were regulated. Those who have not had occasion to observe this phenomenon in acute local inflammation, will understand what is meant, if they have ever attended carefully to the condition of the pulse in some forms of sudden, violent, brief apoplexy, in which, after a short stage of great depression and irregularity, the pulse, gradually rallying, becomes at length almost painfully full and bounding, and so hard to compress that scarcely any force, with the finger's point, will completely extinguish it.

"As inflammations, with this accompaniment, continued to advance in spite of bloodletting; or, when it had been neglected, the condition of the pulse gradually altered, until at length it acquired the same comparatively soft and easily compressible character which is observed to be its ordinary condition at all stages in the present time, as well as for some years past. Now, it is important to remark, that as soon as the pulse put on this altered condition in the advanced stage of inflammation, every medical man practised bloodletting with far greater caution; and I could show, by notes I still possess, of the case of a brother graduate whom I treated at Paris in 1821, in rather remarkable circumstances, that I at least was at that time fully aware of the danger of bloodletting in pneumonia in such a state of the circulation.

"If in those days physicians were aware that the acute local inflammations might, in their course, present characters which contra-indicated bloodletting,

PRACTICAL MEDICINE, ETC.

it does not appear a very violent assumption, that, if they observed those characters presented at the beginning instead of the advanced stage, they would hesitate to draw blood, and at length, as this character became more and more manifest, abandon it in a great measure, and such I apprehend is the real history of the modern change of men's minds as to the employment of the free evacuation of blood in the acute inflammations.

"An attempt has been made to ascribe the change-1, to an improved acquaintance with the phenomena of pneumonia as one of the leading acute inflammations-the consequence of the use of the stethoscope-and 2, to our acquaintance with the antiphlogistic properties of tartar-emetic. Both arguments are baseless. Acquaintance with the stethoscope will not explain the abandonment of bloodletting in other inflammations besides pneumonia and pleurisy; and yet the remedy was surrendered in all acute inflammations, about the same time. Besides, it is altogether a mistake to assume, that the stethoscope came into familiar use in Edinburgh, and more especially among the medical officers of its infirmary, only about the time when bloodletting began to fall into desuetude. Several practitioners of this city had studied long before that date under Laennec himself; one of these was physician of the infirmary so early as 1827; and others besides him used the stethoscope with as much address and familiarity at that period as any of their successors have done since.

"As little can it be admitted, that professional men of this city have been acquainted with the merits of tartar-emetic as an antiphlogistic remedy only since it began to displace bloodletting in the treatment of pneumonia. The use of tartar-emetic, as an antiphlogistic in local inflammation in British practice, is of much older date; when I was a young graduate, it was a familiar remedy in the advanced stage of pneumonia, and was used by myself as the acknowledged resource, and with prompt and excellent effect in the case of pneumonia referred to above in 1821; and as for Laennec's plan by large, frequent, contro-stimulant doses, it was employed in the clinical wards by my predecessor, Dr. Duncan, who died in 1832, and likewise by myself and others some years earlier than that date.

"I feel persuaded, therefore, that the more this interesting subject is investigated, and the more that the personal experiences of those who practised medicine between 1817 and 1830 is brought to bear upon it, the more will it appear manifest that a change to a mere asthenic character has gradually taken place since that period in the febrile condition of the circulation attendant alike upon continued fevers, eruptive fevers, and the acute local inflammations; and the more will it appear probable that this change has been the real cause of the change which has taken place in medical opinion and practice as to their treatment."

ART. 17.-General considerations respecting Fever.

By Dr. HANDFIELD JONES, Physician to St. Mary's Hospital.

(Brit. Med. Journal, Aug., 1858.)

In the following propositions and remarks, an attempt is made to take a general view of the principal phenomena of the febrile state, regarding their pathology from the point of view so well indicated by Parkes and Virchow. The author is far from imagining that we have yet any complete and satisfactory theory of fever; but he cannot think that any one can have any just conception or enlarged view of the pathology of fever, who ignores the capital facts so well elaborated by Bernard.

in con"1. Fever may result from pure nervous exhaustion. I am acquainted with two medical men who have suffered attacks of fever, to all appearance, sequence of fatigue in walking. In such cases, it may be presumed that the sympathetic system has become affected, as well as the cerebro-spinal.

"2. The nervous power of the cerebro-spinal system may be extremely depressed without fever being induced.

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3. Paralysis of the vaso-motor (sympathetic) nerves is probably essential to all fevers.

"4. In the majority of fevers, the nervous power of the cerebro-spinal system is greatly debilitated or impaired.

5. In all varieties of asthenic fever, debility and depression predominate. They may be more marked in some organs than in others, and may be variously combined with degrees of irritation; but still they give its character to the disorder.

"6. All debilitating influences, in their less severe degrees, tend to produce a state of irritability; in their more violent action they cause prostration. The character of irritability is weakness, together with an undue sensitiveness to all stimuli. In such states, there is often a great display of force ('increased action'); but it is to be remembered that this takes place at the expense of the radical forces of the economy, which are drawn upon for the excessive development of the acting. Wild delirium and increased energy of circulation can only occur at the expense of the real power of the brain and heart.

"7. In the sthenic and inflammatory fevers, the heart's action is excited and increased in force, as well as in frequency. The cause of this may be presumed to be, that the blood, being hotter than natural, stimulates the heart unduly. The place of the heart in the vital economy, its highly developed structure, its peculiar power of not knowing fatigue, unlike other muscles, afford sufficient reason why it should be stimulated to increased energy of action, while the arterial muscles are more or less relaxed or paralyzed. It has a higher responsive faculty. At the same time, the tissues of the body generally are not so much debilitated as in asthenic fever.

"8. The causation of pyrexia attending on local inflammations may be viewed as follows. The blood traversing the inflamed part becomes altered in some way (perhaps by having an increase of fibrin generated in itself), so that it comes to contain matter, which may be compared to the miasm of fevers (idiopathic), like it producing irritating and debilitating effects. This view, which is Andral's, is adopted by Mr. Erichsen and Dr. Markham.

9. It may appear a contradiction to the above statements, that, in the more sthenic idiopathic fevers, and in certain pyrexia attending on inflammation, especially in the case of serous membranes, the radial artery is not paralyzed, but rather contracted; the pulse is hard or wiry. This would not certainly prove that the swollen arteries are in the same state, but let it be granted that it does. Observations of the results of dividing the sympathetic nerve in the neck shows that relaxation of arteries and increase of temperature are not inseparably connected. The hyperemia which ensues after the operation diminishes considerably in a day or two, though the elevation of temperature persists. Moreover, in repeating the experiment upon a cat, I found that the temperature became greatly elevated, without the existence of much apparent hyperæmia. It certainly did not appear that the increased heat could be accounted for by the hyperæmia. It is Bernard's opinion that the temperature is not augmented solely in consequence of the part lying in the range of the paralyzed nerves receiving more blood, but that there is actually an altered state of the nutrition of the part. Brown-Séquard and Walter, on the other hand, ascribe the increased temperature solely to the increased afflux of blood. The circumstance that the temperature of the side operated on is sometimes 2° or 3° Fahr. higher than that of the internal parts is materially in favor of Bernard's view. So are also the phenomena of phlegmasia dolens, and some analogous white inflammations (as Dr. Graves calls them), in which at the same time that there is swelling and increased heat, the pallor certainly indicates that the arteries are constricted. In some cases it may be that the vaso-motor nerves are so affected, so debilitated, that increased heat is produced by the derangement and hurry of the nutrition-processes, while yet the arterial muscles retain power enough to be stimulated to contraction by the overheated blood. Their contraction, then, might be explained in the same way as the

increased action of the heart.

"10. The accelerated action of the heart in fever (i. e. the increased rapidity,

*For remarks on this important distinction, see Trousseau, Materia Medica,' vol. i. p. 42.

not force, of its contractions) may very plausibly be explained by considering the medulla oblongata or pneumogastric nerve to be in a debilitated state. It is not indeed so fully established that section of the pneumogastric causes increased frequency of the heart's action, as it is that stimulation of it or of its origin retards or arrests it; but the conclusion is at least eminently probable. The rapid action of the heart, the palpitation, and breathlessness, which occur in anæmic girls, and males not anæmic but of weak tone, on any sudden muscular exertion, are more probably owing to debility of the par vagum and medulla oblongata than to any other cause. If a man in vigorous health attempt a feat of running or swimming, without having practised for a length of time, he will surely find that his 'wind' speedily fails him; he will have much palpitation and panting; but if he is in training, he can bear the exercise without being blown. In this case, the improved power can scarcely be attributed to anything except the increased energy of the nervous system. The hurried action of the heart, as is well known, is in no wise of the essence of fever; paresis of other centres than the regulating cardiac is necessary to produce this effect.

"11. In the more sthenic forms of fever and inflammatory pyrexia, the diminution of the cutaneous and urinary secretions, and of the salivary, is a phenomenon sufficiently constant to require notice. It stands in sharply defined contrast to the profuse flow which is common in states of debility. In various conditions, of which low nervous power is a prominent feature, a copious flow of aqueous urine is a common occurrence; and its connection with some depressing mental emotion is often very apparent, as in the hysterical paroxysm, or the case of hypochondriasis related by Sydenham (Sydenham Society's edition, vol. ii. p. 93). Profuse sweating during sleep is a common occurrence in aguish disorder, without any organic disease or regular fit. Salivation may occur as one of the manifestations of malarious disease. In the case of the kidneys, it is certain that there is not solely increased activity of the glandular tissue, but that the homogeneous membrane of the Malpighian tufts must be in some way altered, so as to allow the more free permeation of aqueous fluid. The same is probably the case with other glands. Now, in the sthenic febrile state, the reverse prevails; the homogeneous membranes are much less permeable by water than usual. In the sthenic fevers, again, this retention of aqueous fluid is not observed; indeed, the limiting membranes allow the transudation not only of water, but also of albuminous matter and fibrin dissolved in it, and even of blood. On what this difference in the filtering power of the limitary membranes depends, is quite a matter of guess; it seems, however, not improbable that it is in part dependent on the amount of fibrin in the blood. In the sthenic inflammations, the amount of fibrin is notably increased; and in these also the diminution of the secretions is, as a rule, most observable. The fibrinous casts of the renal tubes are often so purely homogeneous, that the idea seems naturally suggested that the limitary membranes may be strengthened and thickened by additions of this substance when it is circulating in excess. It is, however, certain that the filtering power of these membranes may be notably affected by variations in nervous influence. There appears to be a general accordance between the behaviour of the arterial coats and the capillary walls. In relaxed states of the contractile coat of the arteries, the capillary membranes are more permeable than usual, and vice versa. The relaxation of the latter may proceed to that extreme degree in which they allow blood-corpuscles to pass through the softened texture, and ecchymosis or hemorrhage recurs. I have seen this twice in aguish disorder, as sub-conjunctival effusion.

"12. The liability of the various organs and tissues to asthenic inflammation during the course of fever probably depends on their vital power having been so lowered by the action of the poison that a little hyperamic afflux becomes a cause of irritation. The case is the same as when a part has been frostbitten, and the circulation has been restored too rapidly. On the same ground, when the sympathetic is cut in the neck of a debilitated animal, severe conjunctivitis sometimes ensues, because the enfeebled tissue cannot withstand the stimulus of the hyperæmia, intensified by the loss of the influence of the