positive inflammation. But we know that sympathetic irritation cannot long exist in so delicate an organ as the brain without producing disease, and further, that we cannot tell when this change takes place. Hence the safe mode of proceeding is always to treat the cerebral symptoms as if they really proceeded from encephalitis. In such a case it is generally unnecessary to use the same degree of vigour in treatment as if the disease was idiopathic inflammation.

When the disease occurs in the adult, the chief remedy will be found to consist in the detraction of blood generally and locally, but particularly the latter, unless in cases where the symptoms run high and threaten peritoneal inflammation. Here the lancet is never to be neglected, and its use must be repeated frequently if the violence of the disease is not subdued. Dr. Abercrombie recommends the practice of following up the first bleeding by smaller detractions of blood, so as to keep up a decided impression on the system. It seems, however, that in most cases we may look on general more as a preparative for local bleeding, which, when properly performed, is a means of extraordinary value. Facts, however, oblige us to admit the efficacy of general bleeding alone in reducing inflammations of the mucous membrane. When the disease exists in the small intestine, we have always found most advantage from local bleeding. It may be performed at various stages of the disease, even when there is great adynamia, and will seldom disappoint the practitioner. Leeches should be applied abundantly round the navel or to the ileo-cœcal region, and the hip-bath used when they fall off. If the symptoms do not yield at once to this treatment, the leeching is to be boldly repeated, and a large poultice applied over the belly. The bowels are to be gently opened by the mildest laxatives, and emollient injections should be frequently given.

The most distressing symptoms in this disease are the vomiting, thirst, tympanitis, and diarrhoea. It is often very difficult to allay the first of these. We have found nothing so efficacious as the application of a dozen leeches to the epigastrium, and the liberal use of iced water, or even plain ice, which may be given nearly ad libitum. It is a most grateful and important remedy, and one from which we have never seen any unpleasant results. In the more advanced stages of the disease we have constantly applied leeches to the epigastrium, though in smaller number, and have seen that assemblage of phenomena which constitute the typhoid state speedily disappear after their use. In addition to this, we have in the hospital often applied a small blister over the region of the stomach, and afterwards sprinkled the surface with a little acetate of morphia, a practice which, in some cases, succeeded remarkably. Effervescing draughts, with the carbonate of soda or ammonia, may be exhibited, but not in too great quantity, as

See Cheyne's Report on Dysentery.

violent diarrhoea and exasperation of all the symptoms may be the result of this excess. Lastly, opiates, and, in some very advanced and low cases, stimulants may be used with advantage. The thirst may be moderated by the use of cold acidulated drinks, such as lemonade, the cream of tartar solution, and tamarind-tea; but let it never be forgotten that the means best calculated to remove these symptoms are those calculated to reduce the inflammatory action. The tympanitis, when it arises, is a symptom commonly maltreated from ignorance of its pathology. Occurring in the early stages of the disease, it is generally in proportion to the intensity of the inflammation. It is a distressing symptom, and hence practitioners are over-anxious for its removal, and are tempted to exhibit turpentine. From witnessing a great number of cases where this practice has been pursued, we feel certain that the exhibition of turpentine or analogous remedies for the removal of tympanitis in the early stage is a practice pregnant with danger. often, indeed, renders the belly flat; but this apparent advantage is commonly followed by an increase of the other symptoms; and the tympanitis is sure to return. If the symptom be not severe, its presence should not make us modify our treatment; if it is excessive, it becomes a sign for increased activity in means calculated to reduce the inflammation without endangering the safety of the patient. In addition to this, stimulating injections, where there is not tenesmus, may be used, and enemata of cold water in all cases. In the stages of the disease, however, where depletion can no longer be practised, the use of turpentine is sometimes successful, a circumstance reconcileable with our knowledge of the effects of stimuli in the advanced periods of mucous inflammation.

It

Nearly the same remarks apply to the diarrhoea. The exhibition of astringents in the early stages is generally followed by the worst effects, a circumstance favouring the doctrine that the secretion is the relief of the inflammation; but when the powers of life are low, and the disease not acute, we must moderate it. This is best done by the warm-bath, a flannel roller, the occasional application of a blister to the belly, anodyne injections, and the use of small doses of Dover's powders, with or without rhubarb. Where the diarrhoea was severe and the patient much depressed, we have often used large doses of opium with the best effect.

The remarks as to revulsion, regimen, &c. which we made in treating of the enteritis of children, apply equally in this form of the disease.

(W. Stokes.)

EPHELIS (from iπì and λ105, sol,) a genus of diseases of the skin, of the order macula, (see the article MACULA,) characterized by discolorations, varying from dark brown to greyish yellow, and presenting great diversity of form, from small distinct points, sometimes scattered, sometimes grouped, to large confluent or continuous patches.

Syn. Maculæ fuscæ (Plenck); Ephelides (Alibert).

We use the term ephelis in the extensive sense which has been given to it by Gorraus"non quod à sole tantum vitia illa in cute contrahuntur, sed quod à reliquis inducta causis, similem asperitatem et colorem habeant;"* although we do not altogether agree with Bateman, that this acceptation of the term is sanctioned by the authority of Hippocrates, for he appears to have distinguished between lenticula (Paxis) and ephelis, both included in this definition. Celsus went farther; he not only distinguished between lenticula and ephelis, but also between lenticula and the axia of the Greeks. These distinctions were lost sight of, and the term ephelis was made more comprehensive by Oribasius,|| Etius,¶ and Actuarius.** Sennertus revived the ancient distinctions, in which course he was followed, more or less, by Sauvages, Lorry, and Plenck; but whilst the first of these raised distinctions on one hand, he removed them on the other, and thus included under ephelis morbid appearances which have no relation to it. This last is also the error of Alibert, who, in his order of Ephelides, includes scorbutic blotches.

These affections of the skin seldom demand or deserve, on their own account, the attention of the practical physician; but as signs of internal disorders they sometimes afford very valuable diagnostic evidence, as much as erysipelas, urticaria, prurigo, and many other eruptions. And we perfectly agree with Alibert, that they afford matter of interesting research to the physiologist, shewing how the integuments may become discoloured, and revealing in some manner, by external appearance, the alterations to which the human body is subject. Besides, it is shewn in the study of the natural sciences that the most trifling facts may be useful, because, being connected by an almost imperceptible chain with phenomena much more important, they sometimes indicate, sometimes explain them.

The process of the formation of the ephelis is unknown. It is not the result of any particular alteration of the epidermis, but some modification of the pigmentum of the skin which science is not yet able to explain. It would seem sometimes to be a consequence of an inflammatory action; it is frequently accompanied with signs of a determination of blood to the skin, but neither of them are constantly observed. It is very variable in its progress and duration, sometimes developing itself fully and extensively in the course of a night, sometimes very slowly; sometimes it is permanent, continuing indelible

* Defin. Med. ad voc. inλív.

+ Synopsis, p. 442.

Prædict. lib. 2. xxxi. 9; de alimento, iv. 18; de sterilibus vi. 8; de morb. mulier. lib. 2, lxvii. 6, Ixviii. 1.

De Medicinâ, lib. vi. cap. 5.

for several years, and sometimes it disappears after a single bath or lotion.

Not having found any previous arrangement of this genus which satisfactorily comprehends all its varieties, we propose considering it under two species, viz. 1. Ephelis lentigo; 2. Ephelis diffusa.

1. Ephelis lentigo. Syn. Qaxis (Hipp. et Græc.); Lenticula vel lentigo (Latin.); Ephelis lentigo (Sauvages and Alibert); Lentigo (Lorry, Plenck); Lentigo ephelis (Frank); Sommersprossen et Sonnensprossen, Sommerflecken (Teutonicè). Freckles.

An eruption of small minute spots of a fawn, yellow, or brown colour, sometimes dissemi nated, sometimes in clusters, unaccompanied with any pain or itching.

This eruption presents itself under two circumstances; it is either hereditary, a natural deformity of the skin, or it is purely accidental, the result of exposure to the sun's rays. This affords the division of the species into two varieties: a. Ephelis lentigo materna. b. Ephelis lentigo estiva.

a. Ephelis lentigo materna. Tâches de rousseur (Gallicè). The well known lenticular eruption, forming, as it were, part of the natural complexion of yellowish or reddishhaired persons, who are, besides, distinguished by the strong odour exhaled by the secretions of their skin. (Alibert, Pl. xxv1.) It is more rarely, but sometimes, observed in persons of a fair and delicate skin with dark hair and eyes. The colour and shade of the eruption bear always a near relation to the colour and shade of the hair, being sometimes as dark as coffee or chocolate, and sometimes of a light yellow. The eruption is not confined to the parts of the body exposed to the light and air, but sometimes occupies the whole surface; neither does it disappear in winter. It is to this variety that the French term, "tâches de rousseur," strictly applies.

viii. 33.

¶ Tetr. ii. serm. iv, cap. 11.

Meth. Med. iv. cap. 13.

tt De cutis vitiis, lib. v. pars 3.

supervening with the summer and disappearing

Phil. Ludov. Bender de Cosmet. Argent. 1764.

prejudice his correct observation of their changes from one season to another.

Viewed practically, epidemic diseases require minute and cautious observation on the part of the physician; for diseases of the same name, as Sydenham remarked, often require different treatment at the beginning of the epidemic and at the decline; as they require different treatment in different countries, and frequently in the same, under different epidemic constitutions. The diseases of an epidemic constitution will sometimes shew an unusual tendency to one part of the system, and sometimes to another; as they will affect a particular type. This tendency is either to the skin, or the head, or the chest, or the stomach and bowels, and often continues for many months, or even years, in the reigning diseases. It was remarked that at the time the sweating sickness raged in England, other diseases assumed the sweating tendency.

It is much to be lamented that many things stand in the way of accurate knowledge on this subject. It is comprehensive, and surrounded with difficulties, in proportion to the extent and variety of the observations which are requisite for forming scientific conclusions. If medical observers had been contented to look with simplicity into the series of events belonging to epidemic diseases, like Hippocrates and Sydenham, we should not have been so much in the dark at the present day. Facts apparently contradictory, at least as to the proper name and the contagious quality of certain epidemic diseases, such as the Levant plague, the Asiatic cholera, and the yellow fever, have been brought forward by men justly eminent in their profession, but wedded to particular opinions. Hence has arisen the extreme difficulty of knowing the truth. Physicians, on the very site of pestilence, have sometimes, like children at play, taken opposite sides, and maintained their ground with unseemly pertinacity; so that we may look in vain to either party for unprejudiced observations. The records of all modern visitations of pestilential epidemics present us with opinions and statements as much at variance as light and darkness; and hence we must conclude either that one set of observers are right and the other wrong, or both partially informed but blinded by prejudice, so that they cannot see any truth in their antagonists' assertions; consequently, that many things which they report as facts are only partial observations, or vague rumours, or hastily formed conjectures, or unconnected and adventitious appear

ances.

Truth is sacred, and error cannot be propagated without some injury. How incumbent, then, is the duty of medical observers to inquire impartially and to report with fidelity! He that presents us with a physical observation clouded by his prejudices, on a subject so deeply important to the health and welfare of his fellow-creatures, is but a degree less culpable than the man who gives a false colouring to some moral or religious truth, which involves the dearest interests of humanity.

If this view be correct, where shall we look for the facts-strictly such-which may assist our reasonings on this weighty subject? It is not, clearly, to recorded observations of infection and of non-infection, adduced by contagionists and their opponents, that we must refer for those unexceptionable data on which some safe practical conclusions may be built. We may perhaps admit something from each, but must reasonably doubt their wholesale inferences.

The subject would be involved in a cloud of darkness which no diligent and honest inquiry could penetrate, if there were not other things besides facts of infection and non-infection-in short, other facts connected with the origin, spread, and decline of pestilential epidemics, (for to these we shall chiefly confine our attention in the present article)-which, though too much overlooked, throw a good deal of light upon the whole question, and not only point to something quite independent of their contagious and non-contagious nature, but help us to determine how much importance we should attach to these circumstances in the general estimate. It is fortunate for our science that there is such a class of facts, and that the lover of truth has not to range in a wilderness of uncertainty. It is also a source of gratification that many of these facts are admitted by both parties, or at least, with few exceptions, are not denied by either.

Now, the facts of a comprehensive nature above alluded to, which belong to pestilential epidemics, may be classed under the following heads; on each of which it is proposed to make a few general observations, with a view of drawing some conclusions from the whole.

1. The natural signs which are either the antecedent indications or the concomitants of a pestilential epidemic, such as intemperate seasons and unusual weather, deficient or unwholesome food, mortality among any species of the lower animals, uncommon abundance of some of the insect and reptile tribes, departure of birds, &c.

2. The singular changes which have been observed to occur in the common or reigning diseases of the place, before, during, and after an epidemic pestilence.

3. The changes in the symptoms, or type and character of the epidemic pestilence itself, and the circumstances attending its migrations from one place to another.

4. The facts relating to the connexion of epidemic pestilence with offensive cities, marshy grounds, and low filthy situations, bad food, and a condensed, filthy, and ill-fed population, in all countries; and, on the other hand, the exemption of those places where due attention has been given to cleanliness, wholesome and sufficient food, and a rational system of health police.

5. The facts given in evidence from quarantine establishments and lazarettos.

Before we proceed further, it is proper to explain what is meant by an epidemic pestilence: the term is used generically to include