GEN. VII. GEN. IX. Empresma tions of accompanied with an increase of heat, which often spreads to the surrounding regions. This is M. Portal's acute modification of the disease: but he also notices an obscure Carditis. Inflammaor latent modification, in which its symptoms are but little tion of the conspicuous, and whatever exists of them are ascribed heart. to some other disease. The spirit, he tells us, is here Modificasuddenly subdued and broken: the pulse is slow, soft and Portal. feeble: there is little pain in the heart, and little or no palpitation. Fainting, nevertheless, is a frequent appendage, and is peculiarly apt to lead astray. This, however, can hardly be called an idiopathic disease. M. Portal has drawn his description entirely from post-obit appearances in those who have died of severe atonic typhus, or of plague: and observing, as M. Chicoyneau had before him, occasional proofs of suppuration and gangrene of the heart, he has inferred the previous existence of carditis, and has ascribed the almost instantaneous sinking of the patient to a rapid march of inflammation in this organ, notwithstanding it was not manifestly accompanied with its ordinary indications tive sym ptoms be flammation We are not in possession of any signs by which an No distinc inflammation of the pericardium can be distinguished from that of the substance of the heart, for here the ste- tween inthoscope affords little aid: and hence we cannot make a of the heart distinct species of the latter. Vogel and a few other and periwriters have attempted it, but the boundary has not been clearly drawn, and has never been of use. cardium. detected discomfort. Upon dissection, adhesions have been occasionally Adhesions found to a very considerable extent between the heart have been and pericardium, even where little inconvenience had when litle been felt during life: and into this fact we are perhaps previous chiefly to resolve the declaration that the heart has occasionally been found without any pericardium whatever. From all which we may, at least, collect that the extent of motion of these two parts on each other is not very great. A purulent kind of fluid has at times also been And some * Mémoires sur la Nature et le Traitement de plusieurs Maladies. Par A. Portal, Premier Medecin de Roi, &c. Tome Quatrième. 8vo. Paris, 1819. times purulent fluid. SPEC. IX. Carditis. tion of the GEN. VII. detected on the outer surface of the heart, without the Empresma slightest appearance of ulceration either of the heart or pericardium; and as the same sort of secretion has often been traced, without ulceration in other cavities, Mr. Hewson, as we have already seen, first suspected, and Mr. Hunter afterwards endeavoured to establish, that this fluid is nothing more than coagulable lymph thrown forth from the vasa vasorum, but changed in its nature in consequence of passing through vessels in a state of inflammatory action. And it was this discovery, and the hint thus founded upon it, that gave rise to the doctrine now so generally admitted, and apparently so well sustained, of a distinct secretion of pus, in many cases without ulceration. Causes and treatment. Walls of the heart some times thick ened. The causes of carditis are often obscure: where we can trace them, they are for the most part those of pneumonitis; and the mode of treatment needs not essentially vary. Dr. Frank gives an interesting case of violent carditis brought on by terror in a prisoner condemned capitally. It proved fatal, but on dissection was found not to be confined to the heart. There seems sometimes to be an increase in the action of the vessels of the heart, which, though short of inflammation, is sufficient to give thickness to its walls, and considerable magnitude to its general substance. And hence a frequent origin of enlargement of the heart. M. Bayle has published an interesting case which appears to belong to this kind of morbid structure. The patient was a young man of delicate constitution, and limited Exemplified. intellect. He was attacked in 1819 with mental derangement; and in a few months afterwards seemed to labour under a general oppression in every organ, under which he died in a few days. The membranes of the brain were infiltrated and thickened: the heart was twice and a half its natural size: the aorta and pulmonary artery, as well as various other vessels, gave evident proof of a direct inflammatory action *. Observations d'Arterite. Bibliotheque Medicale. Sept, 1821. SPECIES X. EMPRESMA PERITONITIS. Inflammation of the Peritonaeum. PAIN AND TENDERNESS OF THE ABDOMEN, ESPECIALLY SPEC. X. THE inflammation may be seated in the peritoneal mem- GEN. VII. brane lining the cavity of the abdomen, or in its extension to the mesentery or omentum. And hence Dr. Cullen has noticed the three following varieties: Cullen: It is singular that Dr. Cullen, after distinctly charac- Noticed terising this species in his Nosology, and following it up with singular into three sub-divisions, each of which, with him, forms brevity by a separate species, as the general disease does a genus, should take no other notice of the entire complaint in any form, except what is expressed in the following laconic remark: "Among the inflammations of the abdominal region, I have given a place in our Nosology to the pe SPEC. X. Empresma Inflamma GEN. VII. ritonitis; comprehending under that title, not only the inflammations affecting the peritonæum lining the cavity Peritonitis. of the abdomen, but also those affecting the extensions of this membrane in the omentum and mesentery. It is peritoneum. not, however, proposed to treat of them here, because it is very difficult to say by what symptoms they are always to be known; and further, because, when known, they do not require any remedies besides those of inflammation in general." tion of the and more so than is expedient. & E. Perito nitis propria. Proper inflammation of the peri tonæum. How far re lated to puerperal fever. This remark is by far too sweeping. If the diseases referred to have no specific symptoms by which they can be known, they have no more claim to be admitted into a system of symptomatic nosology than into a treatise of practice. Dr. Cullen is right in assigning them a place in the former; and he is, therefore, necessarily wrong in banishing them from the latter; and the more só, as the treatment ought, in some degree, to vary from that of enteritis, to which his general observation seems chiefly to refer. The TRUE PERITONITIS Occurs, as we have already observed, as a symptom in PUERPERAL FEVER; and as we have treated of it at some length under that disease, it is the less necessary to be minute in our account at present. Puerperal fever, indeed, is sometimes, though not quite correctly, made a variety of PERITONITIS: for it is a disease of a peculiar kind, produced by peculiar causes, and is only connected with peritonitis as the latter enters as a symptom into its general character, and may hence take the name of puerperal peritonitis, to distinguish it from idiopathic. In what light Dr. Cullen regarded puerpe ral fever does not appear from his writings, since, com+ mon as the complaint is, it does not occur in any of them; which is the more extraordinary as his System of Nosology, which is not comprehensive enough to in clude many diseases, might easily have found a place for this. Dr. Carmichael Smith has well described the progress and effects of this inflammation in the following passage: Description. The symptoms accompanying peritoneal inflammation SPEC. X. a E. Perito pria. Proper in of the peri tonæum. Whence the surrounding little affect ed; are fulness, tension, and a general soreness of the abdo- GEN. VII. men, with purging and fever. The pulse is remarkably small, quick, and thready; and the slightest pressure on nitis prothe part occasionally causes pain, sickness, and vomiting, Upon dissection there is found a kind of gelatinous ex- flammation udation all over the intestines; and the cavity of the abdomen is often filled with a turbid whey-coloured serum.”* In the specific definition it is stated that peritonitis occurs "with little affection of the subjacent viscera or parts but abdominal walls". In effect it often happens that these are not at all influenced, and, whenever they are, it is only secondarily; and hereby peritonitis is sufficiently distinguished from puerperal fever. "If the perito- as explained næum", says Mr. Hunter," which lines the cavity of Hunter. the abdomen, inflames, its inflammation does not affect the parietes of the abdomen; or if the peritonæum covering any of the viscera is inflamed, it does not affect the viscera. Thus, the peritoneum shall be universally inflamed as in the puerperal fever, yet the parietes of the abdomen, and the proper coats of the intestines, shall not be affected: on the other hand, if the parietes of the abdomen, or the proper coats of the intestines are inflamed, the peritoneum shall not be affected."+ We hence perceive another proof that the mem- Substance branous tunics of the different viscera do not hold an of different organs not equally consenting with their sur membranes. equal intimacy of action in every instance. And it would be interesting to follow up the discrepancy, and draw a scale of their readiness or inaptitude to sympathize with rounding the viscera which they cover. The membranes of the brain, as we have already seen, are so peculiarly dis. Illustrated. posed to partake of the inflammatory action of the parenchyma, as to render solitary inflammation of the one or of the other a rare occurrence. In the lungs and in the heart the play of relationship is far less conspicuous, and in the viscera of the abdomen it rarely takes place. And it is owing to this circumstance that we are able so generally to draw the line between inflammation of the * On the different kinds of Inflammation. † On Blood, &c. p. 244. |