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early detection of the disease, and, of course, the early adoption of the treatment which experience has proved to be the only useful one. Towards the fatal period, which, in the worst form of hepatic dysentery, comes on with an overwhelming rapidity, the sudden and unexpected supervention of a general coldness of the surface, with partial cold clammy sweats, an almost total cessation of pulse, an excessive sinking of the spirits, and a discharge from the bowels, composed of a slimy brown substance, floating in a fluid like bloody water, and having a fetor of intolerable offensiveness, mark the irremediable progress the disease has made. This is the worst state of the disease, in which no human means can avail-a less unfavourable form of the disease presents some symptoms less equivocal, and which more early discovers its nature. The commencement, and for three or four days, the symptoms are those usually observed in dysentery; but at the end of that time, together with the pain at the pit of the stomach and the headache, a considerable anxiety at the præcordia, and a sensation as of a continued pressure in the right hypochondrium, with frequent stools, composed of a fluid like the washings of raw meat, are perceived. These symptoms should be particularly noticed, and deemed as truly characteristic of the seat of the disease being the liver. It will be happy for the patient, and creditable to the practitioner, if they are so; and if they are made the regulating principle of the treatment. But if these signs are neglected, and the fatal ones permitted to come on, nothing can be useful; and the progress of the disease from thence to death is most rapid, indeed, so much so, that from the appearance of these signs, death takes place in six, ten, or at the most twenty-four hours.""
On dissection, our author found the liver of all viscera the most diseased,” being inflamed, enlarged, partially suppurated, or, in some portions, sphacelated. The whole intestinal canal was more or less inflamed, especially the small intestines.
“ The mode of treatment I adopted in this obscure disease, after I became acquainted with its nature, was the following. After bleeding once or twice, if the pulse indicated the repetition, a vomit of tartarized antimony, or of what I found generally preferable, sulphate of zinc, and a sufficient purge of castor oil, the following pills were given.-Ro submur. hydrarg. gr. iij. pulv. ipecac. gr. iv. opü, gr. ss. mucilag. q. s. ft. pilulæ duæ. The two were given every three hours during the twenty-four. Emollient glysters, such as the following were administered thrice in the day-R amyl. solut. Zvi. tinct. opii, gt. Ix. ad c. pulv. ipecac. gr. viii. m ft. enema. If the danger was imminent, and the symptoms increased in urgency, the dose of calomel was augmented in such manner as to excite ptyalism as quickly as possible. When this took place, danger ceased, and the patient soon became convalescent. I first began to use this mode of treatment in the year 1786, and have most successfully continued it ever since. It is now more generally known, and every judicious practitioner employs it." 60.
The pathology of dysentery " drawn up by a learned and ingenious friend of the medical staff of the army,” is almost verbatim and literatim that which was given by Dr. Johnson seven years ago, in his work on tropical climates, and we wonder that Dr. Chisholm, whose candour and impartiality are every where conspicuous, should have, in this instance, failed to observe the good old rule—“ suum cuique."
Hepatitis. The next subject discussed by our very intelligent author is hepatitis. We are much inclined to coincide, though not to the full extent, with Dr. Chisholm in the following dogma, sweeping as it may appear to those who have not well considered the subject." All the endemic discases of hot climates have their immediate origin in the over-excitement of the hepatic and cuticular systemsfever, dysentery, and hepatitis, are thus produced." He properly observes that the whole of the abdominal viscera are so connected in their functions, that if an important organ is excited to unhealthy action, all the rest sympathize with it, and the usual consequences, inflammation, congestion, or morbid secretion, follow.
Taking a more extended view of the pathology of the abdominal viscera, we find, that an intimate connexion subsists between the organic system of the skin, and that of the liver ; insomuch, that whatever disturbs the operations of the former, necessarily and concurrently disturbs those of the latter.” 63.
We shall give, in his own words, Dr. Chisholm's rationale of chronic hepatitis in hot climates, which, as most of our readers will readily perceive, coincides very remarkably with that of Dr. Jobnson, detailed in the work on tropical climates abovementioned.
“ Chronic inflammation of the liver is generally the result of active or acute, and may be thus explained. From previous overexcitement of the hepatic and cuticular systems, torpor and atony, the invariable consequences follow—the secretion of healthy bile is suspended, and the expulsion of that already secreted becomes slow, or altogether ceases. The viscid and tenaceous bile thus retained, stagnates in the biliary vessels, or is taken up by the absorbents into the general circulation, causing the yellowness of the conjunctiva of the eyes, and of the skin; whilst the intestines, deprived of their natural stimulus, become torpid, and accumulation of fæces and flatus follows.-Hypochondriasm, the constant result of such a state of things, discovers its usual phenomena, mental depression, solicitude about health, visions of evil, apprehension of death, and despairing consciousness and fear of future punishment. It is, indeed, wonderful, in this state of the hepatic system, how readily the mind receives deep and afllictive impressions of religious enthusiasm ;
the most gloomy ideas are cherished, although, perhaps, the conduct of life
may have been correct and virtuous. I have frequently witnessed this state, and as frequently dissipated it, by rousing the liver into a due performance of its natural functions. Melancholia religiosa, which, in fact, is only another name for hypochondriasm, occasioned by this morbid state of the liver, should never be considered as a disease of the mind. It is physical not moral derangement;-and, if the proper remedy is so applied as to restore the diseased organ to healthy action, this, the effect of that derangement, will disappear.” 64.
Here Dr. Chisholm describes an anomalous hepatitis, or what we should rather call hepatic fever, which he has several times seen both epidemically prevailing, and sporadically occurring in the West Indies, especially among blacks, and young people from the age of 8 to 25-a peculiarity, doubtless, owing to these people being more exposed to the causes, which were observed to be exposure to cold and marsh miasmata.
“ The disease began with a considerable degree of head-ache, pain at the pit of the stomach, and tightness across the præcordia, with difficult respiration. The skin was dry, corrugated and cool; the tongue moist and foul; the belly natural, and the discharge of urine free. No thirst, no sickness, scarcely any diminution of petite; the pulse soft and not more than 70 or 80, and of a natural fulness. On the second day, the head-ache increased much ; the pain at the pit of the stomach became excruciating ; cold shivering came on; the skin, on pressure, communicated an intense, penetrating heat, although, on slightly touching, it felt cold, and its surface excessively dry and corrugated; the tongue covered with a thick moist fur, purplish towards the edges, and grey in the middle. In negroes a bronze
coppery colour on the cheeks, out of which large drops of clammy sweat issued, whilst a greasy moisture overspread the rest of the face; in whites, the colour of the face became dingy with the same kind of moisture—the pulse quickened at once from 80 to 120 and 144, and became hard and contracted. short cough, or rather a sudden, quick respiration came on, with a sensation at the diaphragm, as if a heavy weight pressed on the lungs, and was about to suffocate the patient. On the sixth day, if the patient lived so long, the pulse suddenly sunk, so as to become almost imperceptible; the greasiness of the face increased, a glassiness appeared in the eyes; a disagreeable cold clamminess over the whole surface took place; a great increase of weight at the diaphragm, and a sense of stricture in the pharynx, with excessively difficult deglutition succeeded; and the whole closed with coma and death. The proportion of deaths to recoveries was as one is to six ; and the fatal days were the 3rd, 5th, 7th, 11th. Repeated observations and numerous dissections alone directed to a knowledge of the nature of this most treacherous disease. --The morbid appear
ances were very uniform.-The liver astonishingly enlarged; on its surface, particularly the convex side, an irregular intermixture of red purplish and tallow coloured spots, exhibiting a marbled appearance; yet the texture, although the whole so much enlarged, as, in eight cases out of ten, to occupy both hypochondria and the epigastrium, was otherwise, in a natural state, and without the smallest vestige of suppuration or gangrene. All the other abdominal viscera were in a sound state. The diaphragm seemed, indeed, in most cases inflamed, and its blood-vessels distended with blood.-Every other part of the body had a healthy appearance.” P. 66.
After numerous attempts by other means, the following was found to be the best mode of treatment. The patient was bled as soon as possible, until deliquium animi or relief of symptoms was obtained—for which purpose forty or fifty ounces were frequently subtracted at one bleeding. A blister was then applied to the side, and cooling tartarized medicines given, repeating the venescction, pro re nata, so that in the course of three or four days our author has known from 40 oz. to 10lbs, of blood drawn. But it was not found eligible to trust to these remedies alone. On the second day, after the third bleeding, if there were not evident signs of amendment, " which indeed very seldom happened,” from two to ten grains of calomel made into pills, with or without opium according to the state of the bowels, were given three times in the day. “ This practice generally brought on a copious salivation in two days. When this was effected the patient was safe. It was astonishing how readily cases of the most dangerous tendency yielded to this treatment; and it was no less so, how quickly the sick recovered their usual health and strength, notwithstanding the great loss of blood they sustained; while many who had been bled more sparingly continued in a languid state for months.”
“ It soon became evident, however, that this remedy alone, as I have already observed, could not effect the cure; for when mercurial ptyalism did not take place, while bleeding was liberally employed, recovery was extremely tedious, or the patients died on the 7th or 11th day –Upon the whole, bleeding to a degree beyond all common bounds, and promoting a copious salivation as speedily as possible, were the only means of cure we placed confidence in.” 67.
In respect to acute hepatitis, it is a little curious that, till about the year 1770, it was unknown-that is, undetected. Yet the causes of the disease must have existed, and been in operation. But in those days it was called “ bilious fever," and no post mortem investigations were resorted to. In fact, when our autbor settled in the West Indies, “ the most marked symptoms of hepatic inflammation were entirely
overlooked”-“a putrid diathesis was alone dreaded, and alone provided against by bark, wine, and other stimulating tonics.”
“ The natural consequence followed. Hepatio gangrene, hepatic abscess, and hepatic diarrhæa, have destroyed thousands; and yet improper treatment of the original disease, had never been considered as the cause.” 68.
We recommend the following short symptomatology of acute hepatitis between the tropics, to the attention of the young visitor in the Torrid Zone.
“ Acute hepatitis often comes on without any previous warning; and is distinguished by violent pain in the right hypochondrium, a tightness across the abdomen, and a fulness, difficult respiration, and inability to lie down in any posture, the most easy position being a sitting one, with the upper part of the body inclined forwards. There is no heat, no quickness of pulse at first; but excessive and undefineable anxiety and restlessness. In this forın death sometimes happens, on the 3rd or 5th day, from gangrene of the liver.- When the disease approaches more slowly, there are, for some days, the usual precursors of disease, followed by the symptoms of remittent fever, and a sense of fulness and obtuse pain in the right side. At this period, bleeding in a moderate degree, and the operation of a brisk purge, relieve the patient so much, as to induce him to neglect his situation. In a few days, the same symptoms appear again with greater violence; but again disappear by some purging and other antiphlogistic means. All this time, however, the disease is gaining ground, but the apparent mildness of the symptoms, and the ease with which they seem to be removed, throw the patient off his guard ; and it often happens that medical advice is not deemed necessary until the disease is completely formed, has considerably advanced, and manifests itself by excruciating pain in the right side, attended with twitchings or spasms, and pain in the right shoulder, great anxiety, excessively difficult respiration, and total inability to lie down. In this state, if the most vigorous measures are not adopted without hesitation, and assiduously pursued, gangrene or suppuration in the liver soon follow.” 69.
The treatment of the first form must be prompt and decided—bleeding till the pain is relieved—abundant purging -and mercurial ptyalism, in the shortest space of time possible. Blisters are merely auxiliaries.
The second form admits of more time, and a slower administration of the remedies--but the remedies must be the same.” The following observations are equally important and correct. Many a time have we witnessed the truth of them.
“ If there is a tendency to diarrhæa before ptyalism is excited, it must be checked by opium. An important fact, in endeavouring