On dissection, the right lower extremity was found to be tense and swollen in its superior portion, while the leg and foot were slightly anasarcous. The sac of the pericardium contained some sero-purulent fluid; and that portion covering the auricles and great vessels was vascular, and in many cases covered with coagulable lymph. Both lungs were in a state of extreme sanguineous congestion with commencing solidity in their posterior inferior portion, and general inflammation of the pleura. The bronchial mucous membrane was universally red, and the tubes filled with frothy

mucus.

The vena cava contained a few portions of a substance of a granular appearance, friable, and of a yellowish colour. This did not adhere to the vessel, which otherwise appeared healthy. In the external iliac vein, however, just above Poupart's ligament, there was a large concretion of a similar nature nearly plugging up the vessel, and extending into some of the minute collateral branches. The lining membrane was red, and in one point adhered to the coagulum. No puriform matter could be detected. The femoral and popliteal arteries were healthy. The cellular tissue of the limb was oedematous. The condition of the saphena vein where it enters the femoral is not described, although the inflammation most probably originated in the superficial vessel.

On the 2d of February 1832, the body of an aged man was brought into the dissecting-room of Webb-street school. The whole left inferior extremity was much swollen, and a chronic ulcer was observed over the tibia. The coats of the saphena vein along the leg and thigh were found, on examination, to be much thickened, and plugged up with coagula of blood and lymph. The left common and external iliac and femoral vein to the ham were all completely obstructed with coagula of blood and lymph, and lined with adventitious membrane. The lower part of the vena cava, to the extent of three inches, was filled with a soft yellowish coagulum of lymph, which adhered to the inner coat of the vein. The coats of the principal arteries of the left lower extremity were ossified.

In April 1832 Sir Henry Halford read an account to the College of Physicians of crural phlebitis as observed in the late Earl of Liverpool. The attack commenced many years before; and it is highly probable, from a circumstance stated to us by Sir A. Cooper, that it was induced by exposure to a current of cold air, which passed through an open window and fell upon the lower extremities when but thinly clothed, his lordship being at a crowded levee. The left groin, thigh, and leg were affected; and in the acute stage of the complaint, leeches and the usual antiphlogistic remedies had been employed by Dr. Pemberton and Sir A. Cooper. Lord Liverpool subsequently died from an affection of the brain; and on examining the body, the left iliac, femoral, and saphena veins were found to have undergone changes of structure similar to those which have previously been described as occurring in puerperal crural phlebitis. Sir Henry Halford related two other cases of crural phlebitis in men. They VOL. III.-68

and were succeeded by marked tendency to head affection. In none of the cases of crural phlebitis which have fallen under our observation, has any remarkable slowness of pulse or tendency to disease of the brain been observed. Even where the vena cava and both iliac and femoral veins have become completely impervious, the blood has been returned to the heart without difficulty, and no affection of the brain has taken place.

In a patient of the British Lying-in Hospital, who had suffered much from varicose veins in the latter months of gestation, inflammation of the saphena veins of both lower extremities came on two days after delivery with most severe constitutional symptoms. From the left knee to the ankle on its inner surface, the integuments were hot, and swollen, and tense, and in several places large patches of a dark red colour were observed over the superficial veins, which being laid open in two places, a considerable quantity of purulent fluid was discharged. Where the swelling and tension were least, the superficial veins could be felt distended like hard cords; as could also the saphena through its whole course upward from the ham to its junction with the femoral vein. In the course of this vein there was considerable swelling; and the integuments in this situation, as far as the middle of the thigh, were hot and of a dark red colour.

The symptoms which characterize venous inflammation in its most severe forms took place, and she sank on the fourteenth day after delivery. Dr. Sims assisted us in inspecting the body, when the following morbid appearances were observed. The left lower extremity was very much enlarged. The cellular and adipose membranes from Poupart's ligament, along the inner surface of the thigh and leg to the ankle, were indurated, vascular, and infiltrated with a red-coloured serous fluid. Several abscesses were observed in the cellular membrane immediately beneath the skin in the calf of the leg, and an extensive collection of pus had formed in the interstices of the gastrocnemii muscles. The branches of the saphena in this situation were converted into solid impervious cords; and the coats of this vein, from the knee to its junction with the femoral, were thickened and contracted, and in the lower part the cavity was nearly obliterated. The saphena vein was lined with an adventitious membrane of considerable thickness, which was easily separated from the inner coat. Its opening into the femoral vein, though reduced in size, was pervious; and the coats of the deep femoral vein, from this point to the ham, were thickened and contracted. inner membrane was rugous, and of a deep red colour; but no deposit of lymph was observable, and its canal was pervious. The femoral vein above the termination of the saphena, and the whole of the external iliac, were thickened and slightly contracted in their dimensions, and lined with a thin coating of lymph. These vessels were pervious, and the common and internal iliac exhibited no sign of disease. The intestines were inflamed; and on the ascending colon there was a small part in the state of sphacelus. (Medical and Chirurgical Transactions, vol. xv.)

The

We have related other cases of inflammation of

the saphena veins, of less severity, occurring in puerperal women, where the swelling, heat, and tension were confined to the course of these vessels; and it is now clearly ascertained that the whole limb does not become affected when the iliac and femoral veins have remained pervious. The preceding and other cases likewise prove that the inflammation in crural phlebitis, when violent, is not limited to the coats of the veins, but may extend to the cellular membrane, glands, muscles, and other contiguous tissues.

In July, 1830, the author was indebted to the kindness of Dr. Ashburner for the opportunity of observing the progress of an interesting case of crural phlebitis in a female about the middle period of life, who had not been pregnant for several years. A small ulcer above the left internal malleolus gave rise to inflammation of the saphena and femoral, and probably of the iliac veins, and the whole limb became affected with a hot, shining intumescence.

Sir Charles Bell has informed us that he has observed upwards of twenty cases of painful swellings of the superior extremities in women afflicted with cancer of the mammæ. He has been accustomed to refer these swellings to obstruction of the lymphatics, or to compression of the veins by the induration and enlargement of the glands of the axilla. No opportunity has yet occurred to determine by dissection whether or not the painful swelling of the arms is to be attributed in such cases to inflammation and obstruction of the veins; but this has been rendered probable by the facts already related respecting the effects produced on the iliac veins by malignant ulcerations of the uterus. It is rendered still more probable by the following observation of Laennec: "that it is not uncommon to find the veins in the neighbourhood of a cancerous breast filled with pus, either pure or mixed with blood; sometimes fluid, at other times more or less inspissated, and occasionally of the degree of consistence of an atheromatous tumour." (Translation, 2d edit. p. 652.)

Treatment.—Puzos recommended repeated and copious venesection for the treatment of phlegmasia dolens; but in all the cases which we have witnessed, there has been so much feebleness of pulse and prostration of strength that we have not ventured to draw blood from the arm. There are cases, however, occasionally met with where the symptoms are immediately relieved by a general bleeding. An example of severe crural phlebitis after delivery recently occurred in the practice of Dr. Duffin, where the abstraction of twenty ounces of blood seemed at once to break the force of the attack. In a great proportion of cases venesection is not required, and we are to trust for the relief of the inflammation to the repeated application of leeches above and below Poupart's ligament, in the course of the crural veins. From two to three dozen of leeches should be applied immediately after the commencement of the disease, and the bleeding should be encouraged by warm fomentations, or by a bread and water poultice to the part. Should the relief of the local pain not be complete, it is requisite soon to reapply the leeches in numbers proportioned to the severity of the attack, and to repeat them a third

or even fourth time, at no very distant intervals, should the disease not yield.

Some patients experience greatest relief from the use of warm cataplasms to the limb; others derive most advantage from the application of cold, or of a tepid, evaporating lotion.

The bowels are often much disordered in this disease; but the employment of strong acrid cathartics is always injurious. Repeated small doses of calomel and antimonial powder should be given with some mild purgative, not only with the view of correcting the disordered state of the bowels, but to subdue the local inflammation, and the great constitutional disturbance usually present. It is of importance, also, to administer saline and diaphoretic medicines, and to procure rest and relief from pain by anodynes, until the acute symptoms pass away: the diet should be the same as that usually allowed to patients who are labour. ing under inflammatory and febrile diseases. We have seen no advantage derived from the use of digitalis in any stage either of uterine or crural phlebitis. Dr. Sims has informed us that the painful swelling and tension of the limb, in a case of phlegmasia dolens, were strikingly relieved by puncturing the skin in different parts with a fine needle.

When the acute inflammatory symptoms have passed away, the limb remains in a weak, œdematous state, and great uneasiness is often experi enced from congestion of blood in the veins. Until the collateral branches, which are to carry back the blood to the heart, become enlarged, it is impossible by any means we possess to afford complete relief. Much benefit may, however, be derived in this stage of the complaint from the occasional application of a few leeches to different parts of the limb, and by preserving it in the horizontal position. We have seen mischief produced by having recourse too early to remedies intended to promote the absorption of the fluid effused into the cellular membrane. Blisters, frictions, stimulant embrocations, and bandages to the limb, are only useful when the inflammation of the veins has wholly subsided, and other vessels have become so much enlarged as to carry on the circulation of the blood in the extremity without interruption.

We have not perceived any sensible benefit accrue from the use of mercurial ointment and iodine in crural phlebitis, and we consider the local abstraction of blood at the commencement of the attack to constitute by far the most important part of the treatment. ROBERT LEE.

PHRENITIS. See BRAIN, INFLAMMATION

OF THE.

PHTHISIS PULMONALIS. See TUBER CULAR PHTHISIS.

PITYRIASIS, from sirupov, bran, denotes a cutaneous affection in which irregular patches of the cuticle, varying much in size, appear covered with thin branny or minute powdery scales, which fall off and are soon succeeded by others. This disease is not contagious, and is seldom productive of inconvenience to the patient; it never terminates in crusts or excoriations, but, if neglected, it may alter its character and degenerate into porrigo. During health, the cuticle over the

ternal remedies; and after the patient has been satisfied as to its innocence and the absence of of all syphilitic taint, he often ceases to think of it, and allows time, if it will, to work a cure. Should the disease seem to have originated from any irritation either of the cutaneous surface or of the alimentary cavities, its cause must, if possible, be removed without delay: when the digestion is impaired, light tonics are to be used, as infusion of calumba with sulphuric acid, or small doses of sulphate of quinia; the bowels are to be regulated, and a milk and nourishing diet enjoined, with abstinence from spirituous liquors, and a very guarded use of wine and ale, if any be allowed. When itching exists, a spirit lotion with borax or alumn, or acetate of lead or zinc, will be found useful; or, what rarely fails to give relief, a lotion with hydrocyanic acid. The vapour bath at a moderate temperature will serve to equalize the cutaneous circulation, and soften the branny spots. In our hands nothing has proved so effectual in restoring the natural colour and functions of the parts as a lotion of chloride of lime or soda, varying in strength according to circumstances. The success which has attended this application has exceeded our expectations; but whether its effects are to be regarded as the result merely of a stimulus, or of its bleaching property, admits of question.

[Iodide of sulphur makes an excellent ointment in this as in various other chronic diseases.]

3. Pityriasis rubra (red dandriff.) This differs from the preceding species chiefly in the redness of its colour, and the greater excitement of the surface which attends it. It is more uniformly accompanied by heat, itching, and general languor and restlessness, and may be considered as remotely allied to psoriasis diffusa, although altogether free from elevation above the surface, and vastly more mild in all its symptoms. On its decline, it leaves sallow faded stains marking the parts which were affected. The anatomical seat of pityriasis rubra is certainly deeper than the cuticle; its red colour evidently depending on the injected state of the vascular tissue lying beneath. Treatment. We have never in any case of red dandriff found the irritation such as to require the abstraction of blood; but in every instance the bowels should be opened by mild purgatives, and those which correct acidity. A soothing or slightly astringent lotion, such as those already described, ought to be applied to the affected parts, and any cause of cutaneous irritation immediately removed. Dr. Bateman has recommended a diaphoretic plan of treatment,-antimonials, with decoction of the woods, and the warm sea-water bath; and he adds that he has found benefit from small doses of the tinct. veratri.

4. Pityriasis nigra (black dandriff; éphelide scorbutique). This is an exceedingly rare disease; so much so that Dr. Willan had not seen it at the time of his publication, and Dr. Bateman does not appear to have ever met with it. Alibert has described it under the name quoted above, and figured it as it affects the hands (plate 27 bis.) The cases seen by Dr. Willan occurred in children born in India, and brought to this country. The disease commenced in a partially papulated state of skin, and terminated in a black discolora

|tion, with slight furfuraceous exfoliations: it sometimes affected half a limb, sometimes the fingers and toes. (Bateman, Synopsis, p. 49.) In allusion to the foreign origin of this species of pityriasis, we may mention a curious dusky mottling of the skin, which is seen in the children of mulatto women by European fathers, when they approach, as they sometimes do, to the fair complexion of the European. It seems as if patches of the dark hue of the mother shone through the pure skin of the father; and it is chiefly perceptible when they are heated with exercise, or the skin otherwise increased in vascularity.

Some years ago, we had the good fortune to see a case of pityriasis nigra. The patient was an unmarried female, aged forty-five, a native of Scotland, her parents Scotch; and she had never travelled to any distance beyond the precincts of her native city. The skin of her arms, legs, bosom, and neck, but especially the last, was of a dark tint like that of a mulatto, but varying in different parts in depth of hue; and scattered over the dusky surface were many white spots, from which crusts appeared to have separated; and on other parts some crusts appeared still adhering. Both the white spots and the mulatto-coloured surface were slightly scaly. With this disease was combined an eruption of scabies affecting severely the hands, from the itching of which she suffered great annoyance. The disease had existed for some months; and at the time when it commenced she was reduced to a state of great misery and destitution. By the employment of sulphur frictions, the warm bath, and a plentiful supply of nourishing food, the natural colour of the skin was nearly restored after the lapse of some weeks; but we are ignorant whether a complete cure was in the end effected. This case confirms the remark of Dr. Bateman, that the disease is the result of misery and filth, but not his opinion that both the disease and its cause are wholly unknown in this country. (Synopsis, p. 49, note.)

Treatment. Our first object in pityriasis nigra is to clear out the bowels by mild purgatives, and thoroughly purify the surface of the body with soap and water. A course of tonic aperients, with the regular use of the warm water or vapour bath, should then be prescribed, while the patient is put upon a moderate allowance of nourishing food. As his appetite and strength improve, the quantity of food is to be increased, and the warm bath exchanged for sulphur fumigations; or if the disease prove obstinate, recourse ought to be had to the cautious employment of the arsenical liquor, and the external use of the chloride of lime or soda, as in pityriasis versicolor.

W. CUMIN.

PLAGUE, from Tλnyǹ, Gr. plaga, Lat. a blow or wound; th. уhoow, to strike. This is the name of a well-known and extremely fatal disease, which is endemic in Egypt and certain other countries bordering on the Levant, and has made frequent and destructive irruptions into Europe. The malady thus designated is called pestis and pestilentia by the Latin writers, Xogos by the Greeks, la peste by the French, pestilenza by the Italians, and pest by the Germans, which last name is not unfrequently bestowed upon it by

ourselves. It is a curious fact that these words have each in their respective languages a signification distinct from the primary one, and expressive of various kinds of moral and physical evil, the malignancy of the disease in all situations being thus evinced by its suggesting the same analogy to people differing widely in physical constitution and mental habitudes.

The words plague, pest, and pestilential, and their corresponding terms in different tongues, have frequently, even when applied to diseases, a sense considerably vague. The disease we are about to treat of has always been comprised in these terms, but other maladies have been similarly designated, with which, probably, it had no quality in common excepting that of being extremely diffusible and fatal; and hence by morbi pestilentiales we are not always to understand a form of plague in a strict sense of the word. This want of precision of language is very conspicuous in Hippocrates and his commentator Galen, (Galeni Commentar. in lib. i. Epidemic. in lib. iii. cap. xx.; et in Aphor. lib. iv. &c.) whose idea of a pestilential disease appears to have corresponded very nearly with that which we express by the term epidemic; and a similar want of accuracy is perceptible in the writings of the Arabians, from whom we might for obvious reasons have expected the greatest precision.

The subject was so much obscured by the vague application of terms, that even at so late a period as 1775 the Faculty of Medicine of Paris proposed the following queries as the subject of a prize essay: "If plague be a distinct disease, what is its character? and what are the means of treating and preventing it ?"-queries which were thought| to have been successfully solved by M. Pâris of Arles. We need scarcely observe, what is now universally admitted, that the characters of plague are as distinctive as those of small-pox, measles, scarlatina, or any other disorder.

This disease is endemic in Egypt, and very often exists in adjacent territories; but the former country is unquestionably the great source whence it extends its ravages into surrounding districts; and a very learned and ingenious writer is of opinion that there only is it ever engendered, and that in other regions it is always an alien. (Foderé, Dictionnaire des Sciences Médicales, v. 41. p. 87.) In Egypt it is said to arise every autumn, and to prevail till the beginning of June of the succeeding year: its ravages then cease, and its contagion is extinguished or remains in abeyance during summer, to be again called into existence or activity in the autumn. The vernal equinox is the period of the greatest fatality of the disease. About this time, we learn, southerly winds blow with great violence. They last ordinarily three or four hours, and are frequently renewed daily for fifty successive days. They are very warm, passing over the burning deserts which border Egypt on the south, and they are, moreover, loaded with putrid eroanations exhaled from the animal and vegetable substances which are decomposed in the lakes formed by the retiring of the waters of the Nile, or in the cemeteries which its inundation has reached. At this sickly season, diseases of all kinds assume a malignant character: it was at this season, that after the great inundation of

1801, the plague committed the greatest ravages among the inhabitants of Cairo, and Upper Egypt. In June the wind blows from the north, and being cooled in traversing the Mediterranean, renders that season the most refreshing and salubrious of the year, during which no sickness manifests itself. (Baron Larrey, Description d'Egypte, ou Recueil d'Observations et de Recherches, &c. publié par ordre du Gouvernement, Paris, 1821.)

It was to be expected that a disease eminently contagious should be occasionally diffused through countries having incessant intercourse with the land of its origin; and we find it repeatedly visiting the people, paying allegiance more or less direct to the Ottoman Porte, and not unfrequently ravaging Constantinople. Formerly it penetrated into more northern climes. Previously to the year 1665 it usually invaded England, as Sydenham informs us, at intervals of from thirty to forty years; but since the cessation of the celebrated epidemic of that year, which destroyed eight thousand inhabitants of London in the course of one week, though two-thirds of the population had previously fled from the city, it has not been seen in Britain. In other European countries it has much more recently manifested itself. Marseilles, which had previously suffered twenty severe visitations in the course of seventeen centuries, was ravaged by it in 1720; Moscow suffered a severe infliction in 1771 and 1772; and within the present century it prevailed at Noja in the Neapolitan dominions, in 1815 and 1816; it appeared in the Lazaretto of Venice in 1818, and at Gressemberg in Silesia in 1819. But with these exceptions it has been for a century generally confined to Africa, the land of its origin, and to those portions of Asia and Europe which own the Ottoman

sway.

[A concise history of the disease is given by Vetter, in Art. Pestis, in Encyclop. Wörterb. der Medicinisch. Wissensch. xxvi. p. 625: Berlin, 1841.]

Symptoms.-The following definition will suffice to convey a general idea of plague, although, as is usually the case with nosological definitions, it does not comprise certain cases sometimes observed, which form exceptions to the ordinary character of plague :-an exanthematous disease, the eruption consisting of buboes, carbuncles, and pustules, white, livid, or black, distributed in various parts of the body, and generally attended with malignant and very fatal fever.,

Various divisions have been proposed by systematic writers; but there is every reason to think that there is no difference existing between cases of the disease which can be regarded as specific, all the varieties being found intermingled in the same epidemic. Plague possesses two prominent characteristics-fever and eruption, both of which are found in fully formed cases; but examples of the existence of one of these symptoms without the other are not of unfrequent occurrence. cases in which the eruption is wanting constitute the most rapidly fatal type of the disease; whilst, on the other hand, bubo occurring without constitutional disturbance is the slightest form in which this disorder, usually so fatal, can exist. Between these extremes there are various shades of intensity discernible, which, as well as the most

The