PATHOLOGY AND PRACTICE OF MEDICINE.

On Crises and Critical Days. By M. BRICHETEAU.

M. BRICHETEAU testifies in the present paper to the great benefit he has frequently derived during a long practice from the observation of crises as inculcated by Hippocrates. 'Several times has it occurred to me to suppress a prescription too hastily written, on learning that an abundant sweat or a deposit in the urine has occurred in the night. If asked why the doctrine of crises is now of so little account, we may reply with Van Swieten, that physicians in full employment, who alone have the opportunity of observing them frequently, are so occupied by the great number of patients they have to visit, as to be unable to keep an exact account of the symptoms and progress of disease; and the patients themselves often force their attendants into an erroneous course, and oblige them to deviate from the track pointed out by the masters of our art, by their impatience to get well and their astonishing propensity to swallow medicines. The sad truth, indeed, must be told, that it is far easier for a practitioner to bleed or purge his patient after a rapid examination of the tongue and pulse, and to prescribe a variety of internal and external remedies from the indications of certain symptoms, than it is to observe day by day the successive phenomena of disease, discuss their value, and withhold the hand in presence of critical changes, in spite of the observations of the invalid or his friends! To a certain point the very progress of the medical art itself has been inimical to the reception of the doctrine of crises. Our improved means of diagnosis renders the study of general symptoms, the conditions of the various apparatuses secondarily affected, and the indications which these may furnish of the resolution of disease, less necessary than heretofore. . . . . To exhibit the importance of the observation of these crises, it suffices to mention the advantages derivable from sparing the patient the useless administration of medicines, the application of painful revulsives, or the employment of drugs capable of deteriorating their organs, enfeebling their powers, and retarding their convalescence. Who is there unaware of the incendiary ravages of medicines when given without discernment? The most penetrating mind fails to seize the natural course of the disease amidst the accidents produced by a perturbatory medication."

According to Galen, a crisis is a change which occurs in the course of a disease, whether for good or evil, conducive to cure or death. It is in fact a change. It is generally favorable, announced by precursory phenomena, and characterised by abundant excretions, hemorrhages, &c. Although showing itself generally as a consequence of the administration of medicine, this is not its origin, as it may present itself when no medicine whatever has been given; and most of the ancients attributed the phenomenon to the spontaneous action of the vis medicatrix, effecting an advantageous modification in the economy. If the change be only a result of the re-establishment of excretions suspended at the commencement of the disease, of the re-establishment of general equilibrium, or of a return to the normal condition, and if in place of being, as the ancients supposed, an active cause it is only a result, it matters little, since it is still an essential and integrant part of the disease, which, if the account of a case is to be rendered complete, is always to be noted when it presents itself. It has been pretended that, in order that a crisis may be entire and complete, a rigorous expectancy, dangerous to the life of the patient, is essential; but this is an erroneous view of the subject, since Hippocrates and Galen employed various internal and external medicinal agents to aid nature when too enfeebled, and to develope imperfect crises.

The days on which crises are determined, are called critical, and the others noncritical. The regarding as critical too great a number of days, has greatly exaggerated the difficulty of applying the doctrine of crises to the bedside of the patient. The principal critical days were considered to be the 7th, 14th, and 20th. Others, as the 9th, 11th, and 17th, were of a secondary rank, while the 3d, 4th,

and 5th occupied a still inferior position; and the 6th had so bad a reputation as to be termed the tyrant. At the 8th and 10th were sometimes produced abortive crises, while none were exhibited on the 12th, 16th, and 18th. The 7th day has always been considered the critical one par excellence. The days of inferior critical power were said to be indicators or precursors, announcing by an amelioration or precursory phenomenon a perfect crisis on one of the three radical days. Thus the 4th is the indicator of the 7th, or, in the words of Hippocrates, those whose ailments will determine on the 7th day have an abundant urinary deposit on the 4th. The 11th is the indicator of the 14th, and the 17th of the 25th. These indicating days sometimes themselves furnish crises, and become exceptionally radical. M. Bricheteau gives the abstracts of many cases in which, by attentive observation of these various days, he has been led to their more satisfactory treatment.”—Rev. Med.-Chir., t. iv, pp. 259-67.

On Eruptive Fevers without Eruption. By M. TROUSSEAU.

SOME practitioners doubt the accuracy of the facts related by some of the great observers of former times, concerning the existence of eruptive fevers without eruption. They have been especially considered as apocryphal in our times, when the localization of disease plays so large a part in the nosological systems. But when we consider that all pathologists admit that these diseases attack the mucous membranes as well as the skin, it is obviously improper to consider them as diseases of the skin; and in many cases we observe the eruption to be so very slight, that we can very well imagine it may in others be absent, without the necessity of denying the existence of the disease.

In illustration of such occurrence, Dr. Trousseau details the history of a Lilliputian epidemic that occurred in a retired hamlet near Paris. The hamlet only contained three families, of twelve inhabitants, none of whom had had scarlatina. It appeared in a mild form; every one of them was ill, but in different degrees and forms. Eight persons had the rash and angina in their most distinct forms, but four suffered only from severe fever, with angina and desquamation of the tongue. In these the convalescence was tedious, especially in one case wherein anasarca followed. Who can doubt that these four were likewise subject to scarlatina, although, had they been presented to the observer in an isolated manner, he being unacquainted with their antecedents, the nature of the case would have been

overlooked.

Two facts which have recently occurred in the hospital alike serve to show the possibility of the occurrence of eruptive fevers without eruption, and the difficulty of judging correctly concerning such cases when seen in an isolated condition. A boy, æt. 7, was brought in suffering from croupal cough, laborious respiration, and high fever; an emetic and some small doses of calomel were given, and next day the character of the cough was much better, but there was still much fever and oppression, and auscultation indicated a capillary bronchitis. As the eyes were observed to be somewhat injected and weeping, the tongue red at the tip, and a little blood plugged the nostrils, it was deemed probable that it was a case of measles, but it was only by very diligent search some rose-coloured non-prominent spots could be detected on the forearms. On compressing the arm, so as to inject these more, their measly character became evident. In a few hours they entirely disappeared, never more to return, "though the entire body of the child was whipped with nettles twice in one day (!)." It is evident that the diagnosis of this disease could not have been made had not the arms been examined just when they were, and that even this small manifestation would not have taken place had the arms been exposed to the cold, instead of enveloped in a warm dress. About the same time a child, æt. 2, was brought in, suffering from a severe form of pleuropneumonia, having been ill for eight days. The next day an eruption of measles spread all over the body. No physician, let his sagacity be what it might, could have recognised the measles the first day, and yet it is evident that in this child, as

in the other, the rubeolar eruption had predominated on the pulmonary mucous membrane, so as to produce an antagonistic fluxion, preventive or retardatory of, or diminishing, the cutaneous eruption. Such antagonistic fluxions may not unfrequently suffice to prevent all cutaneous eruption, and then we have eruptive fevers without eruption. In scarlatina it is to the mucous membrane of the pharynx and mouth that the critical phenomena are diverted.—L'Union Médicale, No. 54.

[We were lately in attendance upon a little boy, in whom the eruption of the skin and the angina were so slight, that we merely at first conjectured the possibility of scarlatina, although subsequent desquamation and the peculiar depression, such as is produced in some children by the presence of its poison in the blood, enabled us afterwards to be quite certain on this point. A brother of the above, æt. 5, from being an active, lively lad, became a moping, dull one, suffering much from lassitude and anorexia. Repeated careful examination discovered not a trace of eruption or angina, and no suspicion of the possibility of scarlatina could have been excited but for the teaching of the other case. Nevertheless in a week or two's time, decided anasarca with albuminous urine manifested itself, requiring a long course of aperients, tonics, and baths for its removal.]

On Blue Pus. By M. OLIOLI.

THE case furnishing the blue pus occurred in the person of a woman in one of M. Maisonneuve's wards. She had formerly been operated on for a cancerous breast, and now returned with a reproduction of the disease. Canquoin's caustic was applied, and after the eschar fell off, the pus discharged was observed to be of a greenish-blue, and that whether medicinal applications were made to the part or not. M. Olioli had seen a similar case at Turin, when, after amputation, blue pus was produced, though only simple dressings were employed. M. Bouchardat analysing the pus in the present case, found in it an organic colouring matter of unknown nature, but no other principle capable of explaining the colour. Two cases are recorded in the Gazette Médicale' (1831 and 1834), in which the serum of a blister was coloured blue. MM. Persoz and Dumas conjectured that, in certain ill-conditioned suppurations, hydrocyanic acid might be generated, and subsequently a compound analogous to Prussian-blue formed; but subsequent chemical analyses give no support to this conjecture. In some researches which M. Conte made concerning the composition of this pus, he also found it containing a peculiar organic colouring matter.-Gazette des Hopitaux, No. 47.

[In a well-marked case of the discharge of blue pus, recently occurring at Dublin, the analysis of Dr. Apjohn led him to believe that the colour very probably, though not certainly, depended on the presence of Prussian-blue.-See Dub. Med. Press, April 1849, p. 263.]

On Cephalematoma. By M. CHASSAIGNAC.

M. CHASSAIGNAC believes that whatever operation is performed for the relief of this affection, it proves very hazardous to the infant, and he takes the occasion of a recently occurring case, which he watched closely during life, and examined after death (from other causes), for drawing attention to the remarkable activity of the absorbent power at this age, and to the mode in which Nature thus operates a spontaneous cure. The sanguineous effusion gradually becomes encysted, though for a few days the blood is in direct contact with the bone and periosteum; an organic membrane separated into two layers, and which afterwards takes on all the characters of periosteum, then surrounds it, and the absorption proceeds. In proportion as the quantity of effusion diminishes, the osseous rim or border which surrounds it also diminishes in diameter, by reason of a double simultaneous action, viz. resorption at its external circumference, and a concentrical reproduction at the inner one. Very voluminous tumours in this way disappear; and so great is his fear of exciting suppuration in them, that M. Chassaignac strongly advises all interference to be withheld, save in the extremest cases.

M. Debout agrees with M. Chassaignac, that in the great majority of cases absorption will take place during the first six weeks of life; but after this period sometimes a serous cyst is formed, containing a reddish fluid, very like that found in mammary cysts the results of contusions. This cyst generally inflames and suppurates, giving rise to necrosis and fever, which may be prevented by opening the cyst. This operation, however, may be followed by erysipelas, or the forma tion of abscess, and M. Trousseau's procedure offers the greatest security against these accidents. With a narrow bistoury, so held as to cut from within outwards, he makes a puncture at the lower part of the tumour, and endeavours by pressure to empty it of its entire contents, and then applies strips of diachylon and a bandage, so as entirely to exclude the access of air. In eight or ten days these are removed, and all is found to be doing well.—Bulletin de Thérapeutique, t. xxxv, pp. 448-55.

Dr. Vogler, writing upon this subject, observes, that he is an example of how careful medical men should be in drawing general deductions from even a quarter of a century's experience. Thus, a very short time since he published a paper, in which he stated, that during this space of time he had never had occasion to open a cephalæmatoma, having always succeeded in dispersing the tumour by lotions of sal ammoniac, alcohol, and water, in from three to six weeks. Yet since then has he, in the course of only one year, met with three cases in which he felt called upon to open the tumour. In the first case, he did so because a severe ophthalmia in a child but a fortnight old forbad the use of wet applications. After the blood was discharged, suppuration was set up, but led to no bad consequences. The second case occurred in a child half a year old, apparently as a result of contusion. The swelling had all the appearance of a deep-seated abscess, but on an incision being made pure blood flowed out. A somewhat tedious suppuration followed, but all did well. In a third case (æt. 15 days), the swelling was very tense, and as the parent neglected applying the lotion, the author opened the tumour and discharged the blood. Very insignificant suppuration followed.-Medicinische Zeitung, 1849, No. 13.

On Melana in Children. By M. RILLIET.

M. RILLIET, one of the authors of the classical work on the 'Diseases of Children,' takes the occasion of two cases of intestinal hemorrhage in children, which have come under his notice, to furnish a summary of what is known upon the subject. The cases he relates are unique, inasmuch as they are examples of this rare disease occurring in twins. The first child, though not large, was well formed, and had cried strongly after birth. The meconium had been discharged by castor-oil; the child had sucked, and seemed in all respects doing well, when several hours after birth it passed two or three stools wholly composed of blood, and became deathly pale and cold, and was unable to swallow. It cried, but there was no vomiting or convulsion. Cold compresses were applied to the abdomen, the warmth of the extremities being maintained; rhat any was employed both in injections and external applications, but the former being always returned with blood, the latter were alone continued. The child gradually rallied after six bloody stools had been passed. While this child yet continued in an alarming state, the other twin was seized with vomiting and purging of blood, and decoction of rhatany was in the same way applied to its belly. It recovered, though the bleeding continued more obstinate. Both children remained well, though long continuing exceedingly pale. Different authors have ascribed the affection to various causes, but an analysis of the published cases leads Dr. Rilliet to doubt the efficacy of most of those assigned, e. g. the condition of the health of the parents, the nature of the labour, the too early division of the funis, the weakness or plethoric state of the child, the presence of irritating matters in the intestines, external violence, or the rupture of vessels; and although the affection usually occurs at from the first to the fourth day, it has been met with as late as the sixth, eleventh, or twentieth, boys seeming

more liable to it than girls. Dr. Rahn-Escher, of Zurich, believes that much depends upon hereditary influence, a diseased state of the digestive organs being communicated from parent to child. This view would seem to be best supported in those cases where the parents also suffer from hemorrhages, or where several of their children do so simultaneously or successively. Billard states that the majority of fifteen children dying from it, were remarkable for plethora, but the experience of others does not bear out this view. Numerous pathological observers agree in stating that there is no important vascular lesion, the mucous membrane being sometimes not more injected than natural; others have found the abdominal veins gorged with blood, and the mucous membrane softened and reddened. The naturally injected state of the intestinal tube in the child may act as a predisposing cause when there is atony of its vessels, or obstruction to the abdominal circulation. The difficulty with which respiration is established at birth, especially if the lung is incompletely dilated, may exert an influence.

The bleeding in most cases has followed the meconium, but unpreceded by any premonitory symptom. It is usually abundant and frequent, rich in colour, and either fluid, or in part coagulated. Hæmatemesis, though more rare, may yet be abundant; and Etlinger gives a case in which a pound of blood was discharged by vomiting and stool. Sometimes the hæmatemesis is more abundant than the intestinal hemorrhage, but it is always accompanied by the latter. The hemorrhage may attain its maximum in twenty-four hours; but it may be prolonged to the third or fifth day, and in very rare cases to the tenth even.

Of 23 cases in which the issues have been recorded, 12 recovered and 11 died. In 9 of the 12 recovery seemed complete, but in 3 the constitution was deteriorated. In treating the disease, sometimes mere demulcents, at others astringents, the mineral acids and the internal use of cold, and in others applications to the belly and enemata, have been tried in different cases. M. Rilliet believes that the best treatment consists in the free exposure of the child to the air, the keeping its extremities warm at the same time, the application of astringents to the abdomen, and the careful administration of nourishment, or, if the child's condition requires it, of stimuli,-Gazette Médicale, 1848, No. 53.

On Catarrh of the Mouth. By Dr. PFEUFER.

DR. PFEUFER opposes the prevalent idea, that the appearances of the tongue indicate the state of the stomach, and that its loaded state or perverted sensibility shows the existence of gastric affection. He denies that it undergoes greater changes in the diseases of the stomach than in those of any other part of the body. The stomach may be most extensively diseased by cancer, in which hyperæmia or blenorrhoea be may present, and yet the tongue continue clean and the appetite good, as also may be the case in chronic inflammation of the organ. The tongue may be loaded, and the appetite lost, in that catarrhal state of the mucous membrane of the stomach termed gastricismus, but it is by no means rare to find this not the case. The appetite may be gone, and the tongue be quite clean.

On the other hand, changes may occur in the cavity of the mouth without being at all indicative of disease of the stomach; the tongue may be thick and loaded, an indifference to food exist, and the taste be blunted and pasty, yet whatever the person does take produces no gastric suffering. The affection is, in fact, a catarrh of the cavity of the mouth. It may come on quite suddenly under the influence of mental emotion; it accompanies a variety of affections of the mouth and throat, and may be excited by various stimulating articles of diet, or by medicines acting as local irritants. It sometimes passes away in a few hours, and at others lasts for days, and seldom requires treatment, and certainly not the use of emetics and purgatives, which are usually resorted to, the diligent rinsing the mouth with cold water hastening its removal. Occasionally, however, the affection lasts for weeks or months, and then is usually treated by a great variety of medicines as an obstinate dyspepsia; those who can afford it being at last sent to the Spas. These means,