charge from the bowels, of which, with the liberal plan now recommended, we need not be afraid, and which we should be extremely cautious of checking by opiates. From the less threatening character of the symptoms, as they show themselves in the ERYTHEMATIC VARIETY, this affection, as Rothboel has well observed, often exhibits a fallacious appearance, and is misunderstood.* And it has hence been described on the continent, under the names of occult, apyrectic and anodynet enteritis. Its real nature, however, is as we have explained it above. It has been well ascertained that the seat of this variety is sometimes in the external coat of the intestines; and it is said, by some writers, that this is the most common seat. It is not easy to determine upon this point: nor always, at its commencement, whether the inflammation be of the one variety or of the other, the modifying causes being, in some constitutions, and some seasons of the year and temperaments of the atmosphere, so nicely balanced as to leave the course doubtful. A case of this kind occurred to me in July, 1805, in a healthy and active young gentleman, thirteen years old. The abdomen was tense and tender, the intestinal canal painful through the greater part of its extent; the pulse quick, and moderately full; the skin very hot and dry; the blood, when drawn from the arm, without any buffy coating; the sickness incessant, with deep anxiety and oppresion. The greater part of these symptoms indicated the adhesive variety; but, as the morbid signs increased, the stomach evidently partook of the affection, and shortly afterwards an erythematic sloughing appeared in the throat on the fourth day from the attack, evincing the real nature of the inflammation, and that it had extended up the whole of the oesophagus. On the sixth day the patient died. Bleeding, which was reported within about twelve hours, did not, in this case, prove of any benefit; though it may be justified from the mixed character of the disease. But in distinct and simple examples of erythematic inflammation, it ought, unquestionably, to be abstained from and acids, and the milder tonics, and bitters, as infusion of roses, cascarilla bark, and cinchona, supply its place. I have said that enteritis is sometimes a result of hernias. It has also, occasionally, been produced by a forcible protrusion of a part of the intestinal canal through the anus; of which a singular instance is given in the Medical Transactions, in a paper communicated by Dr. Latham : the part of the prolapsed intestine was very considerable, and the injury was occasioned by the passage of the wheel of a cart over the loins; a portion of the mesentery was protruded with that of the gut; gangrene supervened to the inflammation, and the prolapsed mesentery and intestine were cut off above * Dissert. sistens Observationes circa fallaciam signorum in inflammationibus Abdominalibus. Hain. 1776. Plocquet, Initia. Vol. v. 103. t Vol. IV. Art. XXIV. the line of gangrene; the latter to a length of not less than fiftyseven inches, measured by a string applied to the outward surface. The patient, who was a boy, recovered; had motions regularly from the truncated extremity of the remaining intestine; and was able afterwards to walk twelve or fourteen miles a-day. He had no power, however, of restraining his motions, so as to postpone the evacuation. SPECIES XIII. EMPRESMA HEPATITIS. Enflammation of the Liver. TENSION, SORENESS, AND PAIN IN THE REGION OF THE LIVER; PAIN ABOUT THE RIGHT SHOULDER; DIFFICULTY OF LYING ON THE LEFT SIDE; SHORT, DRY, COUGH. Acute inflammation of the INFLAMMATION of the liver, which may in general be sufficiently known by the above characters, has also two varieties, dependent upon its more rapid and violent, or more tardy and obscure march. a Acuta. In which the above symptoms are clearly marked, and the character of the disease is decisive. In which the specific character is obscure; and the existence of the disease suspected from a previous exposure to its causes, in connexion with an occasional recurrence of the pathognomic symptoms, accompanied with a slight degree of fever. Chronic inflammation of the liver. Sauvages, on the authority of Amati, has given an erysipelatous, or, as it should rather be, an erythematic, variety of this disease, as Lommius has, also, done of pneumonitis; but the parenchymatous viscera do not seem to be subject to an inflammation of this description, as Dr. Cullen has correctly observed; and as has been since confirmed by the remarks of Mr. Hunter which we have already quoted. The ACUTE VARIETY commences with the ordinary symptoms of visceral inflammation; chillness, succeeded by heat, frequent pulse, and a furred tongue: the bowels are irregular, mostly costive; the evacuations little tinged with bile, the urine often saffron-coloured; the skin is dry, the thirst extreme, with occasional sickness. No physiologist has yet been able to explain the cause of the pain so generally felt in the right shoulder. It is however sympa thetic of other affections of the liver, as jaundice, or chololithus, as well as of hepatitis; and hence it should seem to be produced by almost any morbid excitement of this organ, whether from inflammation or the obstruction of gall-stones. The cough, which is often very distressing, is easily accounted for from the vicinity of the diaphragm to the seat of disease, and its sympathy with the liver. The sickness of the stomach is from the same cause. The disease is sometimes accompanied with a jaundiced colour of the skin; and Sauvages and Sager have made such a colour a specific symptom; but it is not always that the bile regurgitates, and hence, such an appearance ought not to be enumerated among the pathognomic characters. Even where it exists it is not a distinct symptom of hepatitis; for, to say nothing of proper jaundice, the feces, as Dr. Latham has well observed, may be light-coloured, and the eyes, skin, and urine peculiarly yellow, from the pressure of an indurated pancreas upon the bile ducts, and an obstruction of their course. And hence Dr. Latham imagines that an enlargement of the pancreas has sometimes been mistaken for hepatitis, and a diseased ovarium still more frequently. On which account it demands a very nice examination of the liver before we can speak with decision, and a pretty tolerable assurance to ourselves, that there is no enlargement of either of the other organs. Dr. Saunders, and with some plausibility, suspects the acute variety is owing to an inflammatory state of the hepatic artery, and the chronic to a like state of the vena porta. Winslow ascribes both to an inflamed state of the ramifications of the vena portæ, which, in his opinion, constitute the seat of the disease; while Cullen refers us to the hepatic artery alone, and limits the seat of inflammation to its extremities. Dr. Heberden does not incline to believe that the liver is primarily affected, but only influenced by a phlogistic diathesis, or preceding inflammatory fever. If the inflammation originate in the membranes, the pain, as in most other cases of membranous affection, is peculiarly pungent, like that of a pleuritis; the fever is severe, the tension very considerable, the pulse frequent, strong, and hard; the urine generally high coloured. When the substance of the liver is primarily affected, the pain and pyrexy are far less acute, and especially at first; but they increase with the progress of the disease, or, in other words, as it extends to the membranes, and not only darts to the right shoulder, but sometimes shoots as far as the throat and clavicle. Where the symptoms are most severe, and we have reason to suspect that the disease is confined to the membranes, the duration is often short, and the termination is in most cases that of resolution. But when less active, and seated in the parenchyma, it generally tends to suppuration; and if the convex side of the liver be the part affected, a tumour is visible externally, the cough becomes aggravated, and there is a difficulty of breathing. If adhesions have preceded the suppuration, the pus points to the skin, and the abscess opens on the surface; but if it break internally it generally proves fatal by inducing a hectic, though sometimes, in consequence of fortunate adhesions, the abscess discharges itself into the hepatic duct, and the pus is carried off by this channel. It has, occasionally, by the same means, made its way into the stomach and intestines, where the abscess has been very large. In which case, however, immediately upon the bursting of the vomica, the patient throws off, by sickness or by purging, a large mass of most offensive matter, often filling the whole house with its noisome smell, and dies in a few hours. In like manner, the pus has occasionally formed an empyema in the thorax; and, in a few instances, has been discharged from the lungs. The disease sometimes also terminates in scirrhosity; in which case the induration bears an extent in some measure proportioned to the range of the preceding inflammation, and may often be felt by applying the hand to the region of the organ. This, however, is a more frequent result of the second or chronic variety. In order to induce acute hepatitis, it is necessary that the organ of the liver, at the time of attack, should be in a state of at least moderate health and vigour; for it is in this condition only, that inflammation running through its regular stages can take place, and hence the acute variety is found far more frequently in temperate, than in intertropical climates; and in the latter more frequently among new comers, than among those that have been long habituated to the climate, and whose livers have been weakened and relaxed by the greater heat of the sun: "Among the men of the eighteenth regiment," says Mr. Christie, who was stationed at Trincomale, and had the care of the entire garrison in 1798, "I found for the first six or eight months, the disease was much more frequent, much more violent in its symptoms, showed more tendency to suppuration, and was more sudden in its crisis, than with the company's European troops, who had been long in India, although the latter were the most debauched. Among the natives hepatitis does not often occur: out of a thousand native troops, I did not, in the course of three months, meet with more than two cases of liver-complaints, which is comparatively a very small proportion."* There is, however, a striking distinction between the state of the bowels as affected by this disease in hot and in temperate climates. In the latter it is rarely we have any diarrhoea, and often an obstinate costiveness, the evacuations being mostly untinged with bile. In the former, from the higher degree of irritation that prevails, and the greater extent of its range, a bilious flux is so frequent as to be almost a pathognomic symptom; and as the gorged vessels are apt to give way from debility, this is sometimes intermixed with blood. In our own climate, bleeding at the commencement of the disease is generally found serviceable, and ought to be prescribed as speedy Letter to the Editor of the Medical and Physical Journal, May 1798. as possible; certainly before the fifth day; and be repeated generally or locally, as the violence of the symptoms may require and the strength of the constitution allow. Free purging, with calomel and Epsom salts, should immediately follow; and mercury be at the same time introduced into the system by the stomach, or by inunction, or by both. From the costiveness that usually accompanies the disease it is rarely necessary to unite the mercury with opium; though where it irritates the bowels, the latter should unquestionably be given; as it should also to allay the cough, when this symptom is very distressing and prevents sleep. The mercurial course, as recommended by Sir James M'Grigor,* should be steadily persevered in, not only in hot climates but in temperate, till a salutary change has been effected, or salivation has been freely excited. It will often be found, however, that the patient will bear a long continuance of the mercurial plan without any affection of the mouth; and will gradually and insensibly improve under it; the soreness and tension subsiding, the cough diminishing, the pulse becoming slower, and the heat and dryness of the skin yielding to a pleasant moisture; all which are prognostics of a favourable issue. The application of large blisters over the hypogastric region in succession, is recommended by most practitioners, but I have not found them successful; and have evidently derived more benefit from fomentations, epithems, and the warm bath. Diaphoretics should certainly form a part of the curative process; and they combine admirably with the mercurial treatment; particularly the antimonial preparations. Cooling, diluent, and even acidulated drinks should be taken copiously; the diet consist chiefly of light farinaceous foods; and the chamber be well ventilated. If from sudden shiverings, and remission of the quickened pulse, we have reason to believe suppuration has taken place, columbo, the mineral acids, and above all the bark, where it can be retained, should be given freely; the cinchona, at least in the proportion of from half a drachm to a drachm, five or six times a-day; and this whether the abscess be likely to burst externally or internally; and if the former, the direction should be encouraged by maturating cataplasms, and the abscess be opened as speedily as possible. The discharge is sometimes very considerable in quantity, and amounts to several pints; the pus is occasionally found pure, but more generally intermixed with coagulable lymph or some viscid, yellow, fluid. It is at times lodged in different sacs, and hence subsequent tumours ensue, and subsequent openings are necessary.† It is not always, however, even after suppuration has taken place, that the abscess must necessarily open in any direction; for the following case will show that when we have full reason to believe * Medical Sketches, passim. + Recueil d'Observations de Medicine des Hôpitaux Militaires, &c. Art. par M. Boucher, Tom. II. 4to. Paris. |