1847] Saucerotte on Latent Pneumonia. 277 precursory symptoms of salivation the blood has already lost some of its morbidly plastic character. It is indeed remarkable to what an extent acute inflammation becomes relieved upon the appearance of the precursors of salivation, and how long these are in making their appearance in intense and essentially exsudative inflammations, as iritis peritonitis, and especially puerperal peritonitis. In this last we are sometimes suprised at finding the abdomen, which the evening before could not endure the weight of the clothes, supporting next day firm pressure with the hand-the precursory symptoms of salivation having manifested themselves in the interval. These are, indeed, the signs of the system having become sufficiently saturated with the mineral, which must be left off as soon as they appear, our object not being, save in very rare and obstinate cases, to excite actual salivation. Instead of then pushing on the mercury, if the disease does not yield, we must, in the case of inflammation, have recourse to other antiphlogistics, and, in the case of syphilis, to iodine, sudorifics, &c.-carefully limiting the regimen, and avoiding exposure to cold. When, however, the precursory symptoms are dissipated, and the disease has yet not yielded, we may recur, again and again, to the mercurial. In syphilis this is almost always necessary. It is from the non-observance of the above rules that so much mischief has been caused by this remedy, and so much prejudice has been raised against it. The excitement of profuse salivation is especially mischievous. The anti-plastic action of the drug may, after long use, so diminish the coagulability of the blood as to produce a mercurial scorbutus, very difficult to cure. It never occurs, however, until long after the induction of salivation, and may be prevented by withholding the drug on the appearance of the precursory symptoms, and recurring to it only after their complete disappearance, if necessary. Marasmus may likewise be produced, especially in children and aged persons, if mercury be employed sufficiently long to induce ptyalism or diarrhea, or the two conjointly. Calomel particularly, must be given with great care to such subjects. It is not sufficient to withhold it when salivation or purging already exist; but at every visit the condition of the salivary organs and digestive tube must be carefully enquired into. From neglect of this precaution infants often suffer severely from the prolonged use of calomel.-Revue Medicale, Nov. 1846. ON LATENT PNEUMONIA. By Dr. SAUCEROTTE. Latent Pneumonia has only of late years sufficiently attracted notice, and indeed it has only been described with any accuracy quite recently by MM. Sestié, Grisolle and Raymond. No observer, that I am aware of, has endeavoured to attach this condition to any prevailing medical constitution, it having been always explained as an individual and exceptional circumstance. Thus, M. Sestié states that pneumonia would not be latent but for the obscurity of the physical signs, and the negligence of those who should seek them. This certainly explains why pulmonary phlegmasia is often unknown; but furnishes no account of the specific nature of the morbid form of disease we have to do with. The important point to bear in mind is, that there is a description of pneumonia which does not follow the ordinary course, or exhibit its usual symptoms; and which from the very first tends to run into a state of hepatization. It is a form of disease which certain medical constitutions favour the development of, as I observed in our garrison at Luneville, where it prevailed in 1844 and 1846, while in other years it is never met with there. The entire series of symptoms which characterise pneumonia may be absent, or so slight as to lead to the referring them to different and slighter causes. In general, however, auscultation and percussion do not betray us; but these in affections apparently so slight and so different are frequently not resorted to. M. Saucerotte thus reviews the cases which fell under his care. Precursory Symptoms.-These were usually ill-developed, referrible to the general system rather than to any particular portion of it. They consisted of lassitude, loss of appetite, shivering, &c.; but these were so frequently of so little amount as to enable the soldier to perform his duties only a short while before extreme hepatization was discovered to exist. Symptoms.-The heat of the skin of the thorax so characteristic of pneumonia was never observed, and the pulse continued of the normal number. Little or no difficulty of respiration prevailed, at least as long as the patient continued quiet. A very distinct and generally pretty extensive dulness on percussion was observed, and bronchial respiration and bronchophony existed. In some cases there was a little crepitation around the hepatized portion of lung. The cough was generally very slight, and sometimes did not exist at all. Duration. This was very variable, according to the constitution of the patient, the treatment adopted, and many other circumstances. The soldiers often obtained leave of the absence during their convalescence; but among those who remained the patient would sometimes struggle against the disease for months before he succumbed. Diagnosis.-Pleurisy is the affection with which it has been most generally confounded, a matter of little consequence considering that the same treatment will relieve both diseases. In pleurisy there is less frequently absence of pain in the side; no elasticity of the walls of the thorax on percussion, while the dulness changes its site according to the position of the patient. At a certain stage of the affection there is gophony, the absence of respiratory sounds if the effusion is considerable, and thoracic vaulting. The disease cannot for any long period be confounded with phthisis. The various acute and chronic affections of the lungs, whether anterior or inter-current, are sometimes masked by, or mask the pneumonia. Prognosis. It is a general rule that the more a disease is removed from its regular type, and becomes anomalous, the more dangerous it is; and latent pneumonia offers no exception to this. The prognosis was of the gravest character, especially when the affection had made great progress. Anatomical Lesions.-The soldiers being usually removed when seriously ill, M. S. made but a few autopsies. In the cases he examined he found the grey induration with a variety of concomitant lesions. Etiology. Soldiers exposed to various anti-hygienic influences are especially liable to pneumonia; and in the year 1844 and 1846, the latent form was often met with. It is at the end of Winter and after exposure to cold, that the disease especially shows itself. The uniformity of the dress of soldiers, whatever may be the susceptibility of their pulmonary organs, leads to frequent attacks of pneumonia duringthe atmospheric vicissitudes so common at the commencement of Spring. Treatment. The absence of febrile re-action forbad large bleeding. I have usually bled but once, and then resorted to cupping or leeches, passing at once to the use of antimony and the application of a very large blister.-Gazette Medicale, No. 50. 1847] Neucourt on Epidemic Erysipelas. 279 ON EPIDEMIC ERYSIPELAS AS IT PREVAILed in the BeAUJON HOSPITAL AT PARIS. BY DR. NEUCOURT. Prior to January and subsequently to March, 1843, a case of erysipelas rarely manifested itself among the patients of this hospital, eighty-four in number; but during January and February it raged as an epidemic, attacking every patient having any breach of surface. The description of the attack may be naturally divided into two periods; during the first of which (10th to 25th Jan.) fewer persons were the subjects of it, but in these it proved exceedingly mortal, while during the second (and a longer period) a much larger number of persons became affected with a much milder form of the disease. It is indeed in accordance with the history of most epidemics, that the persons first attacked suffer most severely; so that we may apply to them the celebrated dictum delivered by Sydenham in reference to treatment-In morbis epidemicis, væ primis. The patients so attacked were almost all already in a debilitated condition, and they sank under the influence of the disease as if they were poisoned-the local lesion in fact being the least grave part of the disease. At the same time, an ill-condition of all the wounds in the hospital manifested itself, indicating the necessity of abstaining from operations. In this first series of cases the erysipelas was palish or violaceous, atonic rather than inflammatory, and leaving livid traces after death. Gangrene readily formed. The general symptoms were those indicative of extreme prostration-an absence of thirst being notably associated with a dry, brown tongue. Post-mortem examination revealed no cause of death in the condition of the viscera or blood-vessels. Only a few individuals became the subjects of this serious form of the disease; but during its second period every patient in the hospital suffering from wounds was affected.. A blister, bleeding from the arm, or any other slight cause, served to induce it. The local symptoms were those ordinarily characterising the disease. The general symptoms were very different from those observed in the first cases; for, instead of the dry, brown tongue, that organ was observed to be broad and white, or sometimes yellowish; the mouth was bitter and pasty; the thirst frequently intense. Nausea and frequent bilious vomitings, disgust for food, sense of uneasiness at the epigastrium, and constant constipation, were other symptoms referrible to the condition of the digestive canal. These symptoms constituting the embarras gastrique of Pinel, the gastric fever of Frank, and the bilious fever of Stoll, are dwelt upon by the author as of leading impor tance. These two conditions, erysipelas and embarras gastrique, invariably coincided; but M. N. does not pretend to decide which acted as cause, which as effect. Nevertheless, in several cases, the embarras preceded the erysipelas, while at the same period a great many other patients presented the same symptoms of disorder of the digestive canal, sometimes occurring idiopathically, and at others united to amygdalites, bronchial catarrh, or sometimes to erysipelas of the face. It would indeed seem to constitute what the ancients termed the epidemic genius of the diseases of the season. Certain it is, that as the embarras became increased or diminished, so did the erysipelas; and that the most certain mode of relieving the disease of the skin consisted in attacking that of the stomach. The condition of the pulse was markedly different in the two series of cases; for, while in the first, it was small, rapid, or intermittent, in the second, it was large and full, and rarely exceeding 100-generally below it. Its fullness and softness indicated that depletion was seldom required. One symptom-cephalgia-offered remarkable intensity and persistence, and which was equally present when the erysipelas affected other parts than the head. It is well known that cephalgia is a frequent symptom of simple embarras gastrique; but it is rarely so intense. The skin in the first period was arid, dry, and earthy; in the second, hot but not burning, and covered with moisture. The disturbed condition of the faculties occurring rapidly in the former was little observed, except in the erysipelas of the head, during the latter. Delirium, indeed, in these cases, did not possess the gravity which it does in other acute diseases. It was not connected with meningitis; for some patients who manifested it would certainly not have been cured had it been so; while in one who succumbed, after prolonged and intense delirium, no trace of inflammation, or even of congestion, was discovered. Treatment. 1. Evacuants.-The changes which the skin undergoes must be looked upon as a mere epiphenomenon, a symptomatic expression of the disease rather than its essence. The numerous topical applications which have been recommended exert no effect upon its ulterior development, and only a few even influence the progress of the actually existing disease. We have adverted to the marked prominence which the gastro-intestinal symptoms presented, and these were also found in a variety of other affections, and often themselves constituted the entire disease, or complicated other diseases. It is to the relief of disorders of this apparatus that treatment should be especially directed. From remote antiquity, and during successive ages, the evacuant method has been regarded with favour, in the relief of this gastric derangement; and it is upon the effectual use of purgatives and emetics that we must rely in the treatment of erysipelas. During their employment the symptoms gradually yield. If the desired improvement is not obtained, the emetic and purgative must be again and again repeated; failure has resulted from such repetition not having been enforced. What should we think of a person declining to repeat venesection in pneumonia, because the disease had not yielded to the first one? The practice of Desault, Tissot, Frank, Boyer, and that of the older surgeons was founded on the recognition of this disordered state of the digestive organs. 2. Bleeding-Although emetics and purgatives are not primary agents in treating this second form of erysipelas, yet they are not the only ones, to the absolute exclusion of others, such as bloodletting for example. In several cases, where the febrile reaction has been predominant over the gastric disturbance, it was employed before having recourse to evacuants, as recommended by Sydenham and Stoll. It is in phlegmonous erysipelas especially, in which the inflammatory character is much more pronounced, that it is indicated. In the first period, the intensity of the symptoms and the rapid progress of the disease rendered all treatment nugatory. 3. Topical Applications.—A great variety of these have engaged attention at different periods each enjoying its temporary reputation. Such means have a purely local action, extinguishing the erysipelas merely where applied. But the affection is far from consisting in a mere local lesion. The general condition of the patient must chiefly occupy our attention, for the relief of the cutaneous affection is not the cure of the disease. Topical treatment is therefore merely accessory; but yet there are cases in which it is truly valuable. Thus, in respect to recent wounds, especially on the face or head, if erysipelas occurs, and continues for some hours, the reparative power becomes arrested, and union by the first intention impossible. This unfortunate result may be prevented if we possess a topical application capable of preventing the development of erysipelas, or notably abridging its duration after it has become developed. None of the means hitherto proposed possess the power of preventing its development; but some of them, and among these the sulphate of iron according to M. Velpeau, seem to exert an influence on its duration. Certain it is that, like cold water, it much assuages the pains, frequently very severe, of erysipelas.-Archives Generales, Tom. xii. pp. 414-456. (Dr. Neucourt illustrates the various points adverted to in his paper by severa 1847] De Boismont on the Nature of Insanity. 281 cases, which are perspicuously detailed; but we regret that he has furnished no statistical account of the total number of persons attacked, proportion of recoveries, &c. We regard the paper as a very useful one in directing attention to the general rather than the topical treatment of erysipelas, and especially to that perverted condition of the alimentary canal which is equally met with in sporadic cases as in the epidemic detailed. We feel surprised, however, to find that he thinks very lightly of the nitrate of silver even as a mere accessory means in the case he has indicated. Conjointly with appropriate internal medication we have seen it render important services—although these have certainly been exaggerated by some writers.— Rev.) ON THE NATURE OF INSANITY, AND ITS TREATMENT BY IRRIGATION AND PROLONGED BATHS. By M. BRIERRE DE BOISMONT. M. Brierre de Boismont recently presented to the Paris Medical Society a Report upon a Memoir by Dr. Turck upon the Nature and Treatment of Insanity. He comments upon some of the Theories of Insanity which have prevailed. Broussais, as is well known, affirmed that insanity always arises from irritation of the brain (and in this statement he has met with many more supporters in this country than he has for his views on gastro-enteritis), but M. B. asks "who has seen the irritation of these capillary vessels? What are the anatomical characters? Most mad-doctors do not admit the existence of pathological lesions, or only regard them as consequences of the disease. I dissected, with M. Bricheteau, the brain of a madman, who had been the subject of intermittent mania for 12 years, and who died after an attack of acute hydrophobic delirium of 12 days' duration, and we were unable to indicate any appreciable lesion. The same thing occurred with respect to an imbecile woman who, after inhabiting my establishment for 18 years, also died after a third attack of acute delirium. It is endeavoured at all hazards to explain the disorders of the mind by anatomical considerations, even when we are quite unaware of what material change takes place in the brain and nerves for the execution of their functions. Every day we observe the most varied and gravest morbid changes without their exciting any influence in producing a state of insanity. The greater or less afflux of blood can so little be considered as the necessary cause of insanity, that frequently apoplexy induces no change in the functions of the intellect, even at the time that effusion has occurred, or paralysis is present. In the physiological condition, the general circulation (as may that of the carotids by some local malady) may be accelerated without the reason suffering. So far from inducing insanity, the greater afflux of blood to the brain induces sleep and somnolence. M. Moreau has of late endeavoured to revive the above theory, by stating maniacal excitement to be the primary modification of the intellect, and essential condition of the manifestation of any description of insanity. But this word excitement means an excess of organic action, and while this will induce certain forms of insanity, others are produced by quite opposite causes. Cerebral anæmia gives rise to insane conceptions as well as hyperæmia. If febrile excitement induces cerebral disturbances, we observe such disorders only commence in many cases when the decline of the fever has plunged the patient into a state of sinking. With an excitement represented as always 'identical in itself,' the most varying forms of insanity have all the same point of departure. A woman sees her child perish, she becomes stupefied and falls into a kind of imbecility, and are we to refer her case to this maniacal excitement ? A man, towards the end of a chronic disease which has reduced him to the last stage of marasmus, is seized with a mild form of delirium, in which he believes he is quitting the hospital and following his occupation. Are we to refer this to the same cause? According to this theory, |