Considerable difference of opinion has arisen re specting the treatment of Erysipelas, and especially re specting the question, whether the antiphlogistic plan is to be employed, and whether external cold is admissible; or whether there is the same danger to be apprehend ed from repelling the inflammation as in some of the proper Exanthemata ? Perhaps no general answer can be given to this question, which will apply to all cases; in the first stage of the disease, the antiphlogistic treat ment, both general and local, is the one which usually ought to be pursued, but afterwards a medium course seems to be the best ; external warmth aggravates the fever, while the feelings of the patient, and the weak ness which supervenes, are adverse to the employment of depletion, or of any considerable degree of external cold. General bleeding is often necessary at the corn mencement ; and purgatives, in this, as in all febrile af fections, form a very valuable remedy. Although it may appear to be indicated by the symptoms, yet topical bleeding is generally condemned, in consequence of the difficulty which sometimes exists in healing the wounds made by the leeches or the scarificator. Diaphoretics are commonly prescribed ; but if they are administered so as to become sudorific, they aggravate the irritation of the surface. Small doses of opiates are often rendered necessary by the restlessness and agitation which attends the disease ; and it is for the same cause peculiarly im portant to avoid all sources of irritation, or to remove them whenever they are present. When the disease terminates fatally, it appears to be from the inflammato ry affection being communicated or transferred to the membranes of the brain ; it is therefore of great conse quence to prevent all those circumstances which might tend to lay the foundation for such a crisis, and to obvi ate the first appearance of any symptoms which indicate the impending danger.
We now come to the third order of the Parhxmasix, the Ilxmorrhagies, those diseases that are character ized by a discharge of blood, which is not the conse quence of external violence or an obvious breach of the surface. As we have already remarked, there is con siderable obscurity respecting the proximate cause of haemorrhage; but it may be stated to consist essentially in an irregular distribution of the blood, or a disposition of it to accumulate in certain parts of the sanguiferous system. It has been usual to divide hxmorrhagies into active and passive, as supposed to depend upon the re lative degree of action in the vessels ; and there seems to he a real foundation for this distinction, whatever may be our opinion concerning the immediate cause which gives rise to the two states. We do not presume to clear up this difficulty, but we conceive that there is sufficient ground for the opinion, that the former ori ginates more particularly in some derangement of the arterial, and the latter in the venous part of the circu lation. Upon this principle we have arranged hxmor rhagies tinder the two genera of arterioFx and ienosx, an arrangement which we think may be usefully adhered to, both for the purpose of elucidating our theory and directing our practice ; although at the same time it is admitted, that there are certain affections which it may be difficult to refer to their proper class, or that, under different circumstances, a discharge of blood may occur from the same part, which is at one time arterial, and at another venous. To the first genus we may refer Epistaxis, Hxmoptysis, and Menorrhagia, or the dis charges of blood from the nose, the lungs, and the uterus; to the latter genus, the discharges of blood from the stomach, the intestines, the hxmorrhoidal ves sels, and the bladder, and that peculiar affection of the skin termed Petechix. \Ve have added, as appendages
to the venous hxmorrhagies, the discharges of blood from the liver and the mouth, although it is probable that they are, in almost all cases, symptomatic affections.
Epistaxis, when idiopathic, appears to be always an arterial hxmorrhage; and although, in consequence of its local nature, and the small size of the vessels con cerned, compared to the whole extent of the sanguife rous system, it is seldom attended with fever, yet it seems always to be connected with an inflammatory tendency in the constitution, and is often followed by fe brile affections, that ultimately prove of serious conse quence. \Ve must, however, observe, that blood is sometimes discharged from the nose, which appears to be of venous origin, but in this case it is always sympto matic, and consequent either upon great debility, or upon a tendency to decomposition of the solids, which, as we have had occasion to notice, exists towards the termination of various malignant fevers. Epistaxis is seldom so urgent an affection as to become the subject of medical treatment ; it is generally sufficient to avoid the exciting causes, especially all those circumstances that produce an undue force or velocity in the circula tion, as external heat, violent exercise, or intemperance in diet. The discharge may generally be restrained without difficulty by the application of external cold to the part, but if it recur frequently, and the state of the body appears to require it, we must have recourse to bleeding, and the other parts of the antiphlogistic regi men. It has been stated that Epistaxis is what has been termed vicarious, that is, the consequence of the ceasing of some other habitual discharge; perhaps this idea is not altogether without foundation, although we appre hend that it has been carried to a very extravagant length, in consequence of a false theory which prevailed on the subject ; it may, however, be necessary to bear in mind the possibility of this occurrence, and to regulate our treatment accordingly.
All the remarks that we have made respecting Epis taxis will apply to Hxinoptysis, making allowance only for the greater size of the organ, and the function which it exercises giving a much greater degree of importance to any of its affections, and necessarily producing a much greater disturbance in the animal economy. The dis charge of blood from the lungs seldom occurs, except in persons of the sanguine temperament, and in them is commonly the immediate consequence of some cir cumstance which excites the part to undue action, and produces an unusual determination of blood to it. The disease does not appear to be essentially connected with fever, and it often exists independently of the febrile state ; but when it is severe, and frequently recurs, the symptoms of fever are generally excited, and these, in their turn, appear to aggravate the complaint. If the patient be not predisposed to pthisis by hereditary con stitution, there is nothing in the nature of the disease which should necessarily render it of' a fatal tendency ; but it so frequently happens that it is connected with a phtlusical disposition, as always to become the subject of great alarm.