(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "The cyclopaedia of practical medicine: comprising treatises on the nature and treatment of diseases, materia medica and therapeutics, medical jurisprudence, etc., etc (Volume 4)"

Hl\\ i 






aNiDiaaw do Aavaan ivnoiivn 



I 



NATIONAL LIBRARY OF MEDICINE 




NATIONAL LIBRARY OF MEDICINE 



NATIONAL LIBRARY OF MEl 




\^*\ I' $*\/ * \^^s I' <^V 



3NIOIQ3W jo Aavaan IVNOIIVN 



SNioiasw do Aavaan ivnoiivn 



3NIDIQ3W do Aavaan TVN 




3Nma3w do Aavaan ivnoiivn 




3Ni3ia3w do Aavaan ivnoiivn 



NATIONAL LIBRARY OF MEDICINE 



NATIONAL LIBRARY OF MEDICINE 



9, 



3Ni3io3w do Aavaan ivn 

ONAL LIBRARY OF MED 




3NOia3w do Aavaan ivnoiivn 



3NIDI03W do Aifvaan ivnoiivn 




1 S^ 



3Nma3w do Aavagn ivn 




NATIONAL LIBRARY OF MEDICINE 
o 




NAL LIBRARY OF MEDICINE 



NATIONAL LIBRARY OF MEDICINE 



NATIONAL LIBRARY OF MEDICINE 




3 V£ 

)3w jo Advuen tvnouvn 



3noio3w jo Asvaan ivnouvn 



3NID 










ff 



THE 



CYCLOPEDIA 



PRACTICAL MEDICINE. 



VOL. IV. 



THE 



CYCLOPEDIA 



ut, 



OF 



PRACTICAL MEDICINE: 



COMPRISING 



TREATISES ON THE NATURE AND TREATMENT OF DISEASES, MATERIA MEDICA 
AND THERAPEUTICS, MEDICAL JURISPRUDENCE, ETC, ETC. 

EDITED BY 

JOHN FORBES, M.D. F.R.S. 

PHYSICIAN TO THE QUEEN'S HOUSEHOLD, ETC. 

ALEXANDER TWEEDIE, M.D. F.R.S. 

PHYSICIAN TO THE LONDON FEVER HOSPITAL, AND TO THE FOUNDLING HOSPITAL, ETC. 

JOHN CONOLLY, M.D. 

LATE PROFESSOR OF MEDICINE IN THE LONDON UNIVERSITY, PHYSICIAN TO 
THE HANWELL LUNATIC ASYLUM, ETC. 

THOROUGHLY REVISED, WITH NUMEROUS ADDITIONS, BY 

ROBLEY DUNGLISON, M.D. 

fROFESSOR OF INSTITUTES OF MEDICINE IN JEFFERSON COLLEGE, PHILADELPHIA, 
LECTURER ON CLINICAL MEDICINE AT THE PHILADELPHIA HOSPITAL, ETC. 



Htec demum sunt qua? non subgessit phantasise imaginatricis temeritas sed phenomena practiea 
edocuere." — Sydenham. 



IN FOUR VOLUMES. 
VOL. IV. 

REFRIGERANTS— YA35LS 




<GEON GENERALS OFFICE 



AU0.-1&-1898 



PHILADELPHIA: 

BLANCHARD AND LEA. 

1859. 






Entered, according to Act of Congress, in the year 1845, by 
LEA AND BLANCHARD, 

tn tne clerk's office of the District Court of the United States for the Eastern District 

of Pennsylvania. 



FAG-AN, STEREOTYPER. 



COLLINS, PRINTER 



& 









CONTENTS OF THE FOURTH VOLUME. 



23 



Contributors. Page 

Dr. A. T. Thomson .17 
Barlow . 
Dunglison 

Cumin 43 

Tweedie 50 

Rubeola Montgomery . . 51 



Refrigerants . 

Rheumatism 

Rickets 

Roseola . . . . 



■::} 



Rupia. 

Scabies. . . 
Scarlatina 
Scirrhus. . 
Scorbutus. 
Scrofula . 

Sedatives . 



Corrigan 58 

Houghton 59 

Tweedie 67 

Carswell 82 

Kerr 104 

Cumin 125 

A.T.Thomson ~i , Ar . 

r 145 



Dunglison . . $ 

Sex, Doubtful Beatty 153 

Small-Pox Gregory 159 

Softening of Organs. . . Carswell 175 

Somnambulism and Ani- 
mal Magnetism Prichard 194 

Spermatorrhoea Dunglison ... .211 

Spinal Marrow, Diseases 

of the 

Spleen, Diseases of the 
" Dislocation of the 



R.B. Todd ...213 

Bigsby 223 

Dunglison 229 

Hawkins . . . ? 22g 



Dunglison . . 3 

Williams 237 

A. T. Thomson. 239 



Statistics, Medical • • • 5 

Stethoscope 

Stimulants 

Stomach, Organic Dis- 
eases of the Houghton 253 

Stomatitis Dunglison . . . .275 

Strophulus Dunglison . . . .276 

Succession of Inheritance 

— Legitimacy Montgomery . .276 

Suppuration R. B. Todd ... 284 



Contributors. 

Survivorship Dr. Beatty . 

Sycosis Cumin . 

Symptomatology M. Hall. 

Syncope Ash .... 

Tabes Mesenterica .... Joy .... 



Throat, Diseases of the • 



Page 
.290 
.296 
.298 
.329 
.333 

Temperament Prichard 349 

Tetanies Dunglison .... 363 

Tetanus Symonds 364 

Tweedie ~) 37g 

Dunglison . . 3 
Tissue, Adventitious . . . 390 

Tonics Tweedie 391 

Toothache Dunglison 404 

***» : I ZgL;::}™ 

Transformations Duesbury 464 

Transfusion Kay 468 

Tubercle Carswell 474 

Tubercular Phthisis . . . Clark,(SirJas.)i89 

Tympanites Kerr 570 

Urine, Incontinence of . Cumin 575 

" Suppression of. . . Carter 578 

" Morbid states of the Bostock 581 

'< Bloody Goldie 588 

Urticaria Houghton 590 

Uterus, Pathology of the Lee 596 

Vaccination Gregory 620 

Varicella Gregory 636 

Veins, Diseases of the. . Lee 639 

Ventilation Brown 650 

Wakefulness Cheyne 653 

Waters, Mineral T. Thomson . . . 658 

Worms Joy 704 

Yaws Kerr 750 

(5) 



rim 



CYCLOPAEDIA 



PRACTICAL MEDICINE. 



REFRIGERANTS (from refrigere, to grow 
cold), may be defined, medicines which diminish 
the morbid heat of the body. Their influence is 
generally admitted, but the theory of their opera- 
tion is not well understood ; and, consequently, 
many and very opposite hypotheses have been ad- 
vanced upon the subject. The first of these which 
deserve notice is that of Cullen, based upon a 
doctrine of Needham ; it forms a remarkable in- 
stance of the obscurity into which hypothesis leads 
men otherwise distinguished for the perspicuity 
and soundness of their reasoning. This hypothe- 
sis supposes " that there is every where, in nature, 
an expansive and a resisting power ; and that, 
particularly under a certain degree of heat, the 
expansive power appears in all the parts of organ- 
ized bodies, in consequence of which they show a 
singular vegetating power; while, at the same 
time, there is, in other bodies, a power resisting 
and preventing the action of this vegetating power, 
and, at least, of diminishing its force." And it is 
assumed that this power is found in those sub- 
stances which are usually employed as refrigerants. 
(Mat. Med. ii. 121.) It is unnecessary to com- 
ment upon these opinions; indeed, their obscurity 
is such as to render them scarcely intelligible. 

A later theory is that of Dr. John Murray, 
whose habit of reasoning upon chemical princi- 
ples led him to call in the aid" of these to explain 
the operation of refrigerants. He founds his opi- 
nion on the presumption of the truth of the theory 
of Dr. Crawford, that, in the process of respira- 
tion, the arteries in the lungs absorb the caloric 
liberated there; and, owing to the great capacity 
of arterial blood for caloric, they instantly render 
it latent, in which state it remains until the subse- 
quent conversion of the arterial into venous blood, 
when it is liberated equally through the system. 
Now, Dr. Murray considers that the consumption 
of oxygen in the lungs, supplying the caloric to 
the arterial blood, is greatly influenced by the na- 
ture of the food and other ingesta received into the 
stomach. He supposes that when these substances 
contain a small proportion of oxygen, the demand 
for that component of the air, and its consumption 
by the lungs, are augmented ; and, consequently, 
the animal temperature is elevated ; whereas an 
opposite effect takes place when the ingesta con- 
tain much oxygen, more especially if it exist in a 
loose state of combination. According to this 
theory, therefore, all substances containing much 
oxygen capable of being extricated by the powers 

Vol. IV. — 3 b* 



of the stomach, should possess a refrigerant influ- 
ence. Plausible as this theory appears to be, its 
accuracy is very questionable; but, in order to 
reason correctly upon its merit, it is necessary to 
take a cursory view of the theory of animal heat 
upon which it is founded ; for if the difference of 
capacity of arterial and venous blood for caloric 
be insufficient to account for the temperature of 
the living body, Dr. Murray's theory of the changes 
produced by refrigerants must necessarily fall to 
the ground. 

Dr. Crawford's object was to prove, as already 
stated, that arterial blood has a greater capacity for 
caloric than venous blood ; and this is also the 
case in reference to common or atmospherical air 
and carbonic acid gas. The latter fact explains 
the augmentation of temperature arising from the 
change which the air undergoes in the lungs when 
carbonic acid is present in them ; but as the caloric 
thus evolved is absorbed by the arterial blood, and 
rendered latent, the sensible temperature of the 
blood is not augmented; and it only becomes so 
as the arterial blood changes to venous in the 
course of its circulation. By this evolution of 
caloric the loss of temperature which the body 
sustains is compensated. Respiration, therefore, 
and the greater capacity of the arterial than the 
venous blood, are, according to this theory, the 
true sources of the peculiar temperature of the 
living body. 

Many facts might be mentioned as favouring the 
truth of Dr. Crawford's hypothesis ; for example, 
the greater the comparative size of the lungs, and 
the greater the quantity of blood which passes 
through them, the higher is the temperature of the 
animal. Thus, the capacity of the lungs is greatest 
in birds, which have the highest temperature among 
animals ; and it is a well-known fact, that what- 
ever lessens the free action of the lungs and dimi- 
nishes the consumption of oxygen, reduces the 
temperature of the animal. Individuals who la- 
bour under a malformation of the heart sufficient 
to prevent the arterialization of the blood, are 
always of a temperature below the natural stand- 
ard. In hybernating animals, also, the tempera- 
ture falls as the respiration is suspended ; and it 
rises with the return and the progress of respira 
tion : and, farther, M. Gallois ascertained, by ex 
periment, that the temperature of the body falls 
exactly in the ratio of any diminished quantityol 
oxygen consumed in respiration. These opinion* 
are strengthened by some experiments of Dr. Wil- 

'17 



18 



REFRIGERANTS, 



son Philip ; and, upon the whole, it is tolerably 
well ascertained that the temperature of the body 
sinks, if it be not maintained by the chemical 
changes which occur in respiration. 

But, notwithstanding the support thus given to 
Dr. Crawford's opinion, many and as strong facts 
have been advanced in support of that view of 
the subject which regards nervous energy as the 
source of animal heat. The most important ex- 
periments on this side of the question are those of 
Mr. [Sir B.] Brodie. He found that, by maintain- 
ing the action of the heart by artificial respiration 
after the brain is removed, although the blood 
undergoes its ordinary changes, yet that the tem- 
perature of the animal thus treated is rapidly 
lowered. Sir B. Brodie's experiments were made 
on rabbits, in which the functions of the brain 
were suspended by dividing the spinal marrow : 
the blood, in both systems, underwent no change 
different from that which occurs in natural res- 
piration. " It may perhaps be urged," says Sir 
B. Brodie, "that, in these experiments, the secre- 
tions had nearly, if not entirely, ceased : it is 
probable that the other changes which take place 
in the capillary vessels had ceased also, and that, 
although the action of the air on the blood might 
have been the same as under ordinary circum- 
stances, yet there might not have been the same 
alteration in the specific heart of the fluid as it 
flowed from the arteries into the veins. But, on 
this supposition, if the theory of Dr. Crawford 
be admitted as correct, there must have been a 
gradual but enormous accumulation of latent heat 
in the blood, which we cannot suppose to have 
taken place without its nature having been en- 
tirely altered. If the blood undergo the usual 
change in the capillary system of the lungs, it is 
probable that it must undergo the usual change 
in the capillary system of the greater circulation 
also, since these changes are obviously dependent 
on and connected with each other." From the 
experiments of Sir B. Brodie it appears that, 
when the functions of the brain are suspended, 
the power of generating animal heat is also sus- 
pended ; although the same quantity of oxygen 
be consumed as in natural respiration under ordi- 
nary circumstances. It is, nevertheless, proper to 
mention here the opinion of M. Le Gallois, that, 
owing to the nature of artificial respiration, upon 
which Sir B. Brodie's conclusions are founded, 
the temperature may fall, and the animal lie killed 
by cold, although every part remain uninjured. 
The air in artificial respiration does not enter the 
pulmonary cells in the same manner as in natural 
respiration, but is forcibly propelled into them ; 
a large formation of frothy mucus occurs, which 
both prevents the air coming in contact with the 
lining membrane of the air-cells, and by its eva- 
poration tends to cool the body. 

Many other facts concur, also, to prove that 
the temperature of the body is regulated by the 
nervous energy. It is true that these demonstrate 
its effect chiefly in maii.ainini; the heat of parts; 
but if its influence on parts be admitted, it is not 
easy to conceive on what grounds its power over 
the entire system can be denied. Sir Everan' 
Home divided the nerves going to the growing 
aniler of a stag, and found that the temperature 
almost immediately fell ; and although, after a 



few days, it rose again higher than before, yet 
this may have originated from the reunion of the 
divided nerves : at all events it does not invalidate 
the fact that the temperature fell on the division 
of the nerves, and, consequently, was regulated 
by their condition. In paralyzed limbs the tem- 
perature sinks, although in many cases the circu- 
lation in the limb is unaffected, and the paralysis 
is confined to the sensibility of the member. In 
a case recorded by Mr. Earle, in which the axil- 
lary plexus of nerves on one side was crushed, 
the paralyzed limb of that side was of a lower 
temperature than the opposite limb: indeed, in 
general we find that increased nervous action, 
whether depending on affections of the mind or 
on other causes, augments the heat of the body ; 
whilst the effect of depressing passions, which 
diminish nervous energy, is followed by either 
general chilliness, or coldness of the extremities. 

These facts undoubtedly go far to prove that 
animal heat is a vital principle closely connected 
with the integrity of the nervous system ; but at 
the same time, as the stimulus of arterial blood is 
requisite for the excitement of the brain and 
nerves, and arterialization is the result of respira- 
tion, the influence of respiration in the production 
of animal heat must be so far admitted ; for with- 
out the function of the lungs the brain would lose 
its energy, and the temperature of the system be 
necessarily greatly lowered. This opinion re- 
ceives also considerable support from some ex- 
periments of Dulong to ascertain whether the 
quantity of caloric, developed by the consumption 
of oxygen in respiration, be equivalent to the 
quantity given out by the body. He found that 
in carnivorous animals the proportion is equal to 
forty-nine and fifty-five parts in one hundred of 
the heat generated by the whole body during the 
same interval of time ; and, in phytivorous ani- 
mals, to betwixt sixty-five and seventy-five parts; 
and that the whole quantity of caloric and water 
together is equivalent to sixty and eighty parts 
only ; so that the animal heat is greater than can 
be accounted for by the fixation of oxygen during 
respiration. Upon, the whole, the examination 
of both sides of the question leads us to conclude 
that both opinions are to a certain extent true; 
that animal heat is influenced chiefly by the state 
of the nervous system, but partly, also, by the 
chemical changes which take place in the lungs 
during respiration. [See, on all this subject, the 
physiological works of Miiller, Carpenter or Dun- 
glison.] 

If this view of the sources of animal heat be 
correct, it presents a considerable obstacle to the 
admission of Dr. Murray's explanation of refrige- 
rants, which can only be regarded in the light of 
an ingenious hypothesis. The subject, therefore, 
remains as he found it; and the question presents 
itself— can no rational explanation of the opera- 
tion of refrigerants be suggested 1 The writer of 
this article, although he does not venture to offer 
a theory likely to be generally adopted, yet con- 
ceives that some approach to a rational explana- 
tion may be attained by ascertaining how far the 
ttUion of refrigerants taken into the stomach re- 
sembles that produced on the skin by similar 
substances. 

In abstracting caloric from the surface of the 



REFRIGERANTS. 



19 



body, or, in other words, cooiing the skin, what- 
ever agent be employed, whether diluted acids, 
salts in a state of solution, cold air, or cold water 
or ice, the activity of the capillaries of the part is 
immediately diminished ; and as their action can- 
not he materially lessened without the whole vas- 
cular system being more or less influenced, the 
vigour of the heart and arteries is also materially 
depressed. The consequence of this diminished 
vascular action is immediately felt on the respira- 
tion ; the blood does not undergo its necessary 
change ; venous blood is conveyed to the brain, 
the function of which being impeded from defect 
of stimulus, a state somewhat resembling para- 
lysis of the nervous system ensues, so that torpor 
of every organ, the function of which depends on 
the enercty of the brain and nerves, must neces- 
sarily follow. The effect of the abstraction of 
caloric on the nerves is strikingly illustrated by 
the numbness and insensibility which follow the 
exposure of the hands, in many individuals, in 
cold weather; a result which is more likely to 
arise from the direct influence of cold on the nerves 
themselves, than from the diminished supply of 
blood to the parts. Indeed, as in this case the 
effect on the nerves is partial, we can scarcely 
imagine any other cause of the diminished action 
of the capillaries than the depression of the nervous 
energy. Now if we suppose, — and the supposi- 
tion is far from being unreasonable, — that an effect 
resembling that produced on the surface takes 
place in the stomach when refrigerant agents are 
introduced into it, we may readily admit that the 
effect on the capillaries of that organ is extended 
by sympathy over the system. The possibility 
of such a result is equally probable in the one 
case as in the other. This opinion receives some 
support from the fact that nitrate of potassa 
operates as a powerful general refrigerant when it 
is swallowed at the instant of its solution ; but it 
acts as an excitant when it is not taken into the 
stomach until after it have been some time dis- 
solved. The sensation of cold which the nitre, 
during solution, causes in the stomach, is evi- 
dently owing to a partial abstraction of stimulus, 
and the effect of this being extended through the 
nerves to the heart and larger branches of the 
arterial system, a general reduction of action is 
produced, and this is followed by a sensation of 
cold over the whole body. Let us now inquire 
how far this theory is borne out by the known 
effects of refrigerants upon the functions of the 
stomach, the lungs, and other organs. 

1. In the healthy condition of the /stomach, re- 
frigerants exert little perceptible influence upon 
it; but when it is either in an irritable state, or 
affected with inflammation, the continued use of 
refrigerants, particularly cold and iced water and 
lemonades, allays the sensation of heat, nausea, 
and general uneasiness. Even when no local in- 
flammation exists, cold water and other cold, bland 
fluids, received into the stomach, moderate general 
excitement and control febrile action ; an effect 
which can only be explained by the influence of 
the refrigerants on the nervous energy. The 
same results follow the administration of refri- 
gerants in enteritis. 

2. Refrigerants exert no evident influence on 
tne circulating and respiratory organs, in the 



state of health ; although in some individuals, 
owing to idiosyncrasy, acidulated fluids cannot be 
taken without so powerfully affecting the larynx 
as to cause a temporary loss of voice ; but in a 
diseased state of these organs the influence of 
refrigerants is well marked. 

In an excited state of the vascular system, 
when the pulse is both quicker and stronger than 
natural, acidulated drinks reduce both states, both 
moderating the action, and relaxing the tension 
of the pulse; nor is their effect on the capillaries 
less manifest ; and it is to their influence on these 
that we must attribute the diminished tempera- 
ture which follows their administration. It is 
surely unnecessary to say how intimately this is 
connected with their impression on the nerves of 
the stomach. In the febrile state, the effects of 
refrigerants on the circulation are necessarily com- 
municated to the lungs; but besides this sympa- 
thetic influence, some of this class of medicines, 
in particular, acids, seem to operate directly on 
the pulmonary tissue. In acute inflammation of 
the air-tubes, or even of the pleura, acid fluids 
greatly augment the cough and oppress the breath- 
ing, when administered before the excitement be 
subdued ; and after this is effected, we still per- 
ceive the evidence of their action on the mucous 
membrane by the aid which they afford to ex- 
pectoration. 

3. But the most decisive illustration of the 
extent to which the nervous system is influenced 
by refrigerants, is observed in the effects which 
acidulated fluids produce on those who are la- 
bouring under diseased conditions of the spinal 
cord. The author had an opportunity of wit- 
nessing this in a gentleman who was labouiing 
under subacute inflammation of the spinal theca. 
Whenever he swallowed a spoonful of lemonade, 
or even an ordinary effervescing draught, a sensa- 
tion of pricking was felt over the surface, the skin 
became so sensitive as scarcely to admit of being 
touched, and the whole system restless and un- 
easy. Hypochondriacal and hysterical persons, 
not unfrequently, suffer in a similar manner from 
the internal use of acids ; and, as this effect is not 
confined to particular individuals, it cannot be 
ascribed to idiosyncrasy. 

Upon the whole, it is evident that refrigerants 
operate to a certain extent as sedatives ; diminish- 
ing the force and rapidity of the pulse, depressing 
morbid temperature, and calming, generally, the 
disturbance which always attends acute diseases. 

The substances employed as refrigerants operate 
either on the organic functions or on the sensi- 
bility of the body in a state of disease. 

1. The refrigerants operating on the organic 
functions are chiefly vegetable acids. The in- 
fluence of acetic acid, in its diluted impure state 
or as vinegar, in cooling the body labouring under 
disease, was very early known. In its undiluted 
state it is a powerful stimulant; and when daily 
taken in large doses into the stomach in its diluted 
form, it produces great uneasiness, cramps, and 
colic, and gradually destroys so effectually the 
texture of the organ and its digestive function, as 
to cause emaciation of the body. When it is 
only occasionally taken, largely diluted with wate' 
and moderately sweetened, it displays decided 
soothing and refrigerant properties, and is eiu 



20 



REFRIGERANTS. 



|l<v ed with advantage in inflammatory and bilious 
fevers, for quenching thirst, calming the vascular 
excitement, re-establishing the perspiratory func- 
tion of the skin, and restoring the action of the 
kidneys. In inflammatory affections of the lunus, 
however, it increases the cough, and augments the 
morbid sensibility of the mucous membrane in the 
same manner as all other acids; and, therefore, it 
is contra-indicated in such diseases, even as an 
expectorant, until the excitement be subdued. 

The refrigerant influence of diluted vinegar on 
the surface is undoubted ; it not only diminishes 
heat but allays pain. In hemorrhagic affections, 
the cold feeling which it produces on the skin is 
extended to the whole system ; hence the benefit 
derived from it in internal hemorrhages, and in 
the inflammation of cavities; as, for instance, in 
uterine hemorrhages applied to the thighs and ab- 
domen ; and in acute meningitis applied as a 
lotion to the shaved scalp. In general fever, 
sponging the body with vinegar and water is ap- 
plicable to every case in which the skin is preter- 
naturally hot, when no idiosyncrasy stands in the 
way. 

When diluted acetic acid is internally admi- 
nistered, if opium be prescribed at the same time, 
it should be recollected that it decomposes the 
meconate of morphia of the opium and forms an 
acetate, which is a more powerful narcotic than 
the meconate. The combination of this acid with 
ammonia, in the prepaiation known by the name 
liquor ammonias acetatis, possesses refrigerant 
powers nearly equal to those of the diluted acid, 
acting at the same time as a diaphoretic ; and it 
is more generally employed than the acid in mo- 
dern practice. The salts procured by the com- 
bination of acetic acid with the other alkalies 
operate chiefly on the kidneys. 

The citric acid is more frequently employed 
than the acetic as a refrigerant; hut chiefly in its 
combined state as prepared by the hand of nature, 
in the juice of the lemon, the orange, and other 
fruits. It is more grateful in its combined than 
in its uncombined state ; a fact which is quickly 
perceived by patients in fever, when it is ordered 
to form the common effervescing draught for 
checking nausea and vomiting. When simply 
diluted with water, in the proportion of the juice 
of two moderately-sized lemons to a pint of water, 
and slightly sweetened, forming lemonade, citric 
acid constitutes a most serviceable and agreeable 
beverage in fevers ; and in those of a typhoid 
characier this is rendered more grateful and bene- 
ficial by using water impregnated with carbonic 
acid gas instead of common water. In the ordi- 
nary condition of the stomach, citric acid, either 
pure or combined, does not weaken the stomach; 
and in some irritable states of that organ, charac- 
terized by a sensation of heat, painful digestion, 
an unpleasant taste in the mouth, and a disgust 
of food, it removes these symptoms and proves 
decidedly beneficial: but on the other hand, when 
the stomach is highly irritable, and its nervous 
susceptibility great, lemon-juice, or the citric acid, 
even when largely diluted, causes heat, uneasi- 
ness, and pain, and not unfrequently obstinate 
vomiting. Nevertheless, as M. Broussais has 
remarked, (Phlegmas. Chron. t. iii. p. 254,) the 



citric acid is that which the stomach supports bes 
when suffering under inflammation. 

The citrates of potassa and of ammonia are 
also refrigerant; the citrate of soda, which is not 
an officinal preparation, operates as a purgative. 

The above remarks are applicable to the juice 
of the orange, the apple, the currant, and the 
gooseberry, all of which owe much of their acidity 
to the citric acid. , . 

The tartaric acid, except as it is contained in 
the tamarind, is much less frequently prescribed 
than the citric as a refrigerant, being more apt to 
disorder the digestive organs, to produce colic and 
to purge; and its morbid influence on those 
labouring under affections of the spine is more 
constant and evident than that occasionally re- 
sulting from the employment of citric acid : indeed, 
so obvious is this, that patients sometimes refuse 
to continue taking it on account of the nervous 
agitation which it causes. Its combination in the 
form of the bitartrale is more frequently em- 
ployed ; and in small doses at moderate intervals, 
it does not operate as a purgative, but as a simple 
acidulous refrigerant. It is best administered in 
the form of whey, or of cream-of-tartar beverage ; 
it moderates febrile heat and softens the skin ; but 
when its employment is followed by a red and dry 
tongue, it ought to be discontinued. Both the 
acid and the bitartrate are incompatible in mix- 
tures with the nitrate of potassa, which it decom- 
poses, and, uniting with its alkaline base, forms 
either a bitartrate or a tartrate. 

The oxalic acid in the form of the binoxalate, 
as found in the oxalis acetosella and rumex ace- 
tosa, was formerly much prescribed as a refrige- 
rant ; but these plants, and, indeed, the oxalic 
acid in any form, are now rarely employed. 

Nitrate of potassa, in small doses, is a well- 
known refrigerant : it produces a powerful sym- 
pathetic effect on the nervous system, depressing 
the strength and diminishing the frequency of the 
pulse, and lowering the animal heat : the skin 
becomes pale, and a sensation of languor is felt. 
To obtain the full refrigerant effect of nitre, the 
salt must not only be administered in small doses 
at short intervals, but it should not be dissolved 
until the instant in which it is to be administered. 
As a refrigerant, the dose should not exceed a 
scruple, or, at the utmost, half a drachm. 

The bicarbonate of soda, although seldom pre- 
scribed as a general refrigerant in this country, yet 
is frequently administered in inflammatory febrile 
affections on the continent. It is, however, better 
calculated for operating as a local than as a gene- 
ral refrigerant. 

2. The refrigerants operating on the sensibility 
of the body are few ; but they are more directly 
refrigerant than those which have been already 
noticed. Cool air, the first of these, is so agree- 
able to the feelings in a heated state of the body, 
that observation alone might have led to its early 
employment as a remedial agent; and nothing 
murks more strikingly the perversity of mankind 
than the opposition of physicians, at one period 
to the indulgence of the instinctive desire for this 
remedy in fever patients. Its utility in moderating 
high vascular action and operating as a sedative 
refrigerant is now generally acknowledged • an*] 



REFRIGERANTS. 



21 



consequently its admission to the apartments of the 
sick, in febrile diseases, is almost universal. 

If cool air he beneficial in the above-mentioned 
conditions of the body, cold water and ice are still 
more so ; and their application is extensive. For 
an account of the effects of cold water and ice in 
reducing the temperature of the body in its healthy 
condition, we must refer our readers to the articles 
Bathtxg and Cold. When cold water and ice 
are employed as curative agents, their influence 
may be obtained either by their internal adminis- 
tration or by their application to the surface ; in 
, both cases their effects are extended by sympathy 
over the system ; but they are modified by the 
manner in which these agents are used. If the 
body be immersed in the cold bath, the most 
striking effect is the shock or nervous impression 
which produces the vascular reaction so beneficial 
when cold bathing is used as a tonic ; an effect, 
however, which must be avoided as much as pos- 
sible when the refrigerant influence only of the 
bath is required. To insure simple refrigeration, 
the water should be of a temperature not much 
below that of the skin ; but as, even at such a de- 
gree of heat, the sudden immersion of the body is 
likely to cause more reaction than would be safe 
in cases requiring mere refrigeration, the cold bath 
is rarely or never employed in this country for 
producing that effect. The shock and reaction 
caused by dashing cold water over the body, con- 
stituting the cold affusion as it is termed, is as 
considerable as when the cold bath is used, but it 
is more transitory, and therefore it is a more use- 
ful refrigerant. Sponging the body with cold 
water, as far as a simple refrigerant effect is de- 
sired, is preferable to either the cold bath or the 
cold affusion : there is no shock ; the fluid, being 
left to evaporate, merely cools the surface ; and by 
persevering in the process, the cooling effect is 
fully obtained, and rendered permanent. One 
great advantage of sponging the surface with cold 
water is the facility of limiting the extent of the 
effect according to the feelings of the patient: in 
general it may be continued until the sensation of 
chilliness comes over the body, when the patient 
should be dried and placed in bed. The more 
simultaneously the influence of cold water is ex- 
tended over the surface, the better; the process 
of sponging should, therefore, be performed by 
several attendants with large sponges on the dif- 
ferent parts of the body at the same time. In 
ordinary cases the temperature of the water may 
be regulated by the feelings of the patient, as the 
beneficial effect depends on the evaporation, which 
may be aided by the addition of vinegar or alcohol. 
Evaporuting lotions applied to a part, operate 
locally in the same manner as general sponging; 
the sedative and refrigerant influence is not con- 
fined to the part, but extends to other parts of the 
body, even to the interior, as, for instance, to the 
brain, the contents of the abdomen, and to joints. 
The sedative effect is still more powerful when a 
small stream of cold water is directed upon the 
part : the author of this article has seen this most 
strikingly exemplified in burns ; the mere immer- 
sion of the part in cold water, or the application 
of cloths dipped in cold or even iced water, is 
much inferior in its effect to this method of em- 
ploying cold water. It is scarcely necessary to 



comment on the influence of the local application 
of ice, which operates exactly in the same manner 
as evaporating lotions, but more effectively, owing 
to the steady continuation of the same low tempe- 
rature to the parts. 

The foregoing remarks lead to this conclusion — 
the utility of refrigerants as curative agents is more 
limited than that of most other classes of remedies. 
They are chiefly employed to depress inordinate 
vascular action, and thereby to lower temperature ; 
consequently, it is in inflammation, active hemor- 
rhages, and febrile affections that they are found 
beneficial ; and in such cases they are, undoubt- 
edly, most valuable remedies. 

In local inflammations on the surface of the 
body, cold water and evaporating lotions prove 
highly serviceable ; whilst in those more deeply 
seated, as, for instance, inflammation of the brain 
and its membranes, ice applied to the scalp is to 
be preferred : the steady abstraction of caloric 
which it effects, operates not only upon the vessels 
and nerves of the integuments, but, by diminish- 
ing action in the carotids and large vessels, it pro- 
duces the most decisive benefit in reducing the 
vascular action within the cranium. These ap- 
plications have been lately recommended in other 
internal inflammations, even those of the thorax 
and abdomen, and under proper circumstances 
have been found highly beneficial. 

Hemorrhage arising from increased action, or 
accompanied by it, is frequently checked by the 
sedative influence of refrigerants. When the 
bleeding is internal, the degree of cold should be 
such as to operate sympathetically on the whole 
system ; and to lessen not only the action of the 
vessels of the part, but to restrain, to a certain de- 
gree, that of the heart. Thus in haemoptysis, not 
only should the patient be freely exposed to cold 
air, but ice and cold acidulous fluids should be 
freely administered ; indeed, the temperature may 
be with safety, and even with advantage, dimi- 
nished so much as to be uncomfortable to the 
feelings of the patient. In such a case, the low 
degree of temperature is accompanied with an evi- 
dent diminution of the irritability of the contrac- 
tile fibres of the whole vascular system, and, con- 
sequently, aids greatly in checking the flow of 
blood. The liquids administered as drink should 
be cooled down to 32°, either by ice or by a 
freezing mixture, and slowly swallowed. The in- 
fluence of nitre has long been regarded as con- 
siderable in such cases ; and much of the benefit 
received has been attributed to a chemical change 
effected on the blood ; but if the opinions advanced 
in this article be correct, it is unnecessary to assert 
that this explanation of the operation of nitre 
must fall to the ground. 

[The notion of nitrate of potassa being refrige- 
rant has probably arisen from the coldness which 
it occasions whilst undergoing solution in water. 
Indeed, as elsewhere stated, (General Therapeutics, 
Philad. 1836, and General Therapeutics and Ma- 
teria Medica, ii. 206, Philad. 1843,) all internal 
refrigerants probably act wholly by their being 
comparatively of low temperature, and thus re- 
ducing the heat of the stomach. A recent writer, 
Dr. Spillan, (Manual of General Therapeutics, 
p. 185, London, 1841,) after citing the published 
opinion of the writer on this subject, states that 



22 



REFRIGERANTS. 



" the refrigerant effects of nitrate of potassa as a 
sedative, when given dissolved in even tepid 
drinks, such as whey, are known to every one." 
They certainly are not known to the writer ; yet 
he has watched most carefully for them ; nor have 
others heen more fortunate. Dr. A. T. Thomson 
says, that " the dose of the salt should not be dis- 
solved until the instant in which it is to be swal- 
lowed," (Elements of Mat. Med. and Therap., 2d 
edit. Lond. 1835) ; and Dr. Pereira (Elements of 
Mat. Med. and Therap., Amer. edit. i. 438,) ac- 
cords with him ; whilst Dr. Christison (Dispen- 
satory, p. 741, Edinb. 1842,) expresses himself in 
a manner that still more strongly corroborates the 
views of the writer : — " Its refrigerant action, gene- 
rally admitted by systematic writers on materia 
medica and by many practitioners, is of doubtful 
existence, having probably been inferred rather 
from the coldness it occasions while dissolving in 
water, than from actual evidence of its effects in 
disease. The sedative action ascribed by some to 
it has been probably inferred from its supposed re- 
frigerant property, and not from observation."] 

In haematemesis occurring in young and vigo- 
rous perons, the same assiduous employment of 
refrigerants is requisite as in haemoptysis; and 
when the bleeding is so violent as to threaten 
quickly serious consequences, the other refrigerant 
plans may be aided by injecting iced water into 
the rectum, and by the local application of cold to 
the epigastrium. In no species of hemorrhage is 
the sympathetic influence of refrigerants more 
strikingly obvious than in epistaxis. Thus dash- 
ing cold water on the genitals has sometimes in- 
stantaneously suppressed bleeding at the nose ; 
and on the same principle is explained, what it is 
scarcely necessary to notice, the popular remedy 
of applying a large cold key or a piece of metal 
between the shoulders under the clothes. 

It is superfluous to say that, however useful 
refrigerants may prove in all cases of active he- 
morrhages, their employment in the passive is to 
be most carefully avoided. 

But it is in fevers that refrigerants under every 
form are to be regarded as the most valuable set 
of therapeutical agents. In continued fever, the 
vegetable acids largely diluted are internally 
administered, especially those found in fruits; and 
not unfrequently nothing is more grateful to fever 
patients than cold water slightly acidulated with 
either the sulphuric or the nitric acid. It is, how- 
ever, the general application of cold to the surface 
which proves the most useful refrigerant in con- 
tinued fever. In those forms of the disease which 
assume a typhoid type, ventilation and the free 
admission of cool air into the apartments of the 
sick are absolutely necessary: irritation is allayed, 
debility obviated, and the whole complexion of 
the disease often changed in a few hours, by the 
removal of the patient into a cool and well-venti- 
lated, from a close and filthy apartment. The 
most direct and effective refrigerant, however, in 
continued fevers is the cold affusion ; but its 
employment requires certain cautions, without at- 
tention to which much mischief may be incurred. 
In the first place, the exact temperature of the 
body must be carefully ascertained. In this 
country, U-. the severest attacks of fever, it has 
'sreU exceeded 108° Fah.; but in tropical 



climates it rises sometimes to 112°; the higher 
the temperature of the patient, the more benefit 
maybe anticipated from the cold affusion. Ine 
temperature of the water should vary according to 
the season of the year and the feelings of the 
patient, the average range being from 40 to 70 
Fah. The effect is to diminish the morbid heat 
of skin, to lower the force and retard the rapidity 
of the pulse, and to induce perspiration and sleep; 
and when such results follow, the cold allusion 
proves beneficial in any form of fever. 

The thermometer is employed to determine the 
temperature of the patient; but if he feel cold 
when that instrument indicates an augmented 
morbid temperature; or if he feel hot when the 
thermometer demonstrates that the heat of the 
body is below that of the natural standard ; then 
in neither case should this form of refrigerant be 
resorted to. It is also improper when the skin is 
bedewed with perspiration ; or if the patient dread 
greatly its use ; nor is it less so during menstrua- 
tion, and in the latter months of pregnancy. In 
the advanced stages of fever, refrigerants of any 
kind are injurious. 

With respect to the kinds of continued fever in 
which refrigerants are indicated, we may enumerate 
six. 

1. In inflammatory fever, (synocha,) a rare dis- 
ease when unaccompanied with topical inflamma- 
tion, the advantages to be derived from refriger- 
ants are well understood. The cold affusion is 
admirably adapted for rapidly abstracting the 
stimulus of heat, diminishing general excitement, 
and operating as a powerful sedative. In the 
more advanced stages of the disease, cool spong- 
ing is often substituted for the affusion ; but when 
the patient can bear the fatigue of the affusion, it 
is always to be preferred. The greater frequency 
of this form of fever among the ancients than the 
moderns explains their constant employment of 
cold drinks and cold bathing in continued fever. 

2. In fevers of a typhoid type, the disease has 
been cut short by the cold affusion ; but in this 
case more perhaps is to be attributed to the shock 
and the reaction which follows, than to the refri- 
gerant influence of the affusion. 

3. In synochus or inflammatory fever, gradually 
assuming the typhoid character, refrigerants in 
general, but more especially the cold affusion, are 
chiefly applicable to the early stages of the disease; 
and, indeed, no form of remedy is more advanta- 
geous when there are no local determinations; 
but when these exist, particularly if the lungs be 
affected, much caution is required. 

4. In remittent fevers, especially those of warm 
climates, and in their more intense and excited 
variety, the cold affusion may be employed with 
great benefit. In severe attacks, also, much 
advantage is derived from the application of ice or 
cold water to the scalp ; in the remissions, how- 
ever, the application of cold in any form must be 
suspended. In yellow fever, the safety of the 
patient frequently depends solely on the early ap- 
plication of the cold affusion. 

5. If hectic be symptomatic of pulmonary af- 
fections, or determination to internal or°- ;lns tne 
cold affusion is decidedly contra-indicaTed •' but 
even in such cases much benefit is often obtained 
by sponging the trunk of the bodv wu u c> | d 



REFRIGERANTS — RHEUMATISM. 



23 



water mixed with vinegar, whilst the lower ex- 
tremities are kept warm in bed. We must, never- 
theless, bear in mind that, under any form of 
hectic, although general refrigerants are useful 
auxiliaries, yet the cold affusion can scarcely be 
regarded as admissible. 

6. In most eruptive fevers, except measles, the 
body should be freely exposed to cool air ; and 
even the cold affusion may be safely and advan- 
tageously prescribed, should the state of the sur- 
face require it, nor should the presence of the 
eruption operate as a reason against its employ- 
ment. The Hindoo physicians plunge their 
patients, during the eruption of small-pox, into 
cold water, and with the best results. It dimin- 
ishes the fever, lessens the number of the pus- 
tules, and is said to prevent pitting. The writer 
of this article has long been in the habit of em- 
ploying the cold affusion in scarlatina during the 
height of the eruption, and has seen the severity 
of the disease instantly checked by it. 

In intermittent fevers, when the skin is dry and 
parched, and the general heat greatly augmented, 
cold in every form applied to the surface, and cold 
acidulated fluids taken into the stomach, are of 
the same value as in continued fever, and greatly 
favour the accession of the sweating stage. The 
affusion should be used in the hot stage of the 
paroxysm, and continued until the temperature of 
the body of the patient be reduced to the natural 
standard. 

It is unnecessary to discuss the nature of the 
various diseases, besides idiopathic fevers, in which 
refrigerants are indicated : in all, much depends 
on die degree of the attendant fever, and the ex- 
istence of local affections. In one local disease, 
plirenitis, however, their advantageous effects are 
very conspicuous: the most furious delirium is 
quickly subdued by allowing cold water to drop 
on the vertex, whilst the rest of the scalp is cov- 
ered with cloths moistened with vinegar and water. 
The degree of collapse, indeed, which is thus 
produced, is often so great as to require most 
active measures to counteract it ; when such 
occurs, the state of sinking is to be treated exactly 
in the same manner as when extreme debility 
suddenly appears from other causes: external 
warmth, particularly the application of bladders 
of hot water to the scrobiculus cordis, friction, 
electricity, and sometimes artificial respiration, are 
the means to be employed to restore animation ; 
and when the power of deglutition returns, the 
administration of excitants, especially aromatics 
and ammonia, is to be resorted to. 

From the foregoing remarks, it is evident that, 
although, as we have already said, refrigerants 
constitute a class of medicines of limited applica- 
tion, yet they are of much value in a few impor- 
tant diseases. Like every other class of thera- 
peutical agents, their utility will be more or less 
obvious as the discrimination, the judgment, and 
the observation of the practitioner are properly 
exercised, in determining the exact condition of 
the body which demands their employment. 

A. T. Thomson. 

RHEUMATISM, from fcfya, a defiuxion. 
This term, originally adopted when diseases ac- 
companied with swelling were usually attributed 



to the flow of some special humour to the part 
affected, has been used for ages to designate an 
affection which has so much of distinct character 
as to justify its being considered a special dis- 
ease. So loosely, however, has the term been 
applied, that a host of ailments, with no character 
in common save that of pain, have been classed 
under it, and much both of false experience and 
of bad practice has thence resulted. Diseases 
called rheumatic have been relieved by stimulant 
remedies, which from the character thus acquired 
have been empirically resorted to in states of con- 
stitution for which they were utterly unsuited. 
In acute rheumatism, a disease intensely inflam- 
matory, vve have known the use of the most pow- 
erful stimulants confidently urged by well-meaning 
but misguided friends, who in support of their 
prescription have pleaded the wonderful cures 
which they had seen their favourite specific per- 
form in what they assumed to have been rheuma- 
tism ; thus misled by a name to recommend in 
active inflammation what could have benefited 
only in a totally opposite state of the system. As 
many affections really rheumatic present an equi- 
vocal character which to superficial observation 
too often appears to justify the use of stimulants, 
it is very necessary to discriminate the real dis- 
ease, so as to distinguish it from those diseases 
with which it is liable to be confounded ; and 
however difficult it may be to class the latter, it is 
better to leave their place in nosology unassigned, 
than, by ranging them under the head of rheuma- 
tism, to beget confusion where clearness and pre- 
cision are of the first importance. 

In the investigation of rheumatism, the best 
mode, similar to what was followed in treating of 
gout, is to consider, first, the simple disease in its 
most perfect form ; and then, with the lights thus 
supplied, to elucidate the more complex conditions 
which the larger portion of rheumatic affections 
present. So contradictory, and, we may add, so 
ineffectual are the means ordinarily used in treat- 
ing the latter, that no greater benefit could be con- 
ferred both on patients and practitioners, than to 
divest the treatment of perplexing confusion and 
inconsistency by reducing it to fixed principles, 
and bringing it within the pale of rational and 
scientific practice. 

In determining the diseased condition to which 
the name of rheumatism should be specially as- 
signed, it is expedient to examine the representa- 
tions given of it by the systematic nosologists. 
Sauvages describes rheumatism as " dolor diutur- 
nus in parte carnosa artuum," and places it in the 
class Dolores, order Vagi, of his nosology. Ac- 
cording to Linnasus, it is "musculorum dolor ad 
motum, a tunica cellulosa injecta ;" class Dolores, 
order Extrinseci.'" Vogel places it in class 
Dolores, as merely " cutis et musculorum dolor." 
It would be difficult to recognise in these brief 
and meagre specifications the ordinary disease of 
rheumatism, such as we daily witness it. 

Sagar is both more copious and more precise. 
He describes two diseases, a chronic one ranged 
in the class Dolores, order Vagi ; and an acuti? 
under the specific name of myositis, in the class 
Plilegmasiae, order Phlegmasia: musculossc, giv- 
ing respectively the following definitions. " Rheu- 
matismus. Dolor Diuturnus in parte carnosn 



24 



tendinosa artuum, vagabunJus, saepius sine coryza, 
rheumate, catarrho, erysipelete, et sine febre nota- 
bili ; (acutus rheumatismus facit genus inter Phleg- 
masias, myositin a me dictum;) sanguis missus 
rheumatisino laborantium, est gelatinosa crusta 
tectus, et urina saepe ad sulphureum colorem ten- 
dit." " Myositis. Febris acuta inflammatoria, 
dolores in diversis musculis artuum, eorundemque 
involucris, diu noctuque discruciantes, motum ve- 
tantes fere omnem, ad noctem exacerbantes ; san- 
guis missus est tectus crusta inflammatoria subge- 
latinosa, vel pelli tenui tenaci: hie morbus vulgo 
audit rheumatismus acutus." It is worthy of re- 
mark that Sagar notices the blood drawn in chro- 
nic rheumatism as exhibiting a buffy crust. Cullen 
considers acute rheumatism alone as a special dis- 
ease, regarding the chronic form as only a sequel 
of it. He places it in the class Pyrexias, order 
Phlegmasia:, and gives the following definitions. 
"Rheumatismus. Morbus ab externa et plerum- 
que et evidente causa ; pyrexia ; dolor circa arti- 
culos musculorum tractum sequens, genua et reli- 
quos majores, potius quam pedum vel manuum 
articulos infestans, calore externo euctus." " Rheu- 
matismi sequela est, Arthrodynia. Post rheuma- 
tismum, nisum violentem vel subluxationem, do- 
lores artuum vel musculorum, sub motu praesertim 
aucti, plus minusve fugaces, calore lecti vel alio 
externo levati ; artus debiles rigidi, facile et saepe 
sponte frigescentes ; pyrexia nulla ; tumor ple- 
rumque nullus. Rheumatismus chronicus aucto- 
rum." 

I. — Acute Rheumatism. 

This disease is often designated by the trivial 
name of rheumatic fever, a term which implies a 
constitutional disturbance as well as a local. The 
ordinary phenomena which characterize it are so 
familiarly known, that a very brief account of its 
accession and progress will here suffice. That 
given by Sydenham, derived as it was from actual 
observation, and marked by his wonted truth and 
accuracy, presents in few words as clear a descrip- 
tion of the early seizure as can well be rendered. 

" This disease happens at any time, but espe- 
cially in autumn, and chiefly affects such as are 
in the prime of life. It is generally occasioned by 
exposing the body to the cold air immediately 
after having heated it by violent exercise, or some 
other way. It begins with chilliness and shiver- 
ing, which are soon succeeded by heat, restless- 
ness, thirst, and the other concomitants of fever. 
In a day or two, and sometimes sooner, there 
arises an acute pain in some one or other of the 
limbs, especially in the wrists, shoulders, knees ; 
which shifting between whiles, affects these parts 
alternately, leaving a redness and swelling in the 
part last affected. In the beginning of the illness 
the fever and the above-mentioned symptoms do 
sometimes come together, but the fever goes off* 
gradually, while the pain continues, and some- 
times increases." 

The latter circumstance Sydenham, in con- 
formity with the pathology then prevalent, attri- 
butes to the " derivation of the febrile matter to 
the limbs," which he conceives to be sufficiently 
shown '-by the frequent return of fever from the 
repulsion of morbific matter by external remedies." 
The theory here propounded may be questionable 



RHEUMATISM. 

Z resting on hypothesis, but the facts with which 
it is connected are not the less valuable. 



It appears, then, that acute rheumatism pre- 
sents a state of active fever accompanied With local 
inflammation of one or more joints. And here 
one of the most important questions respecting 
rheumatism arises— whether the local n.fiamma- 
tion be the cause of the fever, or only its attend- 
ant ? On the solution of this, much both of the 
pathology and treatment of rheumatism must de- 
pend, and accordingly its elucidation will form a 
prominent part of the present article. 

In the foregoing description of Sydenham, it 
appears that the state of febrile excitement pre- 
cedes the local inflammation. In theoretic specu- 
lations this fact seems generally recognised, yet it 
does not appear to have been kept steadily in view 
either by speculative or practical writers. The 
term symptomatic fever, so often applied to the 
constitutional disturbance, implies that this was 
regarded rather as a contingent result of the local 
inflammation, than as a precursor or cause of it. 
To determine this point is of much importance, 
for by the decision must the whole course of treat- 
ment be influenced. If the local inflammation, 
whether seated in the muscular, though more fre- 
quently in the fibrous tissue of the affected parts, 
be the cause of fever, as implied by the terra 
symptomatic, the reduction of local inflammation 
by the most direct means would be the best and 
most effectual relief; and this being duly attended 
to, the contingent fever might, according to the 
familiar axiom, sublata causa tollitur effectus, lie 
little regarded. On the contrary, if the state of 
fever, or rather that condition of the habit which 
gives rise to fever, be the real source of rheumatic 
seizure, then should the constitutional state be 
chiefly attended to, and local treatment be only 
subsidiary to that by which the derangements of 
the constitution are rectified. We hope cleaily 
to show that the constitutional state is that which 
chiefly claims our regard in the treatment of rheu- 
matism. 

When acute rheumatism occurs in its most 
active state, so intense is the inflammatory fever 
attendant, that whatever theory of the disease be 
entertained, the fever claims its full portion of at- 
tention, and is met by adequate activity of treat- 
ment. Bleeding, purging, and other means of 
reducing fever are promptly and freely employed, 
the more so as experience has shown this treat- 
ment to be indispensable for abating the local in- 
flammation. This being the case, then, it may be 
asked, of what importance is it to decide whether 
the local or constitutional affection is to be re- 
garded as the primary disturbance, inasmuch as 
the same treatment relieves both ? It would be 
sufficient to answer that truth ought always to be 
ascertamed, for it can never be unimportant. Were 
acute rheumatism in its more active state to be 
alone considered, the importance of the decision 
JUght be less, both the local and constitutiona. 
o co reTn, r mandlng thG Vig0r ° us employment 

degree "nhe ng "T* But When the »> inor 
degrees of the same disease, constituting what is 

gatTd'ittnt ----rT' COme t0 "e Tntlt" 
fnvolves the n 6 T^ that the "" ? Semial ch ^ le[ 
b" t^!!-!^° lntat ..:," ue; / nd Sunless this 



be determined as truth and 



reason dictate, thf 



RHEUMATISM. 



practice in a malady which is more pr< 
causes more suffering, and leads to more decrepi- 
tude than almost any other, must lie vacillating, 
imperfect, and unsuccessful. 

It will materially abridge the present article to 
refer to certain general principles of pathology al- 
ready detailed in the articles Gout and Pletho- 
ra! These principles apply directly to rheuma- 
tism, and through them alone can its pathology be 
adequately unfolded, or its treatment rationally 
explained. 

Acute rheumatism principally attacks the young 
and vigorous. The period of life most subject is 
said to be from puberty to thirty-five years. 
Though no age is exempt, it yet more rarely oc- 
curs in the very young, or in advanced life. This 
circumstance alone would seem to indicate some 
connection between rheumatism and fulness of 
habit, or that approximation to plethora which 
was formerly noticed as exuberance of health ; and 
if rheumatic seizures be duly scrutinized, they will 
be found to take place in those who from plethora, 
whether absolute or relative, are prone to fever or 
inflammation on any exciting cause being applied. 
The extraordinary health so often remarked by 
patients as having immediately preceded the rheu- 
matic attack is sufficiently intelligible. But direct 
evidence of the state of constitution in which at- 
tacks of rheumatism occur is amply shown in 
those who, having had the disease, are liable to 
its recurrence, and on this account compelled to 
watch the premonitory indications of an attack. 
In these, constitutional disturbance of a febrile 
kind, marked by all the phenomena formerly de- 
tailed as denoting the transition of plethora into 
febrile excitement, will be invariably found to 
exist for a sensible time before the disease presents 
its full character by the establishment of a local 
inflammation. And to these premonitory indica- 
tions should the earliest attention be given, for it 
is in this stage that relief can be most speedily 
and effectually afforded. By reducing plethora 
and subduing febrile action in this stage, the local 
inflammation may be wholly averted, and thus 
may be prevented not only the injury which the 
joints, when affected, are liable to sustain, but 
also the susceptibility to impression from slight 
causes which reiterated attacks of rheumatic in- 
flammation never fail to leave. 

The local inflammation of acute rheumatism 
undergoes a change during its progress which 
seems to have escaped observation. It exhibits 
at different stages two conditions, which may be 
conveniently distinguished as primary and second- 
ary. The former is the immediate result of the 
rheumatic seizure, and must be attributed to the 
specific cause, whatever it may be, from which the 
disease derives its distinctive character. It differs 
from common inflammation in being more tran- 
sient, for it is capable of rapid subsidence without 
any trace of its attack remaining. When this 
inflammation migrates from joint to joint, the oc- 
currence of a fresh inflammation is oftentimes 
followed by a quick subsidence of that which im- 
mediately preceded. Still more signally does this 
rapid subsidence take place if active treatment for 
the relief of the constitutional inflammation be 
resorted to immediately on the attack occurring, 

Vol. IV. — 4 c 



and before the secondary inflammation has had 
time to supervene. In this respect the primary 
or specific inflammation of rheumatism has a close 
analogy with that of gout, from which it differs, 
however, in having a stronger tendency to pass 
into inflammation of a more ordinary and perma- 
nent kind. This specific inflammation is promptly 
relievable by constitutional treatment, no local ap- 
plications being at all needed. 

When from the severity of the attacks, or from 
neglect or delay in having recourse to suitable 
discipline, the specific inflammation lingers in a 
joint, a secondary inflammation results, more per- 
manent in its nature, which does not immediately 
subside on the constitutional inflammation being 
subdued, and which generally leaves some traces 
of its existence, in effusion into the cellular mem- 
brane or bursa? mucosse, or in more or less thick- 
ening and rigidity of the ligaments and other 
membranes surrounding the joints. The distinc- 
tion here noticed is important, because it has a 
sensible influence on the local treatment of rheu- 
matism, both acute and chronic. 

Causes of acute Rheumatism* — The chief, 
if not the only exciting cause, is the application 
of cold to the body when unusually heated. Cold 
is more liable to produce this effect when com- 
bined with moisture, whence a cold and humid 
atmosphere, and wet or damp clothes, are the most 
frequent sources to which rheumatism can be 
traced. Partial cold, as when parts of the body 
are subjected to currents of cold air, is very apt to 
give rise to rheumatism. When the body is pre- 
disposed, a very transitory exposure of this kind 
will suffice to bring on an attack; if the current 
be sustained for any time, few will wholly escape 
some contingent suffering. Of the fact that rheu- 
matism is so excited there can be no doubt. When 
it is reflected, however, that for every instance ol 
rheumatism so induced, numbers continually en- 
dure a much or greater exposure to the alleged 
cause without any disease ensuing, too much im- 
portance should not be attached to it. 

[Other causes have been enumerated, such as 
the repercussion of eruptions, the stoppage of an 
accustomed flux, &c. These may exert an influ- 
ence, if a predisposition exist ; but such influence 
is not easily appreciable. Recently, it has been 
affirmed by Messrs. Maddock and Sigmond, that 
where there is a disposition to acute rheumatism, 
the use of copaiba may develop it.] 

Of far greater moment is it to regard the predis- 
position, without the concurrence of which either 
no rheumatism will take place, or it will be slight 
and partial, exhibiting none of the constitutional 
disturbance and febrile excitement which charac- 
terize acute rheumatism. A predisposition is said 
to he given by many circumstances, as age, tem- 
perament, climate, season of the year. Even he- 
reditary liability has been classed among the pre- 
disposing causes, and possibly with reason, [and u 
is affirmed by Dr. R. B. Todd, (Practical Ri 
on Gout, Rheumatic Fever, &c. Lond. 1843,) 
that the children of gouty parents are more liable 
to the disease than those who have not labourer 
under the gouty diathesis.] Each of these merits 
attention, but the circumstance common to all ot 
them, and that which has most influence in pr; 



2G 



RHEUMATISM. 



the disease, is a state of general constitu- 
tion, which from the prevalence of plethora, either 
absolute or relative, is prone to be aroused by any 
excitement into febrile or inflammatory action. 
This subject having been fully discussed in its 
proper place, (sec Plethoha,) it will suffice on 
the present occasion to apply to the consideration 
of rheumatism the doctrines already explained. It 
furnishes a presumption, at least, of these doc- 
trines having some foundation in truth, that cor- 
responding principles have been advocated by one 
of the most enlightened pathologists of the present 
day. M. Andral, in various parts of his luminous 
Treatise on Pathological Anatomy, traces a variety 
of structural lesions, as well as the inflammatory 
actions which induce them, to a redundancy of 
nutritive matter in the blood, supporting his views 
with a copiousness of illustration, matured expe- 
rience, clear discernment, and sound judgment, 
which claim the respect Jnd confidence of every 
intelligent mind. These views, too, are so reiter- 
ated throughout the work as to show that they 
were not a mere transient conception, but a deli- 
berate conviction deeply impressed. 

A few extracts will evince that in these asser- 
tions we do not misrepresent this acute and philo- 
sophic writer. In discussing the effects of hyper- 
emia, or excess of blood, on particular tissues, he 
says: — "The hyperemia, instead of being con- 
fined to a simple organ, may exist at the same 
time in every organ of the body. The general 
capillary system is thus overloaded with blood, 
and the whole system is said to he in a state of 
plethora or polyasmia. I shall not enter into a de- 
tail of the circumstances which characterize this 
state, the essential character of which seems to 
consist in the formation of a greater quantity of 
blood than is necessary for the purposes of nutri- 
tion and secretion. There are some individuals 
who, according to common observation, naturally 
make a greater quantity of blood than others. In 
general, those persons who live high, and make 
but little exertion, mental or corporeal, are most 
liable to this affection. It has been said, but with- 
out the slightest proof being adduced in support 
of the assertion, that an appearance of plethora 
has been produced in some individuals by an in- 
ordinate expansibility of the blood. When the 
blood-vessels contain a greater proportion of the 
nutritive fluid than is necessary to supply the de- 
mands of the different organs, the superabundant 
quantity becomes a permanent source of excitation 
to the solids, and at the same time the blood has a 
remarkable tendency to accumulate in different 
organs ; so that, in such case, the whole system is 
in a general state of excitation, and some of the 
organs may become the seats of local congestions 
of various degrees of duration and intensity. In- 
deed, the phenomena which result from the ple- 
thoric diathesis, cannot properly be termed morbid 
unless when some local congestion is formed. 
Sometimes the brain is the seat of the congestion, 
and then follow the various symptoms of the cere- 
bral disease, giddiness, headach, drowsiness, alter- 
ation .if the sensorial and intellectual faculties, 
&c. which mav be so violent as to induce death, 
and yet leave no trace of disease except a little 
more blood than usual in the cerebral vessels. 
Sometimes the congestion more particularly affects 



the pulmonary organs. The dyspnoea v. 1 ch ac 
companies this form of the disease arises from an 
unusual quantity of blood transmitted through ^ he 
lungs, which necessarily requ.res a «=orrespondmg 
quantity of air to fit it for the purpose, of the 
^recirculation. It ii this want of proporUon 
between the blood which requ.res to be aerated, 
and the quantity of air inspired for that purpose, 
which produces" the dyspnoea. In other cases the 
complication of palpitation with various degrees 
of dyspnoea proves that the heart has become the 
seat of congestion." 

Corresponding effects are traced through other 
organs and tissues, and due notice is taken of the 
constitutional derangements resulting from polyso- 
mia when no organ more especially suffers, as 
well as of the prostration of strength or false ady- 
namia, as it is expressively called, which so gene- 
rally attends this state. The section closes with 
remarks which are too apposite to our present 
purpose to be omitted, however reluctant we may 
be to indulge in lengthened quotations: — "The 
morbid state which I have now described, and to 
which may be referred some of the species of con- 
tinued fever described by the older nosologists, may 
terminate in recovery or death. When the termina- 
tion is favourable, the symptoms gradually improve 
as the superabundant quantity of blood, the original 
source of all the accidents, is diminished by absti- 
nence and bloodletting. When death ensues, the 
post-mortem examination generally exhibits traces 
of well-marked inflammation of one or more 
organs. This inflammation seems to have taken 
place subsequently to the commencement of the 
febrile paroxysm : at least the symptoms would 
lead us to this conclusion. But on other occasions 
no trace of inflammation can be discovered, and 
the only morbid appearance consists in a simple 
accumulation of blood in the capillaries of the dif- 
ferent organs, their textures remaining perfectly 
unaltered. These slight congestions affecting si- 
multaneously several orgs ns, mav. by the various 
morbid sympathies which they excite, produce as 
violent and formidable symptoms as the most seri- 
ous organic lesion of any individual organ. In 
such case, where are we to assign the origin of 
the disease ? — Wherever the blood is distributed, 
there derangement of function is found. In the 
blood, then, indisputably resides the first cause of 
the disease; the lesion of the solids is only a se- 
condary affection, but may, notwithstanding, be- 
come, during the progress of the disease, the pro- 
minent affection, and give rise to many and for- 
midable accidents. 

In noticing fevers, he particularises one class 
which he refers specially to excess of fibrine in 
the blood. "Lastly, the third class of fevers 
appears to be more particularly connected with 
alterations of the blood. On this head I can but 
refer to what I have already said, when treating 
of the diseases that may arise from that source, 
shall content myself at present with repeating 
that the fever termed inflammatory seems to me 
often to arise _ from no other source than the blood 
being too rich in fibrine." Again, in considering 
the lesions of the blood, he refers the occurrence 
of inflammatory fever, not only to a general 
hypenemu or excess in quantity of the circulating 
iluid, but more particularly to an altered condition 



RHEUMATISM. 



27 



of its quality arising from redundancy of fibrine. 
" I have already established the fact that, under 
the influence of a state of general hyperemia, 
every organ becomes excited ; that death may 
result from such excitation ; and that a super- 
abundance of blood is found all over the body, 
but in no part is there any serious lesion, any 
alteration of texture. In" such cases there exists 
that state of pyrexia, termed by nosologists in- 
flammatory fever. But if, instead of being simply 
in excess, the blood contains more fibrine than 
ordinary, its exciting power will be still greater, 
and what it did in the former case merely by its 
increased quantity, it will now do by its alteration 
of quality." In fine, he applies the doctrines thus 
propounded to the particular disease which is the 
subject of the present essay. « Now if we mark 
the symptoms and progress of acute rheumatism, 
we Mud that very often a well-marked febrile 
action with a strong reaction, but without any 
symptom whatever of local affection, precedes the 
pain. In a word, there is first an inflammatory 
fever, and then rheumatism. Next observe the 
extreme mobility of the rheumatic pains. They 
run along in a manner wherever the blood is dis- 
tributed ; the application of leeches often removes 
the pain from one part, but it soon shifts to an- 
other, and not unfrequently it quits the articu- 
lating tissues and fixes on different internal organs, 
producing, by the derangement of their functions, 
symptoms more or less severe. It often happens 
that bleeding from a large orifice puts an end to 
the disease, as if by diminishing the mass of 
blood it proportionally diminished the stimulus 
that promoted all these shifting irritations." 

The doctrines here advanced we believe to be 
founded in truth, and capable of furnishing much 
valuable guidance in the investigation and treat- 
ment of disease. In such copious extracts we 
may appear to have made too free with the pages 
of an author whose works are so generally known, 
but we could not resist the temptation of fortify- 
ing, by the authority of so distinguished a patho- 
logist, principles which we have long maintained, 
and which we have endeavoured already to illus- 
trate in the articles Gout and Plethora. They 
will suffice, we trust, to justify the assertion lately 
made, that whatever importance may attach to 
the exciting cause of acute rheumatism, the pre- 
disposition induced by a plethoric state of consti- 
tution is far more entitled to the practitioner's 
attention. 

[As stated, however, in the article Plethoha, 
M. Andral has pointed out the marked dilference 
between the condition of the blood in it and in in- 
flammation, and has shown that the increase of 
fibrin in it obeys the same laws as in the ordinary 
phlegmasia!. He analyzed the blood of forty-three 
bleedings : in one of which the fibrin marked four, 
— the healthy proportion being three in 1000 ; in 
six. it marked five ; in fifteen, six ; in thirteen, 
.seven ; in three, eight ; in three, nine ; and in 
two, ten. When, however, the rheumatism was 
sub-acute, it oscillated between four and five ; and 
when decidedly chronic, it did not exceed the 
healthy proportion. A recent writer, Dr. R. B. 
Todd, (op. cit.) regards both acute rheumatism 
and gout to be diseases of the blood, the pheno- 
mena of which are due to the presence of a mor- 



bid element in it, generated under the influence 
of particular causes, " bv an abnormal chemical 
action of the blood itself." 

It does not often happen that opportunities oc- 
cur for examining the textures around the joints, 
whilst the rheumatic affection is active in them. 
As the disease rarely proves fatal, except by the 
supervention of inflammation in some of the 
fibrous or muscular tissues, seated internally, the 
mischief there is generally so predominant, that, 
for some time before death, the joints cease to be 
the source of suffering. Under these circum- 
stances, it is not surprising that pathologists 
should differ as to the precise seat of acute rheu- 
matism of the joints. It has been already re- 
marked, that it invades every muscular and fibrous 
tissue, and that alternately the serous membranes 
may be implicated. Such may be the case in the 
articulations, — the synovial, which is a serous mem- 
brane, becoming affected last. On dissection, no 
decisive appearances may be met with. At times, 
the veins around the joints have been found gorged 
with blood ; the ligaments, periosteum, and syno- 
vial membrane being injected, and thickened, with 
small collections of matter in the surrounding cel- 
lular tissue, and accumulations of pus or serum 
in the cavity of the synovial membrane. (Ferrus, 
art. Rhumatisme, in Diet- dc Med. 2de. edit, xxvii. 
567, Paris, 1843.) 

It is clear, that the hyperemia of acute rheuma- 
tism — active as it is — can scarcely occasion any 
great organic changes, inasmuch as, in the course 
of a few hours, it shifts its seat, and leaves behind no 
evidences of its previous existence. This mobility 
has, indeed, given rise to the opinion, amongst 
many, that the disease is essentially seated in the 
nervous system ; that the sanguiferous system is 
affected secondarily, and that it is very probable 
the nervous filaments of the diseased parts are 
more considerably involved than any other tissue. 
Dr. Mackintosh, (Principles of Pathology, (fee. 
2d Amer. edit. ii. 461, Philad. 1837,) who sup- 
ports this view, remarks, however, that he has 
seen cases, which presented symptoms similar to 
those of rheumatism, in which, after death, the 
lymphatics of the limb were found inflamed, and 
filled with a puriform fluid. Some, again, have 
considered acute rheumatism to be nothing more 
than acute inflammation of the lining membrane 
of the arteries. The whole disease is certainly 
peculiar, and appears to be more neuropathic than 
ordinary inflammation. Its extremely changeable 
character sanctions this idea, and the remedies are 
not always those which we should think of pre- 
scribing in ordinary active phlegmasia.] 

Diagnosis of acute Rheumatism* — This 
may be briefly disposed of. The only disease 
with which it is liable to be confounded is gout, 
in treating of which the distinctive character of 
each malady has been sufficiently noticed. For- 
merly discrimination in this respect was deemed 
of high importance, the prevailing theories of 
gout demanding a course of treatment very dif- 
ferent from that to which rheumatism was sub- 
jected. In the present day a juster pathology of 
gout assimilates the treatment of both disease;, 
sufficiently to render extreme accuracy of dis 
crimination of very slight moment. 

Prognosis of acute Rheumatism. — Tfcj 



28 



RHEUMATISM. 



prognosis is so dependent on the promptitude 
with which suitable treatment is resorted to, that 
any remarks on the natural course or duration of 
the disease are of little worth. Generally speak- 
ing, there is little immediate dancer to life, there 
being no inflammatory disease of equal intensity 
which so little deranges the vital functions. This, 
most probably, is owing to the disease expending 
its violence on the joints and other external parts, 
and being little prone to attack the viscera. The 
peculiar character of the inflammatory action too, 
and the little liability which it has to pass into 
suppuration, or undergo the other changes conse- 
quent to phlegmonous inflammation, may account 
for the safety with which even the metastasis of 
rheumatism to internal parts is borne. It is cer- 
tain that such metastasis is not attended with so 
much danger as the severity of the symptoms 
would seem to denote. In early life we were 
often appalled by the metastasis of rheumatism 
from the joints to the heart, an organ more pecu- 
liarly liable to this transition than any other. 
More extended experience abated such fears, by 
showing that the immediate danger was by no 
means commensurate with the suffering expe- 
rienced 

[Still, the pericarditis and endocarditis of 
acute rheumatism must be regarded as most dan- 
gerous complications — if they may be so termed 
— of the disease ; for even if the patient recovers, 
which is often the case, from the immediate 
attack, cardiac lesions are apt to remain, which 
may lay the foundation for disease afterwards. 
M. Bouillaud (Traite C Unique du Rhumatisme 
articulaire, Paris, 1840,) has affirmed, that about 
one half of those who suffer under acute articu- 
lar rheumatism are affected with pericarditis; and 
we know that endocarditis is a common accom- 
paniment. One of the most important points, 
therefore, in the management of acute rheuma- 
tism is to watch the supervention of the morbid 
action in the fibro-serous tissues of the heart. It 
is not necessary to repeat here the symptoms of 
pericarditis and endocarditis (See Pericardi- 
tis) ; but the occurrence of dyspnoea, wivh more 
or less anxiety, jerking, or feeble and rapid pulse, 
and tumuhuous action of the heart, ought to 
lirect the attention of the practitioner to that 
viscus, and if he discover, by the physical signs 
and functional phenomena, the existence of in- 
flammatory action there, it must be treated as if 
die disease were unconnected with rheumatism ; 
for nothing is better established, according to M. 
Andral, (Cours de Pathologie Interne,) than 
mat, although primary rheumatism, seated in the 
Sbrous and muscular tissues around the joints, is 
remarkable for its great and rapid change of seat; 
secondary rheumatism — if it may be so termed — 
loses this mobility when it fixes upon a serous 
membrane. 

Dr. Graves (Clinical Lectures, Amer. edit. 
Philad. 1842,) states, that rheumatic fever may 
exist without the affection of the joints; and that 
pericarditis may occur as a primary symptom 
before the appearance of the articular swelling. 
This is probable. The writer has certainly seen 
many cases in which the signs of pericarditis 
were amongst the earliest phenomena.] 

If an attack of rheumatism be treated at the 



onset with due activity and discrimina tion, « 7 
be relieved in a very few days w.thou th aflecjj 
joints sustaining any injury. But both wrth 
respect to time and local ravages, much jM 
depend on suitable discipline being resorted ^to 
and adequately pursued, ere the specific inflam- 
mation of the joints becomes complicated with 
that which we have termed secondary I he 
specific inflammation we have repeatedly seen 
subside in twenty-four hours, leaving behind but 
little trace of its accession. When secondary 
inflammation, however, has been suffered to su- 
pervene, the case is materially altered, and greatei 
obstinacy of local affection may be expected. It 
might be laid down almost as an axiom, that the 
severity and duration of the disease are propor- 
tionate to the degree of plethora present, the ac- 
tivity of inflammation, and the length of time 
during which the morbid actions are suffered to 
prevail unrestrained. If the plethora be great, 
inflammation high, and much delay take place in 
resorting to efficient means for correcting the con- 
stitutional derangements, then would it be diffi- 
cult to assign limits either to the constitutional 
disturbance or local ravages, both of which may 
continue, though with abated force, for months 
or years, to undermine health and cripple the 
limbs ; in other words, acute rheumatism may 
then pass into chronic of the most inveterate and 
intractable kind. Thus, though acute rheuma- 
tism rarely destroys life by its immediate seizure, 
however violent, this furnishes no excuse for su- 
pineness or inactivity in the treatment ; for if not 
radically relieved in its early stage, the disease, 
even when of no extraordinary violence, may be- 
come so confirmed as to yield afterwards with 
difficulty to the most active and judicious use of 
remedies, while progressive disorganization oi 
joints may entail protracted suffering ami I 
decrepitude. 

It is true that a slight rheumatic seizure may, 
like a gouty paroxysm, pass away without medical 
interference, the efforts of the constitution sufficing 
for relief. But this is not its general character; 
and to rely on such a contingency would be in 
the highest degree rash and inexcusable. When- 
ever an attack of acute rhematism occurs, the 
constitution must need some relief, which enlight- 
ened practice will never withhold. To neglect of 
this principle may be ascribed a very large pro- 
portion of the decrepitude which the victims of 
rheumatism so continually present. There is no 
truth of which we are more thoroughly persuaded, 
than that if rheumatism were at its onset treated 
as its real nature demands, and if due care were 
afterwards taken to guard against its recurrence 
by prophylactic measures judiciously directed and 
adequately pursued, there need not from this 
malady be one case of disorganized and crippled 
joints for every hundred that are so afflicted. The 
effects of the earlier treatment will, therefore, in 
general, decide the prognosis. There is inflamma- 
tory fever to subdue, local inflammation to remove. 
If early bloodletting in subduing the lever make 
prompt ,mpress,on on the local affection, so that 
both pain and swelling quickly subside thus 
marking the local inflammation as still retaining 
>ts specfic character unmixed with second^ 
effects, speedy and effectual relief may be cS 



RHEUMATISM. 



29 



fidc.-..,y pedicted, medical treatment judiciously 
conducted being fully capable of ensuring it. 
When febrile action is inveterate, and it is often- 
times very obstinate, though chiefly so when the 
earlier periods of disease have been neglected or 
inadequately treated, a tedious progress may be 
expected, for so long as fever remains unsubdued 
are the local inflammations incapable of removal, 
cither keeping their ground unmitigated, or if 
abated by topical remedies, continually recurring. 
Again, when abatement of fever is not followed 
by quick subsidence of local swellings, in conse- 
quence of the latter having passed into the secon- 
dary stage, and especially when effusion and 
organic changes have already taken place in the 
affected joints, then is the restoration of the joints 
much more tedious, though great local derange- 
ments will admit both of speedy and decisive 
relief, provided the local mischief be not rendered 
inveterate, or continually renewed by unsubdued 
fever. 

Much, too, depends on the state of constitution 
in which acute rheumatism occurs. In a healthy 
subject, capable of bearing the depletory and other 
treatment required for relief, great reliance may be 
placed on the efficacy and certainty of the curative 
process. When the constitution is depraved by 
long-continued relative plethora, with its attendant 
febrile excitement, and especially if the feebleness, 
natural or acquired, be such as to render caution 
necessary in carrying bloodletting and other reme- 
dial processes to the requisite extent, more pro- 
tracted disease and more tedious recovery must be 
he natural and inevitable consequence. 

It is said that rheumatic inflammation does not 
tend to suppuration or gangrene, and the remark 
is generally true. Yet we have seen abscess of 
the cellular membrane supervene on rheumatic 
inflammation, and we have also witnessed slough- 
ing ensue when leeches have been applied to a 
highly inflamed joint without adequate constitu- 
tional treatment being conjoined. The most 
frequent consequences are, gelatinous effusion 
nto the bursse, thickening and rigidity of the liga- 
ments and other membranes surrounding the joints, 
contractions of the limbs, and wasting of the 
muscles, all of which will come under considera- 
tion in the latter part of this essay, where it treats 
of chronic rheumatism. 

Treatment of acute Rheumatism* — The 
indications are here to subdue fever and remove 
inflammation. It has been already shown that 
the former claims the first consideration. The 
promptitude with which the local inflammation in 
its earliest stage yields to the treatment by which 
a plethoric state of constitution is corrected, and 
febrile action allayed, — and the obstinacy of the 
local ailments, whenever the constitutional state is 
overlooked or inadequately treated, furnish the 
best proofs of the correctness of this pathology. 
In its simplest form and early stage, acute rheuma- 
tism is speedily and effectually relieved by anti- 
phlogistic treatment, properly directed and ade- 
quately pursued. Bleeding, purging, salines 
with antimony, diluents, and abstinence, suffice 
both for subduing the general fever and removing 
the local inflammation. It continually happens, 
however, that these means, however actively or 
perseveringly employed, will not succeed in re- 



establishing health ; a lurking fever remaining 
unsubdued, the blood retaining its huffy crust 
even when the crassamentum is reduced far below 
its natural and healthful proportions, and the 
local inflammation maintaining its hold of the 
affected joints. Further means are then required, 
which will be noticed in their proper place. The 
treatment of the simple and more manageable 
form must be first discussed. 

One of the earliest practical writers on this 
complaint was Sydenham ; and so direct and ju- 
dicious was his practice, that we cannot do better 
than fo make it the text on which to comment in 
treating this part of the subject. Sydenham's 
theories of disease often involved the pathological 
fantasies prevalent in his day ; but it is his signal 
merit that he never suffered them to mislead him 
from the path which his clear discernment and 
practical experience enjoined him to follow. He 
attributed the local affection to "the derivation 
of the febrile matter to the limbs," which, as he 
observes, " the frequent return of the fever from 
the repulsion of the morbific matter by external 
remedies sufficiently shows." But we cannot 
perceive that he was influenced by this hypotheti- 
cal principle, further than to adduce it in explana- 
tion of facts which his experience had taught him. 
He had witnessed the inefficacy of local treat- 
ment, and also the increase of constitutional dis- 
turbance which resulted when this alone was 
trusted to, and he wisely abstained from repellent 
applications. Having described the disease with 
some of its modifications, he gives the following 
concise instructions for its cure. " Since both 
kinds of this disease seem to arise from inflamma- 
tion, as appears from the concomitants just men- 
tioned, and especially by the colour of the blood 
taken away, which exactly resembles that of per- 
sons in pleurisy, which is universally allowed to 
be an inflammatory disease, so I judge that the 
cure ought to be attempted only by bleeding, the 
heat of the blood being in the mean time abated 
by cooling and thickening remedies along with a 
proper regimen. Accordingly, as soon as I am 
called I order ten ounces of blood to be immedi- 
ately taken away from the arm of the side affected, 
and prescribe a cooling and incrassating julep. 
To ease the pain I order a cataplasm prepared of 
the crumb of white bread and milk tinged with 
saffron, or a cabbage-leaf to be applied to the part 
affected, and frequently renewed. With respect 
to diet I enjoin a total abstinence from flesh, and 
even from the thinnest flesh broths, substituting 
in the [dace barley-broth, water-gruel, panada, and 
the like. I allow only small-beer for drink, or, 
what is more proper, a ptisan prepared of pearl- 
barley, liquorice, sorrel-roots, &c. boiled in a suf- 
ficient quantity of water, and I allow the patient 
to sit up some hours every day, because the heat 
which arises from lying always in bed promotes 
and increases the disease. The next day I repeat 
the bleeding to the same quantity, and in a day 
or two after, as the strength will allow, I bleed 
again. Then interposing three or four days, as 
the strength, age, constitution of the patient, and 
other circumstances indicate, I bleed a fourth 
lime, which is generally the last, unless too hot a 
regimen has preceded, or heating remedies have 
been exhibited without necessitv. But the as* 



30 



of opiates requires more copious bleeding ; and, 
therefore, though the pain be ever so violent 
during the whole course of the disease, yet when 
I intend to effect the cure solely by bleeding, I 
judge it highly necessary to refrain from opiates, 
because the disease is fixed thereby, and does not 
yield so readily to bleeding; so when such medi- 
cines are given too frequently, bleeding must in 
consequence he oftener repeated than is otherwise 
necessary. Besides, in the height of the disease, 
they do not answer the expectations we have con- 
ceived of them. Whilst the above-mentioned 
remedies and regimen are carefully continued, I 
inject glysters made of milk and sugar, between 
times on the intermediate days of bleeding, 
earnestly recommending the exact observance of 
these directions for at least eight days after the 
last bleeding ; and then I prescribe a gentle 
purging potion to be taken in the morning, and 
in the evening a large dose of the syrup of white 
poppies in cowslip flower-water, whereby a check 
is put to the tumultuary motion of the blood 
which might otherwise occasion a relapse. This 
being done, I allow the patient to return by de- 
grees to his customary way of living in relation 
to diet, exercise, and air ; but, at the same time, 
caution him to refrain for a considerable time 
from wine and all spirituous liquors, salt or high- 
seasoned flesh, and, in general, from all food of 
difficult digestion. After having repeated bleed- 
ing as above specified, the pain greatly abates, 
though it does not go quite off; but as soon as 
the strength returns, which bleeding had greatly 
impaired, the symptoms will vanish, and the 
patient perfectly recover." 

In the simplicity, fitness, and activity of the 
foregoing course of treatment, there is much to 
admire. It comprises the more essential articles 
of antiphlogistic discipline, bleeding and absti- 
nence; it discourages the premature use of nar- 
cotics, which, when employed too early, or in 
substitution of depletory measures, only mask the 
symptoms even when they allay pain, while they 
too often exasperate the disease, rendering it both 
more violent and more obstinate. It also incul- 
cates a salutary reserve in the return to animal 
food and fermented liquors. That under this 
simple treatment many would pass safely through 
the disease, there can be no doubt, although re- 
covery would certainly he slower than it might be 
rendered. But cases continually occur in which 
this treatment would he utterly inadequate, the 
febrile action maintaining its ground, and the 
local inflammation migrating from joint to joint, 
notwithstanding the diligent employment of all 
the means which Sydenham's practice in the dis- 
ease comprises. In this practice one great defi- 
lency is observable, the use of purgatives in aid 
oi bloodletting not being at all enjoined. For 
regulation of the bowels, clysters of milk and 
sugar are trusted to, and not until eight days after 
the last bleeding is a gentle purging potion pre- 
scribed. In this and other respects, later expe- 
rience has added much to our means of combating 
acute rheumatism. 

When this disease occurs in its most active 
state, the means suited for reducing plethora, 
abating fever, and checking the progress of in- 
(limmation, must be promptly and adequately 



RHEUMATISM. 

' employed; full bloodletting and active PWgJJ 
...:... /» ;t«1 powers of colchicum and antimo 



with the united powers 

nv being required to lower the circulation and 
Seat th S e evils which ^■"*%^ W £ 
unrestrained is sure to occasion. The 6rst pro- 
cedure in respect both of time and importance ,s 
bloodletting. In many instances the use of tins 
directed by Sydenham would suffice, but in man, 
it would fail. As a rule of pract.ee, therefore, 
Sydenham's directions in this respect are defective, 
j„ nt embracimr conditions of disease which are 



as not embracing con 
of frequent occurrence, a 



nd for which the deple- 
Uonffirected'hy him .would prove utterly inade- 
quate. Indeed, no express rule in this respect 
could be laid down, bolh the amount and fre- 
quency of venesection being in every instance 
dependent on the degree of plethora existing, the 
activity of fever and inflammation present, and 
the natural powers of the constitution to be acted 
on. The pathology of inflammation, and the use 
of bloodletting most effectual for subduing it, 
have been so amply discussed in the articles Gout 
and Plethora, that to recapitulate what has been 
already advanced on these points must he need- 
less. We shall proceed, therefore, on the pre- 
sumption of the principles inculcated in those 
articles being clearly comprehended, and in con- 
formity with these principles state practically how 
the lancet can be most successfully used. In or- 
dinary cases the loss of twelve, sixteen, or twenty 
ounces of blood may suffice to check disease and 
prepare the way for the subsidiary treatment. 
But if absolute plethora be considerable, inflam- 
matory action high, and the constitution robust, 
blood must be drawn to much greater extent if 
adequate impression is to be made on disease. In 
such case the rule should be not to abstract any 
assigned quantity, but to carry the bloodletting to 
the extent of making a sensible impression on the 
force of circulation. Thirty or forty ounces of 
blood may require to flow ere this is effected, and 
so essential is the impression alluded to, that even 
large bleedings, if not carried to this extent, will 
fail to produce their full effect in restraining in- 
flammatory action. It continually happens in 
cases of active inflammation, that notwithstanding 
the loss of thirty or forty ounces of blood, the 
pulse does not yield, but maintains its hardness, 
while the abstraction of a few ounces more, by 
inducing a disposition to syncope, completely 
checks the inflammatory action and abates the 
violence of the disease. By making the consti- 
tutional powers the measure of the depletion, less 
bleeding on the whole is needed; thus by this 
mode blood is virtually saved and unnecessary 
exhaustion prevented, a single venesection carried 
to the necessary extent being far more effectual 
than reiterated bleedings to a far greater aggregate 
amount, if these be respectively of insufficient 
extent. Bleeding to actual syncope is not desira- 
ble, but if inflammation be high, some impression 
on the pulse should be manifested. If this begin 
to falter, while nausea is felt, the lips grow pale, 
and perspiration begin to bedew the forehead such 
bloodletting may be relied on for accomplishing 
all that this remedy is capable of effecting. This 
use of the lancet, however, can onl v be required 
where severity of symptoms with vigorous habit 
demands such active treatment. In a 1 ir <r r,™ 



RHEUMATISM, 



31 



portion of cases much more moderate depletion 
will suffice. From twelve to twenty-four ounces 
of blood may be regarded as the ordinary limits, 
and many repetitions are never advisable ; for 
when bloodletting to such extent, assisted by 
purging and other febrifuge treatment, does not 
make sensible impression on disease, other more 
adequate means of arresting its progress must be 
resorted to. Blood may be drained away until the 
body is blanched and the crassainentum reduced 
to a tithe of its just proportions, yet febrile action 
will continue, inflammation be unsubdued, and 
the blood drawn be still buffed and cupped. 

It is right to mention here, that although a full 
and hard pulse is generally attendant on acute 
rheumatism, yet the absence of hardness is no 
evidence of active inflammation not being present, 
or of bloodletting not being needed. If the gene- 
ral symptoms concur to indicate inflammatory 
action, then, though the pulse be soft and com- 
pressible, bloodletting is nevertheless essential, the 
blood drawn in such case being almost uniformly 
buffed and cupped, the pulse rising after venesec- 
tions, and disease more rapidly subsiding. 

[Of late years, the profession have been startled 
by the extent to which bloodletting has been re- 
commended by M. Bouillaud {Op. cit.) ; bleeding 
coup sur coup, with the view of " strangling" the 
disease, to use his own expression. The writer 
has had recourse to it in what appeared favourable 
cases ; but the results have not been equally 
happy ; and it has seemed to him, that the too 
vigorous use of the lancet has occasionally rather 
favoured the shifting of seat, which has been so 
much dreaded. It can, of course, only be admis- 
sible in vigorous individuals, and even in them, 
a more sparing use of the lancet, with the agents 
to be mentioned presently, appears to he less liable 
to objection. There are cases in private practice, 
and most of those that are seen in our eleemosy- 
nary institutions, in which any abstraction of 
blood from the general system could not fail to 
prove injurious. 

As an adjunct to general bloodletting, the tar- 
trate of antimony and potassa has been highly 
extolled of late years, and there are cases in which 
its sedative influence has been highly advantageous. 
The writer has frequently prescribed it under the 
restrictions and inculcations mentioned under 
another head (See Pjjecmoxia), and occasion- 
ally with the best effects. It has seemed to him, 
however, that the antimony has acted most bene- 
ficially when it produced nausea, and the nausea 
was kept up two or three days in succession.] 

The next measure is to purge freely the stomach 
and bowels ; and here again we must refer to 
what was formerly advanced on this subject in 
illustration of the necessity of suitable and ade- 
quate purging being employed in aid of blood- 
letting. As soon as may be after bloodletting, a 
full do^e of calomel combined with antimony 
(either James's powder or tartarized antimony) 
•should be given, and in a few hours after a 
cathartic draught. The bowels being well evacu- 
ated, diaphoretic salines with antimony and col- 
chicum contribute much to allay fever, quieting 
the pulse, and promoting the several excretions. 

One of the best forms of saline for this purpose 
is a combination of acetate of ammonia, camphor 



mixture, antimonial wine, and wine of the eol- 
chicum seeds, as in the following formula : 
R. Liquor, amnion, acet. 

Mist, camphorae, ia. f.jss. 

Vin. sem. colch. 

Vin. ant. tart, aa m. xx. 

Syrup, aurant. f.gi. m. fiat haustus quartis 
vel sextis horis sumendus. 

The properties of colchicum and the best modes 
of administering it have already been so fully dis- 
cussed in the article Gout, that to avoid needless 
repetition, we shall refer to what is there stated. 
It is only necessary to remark that the effect of 
colchicum on the bowels requires to be watched, 
for when it irritates them so as to excite active 
purging, its use must be discontinued. In our 
early trials of colchicum in gout and rheumatism, 
we were accustomed to give it in full doses, but, 
for reasons already explained, we have for many 
years discontinued them, the salutary effect of the 
remedy being fully attainable from the more 
moderate exhibition of it which has just been 
prescribed. When the use of it irritates the 
bowels, producing frequent watery stools, discon- 
tinuing the colchicum suffices in general for the 
relief of this disturbance ; but should it continue 
troublesome, moderate doses of Dover's powder are 
sure to allay it. It has been surmised that the 
use of colchicum has through irritation of bowels 
led to ulceration of their mucous membrane, but 
this effect we altogether distrust. It must be a 
very rash use of the remedy which could produce 
any such effect, and where it has appeared to re- 
sult, our persuasion is, that the membrane was in 
an advanced stage of subacute inflammation ere 
the colchicum was exhibited. We have given 
colchicum freely and extensively for many years, 
with caution certainly, though not greater than is 
required in the administration of every active 
drug, yet a single instance has never occurred to 
us in which we could trace any injury to its use, 
while its medicinal properties have rendered val- 
uable aid, not only in gout and rheumatism, but 
in many other inflammatory diseases. 

[Aconitia, delphinia, and veratria, have been 
used both internally and externally ; and cimici- 
fuga carried to the extent of producing catharsis, 
and even slight narcosis, has likewise been of 
service. Of the different revellents, cupping on the 
back, strongly recommended by Dr. J. K. Mitchell, 
has appeared to be most frequently attended with 
happy results. An idea has been entertained that 
this has been owing to the depletion and revulsion 
effected near the origin of the nerves that are con- 
cerned in the articular inflammation. Whatsoever 
view may be entertained as to this matter, it is 
unquestionable that the highly sensitive integu- 
merit of the back is an excellent locality for revul- 
sion in many diseases ; and it is not necessary 
that the mischief should be directly or indirectly 
connected with the spinal marrow, or its sheath, 
to explain this. The writer has seen the intense 
suffering in the joints as effectively relieved by 
cupping over the loins as bv any other agency.] 

As the extent and repetition of bloodletting 
must depend on the activity of disease and vigou' 
of constitution, so must the use of purgatives be 
regulated by the condition of the bowels, and tin 
necessity for purging which the stools may evince 



32 



RHEUMATISM. 



So long as these are dark, slimy, fetid, and other- 
wise unhealthy, must purgatives be used; and the 
most effectual are those by which the morbid se- 
cretions of the alimentary canal are evacuated. 
Pills of colocynth, calomel, and tartarized antimony 
should he given at intervals, and, if necessary, 
lie draughts should be interposed. When 
(lines, and the stools present a more healthy 
appearance, milder aperients will suffice. Under 
such treatment low diet and a cooling r 
are indispensable. Barley-water or toast-water is 
quite sufficient during the inflammatory stage. 
Animal food and fermented liquors of every kind 
are prejudicial, and should be carefully withheld. 

The several means now pointed out will in 
many instances suffice to allay fevers, remove in- 
flammation, and restore health. But cases occur 
in which neither fever nor inflammation can be 
thus subdued. If active treatment be not resorted 
to on the first accession of disease, or if it be not 
urged to tire requisite extent, inflammatory action 
acquires an inveteracy which simple antiphlogistic 
treatment is quite unable to correct. In such cir- 
cumstances bloodletting may be pursued until the 
become nearly exanguious, yet the blood 
will still be bulled and cupped, febrile action will 
remain unsubdued, and local inflammation con- 
tinue to disorganize and cripple the joints. 

Even in milder cases of this kind, although per- 
manent injury may be averted, and perfect reco- 
very ultimately ensue, yet the successive migra- 
tions of local inflammations prove harassing to 
both patient and practitioner. We have seen 
such inflammation traverse almost every joint of 
the body, attacking several a second and a third 
time before the disease yielded. When the pro- 
gress is favourable, each successive inflammation 
becomes slighter, until towards the close a mere 
blush of redness marks the morbid effort. 

But this course of proceeding is at best tedious 
and unsatisfactory, even where an issue so favour- 
able as has just been mentioned is attained. Such 
result, however, is not to be relied on ; for in the 
form of disease now considered, it will more fre- 
quently happen that unsubdued fever will exhaust 
the general powers, and inflammation inflict its 
ravages on the joints, producing effusion, thicken- 
ing of ligaments, with enlargement, rigidity, or 
contraction. When, therefore, one or two full 
bloodlettings, assisted by purging, abstinence, and 
other means, fail to make adequate impression on 
the disease, it becomes necessary to call in other 
aids in order to prevent the exhaustion and other 
ills which repeated bloodletting would occasion. 
And fortunately one exists which is worthy of our 
fullest confidence. This is mercury, which, when 
judiciously administered and made subsidiary to 
bleeding and purging, is capable of subduing 
rheumatic inflammation with as much certainty as 
attaches to the operation of any remedy in any 
disease. The practice of arresting the progress 
of rheumatism by mercury has been before the 
public sufficiently to have made it more generally 
known and more justly appreciated than it appears 
to have been. It originated with Dr. Robert Ha- 
milton of Lynn Regis, who published, in the Me- 
dical Commentaries of the year 17S3, an interest- 
ing account of the success with which be had 
administered calomel and opium in the treatment 



of several inflammatory diseases. So far back as 
the year L764 he bad been induced to employ 
calomel for the cure of hepatitis. Its efficacy in 
the disease and in several other inflammatory a lec- 
tions led bun to extend his views of its applica- 
bility, and to conceive that it was a suitable 
remedy for inflammation in whatever viscus or tis- 
sue this might be situated. He accordingly em- 
ployed its a.d with the best effects in inflamma- 
tions of every part, and particularly in acute rheu- 
matism. His practice in the latter was to take 
blood in proportion to the violence of the inflam- 
matory symptoms and to the age and constitution 
of the patient; after which he exhibited calomel 
and opium at suitable intervals until the disease 
yielded, or until the influence of the remedy on 
the constitution was evinced by increased secre- 
tions from the salivary glands, bowels, or skin. If 
in twenty-four hours after the use of mercury was 
commenced, relief did not ensue, or if inflamma- 
tory symptoms continued unabated, he bled again, 
and gave the calomel more frequently. Salines, 
antimony, camphor, and other auxiliaries were 
combined with bleeding and mercury, and through 
their united agency he found disease subside with 
a promptitude which no other mode of treatment 
could command. When this treatment was em- 
ployed early in the disease, recovery was soon ac- 
complished ; if postponed to a later period, its 
effects were more tedious and uncertain. His ex- 
perience also taught him that the curative process 
was most favourable when the salivary glands be- 
came affected by the medicine. This brief account 
of Dr. Hamilton's rational and effective practice 
in rheumatism embraces so many essential points 
of the treatment of this disease, that we shall have 
little to add save the detailed instructions which 
the young practitioner may need for conducting 
that treatment with discrimination and effect. In 
confirmation of the truth and accuracy of Dr. 
Hamilton's views, we may here remark, that hav- 
ing for hve-and-twenty years pursued the practice 
and applied the principles which he inculcates, 
our faith in them has never wavered, and that 
with ample opportunities for subjecting them to 
the test of experience, we can truly say that we 
know of no fact in medicine better established than 
the power which mercury possesses of subduing 
inflammations, when used as subsidiary to bleeding 
and purging. 

Every case of acute rheumatism does not re- 
quire mercury for its cure. Bleeding, purging, 
abstinence, and salines, with antimony and colchi- 
cum, will frequently suffice. But if, after twenty- 
tour hours, the early discipline has not produced 
sensible effect on the disease ; if after this period 
fever continues unabated, inflammation unallayed, 
and further bloodletting be required ; as obstinacy 
of disease is here sufficiently announced, it is ex 
pedient to lose no more time, but to resort to the 
only means by which an adequate check can be 
given to the malady. 

Profuse use of mercury is not needed ; both the 
amount of dose and frequency of exhibition must 
be determined by the circumstances of the particu- 
lar case. Although it is desirable to obtain evi- 
dence of the constitution being affected by the 
remedy, so far as tenderness of gums indicates it 
is not expedient to produce this effect very speedi'ly 



RHEUMATISM. 



33 



and there are many reasons for enjoining caution 
in (he administration of this medicine. It is not 
necessary to urge on its full operation, for the 
curative effect commences ere the specific action 
on the salivary glands appears. Unless the ple- 
thoric state of constitution, too, be adequately re- 
lieved by depletion, there is considerable risk of 
pressing the use of mercury. On this subject we 
must once more refer to what has been already 
advanced respecting it in the article Plethora. 
The susceptibility of impression from mercury, 
too, varies greatly in different persons, so much 
so, that while some cannot be salivated by any 
quantity, a few grains of calomel will in others 
induce severe ptyalism, with inordinate swelling 
of the jaws and extensive sloughing. On every 
account, then, it is advisable to incline to the mi- 
nimum quantity capable of acting on the disease. 
The expediency of combining opium with calo- 
mel, when exhibited for this purpose, admits not 
of question. When thus conjoined, it allays pain, 
abates irritability, prevents the calomel passing off' 
too quickly by the bowels, and promotes its more 
certain absorption* In general, two grains of calo- 
mel and a quarter of a grain of opium is a suffi- 
cient dose, and the frequency of its exhibition will 
be best guided by the severity and threatened ob- 
stinacy of the attack to be combated. In severe 
cases it is beneficial to commence with five grains 
of calomel, one of opium, and one of tartarised 
antimony at bedtime, and to pursue the course 
the next day with the smaller dose. In mild cases 
it may suffice to give this night and morning; to 
administer it thrice a day is no inactive practice, 
and by this use the gums will in general soon 
become affected. Given every six hours, so that, 
in the four-and-twenty, four doses are taken, is 
perhaps the frequency that will most commonly 
be needed. We have never had occasion to en- 
large die dose, nor to exhibit it oftener than every 
four hours; but to this extent we have been occa- 
sionally compelled to employ it. The cases, how- 
ever, requiring the active use of it are rare. The 
circumstances to guide its use are the curative 
effects on the constitutional and local symptoms, 
and its specific effects on the salivary glands, 
bowels, and skin : if any of these be signally in- 
duced, the use of it should abate, and the intervals 
of its exhibition be lengthened. Unless active 
salivation take place suddenly, and unexpect- 
edly, it is never expedient to withdraw it wholly 
so long as fever lurks or inflammation keeps its 
ground. The best practice is to lengthen the in- 
terval, and to do this progressively by reducing the 
employment from four times a day to three, then 
to twice, and finally to continue a single dose daily 
for a short time. By this cautious proceeding, if 
bloodletting be adequately practised, the bowels 
freely purged, and no error in diet committed, the 
beneficial effects of mercury may be ensured with- 
out any risk of injury and scarcely of inconve- 
nience. Should salivation chance to advance 
beyond what would be wished, the evil is but a 
slight counterbalance to the benefit which mercury 
confers in the case of this most painful and disor- 
ganizing malady. When the mouth becomes pain- 
fully affected, we may here remark that saline 
purges abate the distress, and that gargles of chlo- 
ride of soda or of nitrate of silver have considera- 
Vol. IV. — 5 



ble power in allaying the morbid sensibility of the 
gums and tongue which is sometimes experienced 
There are constitutions on which mercury acts so 
unfavourably, producing great derangement of the 
nervous system, that its use cannot be borne. 
When such sinister effects occur, its use must of 
course be abandoned ; but such instances are not 
common, and when they do occur, we strongly 
suspect that neglect of early depletion is more ii? 
fault than any idiosyncrasy inimical to the remedy. 

While mercury is exhibited in the way directed, 
the salines formerly prescribed should be continued, 
and occasional purges should be interposed. The 
use of the latter should be regulated by the degree 
of fever and the state of the stools. If fever con- 
tinues high, with a dry tongue and costive bowels, 
or if the stools be very dark and slimy, purgatives 
must be the more freely used. When the bowels 
are unusually torpid, it is often expedient to sub- 
stitute for the diaphoretic saline a solution of sul- 
phate of magnesia in rose infusion, giving this at 
such intervals as shall keep the bowels free. It is 
generally conceived that purgatives impede the 
constitutional operation of mercury, and in conse- 
quence, when this operation is the object in view, 
purgatives are usually withheld. Without dis- 
cussing this point, we shall merely observe that if 
the degree of fever or the foulness of bowels de- 
mands purging, it should be carried to the full ex- 
tent required, without regard to its supposed inter- 
ference with the effects of mercury. Under such 
circumstances greater injury would result from the 
neglect of purging, than even the unimpeded action 
of mercury would compensate. 

There are cases in which it is not expedient to 
combine opium with the calomel, but they are 
rare. If headach prevail, — if the tongue, instead 
of becoming moist and clean, grow parched and 
dark, and the skin be hot and dry, — opium should 
be withheld, and the calomel given either alone or 
conjoined with James's powder. 

[Opium has not unfrequently been given in 
acute rheumatism, with the view of inducing nar- 
cosis, and of establishing a new impression and 
action on the nervous system. Care must, of 
course, be taken not to push the remedy too far, 
and yet to keep the patient clearly under its influ- 
ence. With this view, any of the preparations of 
opium may be prescribed ; but the soft pill is as 
efficacious as any other ; or the acetate or the sul- 
phate of morphia or the pulvis ipecacuanhas com- 
positus; hut the last can be seldom given in quan- 
tity sufficient for tbe opium to produce its narco- 
tic action, without the ipecacuanha disordering the 
stomach.] 

The progress of recovery and the experience of 
a few cases thus treated will readily guide the 
practitioner in that adaptation of remedies to the 
exigencies of each case which no specific rules 
could prescribe. He who possesses himself of the 
principles on which the treatment here directed is 
founded, will commit no error in the extent or 
duration to which he may carry it. 

There is a period, however, in the progress of 
rheumatism, even when actively and judiciously 
treated, which calls for something more than ha* 
yet been enjoined. In a large proportion of cases. 
the treatment now prescribed will fully suffice. Ii 
will subdue fever, remove local inflammation, pr*< 



34 



RHEUMATISM. 



vent disorganization of joints, and restore the pa- 
tient in moderate time to health and the Tree ex- 
ercise of limbs. But it occasionally happens that 
notwithstanding the full employment of all the 
moans directed, a certain degree of fever lingers, 
the skin continues dry with some morhid heat, the 
tongue too white, and pains of acute character are 
still felt in the joints. When this state first met our 
view, so completely did the assemblage of symp- 
toms simulate active inflammation, that we hesi- 
tated whether there was not an actual relapse of 
disease, and a necessity for reverting to active re- 
medies. But the indecision was of short duration ; 
for assured by the treatment already pursued, and 
the eil'ecls produced by it, that inflammation had 
been successfully combated, we could not regard 
the supervening state as corresponding in its na- 
ture to that which we had already corrected, and 
instead of recurring to bleeding and mercury, we 
made trial of bark as a preferable agent, and with 
such benefit, that we have seen it remove, in 
twenty-four hours, the whole train of symptoms 
which we have just mentioned. Half a drachm 
of bark with ten grains of nitre is the combination 
on which we most rely, giving this twice or thrice 
a day ; and so effectually does it answer the pur- 
pose that we are slow to change it. What we 
have now stated may serve to explain the confi- 
dence with which some writers have advocated the 
use of bark as almost a specific in rheumatism. 
There is undoubtedly a stage of the disease in 
which it may be beneficially given, but in the 
acute stage, to which we have hitherto chiefly re- 
ferred, we at least would not compromise the 
patient's safety by trusting to bark, while bleed- 
ing, purging, and mercury were applicable ; and 
even in what is called chronic rheumatism we 
would as little rely on it so long as plethora was 
unrelieved, the pulse high, the bowels loaded, and 
active fever predominant. When the general 
state of constitution is restored to the proper ba- 
lance of its several functions, should some febrile 
indications linger, and pains continue to infest the 
joints or muscles, bark furnishes then a valuable 
and unexceptionable means of correcting the slight 
remnant of disease, but not before. 

[The writer has had frequent opportunities for 
witnessing the exclusive use of both modes of 
treatment, antiphlogistic and tonic, and it is but 
proper to say, that he does not recollect to have 
seen the symptoms in any case aggravated, under 
the prudent employment of either. In the mass 
of cases that oc-ur, except in very active, vigor- 
ous habits, — and it is generally applicable even to 
them. — a combination of the two modes of treat- 
ment has appeared as advantageous as any other, 
— treating the disease during the early period, by 
the ordinary antiphlogistics, and afterwards en- 
deavouring to remedy the neuropathic condition 
by the cautious employment of tonics, as the sul- 
phate of quit) ia- Dr. D. Davis, late Profes- 
sor in the London University, has expressed a 
confident belief, that cinchona "is the most pow- 
erful remedy that can be employed even in an in- 
cipient case of acute rheumatism, and affirms, that 
he does not remember a case in which the disease 
was not happily subdued. " I have often recom- 
mended it, - ' he adds, " in cases of pure arthritic 
theuinatism during its acutest stage, and the dis- 



ease has 



always yielded to the remedy ; and I have 



of the 



mpanied by alarming complications; 
but never in any one case injuriously to the merest 
of my patient. I have, therefore, no difficulty in 
recommending its adoption to my medical brethren, 
and especially to those who are most frequently 
favoured with opportunities of seeing acute rheu- 
matism in its earlier stages." Dr. Davis prescribes 
the cinchona in the dose of from a scruple to half 
a drachm, repeated three or four times daily. He 
always, however, premises the free abstracuon of 
blood. (See, also, Popham, Dublin Journal of 
Medical Science, Sept. 1844, p. 50.) M. Briquet, 
and others, have advised large doses of the sul- 
phate of quinia — from gi to giss in the course 
of the 24 hours; and, they affirm, with unusua' 
success. M. Briquet considers, from his ohserva 
tion, that the sulphate is a' powerful sedative, 
diminishing nervous excitability, retarding the 
pulse, and lowering the temperature. It has been 
objected by M. Devergie to this plan, that it is apt 
to cause serious disturbance in the functions of 
the brain and organs of sense ; but care in regu- 
lating the dose may prevent this.] 

The cure of rheumatism by profuse perspira- 
tion has fallen so much into disuse that it can 
hardly be necessary to notice it. Yet it was held 
in high estimation not many years back, and very 
generally deemed the most effectual mode of treat- 
ment. The late Dr. Gregory, in his lectures, used 
to represent sweating as the evacuation most to 
be relied on for the cure of rheumatism, and to 
bear his testimony to its efficacy. He gave a 
caution, however, against resorting to it until the 
pyrexia had been abated by bloodletting, and 
stated that his test was, never to employ it until 
the pulse was reduced to 100. The chief agent 
was Dover's powder, given in doses of ten grains 
every two or three hours, assisted by warm cover- 
ing and copious diluents, the latter to be used 
only when the perspiration commenced. To be 
effectual, this required to be kept up for forty-eight 
hours. This practice has, we believe, been very 
generally, and, as we think, judiciously, laid aside, 
the treatment recommended in the foregoing pages 
being far more certain and effectual, producing 
less exhaustion, and leaving less susceptibility to 
recurrence of disease. 

[Recently, iodide of potassium has been recom- 
mended both internally and externally, and the 
treatment by large doses of nitrate of potassa, so 
highly advised in the last century by Dr. Brockles- 
by, has been revived, and, it is said, with much 
success, — from a quarter of an ounce to an ounce 
being given dissolved in a large quantity of gruel 
in the twenty-four hours.] 

We have hitherto treated chiefly of constitu- 
tional disorder, and have considered the local in- 
flammation only so far as it was connected with 
or dependent on the constitutional state. It is 
necessary however, to scrutinize the local affec- 
tions still further. So directly is the local dis- 
turbance dependent on the constitutional in the 
incipient stage, that if the latter be p„,mp,ly and 
vigorously treated, the former will very speedily 



subside without any local treatment l" ' 



»eing needed. 



_ J .v trying I] 

We have seer, the local inflammation thus , 
l s 1 de in rheumatism equally as in a fi rst attack „ f 



RHEUMATISM. 



35 



mild gout, leaving as litth trace of its visitation. 
It must be admitted, how;ver, that such speedy 
decline is not the general character of this local 
affection. Notwithstanding the abatement of fever, 
some pain, heat, and swelling will continue to 
affect the joint for a longer or shorter time ; and in 
order to understand the treatment which this 
requires, it is necessary to bear in mind what was 
formerly stated respecting the change of character 
in the local inflammation. If on fever becoming 
subdued by the means directed, the local inflam- 
mation declines, no topical treatment whatever is 
needed, nor is it expedient that any should be 
resorted to. Decline of inflammation thus ob- 
tained affords conclusive evidence of disease being 
arrested at its source, and relapse need not here 
be apprehended; while, if the local inflammation 
be checked by topical remedies, its abatement af- 
fords no such assurance, and if the constitutional 
derangement be not thoroughly rectified, repeated 
renewal of the local inflammation with successive 
migrations from joint to joint will most probably 
ensue. But independently of this consideration 
there are other objections to the early use of topi- 
cal remedies which ought not to be overlooked. 
Repellent applications may remove inflammation 
from any particular part ; but only to transfer it 
to some other, if not to the heart, stomach, or 
other internal organ. Local bloodletting would 
beget less danger of this kind, but neither is it 
free from objection. The inflamed part is ill 
suited to sustain the operations by which blood 
can be abstracted. We have seen leeches when 
applied to a rheumatic joint prematurely and 
without sufficient regard to the constitutional 
state, exasperate every symptom, and cause in- 
crease of inflammation both in the skin and cellu- 
lar membrane, ending in extensive sloughing, 
with troublesome ulceration, and followed by 
thickening of the ligaments with rigidity and con- 
tractions of unusually obstinate kind. So long as 
it is possible, therefore, to procure decline of local 
inflammation by the constitutional treatment, we 
consider it the belter practice to abstain from to- 
pical remedies. 

When inflammation continues in the joint, 
however, after fever has been sufficiently subdued, 
thus manifesting its having passed into what we 
have distinguished as the secondary state, it then 
becomes necessary to regard it as a local disease, 
and by appropriate topical treatment to avert those 
ravages which its continuance would occasion. 
The means are cupping, leeches, warm fomenta- 
tions, poultices, cold lotions, modified according 
to the degree of inflammation, the sensations of 
the patient, and the effects produced. By such 
means, the local inflammation in this its secondary 
state may be so corrected as to prevent organic 
lesion, and preserve unimpaired the mobility of 
the joint. 

[The application of methodical compression 
around the affected joints by means of a flannel 
bandage is often productive of great relief. It was 
advised many years ago, and has been revived. 
(See the writer's New Remedies, 4th edit. p. 183, 
Phi lad. 1813.) It is especially serviceable where 
there is great effusion. It has been recommended, 
that the compression should be made by means of 
compresses covered with mercurial cerate ; and that 



a position and attitude should be yiven to the 
limb that would be most favourable to resolution. 
An elevated position would certainly tend to prevent 
the engorgement of the parts. The writer has seen 
good effects from compression where it could be 
borne, and a simple flannel bandage is all-sufficient.] 

We would here impress, as we formeily did 
when treating of gout, the importance of an early 
renewal of motion in the affected joints, as indis- 
pensable for re-establishing their health and pre- 
serving their flexibility and power. From neglect 
of this, much protracted confinement and ultimate 
decrepitude continually result. On the subsidence 
of inflammation, the parts so lately disturbed are 
indisposed to motion, and some pain attends the 
early attempts at its removal. Yet leaving them 
at rest is not the means by which the power of 
motion is best restored. Exercise of the parts is 
necessary not only to restore those which have 
been morbidly affected to their healthy functions, 
but to preserve in due energy and activity the 
muscular apparatus by which they are moved. 
By exercise healthy circulation is maintained, 
effusion prevented, absorption promoted and flexi- 
bility preserved. By it, too, the muscles sub- 
servient to the motions of the joint are kept in a 
healthy and efficient condition. When, from too 
great apprehension of exciting pain or renewing 
inflammation, quiescence is too long continued, 
the ligaments and other parts surrounding the 
joints become rigid ; if these be kept bent, con- 
tractions take place, and the mobility of the part 
becomes permanently impaired; while the several 
muscles, from want of exercise essential to the 
maintenance of their nutritive and healthy actions, 
progressively waste and lose power. This latter 
contingency is, we are persuaded, much more fre- 
quently owing to the continued inactivity to 
which the muscles are consigned than to any 
morbid action induced in them by the disease ; 
and as we before observed, so satisfied are we of 
the mischiefs resulting from long-continued rest 
after rheumatic inflammation, that we would in 
our own person much rather hazard any renewal 
of inflammatory attack, than suffer those derange- 
ments to proceed which spring from a state of 
inaction too long continued. 

[Capsular Rheumatism. — When rheuma- 
tism is seated in the lining membrane of the 
joints, and bursa? of the tendons, it is termed cap- 
sular. The parts most liable to its attacks are 
the feet and hands. It is recognised by the en- 
largement of the joints, which is circumscribed, 
owing to the distension of the synovial capsule 
with fluid ; and is thus distinguishable from the 
smaller and more diffused swelling of ordinary 
rheumatic fever. In its history, too, it dilfers 
generally, as Dr. Macleod ( On Rheumatism, &c, 
London, 1842) has observed — affecting seve- 
ral joints, but commonly becoming more especially 
fixed in a limited number, and ultimately local- 
ized, and, in some cases, inducing permanent 
changes of structure, or disorganization. When 
death occurs in the acute stage, the joints are 
found to contain an increased quantity of syno- 
via : when the disease has been more prolonged, 
distensions and nodosities are seen, similar to 
what occur in gout. Deposits are often formed in 
such cases on the cartilages of the joint, — which 



36 



RHEUMATISM. 



Dr. Macleod found to be of urate of soda, as in 
gout. In cases of old synovial rheumatism, how- 
ever. Dr. Chambers found them to consist of car- 
bonate of lime. At times, suppuration has been 
observed in the joint ; but these cases are rare. 

Partial rheumatism of the joints, when of great 
intensity, is almost always of the capsular kind. 

This form of rheumatism is said to occur gene- 
rally in persons of feeble or debilitated constitution; 
or in the robust, after great and protracted men- 
tal or corporeal exertion. It is said, also, to super- 
vene on gonorrhoea and other venereal affections, 
but in the latter case almost exclusively, accord- 
ing to Dr. Macleod, " where long-continued courses 
of mercury have been adopted." It is very rare 
for metastasis to take place to internal organs, and 
when it does, it usually passes to the pleura or 
membranes of the brain, and proves fatal in a very 
high ratio. Of 81 cases of capsular rheumatism, 
recorded by Dr. Macleod, 47 occurred in men, 
and 34 in women. These were much more 
equally diffused over the different periods of adult 
age than acute rheumatism, and much more prone 
to affect persons under forty than genuine gout; 
at the same time, it appeared to be more the dis- 
ease of middle life than either rheumatic fever or 
muscular rheumatism; — from forty to forty-five 
years of age giving twenty-two out of eighty-one 
cases, or rather more than one-fourth, which is a 
much larger proportion than holds good with re- 
spect to either of the two others." 

The average duration of capsular rheumatism 
was found to be more than twice that of acute 
rheumatism. 

The general treatment, both internal and ex- 
tern;! I. is that recommended under Rheumatism 
and Gout.] 

What remains to be said respecting acute rheu- 
matism, ami the sequelae occasionally left by it, will 
be more properly noticed in the division of the sub- 
ject which treats of the chronic form of the disease, 
to the consideration of which we shall now proceed. 
II. Chronic Rheumatism. 

It would simplify the consideration of this form 
of the disease, if it were limited to that morhid 
condition to which analogy with the acute affec- 
tion discussed in the foregoing pages would jus- 
tify the name of rheumatism being applied. So 
many and various, however, are the derange- 
ments loosely classed under this generic term, that 
to give any history of the disease which should 
comprise the whole, would present a mass of con- 
fusion, if indeed it were not utterly impracticable. 
It has been too much the practice to pronounce as 
rheumatic every chronic pain of which the nature 
is obscure, or to which no other specific character 
is assigned. Practical writers have not overlooked 
this tendency ; it is noticed by Heberden in the 
following very expressive passage : « Multi dolo- 
.es quibus nomina nondum propria imposita sunt, 
quanquam inter se distent, ex causis longe diversis 
orti, tamen ad rheumatismum pariter releruntur." 
In order to ensure as much clearness as possible 
in the following observation, it will he expedient 
to commence with that modification of disease 
which, presenting all the essential characters of 
rheumatism, differs from the acute affection already 
treated of only in being less violent in its symp- 
toms, and of longer duration. 



The distinctive characters of this malady are a 
febrile state of the general system, with more or 
less of pain and swelling in certain tissues and 
joints. And in this, precisely as in acute rheuma- 
tism, the continuance of febrile action undermines 
the general health, while the local inflammation, 
however indolent, disorganizes the joints, occasion- 
ing eventual decrepitude. The pain and swelling 
of joints with progressive thickening ol the liga- 
ments, and effusion in the several bursa?, sufficient- 
ly evince the morbid actions from which such 
effects result. But, coincident with these will 
generally be found in the instances now referred 
to, evidences of constitutional derangement suffi- 
ciently marked to denote that a plethoric and 
febrile state of the circulation is also present A 
quickened pulse, some increased beat of skin, and a 
furred tongue, are in greater or less degree the 
invariable attendants of chronic rheumatism of the 
joints so long as the disease in them continues to 
advance. It, no doubt, occasionally happens that 
in the course of time all febrile symptoms disap- 
pear, and the morbid action in the joints ceases to 
make further ravage. In such cases there is no 
longer rheumatism, but only the disorganization 
produced by it ; and the distinction is important, 
for where such ravages alone remain, so far as 
they are concerned, constitutional remedies can be 
of no avail, and any treatment, to be effectual, 
must have special reference to the local lesions by 
which the free motion of the limbs is impeded. 
In the larger proportion of cases, however, the 
disease is strictly rheumatic, that is, it consists of 
a constitutional derangement having a febrile 
character, and of a local inflammation seated in 
the joints. This condition may be, and frequently 
is, the sequela of acute rheumatism ; but it may 
be fully formed without any particular acute attack 
having preceded. Cullen regarded it in the 
former light, as appears from his definition of 
arthrodynia being introduced as "rheumatismi 
sequela." In the definition itself he somewhat 
incongruously represents this as ensuing to violent 
sprains and luxations, though why the pains re- 
sulting from such accidents should he deemed 
rheumatic it is difficult to imagine. In this defi- 
nition, too, which ought to embrace every form 
in which chronic rheumatism presents itself, he 
states somewhat too positively the absence of 
fever and of swelling, — "pyrexia nulla, tumor 
plerumque nullus;" characters which do not 
apply generally to the disease, and which seem 
to have been introduced as an antithesis to the 
definition of acute rheumatism. This imperfec- 
tion obliged him, when treating of chronic rheu- 
matism, to enter into explanations rather at vari- 
ance with his own definition, and in the follow- 
ing passage he describes more correctly and intelli- 
gibly the transition of the acute into the chronic 
stage. « The limits between the acute and chronic 
rheumatism are not always exactly marked. When 
the pains are still ready to shift their place,— 
when they are especially severe in the night time, 

when at the same time they are attended with 
some degree of pyrexia, and with some swelling 
and especially with some redness of the iointa 
the disease is to be considered as still partaklM 
the nature of acute rheumatism. 15.it when then! 
is no degree of pyrexia remaining, — vvhen the 



RHEUMATISM. 



37 



pained joints are without redness, when they are 
cold and stiff, — when they cannot easily be made 
to sweat, or when, while a free and warm sweat 
is brought out on the rest of the body, it is only 
clammy and cold on the joints, — and when especi- 
ally the pains of these joints are increased by cold 
and relieved by heat applied to them, the case is 
to be considered as that of purely chronic rheuma- 
tism." If the character of chronic rheumatism is 
to be derived from the most numerous and pre- 
dominant instances, then we would say that the 
former of these descriptions is far more applicable 
to the disease, as generally met with, than the 
latter; for though all the phenomena recited as 
indicating the continuance of febrile and inflamma- 
tory action may not attend, it rarely happens that 
some or other of them are not present. As the 
former condition is capable of indefinite duration, 
for it may endure for years, and is hence strictly 
entitled to be called chronic, — it could not, where 
any distinction were made, be classed with the 
acute disease lately treated of; while, if it consti- 
tute any part of the chronic malady, a definition 
professing to characterize this ought assuredly to 
embrace it. Perhaps the more perfect representa- 
tion of the disease, if it be necessary or beneficial 
to make any such distinction, would be to include 
both descriptions under arthrodynia, subdividing 
this into sthenic and asthenic. In this view the 
sthenic arthrodynia is by far the most frequent 
form in which the disease presents itself; and, 
what is no less important, it is that which, if un- 
relieved or improperly treated, is productive of the 
greatest mischief and of most distressing results; 
for under it, the disease both local and constitution- 
al, however indolent it may appear, is yet suffi- 
ciently active to continue and extend its peculiar 
ravages, deranging the general health, enfeebling 
and crippling the body through progressive disor- 
ganization of joints, and consequent wasting of 
muscles. In the asthenic form, the mischief is 
already done, and, however the body may suffer 
under the ravages sustained, there is no longer 
the active constitutional derangement inflicting 
further injury, which forms so essential a part of 
rheumatism. In the latter form there is little to 
do but support the general health, and remedy, as 
far as may be, the local lesions. But sthenic 
arthrodynia both admits of and demands more 
corrective treatment, the judicious, discriminating, 
and persevering use of suitable remedies being 
capable of accomplishing much, both in renovating 
health, and restoring power of motion to the still 
inflamed though rigid and contracted joints. With 
the consideration of this form we shall now pro- 
ceed. 

[The chronic form of rheumatism is often de- 
scribed as being frequently the sequel to the 
acute. This does not accord, however, with the 
experience of the writer. So far as his observa- 
tion has gone, the subjects of acute rheumatism 
rarely suffer from the chronic form ; and, on the 
other hand, persons who are constantly more or 
less crippled by chronic rheumatism may pass 
through life without suffering from the acute.] 

It is a prevailing impression that a chronic 
disease cannot be inflammatory. How this origi- 
nated it is needless to conjecture; but, however 
the misconception arose, it is a familiar truth that 



the term chronic conveys to most minds not the 
simple idea of duration, which alone it expresses, 
but something the opposite of inflammatory ; 
some state to which the treatment proper for in- 
flammation cannot be applicable. The pure 
chronic rheumatism of Cullen as described in the 
foregoing extract, is unquestionably of this latter 
character; but as the disease comprises, in addition 
to this, the subacute or sthenic condition also 
noticed by him, it is necessary to understand the 
term chronic, when its application is thus extend- 
ed, in that restricted sense alone which rightly 
belongs to it. 

Practitioners who are accustomed to regard 
chronic rheumatism as asthenic, and to treat it 
accordingly, are little aware of how long a deci- 
dedly inflammatory character may attach to it. 
Years may elapse, yet a distinctly febrile state, 
indicated by its appropriate phenomena, prevail, 
accompanied with evidences of disorganizing in- 
flammatory action on the joints. And so long as 
this state endures, is there progressive deteriora- 
tion of general health, and increasing structural 
derangement of joints. It gratifies the writer of 
this article to see this fact unequivocally stated by 
Dr. Elliotson, in his excellent clinical lectures de- 
livered at St. Thomas's Hospital. He acknow- 
ledges the inflammatory character, and also the 
great length of time for which this may be retained, 
specifying this form of rheumatism as active in 
contradistinction to the term acute, which in its 
strict sense could not apply to it. The same cha- 
racter was long ago indirectly recognised by Sagar, 
when, in his definition of chronic rheumatism, he 
stated the blood drawn to exhibit a huffy crust. 
In this form, however subdued the symptoms may 
be, the characteristics of rheumatism, as they have 
been exhibited in the acute disease, are distinctly 
traceable. There is a febrile state of the general 
constitution, and more or less of inflammatory 
action in the joints; and the principles of treat- 
ment are precisely similar, though they require to 
be modified in their application so as to adapt this 
to the derangements, both constitutional and local, 
which need relief. It will assist in comprehend- 
ing the real nature of this form of the disease to 
bear in mind what was formerly stated in treating 
of relative plethora. Certain delusive appearances 
were then noticed, as misleading practitioners from 
a right conception of the state of circulation or 
condition of health existing; and to similar delu- 
sions has it been owing that the febrile character 
of active or sthenic arthrodynia has been so fre- 
quently overlooked. An apparently feeble and 
compressible pulse induces the persuasion of de 
bility ; the enfeebled powers of the body sanctioE 
the conclusion ; and relief is sought from a class 
of remedies which, in such case, cannot give other 
than transient relief, if, indeed, they do not aggra- 
vate every symptom. Were we sure that the 
doctrines of plethora formerly illustrated were 
rightly understood, we could at once, close the 
discussion of the constitutional state prevailing in 
sthenic arthrodynia, by representing it briefly as 
that of relative plethora. It differs from the con- 
dition formerly described as relative plethora, only 
in having the local inflammations with ti ; ; ir con- 
sequences superadded. In order to determine ac 
j curately this state of constitution, it i« necessat* 



38 



to judge, not from any one indication, but from 
that assemblage of evidences which, when collec- 
tively present, cannot mislead. The pulse, if 
alone trusted to, may deceive, at least where the 
practitioner is not on his guard against the delu- 
sive lowness of pulse which belongs to incipient 
plethora, or is unacquainted with the peculiar 
changes which the pulse undergoes when the con- 
gestive state is passing into that of febrile action. 
Though apparently low in force, it yet evinces 
some resistance to pressure, and is more or less 
quickened ; the skin, too, is hotter than natural, 
and the tongue is white and furred. The gastro- 
intestinal membrane will also be found charged 
with redundant mucus, such as it generally se- 
cretes under febrile action. When all these phe- 
nomena are present, and especially when they are 
accompanied by evidences of local inflammation 
in the joints, no doubt need be entertained either 
of the nature of the disease, or of the principles 
of treatment. In this form of disease, then, it is 
obvious that the indications of cure are in no 
respect different from those which have been 
already shown as applying to acute rheumatism, 
namely, to subdue fever, and remove local inflam- 
mation. And the rationale of the practice suited 
for fulfilling these indications will be clearly per- 
ceived by those who have taken the trouble to 
comprehend the doctrines respecting the patho- 
logy of the circulation advanced in the article 
Plethora. 

The constitutional state of sthenic arthrodynia 
bears the same relation to relative plethora that 
the acute form does to absolute ; and in the prin- 
ciples of treatment laid down for the correction of 
relative plethora, with its concomitant disturbances, 
will be found the best guidance for conducting 
with precision and effect that of active chronic 
rheumatism. On the same principle as in acute 
rheumatism, it is the constitutional state which 
demands the first attention ; for, unless this be 
radically corrected, all efforts to cure permanently 
the local ailments must fail, or be only of tran- 
sient effect. In treating the constitutional dis- 
turbance, it is necessary to bear in mind that it is 
connected with relative rather than absolute ple- 
thora; that, consequently, the derangements exist- 
ing are more complex, and that the practice must 
hence embrace considerations which it was not 
necessary to insist on particularly in discussing 
the acute disease. In acute rheumatism, active 
bloodletting was directed ; the object being not 
only to reduce plethora, but to make speedy im- 
pression on febrile action, in order to arrest prompt- 
ly the injuries which unrestrained continuance of 
this would occasion. In the more chronic form 
it is necessary to diminish plethora, but not equally 
so to make sc speedy impression on febrile action. 
This lattei requires to be regulated, but not ex- 
tinguished ; for some increased energies of circu- 
lation are absolutely necessary for correcting the 
concomitant derangements of function produced 
by defective capillary circulation. To restore the 
impeded circulation of the capillaries, and renew 
the secretory and excretory processes of which 
ihey are the agents, seems to be the final cause 
for which febrile action is instituted ; it is assur- 
edly the end which it often attains, and hence, 
when natural fever fails to accomplish it, we are 



RHEUMATISM. 

~customed to institute an artificial fever through 
he ope-tion of mercury to effect the purpose. 
This however, is not to be forced ; it require, 
time for safe and salutary progress: minute ves- 
sels long obstructed cannot be all at once rendered 



pervtous and efficient for the discharge of func 
lions long disused; and hence, in treating the 
febrile state of chronic rheumatism, the practice 
though corresponding in principle with that of 
acute, must be much less energet.c. Bleedings 
must be of smaller amount and at longer inter- 
vals ; a free state of excretion must be moderately 
but steadily maintained; and mercury must be 
employed for that renewal of function in the ca- 
pillary vessels and their secerning extremities, 
which the powers of the constitution, unaided by 
mercury, are inadequate to accomplish. 

It will be recollected that in relative plethora 
the redundancy of blood results more from its im- 
perfect appropriation than from absolute excess; 
and that correction of this state requires, not only 
that the larger vessels be relieved from the load 
which oppresses them, but that the aggregate capa- 
city of vessels be enlarged by renewal of the sus- 
pended activity of the capillaries, and also by pro- 
moting the natural expenditure of blood through 
the several secretions and excretions. These are 
the curative effects of febrile action ; they consti- 
tute also the beneficial operation of mercury on 
the system, and on regulating them conformably 
with the views here displayed will the success of 
medical practice in a great measure depend, not 
only in this but in many other diseases. In the 
diseased state now under consideration, the first 
object should be to relieve the oppressed circula- 
tion, and thus arouse the energies of the system 
bv taking away some blood; and in conducting 
this part of the treatment, judgment and discrimi- 
nation are so requisite, that, even at the hazard of 
being deemed unnecessarily minute, we must dwell 
on the several circumstances from which any 
guidance can be derived. 

If, with the general evidences of plethoric op- 
pression and febrile action, the powers of the con- 
stitution be very low, and the pulse very feeble, 
it may be advisable to suspend for a while direct 
depletion, and to trust to purgatives. It may, in 
such case, be even expedient to employ gentle 
stimulants in order to arouse the dormant energies, 
and enable them to bear direct bloodletting ; this 
being the end to which the use of stimulants 
should in this stage be directed. The necessity 
for this degree of caution, however, is not of most 
frequent occurrence. Much more generally may 
the curative treatment commence with small bleed- 
ings ; and in these it should never be forgotten that 
the object is not to make impression on the moving 
powers, but to withdraw a portion of the circula- 
ting mass, and this with a view of arousing the 
natural powers to the discharge of functions re- 
quired for the re-establishment of health. Small 
bleedings here suffice; and the extent of six or 
eight ounces will best answer the end designed. 
According as power increases, larger bleeding. 
will be borne; but beyond twelve ounces it is 
rarely necessary to carry them. In general, eveB 
. the first portions of blood drawn will be buffed if 
not cupped; and under such circumstances the 
I pulse, if previously low, will be f uuri j to rise 



RHEUMATISM 



39 



under bleeding. As was before remarked, a soft 
pulse is no contra-indication of bloodletting; for 
we continually find buffy blood and increase of 
power after venesection, where the previous soft- 
ness and feebleness of pulse would, to unreflecting 
observers, appear to prohibit all direct depletion. 
This deceptive character of pulse is too often 
allowed to influence the practice even in acute 
rheumatism ; yet it has been so often the subject 
of remark, that practitioners ought to be fully 
aware of it. Dr. Gregory, who in the treatment 
of acute rheumatism did not employ bloodletting 
indiscriminately, nor deem it essentially necessary, 
but who trusted rather to sweating as the prefer- 
able evacuation, used to acknowledge that he had 
been obliged to have recourse to bleeding after 
several weeks' duration of disease, where he had 
at first been apprehensive of employing it from the 
smallness and apparent debility of the pulse; and 
that after bleeding, the pulse rose and disease sub- 
sided. This is not peculiar to rheumatism, but a 
general fact connected with derangement of circu- 
lation, and worthy of attention in many diseases. 
The explanation of it has been fully and clearly 
given in the article Plethora ; and if the prin- 
ciples there inculcated be duly regarded and dis- 
criminately applied, there will be little hazard 
either of bloodletting being withheld where it is 
needed, or of its being carried to any injurious 
extent. 

Ne\tto bloodletting, the most important evacua- 
tion is purging, which requires to be regulated both 
according to the degree of febrile action present, 
and to the state of the bowels as manifested by the 
stools. In proportion as fever is active will the 
free use of purgatives be required, and saline ca- 
thartics be needed in aid of those which more pe- 
culiarly deterge the mucous membrane of its mor- 
bid secretions ; but so long as these continue dark, 
slimy, and unnatural, must suitable purgatives be 
assiduously employed. Pills of calomel, colocynth, 
and antimony, with occasional doses of sulphate 
of magnesia and senna, are the most effectual 
means of adequate purgation. According as ac- 
tive fever prevails, as evinced by a quirk pulse, 
hot skin, and white or furred tongue, salines with 
antimony and colchicum, assisted by antiphlogistic 
regimen, should also be conjoined. 

If under this treatment febrile action does not 
speedily abate, and local inflammation subside, 
mercury will be required, and for purposes similar 
to those for which its use was directed in acute 
rheumatism. According as fever is active will 
calomel and opium be necessary, for the proper 
administration of which no further instruction can 
be here needed, it being only necessary to observe, 
that as the morbid actions requiring correction 
yield more slowly than in acute rheumatism, a 
more slow and cautious administration of the 
remedy is here expedient. The direct agency of 
the medicine is to excite freer circulation in the 
capillary vessels, by which the larger vessels be- 
come relieved, both through the increased capacity 
thus given to the vessels through which the mass 
of blood circulates, and the increased expenditure 
of blood in the several secretions and excretions 
thus promoted. Whoever bears these facts and 
principles in mind, will experience nodifliculUp in 



regulating the administration of mercury in this 
or any other disease. 

In many cases, however, febrile action, though 
sufficiently manifested by its appropriate pheno- 
mena, is less developed than in those just referred 
to. The pulse is feeble and irregular, the several 
secretory and excretory functions are inactive, and 
the whole frame displays a deficiency of power. 
Here stimulants are needed, and the most effectual 
for arousing the dormant energies is mercury. 
The milder preparations in small doses, repeated 
at intervals, are what should here be employed. 
The compound calomel pill, blue pill, hydrargy- 
rum cum creta, are the remedies chiefly in use 
where a slowly alterative effect is desired. In old 
and obstinate cases minute doses of the oxymu- 
riate have effect when other preparations fail 
When the latter is resorted to, decoction of sar 
saparilla is beneficially combined. Whenevei 
mercury is employed for such purposes, it is 
highly necessary to watch closely the state both 
of the circulation and of the bowels. If under 
its use the arterial system becomes excited, and 
the pulse rises, becoming full, hard, or resisting, 
blood should he taken ; and as mercury, when 
so administered, promotes the intestinal excre- 
tions, these should be assiduously evacuated by 
suitable purges, which in such case serve the 
double purposes of removing from the intestines 
a source of irritation, and of maintaining the 
excretories in an active exercise of those functions 
which so materially assist the curative process. 

Under the foregoing treatment part of the local 
inflammation will subside without any topical 
remedies being applied. But as these inflamma- 
tions have long reached the secondary stage, and 
as local derangements, such as were formerly no- 
ticed, have become more or less established, the 
local treatment suited to the special circumstances 
of each case is here indispensable. According as 
the local inflammation presents an active charac- 
ter, cupping or leeches will be required ; and by 
these, with fomentations, or with cooling and 
sedative lotions, much impression may be made. 
Blisters, too, in time, are of much effect, especially 
where the bursa? are loaded with glairy effusion, 
the ligaments thickened and rigid, and the whole 
joint enlarged. To these changes all the joints 
are liable ; they peculiarly occur in the wrists, 
where they materially impede the motions of the 
hands, rendering the patients very helpless. These 
swellings, when accompanied with heat and red- 
ness, require leeching and cold lotions ; other- 
wise, repeated blisters are the means by which the 
enlargement can be best reduced, the effusions 
absorbed, the ligaments attenuated, and the flexi- 
bility of the articulations restored. In the inter- 
vals of blistering, stimulant embrocations are very 
serviceable; and frictions, especially the kind of 
manipulation termed shampooing, are of much 
avail. 

In the inveterate cases which continually occur 
in practice, it is not any one remedy that can be 
relied on. The combined agency of all is re- 
quired, and they should be assiduously employed 
in such succession and alternation as enlightened 
judgment may direct. By a judicious and steady 
use of them many a case, apparently hopeless, 



40 



RHEUMATISM. 



may be restored to the enjoyment of good general 
health, and to considerable freedom of the affected 
limbs. Throughout the whole course of treat- 
ment warm bathing is signally beneficial, as is 
largely attested by the records and daily expe- 
rience of the noble institution to which the writer 
of this essay is indebted for much practical know- 
ledge — the Bath Hospital. It cooperates with the 
constitutional treatment to improve general health, 
promoting a free circulation in all the capillary 
vessels, and calling into renewed activity the 
highly important excretory functions of the skin, 
while its special effect on the pained and crippled 
joints is eminently salutary. For the latter pur- 
pose, pumping on the limbs, as it is termed, that 
is, directing against those allected a stream of 
tepid water, impelled with such force as to exert 
a mechanical influence on the part, is oftentimes 
a very powerful auxiliary. Even when general 
warm bathing is not admissible, this partial appli- 
cation of wafin water may be used with much 
advantage for the relief of local ailments. 

Subsidiary to these several means, one of the 
most effectual aids for restoring motion to rigid 
or contracted joints is the persevering endeavour 
to render them flexible by assiduous exercise ; and 
the more this can be promoted through the appro- 
priate muscles of the affected joints, the greater 
will be the benefit resulting; for the muscles pre- 
viously wasted will thus recover bulk and strength, 
and through renewal of exertion will prove a most 
valuable instrument both in preserving and ex- 
tending any power of motion that may be gained. 
Frictions and shampooing are a sort of passive 
exercise, and through this, as well as by pro- 
moting absorption and inducing a freer circula- 
tion in the extreme vessels, their effect on en- 
larged or rigid joints is considerable. 

But even where, from great rigidity and extreme 
muscular feebleness, the joints are incapable of 
being exercised by their own proper muscles, the 
advantage derivable from passive exercise is not 
to be despised. Frictions and shampooing may 
lessen rigidity, so as to give more effect to the 
feeble muscles in their languid efforts. When the 
wrist and finger joints are affected, the parties 
may materially benefit themselves by moderate 
but continually renewed attempts to move the 
joints of each hand by means of the other. The 
joints may resist for a long time, but this should 
not discourage, and the slightest renewal of mo- 
bility should be hailed as the sure harbinger of 
further improvement. It is needless to urge this 
further. The principles are obvious, the effects 
proved by ample experience ; and at all events 
perseverance in such endeavours, however little it 
may in extreme cases accomplish, holds out to the 
rheumatic cripple the only hope of recovering 
mobility in joints rendered inflexible by the effects 
of rheumatic inflammation. Attempts to restore 
mobility in such cases by internal medicines 
alone, is worse than fruitless. They may correct 
constitutional derangements where these coexist 
and, by restoring general health, prevent further 
mischief; but they can have no effect in renew- 
ing either mobility or power to limbs so affected. 

It has been shown that the secondary inflam- 
mation of acute rheumatism may survive the 
cause in which it originated. In '' l "~ — 



local inflammation of chronic rheumatism may 
continue, although the febrile state which nurtured 
and aggravated it may have wholly subsided ; and, 
further, the ravages of rheumatism in the joints 
may remain when all fever, as well as local in- 
flammation, whether primary or secondary, has 
ceased to exist. Chronic rheumatism, therefore, 
may be said to present three conditions which de- 
serve to be practically distinguished; — active 
fever with local inflammation; — inflammation un- 
accompanied with fever ; — and structural derange- 
ments of joints unattended by either lever or local 
inflammation. Each of these conditions requires 
to be treated on principles applicable to its pecu- 
liar state ; and any treatment adopted merely on 
account of its being specifically suited for rheu- 
matism, must, if indiscriminately applied, be pro- 
ductive of much mischief. 

There is another diseased condition often con- 
sequent to rheumatism, namely, a loss of nervous 
energy, which constitutes a modification of par- 
alysis ; but this demands a separate consideration, 
which belongs rather to paralysis than to the pre- 
sent subject. 

The first condition of chronic rheumatism, or 
that which comprises both active fever and local 
inflammation, has been sufficiently discussed. 
The next in order is where the local inflammation, 
with the attendant pains and other derangements, 
endures after fever has subsided. This form also 
is of frequent occurrence, and it differs from the 
former in not requiring general bloodletting for 
its cure. Local depletion and occasional blisters' 
constitute the principal topical treatment ; and 
mercury with sarsaparilla and other such auxili- 
aries, is the chief agent for inciting the constitu- 
tional energies to cooperate in the cure. It is this 
form of the disease that has misled even intelli- 
gent practitioners into pronouncing that general 
bloodletting is not necessary in chronic rheuma- 
tism. Dr. Elliotson in his admirable clinical lec- 
tures has expressed himself of this opinion, and 
declared that he has relinquished general bleeding 
in active rheumatism, unless when some internal 
inflammation coexists. That in main such cases 
the treatment recommended by him, namely, local 
bleeding, colchicum, and mercury, will succeed 
without general bleeding, we were well aware; 
but we are no less assured that in very many it 
would pjrove very tedious, if not wholly tail. We 
;r, therefore, that Dr. Elliotson has stated 
this opinion somewhat too broadly ; and that on 
reconsideration he will himself admit that the 
criterion for employing the lancet should be, not 
the presence of an internal inflammation, but such 
degree of plethora and febrile excitement as in 
itself demands direct depletion, independently of 
all coexisting local derangements. Topical bleed- 
ing, low diet, colchicum, and mercury, form a 
combination of influences which has great power 
m subduing febrile and inflammatory action ; but 
if plethora exist to a certain extent, even their 
united agency will be insufficient, unless direct 
depletion be conjoined. And in such case it re 
quires to be borne in mind, that, as has bcen 
already explained, the operation of mercurv is not 
devoid of danger. When there i s |„ c Tfnfl 2 
mation without plethora or fever, t i u ,\ " Z. 
• - . i ' l "e treatment 



RHEUMATISM. 



41 



Even where plethora and fever exist only in slight 
degree, it may also succeed, although the progress 
will he slower than when venesection is conjoined. 
But when plethora and fever exist to any extent, 
then, even though there be no internal inflamma- 
tion, general bleeding ought unquestionably to 
form part of the treatment. 

Chronic rheumatism has been sometimes dis- 
tinguished into hot and cold, — the hot being the 
active rheumatism of Elliotson, the cold the 
arthrodynia of Cullen. In the last, various stim- 
ulants are of much avail, and for the relief of 
such disease they should undoubtedly be resorted 
to. It is to be hoped, however, that their misap- 
plication to acute or to any active rheumatism as 
the appropriate remedies, has passed away, or is 
confined only to ignorant empirics. It illustrates 
the difficulty of adapting treatment explicitly to 
the name of a disease, or even to special degrees 
of it, that there are modifications of active rheu- 
matism in which even stimulants, cautiously ad- 
ministered, are not only safe but beneficial ; and 
this circumstance confirms the necessity of all 
medical treatment being regulated, not by express 
rules, but by those principles from which all rules 
ought to emanate, and to which they ought to be 
subservient. 

It would be vain to enumerate the various 
stimulants which have obtained character for the 
cure of cold rheumatism. The principal are 
essential oils drawn from resinous substances, such 
as turpentine ; various balsams and gum-resins ; 
the latter either in substance or in simple or am- 
moniated tinctures ; sudorific decoctions ; electri- 
city. Any of these may benefit according as the 
general constitution is prepared for their operation, 
or as the special ailments may require. If there 
be no plethoric or febrile state present, their use 
will at least be harmless, if not beneficial ; but 
should the case be such as to need depletory treat- 
ment and the operation of mercury, then must 
the use of such stimulants as are now named be 
watched with great caution. 

Warm bathing and active exercise are among 
the unexceptionable and most powerful means of 
relieving chronic rheumatism. The local treat- 
ment formerly directed for the sequela? of acute 
rheumatism also requires to be assiduously em- 
ployed. 

There are some affections generally regarded as 
rheumatic, which, however connected with rheu- 
matism, seem to depend chiefly on a morbid condi- 
tion of particular nerves. Of this kind are scia- 
tica and lumbago, both of which differ so much 
in their symptoms from acute rheumatism, as 
scarcely to admit of their being classed under it. 
A mere error of arrangement, however, is of little 
consequence, as the same principles of treatment 
apply to all. If the state of constitution be such 
as to require for its correction bleeding, purging, 
colchicum, and mercury, these remedies must be 
employed, else the local affection will not readily 
yield. That sciatica arises from some lesion of 
the sciatic nerve or its investments, most practi- 
tioners are agreed. That this lesion results from 
a primary congestion or inflammatory action, seems 
evidenced both by the whole train of symptoms, 
and by the treatment most successful in giving 
relief. 

Vol,. IV. — f n* 



When there is only the local affection to treat, 
repeated cupping or leeching, and blistering, with 
the warm bath, and a cautious return to exercise, 
will do much to effect restoration. Stimulant and 
sedative embrocations too, are occasionally of ser- 
vice. 

In lumbago, though the spinal nerves affected 
are less distinctly indicated, yet the character of 
the pain marks it as more neuralgic than rheuma- 
tic. Free cupping and the general treatment of 
acute rheumatism will best succeed in relieving 
this disease. 

But there is a form of neuralgia occasionally 
attendant on rheumatism which causes much suf- 
fering, and which does not seem to be generally 
understood. It occurs in paroxysms of great in- 
tensity, attended with a severity of pain which few 
can patiently endure. This may arise ere the 
febrile state has thoroughly subsided ; and this 
circumstance is apt to mislead, for a continuance 
or removal of inflammation is thus apprehended, 
and depletory treatment is pursued, under which 
the disease is aggravated instead of relieved. The 
character of this affection is best denoted by the 
suddenness of the painful accessions. The nature 
of the pain, too, so different from that which at- 
tends inflammation, seems to distinguish it. For 
this affection the most certain and effectual reme- 
dy is iron ; but it must be largely used, and as- 
sisted, if necessary, by full doses of opium. The 
carbonate is the best preparation, and this should 
be given in doses of two drachms three or four 
times a day. By administering it with equal parts 
of treacle, as directed by Dr. Elliotson, its consti- 
pating effects are obviated. Should opium be re- 
quired, it should be given in full doses, and the 
best preparation for the purpose is Battley's seda- 
tive solution, of which from thirty to ninety min- 
ims may be given at bed-time without any sinister 
effect resulting. Under this treatment it may be 
necessary to purge occasionally with the common 
senna draught, which is sensibly improved by the 
addition of half a drachm of spirit of ammonia. 

In the progress of rheumatism the chest is apt 
to become affected with pain and great dyspnoea, 
the distress being referred to the lower part of the 
chest, and described as if the point of the sternum 
were drawn back to the spine. This arises from 
the extension or translation of rheumatism to the 
diaphragm. The means of relief are bleeding, 
purging, and colchicum, with calomel and opium. 
So soon as the gums are touched, the distress 
finally ceases. 

One of the most important affections connected 
with rheumatism is that in which the heart or its 
investments becomes the scat of rheumatic inflam- 
mation. This inflammation may be of the most 
acute kind, constituting complete carditis or peri- 
carditis ; or it may be only such increased action 
of blood-vessels as ultimately leads to hypertrophy. 
For the acute attack the most active treatment is 
required ; full bloodletting, purging, antimony and 
colchicum, but above all the early and decisive 
operation of calomel and opium. If the latter be 
not speedily and effectually obtained in subservi- 
ency to bloodletting, this will be required to such 
extent as to render recovery extremely doubtful, 
sink greatly the powers of life, and occasion a very 
tedious convalescence. Some interesting cases of 



42 



RHEUMATISM. 



rheumatic pericarditis have been recently pub- 
lished by Dr. Davis, the senior physician of the 
Bath hospital. He seems, however, to have 
trusted to general antiphlogistic regimen, without 
calling in the aid of mercury. The principles 
advocated in this article display the merits of mer- 
cury as an adjuvant; and the experience of the 
writer fully confirms their truth and practical uti- 
lity. But independently of this acute seizure 
there is continually found in connection with 
rheumatism inordinate action of the heart, with 
evidences of actual enlargement or hypertrophy 
of that organ. The treatment, of this affection, 
we can from much experience say, is best con- 
ducted on the principles inculcated in this article. 
Moderate bleedings are indispensable, the blood 
being almost invariably buffed and cupped. In 
judging of the state of circulation, the pulse at 
the wrist would mislead, for it may be soft and 
compressible even when the action of the heart is 
tumultuous. The carotid should here be exa- 
mined as furnishing a more certain criterion. 
Free bowels and antiphlogistic discipline are indi- 
cated by the same necessity which calls for ab- 
straction of blood. Mercury with opium is also 
required to produce its specific effects, by which 
alone the morbid action can be effectually or per- 
manently subdued. The use of this requires to 
be cautiously conducted, for its slowest operation 
is that which is here most beneficial. The morbid 
condition is generally of slow formation ; the 
changes wrought are not of a nature to be sud- 
denly rectified ; and attempts to accelerate the 
case beyond what nature permits, would beget 
mischief and lead only to disappointment. Cup- 
ping and leeching over the heart are valuable aux- 
iliaries, and blisters are occasionally needed. 

In fine, when inflammation both general and 
local is allayed, and the action of the heart still 
continues inordinate, or is too easily excited, the 
application of belladonna to the side, in the form 
of plaster, affords a valuable means of quieting 
the heart's motions, and of procuring rest from a 
disturbance which is always distressing. 

Tin this as well as in every form of rheumatism, 
the iodide of potassium, given in large doses, has 
been greatly extolled. (Neiv Remedies, 4th edit. 
p. 396, Philad. 1843.)] 

By the cautious adaptation of such means, and 
steady perseverance in their use, the disturbance 
of heart here treated of may in time be effectually 
relieved. Time, however, is required, for the dis- 
ease yields slowly; and though impression be 
made on it by the early procedures, months may 
elapse ere perfect tranquillity of circulation can 
be restored. The patience, however, which can 
iwait this result, and pursue steadily the means 
of accomplishing it, will be amply rewarded. 

There is one more form of rheumatism which 
• equires to be noticed, namely, that which is called 
rheumatic gout ,- and so far as a name is con- 
cerned, this appellation, though only a popular 
term, is not misapplied. So much has this disease 
in common both with gout and with rheumatism, 
that it is scarcely possible to regard it otherwise 
than as a hybrid malady, in which the elements 
of both these diseases coexist. Its accession cor- 
responds most with rheumatism ; its ravages have 
a greater resemblcnce to those of gout. The en- 



largement of joints to which it is so prone presents 
much more of the character of gout than of rheu- 
matism. Dr. Haygarth has described this disease, 
and proposed to denominate it nodosity of the 
joints. Of its history and treatment there is lit- 
tle to be said beyond what has been already ad- 
vanced under the heads of gout and of rheumatism. 
It is more frequent in women than in men. Its 
commencement is often marked by active fever, 
and in proportion as this is disregarded or inade- 
quately treated, are its ravages more severe and 
inveterate. But in many it advances by a slow 
and insidious progress, disorganizing the joints 
without materially deranging the general health. 
The local swellings long retain the character of 
active inflammation, being hot, red, and painful. 
They in general surround the whole joint, and, 
so far as mere touch can determine, they seem to 
arise from a general enlargement of all the struc- 
tures constituting the joint. It seems strange 
that the structures actually enlarged have not been 
long since ascertained by actual dissection ; ytt 
we are not aware of any account of them, founded 
on anatomical examination, having been published. 
In 1805 Dr. Haygarth had not met with any such 
account, as appears from the following paragraph 
of his treatise : " In this disease the ends of the 
bones, the periosteum, capsules, or ligaments which 
form the joint, gradually increase. These nodes 
are not separate tumours, but feel as if they were 
an enlargement of the bones themselves. This 
point might be anatomically ascertained without 
any difficulty or doubt." The disease, according 
to Dr. Haygarth, does not appear to shorten life ; 
the first patient whom he saw so affected reached 
the age of ninety-three. 

As to treatment, this must be regulated accord- 
ing to the state of constitution and local symp- 
toms, and on the principles inculcated in this arti- 
cle. By local treatment much relief may be ren- 
dered. Frequent leeching has much effect in 
abating heat, swelling, and pain. In the purely 
chronic stage, successive blisters contribute much 
to reduce swelling and restore flexibility. As the 
hands particularly suffer from this malady, it be- 
comes necessary to blister each finger separately, 
and even each joint ; a process, which, however 
irksome, is yet ultimately recompensed by the in- 
creased power of using the hands which may be 
thus obtained. 

[Under the name Rheumatic Dermalgia, Mr. 
Beau {Note sur la Dermalgic, in Archiv. general. 
deMdd. i. ii. 120, Paris, 1840) has described an 
affection characterized by the following symptoms. 
The head and lower extremities are the parts most 
usually attacked, but the pain does not remain in 
one place, often changing its seat gradually, and 
wandering from place to place. Two kinds of 
pain are experienced, the one enduring, the other 
intermittent and severe, resembling the prick of a 
pin or an electric shock, and recurring about every 
half minute. The enduring pain is often little 
more than an exaltation of the natural sensibility 
of the skin. Friction of the part with the finger, 
or with the patient's dress, always augments the 
pain i and if there be hair on the affected part, 
very severe suffering may be produced by passing 
the hand over the hair. ' 

Rheumatism of the skin commonly alternate! 



RICKETS. 



43 



with that form of the disease, which affects the 
muscular and fibrous tissues. Its usual duration 
is a day or two, after which it gradually subsides. 
It is said to be a more frequent occurrence among 
men than women, to be induced by damp, cold, 
and the ordinary causes of rheumatism, and, in 
general, not to require much treatment.] 

E. Barlow. 

[ROBLEY DUNGLISON.] 

RICKETS.— Rhachitis, Rachitis. The term 
rhachitis was derived by Glisson from the Greek 
f>d%<; (spine), because this disease affects, in an 
especial manner, the spinal column ; but he ac- 
knowledges that he was induced to adopt this 
term from its near resemblance to rickets, a word 
by which the malady was commonly known in 
England even before his time.* The work of 
Whistler, and the remarkably , clear and full ac- 
count of rickets afterwards given by Glisson and 
his associates Bate and Regemorter, have procured 
a currency for their opinion that the disease made 
its first appearance in the western parts of England 
towards the middle of the seventeenth century, 
and have obtained for rickets among continental 
writers the designation of the English malady, 
(Morbus Anglicus, Maladie Anglaise, Englische 
Krankheit.) That rickets was never distinctly 
described by any medical author before the times 
of Whistler and Glisson, we readily admit; but 
that it was of such recent origin as the period 
stated above, we conceive to be quite inconsistent 
with the several terms in the Greek and Latin 
languages denoting deformity and decrepitude of 
the human body, and with the instances recorded 
in ancient history of persons so afflicted who were 
distinguished in various departments of letters and 
even in arms. 

The essential characteristic of rickets is a soft- 
ening of the bones ; but the exact change which 
takes place in their structure, and the general 
symptoms by which this alteration is attended, are 
considerably different at different periods of life. 
Taking the term rhachitis in this extended sense, 
to which perhaps osteomalakia would be more 
properly applied, the disease may be divided into 
two species ; — 1st, softening of the bones of chil- 
dren, or common rickets ; 2d, that of adults, mol- 
lifies ossium, or osteo-sarcosis. Softening of the 
bones, like scrofula, is not unfrequently met with 
among the inferior animals. Thus Lordat dis- 
sected a rickety monkey ; Bicherod found soften- 
ing of the ribs of an ox (Act. Maris Balthici, 
1707) ; Dupuy describes the skeleton of a rickety 
horse (Dupuy, De l'Affection Tuberculeuse) ; 
Mason Good (Study of Medicine, vol. v. p. 327) 
asserts that rickets occurs in the lion ; and Comber 
has written a dissertation on the disease as it ap- 
pears in sheep. (Letter on the Rickets in Sheep. 
Lond. 1772.) But to descend from the researches 
of the learned to the information of those who 
are observant of the manners and diseases of our 
domestic animals, curvature of the bones and 
swelling at the joints are not unfrequently seen in 
whole broods of young geese and ducks, when 



* David Whist/er, Dissertat. Inaugur. de Morbo Puerili 
jknglor. clicto "The Rickets." Lugdun. Batavor. 1645. 
This work, which preceded that of Glisson, is now ex- 
ceedingly rare: a copy still exists in the Bodleian Li- 
brary. 



they have been continually exposed to cold and 
wet. The same affection is met with in young 
pointers, and more frequently in greyhound pup- 
pies, when kept in confined and cold damp ken- 
nels. In pigs, the same disease is in some places 
named krinckets ; its causes are cold and moisture, 
and bad nourishment ; and for its cure baths of 
hot grains are used, oily frictions, nutritious food, 
and removal to a warm and dry place. 

I. Rickets or Children. 

1. History. — This disease rarely appears before 
the seventh month, and most commonly does not 
declare itself until the child first begins his attempts 
to walk, or until he suffers from the severity of 
the first dentition. Rickets has also been observed 
at birth, and in the foetus : of the former Glisson 
(De Rachitide, p. 178), Henckel (Abhandl. Chi- 
rurg. Oper. Th. ii. p. 14), Klein, and Lepelletier 
(Maladie Scro f uleuse, Paris, 1830), have given 
examples; and of the latter Bordenave (Mem. de 
Mathemat. et Physique, torn. iv. p. 545), and 
Pinel.f 

[Of 346 rickety children observed by M. Guerin, 
(Gazette Medicale de Paris, pp. 433, 449, 481. 
Paris, 1839,) 209 had been attacked with the dis- 
ease at from one to three years old ; three cases 
only had occurred before birth ; and 34 at from 
four to twelve years of age. Girls appeared to be 
more liable to it than boys. Of the 346 indivi- 
duals referred to above, 198 were females, and 148 
males. (Guersant, art. Rachitisme, in Diet, de 
Med., 2de edit, xxxii. 155, Paris, 1843.)] 

When a child is about to be affected with rickets, 
he becomes dull and languid, the appetite is varia- 
ble and capricious, the bowels are irregular, the 
stools unhealthy and usually pale. Constitutional 
disturbance now arises, and a febrile state is soon 
established : the limbs become emaciated, the belly 
tumid, the face full, and the head disproportionately 
large, the forehead projecting, and the sutures of 
the cranium remaining open or perhaps expanding 
slightly. The extremities of the long bones which 
are least concealed by muscle, as those of the 
wrists and ankles, and the sternal ends of the ribs, 
particularly these last, are swelled out into knobs. 
Some have doubted the tumefaction of the extremi- 
ties of the bones in rickets, ascribing the appear- 
ance of swelling to the emaciation of the limbs ; 
but an attentive examination of rickety cases has 
convinced us of the correctness of the former opi- 
nion. The firm texture of the bony framework 
of the body now begins to yield, and its increasing 
softness becomes apparent by the change of form 
which takes place. The sides of the chest are 
approximated by the combined operation or the 
pressure of the child's arms, the weight of the 

t In Fourcroy's Journal, La Medecine eclairee par les 
Sciences Phys. torn. i. p. 111. This was the case of a rick- 
ety foetus of eight months, in which the distortion was 
chiefly confined to the lower extremities. Farther illus 
trationsof foetal and congenital rickets will be found hv 
referring to ttie following authorities. 

Soemmering Abbildung, et Beschreib. Einiger Missge- 
burten, p. 30, pi. 11. 

Otto. Seltene Beobachtung. I. Sam. tab. i. ng. 1. 

Romberg. De Rhachit. Corigenit. Berol. 1817, cum ta 
bulis. 

Sartorius. Rhachit. Congenit. Observ. 4to. Lips. 18*i, 
cum tabulis. 

Loder. Index Preparator. Sec. Mosquae, 1823. Sect 
11. D. 



41 



RICKETS. 



body when laid on its side, and the mode in which 
children are usually carried ; and thus the sternum 
is made to project like that of a bird, or like the 
keel of a boat. The lower extremities bend under 
the weight of the body, while they yield at the 
same time to the action of the most powerful mus- 
cles : the knees are usually bent inwards and the 
feet thrown out, so that the patient when he walks 
rests on the inside rather than on the sole of the 
foot. At other times the whole of each lower ex- 
tremity forms an irregular curve with its convexity 
looking outwards, and thus the knees, instead of 
knocking against each other, stand far apart. 
Among some of the native tribes of North Ame- 
rica, this particular form of the limbs is esteemed 
handsome : and the utmost care is taken in early 
infancy to mould them by continued pressure into 
the admired shape, which, therefore, must not be 
regarded as any proof of the previous existence 
of rickets. In this disease the natural convexity 
of the thigh-bone is often so much increased as to 
form an elbow ; and the angle between the neck 
and the shaft is converted from an obtuse to a right 
angle, or even to an acute one. The pelvis is 
usually deformed in the reverse direction of the 
chest, the pubes approaching to the sacrum ; but 
in all cases where the pelvis suffers, its cavity is 
diminished, which to the female in after-life is ne- 
cessarily attended with more or less dangerous 
consequences in the event of pregnancy. The 
vertebral column exhibits in a remarkable manner 
the effects of rickets in retarding the completion 
of the bones, and softening their texture : the spi- 
nous processes of the last dorsal and of the lum- 
bar vertebra? are sometimes deficient, and the na- 
tural form of the spine is variously changed; its 
uppermost portion is often bent backwards, while 
the dorsal part projects into a hump, the loins fall 
in, and the extremity of the sacrum is unnaturally 
protruded : thus the gait of the hunchback, who 
has survived the severity of the disease, is stiff 
and formal, and the face directed upwards. The 
distortion of the arms of rickety children is usu- 
ally outwards at the upper part of the humerus 
from the action of the deltoid, and in other parts 
also it is chiefly determined by the operation of 
the most powerful muscles ; but much will depend 
on the positions in which the limbs may chance to 
be placed at the time when the bones are recover- 
ing their strength and firmness. Rickets is con- 
sidered by some to produce little or no change on 
the bones of the cranium, face, hands, and feet. 
Those of the two last, we believe, are little affected ; 
but the vertex in rickety children is, with few ex- 
ceptions, unnaturally flattened, the centres of the 
parietals are expanded, and the forehead is promi- 
nent from an enlargement of the frontal sinuses : 
the bones of the face also appear in most cases to 
undergo some change of form, indicated by the 
shortness of visage and elongated under-jaw usu- 
ally observed in those who have suffered from 
general rickets. In such children the process of 
dentition is protracted, and the teeth soon decay : 
the enamel of the permanent teeth is often craggy 
and worm-eaten, showing its imperfect formation, 
though sufficiently hard ; but the fang during the 
progress of the disease has been found somewhat 
softer than natural. (Wihon, Lectures on the 
Human Skeleton.) 



rapidity with which the bones are softened 
etimes altogether extraord 
observed the whole of the 



by S'^methnes altogether e,,^ 
Brunn.nghausen observed the wW^thjtanj 
b one instance become soft in the bort space of 
six weeks, and the case proving fatal, he presened 

the skeleton. , ,-, 

As the disease proceeds, the bones are readily 
fractured when even a slight force ,s applied and 
it is remarkable that, softened as they are they 
usually reunite: at length they become completely 
pliant. We have seen those of the fore-arm of a 
child of four years as flexible as a piece of soft 
gristle, bending with the weight of the hand 
whichever way it was turned. The muscles grow- 
more and more flabby, the abdomen more tumid, 
the appetite becomes keen, and the bowels slug- 
gish. The urine in rickets is rarely healthy, 
sometimes clear, but more frequently turbid, de- 
positing a copious whitish or light brown sedi- 
ment, indicating the very disordered condition of 
the digestive organs, and consisting in all proba- 
bility of lithate of ammonia, with a large admix- 
ture of the phosphates. During the continued 
progress of rickets, the febrile excitement abates 
until its latter stages, when at length a regular 
hectic is established, and contributes by its perspi- 
rations and diarrhoea to exhaust and destroy the 
patient. 

The intellect of the subjects of rickets generally 
possesses a degree of development far beyond what 
is usual in healthy children of the same age ; the 
children exhibiting a quickness of perception and 
a fluency of language sometimes astonishing. In 
other instances, though much more rarely, they 
are taciturn and stupid, or even verge to a state 
ofidiotcy. The frequent precocity of understand- 
ing has been ascribed to the expansion of the 
skull, and the earlier development of the brain con- 
sequent on that determination of blood to the head 
which appears always to exist at least in the first 
stages of rickets ; but when this disease does not 
occur until the sutures of the cranium have closed, 
the same circumstance of an increased flow of 
blood acting on a part no longer capable of yield- 
ing has been assigned as the cause of the mental 
torpor or fatuity occasionally met with. 

Almost all those who become rickety soon after 
birth perish, but many in whom the disease has 
appeared later recover before their fifth or sixth 
year; the general health gradually improving, the 
tumefaction of the abdomen subsiding, and the 
bones acquiring firmness, though retaining, with 
scarcely an exception, a certain degree of defor- 
mity. The head remains disproportionately large, 
the child preserving its acuteness and vivacity. 
At other times recovery takes place after smart 
febrile reaction, which is occasionally accompanied 
by the appearance of a cutaneous eruption. Some- 
times the child at the approach of convalescence 
exhibits an extraordinary liking to particular arti- 
cles of food. We have known the desire for com- 
mon salt so strong that the little patient would de- 
vour it as others do sweetmeats. The quantitv 
taken m one instance was very great, and to the 
parents it seemed as if the salt had proved the 
means of cure. 

After the cessation of the disease, the bones ac- 
quire a degree of solidity and strength even greater 
than natural, and many persons whose form proves 



RICKETS 



45 



that they were rickety in early years, are in after- 
life distinguished for robustness and activity. The 
deficiency of earthy salts in the bones, which ex- 
isted during rickets, is succeeded by their exces- 
sive deposition ; and that state is induced which 
has been named hyperostosis : the long bones be- 
come more rounded and massy ; and the sutures 
of the cranium are often obliterated, and the lines 
of junction raised into flattened ridges. In some 
instances rickets has been followed after some in- 
terval by a remarkable tendency to the production 
of bony growths. There is related by the Bishop 
of Cork, in the Philosophical Transactions for 
1740, 1741, the case of a man who had been so 
rickety in his youth that almost every bone in his 
body was distorted. At the age of eighteen he 
began to grow stiff, and at length, having lost all 
use of his limbs, he became like a statue : he sur- 
vived till his sixty-first year, and at his death his 
skeleton was found to be one continuous bone 
from the top of his head- to his knees. Many 
osseous growths, some of them of the most gro- 
tesque forms, branched from his head, back, and 
haunches; and a portion of fully-formed bone was 
also found imbedded within one of the large 
muscles. 

Should the disease not yield before the seventh 
or eighth year, the individuals, if they survive, are 
condemned to a life of infirmity, which is seldom 
prolonged beyond middle age. Such persons suffer 
exceedingly from the unnatural pressure and dis- 
placement to which the organs of the chest, and 
even the most important of those of the abdomen, 
are more or less subjected. The stomach in these 
cases is frequently pushed as low as the umbilicus, 
and even the urinary functions have been disor- 
dered by a projecting vertebra pressing upon the 
kidney. These unfortunate individuals are re- 
markable for their shrill voice, dilated nostrils, and 
panting respiration ; and life is generally cut short 
by one of those attacks of pulmonary inflammation 
to which they are peculiarly prone ; at other 
times they are destroyed by the development of 
tubercular disease, and occasionally by dropsy. 

In rickets, as in most chronic disorders, the 
change which takes place at puberty is productive 
of amendment, or of an increase of the disease. 
Ravaton has detailed a remarkable case, which 
serves well to illustrate this influence. A girl, 
whose legs were so deformed that at thirteen years 
she was only three feet high, was seized with con- 
tinued fever ; the catamenia appeared, the limbs 
then gradually straightened, and in less than 
three months her height was five feet one inch. 

The progress of rickets is accelerated by con- 
finement and exposure to cold and damp, by bad 
clothing, imperfect nourishment, and careless 
nursing; and retarded by circumstances the re- 
verse of these : hence it may be that the disease 
is now of less frequent occurrence than in former 
times, and that it has been observed to make less 
progress in spring and summer, and to advance 
most quickly in winter and autumn. But the 
progress of rickets often varies without any ob- 
vious cause ; it sometimes appears to be arrested 
as if recovery were at hand, then revive, and pro- 
ceed with more rapidity than before. As the dis- 
ease advances to a fatal termination, the little suf- 
ferer cannot bear even to be moved in bed, and 



the attempt is often productive of the fracture of 
some bone : hectic fever is now established, with 
its attendant colliquative perspirations and diar- 
rhoea. At this period also, a variety of nervous 
symptoms sometimes present themselves ; such 
as temporary deafness, or blindness, irritation of 
the bladder or inability to expel the urine, or 
paroxysms of epilepsy, or convulsions. Should 
these last not prove the cause of death, the patient 
at length sinks under debility, and dies exhausted. 

On examining the bodies of those who have 
died while still labouring under rickets, the brain 
is found disproportionately large, but often in other 
respects quite natural ; in some instances the 
ventricles are filled, or perhaps considerably di- 
lated with a liquid fluid ; and a similar fluid is 
also found in the basis of the skull and within the 
canal of the vertebrae. The cavities of the thorax 
and abdomen likewise sometimes contain serous 
or bloody liquid ; the lungs are compressed and 
occasionally displaced by the alteration in the 
form of the thorax ; marks of inflammation are 
often apparent in the pleura and pulmonary sub- 
stance, which last is sometimes hepatized, and at 
other times contains numerous tubercles in various 
stages of advancement. It is remarkable that in 
some cases of rickety children from one to ten 
years old, the thymus gland has been found much 
enlarged, and the upper part of the sternum bulg- 
ing out, so as to form a concavity, within which 
the overgrown organ was lodged. {Lobstein, 
Anatomie Patholog. t. i. p. 54.) The heart is not 
found diseased where death occurs during the 
active progress of rickets ; but in those who have 
survived with deformity of the chest, the obstacle 
thus occasioned to the circulation, especially 
through the lungs, rarely fails to produce in the 
end hypertrophy of that organ. {Hope, on Dis- 
eases of the Heart, p. 194.) The liver and spleen 
of rickety subjects are almost in every case en- 
larged, the former in particular. The mesenteric 
glands are usually enlarged, and often filled with 
tuberculous matter; and the other absorbent 
glands, both within the abdomen and externally, 
present similar alterations. 

In the soft parts little or no adipose substance 
is found ; the muscles are pale, flabby, and wasted; 
and the rigidity of death is rarely met with in 
such subjects. The bones, during the active 
stage of rickets, are found to resemble very vas- 
cular cartilage; the medullary cavities are filled 
with a bloody gelatinous-like substance in place 
of marrow ; and the osseous texture presents 
every where, even in the cortex, numerous minute 
cells, from which a thin bloody fluid can be 
pressed. The appearance of rickety bones has 
been well compared to that of a healthy bone 
deprived of its earthy materials by immersion in 
a weak acid ; but there is this difference, that 
the rickety bone is much more vascular, and that 
the cartilage of which it consists is of so loose a 
texture, that it is soluble in the same acid which 
will deprive common bone of its earthy consti- 
tuents. We are not acquainted with any analysis 
of recent bone affected with infantile rickets ; and 
the examination of those which have been dried 
cannot afford much accurate information respect- 
ing the constituents of parts which obviously con- 
tain so unnaturally large a proportion of fluid and 



46 



RICKETS. 



easily destructible ingredients. Nothing, indeed, 
has tended so much to obscure the pathology of 
the bones as the almost exclusive practice of ma- 
cerating and preserving them in a dry state. 
When the bones of those who have recovered 
from rickets are examined, their texture is found 
to be more dense, in consequence of a morbidly 
increased deposition of the earthy salts ; even 
small exostoses and bony spiculse are sometimes 
observed ; and in cases where the spine is de- 
formed, the bodies of many of the vertebra; are 
found united by new osseous substance. The 
bones of the cranium are observed to be much 
heavier and thicker than natural, the sutures often 
obliterated, and the grooves formed by the me- 
ningeal arteries greatly deeper than common. 
Wherever the bones have been bent during their 
yielding state, a larger deposition of earthy salts 
is observed in the interior of the curve where its 
weakness had been the greatest ; and to such an 
extent does the deposit of osseous matter some- 
times take place, that the bone at the point of 
curvature has been converted into a solid sub- 
stance, the medullary cavity being wholly ob- 
literated. {Stanley, Lond. Medico-Chir. Trans, 
vol. vii. See also Wilson's Lectures on the Hu- 
man Skeleton.) Perhaps to some it may appear 
sufficient to say that the earthy salts are thus 
deposited, because they are most wanted at the 
weakest point of the bony shaft ; but the real 
cause of this arrangement seems to be that the 
bending of the bone has compressed into the in- 
terior of the curve a larger quantity of cartilaginous 
substance, which is afterwards filled with an 
earthy deposit ; while it stretches and attenuates 
that on the exterior of the arch, and so diminishes 
there the matrix for the reception of earthy ma- 
terials. It may be observed also, that the effect 
of bending the pliant bone is to bring its opposite 
sides into closer approximation, and thus to pre- 
pare the way for that ossification throughout its 
whole diameter to which allusion has already been 
made. Bones which are distorted are commonly 
named rickety, whether in the active stage of 
that disease or after its cure, when they have ac- 
quired an unnatural density from hyperostosis : 
hence some confusion has arisen in stating the 
composition of rickety bones ; and the assertion 
has been hazarded that a deficiency of phosphate 
of lime is not an essential, but merely an adven- 
titious circumstance in rickets. Dr. John Davy 
found 100 parts of the dry tibia of a healthy sub- 
ject of fifteen to yield 46.4 of animal matter, and 
53.6 of earthy ; while the same quantity of the 
dry tibia of a rickety child contained 74 parts of 
animal and 26 of earthy substance. (Monro, 
Elements of Anatomy, vol. i. p. 27.) 

2. Causes. — Rickets appears under very dif- 
ferent circumstances, and therefore may be sup- 
posed to derive its origin from a diversity of 
causes. It is met with among the children of the 
affluent, enjoying every advantage of careful nurs- 
ing, warm clothing, nutritious food, and airy 
apartments; and it is found likewise in the damp 
unwholesome dwellings of the artisan and la- 
bourer, where the child is neglected, scantily 
clothed, and poorly fed. In the former of these 
classes it is almost always a hereditary disease, or 
if not, it exists in connection with a scrofulous 



habit transmitted from the parent : in the lattei it 
may also arise from hereditary influence ; but it 
seems more generally to originate from those un- 
favourable circumstances in the rearing of the 
child which have just been enumerated. Some 
writers have endeavoured to trace a connection 
between rickets and gout, syphilis, and scurvy ; 
but it has not been satisfactorily shown that any 
of these diseases, either in parent or child, can 
operate as causes of rickets excepting by the de- 
bility which they may induce, and the predisposi- 
tion to the malady which may thus be occasioned. 
Of scrofula, on the other hand, we would speak 
in very different terms; for the connection of this 
disease with rickets appears to be very intimate ; 
although we are far from agreeing with Dr. Tho- 
mas Young in the propriety of classing rickets as 
a mere species of scrofula, scrofula rhachitis. 
(Introduction to Medical Literature.) 

Rickets rarely occurs excepting in delicate and 
sickly children : instances are occasionally met 
with where robust children, born of healthy 
parents, have been attacked with the disease ; but 
it may be questioned whether such cases were 
truly rickety, or if the yielding of the bones had 
not rather arisen from the great weight of the 
infant's body, and from too early endeavours to 
make him walk. 

Many cases have occurred which prove the 
close connection which exists between rhachitic 
disease and affections of the encephalon, such as 
hydrocephalus and convulsions. Biichner (De 
Rhachitide in Haller. Disput. Medics, torn, vi.) 
relates that he saw almost the whole of a family 
of eleven brothers affected with rickets. Most of 
them died of the disease in an advanced stage, 
while the rest were carried off by convulsions. 

Rickets has been observed to prevail in particu- 
lar localities, probably from their unhealthiness, 
and the indigence and misery of their inhabitants. 
Hence it may be regarded as occasionally an en- 
demic disease ; it is so described by Glis>on in 
reference to England, (De Rachitide, p. 3. Lugd. 
Batav. 12mo. 1761,) and instances are recorded 
where it assumed the same character in different 
parts of Germany. (Acta Nat. Curios, vol. ii. obs. 
153. Ephemerid. Nat. Curios, cent. i. et ii. append. 
p. 23.) 

3. Treatment. — During the existence of the 
acute febrile symptoms of rickets, it will be pro- 
per to administer moderate doses of antimonials, 
to employ the tepid bath, and in some instances 
even to apply leeches to the forehead or nape of 
the neck, according to the urgency of the case 
and the strength of the little patient. The im- 
paired appetite, morbid stools, and disordered 
urine require the use of small doses of calomel or 
hydrargyrum cum creta ; followed by magnesia 
and rhubarb, or rhubarb and soda, with an occa- 
sional dose of a more active aperient, such as 
castor oil or senna. If the disease have occurred 
at a very early age, it may be advisable to try the 
effect of changing the wet-nurse ; and in general 
it will be proper to wean the child about the end 
of the ninth month, for protracted suckling is cer- 
tainly one of the debilitating causes which dispose 
to rickets. While the child conti nues at the 
breast, the diet of the nurse ought to be carefully 



attended to, in order that her milk 



may prove 



RICKETS. 



47 



nutritious and easy of digestion : or its powers 
may be assisted by allowing the infant, in addi- 
tion, small quantities of isinglass-jelly, beef-tea, 
or yolk of egg, provided the absence of febrile 
excitement will permit. After the child has been 
weaned, the diet must be suited to the degree of 
constitutional irritation which exists ; but one 
loading principle should be to support the strength 
as much as possible without quickening the circu- 
lation or oppressing the stomach. Farinaceous 
food has been condemned by many writers as in- 
jurious to rickety patients, from its inferior nutrient 
properties; yet it will not be denied that, during 
the existence of febrile symptoms, the various pre- 
parations of starch will be found to yield a mild 
and appropriate nourishment. Whenever the 
state of irritation has so far subsided that a more 
substantial diet can be borne, it ought to be given 
freely, and even a little wine or sound ale may 
be allowed as long as it causes no morbid excite- 
ment. 

In the second stage of the disease our principal 
objects in selecting the means of cure are, to give 
tone to the system, and improve its nutrient and 
reparative powers ; and for these purposes the 
cold plunge-bath, the affusion of cold water with 
salt, careful friction of the whole body, and the 
employment of tonic medicines, will be found 
very useful. Among the tonics best adapted for 
cases of rickets may be enumerated sulphate of 
quinia, gentian, calumba, oxide of zinc, and va- 
rious preparations of iron, of which, perhaps, the 
wine and carbonate are to be preferred. With 
many of these it will be found highly advantage- 
ous to combine the alkalies and alkaline earths, 
the choice of some of them being determined by 
the state of the bowels and the rapidity or languor 
of the circulation ; carbonate of soda being pre- 
ferable when the bowels are relaxed, and carbonate 
of ammonia when the action of the heart is lan- 
guid. In rickety cases, where the nervous energy 
appears defective, it may be proper, in addition to 
the means of invigorating the frame already enu- 
merated, to employ electricity or galvanism, but in 
a very cautious manner. 

The clothing of the child ought to be warm, 
and great care should be taken to preserve it free 
from damp. The apartment in which he sleeps 
should be dry and well ventilated, and his resi- 
dence should be in a pure, temperate atmosphere, 
either in the country or on the sea-coast ; and 
when the weather permits, he should be carried 
about in the open air as much as possible. When 
the rickety child is carried, it should be alternately 
in either arm ; and when placed in a chair or laid 
in bed, his position should be such in regard to the 
various objects of attraction around him, that he 
shall not incline continually to one side only ; or 
so varied from day to day, that the formation of 
any tixed deformity may if possible be prevented. 
His bed should be smooth and comfortably firm, 
and the head but little elevated ; the bed-clothes 
light, yet sufficiently warm. As soon as the con- 
stitution appears to be rallying, and the bones 
acquiring renewed strength and firmness, attempts 
should be made to restore them to their natural 
shape by well-directed manipulations, and the 
employment of such mechanical contrivances as 



will give support without injurious confinement. 
Considerable success is known to have attended 
the treatment practised by the Baron Dupuytren 
(Repertoire generate d'Anat. et de Phys. Patholog. 
torn. v. p. 198,) in deformity of the chest. His 
plan is to place the child with his back against the 
knee or a wall, and make moderate and gradually 
increasing pressure with the palm of the hand on 
the sternum, so as to diminish the antero-posterior 
diameter of the chest, and force out the ribs to- 
wards their natural convexity. This practice is 
repeated day after day very frequently, and at 
suitable intervals, with increasing force and for a 
longer time, augmenting and relaxing the pressure 
so as to suit the movements of respiration ; until 
at length, after long and careful perseverance, the 
natural shape of the thorax is to a certain extent 
restored. 

II. Rickets or Adults. — Mollifies ossium. 

1. History. — The softening of the bones 
which is met with in persons of adult or advanced 
age, presents itself in various degrees of severity. 
Sometimes it is merely a protracted form of in- 
fantile rickets, which has continued with numerous 
checks and interruptions, and successive revivals 
and increase of symptoms, even to advanced life. 
On other occasions, and these are not rare, soften- 
ing of the bones occurs during pregnancy or fol- 
lows parturition, and increases in severity during 
each successive gestation. The parts of the 
osseous system chiefly affected in these cases are 
the spine and the pelvis ; hence the difficulties of 
childbirth are usually augmented at every suc- 
ceeding confinement. But the disease has been 
observed in its most aggravated form among males 
as well as females, although certainly more often 
among the latter. Several notices of this intense 
form of mollities ossium are to be met with among 
the early historians and biographers of modern 
times : thus Abbon, the monk, who lived in the 
ninth century, relates an extraordinary instance 
where a very large man was reduced by it to the 
diminutive size of a child. (Guerres de Paris.) 
And Abulfedda asserts that the body of the 
prophet Gatleb was without bones, so that his 
limbs could be folded up like a garment. (Vita 
Mohammed.) Perhaps the first medical writer 
who has made mention of mollities ossium is 
Hollerius (De Morbis Internis. Rara Qusedam, 
No. 7. 4to. Paris 1609) : he states briefly that 
there was a woman in Paris whose whole body 
was soft and flexible, and without solid bones. 
The next case on record, and it is a well-marked 
and interesting one, is that detailed by Abraham 
Bauda, which occurred at Sedan in 1650. (Mi- 
crocosmus Mirabilis. Sedan, 1665.) Since that 
period many instances of mollities ossium have 
been published in different countries, references to 
the most important of which will be found in the 
present article. 

The softening of the bones in this disease Is 
preceded by severe and long-continued pains, 
which are usually confounded with rheumatism, 
and have sometimes been supposed to arise from 
syphilis: a gradually increasing debility seizes the 
limbs, the nervous system acquires an excessive 
morbid irritability, the patient walks with the 
utmost fearfulness, and the slightest jar or con 



48 



RICKETS. 



cussion of the body causes agony.* Some bone 
now suffers fracture, which all the efforts of the 
surgeon are perhaps unable to unite; the patient 
being constantly confined to bed, the bones soften 
more and more, assume the most strangely dis- 
torted forms, ami before death have in some cases 
been so completely disorganized that the extremi- 
ties were as limber as a rag. (Bevan, in Philos. 
Trans, v. 42.) The patient lies coiled up in bed, 
sometimes scarcely preserving, except in counte- 
nance, the semblance of a human being; the 
limbs appearing more deformed, and the stature 
much more shortened than they are actually found 
to be after death. Every attempt to alter the po- 
sition of the patient produces agonizing pain, and 
perhaps new fractures, if the bones be not already 
loo much softened to snap asunder. In such cir- 
cumstances it is truly astonishing to observe how 
little the general health suffers, the appetite, di- 
gestion, and excretions remaining unimpaired till 
within a few weeks of death, and the mind con- 
tinuing calm and intelligent, almost to the last. 
The urine in such cases is frequently turbid, de- 
positing a copious white sediment ; and in some 
instances small urinary calculi have been voided. 
But this morbid state of the urine is not constant, 
for it becomes clear and then again turbid, and 
occasionally clear for weeks before death. At 
length hectic fever comes on, sometimes with a 
feeling of intense burning heat, such that the pa- 
tient can bear with difficulty the thinnest covering, 
and requires the windows to be kept open even in 
the middle of winter.j Diarrhoea and perspira- 
tions now exhaust the patient, and death at length, 
after years of protracted suffering, comes to his 
relief. 

The appearances on inspection after death 
from mollities ossium differ considerably from 
those which are observed in the bodies of rickety 
children. The bones, instead of presenting the 
appearance of cartilage, as in rickets, are reduced 
to a mere shell resembling the rind of cheese, and 
are sometimes described as soft and membranous, 
and of the thickness of the peritoneum ; in one 
instance the form of some of the bones seems to 
have been preserved merely by the periosteum ;t 
and in the case related by Saviard, (Saviard, 
Nouv. Recueil d'Observat. Chirurg. p. 276,) the 
remnants of the bones are described as crumbling 
between the fingers like the rotten bark of a tree. 
Tne cavity within the changed and wasted bone 
has been found rilled with a soft red or liver-colour- 
ed substance, which in the living body has been 
ascertained to be devoid of sensibility, (Thomson, 
Med. Observ. and Inquiries, vol. v. p. 259); at 
other times the contents have been a reddish fluid 
of the consistence of thick honey, and free from 
any disagreeable odour. (Bevan, Phil. Trans, vol. 

♦See a very interesting case by Mr. Howship Ed 
Med. Chir. Trans, v. n. 

T Planck, de Osteosarcosi Commentatio, 4to. Tuhin* 
1782. This writer has been quoted as an authority on 
isteosarcoma, but Ins essay refers wholly to mollities 
issiuro, of which it contains a very interesting case 
.vith an able and learned commentary. D 

of Madame Supiol, Moraud, in Mem de 
'Acad. R. des Sciences, 1755.— Hosty, in Phil Trans 
• Tiii, ."it. — Bromfie/d, Surzical Cases, vol. ii n 35 Here 
the is called Quenot, her maiden name. The (skeleton 
of Madame Supiol is still preserved in the Museum at 
the Jardin des Plantes in Pans. 



xlii. p. 488.) In Mr. Howship's case (Edin. Med. 
Chir. Trans, vol. ii.) the contents of the wasted 
bony shell were various in their appearance : one 
mass resembled coagulated blood, another gorged 
liver, a third light fibrinous matter, and a fourth 
was like compact fleshy substance. The last 
portions of the long bones which undergo these 
remarkable transformations are the extremities; 
and the remnants of osseous substance which 
they present are found softened and honey-combed 
with numerous irregular apertures, appearing, 
when macerated, like a thin piece of ice when 
partly melted; thus affording unequivocal evidence 
of the powerful action of the absorbent vessels to 
which the osseous tissue had been subjected. The 
cartilaginous coverings of the articular extremities 
of the bones have sometimes been found entire, at 
other times attenuated, but the surface polished 
and raised into eminences ; the cavities of the 
joints sound ; and even when unused for six 
years, filled with healthy synovia. (Case by 
Thomson, Med. Obs. and Inquiries, vol. v.) 

Although fractures of the bones have not appear- 
ed during the life of the patient to have united, 
yet after death a callus has occasionally been 
found to have formed, sometimes only within the 
cavity of the disorganized bone, occupying it com- 
pletely at the point of fracture ; at others it has ap- 
peared externally as a prominent ring, and formed 
within a solid osseous partition, (Planck, de Osteo- 
sarcosi Comment); thus proving that the solution of 
continuity had served to restore to the part its ossific 
powers while they were everywhere else deficient. 
The muscles, in cases of mollities ossium, are 
found pale, and in general totally altered in their 
appearance, so that it would be quite impossible 
from their adhesions and displacement to unfold 
them by dissection. The viscera of those who 
have died of this disease have sometimes been 
found quite healthy, (Saviard, Rec. des Observ. 
p. 276.— Howship, Ed. Medico-Chir. Trans, v. 
ii.); and in most of the cases they are not stated to 
have suffered much serious alteration; in one 
instance indeed the liver was enlarged, (Bevan, 
Phil. Trans.); in another the gall-bladder was 
contracted, and contained no bile, but many 
minute black calculi. (Thomson, Med. Ob. and 
Inq.) It is obvious, however, from the histories 
of other cases, that the lungs and raucous membrane 
of the bowels must in these instances, if carefully 
examined, have presented abundant traces of 
active disease. 

2. Tne Causes of mollities ossium are exceed- 
ingly obscure : syphilis, gout, rheumatism, and 
scurvy, have all been accused as the sources of 
this singular disorganization of the solid frame- 
work of the body. The sagacious Saviard ob- 
serves that syphilis produces caries; but this is a 
softening and melting down of a totally different 
nature: as to the other diseases named above, 
they possess nothing in common with that now 
under consideration, excepting pain, languor, and 
debility. In well-marked and extreme cases of 
syphilis, gout, rheumatism, and scurvy, where 
death has been the result, we do not meet with 
mollities ossium as a concomitant, yet authors 
gravely tell us that softening of the bones arises 
from the diseases now enumerated lying h 1( ] ; n 
the constitution and tainting the habit This 



RICKETS, 



49 



affection appears to be closely connected with an 
enfeebled and relaxed state of the system. Long 
confinement to bed, after acute diseases in young 
persons, is often productive of some degree of soft- 
ening of the ligaments and hones, and consequent 
deformity ; we have seen the pelvis in a delicate 
boy, after tedious convalescence from measles, 
elongated diagonally, producing great deformity 
and lameness ; in old age, we have known a lady, 
who was long bed-ridden, fracture her clavicle by 
the mere eflbrt of attempting to raise herself in 
bed by the help of a cord. Indeed, the progressive 
alteration which the bones naturally undergo in 
advanced life is itself an approximation to decay, 
the cortical part becoming thin, and the medullary 
cavity enlarging ; but the former still preserves its 
hardness of texture. A careful examination of 
the bones, after a long period of inaction, shows 
that their healthy state is almost as much depend- 
ent on the due exercise of the muscles as that of 
the muscles themselves. In the vegetable king- 
dom we see the effect of exercise remarkably ex- 
emplified by the increase which it occasions in the 
bulk and density of the woody fibre. The wood 
of forest-trees which have stood alone, and exposed 
to the full force of the blast, is much closer in its 
texture and more durable than timber raised in 
natural groves or crowded plantations; and the 
size and strength of the roots of trees is always 
much greater in the side which stands exposed to 
the prevailing wind. 

Females are much more liable to mollities ossi- 
um than males ; and pregnancy and parturition 
favour in a remarkable manner the progress of the 
disease. Under such circumstances, the weight 
to he supported, the drain of nourishment for the 
supply of the foetus, and the distending throes and 
exhausting consequences of labour, must all prove 
powerful causes of relaxing the connections of the 
bones and lowering the strength of the system. 
Softening of the bones is observed to occur most 
frequently in persons of a strumous habit ; and 
this peculiarity of constitution may be fairly re- 
garded as forming at least a strong auxiliary cause 
in the development of the disease. 

3. Treatment, — Mollities ossium, unlike the 
rickets of children, occurs at a period of life when 
the reparative powers of the system have lost their 
early vigour, or perhaps when they are already in 
a state of decay : hence a cure of this disease very 
rarely or never takes place ; but it may proceed 
with greater or less rapidity, and may be checked 
in its progress by judicious management. We 
have been unable to discover any case of mollities 
ossium in which a satisfactory cure has resulted, 
either from the unassisted efforts of nature or from 
medical treatment ; but instances of the milder 
form are known to us, where the disease has pro- 
ceeded slowly for years, and some of the individu- 
als have attained even an advanced age. The 
influence which pregnancy has been observed to 
exert in accelerating the progress of mollities os- 
sium, renders it necessary that the patient should 
live as in a state of celibacy ; and every thing 
which tends in any degree to weaken the frame 
ought to be carefully avoided. Frictions of the 
whole body, gestation in the open air, nutritious 
diet, mild tonics, great attention to the state of the 

Vol. IV. — 7 e 



digestive organs, and removal to a dry, warm, and 
pure atmosphere, are the principal points to be 
attended to in our endeavours to arrest the pro- 
gress of this disease. Benefit is likely to be de- 
rived, also, from sponging the body with sea- 
water, or the strong acetic acid obtained from 
wood ; and if the strength be not too far reduced, 
the cold shower-bath, or sudden immersion in sea- 
water, may be tried with caution. 

Before concluding our account of the several 
species of softening of the bones, it is proper that 
we should say a few words on the subject of late- 
ral curvature of the spine, which of late years has 
engaged so large a share of the attention of medi- 
cal men of both branches of the profession. In 
rickets, the curve assumed by the spine is, with 
few exceptions, confined nearly to the mesial line ; 
and in mollities it is sometimes so, and sometimes 
lateral ; but a very large proportion of the cases 
of lateral curvature of the spine are wholly inde- 
pendent of both rickets and mollities ossium, and 
arise from debility or habitual malposition of the 
body, such as are too often induced by the re- 
straints and fatigues to which young persons are 
subjected in the course of education. (Shaw, 
Essay on the Nature and Treatment of Distor- 
tions of the Spine and Chest.) Hence arise 
sinking of the spinal column into the flexures 
naturally assumed under feelings of languor and 
exhaustion, and twisting of a part of the vertebrae 
upon their axes : after a time they remain station- 
ary in their new situations, both the ligaments 
and muscles being so changed that the latter are 
no longer capable of restoring the bones to their 
proper positions. Thus, lateral curvature becomes 
established, and the figure of the patient is per- 
manently deformed. 

On examining after death the individual bones 
of the spine in such cases, we often find them 
quite healthy and natural in their form, but more 
or less twisted upon their axes : in some instances 
we have seen traces of inflammation, and new 
bone formed uniting them to each other ; and, 
more rarely, we have observed the bodies of the 
distorted vertebras somewhat attenuated and ex- 
panded in the interior of the curve where they 
were most exposed to pressure — a change which 
was probably the effect rather than the original 
cause of the deformity. 

The treatment of lateral curvature of the spine 
falls chiefly within the province of the surgeon; 
but it will be the business of the physician to di- 
rect the application of tkose means which tend to 
restore the general health of the patient, and thus 
render effectual the exercises and training, the 
manual efforts and mechanical contrivances of the 
surgeon, which would otherwise prove unavailing 
or injurious. A carefully regulated diet, strict at- 
tention to the bowels, mild alteratives and tonics, 
relief from the restraints of education, and removal 
to a pure air, friction of the body, gentle exercise 
in a carriage or on foot, sea-bathing, or the cold 
shower or plunge-bath, or tepid or warm bathing 
according to the circumstances of the case, consti- 
tute the principal remedies by which the physician 
is enabled to lend effectual assistance in the treat 
ment of lateral curvature of the spine. 

W. Cumin 



50 



ROSEOLA.— This term is applied to a cuta- 
neous efflorescence of a rose colour, not sensibly 
prominent, usually preceded and accompanied by 
mild febrile symptom* In some cases the rash is 
diffused generally over the skin, but frequently it 
is partial or limited to certain regions of the body, 
as the face, neck, trunk, or extremities ; in which 
situations it occurs in patches variously figured, 
and of more or less extent. It has not (infre- 
quently, especially by the older writers, been mis- 
taken for measles or scarlatina; hence, probably, 
originated the notion, which many entertain, that 
scarlatina, unlike other exanthematous fevers, may 
occur more than once in the same individual. 

Roseola is generally preceded by smart feverish 
symptoms — irregular chills alternating with heat 
of skin — pain in the head and limbs — languor and 
lassitude — and sensation of faintness. After these 
symptoms have continued for a few days, the rash 
appears first on the face and neck, spreading in a 
day or two afterwards over the whole body, and is 
generally attended by tingling or itching. When 
it first comes out, the eruption is of a bright red, 
but it soon assumes its characteristic rose colour. 
It begins to decline about the third day, and on the 
fourth, a few dark red specks are only perceptible, 
which wholly disappear on the fifth, at which pe- 
riod the whole disorder in general terminates. 

From the redness and sensation of roughness in 
the throat, it would appear that the efflorescence 
extends over the mucous membrane of the mouth 
and fauces ; and this circumstance tends to render 
the diagnosis between roseola and scarlatina more 
obscure. 

The efflorescence is not always so generally dif- 
fused oyer the skin ; in many cases it is partial, 
appearing only in patches on the face, neck, 
breasts, or shoulders : it frequently recedes and 
conies out again, its recession being followed by 
symptoms of gastric disturbance, which cease 
when the rash re-appears. The recession and re- 
appearance of the rash cannot often be traced to 
any evident cause, though in many instances irre- 
gularities in diet and other indiscretions have been 
supposed to be powerful agents. 

Though roseola may occur at any season of the 
year, it is more frequently observed in summer, 
(Roseola JEstiva,) and is usually attended by 
smart feverish symptoms. On the first day the 
eruption is very liable to be mistaken for measles ; 
but the peculiar character of the eruptive fever, the 
absence of the catarrhal symptoms, and the form, 
colour, progress, and duration of the rash, ate suf- 
ficient to distinguish the two diseases. The rash, 
which is accompanied by sensation of itching or 
tingling, is observed first on the face and neck, and 
in the course of twenty-four to forty -eight hours 
spreads over the whole body. The spots are dis- 
tinct and scarcely prominent, of a circular or oval 
form and deep rose colour, the intervening portions 
of the skin preserving their natural appearance. 
The patches are at first very small, but gradually 
increase in size. The duration of this form of ro- 
seola is from three to four days, unless, as some- 
times happens, the rash reappears at irregular in- 
tervals, and then its course may be protracted in- 
definitely. It generally disappears without sensi- 
ble desquamation Df the cuticle. 

A similar form of roseola is occasionally ob- 



ROSEOLA. 

served in autumn (Roseola Autumnalis). It dif- 
fers from the preceding in being unattended by 
itching or tingling, or feverish ind.spos.tion, and 
in the eruption appearing chiefly if not exclusively 
on the arms. 

Another variety of roseola has been described 
bv Willan (Roseola Annulala), in which rose- 
coloured rings, with central areas of the natural 
colour of the skin, appear on almost every part of 
the body, attended with sensation ot heat, prick- 
ing, and tingling, especially during the night. 
The eruption, which is preceded by symptoms of 
acute fever, rigors, headach, flushing of the face, 
nausea, and pain of limbs, may last four or five 
days, and disappear as the feverishness abates; or, 
as now and then happens, it may be unattended 
with fever, and be of much longer duration. In 
these latter instances the eruption generally ap- 
pears most vivid in the evening, or when the indi- 
vidual becomes warm in bed, and continues till 
morning, when it fades. It is sometimes also sen- 
sibly elevated, and very often, more especially when 
the eruption suddenly recedes, attended with con- 
siderable gastric disturbance. 

Though roseola is not confined to any period of 
life, it is a frequent cutaneous disorder of infants, 
more especially during dentition, derangement of 
the bowels, and various infantile diseases attended 
with fever (Roseola Infantilis'). Dr. Willan 
states that this efflorescence continues in some in- 
stances for a night; in other cases it appears and 
disappears for several successive days, being at- 
tended with symptoms of violent irritation. He 
has seen, even in infants but a few days old, an 
efflorescence on dillerent parts, in numerous coa- 
lescing patches, rounded, though not exactly cir- 
cular, of about the size of a sixpence, and of a 
strong red colour. These continue five, six, or 
eight days, with a slight elevation of the cuticle, 
and terminate by desquamation, but are not always 
attended with constitutional disorder. Occasion- 
ally during the first stage of dentition, a single 
patch of efflorescence appears on one arm or on 
the neck : it remains three or four days, then dis- 
appears, and is in a short time succeeded by ano- 
ther, perhaps on the opposite arm. This fades 
and disappears in about the same period, when a 
fresh patch arises in another place, and thus the 
eruption may be continued two or three weeks. 

Roseola occasionally occurs also previous to the 
eruption of both the natural and inoculated small- 
pox, hut seldom in the former ; and when it does 
occur in connection with the natural small-pox, it 
always indicates a severe and often fatal disease, 
though some inoculators deemed it an indication 
of a tavourable variolous eruption. The early 
writers on small-pox observed this roseolous efflor- 
escence, whuh they regarded as measles converted 



into small-pox. Dr. Willan, who applied the term 
Jioscola Variolosa to the rash when it occurred in 
connection with small-pox, states that it appears 
m about one case of fifteen in the inoculated 
small-pox, on the second day of the eruptive fever, 
which is generally the ninth or tenth after inocu- 
ation J he rash is first observed on the face, 
•as and arms, and on the following day spreads 
o^er the trunk and lower extremities. J, some- 
times assumes the form of oblong reeu ta 
patches; ,n other cases it is diffused w h 



ROSEOLA — RUBEOLA. 



51 



merous interstices; and occasionally it extends 
over the whole body, so that the skin presents a 
continuous redness, with slight elevation in some 
places. The rash continues about three days, 
on the second or last day of which the small-pox 
pustules make their appearance, and may be dis- 
tinguished in the general redness by their promi- 
nence and hardness. 

A similar efflorescence, but appearing generally 
in a congeries of dots and small patches, and 
slightly elevated, takes place in some children 
about the ninth or tenth day of vaccination, and 
about the same time that the areola forms around 
the vesicle. To this rash, which spreads irregu- 
larly over the surface of the body, Dr. Willan 
gave the name Roseola Vaccina. It is generally 
attended with slight febrile indisposition, though 
from the statement of Dr. Jenner it would appear 
to be seldom observed, as his notes did not furnish 
him with a single instance of it, nor did he recol- 
lect in any case more than one or two slight 
patches of redness, which very soon disappeared. 

Lastly, roseola sometimes appears in connec- 
tion with various acute disorders — miliaria, various 
forms of continued fever, acute rheumatism and 
with gout. When it occurs under such circum- 
stances, it is to be regarded merely as an accidental 
complication or concomitant. 

Though attention to the appearance of the 
efflorescence and the constitutional symptoms by 
which roseola is accompanied will seldom leave 
any doubt as to its nature, there are some acute 
eruptive disorders which it resembles in some 
particulars, and from which it must be distin- 
guished. 

Measles may be discriminated by the catarrhal 
symptoms which precede and accompany the 
eruption, which generally appears on the fourth 
day of the eruptive fever, and declines about the 
seventh or eighth ; by the crescentic form and 
vivid red colour of the rash ; by the tendency to 
bronchial or pulmonary inflammation during the 
course of the disease, and by its being propagated 
by contagion. In roseola, the patches are larger, 
more irregular, and more varied in their form ; 
the eruption disappears after four or five days' 
febrile indisposition, is not preceded nor followed 
by any peculiar local inflammation, and is never 
communicated by contagion. 

In scarlatina, the bright red or scarlet colour 
of the eruption, which is more generally diffused, 
and more evident about the flexure of the joints ; 
its appearing on the second day of the eruptive 
fever; the peculiar appearance of the tongue; the 
affection of the throat when it exists ; the desqua- 
mation of the skin at the decline of the rash, and 
its propagation by contagion, will seldom fail to 
distinguish it from roseola. 

It is scarcely possible to mistake roseola for 
erythema, in which the diffused or continuous 
redness of the skin without any distinguishable 
efflorescence, the trifling amount or total absence 
of constitutional disturbance, and its being gene- 
rally symptomatic of some other affection, render 
the discrimination sufficiently easy. (See Enx- 

THKMA.) 

The treatment of roseola includes the adoption 
of an antiphlogistic regimen modified according 
to '•'rcumstances. The little constitutional dis- 



turbance with which it is usually accompanied, 
and the comparatively slight irritation which it 
in general induces, render any active measures 
unnecessary. All that in the majority of instances 
is required, is to keep the patient cool, to prescribe 
light diet and acidulated drinks, to administer 
from time to time a mild aperient ; and as the 
mineral acids have been found useful, they may 
be ordered according to the feelings of the prac- 
titioner. Dr. Bateman was of opinion that the 
decline of roseola was expedited by the use of 
sulphuric acid in the infusion of roses, or the in- 
fusion of gentian, in combination with small doses 
of sulphate of magnesia. The occasional em- 
ployment of the warm or tepid bath may be con- 
joined with these measures. 

When roseola occurs as a complication of some 
internal disorder, the treatment must be directed 
to the removal of the disease of which it is merely 
symptomatic. A Tweedie. 

RUBEOLA, Measles, derived from rubio, red. 
This word appears to be of Spanish origin, and 
probably emanated from the school of Cordova : it 
was formerly written rubiola, or rubiolo. Another 
term by which this affection has been designated 
is morbilli, or the minor plague, being the dimi- 
nutive of il morbo, as the Italians called the 
plague. The restriction now adopted in the ap- 
plication of the term rubeola is of rather modern 
date, and owes its establishment to Sauvages, be- 
fore whose time great confusion prevailed in the 
naming of several of the exanthemata : rubeola, in 
particular, was used to signify equally scarlet fever 
and measles. A similar inaccuracy was to be 
found among the French writers also, for the word 
rougeole, their common name for measles, meant 
at one time scarlatina, and that so decidedly, that 
when it was thought necessary to apply distinct 
names to the two diseases, in consequence of the 
difference between them becoming fully under- 
stood, Chevenan informs us that the Marsellois 
used the word rougeole to signify scarlatina, and 
distinguished measles by the name of senapion. 
(Obs. Med. 454.) In our own country, Morton 
maintained the identity of these two exanthemata, 
and considered the relation existing between them 
the same as that between distinct and confluent 
small-pox. (De Morbillis et Scarlatina, Exerci- 
tat. iii.) Even so recently as 1769, Sir William 
Watson confounded these two diseases, (Med. 
Obs. and Enq. vol. iv. p. 132,) the correct diagno- 
sis between which ought probably to be referred 
to the time of publishing the second edition of Dr. 
Withering's Essay on Scarlet Fever in 1793. 
But this was by no means the only or the most 
remarkable inaccuracy which in former days pre- 
vailed on this subject, since we find Sennertus, 
in the middle of the seventeenth century, discussing 
the question " why the disease in some constitutions 
assumed the form of small-pox, and in others that 
of measles," (Medicin. Prac. lib. iv. cap. 12) ; and 
in a posthumous work of Diemerbroeck, published 
in 1687, it is laid down that small-pox and measles 
are only different degrees of the same affection ; 
" Differunt (morbilli) a variolis accidentaliter, vel 
quod magis et minus." (Tract, de variolis et 
Morbillis, cap. xiv.) The same doctrine was still 
more recently maintained by Lange, a professor ai 



52 



RUBEOLA. 



Leipsic : " Prtcterea tarn morbilli quano variola 
sunt eruptiones in eo duntazat discrepantes, quod 
vel minus vel magis appareant," &c. (Miscell. 
Med. Curios. § xxxiv.) 

Later and more accurate investigations have 
very clearly shown the distinction that exists be- 
tween these diseases, not only in their essential 
characters, but also in the treatment which they 
require ; so that we no longer hesitate in separat- 
ing them, or feel doubtful as to the elements of a 
correct diagnosis between them. 

By the term rubeola, or measles, in modern 
times is understood a contagious inflammatory 
disease, affecting at once the skin and gastro-pul- 
monary mucous membrane, in which, after catar- 
rhal fever has continued about three days, a rash 
appears on the skin, at first in small stigmatized 
dots, not unlike flea-bites, which presently coales- 
cing, form patches of a crescentic or semilunar 
figure, first on the face, and thence spreading gra- 
dually downwards over the whole of the body and 
limbs, at the end of four days disappear by de- 
squamation of the cuticle. 

Rubeola occurs at every period of life, but in- 
fants and persons of ad vanced age are less frequently 
affected by it than those of the intermediate stage, 
[n childhood and adolescence, however, the disease 
is most common. It is asserted by Rosen, Vogel, 
and others, that infants have been born with the 
traces of measles. Guersent mentions (Diet, de 
Med. torn, xviii. p. 513) having seen an infant 
bom with measles on it, having taken the disease 
from the mother; but we presume such instances 
must be of exceedingly rare occurrence. 

.Measles are not unfrequently epidemic; they 
generallyprevail from the beginning of spring to 
the vernal equinox, and decline about the summer 
solstice, though this is only a general observation 
to which numerous exceptions occur. It has been 
frequently observed that whenever measles rage as 
an epidemic, small-pox prevails at the same time; 
and generally speaking, the rubeolous contagion, 
if received into the system previous to that of 
variola, has the power of suspending the variolous 
action till the measles have run their course. This 
has not, however, been invariably the case, for in- 
stances have occurred in which both diseases pro- 
ceeded together ; " this," we are informed by Dr. 
M'Bride, " was observed particularly in the Found- 
ling Hospital of Dublin in 1769. A number of 
the children having been inoculated for small-pox, 
in the meanwhile were seized with the measles, 
and both species of eruption were perfectly dis- 
tinct ; they nevertheless all recovered ;" (Practice 
of Physic, vol. ii. p. 112 ;) and Mr. Russell has de- 
scribed two cases in which the two eruptions ran 
their course together in the same individuals, when 
these diseases were epidemic at Aleppo in 1765.* 
The general law with regard to measles, in 
common with others of the exanthemata, is, that 
they effect the system but once, and this peculi- 
arity is maintained with much greater strictness 
and fewer exceptions than the statements we are 
accustomed to hear in society would lead us to 

* Transactions of a Society for the Improvement of 
Medical ami Chirurgical Knowledge, vol. ii. p. !I0. See 
Frank, torn. ii. p. HOT, French ed. [See. also, a ''Case of 
Ihe Simultaneous Occurrence of Small-Pox and Measles " 
Med. Chir. Trans, vol. xiii. p. 103. 



believe; very many indeed of the cases of secon- 
dary measles so reported, originated merely in the 
parties having confounded roseola or some other 
cutaneous efflorescence with rubeola. Of this we 
have detected several instances, and almost inva- 
riably it has been acknowledged that the former 
disease had not been seen by any competent judge: 
that exceptions have occurred, however, in this 
disease, as in scarlatina and small-pox, cannot be 
denied, but that they have been very rare is proved 
by the few instances which have been recorded. 
Guersent mentions having seen children affected 
with the disease twice in the course of the same 
year ; in one child he observed two very regular 
eruptions of measles in six weeks, and in the in- 
terval between their first and second appearance 
the child had a variety of small-pox. (Diet, de 
Medecine, torn, xviii. p. 512.) The cases of this 
kind related by Dr. Baillie (Trans, of Soc. for Im- 
proving Med. and Chir. Knowledge, vol. hi. pp. 
258 and 263) are not only the most decisive of 
which we are aware, but also the most remarkable, 
as showing not merely an individual but a family 
susceptibility. In the first instance five brothers 
and sisters had it in succession a second time, four 
of them after an interval of six months, and the 
fifth after a lapse of twenty-one years. In the 
other instance two sisters had a return of the dis- 
ease after four months. An observation of Dr. 
Burns (Principles of Midwifery, p. 546, ed. 7.) 
deserves to be noticed here : he observed that 
" When the measles were epidemic, it was not un- 
common to find those who had formerly had the 
disease affected sometimes with catarrh without 
any eruption, sometimes with an eruption pre- 
ceded by little or no fever and without any ca- 
tarrh : this was very distinctly observed during 
every season when the measles were prevalent;" 
but he is doubtful as to the exact nature of the 
eruption. Frank (torn. ii. p. 367) says that a 
second attack of measles is more common than 
of variola, an opinion which appears to be at 
variance with general experience, and decidedly 
with our own. It is also a well-ascertained 
fact that the imperfect form of measles, generally 
denominated rubeola sine cutarrho, does not af- 
ford any protection against a recurrence of the 
disease. 

[Mr. Erasmus Wilson, however, (Treatise on 
Diseases of the Skin, Amer. edit. p. 71, Philad. 
1843,) affirms that one point of difference between 
measles and scarlatina is, that the former "fre- 
quently ( 1 ) attacks the same person twice," whilst 
the latter rarely does.] 

The contagious nature of measles is, we believe, 
universally acknowledged, and there is even rea- 
son to believe that it is infectious before the ap- 
pearance of the eruption (See Rust's Magazine, 
Feb. 1827) ; but, as in other contagious diseases, 
there is a great difference in the susceptibility of 
different individuals equally exposed. We very 
lately attended a young lady with this complaint, 
whose younger sister slept with her during the 
whole of the eruptive fever, and for two nights 
after the eruption made its appearance, and'yet 
escaped the disorder. Heberden mentions that an 
infant who sucked a nurse till the mea c les ap- 
peared on her was not affected. 



RUBEOLA, 



53 



[The communicability of measles was denied 
by Dr. Dewees, (Practice of Physic, Philad. 
1830,) but, evidently, on insufficient grounds.] 

With regard to the latent period of measles, our 
own observation would lead us to fix it at about 
nine or ten days, but this is a point difficult to de- 
termine : after inoculation, the symptoms of fever 
appeared about the seventh day. Dr. Burns (Prin- 
ciples of Midwifery, &c. p. 642) states the latent 
period to be about twelve or fourteen days ; He- 
berden (Commentaries on Diseases, p. 322) from 
ten to fourteen days; Dr. Gregory (Elements of 
Practice of Physic, p. 127, ed. 3) from eight to 
fourteen days ; Dr. Elliotson (Medical Gazette, 
Oct. 1832, p. 99) from five days to a fortnight. 
Dr. Willan says he knew a person who passed 
through the measles and became convalescent, 
whose clothes infected a child in the country ; 
this child had the eruption sixteen days after 
being exposed to the fomites. 

[According to MM. Rilliet and Barthez, (1'raite 
Clinique et Pratique des Maladies des Enfants, 
ii. 747, Paris, 1843,) it generally required an ex- 
posure of from five to twenty-five days in the 
wards before children exhibited the eruptive 
fever.] 

Progress of the Disease. — The symptoms 
of the antecedent fever are not usually such as to 
excite much attention. The child appears at first 
not so well as usual, is less active, and out of 
spirits ; the appetite is impaired, and the sleep is 
disturbed : this derangement of the system is pre- 
sently explained by the patient exhibiting symp- 
toms of catarrh, — frequent cough, sneezing, run- 
ning from the nose and eyes, which are tender and 
generally itchy, so that the child frequently rubs 
the eyes, and picks the nose : the skin is hot and 
dry, with occasional chills ; and the pulse is quick- 
ened. When these symptoms have continued 
about three days, the child feels on the fourth still 
more decidedly sick, and is unwilling to leave its 
bed. Sometimes the precursory symptoms are so 
slight as scarcely to be felt by the patient or no- 
ticed by others. We had lately under our care a 
young lady of seventeen, who was in constant 
attendance on her sister in measles, and the first no- 
tice we had of her having caught the disease was 
the appearance of the rash on her face. (See also 
Heberden, Comment, p. 317.) In other instances 
the precursory symptoms are very severe: there is 
high fever, with violent catarrhal symptoms, rigors, 
total loss of appetite, intense thirst, burning head- 
ach, suffused eyes, intolerance of light, constant 
somnolence, but little or no sleep, or if the patient 
happens to fall asleep, he starts from it as if 
frightened ; the pulse is rapid and sharp, the 
throat sore, and the cough incessant, with pain or 
soreness in the chest. There is an evident exa- 
cerbation of these symptoms towards evening, ac- 
companied often by difficulty of breathing, and 
not unfrequently by nocturnal delirium. 

When the rash appears, which it usually does 
on the fourth day, it is not in general productive 
of much relief of the precursory symptoms, which 
are, indeed, more frequently somewhat increased : 
it is first perceived in general about the roots of 
the hair, on the upper parts of the forehead, and 
on the chin, in the form of small red spots some- 
what resembling flea-bites, which are at first dis- 



tinct, but soon coalesce and form patches of an 
irregular crescentic or semicircular figure, of a dull 
red colour, slightly elevated, and having between 
them portions of the skin retaining its natural ap- 
pearance. If the finger be passed over the sur- 
face, the patches of eruption are felt slightly pro- 
minent and rough ;* this roughness is frequently 
stated to be perceptible only on the face, but we 
have repeatedly found it most remarkable on the 
arms. In a case which we very lately attended, 
the elevation of the patches on the latter parts 
attracted our particular attention. In the course 
of the fourth day the eruption spreads over the 
face ; spots also may be observed on the palate 
and fauces of a dark red colour, which are still 
more distinct after another day, the inflammation 
attending which causes a sensation of dryness and 
roughness in the pharynx, and increases the 
hoarseness. On the next day (the fifth) the 
eruption extends over the neck, breast, and upper 
parts of the trunk ; it is now very vivid on the 
face, which is not unfrequently so much swelled, 
especially the eyelids, that the eyes are quite 
closed up as in small-pox, while the other features 
are from the same cause greatly altered. Towards 
the close of the same day, the eruption begins to 
appear on the arms, and spreads over the lower 
part of the trunk. On the sixth day the eruption 
is vivid on the trunk and arms, and appears on 
the lower extremities about as far as the knees, 
while it is declining or nearly faded on the face. 
On the seventh day it is fully out on the legs and 
feet, and on the hands, while on the body it is 
fading, which it does in the same order as to paris 
as it appeared on them. On the eighth day the 
rash is fading from the parts last invaded, so that 
on the ninth it is hardly perceptible, arid by the 
tenth it has in general entirely disappeared. 
While the fading proceeds, the elevations of the 
cuticle drop off in the form of little scales, so that 
the surface of the body appears as if it had been 
sprinkled over with fine bran. 

Such is the usual course of the disease in its 
simple and regular form; but we occasionally 
meet with deviations or peculiarities requiring to 
be noticed. Thus the eruption, sometimes anti- 
cipating the usual time of its appearance, comes 
out on the third or even the second day of the 
eruptive fever, while in other instances it has been 
delayed many days beyond the ordinary period. 
Buchobz gives an instance of its not appearing 
till the twenty-first day, and Dr. Elliotson in his 
description of the disease says, " these catarrhal 
symptoms will sometimes last two days, some- 
times twenty, before the appearance of the erup- 
tion : in some instances the disease is ushered in 
by severe vomiting, and occasionally, though 
rarely, free salivation takes place." Heberden 
(Commentaries, p. 317; see also Frank, torn. 2, 
p. 370,) tells us of a patient who on the first day 
of the eruption " was seized with a spitting 
which continued to tease him for forty-eight hours, 
without suffering him to rest at all by day, or to 
sleep by night; the cough in the mean time al 



* It appears very singular that Rayer should describe 
the patches of eruption as not arising above the surface; 
his words are. "ces taches ne donnent pas sous le doigt 
la sensation d'une surface ineeale et proininente." - 
Maladies de la Peau, torn. i. p. lb. 



54 



RUBEOLA 



most ceased, and all the other symptoms were as 
mild as in a favourable sort of the measles." 

Convulsions also have occasionally preceded the 
attack, as happens sometimes in small-pox ; and 
one person is mentioned by Heherden, who had a 
most excruciating pain in the hack, which contin- 
ued for a day or two after the eruption. In some 
instances the spots have appeared first on the body 
instead of the face, and in a few rare cases the 
rash has not spread to the arms during the whole 
course of the disease. Sometimes the eruption is 
not followed by desquamation. In many the rash 
is accompanied and intermixed with a very full 
crop of miliary vesicles of such size and distinct- 
ness as to lead to a suspicion ol the approaching' 
disease being small-pox. The production of these 
vesicles has been ascribed by some writers to an 
unusual intensity in the inflammatory action at- 
tending the disease, but this is certainly incorrect, 
as we have seen them very numerous in perfectly 
mild cases. It has happened, but we believe very 
rarely, that the eruption has broken out anew: 
Dr. Oonolly (see article Hysteria in this work, 
vol. ii. p. 568,) relates the case of a young lady 
at school, who became the subject of a very sin- 
gular hysterical affection a few months after 
having had rubeola in an unusual form ; the 
eruption came out and seemed to be disappearing 
at the usual period, when it suddenly broke out 
afresh, and to such an excessive degree as to make 
it impossible to recognise the features of her face : 
very nearly the same thing was observed in a case 
detailed by Frank. (Tom. ii. p. 377.) 

[In his examinations of the blood in measles, 
M. Andral (Pathologie Hematologique, Paris, 
1843, or Amer. Translation, 1844,) found the 
proportion of fibrin to be the same as in health — 
3 parts in 1000. In many adults it was not more 
than from 2£ to 3£. This mean persists at the 
commencement of the disease; but after the 
eruption, and especially in the adynamic form of 
the disease, there is a tendency to the diminution 
of this principle. The proportion of the blood 
corpuscles is, however, augmented from their 
normal proportion, which is 127 in 1000. M. 
Andral has seen them raised to 137, 140 and 146. 
These modifications of the blood are very differ- 
ent from those seen in the phlegmasia;, in which 
there is augmentation of the fibrin, which may 
exceed 10 in 1000, without any increase of the 
proportion of globules. So far, therefore, as the 
state of the blood affords an element for discrimi- 
nation, measles is properly classed with the pyrexiae 
or general fevers. (Guersant and Blache, art. 
Rougeole, in Did. de Med. xxvii. 676, Paris 
1843.)] 

Treatment. — The treatment of measles in its 
ordinary and simple form may be comprised in 
very few directions. The patient should be kept 
in bed, with so much covering only as will secure 
comfort, avoiding equally too much heat or expo- 
sure to cold ; on these points we almost always 
nave to contend against one or other of two pre- 
judices, the most common of which is that a 
breath of cool air is most pernicious to a patient 
in measles, arid in consequence of this belief the 
individual is kept constantly enveloped in a 
smothering heap of bed-clothes with drawn cur- 
tains and the room well heated by fire, by which 



means the fever and all its roncom.tant dangers 
are greatly augmented; others again, who have 
had "children in the small-pox, insist upon the 
advantages of cold, not being able to discriminate 
between the widely different natures of the fevers 
accompanying the two diseases. The patient 
should be kept free from disturbance or noise, 
and, on account of the tenderness of the eves, a 
subdued light only admitted into the chamber ; 
he should be liberally supplied with mild muci- 
laginous drinks, and little or no food, and what- 
ever is taken should be of the simplest kind ; he 
should be solicited to inhale watery vapour by in- 
clining the face over a basin of warm water or of 
chamomile infusion, by which means the tender 
eyes have at the same time the advantage of the 
soothing effect of the vapour; sponging the face, 
chest, arms, and hands with the same infusion, or 
with vinegar and warm water, is productive of 
great comfort by removing the heat, dryness, and 
itching of the skin, which are often distressing; 
for a similar reason mild diaphoretics should be 
given, which may be advantageously combined 
with gentle aperients in such quantity as the state 
of the bowels absolutely requires, active purgation 
being neither useful nor safe. In the opinion of 
some the administration of an emetic should form 
part of the treatment, but the propriety of such a 
remedy has always appeared to us doubtful, and 
we think we have had reason to be satisfied that 
its effects were often decidedly injurious by ex- 
citing disorder of the alimentary canal. 

However favourable may be the condition of the 
case, we should guard against being lulled into 
security as to the event. There is no disease in 
which a change of symptoms occurs more sudden- 
ly, or danger more quickly takes the place of 
safety ; we must therefore at every visit carefully 
ascertain the state of the head, chest, and abdo- 
men ; since from these, and especially the two 
latter, are likely to arise those dangers which may 
compromise the life of the patient. Thus the dis- 
covery, at any period of the disease, of severe 
headach, with pain piercing through the temples, 
and perhaps accompanied by delirium and suffused 
eyes, to which the least ray of light is torture, 
with a rapid hard pulse, is calculated to excite 
great apprehension, and demands the immediate 
adoption of very active measures. The state of 
the lungs should most particularly engage our at- 
tention, as being the organs most constantly and 
most severely affected in this disease. The period 
at which danger may generally be apprehended 
from this source is about the decline of the erup- 
tion, that is, from the seventh to the ninth day; 
but we should be equally on the watch at all times 
to detect the first symptom of inflammation with- 
in the chest, and for this purpose we would 
strongly inculcate the necessity, where there can 
be the slightest doubt, of always determining the 
point by auscultation, instead of trusting to the 
ordmary symptoms to be collected from the state 
of the pulse and respiration, or the expression of 
the countenance, all of which, under the peculiar 
circumstances of this disease, are but little likely 
to afford satisfactory information. When once 
vve have satisfied ourselves of the presence of in- 
nammaUon, our sheet-anchor is bloodletting W» 



should bleed at once ; and if th 



e symptoms are 



RUBEOLA. 



55 



not subdued bleed again ;* we would even say, if 
there be doubt bleed, but of course very cautiouslv, 
— carefully watching the effect, which, in ninety- 
nine cases out of a hundred, will be decidedly 
beneficial. Heberden (see Commentaries, p. 321), 
Cullen (Practice of Physic, vol. ii. p. 180 and 
181), and others of our most celebrated physicians, 
appear to have considered bloodletting as an essen- 
tial part of the treatment in almost all cases, and 
to have practised it in every stage of the disease. 
Mead (.Medical Works, p. 261. Edit. 1767.) 
makes no exception, but directs it in every instance. 
We should, however, be very far from recom- 
mending an indiscriminate adoption of such a 
practice, which under the ordinary circumstances 
of the disease is not required, and might often be 
injurious. Bloodletting is seldom necessary during 
the eruptive fever ; and when the rash has appeared 
we must take care not to fall into the error of mis- 
taking the hurried and labouring respiration and 
quick pulse which accompany the disease during 
the height of the eruption, for proofs of pulmonary 
inflammation, these conditions being merely symp- 
tomatic, and subsiding after a day or two without 
any morbid condition of the lungs coexisting, as 
may be ascertained by the careful application of 
the stethoscope. Should the character of a pre- 
vailing epidemic or of a particular case be low, 
typhoid, or putrescent, the abstraction of blood 
would be altogether inadmissible ; we must also 
bear in mind that a great majority of our patients 
are of tender years, and must be treated accord- 
ingly. In most cases all we desire may be ac- 
complished by the application of a few leeches, 
which should always be applied over a part where 
there is a solid resistance to pressure, should it be- 
come necessary to restrain the bleeding ; in general 
the back of the foot is preferred for this purpose 
in most of the diseases of children. If the object 
be to relieve the head, the leeches may be applied 
to the temples, or still more advantageously behind 
the ears. Whenever we find the patient harassed 
with an incessant hacking cough, complaining of 
pain or soreness within the chest, with a sensation 
of tightness or constriction across that cavity, in- 
creased by a full respiration, and with a full hard 
pulse, we should not hesitate to bleed, even though 
we may not be able fully to satisfy ourselves of the 
absolute existence of thoracic inflammation, the 
effects of which we shall too probably have to la- 
ment if we postpone the application of the most 
effectual remedy for its control. 

We do not propose to enter here into the details 
of the treatment of pneumonia, bronchitis, orpleu- 
ritis, which may be consulted in full under their 
respective titles in other parts of this work: we 
will only here observe, that the remedial agents 
on which our reliance must be placed for subduing 
the inflammations incident to this disease are — 
tting, leeches, blisters, or vesicating lini- 

itll r;reat success ordered even the ter.derest 
i. ifants to In' blooded in the arm, in such quantity as their 

strength indicated. And sometimes also, when 
the disease (pneumonia) has been urgent, I have not 

i repeal the operation; and in reality, by bleed- 
in:.'. I have snatched abundance of children from immi- 
nent death. This disorder attacks children upon the de- 
parture of the measles, and proves so fatal, that it may 
justly be esteemed one of the principal ministers of death, 
destroying greater numbers than the small -pox."— Syden- 
ham, p. 177-d. 



ments, calomel, ipecacuan, tartar-emetic, arid the 
warm bath. Vesicating liniments will often be 
found preferable to the common blister in treating 
this and other diseases of children, from the much 
greater quickness with which they may be made 
to act, and their not being nearly so apt to pro- 
duce ugly sloughing sores, — an effect which is too 
often found to follow the action of the common 
blister, especially in measles ; besides we can very 
conveniently regulate the degree of activity by 
altering the relative proportion of their components. 
A very eligible formula for such an application, 
the efficacy of which we have repeatedly proved, is 
three or four parts of linim. camph. comp. or linim. 
ammonia? with one part of ol. terebinth. If this 
liniment be applied warm to the skin, by sopping 
it in a fold or two of lint of whatever size and 
shape may be thought necessary, it will produce 
vesication generally within twenty minutes. M. 
Luroth has recently recommended frictions with 
strong tartar-emetic ointment over the chest and 
epigastrium in this disease ; but when we consider 
the extreme irritability of the skin in children, it 
would require a strong conviction of the indispen- 
sable necessity for such an application before wo 
should venture to resort to it. Cold affusion has 
been recommended (see Bateman's Synopsis, p. 
61, and Edin.Med. and Surg. Journ. April, 1814), 
and in a few instances adopted in the treatment 
of measles, and it is said successfully. Kocmpfcr 
assures us that at Java the children die of measles 
if they are not washed with cold water; and 
Guersent says he would not hesitate to use it 
where there was pure debility free from disease in 
the chest. (Diet, de Med. torn, xviii. p. 516.) 
We have never witnessed the adoption of this 
practice, and we confess that it appears to us so 
hazardous and so unnecessary, that it would be 
difficult to induce us to venture on the experiment. 
It sometimes happens that the rash comes out 
imperfectly, or having appeared properly, suddenly 
retrocedes and disappears : under such circum- 
stances the nurse will almost certainly, if not well 
watched, give the child a good dose of sulphur in 
diluted spirit, or a glass of punch containing saf- 
fron, which are considered specifics for helping to 
bring out the eruption. The pernicious results 
of such remedies it is unnecessary to point out, 
especially when we consider that in almost every 
such instance the retrocession is the effect of some 
internal disorder which is generally inflammatory, 
or of too high a degree of fever, the reduction of 
which should be the primary object of our treat- 
ment. If the retrocession have been caused by 
exposure to cold, the use of the warm bath, dia- 
phoretics, and warm or perhaps slightly stimu- 
lating drinks, are all that will be required. Should 
debility appear to have been the cause, a stimu- 
lating plan must be adopted, not only because tho 
rash has receded, but because it has done so in 
consequence of a condition of the system which, 
if allowed to continue, might place the patient in 
danger. The improper use of active cathartics 
may have been the source of the evil, or it may 
have arisen from a spontaneous diarrhoea setting 
in from the commencement ; if so, the state of 
the alimentary canal claims our particular car;;. 
Should there be tenderness and other evidence of 
inflammation, we must bleed, or apply leeches 



to 



RUBEOLA. 



and use the warm hath ; if the discharges are ill- 
coloured and of very foul odour, we should give 
calomel, or mercury with chalk and rhubarb ; 
afterwards an anodyne injection may be advisa- 
nle. These observations apply to the treatment 
of diarrhoea when it comes on at the termination 
of the disease : Sydenham says, " Bleeding, also, 
cures the looseness which succeeds the measles;" 
(Works by Swan, p. 178;) but we must observe 
that we cannot always venture to bleed when 
there is tenderness present, which may exist with- 
out any other evidence of inflammation. On the 
contrary, there may be much debility ; and here 
we must have recourse to blisters, irritating lini- 
ments, the warm bath, opiates, astringents, and a 
rice diet, with removal into the country to com- 
plete the cure. 

A'arieties of Rubeola. — 1. Rubeola, sine 
catarrho is a form of the affection in which the 
eruption appears unaccompanied by the usual 
symptoms of fever and catarrh, and its invasion 
does not protect the individual against a second 
attack. This variety has been called by the Ger- 
man writers rubeola spuria, and by Dr. Good 
rubeola incocta. Rayer denies the existence of 
this form of measles, and maintains that such 
cases are merely roseola mistaken for measles ; 
but the descriptions of Willan, Heberden, and 
many other very accurate observers, leave no 
room for doubt on the subject. The most satis- 
factory example the writer ever saw of it was in 
one of his own children ; the rash was perfect, 
but the catarrhal symptoms were entirely absent. 
There is nothing peculiar in the management of 
this variety, but we should warn the parents that 
they may expect the occurrence of the disease in 
its usual form. Frank, in his general observa- 
tions (torn. ii. p. 216, French edit.) on the exan- 
themata, maintains that as " there is no exanthem 
which does not occasionally exist without its pe- 
culiar fever, so on the other hand there is not one 
of the exanthematous fevers which does not in 
certain cases pursue its course without any cuta- 
neous eruption, and with the same consequences 
as in other cases." This appears in some mea- 
sure supported by the observation of Dr. Burns 
already quoted, but we confess that our own ex- 
perience has made us very sceptical on the point. 
Rayer is of opinion that the cases which have 
been supposed rougeole sans eruption were nei- 
ther more nor less than catarrkes sans rougeole ,• 
and it is to be remarked that Frank himself, speak- 
ing of measles, declares " he never met with the 
fever of measles without the eruption (febris 
morbillosa sine morbillis), and doubts its exist- 
ence until it shall have been proved by inocula- 
tion that persons who have had such a fever are 
not susceptible of taking measles." (Tom. ii. 
p. 370.) 

2. Rubeola nigra.. — This designation is applied 
to a peculiar appearance which the rash occasion- 
ally assumes about the seventh or eighth day, the 
spots becoming of a livid colour, or, more proper- 
ly, of a brownish hue, inclining to yellow. It is 
generally accompanied by languor and a quick 
pulse, but seldom lasts more than a week or two. 
Guersent, (Diet, de Med. torn, xviii. p. 509,) how- 
ever, met with a case in which it continued for 
more than five weeks ; he thinks it ou°-ht to be 



distinguished from measles. Practically it is not 
a matter of much importance, as it is not pro- 
ductive of anv bad consequence, the patient re- 
covering quickly under the use of tonics, of which 
Dr Willan preferred mineral acids, which may 
be very conveniently and advantageously given in 
combination with sulphate of quinine. It is to 
be recollected that this is a condiUon totally dis- 
tinct from the presence of petechia;, which mark 
a debilitated and broken-down state of the system, 
likely to occasion great danger. 

3. Rubeola putrida vel maligna. — This dis- 
tinction has been made to designate a class of 
cases in which the concomitant symptoms arc 
such as accompany the low form of typhous fever, 
with a tendency to putrescency throughout the 
system. The form of disease described by Sir 
William Watson (Med. Obs. and Enq. vol. iv. p. 
132,) as prevailing in the Foundling Hospital in 
1769, which proved very fatal, was evidently 
scarlatina in its malignant form, and not measles. 
At that time the two diseases were confounded, 
and Dr. Watson was one of those who even 
thought that the term scarlatina might be alto- 
gether dispensed with. 

This variety of the disease is said to have pre- 
vailed at Plymouth in 1745, in London in 1763, 
and at Edinburgh in 1816. (See Edinb. Med. 
and Surg. Journ. Jan. 1817.) In these epidemics 
the symptoms of the eruptive stage were particu- 
larly violent : the patients were early seized with 
extreme debility, restlessness, sometimes with 
coma; the tongue became dry, hard, and black; 
the fauces were of a deep red colour, accompa- 
nied with great irritability of the stomach ; the 
eruption did not exhibit its usual characters; it 
frequently receded very soon after it made its ap- 
pearance, was less elevated than it ought to be, 
and of a dark or livid colour. A large majority 
of these cases died, and on examination there 
were found well-marked evidence of inflammations 
within the thorax. In Edinburgh the retroces- 
sion of the eruption was almost always a fatal 
symptom. Such a form of the disease we believe 
to be extremely rare in this country, at least wc 
have never met with it. At the same time, how- 
ever, it is not to be doubted that in particular con- 
stitutions, or under certain contingencies, the com- 
plaint may assume these characters. Thus Dr. 
Perceval mentions that in a charity-school wheTe 
measles prevailed, typhous infection was intro- 
duced, and a corresponding change was immedi- 
ately observed in the character of the measles. 
Dr. Thompson saw a case in which the languor 
and state of the pulse were alarming, and the skin 
rubbed off like a moist cobweb, but the patient 
recovered by the use of wine and cordials, the ad- 
ministration of which, with the addition of some 
of the preparations of hark and ammonia, with 
the warm bath, constitute the chief remedial 
agents suited to such a condition of the system. 

4. Morbilli vuriolosi is a variety mentioned by 
Dr. M'Bride, (Practice of Physic, vol. ii. p. 116,) 
in which he says « the eruption is prominent, the 
face swells greatly, and many pustules actually 
suppurate like those in the small-pox ;" and he 
adds, " the cough and other catarrhal symptoms 
are the things which distinguish this "from the 
small-pox." Such a disease as that here described 



RUBEOLA. 



57 



we have never seen, except it should be merely 
what we have already alluded to, — measles ac- 
companied by a great number of miliary vesicles, 
some of which occasionally suppurate, but bear 
no resemblance whatever to small-pox : the occa- 
sional conjunction of the two diseases has been 
already spoken of. 

Inoculation. — Some time about the middle 
of the last century it was proposed to adopt inoc- 
ulation of measles for the purpose of rendering 
the disease milder ; and Dr. Home (Clinical Facts 
and Experiments, 1758,) of Edinburgh performed 
several experiments on the subject, inoculating 
with a little blood drawn from one of the exan- 
thematous patches. The result does not appear 
to have been either very decisive or satisfactory ; 
nor has the eligibility of the practice been at all 
proved by subsequent trials, many of which failed 
altogether ; and even where they succeeded in 
producing the disease, the operation did not always 
ensure a mild form of the complaint; on the con- 
trary, many of the cases so produced were as 
severe as those arising naturally. On this point 
we have no evidence to offer from our own expe- 
rience, never having seen the practice put to the 
test ; and we can only find that authorities of 
equal weight are completely at variance on the 
subject. Theurmen and Tellegen, as we learn 
from Rayer, inoculated five infants without any 
other result than the production of slightly in- 
flamed spots where the punctures were made. 
The same want of success attended the trials made 
by Dcwees and Chapman at the Philadelphia 
Dispensary in 1801. The most recent trials of 
which we are aware are those made by Professor 
Bperanza of Mantua: he inoculated in the first 
instance six individuals, and afterwards himself, 
with blood taken from a vivid patch of the erup- 
tion : in a few days the measles appeared, and 
proceeded mildly and regularly ; in consequence 
of this he made, further experiments, and he says 
they were all successful. Dr. Elliotson thinks 
it " likely that the vesicles which occasionally ac- 
company the eruption may contain the contagion 
itself in a concentrated form." 

Prognosis* — The prognosis in simple measles 
is almost always favourable ; but nothing is more 
certain than that the mildest form may be speedily 
converted into the most dangerous ; a sudden 
change taking place in the symptoms which could 
not have been foreseen, or produced by improper 
treatment, such as the administration of stimulants, 
by too much heat, or by exposure to cold. It is 
to be recollected that it is not the eruption or the 
mere disease which endangers the safety of the 
patient, but the internal inflammation which may 
accompany or follow it; and hence the great ne- 
cessity for ascertaining exactly the degree of their 
development by a most careful examination of the 
organs of respiration and digestion, to enable us 
to form a correct opinion as to the probable result. 
There is a very general impression that adults are 
in greater danger from measles than younger sub- 
jects ; but as far as our experience enables us to 
judge, we should pronounce exactly a contrary 
opinion, supposing each to be in an equally good 
state of health at the time of being attacked. Of 
course, if an adult encounters the disease with a 
constitution naturally delicate or previously broken 

Vol. IV. -8 



up by intemperate habits, or with some old pul- 
monary complaint, such a patient would be ill 
great danger ; but as a general rule, young chil- 
dren are most likely to suffer severely, because 
they are most disposed to severe attacks of pul- 
monary inflammation; so that, in our opinion, 
the younger the subject the greater the danger. 
Pregnant women are known to bear all the 
exanthematous diseases badly, and especially small- 
pox ; this might, a priori, be expected, because 
their system is already in a state very unfavoura- 
ble for the reception of an inflammatory disease. 
Rayer considers measles under such circumstances 
peculiarly dangerous. The cases which the writer 
has seen have done well ; and Heberden (Com- 
mentaries, p. 322,) expressly mentions that he 
" attended several who were greatly harassed by 
the violence of all the usual symptoms in this ill- 
ness, but never knew it make one woman mis- 
carry, or be in more danger on account of the 
pregnancy." 

The character of a prevailing epidemic should 
always be taken into account : thus that of 1670, 
described by Sydenham, was particularly mild, 
while that of 1674 was remarkable for the frequen- 
cy of pneumonia.* The season of the year also 
has no inconsiderable influence on the progress 
and issue of the complaint, which is likely to pro- 
ceed more favourably and safely in mildly warm 
and temperate weather than when there prevails 
either extreme of heat or cold. When measles 
and some other disease are conjoined, as for 
instance variola or pertussis, or when measles 
follow close upon the subsidence of some other 
ailment, especially if that has affected the lungs, 
the danger to be apprehended will be greatly 
increased : the same may be said when this disease 
attacks persons of a scrofulous or a plethoric habit. 
The following may be considered as the general 
circumstances which should forewarn us of danger : 
great violence in the symptoms of the eruptive 
fever; the eruption appearing too soon or too late ; 
the approach of pulmonary or abdominal inflam- 
mation ; severe headache with delirium, suffused 
eyes, or coma ; a hacking cough, with a hard 
pulse ; extreme dyspnoea ; retrocession of the 
eruption, which is generally owing to some serious 
internal derangement; the accession of typhoid 
symptoms ; the appearance of petechias ; profuse 
hemorrhages, inducing prostration of strength :+ 
while, on the other hand, a favourable case may 
be known by the regularity with which the erup- 
tion appears and proceeds, and its equal distri- 
bution on the different parts of the body succes- 
sively; by the absence or slightness of the symp- 
toms of thoracic or abdominal inflammation ; free- 
dom from headach ; the soft state of the pulse ; 
the naturally moist condition of the skin ; and 
the patient obtaining a sufficiency of refreshing 
sleep. From the London bills of mortality, it 

* The number of deaths from measles that year amount- 
ed to 795; while for the three preceding years, taken to- 
gether, they amounted only to 140. 

t When females, especially girls, are the subjects of 
measles, it very frequently happens that during the 
eruptive stage of the disease the catamenia make theii 
appearance perhaps a week or two before their natura. 
period, and sometimes much more profusely than is 
natural ; this we have repeatedly observed to happen, 
not only without injury, but we have thought wi*> 
advantage. 



58 



RUBEOLA — RUPIA 



appears that there died, from December to October 
1831, of measles 532, of" small-pox 436, and 
during the same period in 1832 the number of 
deaths were, of measles 508, of small-pox 532 ; 
making a total of measles 1040, of small-pox 
968. Morton has given a very highly exaggerated 
account (Append, ad Exer. de Morb. Acutis, p. 
427,) of the mortality during the epidemic of 
1672, when he says the deaths from measles were 
three hundred every week ; whereas it appears, 
from the public bills of mortality, that the whole 
number of deaths for that year by measles amount- 
ed only to 118. (See paper by Dr. Dickson in 
Med. Obs. and Enq. vol. iv. p. 256.) 

Sequelae. — Measles are very frequently follow- 
ed by a train of symptoms indicative of serious 
pulmonary lesions, very generally by a distressing 
and tedious cough, by chronic bronchitis, chronic 
pleuritis, pneumonia,* tubercles and phthisis ; 
chronic diarrhoea, generally of an inflammatory 
character, sometimes harasses and exhausts the 
patient; ophthalmia, ear-ach, and running of the 
ears, occasionally also supervene. There are 
several cutaneous affections apt to appear after 
measles ; amongst them is a very troublesome 
eruption of inflamed pustules, sometimes termina- 
ting in ulceration. In a few instances gangrene 
of the inside of the cheeks, gums, and lips, in the 
horrid form of cancrum oris, has been observed ; 
in other instances the mortification has affected 
the vulva. Anasarca has been known to appear 
after measles, as it very often does after scarlatina ; 
but this is so rare an occurrence, that where 
anasarca is found, and said to have been preceded 
by measles, there is much reason to suspect that 
the previous disease was scarlatina. (Frank, torn, 
ii. p. 372, op. cit. Guersent, Diet de Med. art. 
Rougeole.) Dr. Harty, who has had extensive op- 
portunities of observing this disease, informed the 
writer that he has very frequently found during 
convalescence from measles that the pulse became 
unusually slow, about forty or fifty beats in a 
minute ; but it did not appear to be connected 
with any thing unfavourable in the condition of 
the patients, whose recovery was uninterrupted. 

William F. Montgomery. 

RUPIA, from j>6*os, sordes, may be character- 
ized as an eruption of flattened and scattered bulla?, 
each surrounded with an inflamed areola ; the 
bullae filled with serous, purulent, sanious or dark 
bloody fluid, and succeeded by thick dark-coloured 
scabs covering unhealthy ulcerations. Bateman 
and Biett describe the varieties of rupia under 
three species or heads, viz. rupia simplex, rupia 
prominens, and rupia escharotica. The last of 
these, rupia escharotica, being the same disease 
as gangrenous or infantile pemphigus, and as 
such already fully described in the article Pem- 
i'Iiigus ; the other two species, rupia simplex and 
rupia prominens, alone demand a place here : 
moreover, as these differ from one another merely 

* Laennec thinks that the suffocating orthopnea 
which sometimes very suddenly carries off young children 
after measles is produced by an idiopathic oedonia of the 
luncs. In the greater number of cases examined after 
death by the writer, the morbid alteration existing was 
the condensation of the pulmonary structure ordinarily 
found as the effect of pneumonia. 



in degree of severity, they may be comprised under 
one general description. 

The bulla; of rupia are observed most often on 
the lower extremities, but are also frequently seen 
on the loins, the upper extremities, and about the 
shoulders. They are always few in number, and 
are generally scattered at some distance from one 
another. In the mild form, (rupia simplex,) one 
or more oval bulla? arise with little or no premoni- 
tory redness of the skin. These bullae are flat- 
tened, and are filled with a sero-purulent fluid, 
and seldom exceed a sixpence in size. After the 
lapse of a few hours from their formation, they 
become partially flaccid ; the contained fluid grows 
muddy and puriform, and dries into a dark-brown 
scab, thick in the centre, and thin towards the 
circumference. Around the scab there is a dusky 
red areola, the cuticle covering which is slightly 
raised or separated from the true skin, and con- 
tinues all round with the thin edges of the seal). 
The latter is in general easily removed, or falls 
after a few days, leaving an unhealthy-looking 
ulceration of the skin, which either becomes crusted 
with a fresh succession of scabs, or heals, leaving 
a dark purple mark. In the aggravated degree 
of the disease, (rupia prominens,) a circumscribed 
inflammatory redness precedes the formation of 
the bullae. The bullae rise slowly, and, instead 
of serous fluid, contain purulent matter or a mix- 
ture of purulent matter and blood, which consti- 
tutes the blackish fluid already mentioned as some- 
times found in the bulla?. The contained fluid 
dries into a very dark-coloured scab, which covers 
a deeper ulceration, and is surrounded by a widei 
inflammatory areola than in rupia simplex, and 
as the ulcerated surface is continually secreting 
pus, and at the same time enlarging in circum- 
ference, the scab is increased by successive layers, 
each wider than the preceding, and at length, at 
the termination of ten or twelve days, acquires a 
conical shape similar to a limpet-shell, sometimes 
extending at the base to the size of a dollar in 
area, and protruding in the centre an inch above 
the surface of the skin : hence the name of this 
variety of the disease — rupia prominens. This 
scab is superficial, and if removed is either replaced 
by a fresh scab, or leaves exposed a pale unhealthy 
spreading ulcer, bleeding on the slightest touch, 
of a depth proportionate to the duration of the 
scab, with livid swollen borders, and in old per- 
sons often very difficult to heal and even when 
healed leaving a dark-coloured cicatrix. 

Diagnosis. — Rupia may be confounded with 
pemphigus, ecthyma, and venereal pustular erup- 
tion, but the bulla? of pemphigus are large, full, 
and very prominent, and generally contain a serous 
fluid, while the bullae of rupia are small, flattened, 
quickly become flaccid, and contain a fluid, which, 
if not sanious or purulent from the commence- 
ment, very quickly becomes so. Gangrenous pem- 
phigus pours out a sanious fluid, but does not 
form scales like rupia. The ulcerations of rupi- 
are deep and indented, while those of pemphigus 
are superficial, resembling excoriations. The 
shape of the scab in rupia prominens at once dis- 
tinguishes this variety from pemphigus. Rupia 
>s frequently found in conjunction with ecthyma 
lundum and cachecticum, and Plumbe has classed 
rupia and ecthyma together. The two disease* 



RUPIA — SCABIES. 



59 



are, however, very distinct in their pathology and 
appearance. Ecthyma commences as a pustule, 
rupia as a bulla. The scab of rupia is generally 
easily removed ; the scab of ecthyma is strongly 
adherent. Around the circumference of the scab 
of ecthyma there is deep-seated inflammatory hard- 
ness, extending into the subcutaneous cellular 
tissue; around the scab of rupia there is only a 
superficial red areola, the cuticle over which can 
be traced in continuation with the surface of the 
scab. The scab formed on some of the pustular 
venereal eruptions bears a very close resemblance 
to the scab of rupia ; and as both diseases are 
likely to occur in the same broken-down constitu- 
tions, there is risk of confounding them. The 
venereal scab and pustule are, however, found to 
proceed from pustules with hardened bases, not 
from bullffi as in rupia, and they are generally 
surrounded with the peculiar syphilitic copper- 
coloured areola?. These characters, with the pre- 
sence of some of the usual constitutional symp- 
toms of syphilis, will suffice to distinguish the two 
diseases. Plumbe speaks of having seen evil re- 
sult from mercury being administered for rupia, 
under the mistaken supposition of its being a 
venereal affection. Few practitioners, however, 
in the present day, after the clear and lucid view T s 
laid down for the treatment of venereal affections 
by Mr. Carmichael, (an Essay on Venereal Dis- 
eases, and the Use and Abuse of Mercury in their 
Treatment, by Richard Carmichael, M.R.I. A., 
&c), would push mercury to any extent for such 
appearances, even admitting them to be of vene- 
real origin. 

Prognosis. — The duration of rupia is very 
uncertain, running through its course in a few 
days, or extending to months. The disease is 
severe in proportion to the age of the patient, or 
weakness of the constitution. The slowly-healing 
ulcerations often keep up a low fever in the sys- 
tem, and thus injure the health, but rupia is 
scarcely if ever a fatal disease. 

Causes* — Rupia may be considered as altoge- 
ther a constitutional affection, being only seen in 
the aged, or in the debilitated from any cause, but 
particularly from intemperance, abuse of mercury, 
or want. Acute diseases affecting the skin, and 
leaving much debility after them, predispose to 
it; thus it appears as a sequela of small-pox and 
scarlatina. The scrofulous are peculiarly subject 
to it, and it is most prevalent during the winter 
season among the poor who are badly fed and 
clothed. 

Treatment. — From what has been just stated 
relative to the causes of rupia, its treatment is 
easily anticipated. The remedies are a light nu- 
tritious diet, cleanliness, the warm bath, attention 
to the state of the bowels, and sarsaparilla or cin- 
chona, with the mineral acids. Dr. A. T. Thom- 
son, in his edition of Bateman, says that slight 
mercurial courses carried so far as to affect the 
mouth are sometimes necessary. Mercury, when 
used in this disease, should according to the best 
observers be used only as an alterative, and in its 
mildest forms, as in Plummer's pill. As to local 
applications, the scabs should be removed by a 
poultice, and the raw surfaces, if painful, are to 
be stuped with decoction of bran and poppy- 
heads. Relaxing or emollient applications, how- 



ever, should be used only for a short time : the 
surfaces of the ulcers very soon require stimulat- 
ing applications, and the strength of these must 
vary, according to the relaxed state of the ulcers, 
from a weak solution of nitrate of silver to the 
application of the solid nitrate, the strong nitric 
or muriatic acid, or ointment of red precipitate of 
mercury. Rayer recommends the ulcers to be 
dressed with saturine cerate, pledgets of lint to be 
placed over this dressing, and all to be confined 
with a bandage which shall keep up a moderate 
compression. He recommends the ulcers when 
indolent to be dusted with powdered supertartrate 
of potass, or a solution of it to be used as a lotion. 
In this, as in all skin diseases where there is ul- 
ceration attended with low irritative fever, internal 
opiates given at bed-time to procure sleep form an 
essential requisite in the treatment. 

D. J. CORRIGAN. 

[SALIVATION, See Pttalism.] 
SCABIES. — This is the classical word now 
universally used to designate the well-known con- 
tagious vesicular disease of the skin, called popu- 
larly, in English, itch, French, gale, German, 
Krutze, Italian, rogna, &c. These vulgar appel- 
lations, except the French, (the etymology of 
which is doubtful,) are derived from the property 
which our English expresses, the intense itching 
and irresistible scratching which it excites. Sca- 
bies is the word by which the Latins rendered thtt 
4*u>pa of the Greeks, a term under which the lattei 
comprehended a number of papular and squamous 
affections, although they at length appropriated if 
to the disease which we now denominate psoriasis 
The confusion which for a long time attached to 
\lwpa necessarily involved its synonym scabies, 
and prevented it from becoming definite in ita 
signification, until they were divorced by Celsus, 
who restricted the Greek term to scaly diseases, 
and excluded these from the comprehension of the 
Latin scabies. The Roman physician and his 
successors did not, however, confine its significa- 
tion within its present limits, but included under 
it other pustular and pruriginous affections, and 
so caused an inaccurate latitude in its acceptation, 
which prevailed to a comparatively recent period. 
The advance of cutaneous pathology at length 
isolated the disease, but the verbal confusion was 
revived by Cullen and others, who, when scabies 
had been definitely fixed, chose for the designation 
of the itch the term anciently used in so indefinite 
a sertse by the Greeks, psora, which (with a pro- 
longed termination) Willan, with a greater regard 
to 'ts old signification, appropriated to the scaly 
disease. No imputation of inexactness in this 
instance attaches to the old medical writers, for 
words must ever be varying and inconstant in 
their signification until the state of science per- 
mits the diseases which they represent to be 
investigated upon enlightened principles, and dis- 
criminated by a true nosology; but authors are to 
blame, who, after this period arrives, embarrass 
the received nomenclature by arbitrarily multiply- 
ing names, or changing them from their general 
acceptation. 

Scabies is one of the cutaneous diseases the 
distinct identity of which is best confirmed by pe 
culiar characters, yet in the description of which 



60 



SCABIES, 



such a variety exists as to render it extremely 
difficult to give a comprehensive account of its 
history and symptoms. An artificial arrangement 
would be very desirable for this purpose, but in 
seeking for such we find how difficult it is to fix 
arbitrary bounds within which natural phenomena 
may be circumscribed. "This troublesome dis- 
ease," says Baternan, " from its affinity with three 
orders of eruptive appearances, pustules, vesicles, 
and papula?, almost bids defiance to any attempt 
to reduce it to an artificial classification." (Sy- 
nopsis, 7th edition, 1829, p. 278.) A ready illus- 
tration of this statement is found in the fact that 
while Willan has placed it in his order "pustulse," 
Biett and Rayer, who have adopted his system, 
classify it among the vesicles; and again, Dr. 
Paget, the author of a late ingenious essay on the 
classification of cutaneous diseases, (Edin. Med. 
and Surg. Journal, vol. xxxiv. p. 270,) coincides 
with others who consider it as appertaining to the 
papulae. It does not belong to our object to main- 
tain the credit of the artificial arrangement, but 
we may remark that this discrepancy, which 
shows its defectiveness in this particular as a 
system, by no means detracts from its practical 
advantages ; on the contrary, the purposes of 
study and description demand more urgently the 
aid of arbitrary methods of arrangement when 
the natural appearances are diversified. 

It is admitted by the majority of observers, that 
by far the greatest part of the eruption of scabies 
is composed of vesicles, so that we unhesitatingly 
agree with the French authors above cited in 
regarding its type as essentially vesicular. The 
transparent apex of the elevation is often so 
minute or so fugitive as to give the idea of a 
papula, if not observed attentively and at the 
seasonable period of its course. With respect to 
the true papulae, which are often interspersed 
amongst the vesicles, it is to be observed that in 
all eruptions of the skin (whether their real type 
be vesicle or pustule) there is a period at which 
the elevation is merely a papula, and it frequently 
happens that in a vesicular or pustular eruption 
some pimples proceed no farther in their develop- 
ment than the state of papulae. Nothing is more 
common than to see among the pustules of porrigo 
several which have no purulent apex, having 
never advanced beyond the papular stage ; but on 
this account their genuine character is not the less 
established, being properly regarded as undeve- 
loped pustules. The papula; which complicate the 
vesicles of scabies bear a larger proportion to the 
true type than in the example of porrigo, but they 
appear to possess a similar relation to it, being as 
it were abortive vesicles. The occurrence of pus- 
tules in scabies forms, indeed, a more decided va- 
riety, as one species of it seems to be truly pustular 
in its nature. Yet it is not to be overlooked that 
some of these apparent pustules are also primi- 
tively vesicles, in which an inflammation of more 
than ordinary acuteness has produced a purulent 
secretion instead of transparent serum. Accord- 
ing, then, to the opinion here stated, we embrace 
the vesicular as the true type of the eruption, and 
>egard the deviations of papulae, and in part those 
of pustules, as caused by casual variations in the 
intensity of the inflammatory action. On the one 
hand, papulae occur where the inflammation stops 



short of maturing ves.cles ; and on the other 
pustules are met with when, proceeding 
immoderate degree, it fills the ves.cles with pus in 

place of serum. . ,. 

P The contagious nature of this eruptive d.sease 
is the most essential character of its h.story. Its 
vesicles are minute and slightly acuminated, with 
a pearly semi-transparency at the.r sum nut. They 
may arise at any part of the body, and spread 
until it cover every part except the face, which 
appears to possess a singular immunity from their 
invasion. The hands and arms are always prin- 
cipally affected, and are often so when no other 
part of the body partakes of the eruption, which 
is sufficiently accounted for by the fact that infec- 
tious contact usually occurs in this situation. 
The vesicles are mostly distinct, but have a dis- 
position to accumulate at the flexures of the joints; 
being almost invariably found confluent on the 
soft fold of skin between the fingers and at the 
joint of the phalanges and wrist, and often at the 
larger articulations, if the eruption be more exten- 
sively spread. The intense itching which is the 
characteristic feature of this troublesome disease 
accompanies the first appearance of the eruption, 
and, indeed, seems generally to precede it, as the 
inflammatory elevation which generates the vesicle 
is much promoted by the scratching, which the 
pruritus irresistibly induces. It increases from the 
commencement until each vesicle attains a certain 
degree of maturation, when it decreases. The 
annoyance which it produces is in proportion to 
the extent of the eruption ; if the vesicles be few 
in number, are developed slowly, and confined to 
a circumscribed locality, it may cause little atten- 
tion ; but when they are numerous and extensive, 
and come out with rapidity, the pruritus rises to 
an intolerable height, and produces inexpressible 
irritation. The patient then seeks to assuage it 
by scratching, from which, howsoever he may lie 
cautioned against it, he feels it impossible to 
refrain. Temporary relief may be obtained from 
this by changing the itching sensation into the 
pain of laceration, but he only lays up in store a 
future visitation of greater intensity. The action 
of the nails increases the inflammation, which 
causes new crops of vesicles to spring up, and 
aggravates the pruritus in the old. More or less 
of the same consequences flow from any other cir- 
cumstances which give rise to even a transitory 
excitement of the cutaneous circulation, as the 
warmth of bed, the digestion of a stimulating 
meal, or the use of spirituous potations. 

Several days elapse between the time of infec- 
tious contact and the manifestation of the pruritus, 
which period is called in this as in other eruptive 
diseases the incubation. Its length is much mo- 
dified by the age of the individual, as connected 
with the susceptibility of the cutaneous surface to 
impressions. In childhood, when the skin is soft 
and active in its functions, the incubation has 
generally three or four days' duration ; in adults 
it averages ten tn fif*,,„~ _-j • , ■. ._ 




r a Tsol m - th f lymphatic and sanguine,* 

of c im,,r P Y y P r ° traCted - The relations 

oi climate and seasons, moreover, hav„ vjim 

» c, > «a\e a sens.ale 



SCABIES. 



61 



effect on it, cold and heat respectively retarding 
and accelerating the first appearance of the dis- 
ease. The existence of an inflammatory affection 
of any internal organ is another condition which 
appears to diminish the susceptihility of the skin 
to its infection, and to add to the period of incuba- 
tion. The circumstances connected with this 
latent period are worthy of attention, not only on 
account of their intrinsic interest as pathological 
facts, hut because they afford an important prac- 
tical deduction, which is as follows : the duration 
of this period has a relation to the actual course 
of the disease, and the facility with which it may 
be removed ; when the eruption appears promptly 
after infection has been contracted, it may be in- 
ferred th;it the disease can be speedily conquered 
by the appropriate remedial applications ; but if, 
on the contrary, the skin has exhibited a tardy 
inactivity in producing the eruption, when fully 
developed, the latter will be proportionately in- 
veterate anil less amenable to therapeutic means. 

When scabies has fully appeared, although it 
may be modified as to its intensity by circum- 
stances, it always assumes a progressive course, 
until arrested by treatment ; it has no tendency 
like the exanthematous eruptions to a spontaneous 
cure. From its original scat it spreads until the 
whole surface is affected, but collects especially 
where the skin is disposed in loose folds, subject 
to friction, as the axilla, the internal parts of the 
thighs, and fold of the buttock, as well as the 
flexures of the articulations. The situation where 
it may first show itself appears to be entirely de- 
pendent on the liability of dill'erent parts to con- 
tact with infected persons. This is demonstrable 
from the consideration of it in different individuals, 
whose condition in life exposes one part of the 
body more than the rest : for example, in tailors, 
sempstresses, and shoemakers, it commences on 
the hands; in infants in the nurses' arms, the 
nates are frequently found to be the part first af- 
fected ; and if, on the contrary, the nurse receive 
it from the child, it breaks out on the hands, and 
sometimes (which is more in point) on the breast. 
An exception to this rule would seem to exist in 
the case of dyers, smiths, and sawyers, whose 
hands and wrists are rarely primitively affected, 
and often escape, while it infests other parts : this 
is to be ascribed to the rough hardened state 
whirl) tbe hands of these tradesmen contract from 
labour, and doubtless in the first two their im- 
munity must be in some part owing to the chemi- 
cal agents with which their employments bring 
their hands in contact. Sulphuric acid and other 
powerful astringents form a main ingredient in 
the dyers' liquors, and the iron and embers of the 
forge constantly impregnate the smiths' hands 
with sulphureous vapours, which are at once its 
best prophylactic and cure. Redi asserts that he 
knew an instance in which the face became the 
first part affected, from the contact of the collar 
of an infected mantle ; but its appearance on the 
face at all is so contrary to experience deduced 
from innumerable observations, that this has been 
denied to be a genuine case of scabies by later 
writers. 

Willan and Bateman divided scabies into four 
species, derived purely from the variety of form 
which the disense assumes. They have no» been 



followed in this by the recent authors who have 
borrowed their arrangement. As the framer of a 
system, Willan was disposed to attach too much 
nosological importance to his divisions, and 
his followers conceiving that they imply theo- 
retic error, have in many instances relinquished 
them. It does not appear, however, that by so 
doing they have attained either to more simplicity 
of arrangement or fidelity of description, but rather 
the contrary. In our opinion, the specific distinc- 
tions which Willan employed are as valuable as 
the grander divisions of his system, and to those 
who are jealous about natural arrangement they 
are less objectionable, as being the mere expres- 
sions of facts, which may be received without re- 
ference to any theory of classification. Artificial 
subdivisions of cutaneous diseases founded on 
real differences in external characters, if they have 
no other advantages, greatly facilitate their study, 
and without the aid derived from this source their 
description becomes necessarily either vague or 
defective. In scabies, these practical means of 
discrimination are particularly requisite, as its di- 
agnosis, which is of great importance, is chiefly to 
be arrived at (where contagion cannot be proved) 
by an accurate knowledge of its external characters. 
We now proceed further with its description, 
and in addition to the general remarks with which 
we commenced it, we recommend attention to the 
following divisions, which are the same as those 
proposed by Willan. Far from being the mere 
offspring of theory, they were suggested to him by 
their common use amongst the lower order, whose 
familiarity with it forces them to be intimately ac- 
quainted with the various forms in which it ap- 
pears. Of these they distinguish four, designated 
the rank, watery, pocky, and scorbutic itch, which 
Willan adapted to his nomenclature under the fol- 
lowing titles, viz. : — 

Scabies papuliformis. 

lymphatica. 

purulenta. 

cachectica. 

Scabies Papuliformis, or Rank Itch. — In 
this form of scabies the eruption is generally ex- 
tensive, and accompanied with slight inflammation 
in the vesicles, and intense itching. It is found 
chiefly to infest the fingers and wrists, but also 
spreads extensively upon the trunk, particularly 
the front part of the chest and abdomen. The 
elevations resemble papula?, and thus seem to 
evince an affinity between this form and prurigo 
and some varieties of lichen ; but where they are 
fully developed and unbroken by scratching, a 
close inspection may always detect the transparent 
apex which indicates its vesicular character. The 
itching is so troublesome that frequent scratching 
is resorted to, and the abrasion of the vesicles and 
even of the skin which ensues, changes the primi- 
tive appearance of the eruption ; " long red lines 
are here and there left, and the blood and humour 
concrete upon the vesicles into little brown or 
blackish scabs." When it occurs in a sanguine 
habit, or if it be inordinately exasperated by 
scratching or other circumstances, some scattered 
pustules sometimes make their appearance, filled 
with thick yellow purulent matter. 

Scabies Iiymphatica, or Watery Itch* — 
The difference between this and the former is ir- 



6J 



SCABIES. 



considerable. The separate vesicles are larger and 
do not partake of the papular character, being full 
of serum to the base, which besides exhibits no 
inflammatory redness. The pruritus is extremely 
troublesome, and when the vesicles are ruptured, 
moist excoriations are apt to form, upon which 
ufter a certain time dark scabs concrete. The 
most ordinary appearance which this variety pre- 
sents is a compound of the three stages just re- 
ferred to, viz. the entire vesicle, the excoriation 
succeeding its laceration, and the scab which co- 
vers this ulcerated part when it begins to heal. It 
seldom extends like the former variety to the 
trunk, but is chiefly found collected at the lower 
parts of the extremities, on the fingers, wrists, 
luck of the hands, and on the feet and toes. 

Scabies Purnlenta, or Pocky Itch. — This 
possesses more the characters of a distinct species 
than any of the other forms, and evinces the ne- 
cessity of marking these varieties. As Bateman well 
remarks, " it is often mistaken by those who con- 
fine their notion of scabies to the ichorous vesicles 
of the varieties already noticed." Heberden had 
divided the disease into two species, comprehend- 
ing in the first two former varieties under the 
name of " pustular exiguae, aqua plenae." (Com- 
ment, de Morb. Histor. et Curat. Frankf. ad Moen. 
1804. P. 102.) The other he describes as " ma- 
jusculae cum fundamento rubro, et pure implean- 
tur, fere tanquam variola?." This resemblance of 
the round pustules which constitute this species to 
small-pox, caused the vulgar to denominate it 
pocky itch. They arise distinct, upon an inflamed 
base, above which they are considerably elevated : 
after a few days they maturate and break, having 
attained frequently to a diameter of two or three 
lines. The pruritus which they occasion is mixed 
with a painful tension of the part, different from 
that which occurs in the vesicular forms. After 
their breaking they leave a cracked ulceration be- 
hind, the heat and stiffness of which cause con- 
siderable pain. The pustules may spread like the 
\esicular form over the body, but seldom extend 
far from their original seat, which is usually the 
hands or feet. In these situations they are largest, 
and two or three of them sometimes coalesce be- 
tween the knuckles, especially between the index 
finger and thumb. The scabby concretions which 
at length firm upon the ulcerations adhere for a 
considerable time during the healing process. 
The pustular scabies occurs usually in children 
before the age of ten years. 

Scabies Cacnectica, or Scorbutic Itch. 

This is not distinguished from the forementioned 
varieties by difference in external character ; for 
it appears under the forms of the other varieties 
at one time indiscriminately mixed, at another ex- 
hibiting them separately in different parts of the 
body. It mostly occurs in persons of debilitated 
constitution, brought on by indigence and intem- 
perance, and is the most intractable form of 
scabies. It is not unfrequently combined in such 
individuals with other cutaneous maladies as 
lichen, prurigo, ecthyma, and impetigo ; and Bate- 
man asserts that when the latter disease is super- 
added, it, as well as the scabies, possess a conta- 
gious character. He also remarks that the most 
severe decree of it which his experience made 
mm acquainted with, exhibited itself in persons 




CDe Medicina muuju.i. - 

under the name of herpes, seu impel go Indtca, 
and Sauvages under that of scabies Ind.ca. 

It was, perhaps, superfluous to make a separate 
spucies of this, inasmuch as it possesses no par- 
ticular form which distinguishes it from the others; 
yet, as it is so disposed in Willan s divisions, it 
might be invidious in such a matter to use an 
arbitrary power in altering an established arrange 
ment, which we have taken advantage of fc 
greater facility of description. 

In whatsoever form scabies manifests itself, it is 
to be regarded entirely as a local affection, being 
never like other vesicular eruptions connected 
with disorder of the internal organs. It gives rise 
to no disturbance of the circulation, except in 
severe cases of the pustular scabies, which, from 
the inflammation sometimes attending it, causes 
slight febrile action in children. Some authors 
recount a list of the most formidable diseases as 
liable to be produced by its retrocession and the 
metastatic transport of the cutaneous irritation to 
the vital organs. These notions, however, are 
now disregarded, being justly considered as the 
imaginary fabrications of an exploded theory, 
which pretended that a specific virus residing in 
the serum of the blood was the cause of scabies. 
We conceive that the observations of olhers which 
assert that important diseases of the internal or- 
gans have been cured by its eruption are to be 
equally unheeded. Unprejudiced experience de- 
monstrates that it exerts little or no pathological 
sympathy upon the internal organs, and therefore 
such cases as those narrated by Beer* and others 
can be only regarded as coincidences. 

The disease chiefly shows itself amongst chil- 
dren ; yet on this account it is not to be inferred 
that it shows a preference for youlh more than 
age. This is to be attributed solely to the fact, 
that children are more brought in contact with in- 
fection than adults, from their heedlessness of ex- 
posure and inattention to cleanliness. It depends 
upon the same cause that amongst the working 
classes males are more generally affected with it 
than females. Climate docs not appear to have 
much effect in modifying its prevalence, — although 
it is certainly more common in the northern parts 
of Europe than the southern, an observation which 
we think must be connected with the fact that in- 
dividuals of sanguine and lymphatic are much 
more liable to it than those of bilious tempera- 
ments. Habits of uncleanliness, however, are 
more powerful than this predisposition arising 
from the temperaments, of which its great preva- 
lence amongst the Polish Jews and Spaniards 
aftords examples ; for amongst these people, as is 
well known, the bilious preponderates beyond 
comparison over the opposite temperaments. 

It prevails in so general and constant a mannei 
in some countries that it may be said to be en- 
demic. In Poland and Hungary the mass of the 



•Geechichle einea geheilten vollkoinmenpn von n- 
Account of an Amaurosis cans,,] ... "'";""'» ?uu* 
Uch, wind, was perfectly cured ) 8vo Vien^WB 



SCABIES. 



63 



population are constantly more or less infected, 
and it is equally rife in Galicia and Asturias in 
Spain, in Lower Brittany in France, and in cer- 
tain parts of the Highlands of Scotland. It is, 
however, no stranger amongst the indigent classes 
of every country, and where it is found to infest 
one region with peculiar pertinacity, this is not to 
be attributed to any special influence of the atmo- 
sphere or the soil, which alone would properly 
entitle it to be called endemic, but to the habits 
of the poor population. It has been suggested 
that salt diet and the neighbourhood of the sea 
were concerned in maintaining it in some districts, 
but these circumstances have no influence in pro- 
ducing it, although they are frequent concomi- 
tants of that which is its true promoting cause, — 
inattention to cleanliness of the person, and par- 
ticularly of the habiliments. Change of linen is 
the surest protection from it in a family or in a 
country, and we may with certainty predict its 
prevalence amongst every people where custom or 
necessity has precluded this best preservative of 
the health of the skin. 

This malady inspires, as might be supposed, 
no friendly feeling in communities, and it is cu- 
rious in this respect to remark the difference be- 
tween it and those contagious eruptions which 
put life in jeopardy, as small-pox, measles, &c. 
With whatsoever dread the latter may be contem- 
plated, they do not produce disgust; but the itch, 
bein'4 free from danger, may be treated more dis- 
respectfully, and is very generally regarded as 
contemptible. However, different nations have 
different opinions on this subject ; it is reported 
of the inhabitants of the Spanish provinces before 
mentioned, that they retain it often from the cradle 
to the tomb, and that they are not only careless 
of its concealment, but regard it as a kind of 
hereditary possession ; they even refuse to use 
means to be freed from it, alleging that they are 
not willing to change the customs of their ances- 
tors. (Diet, des Sciences Med. t. xvii. p. 183.) 
But in countries where civilization is more dif- 
fused, its residence is less tolerated. Here even 
the imputation of the itch becomes almost inju- 
rious, and sometimes engages philosophers in its 
refutation, of which the following is an example. 
" Laennec was a true Breton, fond of his country 
and jealous of its honour. It is amusing to ob- 
serve the high tone he assumes in refuting a 
charge brought by a certain writer against his 
native country, for being infamous for an epidemic 
itch. He solemnly assures us, that if in very 
truth ' la gale s'observe quelquefois en Bretagne, 
on en doit moins accuser les localites, que le 
passage et le sejour des matelots." (Forbes's 
Translation of Laennec, Author's Life, p. xxviii.) 
Equally patriotic renunciations of it have been 
made in our own islands. 

Diagnosis. — There is scarcely any disease 
compromising the general health in so trivial a 
degree in which it may be more important to the 
reputation of the practitioner to be able to deliver 
a categorical diagnosis than in scabies. He is in 
fact frequently consulted for no other purpose 
than to decide whether an individual has not 
brought this contagious affection into his circle ; 
and as the physician's opinion on the one hand 
sets him free from this suspicion, and on the other 



sentences him to a temporary banishment from 
society or even from his employment, it is obvious 
how much it behoves him to be able to distinguish 
it without error. In forming his opinion, he 
should learn to be as much as possible independ- 
ent of the criterion furnished by its contagious 
quality, for it will be generally where this point 
is yet undecided that his judgment will be sought 
for. When some evidence of exposure to infec- 
tion exists in addition to the proper characters of 
the eruption, there is no difficulty ; but if such 
be unattainable, it will often require all the re- 
sources which an accurate acquaintance with it 
and other affections which resemble it supplies to 
distinguish between them. The eruptions with 
which it is liable to be confounded are some forms 
of lichen, prurigo, and eczema. The papular ele- 
vations of lichen are attended with considerable 
itching, and are frequently abraded by scratching, 
so that considerable resemblance may exist be- 
tween them and scabies, particularly the first va- 
riety of it above noted, (*. papulifurmif;.) If 
the latter be present, the apparent papula?, ex- 
amined in an unbroken state, will be found to be 
topped by a vesicular apex, and where they have 
broken spontaneously, a dark scab remains ; but 
in lichen the papula is solid, even to the summit, 
and it passes away in a scurfy exfoliation. Lichen 
occupies the back of the hand, and the external 
surface of the limbs, and is seldom or never de- 
veloped in the intervals of the fingers. Moreover 
the itching is not nearly so intense as in scabies, 
and is of a more remitting nature, and the papu 
lar eruption is commonly attended by some con- 
stitutional disturbance which is foreign to scabies. 
In the lichen urticatus the eruption is of a more 
acute nature, and has occasionally a few vesicles 
interspersed amongst the papulae, which might 
confound an observer who relied on any single 
characteristic; but the diagnosis in this case is 
still easier than in the simple lichen — the inflamed 
wheel-like papulae, causing rather a deep tingling 
than an intense itching, sufficiently distinguish 
this eruption. Finally, the suspicion of contagion 
will seldom attach to any form of lichen. 

The itching of prurigo is of a still more vehe- 
ment character than that of scabies ; they were 
of old frequently confounded, insomuch that the 
former was sometimes erroneously denominated 
scabies sicca. (See Prurigo.) The diagnosis 
between them is not difficult if these points be 
held in memory. Prurigo occurs chiefly in elderly 
individuals; its papulae are flat, and when abraded 
by the nails no serous fluid is effused, but a dark 
spot of blood concretes upon their surface. The 
situation also of the pruriginous eruption (as that 
of lichen) is distinguished from scabies by its 
preference to the surfaces of extension on the ex- 
tremities, instead of those of flexion, which the 
latter particularly affects. Prurigo, moreover, is 
not contagious. 

In eczema we have a vesicular eruption, which 
often bears a striking resemblance to scabies in 
the second variety, (.s. li/mphu!ic<i.) Its vesicles. 
however, are more flattened and confluent thar> 
those of scabies, which are acuminated and dis- 
tinct. But when the disease is passed to an ul 
ceratcd and scabby state, such distinguishing 
characters may be wanting, and then other cr 



64 



SCABIES. 



cumstances must be sought out. Eczema is for 
the must part a local affection, and when the itch 
has in any place assumed the ulcerations and soft 
scabs which resemble it, the eruption has pro- 
ceeded to a considerable extent, and will doubtless 
show its proper form in the parts which it has 
most recently invaded. The irritation of eczema 
is a stinging or tingling sensation very different 
from the pruritus of the itch, and its origin may 
be often traced to the action of irritating causes 
upon the skin, as sugar, lime, and other acrid 
substances, or to exposure to the solar rays or 
great heats. 

Very lately a female presented herself to the 
writer with an eruption at the root of the right 
middle finger, which from its situation and ap- 
pearance was difficult to distinguish from scabies. 
She ascribed its origin t« milking cows, whose 
teats were in a diseased state. The pruritus was 
not that of .scabies, and after a careful examina- 
tion it was concluded to be a vesicular form of 
impetigo. Bateman calls attention to the possi- 
bility of confounding the pustular form of scabies 
with impetigo, and even with ecthyma; and al- 
though this seems remote, it is yet only a prudent 
caution to keep in mind every form of cutaneous 
disease which bears any affinity to it. 

A circumstance in the history of scabies of the 
greatest moment, is the simultaneous presence of 
the diseases which we have just contrasted with 
it for the sake of diagnosis. This is indeed rare 
in ordinary cases of itch, but the fact of its occa- 
sional occurrence forcibly impresses the necessity 
of cautious examination, and adds much practical 
importance to the diagnosis, because those com- 
plications require a line of treatment quite dis- 
tinct from that of scabies. They are met with in 
the cases in which much inflammation has at- 
tended the scabid eruption, and (which serves to 
illustrate what we have said as to their different 
treatment) they are very frequently produced by 
improper applications for its cure, such as power- 
fully irritant lotions or frictions. The actual 
complication which may be present will he much 
influenced by the constitution and age of the 
subject ; in young and vigorous habits, the excess 
of irritation will mostly take the form of eczema 
or of impetigo, while in those of an opposite 
condition pustules of ecthyma may appear, or the 
inflammation may seize on the cellular tissue, and 
an eruption of boils be the consequence. Caze- 
nave and Schedel remark that the same subject 
may present at once " vesicles of itch, pustules 
of impetigo, pustules of ecthyma, and boils," 
(Abrege Pratique des Mai. de la Peau, Paris, 
1828, p. 120,) a case which would exercise the 
diagnostic tact of the physician to discover the 
primary contagious disease amongst so many 
complications. 

Causes. — The universally diffused cause of sca- 
bies is contagion, and it appears to be the disease 
which of all is most readily communicated by 
contact. When it once gains admission into a 
family, the greatest caution often fails in prevent- 
ing it from infecting every individual. A question 
exists undecided among pathologists as to whether 
:t ever originates from any other source than con- 
tagion. It was observed by Sir John Pringle, that 
.n military hospitals the patients often became the 



subject of itch after the crisis of fevers, (L..teman s 
Synopsis p. 388, note); but there rema.ns httfe 

dub in oir mind that this excellent physician tn 
these instances mistook some of the papular erup- 
tions, as lichen or prurigo, for scab.es, for those 
are not uncommonly observed to occur when the 
skin recovers its tone in the convalescence from 
fever. We would make the same remark with 
respect to a kind of it which Heberden describes 
as primarily contracted by contagion, but which 
being cured by the customary remedies, << tamen 
non cessat redire semel vel bis quotamms." (Op. 
cit. p. 102.) This is rather the description of the 
lichen simplex, occurring periodically in a person 
who has been once affected with scabies; for this 
faithful observer adds, that after its first attack it 
is no longer communicable by contagion, even to 
those who lie in the same bed, and that it as often 
terminated spontaneously as it was removed by any 
remedy. Bateman thought that it might originate 
without contagion in crowded, close, and un- 
cleanly houses, and wherever the means of clean- 
liness were not obtainable. (Synopsis, p. 289.) 
These are, however, just the circumstances which 
facilitate the propagation of contagion. On the 
whole, there are no facts which contravene the 
opinion of those who assert that the latter is its 
sole origin, and it appears to us that it agrees best 
with every analogy. 

We have reserved to this head the notice of a 
very remarkable circumstance connected with the 
etiology of scabies, the existence of the insect 
called by Linnseus and by preceding naturalists 
" acarus scabiei." First in the writings of Aven- 
zoar, the Arabian physician, and subsequently in 
those of Ingrasias, Gabusinus, and Joubert, notices 
of a minute insect occurring in a certain disease 
of the skin attracted the attention of the English 
entomologist Thomas Moufet, who examined and 
described them with considerable accuracy. They 
are, according to him, minute animalcules similar 
to the acari of decayed cheese or old wax, which 
burrow under the cuticle, and excite intense itch- 
ing, with an eruption of vesicles. His observa- 
tions were repeated by various naturalists in dif- 
ferent parts of Europe, and Hyacinth Cestoni, at 
the end of the seventeenth century, investigated 
the characters of this insect with much exactness, 
and was the first proposer of the theory which 
regards it as the proximate cause of the itch.* 

This doctrine gave rise to a controversy which 
has continued ever since, and seems at the present 
day to be as far from being settled as ever. In the 
order of time, two questions are involved in this 
subject. By the first the acarus, or (as Latreille 
denominated it generically) sarcoples scabiei, was 
universally received ; but issue was joined on the 
opinion first mooted as a conjecture by Cestoni, 
that scabies is nothing else than the bite of these 
small insects, which produces the itching and an 
extravasation of serum collecting into vesicles 
moreover that the contagion is effected by the 
transfer of those insects from one individual to 
another. Experiments were made, and opinions 
were contested negatively and affirmatively, by 

n^„I hiS - Vas co "»municated by Cestonis rn„li„tnr ft 



SCABIES. 



65 



many eminent medical men in different countries. 
Redi, Wichmann, Osiander, Pringle, and many 
others, considered the contact of the insect as the 
only exciting cause of the itch ; while as great a 
number insisted that the acarus was produced by 
the disease. Again, a middle opinion was em- 
braced by the majority, to which Morgagni at- 
tached himself. They held that in most cases the 
insect was the product of the disease, but admit- 
ted that in some instances the latter owed its 
origin to the insect. M. Gales, apothecary to the 
Hdpital St. Louis in 1812, undertook a scries of 
investigations, which he conducted with the great- 
est variety and perseverance, and which finally 
seemed to leave nothing undecided as to the whole 
subject. He observed with the microscope up- 
wards of three hundred of the insects taken from 
the scabious vesicles.* He confined the insect 
upon his hand with a watch-glass, and observed 
it penetrating the cuticle, upon which, after a few 
hours, three vesicles appeared, the intense itching 
of which left no doubt of their identity with 
scabies. He inoculated in the same manner three 
children with the insect, who became covered 
with the itch. These experiments were testified 
to by many of the first naturalists in Paris ; and 
as they appeared to have the force of demonstra- 
tion, after their publication the opinion that the 
itch was produced by the insect was ratified by the 
assent of almost all. They doubtless proved the 
presence of the acarus, and moreover that its pen- 
etration of the skin is an occasional cause of 
scabies ; but witli all, this may be a very second- 
ary matter in the production of the disease. In 
fact, it seems to us somewhat singular that these 
observations were permitted to prove more than 
that the insect taken from a scabious vesicle, 
being charged with the virus, the fluid of the 
vesicle, by penetration of the cuticle, inserted this 
virus, and produced the disease, like the inocula- 
tion of cow-pox. 

At a later period, however, the opinion supposed 
to be thus incontestably fixed by M. Gales' ex- 
periments was not only called in question, but, 
singular to relate, the existence of the acarus was 
again doubted. M. Suriray of Havre, and after- 
wards MM. Lugol and Mouronval, revived the 
discussion of the subject, and, as the result of their 
researches, denied that any insect could be found. 
This extraordinary revulsion of opinion was con- 
firmed by M. Biett, who, even with the use of 
microscopes of high power, was unable, in a great 
number of trials, to discover it in a single instance. 
Cazenaze and Schedel state that many others have 
made an equally unsuccessful search for the in- 
sect ; and n jecting for themselves the idea of its 
existence, they announce a kind of challenge to 
M. Gales to transport himself again to the Hopi- 
tal tSt. Louis, and demonstrate it anew. 

It would follow from these negative researches, 
that while at one period the disease is attended by 
the acarus, at other times it exists without it. In 
these countries it is a notorious fact that the insect 



* Flis descriptions of the insect agree witli those of 
Linnseus and Latreille, hut are much more extended and 
!i has six legs, witli a few filaments hesides pro- 
jecting from the body, and is not unlike the minute 
puli.v sometimes accompanying prurigo. It lies in the 
centre of tin- vesicle, round the margin of which it de- 
posits its ova. 

Vol. IV. — 9 r * 



is frequently found. Moufet originally stated 
that the common people were in the habit of ex- 
tracting it from the vesicles with the point of a 
pin ; but that more usually it may be found in a 
small channel which it frets from the vesicle in 
the adjoining cuticle. We have conversed with 
those who have frequently seen them, and whose 
description of their being found not in the vesicle 
but in the red streak adjoining it, exactly coincides 
with Moufet. Bateman and Mr. Plumbe bear the 
same testimony ; and the latter adopts an hypo- 
thesis proposed by Gales and Founder, (Diet, des 
Sc. Med. art. Gale, torn. xvii. p. 109,) by which 
it is conjecturally affirmed, that when the elevation 
becomes large and full of lymph, it being no 
longer possible for the insect to exist in it, in 
obedience to a preservative instinct it makes ; ts 
way laterally, and is then found beside and not 
within the maturated vesicle. He supposes, also, 
that it is sufficient to account for the ill-success 
of those who have not found it, to presume that 
they happened to select for their researches vesi- 
cles which had been evacuated by the acari. This 
does not occur to us as by any means satisfactory ; 
but the opinion of Sauvages, adopted by Bateman, 
seems more plausible, that the insect is generated 
only in some instances of scabies, of which cases 
Sauvages proposes to make a particular species 
under the title of " scabies vermicularis." This 
is not irrational ; yet we deem it more consonant 
with the varying history of the researches to sup- 
pose that there is a variation in the disease itself 
in this respect at different epochs. This view is 
more consistent with analogy, us we know how 
often the type of diseases changes at different 
epochs in the same locality, without therefore 
losing their identity. Of tins lever is a familiar 
example, which it is unnecessary to do more than 
mention in respect to its change of type; but an 
occasional phenomenon which it presents (as was 
remarked by M. Ranque of Orleans) may be ad- 
duced, and reflected on in connection with the 
generation of the acarus eccbioi We allude to 
what is occasionally observed when a favourable 
crisis takes place at the last extremity of typhus ; 
the head is sometimes swarmed by a sudden pro- 
duction of lice, so unaccountably numerous as 
only to permit the supposition that they are se- 
creted by the skin. 

According to the view here propounded, and in 
i it with the analogy just mentioned, the 
animalcule of scabies is regarded as a secretory 
product of the disease, which at certain periods is 
endemic; but ignorance is professed as to the cir- 
cumstances which give rise to it at one time more 
than another; and at the same time we agree 
with Bateman, that the contagious property of 
scabies exists in the fluid, and not in the insect, 
which, however, may be the occasional means of 
transport of the latter. We would finally remark, 
with regard to the whole controversy, that it in 
eludes a lesson at least to medical theorists: here 
many ingenious men oppose each other in a mat- 
ter of fact and observation ; with what sobriety, 
then, should dogmatic opinions be entertained, 
when it is often so difficult even to lay their 
foundation in certain facts ! 

[Most recent writers on the subject are disposed 
to consider the acarus as the cause of itch (E 



G6 



SCABIES, 



Wilson, Practical Treatise on Diseases of the 
Skin, Amer. edit. p. 23.5, and W. Horn, art. Sca- 
bies in Encyclop&d. Wdrterb. der Median. Wis- 
senschaft. xxx. 138. Berlin, 1843.) Mr. Wilson 
classes scabies as the only example of inflamma- 
tion of the skin induced by parasitic animalcules 
inhabiting the epidermis; yet it is not easy to un- 
derstand how it is readily communicated by con- 
tact, under the idea that it must be conveyed by 
the insects, as it is by no means a matter of faci- 
lity to extract them from the furrows where they 
are domiciliated. 

It was not until the year 1834, and after seve- 
ral distinguished individuals had tried in vain, 
(Biett, art. Gale, in Diet, de Med. 2de edit. xiii. 
547, Paris, 1836,) that the manner of finding the 
acarus was clearly demonstrated. A medical stu- 
dent from Corsica, M. Renucci, had frequently 
seen the women of his country extract the insect, 
and had often done so himself; and he showed, 
that it must not be sought for in the vesicle, but 
in the furrow which sets out from it, and which is 
made by the insect beneath the epidermis.] 

Treatment. — The cure of scabies appears to 
have been considered a matter of no slight medi- 
cal interest. Treatises have been written upon 
it, and a vast variety of means discussed with so 
much earnestness, that we are led to the conclu- 
sion, (which we believe coincides with general 
tradition,) that it was formerly a scourge to the 
community of greater extent and virulence than 
at the present day. It is now regarded as of tri- 
vial importance. Never in itself dangerous, it 
gives much annoyance to the individual by its un- 
appeasable itching ; but the fear and restraint 
which it puts upon him of infecting others often 
causes as much discomfort to him as its action 
upon himself. Neglect of the appropriate means 
may indeed protract it to an indefinite length ; 
but by their use its treatment is conducted with so 
much certainty that we have scarcely any other 
care in the choice of remedies than to select that 
which experience has approved of as effecting a 
riddance of the disease in the most secure and 
speediest manner. A multitude of such has been 
vaunted, but modern practice has contracted the 
most useful within a small circle ; and it is unne- 
cessary to enumerate here any of minor efficacy, 
as we are in possession of some whose virtues are 
almost infallible. 

Sulphur is considered in the light of a specific 
remedy in the cure of itch. It is the basis of the 
applications which by universal consent are con- 
sidered its most effectual antagonists. In the or- 
dinary forms of the disease the common people 
have long used it as an ointment, mixed with 
equal parts of hog's lard or butter, with which 
they smear the parts on which the eruption exists 
once or twice a day. They administer it inter- 
nally at the same time, in doses of from ten grains 
to half a drachm given in milk at bed-time. By 



it speedily after its first appearance, as the dura- 
tion of the treatment will be longer if long ne- 
glect has permitted it to gain a certain inveteracy. 
\ areat improvement was made in the applica- 
tion of the sulphur ointment by the combination 
of an alkali with it. This adds to the specific 
effect of the sulphur the advantage of a detergent 
action, which loosens and dissolves crusts or scabs, 
and permits the skin to be well penetrated by the 
ointment. M. Helmerich, a French army surgeon, 
became famous for a method of using sulphur 
which cured the itch more promptly, and also per- 
mitted the greasy stain of the ointment to be re- 
moved from the linen by washing, obviating an 
objection to the use of unguents which was very 
generally felt. He kept it a mystery, but it was 
analyzed by M. Burdin, and found to consist of 
the following ointment : 

Sublimed sulphur, two parts, 
Sub-carbonate of potass, one part, 
Axunge, eight parts, intimately mixed.* 
This deserves a preference over all other methods 
of applying the sulphur externally. It has the 
most constant and prompt success, and is seldom 
attended by the cutaneous affections which some- 
times result from the use of other stronger but 
more irritating sulphureous applications. It is the 
ointment which Biett has exclusively employed at 
the Hopital St. Louis for several years. He or- 
ders half an ounce of it to be rubbed, morning 
and evening, over all the parts occupied by the 
vesicles. The action of this ointment is favoura- 
bly promoted by the use of a tepid bath every 
second day during its application, which will rare- 
ly have to be continued beyond ten or twelve days. 
Another sulphureous friction which, in the Paris 
hospitals, rivals the reputation of the above-men- 
tioned ointment, is made with the sulphuret of 
lime. A scruple or half a drachm of this powder 
is to be triturated with a small proportion of olive 
oil, so as to render it sufficiently fluid for using as 
a friction, and this quantity is to be rubbed upon 
the affected parts twice a day. This is a very ef- 
fectual cure, but it is not so applicable as the for- 
mer when the itch has already spread to any con- 
siderable extent. 

[In more obstinate cases, the Unguentum Sulphu- 
ris compositum of the Pharmacopoeia of the United 
States, which contains — in addition to the sul- 
phur — ammoniated mercury, benzoic acid, oil of 
lemons, sulphuric acid, and nitrate of potassa, may 
be substituted. The writer is more in the habit 
of prescribing the Unguentum Sulphuris composi- 
tum of the London Pharmacopoeia, which contains 
— sulphur, §iii.; veratr. pulv. gi. ; potas. nitrat. 
3'j-; saponis mollis, giij. ; adipis, gix.; ol. berga- 
mot, m xv.] 

The use of ointments over an extensive surface 
of the skin may be considered unadvisable in some 
cases, as interfering with the cutaneous transpira- 
tion. When these objections exist, substitutes of 



this treatment they scarcely ever fail to cure it ex- no ' ess efficacy are found in the proper use of lo- 
peditiously. The internal use of sulphur is 
adapted for it in children, and is occasionally 
combined with magnesia; in adults, however, it 
is unnecessary to have recourse to any but the ex- 
ternal use of the sulphur ointment. The assidu- 
jus use of it for a fortnight is sufficient to cure 
the common forms of it, if they be attacked with 



tions. None of these, is preferable with regard to 
activity to the solutions of sulphuret of potash, or 
of lime. These have been long known and ex- 

* For the sake of depriving this ointment of the smell 
and appearance of sulphur, it would be agreeable to add 
to each ounce of the axunge a fu\\ drops of oil of laven 
der or bergamotte, and ten grains of the hydrareyri sul 
phuretum rubrum (vermilion). 



SCABIES — SCARLATINA, 



67 



tensively used in scabies, and a saturated solution 
of the latter is an excellent remedy in the mange 
of sheep or dogs. The following formula of a 
lotion was prescribed by M. Dupuytren, and high- 
ly extolled in France for the promptitude with 
which it effects the removal of the disease : 

K. — Sulphureti potassae ^v. 

Aqua; purse lb. iss. 

Acidi sulphurici ^ss, dissolve ut fiat lotio. 

Whatsoever part of the eruption has invaded is 
to be moistened by a gentle friction with this lo- 
tion twice a day. It has the advantage of not in- 
juring the linen of the patient, nor does it compel 
him to renounce his employment during its use. 
However, it produces a smarting of the skin, which 
will sometimes require it to be used in much 
weaker proportions, and renders it not so appro- 
priate in some irritable habits. 

If the individual entertain insuperable objec- 
tions to the use of sulphur from disgust to its 
odour, many other external remedies of approved 
efficacy are at hand. The ointment of white hel- 
lebore, in the proportion of a drachm of the pow- 
der to an ounce of lard, is both a safe and expedi- 
tious application. Solutions of the chloride of 
lime or of soda have been extolled as highly bene- 
ficial by some practitioners; they are used as a 
lotion in the proportion of an ounce to a pint of 
water. The aqua chlorinii applied in the same 
manner is also mentioned with applause. Heber- 
den strongly recommended a lotion composed of 
a solution of the muriate of mercury, made with 
one drachm, or two, (according to the inveteracy 
of the disease,) to a pint of water. This is ac- 
knowledged to be a remedy of great power in cur- 
ing scabies, but it is objected to by some as liable 
to produce the constitutional effects of mercury. 
We have, however, been assured that these fears 
are vain, by an esteemed practitioner, who has 
had a very favourable experience of this lotion, 
and has used it on his own person with success ; 
and in our own more limited sphere of observa- 
tion, we never saw any such effects from it. 

[These ointments are less offensive than the 
ointments of sulphur, but they are certainly less 
sure. The same may be said of those of creasote 
and of chlorinated lime.] 

Sulphureous baths are an excellent auxiliary 
means in many cases of scabies. In cases of very 
irritable skin they are frequently the only form 
in which general applications of this remedy can 
be made to the surface ; in young children, there- 
fore, they are a very valuable resource. The arti- 
ficial are found to answer the purpose equally 
well with the water of sulphureous springs, and 
their employment possesses the advantage of being 
proportioned according to circumstances. They 
may be prepared by simply adding to an ordinary 
sized warm bath six ounces of the sulphuret of 
potash in powder, and agitating it until it be dis- 
solved, and the water be reduced to a lukewarm 
temperature. 

Sulphureous vapour baths are another means 
which possess great power in this as well as in 
some other diseases of the skin. This is evident 
from the testimony of all who have used them, 
from M. Gales, who was the first to construct an 
Apparatus for their convenient administration, to 



Mr. Wallace, who has also ably illustrated their 
use. Dr. Bardsley informs us, that he has " al- 
ways seen the most obstinate and neglected cases 
of it yield very speedily to a few fumigations." 
(Hosp. Facts and Observations, p. 198.) It is hap- 
pily to such inveterate cases that they are mainly 
applicable ; for even if they did possess the supe- 
perior advantages over ordinary methods of treat- 
ment which are claimed for them, they are too sti- 
mulating to be employed in many cases except 
where the disease has become chronic through ne- 
glect, and has induced an unhealthy torpid condi- 
tion of the skin. They are particularly contra-in- 
dicated where there exists any tendency to con- 
gestion in the gastric or pulmonary mucous mem- 
branes, and in females with complaints depending 
on morbid conditions of the uterine functions. 

In the conduct of the treatment the practitioner 
has but little to be solicitous about ; but, having 
used his discrimination in the adoption of the 
most appropriate remedy, he perseveres until the 
cure is complete. He should inculcate great at- 
tention to cleanliness and change of linen, espe- 
cially during the convalescence. A vigilant in- 
spection must be made for the purpose of detecting 
any of the complications previously noticed as apt 
to coexist with certain forms of the disease, or to 
spring up under improper treatment. If any of 
those be present, it will be necessary to modify 
his plan accordingly, and often to suspend the use 
of the stimulating remedies, with which he had 
commenced to combat the scabies. The state of 
the alimentary canal now demands particular at- 
tention ; cooling laxatives and alteratives will be 
proper; and for topical applications recourse should 
be had to emollient fomentations, and the other 
soothing means specially adapted to the individual 
complication, for which we refer to Ecthyma, 
Eczema, Impetigo, Lichen, &c. 

James Houghton. 

SCARLATINA.— Syn. Morbilli Confluentes, 
Morton : Rubeola Rossalia, Hoffmann : Febris 
Scarlatina, Sydenham : Febris Rubra, Heberden : 
Scarlatina, Sauvages, Vogel, and Cul/en : Pur- 
pura, Shullz, Junck: Enanthesis Rosalia, Good .■ 
Fievre Rouge, Scarlatine, Fr. : Der Scharlachauf- 
schlag, Germ. : Scarlet Fever. Scarlatina desig- 
nates a contagious febrile disease, the distinguish 
ing characters of which are, a scarlet efflorescence 
of the skin and of the mucous membrane of the 
mouth and pharynx, appearing on the second day 
(though often later) of a febrile disorder, and ter 
minating about the fifth ; accompanied, in the 
majority of instances, with inflammation of the 
throat, either of a phlegmonous or gangrenous 
character ; and occasionally with tumefaction of 
the cervical absorbents and subcutaneous cellular 
membrane. Other organs become also sometimes 
involved in the progress of the disease, giving rise 
to lesions of greater or less severity. The type of 
the accompanying fever is various, and modifies 
remarkably the whole aspect of the malady. In 
some cases, the constitutional disturbance is so 
trivial as scarcely to attract notice; in others, the 
febrile symptoms are those of strong inflammatory 
excitement; while in individual instances, or dur 
ing the prevalence of an entire epidemic, the feve.i 



63 



SCARLATINA. 



is of a low typhoid form, the local inflammation 
with which it is associated, partaking very much 
of the same character. 

The origin of scarlatina is involved in great 
obscurity. It was evidently unknown to the an- 
cients; no allusion to it can be discovered in the 
writings of Hippocrates, or in the early Greek and 
Roman writers; and, notwithstanding the opinion 
of some modern authors of the French school, that 
it was described about the middle of the sixteenth 
century, it is generally admitted that Prosper 
Martiaiius, an Italian physician, who gave a de- 
scription of the disease as it prevailed in Rome 
about the middle of the seventeenth century, if 
not the first, is among the earliest writers on scar- 
latina. It made its appearance in London in 
1689, and was described by Sydenham and after- 
wards by Morton, though it is evident by com- 
paring the description given by these two writers, 
that they had observed different epidemics; the 
one described by Sydenham being a very mild 
disease compared with that of which Morton has 
given an account. From the various names, 
however, given to scarlatina on its first appear- 
ance, it is evident, that about the period to which 
we refer, the notions entertained with regard to it 
were vague and unsatisfactory ; indeed, it was 
scarcely distinguished from measles, roseola, or 
purpura. For example, it was named by Morton 
morbilli conjlucnles ; by Hoffmann, rubeola rossa- 
lia s by Heberden, febris rubra; and even till 
within a little more than half a century, both these 
diseases (measles and scarlatina) appear to have 
been considered by medical writers as the same, 
or at least as so closely allied, as only varieties of 
a common species. Morton, indeed, maintained 
their identity, and considered their relative con- 
nection to be nearly the same as that existing 
between the distinct and confluent small-pox. 
(De Morbillis et Scarlatina, Exercit. iii.) The 
description of the epidemic given by Huxham 
under the name malignant ulcerated sore-throat, 
which prevailed in the year 1734, resembles in 
almost every particular one form of scarlatina — 
that form in which the eruption is accompanied 
with affection of the throat. The treatise on this 
subject is a valuable record of the characters of 
this epidemic, the description being evidently 
taken from what he had observed in his inter- 
course with the sick. Dr. Fothergill also has 
given the history of a " sore throat attended with 
ulcers," which appeared in London in 1747-8, 
which there can be little doubt was an epidemic 
scarlatina; and from the remarks he has made, it 
is evident, that he had observed various forms of 
the disease, from the mildest to the more malig- 
nant. Dr. Withering published an essay on scar- 
let fever in 1778, a second edition of which ap- 
peared in 1793; to this author is due the merit 
of having first accurately described scarlatina as a 
distinct disease ; since that period, various treatises 
have appeared both in this and other countries. 

Causes. — Nothing satisfactory is known as to 
the exciting causes of scarlatina. It appears to 
be induced, like the other eruptive fevers, by ex- 
posure to the influence of a specific poison. At- 
tempts have been made to induce the disease by 
inoculation, by inserting the thin scales, which 
arc. thiown off at the period of desquamation, under 



the skin of individuals who have never had scar- 
let fever, but hitherto without success. How far 
inoculation with the blood might be followed by 
different results is a question which can only be 
determined by experiment. 

That scarlatina may be propagated by conta- 
gion is, we presume, admitted even by those who 
profess themselves sceptical on the question of 
contagion in general. Instances of the disease 
spreading in a manner which can only be ex- 
plained by admitting its contagious origin are so 
numerous, that practitioners of the most limited 
observation must have had repeated opportunities 
of determining the question. We have known, 
in several instances, convalescents from scarlet 
fever, on their removal to a considerable distance 
from the situation in which they had passed 
through the disease, infect individuals with whom 
they came in immediate contact, though several 
weeks had elapsed from the period of desquama- 
tion. The period of invasion after exposure to 
sources of contagion is exceedingly various. Some 
individuals are seized within a few hours; others 
do not exhibit any of the peculiar symptoms for 
several days ; and in some more rare cases, five 
or six weeks have intervened between the period 
of exposure and the accession of the disease. The 
poison also appears to affect individuals very dif- 
ferently. Of a number of persons exposed to the 
same source of infection, some may escape alto- 
gether; others have a mild form of the disease; 
or it may happen, perhaps, that in several, the 
disease proves severe. Even in the same family 
the various forms which scarlatina presents may 
occasionally be observed. One or more may ha\e 
both the efflorescence and the sore throat ; in 
others there may be fever with the characteristic 
rash but without any affection of the throat; an- 
other case may present the characters of the ma- 
lignant disease; while, again, those who have 
been in constant attendance on the sick become 
indisposed with smart inflammation of the throat 
and a considerable degree of fever, which lasts for 
some days, and then subsides with the local affec- 
tion. In these latter cases, (though there have 
been no efflorescence), desquamation of the cuti- 
cle occasionally occurs. Dr. Rush, in an account 
of an epidemic scarlatina which prevailed at Phi- 
ladelphia, remarks that such was the prevalence 
of the contagion which produced the scarlatina 
anginosa, that many hundred people complained 
of sore throat without any other symptoms of in- 
disposition. The slightest occasional exciting 
cause, particularly cold, seldom failed of producing 
the disease. (Medical Enquiries and Observa- 
tions.) The same thing has been repeatedly 
observed in this country. 

Although sporadic cases of scarlet fever are met 
at all seasons, it is more prevalent at the end of 
summer, and in the autumn, than at other periods 
of the year. Epidemic visitations have been most 
frequently observed after a warm summer, espe- 
cially when the heat has been accompanied with 
continued rains; and when the succeeding winter 
has been open and mild, the disease has continued 
till it has been checked by frost. It generally dis- 
appears in the spring months, though it has been 
observed to continue uninterruptedly for one o* 
more years. 



SCARLATINA 



69 



It is necessary to advert in this place to the dif- 
ference in the characters of epidemic scarlatina, 
though the causes of such remarkable variation are 
unknown. For a whole season, the disease may 
assume a mild aspect, so that a fatal case is rarely 
met with ; in such instances, the danger is gene- 
rally produced by some local inflammation which 
has supervened in the progress of the disease, or 
during the period of convalescence. On the other 
hand it should be remembered, that during a com- 
paratively mild epidemic, one or more cases may 
assume a malignant character, and resist the best 
directed curative efforts. Sometimes an epidemic 
of a malignant form, or, as it is popularly termed, 
a putrid form of scarlet fever suddenly breaks out 
and proves extremely fatal. From its commence- 
ment the symptoms often denote a severe form ; 
at other times on its first irruption the disease is 
mild, but suddenly, without any apparent cause, 
the symptoms assume an unfavourable appear- 
ance, which continues as long as the epidemic 
lasts. It is therefore of great practical importance 
to ascertain the prevailing type of the disease, as 
the character which it assumes must regulate the 
treatment to be adopted. 

Dr. Willan observed, (On Cutaneous Diseases, 
p. 277 and 281,) that when the scarlatina spread 
widely, it exhibited in the different persons affected 
every gradation of appearances, from the slightest 
to the most malignant form of the disease ; yet 
during its diffusion through some large families 
and schools, he had seen it uniformly retain the 
series of symptoms which occurred in the first 
patient, with nearly the same degree of fever. In 
the autumn of 1786, and occasionally since that 
period, the scarlatina maligna above described 
affected the inhabitants of several districts in 
London, comprising narrow courts, alleys, and 
close crowded streets, and afterwards extended to 
some adjoining villages in low, damp, or cold 
situations. It is, however, more frequently inter- 
mixed with the other varieties of scarlatina, and 
it sometimes unexpectedly supersedes the milder 
forms of the disease on the fourth, fifth, sixth, or 
seventh day of their course. 

" It is truly singular," he adds, " that the slightest 
of all eruptive fevers, and the most violent, the most 
fatal disease known in this country, should rank 
together and spring from the same origin. Expe- 
rience, however, decides that the simple scarlet 
fever, the scarlatina anginosa, the scarlatina (or 
angina) maligna, and the scarlet ulcerating sore- 
throat, without the efflorescence on the skin, are 
merely varieties of the one disease. That all of 
them proceed from the same source of contagion 
is evident, because under the same roof in large 
families some individuals have the disease in one 
form, some in another, about the same period." 

Scarlatina occurs more frequently in the early 
than in the advanced periods of life, and in our 
own experience females are more liable to the dis- 
ease than males. Dr. Withering states that the 
epidemic which appeared at Birmingham in the 
year 1778, affected children more than adults, but 
seldom occurred in the former under two years of 
age. In children, the number of boys and girls 
that suffered from it was nearly equal ; but in the 
adults, the number of female patients considerably 
exceeded that of the male. 



In order to determine its relative frequency in 
the sexes at different ages, we selected from the 
register of patients admitted into the London 
Fever Hospital, .two hundred cases in the order 
of their admission. The following table gives the 
general results : — 



Age. 


Males. 


Females. 


Tota 


From 6 to 10 


7 


8 


15 


10 " 15 


8 


15 


23 


15 » 20 


17 


40 


57 


20 « 25 


14 


39 


53 


25 « 30 


8 


21 


29 


30 « 35 


6 


10 


10 


35 « 40 


1 


2 


3 


40 


1 





1 


42 





1 


1 


48 





1 


1 


57 





1 


I 



62 



138 



200 



It is proper, however, to state that this table 
cannot be considered quite complete, the number 
of children under six years of age who take the 
disease not being ascertained, in consequence of 
the regulations of this hospital precluding the ad- 
mission of children under six years of age. The 
table shows the great majority of females at every 
age, and also disproves the assertion of Sir Gilbert 
Elane (Select Dissertations, p. 213) and others, 
that the majority of those who are seized with 
scarlatina are under puberty. 

Scarlatina in general affects the same individual 
only once during his life, and in this respect obeys 
the general law of exanthematous fevers. Occa- 
sional exceptions have certainly been observed by 
practitioners, though, from the testimony of Dr. 
Willan, a second attack of scarlatina in the same 
individual is extremely rare; he states that he had 
never seen such a repetition among two thousand 
patients whom he had visited in scarlatina. We 
certainly have met with several well authenticated 
instances of a second attack of scarlatina in the 
same person. 

[Dr. Billing (First Principles of Medicine, 
Amer. edit. p. 191, Philad. 1842) states, that he 
has known it occur three times in the same indi- 
vidual, — frequently twice; in one instance, twice 
within ten months, in its exquisitely marked form, 
as to inflamed tonsils, appearance of tongue, erup- 
tion, and desquamation of cuticle. Recently, the 
writer attended a lady who, six years ago, was 
affected with it, for the first time, in childbed, — 
the child being born with the eruption : three 
years afterwards, her child had it for the second 
time, and died ; and she also suffered severely 
from a second attack. Lately, from attending 
on a young gentleman who died of the disease, 
she had a third attack. 

It is by no means uncommon for those who 
have had the disease, to suffer from sore-throat — 
scarlatina faucium — when they are in attendance 
upon one labouring under scarlatina. (See Guer- 
sant 3f Blache, art. Scarlatine, in Diet, de Med 
2dc edit, xxviii. 158, Paris, 1844.)] 

It is proper to notice the discovery of the sup- 
posed efficacy of the extract of belladonna as a 
preventive of the infection of scarlatina. Thii 
■was first suggested by Hahnemann, of Leipsic. ir< 



70 



SCARLATINA. 



1807. The belief that this narcotic possesses 
such a preventive power is gaining ground in 
some parts of the continent, ami lately even in 
our own country. The following ahstract will 
explain the views of Hahnemann on this suhject. 
A favourite doctrine of this writer is, that diseases 
are to be combated by remedies, the effects of 
which are similar to the diseases for which they 
are given. This is the doctrine to which the 
term homccopathia has been given, and which 
has of late years gained many proselytes in 
Germany, France, and Italy. Hahnemann ob- 
served, that belladonna given in small doses produ- 
ced heat and dryness in the throat, swelling of 
the submaxillary glands, and a cutaneous eruption, 
sometimes an efflorescence only, at other times a 
papular rash, like miliaria; he therefore inferred 
that this medicine, from its producing symptoms 
analogous to those of scarlatina, might prove a 
preservative against its infection. About ten 
years after Hahnemann had entertained this notion 
of the anti-scarlatinous power of belladonna, a 
severe and fatal epidemic appeared in several cities 
of Germany, and consequently the physicians 
were naturally desirous of adopting measures 
calculated to arrest its progress. From the result 
of the trials made by Berndt, of Custrin, who 
was the first who made a series of experiments, 
we find, that in an epidemic scarlatina which 
prevailed in Custrin in 1818 and 1819, he em- 
ployed the belladonna as a preservative in one 
hundred and ninety-five children under fifteen 
years of age ; though they were freely and con- 
stantly exposed to the contagion of scarlatina, 
only fourteen took the disease, and that after 
employing a stronger preparation of this drug, 
every individual escaped. A still stronger testi- 
mony in favour of its efficacy is given by Duster- 
berg, a physician of Warburg ; he states, that every 
child who took the belladonna for a sufficient 
length of time before exposure to infection escaped; 
that when a child was left in an infected family 
to nature, (the belladonna not having been ad- 
ministered with the object of determining its effica- 
cy) it was invariably attacked with scarlatina, 
while the others who took the remedy escaped. 
Behr, of Bcrnberg, also affirms that of forty-seven 
persons who took the belladonna as a preservative, 
only six were attacked. Professor Koreff, of 
Berlin, after extensive and long-continued trials, 
asserts that if the belladonna be taken in proper 
doses for eight or nine days before exposure, and 
be continued till the period of desquamation, there 
is little danger to be apprehended from free inter- 
course with persons affected with scarlatina. 
Similar testimony has been given as to the efficacy 
of this narcotic by Hufeland, Kunzman, of Berlin, 
and others.* 

[On the other hand, the belladonna has failed 
to exhibit any prophylactic powers in the obser- 
vation of many respectable practitioners, (Pereira, 
Elements of Mat. Med. and Therapeutics, Amer. 
edit. ii. 307, Philad. 1843, and Rilliet and Barthez, 
Traite Clinique et Pratique des Maladies des En- 
funis, ii. 641, Paris, 1843.) Dr. Pereira remarks, 

* \iite Arch. Gen. de Med. Juin, 1824. — Journ. Com- 
plement. Juin, 1834. — Hufeland, Joorn. der practischen 
lleilkunde, Nov. 1815. — Rust Magazin fiir die gesammte 
Ifeilkunde x». i. lt-2. 



that whilst the facts brought forward ... favour of 
(he existence of the prophylactic power are only ne- 
gative, those which can be adduced against it are 
Litive; for twenty casesoffa.lure.be conceive., 
L mo re conclusive against .t than one thousand 
of non-occurrence are in favour of . . I he writer 
has repeatedly administered it; and as elsewhere 
remarked, ( Practice of Medicine, 2d edit ... 538, 
Philad 1844,) until the winter of 181.J, none 
took the disease. At that time, during the preva- 
lence of scarlet fever in his own neighbourhood, 
the belladonna was sedulously administered to his 
children, five in number, — two of whom, the 
youngest three years old, and the oldest six, after 
having taken the belladonna for six weeks, were 
attacked,— the others escaping. The disease was 
severe, but it was not attended by any specially 
alarming symptoms.] 

The quantity administered is very minute. 
Three grains of the extract of belladonna are to 
be dissolved in one ounce of distilled water ; of 
this solution two or three drops are to be given 
twice a day to a child under twelve months old, 
and one drop more for every year above that age. 
In general, no sensible effect is produced by it, 
but in some instances, it brings out an eruption 
similar to scarlatina. It is also asserted by those 
who have tried this remedy, that even when it 
does not prove a preventive of the infection of 
scarlatina, which may be in consequence of its 
not having been administered for a sufficient 
length of time before exposure, it renders the dis- 
ease more mild, and even that if it be taken for 
four or five days before exposure, the disease 
never proves fatal. As we have never employed 
the belladonna as an anti-scarlatinous remedy, we 
can offer no opinion of its merits, though we cer- 
tainly profess ourselves sceptical as to the powers 
ascribed to this drug. The subject is, however, 
worthy of further experimental inquiry. It has 
one advantage, that of being perfectly harmless, if 
it do not act as a preservative. 

Varieties. — Scarlatina occurs under several 
forms, to which it is necessary to advert. In the 
first, the afflorescence is attended with mild febrile 
symptoms, but there is no inflammation of the 
throat (scarlatina simplex). In the second the 
fever is of a more severe character, and the efflo- 
rescence is accompanied with inflammation of the 
throat (scarlatina anginosa). In the third, the 
whole character of the disease is more severe than 
in either of the preceding varieties : the fever is of 
a low or typhoid type ; the throat is affected with 
gangrenous inflammation, accompanied with tu- 
mefaction of the cellular tissue and absorbents of 
the neck, and in general with an acrid discharge 
from the nostrils and ears (scarlatina maligna). 
In other instances, the efflorescence is confined to 
the mouth and throat, and does not affect the 
skin. This form (to which no name has been 
given) is often observed during the prevalence of 
epidemic scarlatina; not unfrequently in adults, 
when some other form of the disease is prevailing 
in the family. It may be designated by the name 
scarlatina faucium. 

1. Scarlatina simplex.— In this form of the 

d.sease there is only the efflorescence with a 

moderate degree of fever. The rash is preceded 

; by slight symptoms of fever— irregular shivering, 



SCARLATINA. 



71 



nausea, sometimes vomiting, thirst, and heat of 
skin. The degree of fever is by no means uni- 
form ; the symptoms are sometimes so moderate 
as scarcely to attract attention, though there is 
often smart constitutional disturbance, indicated 
by pungent heat of skin, flushing of the face, suf- 
fusion of the eyes, pain of head, restlessness, and 
occasionally delirium. The efflorescence or rash 
generally comes out on the second day of the 
eruptive fever, but in some instances it does not 
show itself till the third, and accordingly we find 
authors differing as to the precise period at which 
it appears. Sauvages and Cullen state that it 
does not come out till the fourth day after the 
accession of the febrile symptoms. Plenciz (Trac- 
tatus de Scarlatina, 1776,) does not limit the 
period, but affirms that the rash makes its appear- 
ance on the second or third day, or sometimes 
later. Heberden restricts it to the first or second 
day. It is, however, probable that in the majority 
of instances, the rash comes out on the second 
day of the fever, and that in cases in which it ap- 
pears sooner or later, there is some peculiarity in 
the individual or in the disease to account for the 
variation. 

The efflorescence, which is first perceptible on 
the face, neck, and chest, becomes gradually dif- 
fused over the body ; in twenty four hours or less 
from its first appearance the trunk is covered with 
the eruption ; on the following day (the third) it 
extends to the upper and lower extremities, at 
which period the whole body is of a bright red 
colour, and pungently hot and dry. On the ex- 
tremities, particularly the hands and fingers, the 
rash is diffuse and continuous, but on the trunk it 
is distributed in irregular patches, the colour 
being most deep on the loins, buttocks, flexure of 
the joints, and on those parts of the body which 
are subjected to pressure ; it is generally more 
vivid in the evening, gradually becoming paler 
towards the morning. 

This is the ordinary progress of the efflores- 
cence in the skin : it is not, however, confined to 
the cutaneous tissue ; the mucous membrane 
which lines the nostrils, mouth, ami fiuces being 
covered with the eruption, so that the lips, the 
tongue, the pharynx, the velum palati, the nostrils, 
and even the internal surface of the eyelids are of 
a bright red colour. The papilla? of the tongue 
become considerably elongated, the red points 
shooting through the white fur, and from which 
it derives its characteristic appearance. In cases 
where the tongue is clean, it has nevertheless a 
bright red colour, and the scarlet points may be 
seen shining through its polished surface. 

The rash of scarlatina consists of innumerable 
red points or dots, which are at first of a pale red 
colour, but afterwards acquire a deeper hue, giving 
the affected portions of skin not only a uniform 
red appearance, but a perceptible roughness, 
which is most evident on the breast and extremi- 
ties, in consequence of the greater determination 
of blood to the papillae of the skin in those situa- 
tions. 

The efflorescence on its first appearance some- 
times closely resembles a papular eruption, and 
occasionally small miliary vesicles make their ap- 
pearance, though this latter phenomenon is rarely 
observed, except when the individual has been 



subjected to a heating stimulating regimen, or con- 
fined in a small, crowded and ill-ventilated apart- 
ment. These papular or vesicular spots, however, 
are now and then observed when the disease oc- 
curs under the most favourable circumstances. 
Dr. Mason Good (Study of Medicine, vol. iii. p. 
13,) supposes that they arise from the great deter- 
mination of blood to the cutaneous vessels pro- 
ducing an effusion of coagulable lymph, which is 
not entirely absorbed by the time the efflorescence 
subsides, hence there is occasionally, though not 
often, an appearance of vesicles, sometimes nearly 
empty, and sometimes nearly filled with a pellucid 
fluid, according as the effused fluid has been more 
or less carried off. The occasional appearance 
of these vesicles during the progress of scarlatina 
has been noticed by Rush, Withering, Plenciz, 
and other writers ; Sauvages, indeed, under a mis- 
taken view of their importance, has constituted a 
distinct species under the name scarlatina vurlo- 
lodes. 

In ordinary cases of scarlatina, the eruption 
may be regarded at its height on the fourth day ; 
it begins to decline on the fifth, disappearing in 
irregular patches-, on the following day it is still 
more indistinct, and on the eighth day no trace 
of the rash is discernible. The various symptoms 
with which the eruption is accompanied gradually 
disappear with the efflorescence, but the tongue 
still remains morbidly red and clean. The des- 
quamation of the cuticle, which begins about the 
end of the fifth day on the parts on which the 
eruption first appeared, proceeds, so that about the 
eighth or ninth, portions of cuticle are thrown oft", 
the thickest and largest being those detached from 
the skin of the hands and feet. 

2. Scarlatina anginosa. — In this form, the 
fever and efflorescence are accompanied with in- 
flammation of the throat. The anginose inflam- 
mation sometimes precedes the fever, but most 
frequently appears at the same lime with the 
febrile symptoms, though, in some cases, not until 
the rash or efflorescence is at its height : in the 
majority of instances, however, it is felt when the 
eruption appears, and goes through its progress 
of increase and decline with the cutaneous erup- 
tion. 

The precursory symptoms of scarlatina anginosa 
indicate a more acute disorder than the scarlatina 
simplex. The headach is often accompanied with 
slight delirium ; the heat of skin is more pungent, 
and the prostration more marked from the begin- 
ning. In the course of the second day, the 
patient complains of a sensation of stiffness or 
pain about the muscles of the, neck, extending to 
the angles of the jaw and under the ears, with 
feeling of roughness in the throat, painful deglu- 
tition, and some degree of hoarseness. The viscid 
secretion from the mucous crypts of the tonsils 
and pharynx, which takes place in the more se- 
vere cases, aggravates the patient's sufferings, 
from the frequent and often ineffectual efforts 
made to expel it. On examining the tauces, the 
palate, uvula, and tonsils are red and swollen, and 
when the local inflammation is severe, coagulable 
lymph is effused in small irregular masses on the 
inflamed surfaces. These exudations are very 
liable, on a superficial examination, to be mistaken 
for ulcers, or, when the subjacent surface is tends* 



72 



SCAR1 



nntl disposed to blood, the admixture of blood im- 
parts to them a brown or almost black colour, and 
thus, more especially if there be fetor of the 
breath, they may be mistaken for gangrenous in- 
flammation of the fauces. On attentive inspection, 
however, after cleansing the throat by acidulated 
gargles, the entire continuity of the membrane 
from which the crusts have been detached, at 
once distinguishes this form of acute symptomatic 
angina, from the gangrenous inflammation and sub- 
sequent ulceration observed in scarlatina maligna. 

These exudations of lymph often extend to the 
lateral parts of the pharynx, and occasionally as 
far as the oesophagus, though, according to Raycr, 
they are never observed after death in the larynx 
or trachea. This coincides with our own expe- 
rience, as in the dissections of scarlatina with an- 
ginose inflammation which we have made, we 
have not seen an instance of membranous exuda- 
tion extending to the larynx. 

As the anginose inflammation becomes devel- 
oped, the febrile symptoms increase, the pulse rises, 
the respiration becomes oppressed, the skin more 
pungently hot and dry, (sometimes rising to 106°, 
108°, or even as high as 112° of Fahrenheit,) 
and the thirst urgent. The mucous lining of the 
mouth as well as the tongue, especially at its 
point and edges, assumes a florid red colour, the 
papillae being much elongated and protruding their 
inflamed points over its surface. All these symp- 
toms are increased towards evening, at which 
period, the febrile restlessness is often succeeded 
by delirium. 

The rash does not appear so early as in the 
simple form of the disease. It is sometimes per- 
ceptible on the second, hut more generally on the 
third day, and comes out in irregular patches on 
various parts of the body, particularly about the 
elbows and wrists. It has been occasionally ob- 
served that when the attack is severe, the eruption 
is sooner thrown out, a circumstance which was 
noticed by Dr. Clark, who informs us that in an 
epidemic which broke out in Newcastle-upon- 
Tyne, in the year 1778, when it began with great 
vehemence the eruption was often observed on the 
first day, though commonly it did not make its 
appearance till the second or third, and sometimes 
not until the fourth. It evinces also a great ten- 
dency to recede or entirely vanish the day after it 
first comes out, and in these cases, it re-appears 
partially and at uncertain times, but without any 
perceptible change in the other symptoms, only 
that the duration of the disorder is protracted. 
About the fifth or sixth day of the disease, the 
fever and inflammation of the throat begin to abate; 
at the same time the rash declines, becoming faint 
first on those parts on which it first came out, its 
disappearance being generally followed by desqua- 
mation of the cuticle. This process is, however, 
uncertain. When the rash is slight, or recedes 
soon after it comes out, desquamation does not 
take place; in the more severe cases, the cuticle 
begins to separate after the eruption and febrile 
symptoms decline, and continues to desquamate 
to the end of the second or third week, or some- 
times later, during which large portions are thrown 
off; sometimes the cuticle of the whole hand and 
fingers is completely detached, resembling precisely 
* glove in shape. 



A T I N A . 

~Tbough this is the usual progress of scarlatina 
angi nosa, the disease Frequently assumes a stdl 
Ze severe character. Thus we observe in some 
instances, acrid discbarge from the nostnls or ea«, 

often accompanied with deafness; enlargement of 

the parotid or cervical glands, appearing sometimes 
at the commencement of the disease, at other 
times about the fifth or sixth day, but occasionally 
not till the decline of the eruption, and followed 
in some cases by abscess of the surrounding cel- 
lular tissue : and towards the decline of the dis- 
ease, ulceration at the corners of the mouth, or of 
the tongue. Though these local affections are 
painful, and keep up or even increase for a time 
the constitutional excitement, they are seldom at- 
tended with danger ; and in general, after continu- 
ing a short time after the prominent symptoms of 
the disease have disappeared, they subside under 
judicious treatment. 

In scarlatina, as in all febrile disorders, the con- 
dition of the several internal organs demands at- 
tention. We have often remarked, in investigating 
the complications of scarlatina, the great disposi- 
tion to inflammation of serous membranes ; there- 
fore, when an organ becomes inflamed during its 
progress, its investing membrane is much more 
generally the seat of inflammation, than the sub- 
stance or parenchyma. 

In some cases, the general symptoms are accom- 
panied "with evidence of gastro-enteritis. The 
tongue is morbidly red and clean, and the patient 
is harassed with sickness, vomiting, and diarrhoea. 
These symptoms are not uncommon when scarla 
tina prevails in the autumn, at which season 
bowel-affections generally prevail, and constitute a 
leading feature of an epidemic. 

As we have already, in the article Feted, de- 
tailed the various complications which arise, and 
the symptoms by which they may be detected, it 
is unnecessary in the present article to enter into 
more minute details, especially as the exanthemata 
bear so close a resemblance to the other forms of 
fever. We deem it, therefore, sufficient earnestly 
to impress the necessity for minute inquiry into 
the condition of the several organs in scarlatina, 
and more particularly for watching the convales- 
cence. Cases, apparently mild, are often rendered 
alarming from an attack of inflammation in some 
ors;an : the suddenness of the seizure and the ra- 
pidity with which it often proceeds, prove the ne- 
cessity for vigilance, however mild the symptoms 
of the disease may be at its commencement. Dr. 
Armstrong has well observed, " that scarlatina an- 
ginosa is sometimes attended with moderate, and 
at other times with severe symptoms ; and it is of 
great consequence to bear this in mind, more 
especially as the severe may follow the moderate 
symptoms at any period of its progress. In those 
cases where the symptoms are moderate, the in- 
flammation is chiefly limited to the throat and 
mucous membrane of the nose, and the excite- 
ment of the arterial system subsides without in- 
ducing actual inflammation of the viscera; yet 
where the symptoms are comparatively severe, the 
inflammation is not limited to the throat and nasal 
lining, but attacks some of the viscera commonly 
under a sub-acute character." (Practical Illustra- 
tions of the Scarlet Fever, &c. h v John Arm- 
strong, M. D.) 



SCARLATINA. 



3. Scarlatina Maligna. — This variety has been 
described by some writers by the name of angina 
gangrxnosd or ci/nanche maligna. Thus Cullen, 
in his noso'ogy, places it as a variety of cynanche, 
and likewise makes it one of the species of scar- 
latina, from which circumstance much unnecessa- 
ry confusion has arisen. He was, however, can- 
did enough to remark, that the scarlet eruption 
appears on the skin under the same form in both 
diseases, adding, that he had five or six times seen 
the angina maligna united with the common scar- 
latina ; and that in different epidemic constitutions, 
sometimes one disease predominated, and some- 
times the other. 

In fact, two names have been given to one dis- 
ease, which has almost invariably the same cha- 
racters, and requires nearly the same treatment, 
making due allowance for the variation observed 
in epidemics, and the ever-varying circumstances 
under which it occurs. Indeed, we are inclined, 
from our own experience, to affirm that the scarla- 
tina simplex, scarlatina anginosa, and the scarla- 
tina or angina maligna, and the sore-throat without 
efflorescence on the skin, are merely varieties of 
one and the same disease. 

Though several Spanish and Italian physicians 
had described the angina maligna, which raged 
with great violence and mortality in Spain and 
Italy in the beginning of the last century, Dr. Fo- 
thergill was the first writer in this country who 
described this malignant form of scarlatina as it 
prevailed in London in the years 1747-8. (An 
Account of the Sore-throat, attended with Ulcers, 
by John Fothergill, M. D. 4th edit. London, 1754.) 
From the description he has given, it is evident, 
that he witnessed during this epidemic the various 
forms of the disease, and consequently the malig- 
nant variety. This is apparent from the following 
passage: "Thus much, however, seems to be 
true in fact, that, in some cases, the disease ap- 
pears to be of so mild a nature, and so benign, as 
to require but little assistance from art. Persons 
even recover from it under the disadvantages of 
unskilful and injurious management, whilst in 
others the progress of the symptoms is so rapid, 
and the tendency to corruption so strong, that 
nothing seems able to oppose it. Just as it hap- 
pens in the small-pox : the benign and the distinct 
sort bears ill treatment without injury ; in the 
malignant flux kind, the utmost art and experience 
are too often insufficient to conduct the distemper 
to a happy issue. Whether this diversity in the 
sore-throat we are speaking of is owing to differ- 
ence of constitution or of seasons, to the different 
quality or quantity of the contagion, or the man- 
ner of receiving it, or whether there are in reality 
distinct species, may perhaps hereafter be more 
certainly determined." 

A few years afterwards Dr. Huxham gave a 
faithful account of a similar epidemic as it ap- 
peared in London from the end of the year 1751 
lo May, 1753, and was very mortal. It is evi- 
dent, however, that in this epidemic, as well as in 
others which have been subsequently described, 
the malignant form was only occasionally ob- 
served. 

In this form of the disease, the symptoms as- 
sume very early a malignant or typhoid character; 
to the affection of the throat and skin are super- 

Vor,. IV.— 10 g 



added great cerebral disorder, and often inflamma- 
tion of the pulmonary and gastric mucous mem- 
branes. On the first appearance of the disease, 
the symptoms may differ little from those of the 
other forms of scarlatina. The pulse is at first 
soft and frequent, but soon becomes small, rapid, 
and often irregular : the patient is restless, and at 
times delirious, the delirium being sometimes so 
violent as to require restraint, though more gene- 
rally it is of the low muttering kind. The rash 
comes out later and is very uncertain in its dura- 
tion, often suddenly disappearing a few hours after 
it is first perceptible ; and, five or six days after- 
wards, coming out again for a period of perhaps 
two or three days. It may thus suddenly recede 
and re-appear several times. The colour of the 
rash is at first faint, except in a few irregular 
patches, which assume a deep rose hue, but the 
whole efflorescence is speedily changed to a dark 
livid red, and in the worst forms is interspersed 
with petechias. The temperature of the skin is 
generally cool on the trunk of the body, and cold 
on the extremities ; the eyes are suffused and often 
covered with a film of mucus ; the countenance 
is pale and dejected, while the cheeks are of a 
dusky red colour ; the tongue is covered with dry 
brown, or almost black fur ; in other cases, it is 
smooth, red, and glossy, and often so tender and 
fissured that it easily bleeds ; the odour from the 
skin and breath is extremely fetid. 

The throat is not much swollen, but appears of 
a dark red hue, and covered with small ash- 
coloured sloughs surrounded by a livid base ; the 
gangrene often extends with alarming rapidity, 
destroying the uvula and arch of the palate. A 
viscid secretion with which the fauces are covered 
aggravates materially the sufferings of the patient 
by increasing the difficulty of swallowing, as well 
as by the obstruction which it offers to the 
breathing, so that when symptomatic bronchitis 
occurs during the progress of the disease, there is 
great danger of fatal asphyxia. The inflamma- 
tion generally spreads from the throat to the 
cervical glands, giving rise to enlargement and 
sometimes abscess; and when the inflammatory 
action extends to the nostrils, as it almost invari- 
ably does, there is an acrimonious discharge, at 
first thin but afterwards thick and yellow, which 
produces excoriation of the nostrils, lips, and 
angles of the mouth, which are generally in these 
instances covered with black crusts. 

In the more severe cases of malignant scarla- 
tina, the symptoms are more alarming from the 
first appearance of the disease: the pulse is small, 
rapid, and indistinct : there is more marked cere- 
bral disturbance, — stupor, coma, or violent deli- 
rium ; the ulcerations of the throat are more ex- 
tensive, and covered with dark sloughs, and the 
colour of the rash becomes livid. We frequently 
also observe pulmonary disease in the form of 
latent bronchitis, which is often combined with 
inflammation of the gastro-intestinal mucous mem- 
brane, giving rise to diarrhoea and its pathogno- 
monic signs. Some writers mention that hemor- 
rhage from different surfaces, — from the mouth 
and throat, lungs, intestines, or bladder, takes 
place, under which the patient in general rapidly 
sinks, unless the constitutional powers nave beex 
unusually vigorous. 



74 



S C A R L A T I >' A . 



In a severe epidemic described by Dr. Wither- 
ing, after detailing the ordinary progress of the 
disease, he gives the following outline of a fatal 
form which it frequently assumes : — "In children, 
the delirium commenced within a few hours after 
the first seizure. The flesh was intensely hot; 
the scarlet colour appeared on the first or second 
day, and they died very early on the third. In 
others who escaped this rapid termination, when 
the scarlet colour turned to brown, and their re- 
covery might have been expected, the pulse still 
remained feeble and quick, the skin became dry 
and harsh, the mouth parched, the lips chapped 
and black, the tongue hard, dry, and dark brown ; 
the eyes heavy and sunk ; they expressed an 
aversion to all food, and extreme uneasiness upon 
the least motion or disturbance. Thus they laid 
for several days, nothing seeming to afford them 
any relief. At length a clear amber-coloured 
matter discharged in great quantities from the 
nostrils, or the ears, or both, and continued so to 
discharge for many days. Sometimes this dis- 
charge had more the appearance of pus mixed 
with mucus. Under these circumstances, when 
the patients did recover, it was very slowly : but 
they generally lingered for a month or six weeks 
from the first attack, and died at length of extreme 
debility. In adults, the rapidity of the fever, the 
delirium, &c. was such that they died upon the 
fourth or fifth day, especially if purging super- 
vened. Some survived to the eighth, or to the 
eleventh day : in all these the throat was but little 
affected ; the eyes had an uncommon red appear- 
ance, not that streaky redness which is evidently 
occasioned by the vessels of the cornea being 
injected with red blood, but an equal shining red- 
ness, resembling that which we remark in the eye 
of a ferret. But notwithstanding this morbid 
appearance in the eye, the strongest light-was not 
offensive. This redness might often be discovered, 
by lifting up the upper eyelid some hours before 
it showed itself in the part of the eye that is 
usually visible : and it was of some consequence 
to attend to this circumstance, as it greatly in- 
fluenced the event of the case. These patients 
were extremely restless, clamorous, and desirous 
to drink; but after swallowing one or two mouth- 
fuls, upon taking another they seemed to forget to 
swallow, and let it run out at the corners of the 
mouth ; whilst others spurted it out with con- 
siderable force, and were very angry if urged to 
drink again. In these cases, the scarlet colour 
appeared very soon after the attack, but in an un- 
settled irregular manner, large blotches of red 
intermixing with others of white, and these often 
changing places. Besides the full scarlet colour 
described as above, there were frequently small 
circular spots of a livid colour, about the breast, 
knees, and elbows. The pulse from the very be- 
ginning was so quick, so feeble, and so irregular, 
that it was hardly possible to count it for half a 
minute at a time. It is needless to add, that the 
greater part of those who laboured under these 
dreadful symptoms died. A few recovered, and 
others fell into a state of debility bordering upon 
idiotism, from which they were rescued by time 
and generous living. In one patient, a man, the 
jaw was so perfectly locked upon the third day, 
♦hat it was impossible to get any thing down his 



throat, and he died early upon the ; fifth day.'' 
(Account of the Scarlet Fever and bo.c-I hroat, 

P ' In '1 few instances, we have seen the large 
joints suddenly become extremely painful, to 
which swelling with evidence of fluctuation suc- 
ceeded, and the patient was destroyed in a very 
short time. 

In many instances this malignant form of scar- 
latina proves fatal on the third or fourth day, 
though the patient often lingers till the second or 
third week : it is not uncommon for the patient 
to die suddenly on the second, third, or fourth 
day, without the practitioner being able to assign 
any satisfactory reason, or discover any lesion on 
the most careful examination of the body. Some- 
times, on the other hand, recovery takes place 
under the most unfavourable circumstances, but 
the convalescence is exceedingly tedious, and 
often retarded by the recurrence of some local 
inflammation, which had arisen during the pro- 
gress of the disease. 

It should not be overlooked that, when the 
early symptoms have been comparatively mild, 
the disease may suddenly assume the malignant 
character. Indeed this form (scarlatina maligna) 
is more frequently intermixed with the other va- 
rieties of scarlatina, and it sometimes unexpect 
edly supersedes the milder forms of the disease, 
on the fourth, fifth, sixth, or seventh day of their 
course. (Willan.) 

4. Scarlatina faucium It has been frequently 

observed, that when scarlatina prevails epidemi- 
cally, cases occur in which there is no appearance 
of rash on the skin, the efflorescence being con- 
fined to the throat and mouth. In some cases, 
the characteristic red appearance in the throat is 
unattended with swelling ; in others, the efflor- 
escence in the throat is accompanied with swell- 
ing of the tonsils, and consequent painful deglu- 
tition. Dr. Willan states, that this complaint 
seems peculiar to adults, and is evidently a species 
of scarlatina, because it affects some individuals 
of large families, while the rest are labouring 
under other forms, and because it is capable of 
communicating by infection all the varieties of 
that disease. It is sometimes succeeded by an 
enlargement of the parotid glands, but not by 
dropsical swellings. Persons who have previously 
gone through the scarlatina anginosa, experience, 
while conversant with the sick, very uneasy sen- 
sations in the throat: in some there is a swelling 
and inflammation, or ulceration of the tonsils, 
producing considerable pain and irritation, but 
without the specific fever and efflorescence. (On 
Cutaneous Diseases, p. 274.) Similar instances 
have been related by Dr. Johnstone, in the descrip- 
tion of the epidemic scarlatina which prevailed at 
Worcester in 1778. Some individuals, at the 
first seizure, were more or less severely attacked 
with the scarlet eruption, with swelling, redness, 
and ulcers in the throat ; yet others in the sara* 
family, infected from them, and by them, often 
had the ulcerated sore throat, without any efflor- 
escence or eruption on the skin. Again, the first 
seized sometimes had the simple ulcerated sore- 
throat only, and yet the others infected by them 
had the more severe attack of the disease, of 
fever, and scarlet eruption, as well as sore-throat 



SCARLATINA. 



75 



(Memoirs of the Medical Society of London, 
vol. iii.) 

In a paper by Dr. Lettsom, entitled Cursory 
Remarks on the Appearance of the Angina Scar- 
latina in the spring of 1793, several cases are 
given of this form of scarlatina. In one case the 
disease assumed the characters of scarlatina ma- 
ligna, but without efflorescence. The sister of 
this patient, a day or two after, became also the 
subject of the disease ; but in this case, the affec- 
tion of the throat and fever of the malignant kind 
were accompanied by general florid efflorescence. 
In another family, one of the children had ulcera- 
tion of the throat, but no eruption : a second, about 
a year older, caught the disease, but had both the 
affection of the throat and the efflorescence. In 
another family, some had the sore-throat without 
any eruption, others had the eruption with a very 
moderate degree of sore-throat ; and this was ob- 
served not only among the children, but also 
among the servants. (Memoirs of the Medical 
Society of London, vol. iv.) 

These statements accord exactly with our own 
experience of epidemic scarlatina. We had very 
lately an opportunity of observing in one family 
the simultaneous appearance of the various forms 
of the disease. In one cf the children, who was 
the first subject of it, the symptoms early assumed 
a most malignant aspect ; the velum and uvula 
were destroyed by gangrenous inflammation, and 
death took place about the fifteenth day. Some 
days after the disease had appeared in this child, 
one of the servants became ill, and passed through 
a mild form of scarlatina anginosa without any 
untoward symptom. No sooner had this servant 
recovered than the father of the child began to be 
indisposed, and in a day or two, considerable fever, 
with efflorescence of the mouth and throat, and 
inflammation of the tonsils, came on. The fever 
and anginose inflammation lasted for several days, 
and terminated in desquamation of the cuticle. 

It appears, then, that the various forms of scar- 
latina may be produced by exposure to the same 
exciting causes, and that the differences observed 
depend on some individual peculiarity or idiosyn- 
crasy, which cannot, a priori, be ascertained. 

[The blood in scarlatina has been examined by 
M. Andral, and found to be constituted as in mea- 
sles, — preserving, in other words, pretty nearly 
its mean proportion of fibrin — 3 in 1000, with an 
augmentation of the proportion of globules, 127 
in 1000. In four patients, he found the ratio of 
fibrin to be 3, 3£ and 4 ; in two others, that of 
the globules 136 and 146. (Cours de la Faculte, 
1841, cited by Guersant & Blache, op. cit.)] 

Sequelce* — Scarlatina is occasionally followed 
by troublesome local affections — ophthalmia — en- 
largement and frequently suppuration of cervical 
glands — abscess in the pharynx — laryngitis — 
chronic bronchitis — inflammation of the ear, end- 
ing in purulent discharge from the meatus ex- 
ternus, or suppuration and consequently destruc- 
tion of the internal ear. 

In some instances, dropsical effusion comes on 
during the convalescence from scarlatina, and 
always proves an alarming affection. 

Anasarca is the form in which the dropsy more 
generally appears, and though the fluid may be 



confined to the subcutaneous cellular tissue, it 
sometimes accumulates in the different cavities ; 
when this is the case, the patient may De consi- 
dered in great danger. It is singular, that the 
dropsy has been remarked to succeed as often to 
mild as to the more severe forms of the disease ; 
but it has never been observed to supervene in 
cases of malignant scarlatina : it would, therefore, 
appear to be connected with the acute or subacute 
forms of scarlatina only. It is almost entirely 
confined to children, rarely occurring after puber- 
ty ; Dr. Wells, however, had occasion to treat one 
case which occurred at the age of seventeen. It 
seems peculiar to some epidemics. We have seen 
it occur in several children of the same family, 
who had passed through scarlatina at the same 
time. Some writers seem to view this secondary 
affection as of trivial importance ; others regard it 
as more serious than the primary disease. Plen- 
ciz, indeed, affirms that more persons die of it 
than of scarlatina. This, however, is not the 
result of the cases which we have witnessed, 
though in this country it occasionally proves fatal. 
It generally comes on ten or twelve days after the 
period of desquamation, and often without any 
evident cause: sometimes it does not come on for 
two or three weeks after the disappearance of the 
rash ; and in one case which came under our care, 
the dropsical symptoms did not appear till five 
weeks after the desquamation. Previous to its 
appearance, the patient, after perhaps satisfactorily 
proceeding in his convalescence to a certain point, 
finds he does not advance, but rather retrogrades 
he complains of unaccountable languor and lassi 
tude, loses his appetite and strength, his sleep is 
disturbed, his pulse becomes quick, the bowels 
costive, and the urine scanty : sometimes there is 
considerable gastric disorder, indicated by sick- 
ness, vomiting, and purging. The swelling is 
first observed in the face and upper parts of the 
body, to which it is sometimes confined, thougli 
more generally it extends over the whole body, 
and occasionally effusion takes place in the brain, 
cavity of the chest, or belly. In fatal cases, fluid 
has been effused in these three cavities in a very 
short time. In an epidemic scarlatina, described 
by Dr. Hamilton, which occurred among the boys 
in Heriot's Hospital, in three cases the disease pro- 
ceeded with a rapidity which afforded little ippor- 
tunity for deliberation or action. The stomach 
gave way ; all food, cordials, and medicines were 
rejected by vomiting. The watery effusion rapidly 
filled the cellular membrane, and inundated every 
cavity. Within less than six-and-thirty hours 
from the occurrence of the ailment, the boys died, 
labouring under symptoms denoting ascites, hy- 
drothorax, and hydrocephalus. 

In this form of dropsy, the urine generally 
coagulates by exposure to heat or the addition of 
nitric or muriatic acid, alcohol, or a solution of 
the chloride of mercury. Sometimes it deposits 
a dark-red or brown sediment, which seems to 
arise from the admixture of the red globules of 
the blood. 

[Not unfrequently, in these cases, the kidneys 
exhibit signs of glandular disease , so that a ques- 
tion has even arisen, whethei the anasarca may 
not be owing to the renal disease. (Guersant et 



76 



SCARLATINA. 



Blache, Op. cit. See, also, Rillict and Barthez, 
Traite C/inique et Pratique des Maladies des 
Enfants, ii. 613, Paris, 1843.)] 

As dropsical effusion is to be regarded only as a 
secondary affection, it is of importance to ascer- 
tain its source. We have always regarded the 
dropsy succeeding to scarlatina as of an acute 
or subacute kind, arising from increased action in 
the sanguiferous system ; the consequence of this 
increased action is the effusion of serous fluid into 
the external tissues of the body, or when there is 
a still greater degree of vascular excitement, into 
one or other of the cavities. That this is the 
cause of the effusion, if not invariably, at least in 
the majority of instances, and certainly in all those 
which have come under our observation, was evi- 
dent from the character of the pulse as to fre- 
quency and power, the coagulable urine, the 
rapidity with which the fluid accumulated if not 
arrested by prompt treatment, and from the effi- 
cacy of bloodletting, purging, and other antiphlo- 
gistic measures, which were generally necessary 
to remove the dropsical effusion. 

Burserius, (Instit. Med. Pract. vol. ii.) in the 
account he has given of an epidemic scarlatina 
which prevailed at Florence in the year 1717, 
mentions that on opening the bodies of several 
persons who had died of this disease, the lungs, 
pleura, intercostal muscles, diaphragm, kidneys, 
and intestines, were more or less inflamed : that 
peripneumony having been considered as the 
primary disease, and the dropsical swelling only a 
consequence, blood was taken from the arm in the 
succeeding cases, once or oftener, as the occasion 
required ; and that no one afterwards died of the 
dropsy who was thus treated. 

[Effusions, of fatal tendency, occasionally take 
place into the larger joints. Gangrene of the 
extremities likewise occurs at times. In an ac- 
count of scarlatina that prevailed in the London 
Foundling Hospital, Dr. Watson gives one case 
that died of mortification of the rectum ; and six 
others that died sphacelated in various parts of 
the body. In the girls, some had the pudendal 
region mortified ; two had ulcers of the mouth 
and cheek, which sphacelated externally ; whilst 
one had the gums and jawbone so corroded, that 
most of the teeth fell out before she died. The 
lips and mouth of many that recovered were ul- 
cerated, and continued so for a long time.] 

Morbid Anatomy. — In scarlatina the appear- 
ances on dissection are by no means uniform ; 
indeed, we have frequently been surprised, in ex- 
amining rapidly fatal cases, to find no morbid 
appearances that could explain the cause of death : 
in such instances, it is more than probable, that 
the diseased condition of the blood and fluids has 
had an important share in the fatal issue. The 
skin runs rapidly into putrefaction : it is generally 
of a dark red colour, the redness being of a deeper 
colour in different parts, and frequently inter- 
spersed with livid spots. When there have been 
violent delirium and other symptoms of cerebral 
excitement, the arachnoid membrane is vascular 
or even opaque, with effusion of a serous or some- 
times milky fluid underneath. In such cases, the 
substance of the brain is also unusually vascular. 
The mucous membrane of the mouth, cavity of 
He nose, pharynx, and sometimes even of the 



trachea and bronchi, is often red from sangu neou- 
injection; and when there has been considerable 
acute anginose inflammation, there is nreUing of 
the tonsils with exudation of lymph. In the ma- 
lignant scarlatina, there is little or no swelling, 
but the membrane of the pharynx is sometime, 
of a dark livid colour, and occasionally in a 
sloughing state. In some cases, there is a small 
quantity of puriform fluid in the sacculi of the 
larynx, and in two or three instances wc have 
seen ulceration of the cartilages. These appear- 
anccs in the throat are, however, by no means 
uniform or frequently observed, and the state of 
the throat after death very often presents no ap- 
preciable morbid appearance, even when there has 
been considerable anginose affection during the 
disease. In the chest, redness and thickening of 
the bronchial membrane, the smaller bronchial 
tubes and air-cells being filled with a viscid secre- 
tion, and a gorged state, with extreme softening 
and tendency to rapid decomposition of the pul- 
monary tissue, are the principal morbid appear- 
ances. In the abdomen, there are seldom any 
appearances that can be called morbid ; in some 
cases, the mucous membrane of the stomach or 
of some portions of the alimentary canal has been 
slightly injected, though more frequently this 
membrane throughout the whole tract of the in- 
testines retains its natural colour. When puru- 
lent deposits take place in the joints — a compli- 
cation or sequela which we have occasionally 
observed — there are not always marks of inflam- 
mation of the synovial membrane. In the last 
case of this kind, however, which we examined, 
in which pus was deposited in the left wrist and 
in both ankle joints, there was deposition of pus 
exterior to the wrist joint, among the carpal 
bones. The synovial membrane of the wrist and 
ankles was evidently redder than natural, but there 
was no abrasion. We are therefore inclined to 
think, that these purulent formations in the joints 
may occur without antecedent inflammation \ and 
even in the case alluded to we doubt the co-ex- 
istence of inflammation : it is more probable that 
the pus which was deposited was not the conse- 
quence of the inflammatory action, but that the 
purulent fluid was deposited from the blood in the 
same way as it is sometimes deposited in other 
parts of the body. 

Diagnosis.— It is seldom difficult to distinguish 
scarlatina from other acute eruptive diseases. There 
is some resemblance, in the cutaneous efflorescence, 
to measles and roseola. 

It may be distinguished from measles, 1st, by 
the period at which the eruption appears ; 2d, by 
the accompanying symptoms ; 3d, by the character 
of the eruption ; and 4th, by symptoms which are 
frequently observed after the disappearance of the 
rash. In scarlatina the efflorescence generally 
appears about the second day of the fever, attended 
(with the exceptions stated) by affection of the 
hroat, and the characteristic appearance of the 
tongue : in rubeola the rash does not come out till 
the fourth day, its appearance being preceded bv 
sneezing, coryza, inflamed and watery eyes, cough, 
and other catarrhal symptoms, which continue 
during its progress. The eruption in scarlatina 
consists of innumerable minute dots or points, dif- 
tused in patches with uneven edges, of various 



SCARLATINA, 



77 



sizes and forms, and gives to those portions of the j 
skin on which it appears a diffused bright red 
colour. In measles, the efflorescence comes out 
in irregular semilunar or crescent-shaped patches, 
distinctly elevated, the spots being of a deeper red 
in the centre than in the circumference, and leav- 
ing intervening spaces in which the skin retains 
its natural pale colour. The desquamation of the 
cuticle is besides more general and more considera- 
ble in scarlatina than in measles. The sequels of 
measles are principally affections of the organs of 
respiration, croup, bronchitis, or pneumonia, which 
are more liable to come on towards the decline of 
the eruption. In scarlatina, there is more frequent 
affection of the glandular system, and liability to 
inflammation of the joints and serous membranes, 
and to anasarcous and dropsical effusion into the 
cavities. 

Roseola is always a much milder disease than 
even the simple form of scarlatina : the efflorescence 
is more continuous, of a deeper rose colour, and 
does not terminate by desquamation. Besides, in 
roseola, the anginose inflammation and appearance 
of the tongue peculiar to scarlatina are awanting. 
The whole duration of roseola too is short, seldom 
exceeding five or six days, and it cannot be propa- 
gated by contagion. It is also often symptomatic 
of other disorders. 

Prognosis and Mortality. — It has been ge- 
nerally observed, that scarlatina proves more severe 
to adults than to children, and that when it attacks 
pregnant or puerperal women it is often fatal. It 
has been also noticed, that it is generally mild in 
spring and summer, but severe during the winter 
months. 

Simple scarlatina is in general a very mild dis- 
ease and seldom proves dangerous unless some 
local inflammation supervene during its progress ; 
but thus a form of scarlatina, mild in the begin- 
ning, may be rendered suddenly and unexpectedly 
dangerous. 

Scarlatina anginosa is always a more severe 
disease than the scarlatina simplex, since to the 
more acute form of fever there is superadded in- 
flammation of the throat. The anginose inflam- 
mation, however, seldom of itself renders the dis- 
ease dangerous, especially if proper measures be 
adopted at the beginning. There is in general a 
manifest disposition in the affection of the throat 
to terminate in resolution, and it is often surpris- 
ing how readily it yields to general or local deple- 
tion. A moderate degree of swelling, with bright 
red efflorescence in the throat, is a more favoura- 
ble indication than when there is little or no 
swelling, and the redness assumes a dark or livid 
appearance. It was stated in the description of 
this variety of scarlatina, that the inflammation 
sometimes extended from the throat to the larynx: 
when this takes place, the danger is imminent ; 
since if osdematous swelling of the glottis ensue, 
death almost inevitably ensues. Danger may also 
arise from inflammation in some of the cavities — 
cerebral, pulmonary, or abdominal disease being 
thus superadded to the anginose and cutaneous 
inflammations. 

A favourable or unfavourable prognosis may be 
often, in some measure, inferred from the cutane- 
ous efflorescence. In the scarlatina anginosa, the 
rash appears late in the disease, and though in 



most instances, it is diffused generally over the 
surface, it is often only partial, coming out in 
small irregular patches on different parts of the 
body. In these latter cases, it is more apt to dis- 
appear suddenly, which is a less favourable cir- 
cumstance than when the rash is general and re- 
mains out for several days. The colour of the 
eruption seems also connected with the general 
character of the disease. A bright red or scarlet 
efflorescence is more favourable than the dark red, 
crimson, or brownish colour which it sometimes 
assumes. A very pale rash, more especially if it 
be partial and evanescent, is also unfavourable ; 
and when the eruption, whatever be its colour or 
the extent of its diffusion, disappears suddenly, 
and afterwards reappears, or if it do not again 
come out, more especially if it have receded at the 
beginning of the disease, the danger is considera- 
ble. The more perfectly the desquamation takes 
place, the case is to be regarded as the more 
favourable, as secondary disorders are less likely to 
arise. 

From the description which has been given of 
the scarlatina maligna, the danger in almost every 
case must be apparent, though it does not appear 
to arise from the visceral complications which oc- 
casionally supervene, as in fatal cases there is sel- 
dom discovered in the internal organs satisfactory 
evidence of the cause of death. In estimating the 
amount of danger and probable issue of the case, 
however, it should be kept in view, that though 
this form of scarlatina proves fatal in a much lar- 
ger proportion of cases than any of the other va- 
rieties, there is every intermediate shade or grada- 
tion between the less severe and most malignant 
cases. In this more severe form of scarlatina 
some particular symptoms or appearances however 
modify the prognosis. Children are observed to 
struggle better against it than adults, though in 
some epidemics no age seems to be exempt from 
its ravages. The existence or non-existence of 
local inflammation in any organ must also be taken 
into account, in estimating the degree of danger, 
and it should be kept in mind how little such 
topical inflammations are under the control of the 
treatment, which it is necessary to modify accord- 
ing to the general powers of the patient; if active 
measures be resorted to in cases of malignancy 
with the hope of subduing the low forms of vis- 
ceral inflammation, the powers of the patient would 
be endangered if not irrecoverably sunk. 

With regard to the prognosis of malignant scar- 
latina to be deduced from particular symptoms, a 
favourable result may be predicted from the fol- 
lowing circumstances — mild fever and moderate 
affection of the throat — early and copious eruption 
succeeded about the third or fourth day by gentle 
moderate perspiration, and general desquamation 
of the cuticle — the throat assuming a florid red 
colour, and if there have been sloughing, the ulcer- 
ation looking clean and healthy — diminution in 
the frequency, with firmness and equality of the 
i pulse — the breathing becoming soft and free, while 
j the eye resumes its brilliancy, and the counte- 
I nance its natural expression. On the other hand, 
the prognosis may be deemed unfavourable, when 
the following symptoms occur — a partial eruDtiou 
disappearing suddenly — or assuming a uusky or 
livid colour, more especially if accompanied with 



rs 



SCARLATINA. 



petechia; — smallncss and great rapidity of the 
pulse— frequent sighing with sensation of great 
faintness — hot dry skin— hurried breathing not 
depending on disease of the lungs — acrid dis- 
charge from the nose and ears — ulceration of the 
lips and angles of the mouth — paleness or shrink- 
ing of the features — sunken eyes — partial cold 
sweats— coldness of the extremities — low mutter- 
ing delirium — coma — hiccup — subsultustcndinum 
— involuntary stools — gangrenous inflammation 
of those parts subjected to pressure, as the sacrum 
and hips — swelling and purulent deposits in the 
larger joints. Huxharn observed in some indivi- 
duals previous to the fatal issue, the face bloated 
and shining, and the neck swollen and of a cada- 
verous appearance, the whole body even became 
in some degree oedematous, so that the impression 
of the finger remained. 

[The form of scarlatina, which has been termed 
the hemorrhagic, is almost always fatal. It is 
indicated by the ordinary signs of purpura, — dark 
spots appearing here and there, followed by ex- 
udation of blood from the mucous membranes — 
of the mouth and nose especially, which is occa- 
sionally so profuse as to cause death. In these 
cases, if a puncture be made, it becomes the seat 
of hemorrhage. In a case of the kind referred to 
by Dr. Morton, (Mackintosh's Principles of Pa- 
thology, 2d Amer. edit. i. 224, Philad. 1837,) an 
abscess in the neck suddenly filled with blood, 
and this, making its way through a leech-bite, 
flowed out as if from a divided artery, and de- 
stroyed the patient in a few hours.] 

The mortality of scarlatina varies much in dif- 
ferent epidemics, although nothing has been satis- 
factorily established as to the causes which influ- 
ence the fatality of the disease. The difference 
observed in epidemics is not confined to scarlatina, 
but occurs in every variety of fever, whether of 
the continued, periodic, or eruptive form. In some 
epidemics scarlatina is a very mild disease through- 
out ; and when it does prove fatal, the cause may 
often be traced to the supervention of some acci- 
dental inflammation ; or it may happen, that in 
particular instances, the symptoms may assume a 
malignant character, though the general aspect of 
the epidemic be very mild. It is unnecessary to 
pass under review the histories which have been 
recorded of epidemic scarlatina which have at 
various times appeared ; they are alluded to, prin- 
cipally with the object of directing attention to 
the influence which certain, though unknown cir- 
cumstances exert over the character and symp- 
toms of this disease. It is often sufficient for the 
practical inquirer to be a diligent and faithful ob- 
server of nature, without attempting to discover 
the hidden causes, and invent explanations of her 
secret operations. The extreme mildness of some 
epidemics has induced many to assert, that the 
mortality of scarlatina has been overrated, and 
even Sydenham from his observance of the disease 
(its milder forms only having evidently been pre- 
sented to his notice), came to the conclusion that London Fever Hospitll^That the" nmUlity of 
it scarcely required medical aid, and when it did scarlatina shows great variation In the years 
prove fatal, this result was to be traced to the * 
nimia medici diligentia. Had the attention of 
this illustrious physician been directed to the epi- 
demic described by Morton, a very short time 
»'i'i this opinion was deliveied to the world, his 



candour would have compelled him to acknow 
ledge, that the views he entertained and promul 
gated of the nature of scarlatina had been formed 
on too limited experience of the disease. The ra 
pidity with which patients are hurried off is often 
striking. In an epidemic scarlatina which pre- 
vailed in Paris in 1743, we are told that every in- 
dividual who was attacked perished — many indeed 
within nine hours from its first invasion. That 
which raged at Bromley, near Bow, in Middlesex, 
in the year 1746, it is stated by Dr. Fothergill, 
seemed to yield to no remedies or applications; 
several of the inhabitants were greatly alarmed by 
it, some losing the greater part of their children 
after a few days' indisposition. These are by no 
means solitary examples of the great fatality of 
scarlatina, as similar epidemic visitations have 
been recorded by Huxharn, (Dissertation on the 
Malignant Ulcerous Sore Throat,) Cotton, (On a 
particular kind of Scarlet Fever, prevalent at St. 
Alban's in the year 1748,) De Haen, (Philos. 
Trans. 1749,) Johnstone, (Remarks on the Angina, 
and Scarlet Fever of 1788, in the Memoirs of the 
Medical Society, vol. iii.,) Rush, (Medical Obser- 
vations and Enquiries,) Lettsom, (Memoirs of the 
Medical Society, vol. iv.,) Sims, (Ibid. vol. v.,) 
Willan, (Miscellaneous Works, edited by Ashby 
Smith, M.D.,) Bateman, (Reports on the Diseases 
of London,) Blane, (Med. Chir. Trans, vol. iv.,) 
Macgregor, (Ibid. vol. v.,) Tweedie, (Clinical Il- 
lustrations of Fever,) Carbutt, (North of England 
Med. and Surg. Journ., vol. i.,) Sandwith,* and 
others. 

Dr. Willan has given the result of his expe- 
rience of an epidemic scarlatina, from cases which 
occurred in his own practice in the year 1786. 
Of 251 cases, there were 152 of scarlatina angi- 
nosa, 42 of sore throat without eruption on the 
skin, and 39 of scarlatina maligna. Dr. Clark, in 
the description he has given of an epidemic scar- 
latina which prevailed at Newcastle in 1778, ob- 
served, that of 131 patients, 75 had the eruption 
with sore throat ; in 33 the disease occurred with 
every distinguishing symptom of scarlatina ma- 
ligna ; and that in 23 cases it was succeeded by 
dropsy. He adds, when it is considered that 
great numbers had the distemper in such a mild 
manner as to require no medical assistance, and 
that application was only made for the advice of 
a physician when the patients were severely 
attacked, perhaps the malignant cases ought not 
to be estimated higher than as one to twenty in 
all who took the disease. 

No deductions however can be drawn from 
these averages, as they have reference only to 
solitary epidemics, and it is well known that in 
one or several epidemics a large proportion of the 
cases assume the characters of a malignant disease, 
while, as was formerly stated, a few malignant 
cases only may occur out of a large number of in- 
dividuals affected. 

We find from the register of cases kept at the 



years 



1822 and 1823, the disease appears to have been 
extremely mild, as none of the patients died during 
these years. In 18 24, the mo rtality was one in 

* Edin. Med" and Surg. Journ., NoTc^vn fa most e* 
celleiit practical paper.) <-a.wi., (a mosie» 



SCARLATINA, 



79 



twenty-one; in 1825, one in thirteen ; in 1826, 
one in twenty-nine; in 1827, one in forty-one ; 
in 1828, one in ten; in 1829, one in six; in 
1830, one in six; in 1831, the disease was not 
prevalent, and none of the cases proved fatal ; in 
1838, the mortality was one in forty ; and during 
the last year, the average has heen about one in 
twenty-two. Of 044 cases treated at this hospital, 
the gross mortality was thirty-eight ; of these 
there were thirteen males and twenty-five females. 
The following table exhibMo the comparative ages 
of the fatal cases : — 

Males. Females. 
7 years of age 1 



10 ditto 1 

11 ditto 

12 ditto _ 

13 ditto 1 

18 ditto 

19 ditto 2 

20 ditto 

21 ditto. . 

22 ditto. . 1 

23 ditto 1 

24 ditto 2 

25 ditto 2 

26 ditto 2 

27 ditto 

30 ditto 

33 ditto . 1 

40 ditto 

13 



1 
2 
1 
1 
1 
3 
2 
2 
2 
1 
2 
1 
1 
2 
1 

1 

25 



\ T n England and Wales, the number of deaths 
amongst children from scarlatina was in 1838, 
5802; in 1839, 10,325; less than the mortality 
from measles. (W. Farr, Third Report of the 
Registrar-General, Lond. 1841.) If, however, 
the year 1840 be reckoned, the preponderance is 
on the sids of scarlatina : — the deaths during that 
year being 19,816 ; whilst those from measles were 
9326. 

In all the Atlantic cities of the United States, so 
far as statistical examinations have been made, scar- 
latina appears to be a more fatal malady than mea- 
sles. In an inaugural " Essay on the Comparative 
Mortality of Measles and Scarlet Fever," presented 
to the faculty of Jefferson College in Feb. 1844, Dr. 
George King Smith makes the number of deaths 
from measles in Philadelphia, from 1807 to 1841 
inclusive, 1376; from scarlatina during the same 
period, 2226. In New York, from 1819 to 1834 
inclusive, the deaths from measles were 1337; 
from scarlatina, 1500. In Boston, from 1811 to 
1840 inclusive, from measles 700 ; from scarla- 
tina, 970.] 

Treatment. — From the description which 
has been given of the various forms of scarlatina, 
it is obvious that the measures to be adopted for 
its treatment must have reference to each indivi- 
dual case, as well as to the various circumstances 
with which it may be associated. 

It is also indispensably necessary that the treat- 
ment should have reference to the prevailing type 
or character of the fever, an indication which it is 
of the utmost importance to bear in mind in the 
management of this disease. We have already 
endeavoured to impress this circumstance strongly 



in a former part of this article, so that it is suffi- 
cient merely to advert to it again. 

1. In the scarlatina simplex, the symptoms are 
generally so mild, that it is only necessary to con- 
fine the patient to bed, to keep the apartment cool, 
to prescribe occasional aperients, cooling drinks, 
and abstinence from animal food, so long as there 
is any febrile indisposition. Should the skin feel 
hot at intervals, it is advisable to sponge the sur- 
face with cold water, by which the morbid heat is 
rapidly dissipated, and the feelings of the patient 
are rendered more comfortable. It is seldom ne- 
cessary in this form of scarlatina to abstract blood, 
unless it be deemed expedient in cases where the 
fever runs high. In those cases, it may be pru- 
dent to take away a moderate quantity of blood, 
with the view of subduing the vascular excite- 
ment, and preventing the local inflammations 
which frequently arise in scarlatina. Whether 
bloodletting be deemed expedient or not, an emetic 
is often attended with good effects; after which 
the bowels should be freely opened by brisk 
aperients, and the various saline remedies, in 
combination with antimony, administered as cir- 
cumstances require. It is necessary to watch 
every case of scarlatina, however mild at the be- 
ginning, as the character of the disease is often 
materially altered by the sudden accession of in- 
flammation in some internal organ, by which a 
mild disease may in the space of a few hours be 
converted into one of severity and danger. 

2. We have pointed out the more active nature 
of the symptoms in scarlatina anginosa. In 
adults of a plethoric tendency, more especially if 
the patient be young, bloodletting is sometimes 
necessary ; and even in children, a moderate bleed- 
ing from the arm, when there is much excitement 
at the beginning, is often useful in moderating the 
fever, and diminishing the tendency to visceral in- 
flammation. General bloodletting has been strong- 
ly recommended by several continental physicians 
in this form of scarlatina, more especially when 
there is much cerebral disturbance. Morton em- 
ployed it with success in the epidemic he has de- 
scribed ; and in the scarlatina which prevailed at 
Edinburgh in 1733, we find it stated, that few 
died who were timely and plentifully blooded, 
which weakened the fever, relieved the throat, 
and was the only medicine that removed the vom- 
iting and diarrhoea. (Edinburgh Medical Essays, 
vol. iii. p. 27.) Huxham advocates this practice 
at the commencement of the fever, when the blood 
was often sizy, but recommends one moderate 
bleeding only, as patients did not hear a large 
bleeding, and scarcely any a second. 

On the other hand, in some epidemics, evacua- 
tions of blood are less efficacious, or wholly inad 
missible, either from the form of fever being of a 
less acute character, or from the tendency of the 
general powers to decline, when active depletion 
has been adopted. The successful treatment ol 
the disease by bloodletting and other antiphlogistic 
measures at one season, docs not warrant the prac 
titioner in employing the same plan in another 
epidemic; the type of the fever, the pulse, and the 
general aspect of the symptoms must be his guide. 
In the epidemic described by Dr. Withering, such 
was the state of the pulse, that bloodletting was 
inadmissible, unless In the autumn, when rha 



60 



SCAR L A T I N A 



colour of the rash was not intense, or ilid not 
appear at all, the swelling of the throat great, and 

the pulse firm. Dr. Wilhin also states, that 
during the years 1785, 1786, 1787, and since, 
when the scarlatina anginosa was epidemic in the 
metropolis, he never saw a case in which blood- 
letting appeared to be indicated. Whenever it 
had been employed, great depression and faintness 
were the immediate consequences, the pulse be- 
coming more weak and frequent, and often irregu- 
lar. Of two adults who had been bled largely, 
one died before the period of desquamation, the 
other lingered in a very precarious state upwards 
of twenty days, hut at length recovered. 

It is therefore almost impossible to lay down 
general rules for the treatment of a disease which 
varies so much in its character at different times. 
At one season, or in one epidemic, bleeding may 
be required — at another, the lancet is to be em- 
ployed with the greatest caution, and not unless 
some urgent circumstance arises to require its use. 
We have seldom had occasion to bleed from the 
arm, unless in particular instances of unusual 
febrile excitement, or when some important organ 
was threatened with inflammation. We generally 
prefer the free topical abstraction of blood by cup- 
ping behind the neck, which is the most effectual 
mode of relieving the inflammation of the throat, 
or by the application of leeches under the jaw, or 
behind the ears. We have seen great benefit also 
from the free scarification of the tonsils when skil- 
fully performed, though many patients object to 
this mode of topical bleeding, which is also often 
not easily performed in timid persons. 

We have seldom observed any decided benefit 
from the use of gargles, indeed the inconvenience 
felt by the patient in their employment often pre- 
cludes their adoption. The inhalation of the va- 
pour arising from warm water gives much more 
decided relief. 

The exhibition of emetics in the commencement 
of scarlatina anginosa as well as of the other 
forms, has been strenuously recommended by some 
physicians. Dr. Withering prescribed them not 
only in the beginning, but even in the lafer stages 
of the disease. Their employment, however, 
should be restricted to the period of invasion, as 
it has been observed that they are much more 
beneficial at this stage than when the symp- 
toms are more advanced. The shock which is 
given to the system by the action of vomiting in 
the early stage of eruptive fevers is often followed 
by most decided improvement in the general symp- 
toms and feelings of the patient. Dr. Rush exhi- 
bited an emetic, combined with calomel, in every 
case he was called to, which, besides inducing 
vomiting, seldom failed to produce two or three 
stools ; in several cases he was obliged, by the 
continuance of the nausea, to repeat the emetic, 
and always with obvious and manifest advantage. 

The abatement in the symptoms which is gene- 
rally observed after the bowels have been freely 
evacuated, has induced physicians to purge freely 
in the early stages of scarlatina anginosa, and 
certainly no class of remedies is more entitled to 
confidence than purgatives, when administered 
with discernment. Many writers have expressed 
heir doubts of the safety of this practice, from the 
fciar of inducing debility and repelling the efflo- 



nsccncc. Dr. Hamilton, however, has adduced 
ZeS arguments in support of it, and has ill^ 

U, |" B views by an appeal to the result of case. 
treated in public and pr.vate practice. No variety 

of the disease, as appearing in d.lleren opulemics, 
or in the course of the same epidemic, has hitherto 
prevented this distinguished physician from fol- 
lowing out this practice to the necessary extent. 
The pungent heat of surface, violent headach, 
tumescence of features, and full and quick pulse, 
the earliest symptoms in some epidemics of scar- 
latina, and which may have suggested and war- 
ranted the practice of bloodletting, are often quickly 
subdued by one or two brisk purgatives. Dr. Ha- 
milton states, that full purging is not required in 
the subsequent periods of the disease, in which 
the sole object is to remedy the impaired action of 
the intestines ; to secure the complete and regular 
expulsion of their contents ; and thus to prevent 
the accumulation of faeces, which never fails to 
aggravate the symptoms and to prove the source 
of further suffering to the patient. He has added 
some very useful hints as to the same activity not 
being required in the exhibition of purgative me- 
dicines in every case of scarlatina, acknowledging, 
that he had not ascertained to what this different 
state of the bowels in scarlatina is to be ascribed, 
and observing that on whatever cause the differ- 
ence depends, it is necessary to adapt our practice 
in the use of purgatives to the nature of the pre- 
vailing epidemic. 

In the early stages, when there is nothing to 
contra-indicate the use of purgatives, a brisk ape- 
rient may be exhibited daily. We generally pre- 
scribe a combination of calomel and rhubarb at 
bed-time, and on the following morning a moderate 
dose of castor-oil, or infusion of senna with manna 
and sulphate of magnesia. When the cuticle 
begins to desquamate, and the febrile symptoms 
decline, active cathartics are improper ; at this 
stage of the disease, it is necessary only to ensure 
the regular evacuation of the bovvels, for which 
purpose the mildest aperients are best adapted, 

Though we have advocated the employment of 
purgatives in the more severe cases of scarlatina, 
they are to be prescribed with the greatest caution, 
if not altogether withheld, when the mucous mem- 
brane of the intestines betrays signs of irritation 
or of inflammation. In such cases, the bovvels 
are generally purged, and the dejections of an 
unhealthy appearance. Under such circumstances 
the gastric irritation must be allayed by leeches 
applied to the abdomen, counter-irritation, and 
bland nourishment. Aperients, even of the 
mildest class, must be withheld, until the intestinal 
derangement is allayed; and should it become 
necessary to administer an aperient occasionally, 
the least irritating should he selected ; none is pre- 
ferable to castor-oil suspended in mucilage, with 
the addition of a few drops of laudanum. 

The free application of cold is decidedly benefi- 
cial in the acute stage of scarlatina, and more 
especially m the anginose form. The bed-cham- 
ber should always be properly ventilated by fre- 
quently renewing the air, and allowing a current 
ot cool fresh a.r to pass round the patient. If the 
skin be hot, the body should be occasionally 
sponged with cold water, by which the morbid 
heat is rapidly abstracted, and the patient refresh- 



SCARLATINA. 



81 



ed. The sponging should be repeated when the 
skin feels pungently hot. The testimony of Dr. 
Baternan, as to the efficacy of this practice, is 
very strong: — " We are possessed," he says, " of 
no physical agent, as far as my experience has 
taught me, (not excepting even the use of blood- 
letting in acute inflammation,) by which the 
functions of the animal economy are controlled 
witli so much certainty, safety, and promptitude, 
as by the application of cold water to the skin, 
under the augmented heat of scarlatina, and of 
some other fevers. This expedient combines in 
itself all the medicinal properties which are indi- 
cated in this state of disease, and which we should 
scarcely a priori expect it to possess : for it is not 
only the most effectual febrifuge, (the " febrifugum 
magnum," as a reverend author long ago called it,) 
but is, in fact, the only sudorific and anodyne 
which will not disappoint the expectation of the 
practitioner under these circumstances. I have 
had the satisfaction in numerous instances of 
witnessing the immediate improvement of the 
symptoms, and the rapid change in the counte- 
nance of the patient produced by washing the 
skin. Invariably, in the course of a few minutes, 
the pulse has been diminished in frequency, the 
thirst has abated, the tongue has become moist, a 
general free perspiration has broken forth, the 
skin has become soft and cool, and the eyes have 
brightened ; and these indications of relief have 
been speedily followed by a calm and refreshing 
sleep. In all these respects, the condition of the 
patient presented a complete contrast to that 
which preceded the cold washing: and his languor 
was exchanged for a considerable share of vigour. 
The morbid heat, it is true, when thus removed, 
is liable to return, and with it the distressing 
symptoms, but a repetition of the remedy is follow- 
ed by the same beneficial effects as at first." (Practi- 
cal Synopsis of Cutaneous Diseases.) 

[The use of ice internally is the best and most 
grateful refrigerant. Chlorinated soda, chlorinated 
lime, or the aqua chlorini, is sometimes added to 
the water employed in ablution.] 

Little confidence should be reposed in any of 
the ordinary saline remedies. We prefer the 
mineral acids, more especially the saturated solu- 
tion of chlorine, prepared according to the direc- 
tions given in the Dublin Pharmacopoeia, which 
contains about twice its volume of chlorine. Of 
this remedy a fluidrachm and a half, mixed with 
eight ounces of water, and two drachms of syrup 
of lemons, may be taken in divided portions during 
the day, For children, ten or twelve drops every 
six or eight hours is a sufficient dose. 

The solution of chlorine is readily decomposed 
by exposure to light and air, and in this state it is 
very apt to disorder the stomach and bowels, pro- 
ducing sickness, griping pain of the bowels, or 
diarrhoea. It is therefore necessary, that the 
remedy should have been recently prepared before 
it is exhibited. If recently prepared chlorine 
cannot be readily procured, (though it is obtained 
by a very simple chemical process,) the diluted 
sulphuric arid may be substituted. 

In the advanced stages of scarlatina anginosa, 
when the general fever has declined, and the 
efflorescence has disappeared, it is often necessary 
to give, with due caution, a little support. Mild 

Vol. IV.— 11 



nourishment is often sufficient, but should the 
pulse be soft and rather weak, with a cool skin, 
small doses of quinine in acidulated infusion of 
roses are generally very beneficial. It is seldom 
necessary to administer wine, except under circum- 
stances of unusual debility after a protracted ill- 
ness. The moderate use of it in such cases tends 
much to assist the convalescence. 

When visceral inflammation arises in the pro- 
gress of scarlatina anginosa, no time should bo 
lost in endeavouring to arrest it. In such cases, 
the judgment of the practitioner must direct him 
as to the extent to which it is necessary to carry 
the antiphlogistic treatment. We have already 
entered so fully into the management of the 
various local lesions which arise in the progress 
of fever, (and the indications to be observed in 
scarlatina are precisely similar,) that we deem it 
unnecessary to repeat what has been already 
advanced, (see Feveh,) though the necessity of 
watching narrowly the state of the several organs, 
and of adopting suitable measures on the first 
evidence of local inflammation, cannot be too 
forcibly impressed on those who may not have 
had much experience in the treatment of this 
disease. 

3. In scarlatina maligna, the acute stage, in 
which only antiphlogistic measures can with safety 
be employed, soon passes off, and is succeeded by 
a low depressed state of the general powers, which 
renders any form of depletion not only doubtful 
but hazardous. If the practitioner be called on to 
treat this form of scarlatina at its very commence- 
ment, and before it is fully formed, an antimonis' 
emetic is generally very beneficial, more particu 
larly when the bowels are afterwards evacuatea 
either by the antimony, or by an active aperient. 
If, however, those means be insufficient to subdue 
the excitement, moreover if the pulse be rapid and 
firm, the skin hot, and there be much pain in the 
head, or delirium, a moderate quantity of blood 
should be taken from the arm, and another aperient 
given. This treatment, if adopted at the onset 
of the symptoms, will generally not only moderate 
the fever, but shorten the duration and violence 
of the disease. In many cases, however, such is 
the violence of the symptoms, more especially if 
they have been neglected in the beginning, that 
the acute stage is speedily followed by symptoms 
of a low typhoid character, which requires a cor- 
dial tonic plan of treatment. It then becomes 
necessary to support the sinking powers by ani- 
mal broths, quinine, and a moderate allowance of 
wine. 

The volatile alkali has been strongly recom 
mended in cases of malignant scarlatina ; it was 
considered by Dr. Peart to be endowed with a spe- 
cific power over the malignant scarlet fever and 
sore throat. He directed two drachms of the carbo- 
nate of ammonia to be dissolved in five ounces of 
water, of which the dose was two spoonsful every 
two, three, or four hours, according to the urgency 
of the symptoms. This remedy was administered 
in every form and stage of the disease, and were 
we to judge from the result of the cases in which 
this remedy was given, it would appear never to 
have failed even in the worst. We certainly havo 
tried this remedy repeatedly, but our experience 
of it does not warrant such an inference no- <\u 



82 



SCARLATINA. 



we deem it preferable to other diffusible stimu- 
lants. Capsicum is a remedy which appears to 
have been employed with much success by Dr. 
Stephens, in an epidemic scarlatina which pre- 
vailed at St. Christopher's in 1787, and of which 
an account was published in the second volume 
of the Medical Communications, and also in Dun- 
can's Medical Commentaries for the year 1787. 
This remedy was used in the form of infusion 
prepared according to the following formula : two 
tablespoonfuls of small red pepper, or three of the 
common Cayenne pepper, and two teaspoonfuls 
of fine salt are to be beat into a paste, to which 
half a pint of boiling water is to be added. When 
cold, the liquor is to he strained off, to which half 
» pint of very sharp vinegar is to be added. Ot 
this mixture, the dose for an adult is one table- 
spoonful every four hours, the quantity being di- 
minished in proportion for children. This reme- 
dy has been commended by several writers who 
have employed it successfully ; but having never 
employed it, we cannot offer an opinion of it. 

When topical inflammations arise in scarlatina 
maligna, general bleeding is seldom admissible, 
unless they supervene in the beginning of the 
disease : the application of leeches, in numbers 
proportioned to the age and powers of the patient, 
is better adapted to the low forms of local inflam- 
mation which arise in this malignant disease. 

With regard to the local treatment in scarlatina 
maligna, we may observe, that in the very begin- 
ning of the disease, the inflammation in the throat 
is best managed by the application of leeches 
under the jaw or behind the ears ; but this treat- 
ment must be confined to the very onset of the 
anginose affection, since the inflammation in most 
cases very speedily passes into gangrene. The 
vapour arising from warm water may be fre- 
quently inhaled. Some physicians recommend 
the occasional exhibition of an emetic with the 
view of dislodging the viscid secretion with which 
the fauces are clogged, and unless the powers be 
so feeble as to render the shock of an emetic 
hazardous, benefit is often derived from their em- 
ployment. 

Acidulated bitter effusions, as of cinchona, 
cusparia, serpentaria, contrayerva, or an infusion 
of capsicum, prepared as recommended by Dr. 
Stephens, may be used as a gargle. 

A weak solution of the nitrate of silver, or of 
sulphate of copper, applied by means of a proper 
syringe, after the throat has been well cleansed by 
warm water, often improves the aspect of the 
ulceration. 

Dr. A. T. Thomson recommends the chloroso- 
diac solution of Labarraque in the proportion of 
f.^xii of the solution to f.Sjvss of water and 
ziv of honey, as an excellent gargle. The same 
solution in the proportion of 'gvi to ^v of water, 
without the addition of honey, if frequently 
thrown into the nostrils by means of an elastic 
bottle mounted with a tube, soon removes the 
corvza. (Bateman's Practical Synopsis of Cuta- 
neous Diseases, edited by Anthony Todd Thom- 
son, M. D.) 

Fumigations by the nitrous acid gas, ^separa- 
ted trom pulverized nitre by the strong sulphuric 
acid,) or the nitro-muriatic acid gas, (chlorine,) 
.separated from a mixture of equal parts of pul- 



verized nitre and of sea-salt, by the strong ■sul 
phuric acid,) have been strongly recommended by 

W it' a i"' almost superfluous to state, that proper 
ventilation is most essentially necessary in this, as 
in the other forms of scarlatina. I he admission 
of fresh air around the patient generally invigor- 
ates his powers, and often proves a most excel lent 
tonic. Warm sponging, a tepid bath, or it there 
be much cerebral disturbance, fomentations to the 
extremities may be employed in addition to the 
other means. , 

The treatment of the dropsical effusion which 
we have described as an occasional occurrence 
towards the termination of scarlatina, is to be 
regulated by the condition of the system, and 
more especially of the several internal organs. 
The effusion in general speedily disappears under 
judicious treatment; in all the cases which have 
fallen under our notice, the dropsy has been evi- 
dently dependent on general or local excitement, 
which it was necessary to subdue by bloodletting 
and purging, after the adoption of which measures 
the effusion quickly vanished. In some instances, 
when the state of the pulse did not require the 
abstraction of blood, a few doses of brisk purga- 
tives have carried off the fluid : in others, the 
activity of the circulation, the heat of skin, scanty 
urine, and oppressed breathing, at once suggested 
the necessity of bloodletting, from which the most 
decided relief was immediately obtained, after 
purgatives and diuretics had completely failed. 
The efficacy of the antiphlogistic treatment of 
dropsy succeeding to scarlatina has been corrobo- 
rated by many practical writers in other countries 
as well as our own ; and though some still hesi- 
tate to adopt the practice, we are satisfied that in 
cases accompanied with phlogistic symptoms, it is 
the only safe and rational mode of treatment, 
Besides, when we consider the condition in which 
the internal organs have been occasionally found 
in fatal cases of scarlatina complicated with 
dropsy, the propriety of vigorous antiphlogistic 
treatment is apparent. We admit that in some 
instances, in which the symptoms are of a less 
acute character, bloodletting may he dispensed 
with : we allude more particularly to those in 
which, though the general powers be feeble, there 
is congestion or chronic insidious inflammation in 
some organ. Under such circumstances, topical 
bleeding, mild purgatives, and diuretics, with a 
bland diet, will be found more appropriate mea- 
sures. As to the employment of tonics, on the 
supposition that the dropsical effusion depends on 
loss of power or tone in the exhalants, we con- 
fess we are sceptical as to this being the patholo- 
gical state of the vessels in any case of dropsy 
succeeding to scarlatina, and therefore we are dis- 
posed to place little or no confidence in this class 
of remed.es. When the effusion 1ms been re- 
moved by suitable measures, pure air, mild nourish- 
ment, am] attention to the bowels will be found 
the best mode of invigorating the general powers. 

A. TwEEDIE. 

SCIRRHU8— The term «W„, from ««>«, 
marble, was given by the Greek physicians to cer- 
tain tumours characterized chiefly by a great de 
gree of hardness ; but the application of the term 



SCIRRHUS. 



83 



scirrhus has for a considerable length of tune 
been limited to tumours or portions of organs or 
lis ues which present not only this character, but 
which terminate in the disease called cancer. 
Hence the stale of induration to which the appel- 
lation of scirrhus is given is regarded as the first 
stage of cancer. We shall overlook, for the pre- 
sent, the propriety of this distinction, and instead 
of confining ourselves to the consideration of 
scirrhus, shall in the present article give a general 
view of those morbid conditions which have been 
denominated scirrhus, cancer, fungus hsematodes, 
and the several kinds of sarcoma, under the generic 
term of Carcinoma. The reasons for our group- 
ing together under the term of carcinoma so many 
diseases which have generally been described as 
differing widely from that which is commonly 
known by this designation, will be fully exposed 
as we proceed. In the mean time, however, the 
following may be regarded as the more remarkable 
phenomena which these diseases, considered in a 
general and anatomical point of view, present in 
common with one another, and which we con- 
ceive, while they express in a concise and con- 
spicuous manner those characters by which they 
are distinguished, justify our having brought thorn 
togelher under the same general denomination ; — 
1. They are essentially composed of a solid or 
fluid substance, different from any of the solids or 
fluids which enter into the healthy composition 
of the body. 2. They often present in the early 
periods of their formation certain characters com- 
mon to all of them, however much they may differ 
from each other in (he subsequent periods. 3. 
They all terminate in the gradual destruction or 
transformation of the tissues which they affect. 
4. They hive all a tendency to affect, successively 
or simultaneously, several organs in the same in- 
dividual. 5. They all possess, although in various 
degrees, the same reproductive character. 

Specific Divisions of Cax'cijtonsa. — When 
we examine the several morbid conditions which 
we have included under the genus carcinoma, we 
find that they present differences, some of which 
are of considerable importance, others less so; and 
therefore it becomes necessary to separate them 
into distinct groups, and to arrange them into 
species and varieties. The diliercnecs to which 
we allude are referable to two states of the carci- 
nomatous substance to which the diseases in ques- 
tion owe their origin. The first is that in which 
this substance has little or no tendency to become 
organized : its form and arrangement appear to he 
determined chiefly by external circumstances, and 
its formation and subsequent increase are entirely 
dependent on the nutritive function of the organ 
in which it is contained. In the second state this 
substance exhibits, on the contrary, a greater or less 
tendency to become organized: although it may at 
first assume a determinate form and arrangement, 
in consequence of the influence of external circum- 
stance's, it possesses in itself properties by means 
of which its subsequent arrangement and develop- 
ment are effected, independent of the nutritive 
function of the organ in which it is formed, ex- 
cept in so far as the materials of its growth may 
be derived from this source. 

On account, therefore, of these two opposite 
states of this particular substance, carcinoma may 



be divided into two species, the first of which we 
have called scirrhoma, the second cephaloma. 
Although neither of these terms expresses the 
essential characters of the respective states to 
which they are applied, we have not been able to 
find or devise others better calculated to accom- 
plish this object ; it is therefore necessary to bear 
in mind that they indicate only one of the cha- 
racters of these states, viz. a certain degree of 
consistence, and which, it may be observed, is far 
from being constant in either, because of various 
circumstances, which we shall afterwards endea- 
vour to explain. 

In these two species, scirrhoma and cephaloma, 
the carcinomatous substance presents itself under 
various forms, which may be regarded as consti- 
tuting so many varieties of each species. 

Varieties of Scirrhoma. — The varieties of 
scirrhoma are determined chiefly by the relative 
quantity of the carcinomatous substance, the man- 
ner in which it is distributed, and the difference 
of colour and consistence which it presents. Thus 
it may be collected in numerous points in the form 
of a hard, grey, semi-transparent substance, inter- 
sected by a dull white or pale straw-coloured 
fibrous or condensed cellular tissue, and, as such, 
is commonly denominated scirrhus. When it 
assumes a regular lobulated arrangement, so as to 
present an appearance similar to a section of the 
pancreas, it forms what was called by Mr. Aber- 
nethy the pancreatic sarcoma. (Surgical Ob- 
servations, London, 1804 and 1816.) Again, it 
may be disseminated uniformly throughout the 
texture of an organ, which it converts into a solid 
substance, resembling a slice of raw or boiled pork, 
and is then called by the French tissu lardace. 
Lastly, when it presents the appearance of firm 
jelly, and is collected into masses of greater or 
less bulk in a multitude of cells, it is the matiere 
colloid of Laennec, the cancer gelaiiniforme or 
are'olaire of M. Cruveilhier. (Anatomie Patho- 
logique, Dixieme Livraison.) 

Varieties of Cephaloma. — The principal va- 
rieties of cephaloma are derived from the appear- 
ances which the carcinomatous substance presents 
either in different organs or at different stages of 
its development. When it presents the appear- 
ance of firm coagulable lymph, or fibrine deprived 
of the red colouring-matter of the blood, possess- 
ing a uniform, fibriform, or lobuliform arrange- 
ment, with a certain degree of transparency and 
vascularity, Mr. Abernethy gave to it the name of 
common vascular or organized sarcoma. In this 
state the carcinomatous substance is generally col- 
lected into a mass of greater or less bulk, in which 
few or no traces of the proper tissue of the organ 
in which it is contained are observablt If, on 
the contrary, it be uniformly disseminated through- 
out the texture of an organ, so as to transform it 
into a substance resembling a section of the mam- 
mary gland, or the udder of the cow when boiled, 
the appellation of mammary surcoma was given 
to it by Mr. Abernethy. When it presents an 
appearance similar in colour and consistence to 
the substance of the brain, it was called medullary 
sarcoma by the same distinguished surgeon ; ma- 
tiere cerebriforme or encephaloide by Laennec, 
(Diet, des Sciences Med. art. Encephaloi'des), and 
spongoid inflammation by Mr. Burns. (Lee- 



-4 



tures on Inflammation.) The milk-like tumour 
of Dr. Monro, (Morbid Anat. of the Human Gul- 
let, Edinb. 1811,) the soft cancer of various au- 
thors, and the pulp}/ testicle of Dr. Baillie, (Mor- 
bid Anatomy, London, 1795,) are names which 
have been given to the same state. 

Of all the varieties of cephaloma, the last is 
that in which a vascular organization is most con- 
spicuous, and as the coats of the vessels with 
which it is supplied are remarkably delicate, the 
circulation of the blood through them is readily 
interrupted ; hemorrhage from congestive rupture 
takes place, and the effused blood is mixed in 
greater or less quantity with the brain-like matter. 
From this accidental circumstance, together with 
the protrusion of this substance through the ul- 
cerated integuments for example, in the form of a 
bleeding fungus, it has been described by Mr. 
Hey (Pract. Observat. on Surgery, London, 1803) 
and" also by Mr. Wardrop, (Observat. on Fungus 
Haematodes, Edin. 1809,) under the appellation 
»f fungus hxmatodes. Sir Astley Cooper calls 
li fungoid disease. 

Such are, we conceive, the principal varieties 
of scirrhoma and cephaloma, and the general cha- 
racters by means of which they may be recognised. 
But although we have said that the essential differ- 
ence between the two species of carcinoma consists 
in the former having little or no tendency, the latter 
a greater or less tendency, to become organized, 
it is by no means always easy, nay, it is some- 
times impossible, to draw a distinct line of sepa- 
ration between them ; for the carcinomatous de- 
posit when first formed, and, indeed, frequently 
for a considerable length of time after its forma- 
tion, does not furnish us with any signs which 
show that it will or will not become organized. 
We cannot determine what those properties are 
by means of which it is afterwards to assume a 
definite arrangement, or to possess within itself 
the powers of contributing to its subsequent de- 
velopment. These facts may be illustrated by the 
two following circumstances: 1. the carcinoma- 
tous deposit may exist as we have described it in 
the form of scirrhus, pancreatic sarcoma, or the 
Iardaceous tissue, without its presenting any trace 
of organization ; the textures which it invades 
beisg gradually destroyed by its presence, and 
both ultimately converted into a soft, granular, 
pulpy, or liquid mass, of the colour and consist- 
ence of cream or milk. 2. The same deposit may 
exist under the same forms as those we have just 
named, but it undergoes changes of an entirely 
opposite kind ; that is to say, it assumes the cha- 
racters of the mammary or medullary sarcoma, 
becoming more or less soft and vascular, and fre- 
quently terminating in hemorrhage by the rupture 
of its vessels, or in that state called fungus haama- 
todes. Numerous examples might be given of 
scirrhus, medullary sarcoma, and fungus haema- 
todes, as they are commonly called, originating in 
the same morbid state, and passing successively 
from the one into the other in the order in which 
we have named them. Indeed, we often met with 
all the varieties which we have enumerated of 
both species, not only in different organs of the 
same individual, but even in a single organ. 

If such are the successive changes observed to 
k3k<* place in carcinoma, the distinction of the dis- 



SCIRKHUS. 

by 8 ome to beofUUle importance. Such how- 
ever, cannot be the case, fin- we know hat the 
curability of a disease often depends on the time 
at which a remedy is employed, or vanes with the 
state or period of the disease ; and therefore itu 
obvious that whatever means may be adopted fit 
the cure of carcinoma, we can form no precise 
opinion as t,» their relative efficacy, unless the par- 
ticular condition or variety of the disease be kept 
in view. And it is far from being an unimportant 
fact that several of the varieties of both species of 
carcinoma differ materially from one another as 
regards the comparative rapidity of their develop- 
ment, as well as their reproductive tendency. 
Thus in both these respects the pancreatic differs 
from the Iardaceous, the Iardaceous from the mam- 
mary, and the mammary from tiie medullary sar- 
coma ; the first often remaining stationary for a 
long space of time, months or years ; the last 
frequently acquiring its maximum of bulk in a 
few weeks, and when removed being sometimes 
reproduced with a degree of rapidity which is 
never observed in any of the other varieties. It 
may be said that the more the varieties of botl 
species of carcinoma partake of the characters ol 
those accidental formations which resemble th.€ 
healthy tissues of the body, as the cellular, ccllulo- 
fibrous, and fibrous, they are, asteris paribus, the 
less rapid in their development, and have less 
tendency to be reproduced. 

Before proceeding to the description of the 
physical, anatomical, chemical, and physiological 
character of carcinoma, we shall endeavour to 
establish on the evidence with which our anato- 
mico-pathological investigations have furnished 
us, the seat, origin, and mode of formation of this 
disease ; for unless we possess clear and accurate 
notions on these important points, we should meet 
with numerous difficulties besides those which are 
inseparably connected with our subject, under the 
several points of view in which it is necessary to 
consider it. 

Seat, origin, and mode of formation of 
Carcinoma.— Various opinions have been enter- 
tained regarding the seat, origin, and mode of 
formation of carcinoma, same of which have at- 
tracted notice merely from their novelty, others 
from their possessing much higher claims to our 
consideration, and to these we shaft more parti- 
cularly allude. 

There arc several organs subject to carcinoma 
which, from the peculiarity of their structure or 
other circumstances, afford us the means of ascer- 
taining the precise scat of this disease, its origin, 
and mode of formation. But to derive all the 
advantages which these circumstances are capable 
of affording, it is necessary to catch, as it were, 
the disease at its earliest period, that is to say, 
when the peculiar substance of which it i 
has just been deposited, and has not effaced the 
texture or structure of the part in which it is con- 
tained. Investigated in this its first stage, we 
ascertam with greater or loss facility that this sub- 
stance becomes manifest to our senses either as a 
product of nutrition or of secretion. In the former 
case u i s deposited in the same manner as the 
nutritive element of the blood enters into the 
molecular structure, and assumes the form and 



SUlRRHUS. 



85 



arrangement of the tissue or organ into which it 
is thus introduced. In the latter it makes its 
appearance on a free surface, after the manner 
of natural secretions, as on serous surfaces in 
general. 

Such are two of the modes iii which the forma- 
tion of carcinoma takes place, and also two of the 
principal differences in regard to the seat of the 
disease. Proceeding, however, still farther in our 
researches, we arrive at the important discovery 
that the carcinomatous matter exists in the hlood 
under circumstances which can leave no doubt 
as to this fluid being the primary seat of its forma- 
tion. As, in our opinion, too much importance 
cannot be attached to these three positions, viz., 
the formation of carcinoma in the molecular struc- 
ture of organs, on free surfaces, and in the blood, 
we shall endeavour to demonstrate the truth of 
them by a statement of the evidence derived from 
our own researches on the subject. 

1. The liver and stomach, organs in which car- 
cinoma is of frequent occurrence, afford us the 
most striking examples of the formation of carci- 
noma in the molecular structure of organs. If we 
make a section of a liver containing what are 
commonly denominated carcinomatous tumours, 
that is to say, round or irregular masses of a sub- 
stance resembling one or more of the varieties of 
scirrhoma or cephaloma, we shall often be able to 
detect the first stage of these tumours, and dis- 
cover the manner in which they are formed. 
Thus, the first thing which we have frequently 
been able to perceive in those portions of the liver 
in which the carcinomatous matter was just mak- 
ing its appearance was a slight change of colour, 
observable only in a very limited and well-defined 
space, and which could be distinctly seen to exist 
in those minute divisions of the organ denominated 
acini. This change of colour may take place in 
a single acinus, or in several of these bodies suc- 
cessively or simultaneously. The red or yellow 
colour which they naturally present gradually dis- 
appears, and is succeeded by a pale milk-white or 
straw-colour, accompanied by an increase of the 
consistence. But the most important circum- 
stance is, that while these changes of colour and 
consistence are taking place, the form and bulk 
of the acini remain unaltered. Now it need hardly 
be remarked that the form and bulk of the acini 
could not remain unaltered unless the foreign sub- 
stance, to which their change of colour and con- 
sistence must be ascribed, were introduced into 
them in the same order as the normal element of 
nutrition, unless it were deposited in the molecular 
structure of the acini in a manner precisely simi- 
lar to that in which their nutritive function is 
carried on. Otherwise, along with the change of 
colour and consistence which they present, we 
should have a simultaneous increase of bulk. The 
more we examine the acini in this state, the more 
shall we be persuaded that they are thus trans- 
formed by the molecular deposition of that pecu- 
liar substance which constitutes the essential 
anatomical character of the disease in question. 

By tracing the transformation of the acini from 
a lesser to a greater degree, we can perceive them 
terming groups, for example, of three, four, ten, 
or twenty, the reunion of which constitutes tu- 
mours varying from the size of a hemp-seed to 



that of a cherry, in all of which the structure of 
the liver as characterized by the form, bulk, and 
arrangement of the acini, is more or less con- 
spicuously marked, but becoming gradually less 
so with the increasing bulk of the tumours, until 
it entirely disappears, being transformed into a 
uniform lardaceous mass, or into some one or 
other of the tissues or substances which belong to 
either of the species of carcinoma. 

We have said that a similar mode of formation 
of carcinoma is observed in the stomach. It is, 
however, chiefly in the muscular coat of this 
organ that it is most conspicuously seen, on ac- 
count of the difference between the natural colour 
of the muscular fibres of this coat and that of the 
cellular tissue which enters into its composition. 
The change cf colour which accompanies the 
presence of the carcinomatous deposit is, there- 
fore, hardly perceptible except in the muscular 
fibres. These, however, become pale and acquire 
an increase of consistence ; but their bulk does 
not appear to be increased at first, and they retain 
their form and distribution. Such, also, is the 
state of the intermuscular cellular tissue at the 
same period, except as to colour, which is not 
sensibly changed on account of its being naturally 
pale. By-and-bye both acquire a greater or less 
increase of bulk, become remarkably distinct, and 
present that fibriform arrangement, hardness, and 
transparency which are regarded as so character- 
istic of scirrhus. At a more advanced period of 
the disease we no longer trace this nutritive pro- 
cess of transformation, the muscular and cellular 
tissues being converted into a homogeneous mass, 
which is afterwards softened down, or assumes 
the mammary, medullary, or haematoid forms of 
carcinoma. 

2. The fact of carcinoma forming on the free 
surface of serous membranes is strongly corrobo- 
rative of the accuracy of the preceding remarks ; 
for although in the former case we refer the pre- 
sence of the carcinomatous deposit to a modifica- 
tion of nutrition, and in the present to a modi- 
fication of secretion, the difference is merely 
nominal. The distinction, however, between 
nutrition and secretion is valuable as regards the 
formation of carcinoma ; for considered as a 
modification of the latter, we possess ourselves 
of the advantage of studying the disease where 
it presents itself under, perhaps, the most simple 
of its forms, viz., on extensive serous surfaces, 
such as that of the pleura or peritoneum. Here 
the carcinomatous substance is found to be effused 
on the free surface of these membranes, without 
our being able to perceive that they have under- 
gone any previous change whatever. Multitudes 
of tumours are sometimes found on these two 
surfaces, varying in bulk, consistence, and colour. 
Some of them are as large as a plum or an 
orange; others of the size of cherries, peas, hemp, 
or millet-seed, and composed of a substance re- 
sembling pork, the mammary gland, brain, or a 
mixture of the latter, fibrine, and blood. We 
may, in fact, have almost all the varieties of car- 
cinoma formed in these membranes, and, as we 
have said, without their having undergone any 
previous change. Under such circumstances we 
must refer the presence of these tumours to the 
separation if the carcinomatous matter fom 'he 



SCIRRHUS. 



bloou, much, being effused in the form of a secre- 
tion, afterwards undergoes changes peculiar to 
tself. 

3. The presence of carcinomatous formations 
in the blood is a circumstance of great import- 
ance, and unless it be clearly demonstrated that 
their presence is the consequence of a modifica- 
tion of the blood itself, in whatever manner pro- 
duced, we should find it impossible to explain 
many of the phenomena which the disease pre- 
sents, and more especially those which accompany 
its formation in molecular structure and on the 
free surface of the membranes. 

The following facts may be adduced as fur- 
nishing strong evidence that the formation of the 
carcinomatous substance takes place in the blood, 
whether it be found in this fluid alone or in other 
parts of the body at the same time: 1. the pre- 
sence of this substance in the vessels which 
ramify in carcinomatous tumours or in their im- 
mediate vicinity ; 2. in the vessels of a portion 
or of the whole of an organ, to the former of 
which the carcinomatous substance is exclusively 
confined, and can be traced from the trunks into 
the branches and capillaries; 3. in vessels having 
no direct communication with an organ affected 
with the same disease, as, for example, when it is 
confined to a small extent of the vena porta? ; 
and, lastly, in blood which has been effused into 
the cellular tissue and on the surface of organs. 

The appearances which the carcinomatous mat- 
ter presents in the blood are very various : some- 
times they are perfectly similar to those which 
mark its presence in the substance or on the sur- 
face of organs. When contained in large veins, 
such as the vena porta? and its branches, the 
emulgcnt vein, &c. it may present the lardaceous, 
mammary, medullary, or hffimatoid characters, all 
in the same venous trunks. These varieties of 
the disease may be found mixed together in mi- 
nute quantities, or isolated into masses so con- 
spicuous that we can readily distinguish them 
from one another. Sometimes they lie merely in 
contact with the internal parietes of the vein ; at 
other times they are united with these by means 
of a thin layer of colourless fibrine ; or minute 
blood-vessels pass from the one into the other, 
and are often very numerous and remarkably con- 
spicuous in the cerebriform matter. 

The divisions of the vascular system in which 
the carcinomatous substance has been observed, 
are the venous and capillary, — a circumstance 
which may be ascribed to the contractile power of 
the arteries preventing, under ordinary circum- 
stances, the blood from accumulating, and conse- 
quently this substance from forming within them, 
and not to any peculiarity of function exercised 
by the former. The presence of the carcinoma- 
tous matter in the veins might be, and indeed is, 
in general, supposed to be owing to its having been 
absorbed by these vessels ; but without entering 
into minute anatomical details which disprove such 
to be the case, we shall again repeat the fact that 
there are cases of carcinoma in which the venous 
blood alone is found to be the seat of the disease. 
There is no accumulation of the carcinomatous 
; natter either in the vicinity of the veins in which 
the blood is thus affected, or in any other part of 
me body ; and in those cases in which this com- 



Lee ofthis matter in the vetna to the exerc^ert 

the function of venous absorption, as that i c. i- 
me uuicuun cretaceous formationa 

lular fibrous, osseous, and i ri wc« 

. . ., ..imilir Droccss, winch we 
in the s.unc vessels to a similar pro 

know not to be the case. 

From this view of the origin of carcinoma in 

the blood, its formation in the intimate structure 
and in the free surface of organs, alter the man- 
ner of nutrition, and secretion, follows as a natural 
consequence. The material element of the disease 
is separated from the blood and deposited under a 
variety of circumstances which modify in a greater 
or les's degree the form, bulk, colour, and consist- 
ence which it afterwards present., in the several 
periods of its development. We cannot therefore 
limit the seat of the disease to any one tissue, or 
ascribe its origin io any modification of structure 
or special organization, as has been done by several 
pathologists. 

Perhaps the most ingenious attempt that has 
been made to explain the local origin of carcinoma 
is that of Dr. Hodgkin, published in the fifteenth 
volume of the Medico-Chirurgical Transactions. 
Dr. Hodgkin has endeavoured to show that the 
presence of a serous membrane, having a cystiform 
arrangement, is necessary for the production of 
carcinoma and some other diseases of a malignant 
character. The existence of the former precedes, 
he believes, the formation of the latter, and conse- 
quently is at once the seat and origin of the dis- 
ease. That such is the manner in which carcino- 
matous formations are sometimes formed, we can 
have no doubt, inasmuch as we have had occasion 
to see them as they have been described by Dr. 
Hodgkin. But we have here no new law in ope- 
ration, nor even an exception established to that 
the principles of which we have several times al- 
luded to. Cysts are a very simple modification of 
a serous membrane ; they partake of the structure 
and functions of the latter, and, consequently, are 
subject to similar diseases. If, therefore, such 
cysts should exist in an individual having the can- 
cerous diathesis, they may, in the same manner as 
a natural serous membrane, become the seat of any 
variety of carcinoma. But although carcinoma- 
tous tumours, such as those described by Dr. Hodg- 
kin, are found in cysts, attached, single, or in 
groups, and covered by a reflected serous mem- 
brane, these tumours may, and frequently do, not 
originate in the cysts. They form in the cellular 
tissue external to the cysts, and during their de- 
velopment project inwards, carrying before them 
as their common envelope the internal and serous 
lining of the latter. Such, in fact, is seen to be 
the origin of these tumours in most of the cvsts 
represented by Dr. Hodgkin in the work referred 
to. They are situated external to the cyst, are 
supplied with vessels which do not belong to the 
cyst, and are placed in the same circumstances as 
tumours formed in the cellular tissue where no 
cyst is present. 

As an objection to the general application of 
he cystic origin of tumours, it may be observed 
that there are numerous organs in which the pre- 
sence of cysts ls not to be detected at anv period 
or the development of carcinoma ; and therefore, 
when they do occur in other organs, they must be 
looked upon as a mere coincidence, or as a conse 



SCIRRHUS. 



S7 



quence of the disease, anJ not as a cause or ne- 
cessary condition of it. 

After what we have just said on the cystic origin 
of carcinoma, it will not be expected that we shall 
do more than notice the theory which maintained 
that the formation of this disease depended on the 
previous existence of an accidental organization, 
which received the name of hydatid: how far 
such was the appellation it should have received, 
must now be a matter of indifference. 

Mr. Abernethy referred all adventitious forma- 
tions to the coagulable part of the blood as their 
origin, and fixed their seat in the cellular tissue, 
in the parenchyma, and on the surface of organs. 
This plastic substance was supposed by him to be 
effused in one or other of these situations, to be- 
come organized, and to derive the materials of its 
subsequent growth from the vascular system of 
the surrounding parts. 

According to Andral, the cellular tissue is in 
general the scat of carcinomatous formations ; but, 
that as the)' depend on a modification of secretion, 
they may form wherever this function is accom- 
plished ; the speciality of each being determined 
by a previous modification of the economy in ge- 
neral, or of the functions of nutrition, innervation, 
or hematosis in particular. 

The only other opinion to which we shall allude 
regarding the seat and origin of these formations, 
considered in an anatomico-pathological point of 
view, is that of Cruveilhier. This pathologist 
regards all organic transformations and degenera- 
tions (as he calls them) as exclusively the result 
of the deposition of morbid products in the cellu- 
lar element of organs. He believes that the tis- 
sus propres of organs are incapable of undergoing 
any organic lesion except hypertrophy and atrophy. 
Both these statements we have shown to be dis- 
cordant with facts. The source whence these pro- 
ducts are derived is, according to the same author, 
the venous capillary system, to which we formerly 
alluded, and we assigned a reason for their being 
found in these vessels, and especially in the venous 
trunks and their larger branches. 

[Although cancer in its various forms may be 
a mere local degeneration, it can scarcely be 
doubted, at the present day, that such degenera- 
tion is connected with a special condition of the 
system, or is a cachexia. Accordingly, this has 
been made to enter into the definition of the dis- 
ease by pathologists. One of the most recent, 
Dr. W. H. Walshe, {Op. cit.) properly defines 
cancer to be, — " a disease anatomically character- 
ized by the presence of scirrhus, encephaloid or 
colloid, originating in a general vitiation of the 
economy, and possessing the properties of assimi- 
lation, of reproduction, and of destroying life by 
a peculiar cachexia." 

J. Miiller, from his anatomical researches, is 
disposed to consider, that no division of patholo- 
gical structures into homologous and heterologous 
can be established ; and he maintains, that the 
elementary structures of all morbid growths, 
hitherto examined, resemble, in every respect, the 
structures presented in the several stages of de- 
velopment of the elements of the healthy tissues 
of the body ; and as the element in the healthy 
tissues is a nucleated cell, so also cells growing 
upon nuclei, and developing new cells within 



themselves, or elongated into caudate or spindle- 
shaped bodies, or in a still higher stage of develop- 
ment forming fibres, are conceived to form the 
main structure of all morbid growths. Blood- 
vessels are later formations, as they are known to 
be in the materials that constitute the embryo. It 
appears clear, however, that even if we admit the 
nucleated cell to be the same in the healthy and 
the heterologous tissue, there must be an impulse 
seated in the one which is not present in the 
other, and which leads to a different development ; 
and hence we may, with much propriety, regard 
cancer as a heteroclite or heterologous formation. 
(For the microscopical characters of cancer, see 
J. Miiller, Op. cit. and Walshe, art. Cancer, in 
Cyclop, of Surgery, or Amer. edit, by Dr. J. M. 
Warren, p. 12, Boston, 1824.)] 

Physical characters of Carcinoma. — The 
physical characters of this disease comprehend the 
form, bulk, colour, and consistence which it pre- 
sents in the different tissues and organs of the 
body, and in the several periods of its develop- 
ment. 

Form. — Carcinoma presents considerable vari- 
ety of form. In its first stage, and when the 
material of which it is composed is deposited after 
the manner of nutrition, carcinoma assumes the 
particular form or structure of the organ which it 
affects, as that of the liver and stomach, the acini 
of the former, and the muscular, cellular, and mu- 
cous tissues of the latter, determining in these 
organs respectively the primary form of the dis- 
ease. In the brain, lymphatic glands, testes, we 
cannot, however, perceive any particular arrange- 
ment of the carcinomatous matter at this early 
stage, either on account of the colour, homogene- 
ous aspect, or minute structure of these organs, 
preventing us from detecting its presence, and the 
manner in which it is deposited. 

At a more advanced stage of the disease, the 
forms which the carcinomatous matter derives 
from the structure of the parts in which it is de- 
posited disappear, and those which it afterwards 
presents are determined chiefly by external cir- 
cumstances. The most important of these forms 
are the tuber/form, stratiform, and ramiform. 

1. Tuberiform carcinomatous matter is by far 
the most frequent, and presents considerable va- 
riety. When this matter is deposited in organs 
possessing a uniform density, and in parts submit- 
ted on all sides to an equal degree of pressure, it 
assumes a globular form. Although at first globu- 
lar, it becomes pyriform on natural and accidental 
serous surfaces, either on account of the mode of 
its attachment, or of less resistance being opposed 
to its growth in one direction than in another. It 
assumes a fungiform shape when placed in cir- 
cumstances which facilitate its lateral, and retard 
its peripheric development, as when it passes from 
a dense into a soft tissue, or escapes from beneath 
the skin to the surface of the body. It often pre- 
sents a lobulated appearance when accumulated 
in separate portions of the cellular tissue into 
rounded masses, grouped together and included 
within a common capsule; and in the submucous 
tissue in particular it frequently exhibits the ex- 
ternal arrangement of the cauliflower or mulberry. 
That appearance of carcinoma which resembles 
the structure of the pancreas depends generally r>rj 



98 



he agglomeration of very small globular or pyri- 
f orm tumours, separated from one another by cel- 

ular or cellulo-fibrous tissue, but enclosed in a 
common capsule. 

2. Stratiform carcinomatous matter is chiefly 
met with in the subserous cellular tissue. Al- 
though it may be deposited in layers of various 
extent, which present no definite arrangement, it 
more frequently assumes the form of thin circular 
patches, varying from the breadth of a pin's head 
to an inch or more in diameter, and presenting an 
appearance similar to what might be imagined to 
follow the infusion of a small quantity of milk 
into a number of isolated points of the subserous 
cellular tissue. Patches of this kind, which are 
composed of a substance having the colour and 
consistence of cream or milk, are most frequently 
met with beneath the pia mater and pleura pul- 
monalis, and are remarkably conspicuous in the 
latter situation, on account of their white pearly 
aspect contrasting so strongly with the surround- 
ing dark colour of the lungs. These patches 
may occur in the situations we have named with- 
out the substance of the brain or lungs presenting 
any trace of carcinoma ; but we have never met 
them unless when the disease existed in some 
other organ, as the breast, eye, liver, stomach, 
kidney, or uterus. In some cases, lymphatics 
filled with fluid carcinomatous matter are observed 
to communicate with the patches; in other cases 
no such vessels are observed. 

3. We formerly alluded to the ramiform ar- 
rangement, when treating of the seat and mode 
of formation of carcinoma in the molecular struc- 
ture of organs and in the blood. This arrange- 
ment, as well as the seat of the carcinomatous 
matter in the veins on which it depends, may 
readily be detected in the liver, where this matter 
is collected in the form of tumours of various 
sizes. When such tumours are divided and sub- 
mitted to pressure, we can often perceive the 
carcinomatous matter issuing from a number of 
small circular orifices in the state of a creamy 
fluid ; and if these orifices are attentively exam- 
ined by a careful dissection of the tumour from 
its cut surface towards its circumference, we find 
that they are the cut extremities of veins filled 
with this matter to a greater or less extent beyond 
the tumour. But there is no organ in which the 
ramiform arrangement of the carcinomatous mat- 
ter is so conspicuously seen as the kidney. The 
whole of the venous system of this organ, in- 
cluding the emulgentvein to its termination in the 
vena cava, is sometimes found completely distended 
with this matter, either in a fluid state, of the con- 
sistence of brain, or as firm as the pancreas. 
When the kidney thus affected is divided, it ap- 
pears as if it were formed of a multitude of 
encysted tumours of various sizes, on account of 
the carcinomatous matter being contained within, 
and bounded by the walls of the cut extremities 
of the veins. This form of carcinoma of the 
kidney is easily ascertained by dissection, or by 
the introduction of a probe from the emulgent 
vein into its branches. 

A similar arrangement is also remarkably con- 
spicuous in carcinoma of the stomach. Not only 
are the minute veins, which ramify beneath the 
mucous membrane in the vicinity of the disease, 



SCIRRHUS. 

^filled with the carcinomatous matter, but also the 



E, branch;; Tseen on the externa, svrfaceof 

the stomach, and the coronary veins .n which 
they terminate. The ridorninal division of the 
vena port* furnishes us with a remarkable exam- 
ple of the ramiform arrangement of carcinoma, 
isolated from any organ affected with the disease, 

There is another variety of form of the carci- 
nomatous matter which may be noticed in tins 
place, as it may be regarded as a modification of 
the preceding. It is that which is observed when 
this matter is contained in the lymphatics and 
lacteals, and which is derived from the particular 
form of these vessels. The lacteals, more frequently 
perhaps than the lymphatics, contain this matter, 
and are sometimes seen in great numbers quite 
filled with it on the surface of the stomach and 
intestines, and between the folds of the mesentery, 
in carcinoma of these organs. 

Such are the principal forms of carcinoma, 
whether we consider the disease in a general or 
special point of view. They are certainly not 
equally prevalent, nor precisely the same in both 
species, viz. in scirrhoma and cephaloma, nor in 
the several varieties of each ; but they are found 
to occur in all of them ; and as the modifications 
which they present in this respect are very unim- 
portant, it is not necessary to allude to them more 
particularly. 

Bulk The quantity of the carcinomatous 

matter deposited in the molecular structure or on 
the free surface of organs is extremely various, but 
it is perhaps never so great in the former as in 
the latter. In the liver it may vary from the size 
of a pin's head to that of an orange. In softer 
or more yielding organs, as the lungs, testes, and 
even the mamma, it may equal in bulk the head 
of an infant or of an adult; and in the intermus- 
cular and subcutaneous cellular tissue its bulk is 
sometimes still more considerable. We now 
speak of individual tumours, and not of those 
masses formed by the aggregation of tumours, 
during their progressive development, as occurs in 
the liver, lungs, &c. nor of those produced in a 
similar manner in the abdominal cavity, posterior 
to the peritoneum, in carcinoma of the mesenteric 
glands. 

The influence of pressure in favouring or re- 
tarding the development of carcinomatous tumours, 
and consequently in modifying their bulk, is most 
conspicuously seen when they are situated near 
the external surface of tne body. So long as 
their progress outwards is obstructed by an un- 
yielding fibrous membrane, they often remain for 
a considerable time nearly stationary ; but so so&n 
as this obstacle is removed, they acquire a rapid 
increase of bulk. This rapid increase of bulk on 
the removal of all pressure is still more remarkable 
when these tumours project through the ulcerated 
integuments in the frightful form of bleeding 
fungi. But the best illustration of the influence 
of pressure on the development of these tumours 
is met with in carcinoma of the eve. A tumour 
which may have required several months before it 
reached the external surface of this organ, will, 
after it has been removed, together with the whole 
contents of the orbit, reappear, and in the course 
of one or two weeks acquire a much greater bulk 
than before the operation. 



SCIRRHUS, 



89 



Independently, however, of this physical circum- 
stance, which modifies so conspicuously the bulk 
of these tumours, there is another of an opposite 
nature, which requires to be particularly noticed 
on account of its constituting the distinctive cha- 
racter of the second species of carcinoma. We 
allude to the physiological properties of the cephal- 
omatous tumours, by means of which they possess 
within themselves the power of increasing their 
development to an almost unlimited extent. It is 
to the vascular organization, which we shall after- 
wards describe, of the tumours of this species, that 
the rapidity of their growth and the great bulk 
which they attain are to be attributed, and which 
renders them less subject to the influence of pres- 
sure than those of the species scirrhoma. How- 
ever, unless we were aware of the modifying in- 
fluence of pressure, we should often be unable to 
explain why tumours possessing the same charac- 
ters are subject to" differences both as regards the 
rapidity of their development and the bulk which 
they acquire. 

Colour. — The colour of carcinoma differs 
greatly from that of any of the other adventitious 
formations. It is, therefore, a character of consi- 
derable importance, inasmuch as it frequently ena- 
bles us to distinguish this disease from others of 
the same class ; and we have already seen that it 
is chiefly by the same means that we are led to a 
knowledge of the seat and forms of carcinoma in 
the early stages of its formation. It is most fre- 
quently white, with a shade of grey or blue ; 
sometimes it inclines to yellow, brown, or red, in 
consequence of the colour of the organs affected 
with the disease, of the presence of blood, bile, 
pus, or other fluids in various proportions, or of 
some other accidental circumstance. But the 
principal modifications of colour of carcinoma are 
seen in the several varieties of both species of the 
disease, these varieties, as we have already stated, 
resembling more or less in colour that of the organ 
or tissue whence have been derived their respective 
appellations ; as that of cartilage, of the pancreas, 
of fresh boiled pork, of coagulated albumen or 
fibrine, of the mammary gland, of the substance 
of the bruin, or a mixture of the latter and blood. 
Consistence — To none of the physical charac- 
ters of carcinoma has so much importance been 
attached as to that of consistence, but more espe- 
cially to an increased degree of this property when 
considered in relation either to the disease itself or 
the tissues of the affected organ. Hence the term 
scirrhus, which implies a state of induration, in 
consequence of its being frequently not only one 
of the first, but likewise one of the most marked 
changes which we are capable of perceiving in the 
affected oriran, has been employed to characterize 
the early or occult stage of carcinoma. The op- 
posite condition of carcinoma, that in which this 
disease presents a degree of consistence less than 
that of the organ which it affects, has been consi- 
dered as a change succeeding to the state of indu- 
ration or scirrhus, and the result of a process of 
softening ; consequently, as indicating a more ad- 
vanced period of the disease. But the degree of 
consistence of the carcinomatous formations is not 
an invariable character of a particular stage of 
their development ; for these formations may, 
when first perceivable, be as hard as cartilage, soft 
Vol. IV.— 12 h * 



as brain, or fluid as cream ; or they may become 
soft or fluid after having remained for a greater or 
less length of time in a state of hardness. This 
variety in the consistence of the carcinomatous for- 
mations depends on the following circumstances : 
— 1st. the nature of the organ in which the car- 
cinomatous deposit is contained ; 2d. the ele- 
mentary composition of the deposit ; 3d. the sub- 
sequent changes occurring either in the deposit it- 
self, or in the tissues with which it is in contact. 

1st. The structure, situation, connection, and 
greater or less density of organs and tissues, greatly 
modify the consistence of the carcinomatous de- 
posit, either in consequence of a difference between 
the quantity of this substance relative to that of 
the tissues in which it is contained, or of a differ- 
ence in the degree of resistance opposed by the 
latter to its accumulation or development. Thus it 
is more consistent in the liver than in the lungs 
or brain ; in the skin than in the cellular tissue or 
a mucous membrane ; in a tumour situated beneath 
a dense covering than on a free surface. 

2d. Modifications in the composition of the 
carcinomatous deposit exercise a considerable in- 
fluence over the degree of consistence which it 
presents, for we often meet with it possessing va- 
rious degrees of consistence, when examined at 
the same stage of its development, and in the 
same or in different organs. Examples of this 
kind, although common in almost every or^an of 
the body, are best seen where the deposit is col- 
lected into isolated masses containing little or none 
of the natural tissues, and where consequently its 
consistence must depend on the nature of the ele- 
ments of which it is composed. It is found in 
this state in cellular tissue and in serous mem- 
branes, and more especially on accidental surfaces,- 
such as those of sores formed by the destruction 
of the protruded portion of tumours, or after the 
removal of an external organ affected with carci- 
noma. In these situations this substance may, at 
the same stage of its formation, present the oppo- 
site extremes of consistence, being in one case as 
hard as cartilage and more or less transparent, and 
in another as soft as brain, or quite fluid and 
opaque. But these opposite extremes of consist- 
ence are most strikingly manifested in those fungi- 
form tumours which arise from the bottom of the 
orbit after the extirpation of the eye, or from the 
cicatrix of the integuments after the removal of 
the breast in consequence of carcinoma. In these 
two instances it is obvious that the stage of de 
velopment of the tumours is the same in both , 
and that the difference of consistence which they 
present is no evidence of their being different in 
their nature, is equally obvious, inasmuch as the 
hardest of them often assume, after a certain length 
of time, the consistence of the softest, a part or 
the whole of the dense transparent substances of 
which they are composed being gradually trans- 
formed into a soft, brain-like, pulpy mass. This 
process of transformation is also most conspicuous 
in those tumours which constitute the vascular or 
organized sarcoma of Mr. Abernethy. They are 
at first more or less transparent, presenting the 
appearance of a solid mass of albumen, coagula- 
ble lymph, or fibrine, but become gradually opaque, 
soft, and pulpy, resembling foetal brain, and ar<= 
then not to be distinguished from those carcin.'>- 



90 



S C I R R H U S 



raatous tumours which, from their commencement 
possess the cerebriform character. These exam- 
ples will suflice to show that the carcinomatous 
deposit, besides being modified in its consistence 
by the tissues in which it is contained, is equally 
so in consequence of a difference in its composi- 
tion ; that its consistence may or may not be the 
same when first formed ; that it may be cither 
hard or soft at this period ; and, consequently, that 
the latter state is not necessarily preceded by the 
former, as was maintained by Laennec and the 
greater number of pathologists who have published 
on this subject since his time. 

3d. The last modification of consistence of the 
carcinomatous formations is that to which the at- 
tention of pathologists has almost exclusively been 
directed. It depends on a series of changes taking 
place either in the carcinomatous matter itself, the 
tissues with which it is in contact, or in both at 
the same time. But in order that these changes 
may be more fully understood, we shall first de- 
scribe the chemical and anatomical characters of 
carcinoma. 

Chemical characters of Carcinoma. — In 
order to ascertain the chemical composition of the 
several varieties of scirrhoma and cephaloma, it 
would be necessary to procure a sufficient quantity 
of the carcinomatous matter isolated from the tis- 
sues with which it is so frequently more or less 
intimately united or combined. The difficulty, 
and in many cases the impossibility of obtaining 
it in several of these varieties in a separate state, 
has prevented the pathologist from determining 
accurately its chemical composition. Indeed, the 
results of the analyses that have been published 
may be regarded as indicating the chemical compo- 
sition of particular organs and tissues affected with 
carcinoma, rather than of the carcinomatous mat- 
ter itself. The most recent analysis of carcinoma 
in the scirrhomatous and cephalomatous states, is 
that published by Lobstein in his " Traite d'Ana- 
tomie Pathologique." Seventy-two grains of scir- 
rhous breast were found to contain — 

Albumen 2 grains 

Gelatine 20 

Fibrine 20 

Fluid fatty matter 10 

Water 20 

72 

Seventy grains of the uterus in a state of scirrhus 

contained — 

Gelatine 15 grains 

Fibrine 10 

Fatty matter 10 

Water 35 

70 
According to tne same author, it would appear 
that the chemical composition of cephaloma is not 
the same at different periods of its development. 
Thus in the first stage of the disease, or that of 
crudity, it was found to contain a greater propor- 
tion of gelatine than of albumen ; and in the se- 
cond stage or that of softening, that is to say, 
when the carcinomatous matter is of the consist- 
ence of soft brain, the albumen is in much greater 
quantity than the gelatine. 



[Other observers enumerate, also, gelatin among 
the constituents of encephaloid and scirrhous ; in 
an analysis, however, by M. Foy, not a particle 
of that principle was detected in either. (Walshe, 

Op. «{.)] . , , 

For the reasons already stated, it must be ob- 
vious that no great importance can be attached to 
these results of the chemical analysis of the carci- 
nomatous matter ; and, independent of the differ- 
ence of composition which it must present from 
its admixture, in various proportions, with the 
same or different tissues, it is highly probable that 
it is likewise modified, in this respect, by the phy- 
siological influence of the organ in which it is 
formed, and the constitution of the individual in 
whom it exists. 

Anatomical characters of Carcinoma. — 
We have already pointed out the most important 
circumstances illustrative of the anatomical cha- 
racters of carcinoma, when treating of the specific 
divisions of the disease, its varieties of form, bulk, 
and consistence ; its seat and mode of formation. 
We shall, therefore, now examine more especially 
the structure or anatomical arrangement of the 
carcinomatous matter itself. 

We formerly stated that the carcinomatous 
matter may exist in two states ; that in the first 
state it has little or no tendency to become organ- 
ized, its form and arrangement being determined 
chiefly by external circumstances ; and that in the 
second it exhibits a greater or less tendency to be- 
come organized, possessing in itself properties by 
means of which its form, arrangement, and deve- 
lopment are effected. The carcinomatous inattet 
may, as we have seen, exist in three situations. 
viz. in the molecular structure of organs on free 
surfaces, and in the blood. It is, perhaps, only 
in the two latter situations that we can submit it 
to minute anatomical investigation. When, there- 
fore, we examine anatomically a mass of carcino- 
matous matter contained in a large vein, or situated 
on the surface of a serous membrane, in loose 
cellular tissue, on the surface of a sore or cicatrix 
after the removal of an organ affected with carci- 
noma, we find it composed of the following ele- 
ments in various proportions, viz. carcinomatous 
matter; cellular, fibrous, and serous tissues; and 
blood-vessels. 

The carcinomatous matter, whatever may be 
its consistence, almost always forms by far the 
greater bulk of the disease. If, however, its con- 
sistence be considerable, it generally presents a 
uniform, granular, or radiated, and, when soft, a 
lobulated arrangement. These three varieties are 
sometimes met with in the same tumour, and in- 
dicate the progressive development of the disease, 
the radiated arrangement being seen at the basis, 
the uniform and the lobulated towards the cir- 
cumference. 

The cellular tissue is often small in quantity, 
and sometimes so fine and loose, as not to be per- 
ceptible till after the carcinomatous matter has 
been separated from it by pressure and maceration. 
It encloses that matter, separates it into granules, 
bundles, or lobules, intersects these in various 
directions, and serves to conduct the vessels which 
administer to the nutrition and growth of the dis- 
ease. 

The fibrous tissue is not often met with as an 



bCIRRHUS. 



91 



anatomical element of carcinoma in the situations 
in which we are now considering this disease. 
The serous tissue, on the contrary, is frequently 
present, and may form either a capsule to the car- 
cinomatous substance, which is then said to be 
encysted, or give rise to the formation of cysts of 
various sizes, containing gelatinous, albuminous, 
or other fluids. 

When the carcinomatous matter is deposited in 
the molecular structure instead of on the surface 
of organs, as we have just been considering it, the 
quantity of the cellular and fibrous tissues which 
intersect it in various directions is sometimes very 
considerable. In carcinoma of dense organs, such 
as the breast, uterus, ovaries, liver, walls of the 
stomach, &c. these tissues are often very abundant. 
Indeed, in the early stage of carcinoma of these 
organs, a firm, pale, compact, cellulo-fibrous-look- 
ing tissue is not unfrequently the only anatomical 
element discoverable, and which on this account, 
and from the increase of bulk with which it is ac- 
companied, has been described by Andral as hyper- 
trophy of the cellular tissue, an appellation which 
does not appear to us to be warranted by analogy 
or by the changes which this tissue subsequently 
undergoes. For hypertrophiated cellular tissue, 
such as we find in elephantiasis Arabum or Bar- 
badoes leg, has no tendency to terminate in carci- 
noma; nor docs hypertrophy of the heart from 
disease, or of the muscles of voluntary motion 
from frequent exercise, ever present any other 
change than that implied by this term, except a 
certain increase of consistence, generally in pro- 
portion to the increase of bulk which has taken 
place. Besides, admitting that a certain degree 
of hypertrophy may precede the presence of car- 
cinoma, the facts which we have already brought 
forward in illustration of the mode of formation 
of the disease, its seat and origin, clearly show 
that no such change is necessary, inasmuch as all 
(he varieties of carcinoma may form in situations 
in which the cellular tissue is either extremely 
small in quantity or does not at all exist. What, 
therefore, appears to be hypertrophiated cellular 
tissue must he regarded a tissue sui generis, pro- 
duced by the uniform distribution and molecular 
deposition of the carcinomatous matter, either in 
the cellular tissue of an organ, or in an accidental 
tissue of a similar kind, formed at the same time, 
and deposited along with the carcinomatous matter. 
Such is, in fact, the manner in which the cellular 
and fibrous tissues which enter into the composi- 
tion of the carcinomatous matter are generally 
formed. These tissues are most conspicuous in 
the early stage of the disease, becoming gradually 
less apparent as it advances, and ultimately disap- 
pearing in consequence of their undergoing the 
carcinomatous transformation, or other changes 
which we shall afterwards describe. 

The blo^d-vessels which enter into the compo- 
sition of the carcinomatous matter vary greatly in 
number, and sometimes also in bulk. They are 
rarely perceptible in any of the varieties of scir- 
rhoma; are generally few in number in the first 
and second varieties of cephaloma, or in the or- 
ganized and mammary sarcoma of Abemethy ; 
but in the last variety or medullary sarcoma, they 
are often so numerous as to form the greater por- 
tion of the brain-like tumour in which they 



ramify. When these vessels are examined in 
cephaloma, they are found to vary in diameter 
from the breadth of a hair to a line, and present 
that peculiarity of distribution, always more or 
less conspicuous in newly-formed blood-vessels ; 
that is to say, the ramifications of which they are 
composed communicate with a common trunk at 
its opposite extremities in the same manner as the 
hepatic and abdominal divisions of the vena porta? 
do with this vessel. They are frequently varicose, 
their walls are remarkably delicate, and they have 
altogether much more a venous than arterial cha- 
racter. They appear to be formed apart from the 
vascular system of the surrounding tissues, as 
they can be seen forming from small specks of 
blood situated at the centre or at the circumference 
of the carcinomatous mass, in the form of stris, 
or slender streaks of blood, and gradually assum- 
ing a cylindrical arrangement and ramiform dis- 
tribution, and thereby constituting what may be 
called the proper circulation of cephaloma. The 
communication which exists between these vessels 
and those of the organ in which the carcinomatous 
substance is contained, is frequently very imper- 
fect, — a circumstance which, together with the de- 
licacy of their structure, renders them extremely 
liable to congestion and rupture. The most mi- 
nute divisions of these vessels terminate by peni- 
cillated extremities in the carcinomatous matter, 
where they communicate with veins and arteries 
belonging to the affected organ. The latter ves- 
sels, which may be said to form the collateral cir- 
culation of cephaloma, are seldom so numerous 
as the former, but there are cases in which they 
appear to constitute the greater part of the vascu- 
lar structure of the disease. They proceed in a 
radiating direction, from the pedunculated attach- 
ment of a tumour for example, or arise along its 
circumference in the cellular tissue which sepa- 
rates it from the neighbouring parts. It is by 
means of these vessels that the materials required 
for the nutrition and growth of such tumours are 
supplied ; and, as we shall afterwards see, the 
partial or even complete destruction of these and 
other tumours similarly situated, is occasioned by 
causes which interrupt this their collateral circu- 
lation. 

The blood-vessels which are seen in scirrhoma 
appear to be no other than branches of those 
which belong to the neighbouring tissues, and 
which have become inclosed within the substance 
of which its several varieties are composed. 

Physiological characters of Carcinoma. 
— The anatomical characters just described are 
the most unequivocal circumstances by means of 
which we are enabled to perceive the existence and 
estimate the degree of those properties termed vital 
or physiological which manifest themselves duiing 
the developement of carcinoma. But it is more 
especially the formation of cellular tissue and 
blood-vessels in the carcinomatous matter which 
shows it to be in possession of these properties. 
We have already seen that the functions of circu- 
lation and nutrition are actively carried on in the 
carcinomatous matter. Of these functions, that 
of circulation is far the most important, inasmuch 
as many of the more remarkable phenomena 
which present themselves during the progress ol 
carcinomatous formations depend on chaner* t 



U2 



SCIRRHUS. 



which take place cither in the proper or collateral 
circulation which we have described. Thus, the 
quantity of blood contained in a carcinomatous 
tumour, and consequently various shades of colour 
of the substance of which it is composed, will de- 
pend much on the degree of facility with which 
the circulation is performed in either or both sys- 
tems of vessels. An imperfect communication 
between these vessels, owing to the manner in 
which they are connected, or the presence of a 
mechanical obstacle in the situation of the colla- 
teral veins preventing the return of the venous 
blood, frequently gives rise to congestion of the 
whole or a portion of a carcinomatous tumour, 
the colour of which becomes more or less red, 
purple, brown, or black. The congestion thus 
produced may be such as to give rise to rupture 
of the vessels, and internal or external hemorrhage. 
In the former case the carcinomatous substance, 
when situated externally in the form of a tumour, 
is seen to acquire a rapid increase of bulk, pro- 
portioned to the extent of the effusion, and, when 
examined afterwards, is found to be infiltrated 
with blood, or broken down and mixed with clots 
of this fluid, and irregular masses or layers of 
fibrine, thereby producing, when the tumour pos- 
sesses the cerebriform character, appearances very 
similar to those observed in cerebral apoplexy from 
sanguineous effusion. If the obstacle interrupt 
entirely the circulation in the tumour, nutrition 
ceases, and death ensues in all those parts of it 
from which the obstructed vessels proceeded. The 
termination of carcinoma in mortification from 
obliteration of veins is far from being a rare occur- 
rence. Jt sometimes occurs in whole tumours, 
but is most frequently observed in portions of 
them, or in some of the small tumours of which 
larger ones are frequently composed, that are at- 
tached by narrow pedunculated extremities. The 
unequal development of one of these small tu- 
mours may give rise to compression of a neigh- 
bouring one ; or the tissue to which they are 
attached may, from its unyielding nature, act as a 
ligature on their pedunculated extremities, and 
intercept the return of the venous blood through 
them. The same thing sometimes happens to 
tumours that have perforated fascia? or even the 
skin. The protruding portion, now relieved from 
the pressure to which it was before subjected, in- 
creases rapidly in bulk ; but the dimensions of the 
opening remaining the same, very soon exercise 
a degree of constriction which arrests the circula- 
tion through the vessels of the neck of the tumour, 
and it dies and sloughs. 

Changes of a similar kind result likewise from 
the presence of the carcinomatous matter acting 
as a stimulus, and exciting various degrees of con- 
gestion. In consequence of the congestion thus 
produced, and the modification of nutrition which 
necessarily follows, softening takes place, not 
only of the '■arcinomatous substance, but likewise 
of the tissues which enter into its composition. 
Softening of this kind is sometimes effected with 
great rapidity, and tumours which before felt 
firm or even hard, acquire a soft, pulpy feel, and, 
when laid open, are found to contain a fluid of 
the consistence of cream intermixed with shreds 
of cellular tissue, detached blood-vessels, blood, 
%nd sometimes pus This process of softening is 



frequently seen taking place in carc.nomatou, 
tumours that have perforated the skin, and when 
considered in connection with the state o the or- 
culation which has given rise to it, enables us to 
explain the peculiar appearance of those frightful 
solutions of continuity by which it is followed, 
such as their projecting everted edges, and rugged 
central excavation. It is well known that it is 
the most projecting part of a tumour situated be- 
neath the skin in which a solution of continuity 
commences, and the reason of this is, that it is 
here the circulation is first arrested from the greater 
degree of compression to which the blood-vessels 
are subjected, together with the increased influx 
of blood caused by a greater degree of excitement. 
The most elevated portion of the skin becomes 
atrophiated during the first stage of compression 
and irritation, that is, when the circulation of the 
blood through it is only impeded ; but so soon as 
this all-important function has ceased, which is 
announced by a change of colour from bright to 
dark-red, purple or black, and a diminution of 
sensibility and temperature, it begins to soften, 
soon sloughs, and exposes the subjacent portion 
of the tumour whose circulation had been similarly 
modified, softened, and deprived of its vitality, to 
a greater or less depth. The edges of the solution 
of continuity of the skin when first formed are 
sharp and irregular; they are not everted,- they 
are, on the contrary, sometimes inverted; and 
their thickness is in proportion to the depth of the 
slough. The peculiarity of form assigned to 
them is produced by the subsequent development 
of the carcinomatous substance situated beneath 
them, which, being entirely freed from pressure 
all round their internal margin, necessarily projects 
forward, as it grows, towards the centre of the 
tumour hollowed out by the softening and slough- 
ing process, and, consequently, carries them gra- 
dually upwards and backwards. They acquire 
at the same time a great accession of bulk, and 
form a rounded undulating border, beneath which 
the skin is found doubled upon itself, encircling 
the carcinomatous excavation. 

All these changes, viz. congestion, hemorrhage, 
softening and sloughing, which we have described, 
take place in both species of carcinoma. In 
scirrhoma, however, they originate in the vascular 
system of the tissues included within the carcino- 
matous substance, but are not on that account 
less frequent and destructive than those which 
arise in the proper and collateral circulation in 
cephaloma. In general the softening is less com- 
plete, the hemorrhage not so considerable, and the 
sloughing more extensive in the former than in 
the latter. 

Softening may take place in any portion of a 
carcinomatous tumour, although it has been main- 
tained that the central portion is the primary seat 
of this change. Instead of being softer, the centre 
of the tumour is often much harder than any 
other portion of it. In such cases it consists of a 
nucleus of firm, grey, semi-tiansparent substance 
and obliterated blood-vessels, forming a central 
depression, around which the rest of the tumour 
presents a radiating structure. The depression is 
not observed unless when the tumour is divided, 
or is situated on the surface of an organ, as the 
liver, where tumours of this kind are generally 



SCIRRHUS. 



93 



met with. In the former case the depression 
arises in consequence of the softer substance, after 
the division of the tumour, raising itself by its 
elasticity above the unyielding nucleus ; in the 
latter it is produced by the peritoneum adhering 
to the surface of the tumour when small, and pre- 
venting its development in that direction. If the 
lumour does not come in contact with the perito- 
neum until it has acquired a considerable size, it 
presents no such depression, or only a very small 
one. Hence the reason why, in carcinoma of the 
liver, we meet with some tumours having a 
smooth globular surface, and others with a central 
depression of greater or less extent. 

Nerves have never been detected in any of the 
varieties of carcinoma as a new formation. They 
are sometimes included within agglomerated 
tumours, or even in a single tumour that has hap- 
pened to form in a situation through which they 
puss. It is on this account that some pathologists 
have supposed the carcinomatous matter to be 
supplied with nerves : and M. Maunoir of Geneva 
(Loc. cit.) hazarded the opinion that cephaloma, 
no doubt from its frequently resembling the sub- 
stance of the brain, is in reality this substance 
effused by the nerves when under the influence 
of some peculiar morbid state ; an opinion to the 
accuracy of which the facts related in the preced- 
ing pages do not leave even the semblance of pro- 
bability. 

The last circumstance connected with the 



pathological anatomy of carcinoma to which we 
shall allude, is the development of the subcutane- 
ous venous system sometimes so conspicuous 
when the disease affects the breast in the form of 
a tumour, or any other external part where the 
skin is capable of considerable extension. The 
dilated and varicose state of these veins is simply 
the consequence of the mechanical obstacle occa- 
sioned by the tumour to the venous circulation in 
its vicinity, and not the result of any special in- 
fluence exercised by the disease. It is produced 
by tumours of every description, similarly situated, 
— fatty tumours and even cysts, and cannot there- 
fore be considered as furnishing any evidence of 
the existence of carcinoma in particular. 

The great difficulty generally experienced by 
physicians in distinguishing carcinoma under the 
various forms which it preser+ts in the different 
stages of its development, and in different organs 
of the body, will, we trust, furnish a sufficient ex- 
cuse for our having given such a lengthened de- 
scription of what strictly relates to the anatomy 
of the disease. If we have not succeeded in con- 
veying a clear impression of this part of our sub- 
ject, much assistance may be derived by consult- 
ing the coloured plates of the second and third 
fasciculi of the author's work on the Elementary 
Forms of Disease. 

[In a recent work, already referred to, Dr. 
Walshe has thus classified the genus cancer or 
carcinoma : 



GENUS CANCER OR CARCINOMA. 



Species. 



Varieties. 



Common vascular sarcoma, j «„„„„_.. 
Mammary sarcoma? \ ABERNET 

Solenoid. Recamier. Zang. 
Nephroid. Idem. 
Enccphaloid ^ Napiform. Idem. 

Carcinoma fasciculatum vel hyalinum. 

LER. 

Fungus nematodes. Hey. 
Hemalode cancer. Auct. Gall. 



Scirrhus 



Pancreatic, sarcoma ? Abernethy. 
Napiform. ) „ 

J n| ,' 1|i(|mi(I JRECAMtER. 

j Lardaceous tissue. Acct. Gall. 
Carcinoma reticulars. Mueller. 



Colloid 



5 Pu 

•jPe; 



Itaceous cancer. j 
arly alveolar ditto. ' 



Croveilhier. 



Syvonyms of the Species. 
Spongy or ossivorous tumour. Rcjysch. J 

LETTA. 

Struma fungosa (testis). Callisen. 
Spongoid inflammation. Burns. 
Milt like tumour. Munro. 
Medullary sarcoma. Abernethy. 
Cerebrifonn disease or cancer. Laennec. 
Pulpy testicle. Daillie. 
Carci nus spongiosus. Good. 
Carcinoma spongiosum. Young. 
Fungoid disease. A. Cooper. Modgkin 
Medullary fungus. Maunoir. Chelius. 
Acute fungous tumour. C. Bell. 
Medullary cancer. Travers. 
Cephaloma. Hooper. Carswell. 
Carcinoma medulla re. Mueller. 
Soft cancer. Auct. Var. 

Carcinomatous sarcnins. Abernethy. 
Carcinoma ecirrhosum. Young. 
Scirrhus cancer. Travers. 
Scirrhoma Carswell. 
Carcinoma simplex (ibrosum. Mueller. 
Stone cancer. Auct. Var. 

Areolar gelatiniform cancer. CruveilhieR. 
Carcinoma alveolare. Mueller. 
Gum cancer. Hodgkin. 



These three species of carcinoma are thus described in a tabular manner by Dr. Walshe. 



Encephaloid. 

Resembles tabulated cerebral mat- 
ter. 

I< commonly opaque from its ear- 
liest format'on. 

Is of dead white colour. 

Contains a multitude of minute 
vessels. 

Is less hard and dense than scir- 
rhus. 

Is frequently found in the veins 
issuing from the diseased mass. 

The predominant microscopical 
elements are globular, not always 
distinctly cellular, and caudate cor. 
puscula. 



Scirrhus. 

Resembles rind of bacon traversed 
by cellulo-fibrous septa. 

Has a a semitransparent glossi- 
ness. 

Has a clear whitish or bluish yel- 
low tint. 

Is comparatively ill-supplied with 
vessels 

Is exceedingly firm and dense. 



Has not been distinctly detected in 
this situation. 

The main microscopical consti- 
tuents are juxtaposed nuclear cells; 
caudate corpuscula do not exist in 
it. 



Colloid. 

Has the appearance of particles ol 
jelly inlaid in a regular alveolar htd. 

The contained matter is strikingly 
transparent. 

Greenish yellow is u predominant 
hue. 

(Its vessels have not been suffi- 
ciently examined as yet ) 

The jelly-like matter us txceedingly 
soft ; a coiloid 7nass is, however, firm 
and resisting. 

The pultaceous variety ;.as been 
detected in the veins. 

Is composed of cpIIs in » »i .to if 
emboitcment. 



94 



SCIRRHUS. 



Enccphaloid. 

Occasionally attains an enormous 
bulk. 

Has been observed in almost every 
tissue of the body. 

Very commonly coexists in several 
parts or organs of the same subject. 

Is remarkable for its occasional 
vast rapidity of growth. 

Is frequently the seat of intersti- 
tial hemorrhage and deposition of 
black or bistre-coloured matter. 

When softened into a pulp, ap- 
pears as a dead white or pink opaque 
matter of creamy consistence. 

Subcutaneous tumours are slow to 
contract adhesion with the skin. 

Ulcerated encephaloid is frequently 
the seat of hemorrhage, followed by- 
rapid fungous development. 



The progress of the disease after 
ulceration is commonly very rapid. 



Is the most common form under 
which secondary cancer exhibits it- 
self. 

Is the species of cancer most fre- 
quently observed in young subjects. 



Scirrhus. 

Rarely acquires larger dimensions 
than an orange. 

Its seat, as ascertained by obser- 
vation, is somen hat more limited. 

Is not unusually solitary. 

Ordinarily grows slowly. 

Is comparatively rarely the seat 

of these changes. 

Resembles, when softened, a yel- 
lowish brown semitransparent gela- 
tinous matter. 

Scirrhus thus situate usually be- 
comes adherent. 

Scirrhous ulcers much less fre- 
quently give rise to hemorrhage, and 
fungous growths (provided they re- 
tain the scirrhous character) are now 
more slowly and less abundantly de- 
veloped. 

There is not such a remarkable 
change in the rate of progress of the 
disease after ulceration has set in. 



Colloid. 
Observes a mean in this reFpect. 

Has so far been seen in a limited 
number of parts only, 
lias rareiy been met with in more 

than one organ. 

Grows with a medium degree of 
rapidity. 



Undergoes no visible change cf 
kind. 



Is much less common before pu- 
berty. 



Has so far been observed in adults 
only.] 

organs, such as both eyes, the mammce, testes, or 
kidneys, are affected at the same time. We have 
never met with carcinoma of the pancreas, muscu- 
lar, venous, and arterial tissues, serous, mucous, 
and fibrous membranes, without the disease being 
present in a neighbouring organ or tissue, and 
from which it was communicated to the former. 

The greater liability of some organs atid tissues 
than others to beeome affected with carcinoma is 
a circumstance of considerable practical import- 
ance. So, likewise, is its occurrence as a primary 
more frequently the pyloric than the cardiac ori- and secondary affection. In this latter respect the 
fice ; it much more often affects the stomach than disease may be secondary only as regards the order 
the oesophagus or intestines ; the large than the of its appearance, the same morbid condition of 
small intestines. In the latter, it is rarely metj the economy which gave rise to it in one organ 
with, and perhaps only in the duodenum and com- giving rise to it in the others, which become suc- 



liocal and other relations of Carcinoma. 

— There are no organs, and few tissues, which 
may not become affected with carcinoma. Among 
the former, the stomach, liver, uterus, breast, and 
testes, are much more frequently the seat of the 
disease than any of the other organs of the body. 
It is also worthy of remark that it is met with 
more frequently in certain portions of organs and 
systems than in others. Thus, when it affects 
the uterus, it is almost always the os tinea? in 
which it commences ; in the stomach it is much 



mencement of the jejunum ; and in the former it 
is exclusively confined to the rectum, sigmoid 
flexure of the colon and ileo-csecal valve, unless 
when propagated from a neighbouring organ by 
contiguity of tissue. 

If we pass in review the several tissues subject 
to carcinoma, we find that the cellular is infinitely 



cessively affected ; or it may be secondary in one 
organ in consequence of the intimate physiologi- 
cal connection existing between it and anothei 
previously affected ; and, lastly, it may be secon- 
dary from mere contiguity of tissue. 

In the first case the secondary appearance of 
the disease is recognised partly by the extent 



more so than any of the other tissues in which I which it occupies, and partly by the physical and 
the disease occurs, although we have proved that I anatomical characters which it presents in the 
'is far from being so frequently the seat of the different organs in which it is present. By the 



• lisease as was, and still is, generally believed. 
The mucous and cutaneous tissues are the next in 
the order of frequency, and lastly the osseous, ve- 
nous, and arterial. We have never observed the 
disease in cartilage, tendon, or ligament; but we 



same means, and more especially in consequence 
of two or more organs being found to be much 
more frequently than others affected with the dis- 
ease, we infer that its propagation in the former 
is influenced by the intimate physiological con- 



lave shown, when treating of the mode of its nection which is known to exist between them, as 
formation in the stomach, that, contrary to the j is exemplified in carcinoma of the uterus and 
general opinion, the muscular tissue of this organ ! mammas, and of the liver and stomach succeeding 
is frequently the seat of it. 1 10 eac h other. The secondary production of car- 

I he number of organs that may become affected cinoma from contiguity of tissue whether of a 
with carcinoma in the same individual varies similar or dissimilar kind, is frequently observed; 
considerably. In some cases there may be only \ such as the gradual extension of the disease from 
vne organ or tissue affected with the disease, as the walls of the stomach to those of the intestines, 



the stomach, intestines, oesophagus, liver, lungs, 
kidney, uterus, testis, breast, brain, eye, tongue, 
chin, cellular tissue, lymphatic glands, bone, capil 
laries, and veins. In other cases it m 



and from the latter to the parietes of the abdomen; 
from the stomach to the liver ; from the uterus to 
the bladder or rectum, and vice versa. But in all 



ay be found these cases the contiguous tissues and orga 
11 a great many organs- and t.ssues in various come united or continuous before the disease 
'*eo of its progress. It v seldom that double passes from the one to the other, which is then 



SCIRRHUS. 



95 



propagated by the gradual molecular deposition 
of the carcinomatous matter, in the same manner 
as we see it accomplished in the skin during the 
ulcerative stage of the disease. 

An opinion very different from that we have 
now given respecting the secondary production 
of carcinoma has long been entertained, chiefly by 
surgeons. Finding, as they frequently must have 
done, cancer in an internal organ which had given 
no signs of its presence until after it had existed 
for a greater or less length of time in some exter- 
nal part, they considered the production of the 
in the former situation to be subsequent to 
that in the latter, and to arise in consequence of 
the absorption of a specific virus from the sup- 
posed primary disease, and its transmission into 
the system. This opinion was strengthened by 
the fact that symptoms of cancer of an internal 
organ frequently make their appearance soon after 
the hreast, testicle, or other external part has been 
removed by a surgical operation, and was consi- 
dered as fully confirmed by another fact, viz. that 
the lymphatic glands situated in the vicinity of a 
cancerous tumour or ulcer are seen to become 
affected during the progress of the primary dis- 
ease. We shall only remark with regard to this 
view of the secondary production of carcinoma, 
that the facts adduced are far from justifying the 
application which has been made of them ; for 
they furnish no proof that the occurrence of the 
disease internally, at any period subsequent to its 
existence externally, may not depend on the same 
morbid condition of the economy producing its 
effects successively or simultaneously, in a greater 
or less number of organs, inasmuch as we know 
that carcinomatous tumours may exist for a con- 
siderable period, even in the most important of the 
internal organs, without giving rise to any appre- 
ciable modification of function calculated to lead 
to their detection. Hence, under whatever cir- 
cumstances the signs of carcinoma may present 
themselves for the first time in an internal organ, 
we cannot determine either the length of time it 
may have existed, or the relative order of its suc- 
cession. Besides, the extension, as it is called, 
of carcinoma from the breast or testis, for exam- 
pic, to the neighbouring lymphatic glands, affords 
no proof that it takes place through the medium 
of absorption ; for we have found these glands in 
the axilla, and in the lumbar region, extensively 
diseased in carcinoma of the breast and testis, 
without any of the carcinomatous matter of which 
all these were composed being visible in the 
lymphatic vessels passing from the one to the 
other. The more natural explanation of the oc- 
currence of the disease in these glands in such 
cases is, that, being subjected to the irritation 
which accompanies the latter stage of the disease, 
(the period at which the lymphatic glands are 
generally observed to become affected,) they be- 
come the seat of congestion, and, as we have 
already endeavoured to show, the matdial ele- 
ment of carcinoma being contained in the blood, 
it is separated from this fluid and deposited in 
their substance. 

We arc, however, well aware that there are 
cues in which this matter is absorbed and accu- 
mulates in the lymphatic glands; but from the 
circumstance just stated, and from the fact already 



noticed that these glands may be the only organs 
in the body in which, after the most careful ex- 
amination, the disease is found to exist, we are 
surely not entitled to say that they are always 
secondarily affected, whatever signification we 
may attach to this term. We have seen several 
instances of cephalomatous tumours formed exclu- 
sively in the mesenteric glands and abdominal 
lymphatic glands ; and in one case the latter 
glands of the principal regions of the body, on 
both sides of the neck and under the jaws, in the 
axillse and groins, in the chest and abdomen, were 
extensively affected with the disease, and forming 
tumours varying from the size of a cherry to that 
of an egg. The spleen was the only other organ 
which presented any trace of the disease. 

Carcinoma is a disease which is far from being 
equally frequent at the different periods of life. 
It is observed to make its appearance most fre- 
quently in the male from between thirty to forty 
or fifty years of age, and in the female after the 
cessation of the menstrual discharge, than at any 
other period of life. It is also on account of the 
more complicated nature of the organs of repro- 
duction in females that they are more subject to 
the disease, generally considered, than males; for 
the uterus and mammse are the organs which, in 
the former, are most frequently the seat of the 
disease. In the latter it rarely makes its appear- 
ance in the breast, and not so frequently in the 
testes as in the uterus. The stomach and liver 
are, according to our own observations, the most 
frequent seat of the disease in males, although 
these organs are, perhaps, equally so in females. 
The tongue, and especially the lips, are oficn 
affected in the former, and rarely in the latter. 
It is also worthy of remark that from childhood 
up to the age of puberty, and even to twenty or 
twenty-five years of age, we seldom meet carci- 
noma unless in particular organs or regions of the 
body. Thus it is chiefly the lymphatic and me- 
senteric glands, the great joints, as the elbow and 
knee joints, the brain, and cellular tissue, where 
it is considerable in quantity ; whereas the sto- 
mach, intestines, uterus, and mamma; are almost 
exempt from the disease till a later period of life. 
And it is interesting to observe that the exceptions 
to its non-occurrence in these latter organs within 
the period alluded to are met with in such of them 
only the exercise of whose functions are suscepti- 
ble of being prematurely and preternaturally ex- 
cited, particularly the testes and ovaries. 

These remarks on the relative frequency of car- 
cinoma under the circumstances of age and sex 
apply to the disease, generally, and not to both 
species and their varieties ; for while scirrhoma is 
rarely met with within the period which we have 
specified, cephaloma is of frequent occurrence, and 
seldom proceeds to such an extent or with such 
rapidity in advanced as in early life; a circum- 
stance which may probably depend on the greater 
activity of nutrition and the more plastic quality 
of the blood in the latter than in the former condi- 
tion of life ; and thus also a corresponding charai 
ter may be given to the morbid products which 
manifest themselves in each. 

The frequency of carcinoma is said to be con- 
siderably influenced by temperament. Thus ou 1 
of forty -four cases of the disease in whi^ 1, ** ori*. 



fly 



SCIRRHl'S. 



nal temperament was sufficiently characterized, 
Breschet and Ferrus found the lymphatic to pre- 
vail twenty times, the sanguineous twelve, the 
bilious eight, and the nervous two; and in almost 
all the patients submitted to their observations, the 
lymphatic temperament had acquired a marked 
predominance during the progress of the disease. 
(Diet, de Med. t. iv. art. Cancer.) 

The observation of carcinoma in individuals 
of different kubits and modes of life submitted to 
the influence of various external agents arising 
out of locality, profession, or climate; in the mar- 
ried and unmarried ; in women who have or who 
have not had children ; in the poor and wealthy; 
in the temperate and debauched, &c. &c. has not 
led to very satisfactory results regarding the rela- 
tive frequency of the disease. It is, however, said 
that it is as rare in peasants and country-people 
in general, as it is common among the inhabitants 
of large cities; and that it is more frequent in 
the lower and higher than in the middle classes 
of society. 

Causes and nature of Carcinoma. — The 
observations which we have made on the relative 
frequency of carcinoma as to age, sex, tempera- 
ment, and condition of life, contain the greatest 
part of what we have to say on the predisposing 
causes of the disease. Among these have long 
been enumerated the frequent and direct operation 
of irritating substances ; external injuries, espe- 
cially blows; the abuse of stimulating potions; 
immoderate indulgence in venery ; the depressing 
influence of moral afflictions; bad food, conjoined 
with the debilitating effects of cold and otherwise 
unhealthy habitations; the injurious influence of 
one or more of these predisposing causes on par- 
ticular organs being determined or modified by 
the individual or accidental circumstances of the 
case. The frequent occurrence, however, of car- 
cinoma in individuals in whom none of these 
predisposing causes seem to have co-operated in 
the production of the disease, as well as its non- 
occurrence in many who have been subjected to 
the influence of these causes, has led many pa- 
thologists to consider it as having an hereditary 
origin. They believe that the germ of the malady, 
or cancerous virus, is transmitted from the parent 
to his offspring, and cite, in favour of their opinion, 
the occurrence of the disease in several members 
of the same family. This opinion, however, has 
few advocates, particularly since Alibert, (De- 
scription des Maladies de la Peau, p. 118,) Biett, 
and Dupuytren (Diet, des Sciences Medicales, t. 
ili. p. 677,) have shown that the carcinomatous 
matter may be introduced in the form of inocu- 
lation into the digestive organs, the serous cavi- 
'ies or veins, without giving rise to the disease ; 
experiments, it may be remarked en passant, to 
which no more importance can be attached than 
to the fact that the disease may occur in several 
individuals of the same family. A more generally 
received opinion, and one much more in accord- 
ance with the results of accurate observation, is, 
that the manifestation of the disease is at all times, 
and under all circumstances, dependent on the 
.revious existence of a peculiar state of the con- 
stitution, either congenital or acquired, termed 
diathesis. The evidt ice on which this opinion 
rests -ve hive in grea art already exposed when 



treating of the seat, local origin, and mode of 
formation of carcinoma. We have shown that 
the material element of the disease — without 
which it can have no existence— is contained in 
the blood, is separated from this fluid after the 
manner of nutrition or secretion, either m the 
molecular structure, or on the free surface, of 
organs ; and that, while the formation of the dis- 
ease is thus going on, there may be no apprecia- 
ble physical or physiological modification of the 
part in which it is observed. It is thus that we 
meet with carcinomatous tumours in the brain, 
which, from their bulk and other characters, must 
have existed long before the functional disturb- 
ance of the organ gave signs of their presence ; 
and we have an equally striking example of the 
silent development of these tumours in the eye, 
until, acting simply as a foreign body, they ob- 
struct the rays of light, and render vision more or 
less imperfect. In persons, too, apparently in the 
enjoyment of the most perfect health, we often 
see the disease making its appearance in the form 
of a small pimple, proceeding more or less rapidly 
in its course, extending in breadth and in depth, 
and terminating ultimately in death, in spite of 
all the means which art has devised. In others, 
a similar pimple arises under similar, or even un- 
favourable, circumstances, proceeds like the former 
to ulceration ; and although it may have been 
neglected, irritated, and excited from time to time, 
and maltreated in every possible way, disappears, 
and leaves the patient in perfect health. There 
is, indeed, no form of inflammation which may 
not exist for any definite length of time, and in 
every organ of the body, without being followed 
by carcinoma. Of the truth of this position every 
candid inquirer must be fully aware, although it 
is still attempted to support the unphilosophical 
theory which maintains that this disease is always 
preceded by chronic inflammation. It would, 
however, be a great practical error were we to 
overlook the influence of this pathological state 
on a constitution predisposed to carcinoma; for 
this disease does make its appearance in organs 
which we have every reason to believe would not 
have become affected with it, had they not been 
previously modified by the former. We must, 
therefore, conclude that, if carcinoma makes its 
appearance in individuals, however they may 
have been placed in regard to the operation of 
what are called predisposing and exciting causes, 
there must be present in such individuals a pecu- 
liar condition or disposition of body, previous to 
the manifestation of the disease. In what this 
disposition consists, we are entirely ignorant. Its 
very existence is made known to us only by 
means of the peculiar characters of the products 
to which it gives rise. We have certainly seen 
that the great function of nutrition is that which 
is more especially affected, and that, as the mate- 
rial element of carcinoma is contained in the 
blood, it is highly probable that a modification of 
this fluid constitutes the primary if not the essen- 
tial condition of the formation of the disease. 
But, unacquainted as we are with the nature of 
nutrition as a physiological function, we can offer 
no explanation of the nature of the change ef 
lected in the blood, nor, consequently, of the 
nature of carcinoma. It is, however, an interest- 



SCIRRHUS. 



97 



ing fuct, — the result of our anatomical researches 
in particular, — that, as carcinomatous formations 
derive the materials of which they are composed 
from the blood, instead of their being local trans- 
formations or degenerations of pre-existing tis- 
sues, they do not, in this point of view, form an 
exception to the law, viz. that the natural and 
he.iltliy solids, as well as the fluids of secretion, 
derive also their respective materials from the 
same source ; and, therefore, we are led to hope 
that a more intimate knowledge of the manner in 
which these two functions are performed will 
enable us, at some future period, to determine the 
nature of a disease which hitherto has only been 
rendered more obscure by the attempts which 
have been made to explain it. 

[For some excellent observations on the etiology 
of Cancer, see the work of Walshe, already cited.] 

Symptoms of Carcinoma. — Considered in 
a general point of view, the symptoms of carci- 
noma refer to changes taking place during the 
progress of the disease, as they occur in the carci- 
nomatous substance itself, in the organs in which 
it is contained, and in remote organs or the con- 
stitution generally. The symptoms are therefore 
local or general. The former are referable to 
changes in the bulk, consistence, form, colour, 
temperature, sensibility, circulation, nutrition, and 
special functions of the organ affected ; the latter 
to changes in the functions of circulation, nutri- 
tion, and innervation in general. Both series of 
phenomena are greatly modified by the seat, stage, 
or period of the disease. They present also marked 
differences in the two species of carcinoma, those 
observed in the first species being often absent in 
the second ; or, being present in the former from 
the commencement, either do not occur in the 
latter at all, or only towards its termination. We 
shall pass in review the local and general pheno- 
mena which accompany the presence of carcinoma 
in those organs the disease of which belong more 
especially to the province of medicine. 

Local symptoms. — Few of the changes to 
which we have referred the local symptoms of 
carcinoma are discoverable in internal organs, and 
all of them may be absent in the early stage of 
the disease. Changes in the colour, temperature, 
circulation, and nutrition of the affected organ, 
cannot be detected by direct observation ; and 
those of bulk, consistence, and form, can be de- 
termined only in certain organs, and at a more or 
less advanced period of the disease, such as the 
stomach and intestines, liver, spleen, kidneys, 
ovaries and uterus, lungs, and mesenteric glands ; 
in all of which organs these changes may be re- 
cognised either by the touch, percussion, or aus- 
cultation. But it is more particularly the change 
of bulk which is detected by these means, and 
which, as a local symptom of the presence of car- 
cinoma, is that to which the greatest importance 
is to be attached. The increase of bulk which 
accompanies the presence of carcinomina is not 
perceptible till the disease has made some pro- 
gress. It is most considerable in solid organs, 
such as the liver, kidney, ovary, &c, and is sel- 
dom very marked in hollow organs, such as the 
stomach or intestines. Considerable increase of 
bulk may, however, have taken place in the walls 
of the stomach and intestines, without our being 
Vol. IV.— 13 i 



able to detect its presence, which happens when 
the carcinomatous matter accumulates in the 
direction of the internal surface of these organs. 
In such cases an increase of bulk of a different 
kind is produced, viz. dilatation, in consequence 
of the obstacle presented by the carcinomatous 
matter to the passage of the food or faeces. When 
dilatation of the stomach is thus produced, the 
obstacle is situated at the pylorus ; when of the 
small intestines, it is, in the great majority of 
cases, situated at the termination of the duodenum 
or commencement of the jejunum, and caput cae- 
cum coli ; and at the sigmoid flexure of the colon 
and rectum, when the dilatation occupies the 
large intestines. The increase of bulk which the 
stomach and intestines acquire in consequence of 
an obstacle of this kind is sometimes very great. 
In some cases of scirrhus pylorus, the stomach has 
been found to occupy the greater pari of the ab- 
dominal cavity, stretching down to the symphysis 
of the pubis, and from one lumbar region to the 
other; and the large intestines sometimes measure 
from four to six inches in diameter, when similarly 
affected. We have seen the small intestines equal 
in size to the ordinary dimensions of the stomach. 
It is important to know that the extent of the 
dilatation is not to be taken as the measure of 
the extent of the disease. The greater the dilata- 
tion the greater we may infer is the obstacle by 
which it is occasioned ; but this obstacle may con- 
sist in a slight scirrhous enlargement, which pre- 
vents the passage of the food or faeces as effectu- 
ally as when it is occasioned by one or more 
tumours of considerable size, or great thickening 
occupying several inches in length of the whole 
circumference of the walls of the stomach and in- 
testines. 

There are two circumstances connected with 
the dilatation of these organs from carcinoma 
which merit particular notice. The first is the 
disappearance of the dilatation at a particular 
period of the disease. This may happen a con- 
siderable time after the dilatation was first per- 
ceived, and is the consequence of the destruction 
of the carcinomatous substance from softening, 
ulceration, or sloughing. The obstacle being thus 
removed, a free passage is opened to the accumu- 
lated contents of the stomach and intestines, and 
the dilated walls of these organs are allowed to 
contract, and in some instances regain their na- 
tural dimensions. The second circumstance is the 
re-occurrence of the dilatation, which we have 
observed to take place only in the intestines. It 
does not occur, unless the mucous and muscular 
coats have been destroyed by ulceration, after the 
destruction of the carcinomatous substance, and 
not until cicatrization has commenced. The cica- 
trix being formed of cellulo-fibrous tissue, contracts 
and produces stricture of the intestine. The pas- 
sage of the faeces is again obstructed, and the 
intestine acquires an increase of bulk much greater 
than before the destruction and removal of the 
carcinomatous substance. We shall again allude 
to these changes in bulk when speaking of the 
modifications of function, and the diagnosis of 
carcinoma in the digestive organs. 

The increase of bulk which accompanies car- 
cinoma of the liver is often very considerable. 
Cases have been met with in which the left lob* 



98 



S C I R R H U S . 



of the liver extended into the left hypochondrium, 
and the right down to the iliac fossa on the same 
side. It is always produced in this organ by the 
accumulation of the carcinomatous matter in the 
form of tumours, which may often be felt pro- 
jecting above its surface. It is chiefly from this 
latter circumstance that we are enabled to detect 
carcinoma of the liver. It is, however, necessary 
that the tumours should occupy the convex sur- 
face of the liver, and that this organ should pro- 
ject beyond the false ribs. 

In one instance only have we found the spleen, 
when affected with carcinoma, much increased in 
size ; it was nearly six times larger than natural. 
We have also found the kidney enlarged to the 
same extent in a young person, but it is seldom 
more than twice its natural size in this disease. 
Carcinoma of the uterus is not accompanied by 
any perceptible increase of bulk, unless examined 
per vaginam, when, in the early stage of the dis- 
ease, the os uteri is found enlarged and projecting 
into the vagina. The ovaries acquire the size of 
the fist or even of the head of a child, but never 
become so large as when they are the seat of 
dropsy, or contain fibrous tumours. We have 
never seen the bulk of the lungs so increased by 
the presence of the carcinomatous deposit as to 
give rise to dilatation of the walls of the chest. 
We have already noticed the great increase of 
bulk which accompanies carcinoma of the mesen- 
teric and lymphatic glands. 

The only modification of the sensibility which, 
as a local symptom, accompanies carcinoma, is 
that of pain. There is, however, no symptom of 
carcinoma more deceptive than pain. The im- 
portance attached to it, more particularly when it 
possesses a lancinating character, must have 
originated in the study of the disease in external 
parts of the body, as the face, breast, or the skin 
and subjacent tissues in general ; for there are 
several organs in which the pain is either very 
slight or seldom acquires the lancinating character 
ascribed to it: such is the case in carcinoma of 
the liver, spleen, kidneys, ovaries, stomach and 
intestines, (with the exception of the rectum,) the 
mesenteric glands, and even the brain. It is also 
to be remembered that pains, described by patients 
as lascinating, may occur without any trace of 
carcinoma being found in the organs to which 
they are referred. 

Of all the varieties of carcinoma, it is that of 
scirrhus which is most frequently accompanied 
with pain ; and it is also in this variety that the 
pain is most severe, acute, and lancinating. In 
medullary sarcoma this symptom is less frequent 
and severe than in any of the other varieties. 
But it is not according to the several varieties of 
carcinoma that we are to form an estimate either 
of the frequency or severity of the pain. For 
this symptom may, in both these respects, be said 
to vary with the degree of induration of the car- 
cinomatous substance ; of the distension or com- 
pression, and of irritation to which this substance 
gives rise in the neighbouring tissues. Under the 
influence ot the two former of these conditions, 
pain would seem to result from compression of 
tne nerves which happe" to be included within 
the dense carcinomatous substance, or that are 
distributed in its immediate vicinity. Pain from 



irritation may also be produced under similar or- 
u ns.a,,ces, but it is much more frequently when 
softening and sloughing of the carcinomatous 
substance, and ulceration of the neighbouring 
tissues, have taken place, that pain from his cause 
makes its appearance, and acquires a degree of 
severity which gives rise to the most intolerable 
suffering. It is in this stage of the disease that 
pain occurs in internal organs, in consequence of 
the extension of the irritation to the nerves of 
sensation. 

The pain may be intermittent, remittent, and 
continued, whatever may be the organ affected 
with carcinoma. The intermittent character is 
most frequently observed during the early stage 
of the disease ; and the remittent and continued 
during the progress of softening, sloughing, and 
ulceration. Numerous circumstances concur to 
produce these varieties in the duration of the pain 
in carcinoma ; but in the great majority of cases 
they appear to depend on varying and opposite 
states of the sensibility and circulation of the af- 
fected organs. For we know that the direct 
application of those means which increase the 
sensibility and circulation excite, in an organ 
affected with carcinoma, pain when absent, and 
increase it when present ; whilst those remedies 
which are known to diminish the sensibility and 
the action of the vascular system, effect also a 
diminution or an entire cessation of the pain in 
this disease. 

The symptoms which depend on the modifica- 
tions of the functions of organs affected with 
carcinoma, are far from being so conspicuous as 
the fatal character of the disease would lead us to 
suppose. We allude to the special modifications 
of function observed in carcinoma of internal 
organs. Before taking a general view of these 
modifications of function, we may remark that 
there is not one of them which may not be found 
to accompany other diseases than carcinoma. 
They nevertheless require to be studied with great 
care, because of the effects to which they give 
rise being sometimes more intolerable than the 
disease itself, and requiring a separate mode of 
treatment. 

The modifications which are observed to occur 
in the special functions of organs, present great 
variety not only in different organs, but also in the 
same organ, according to the stage, extent, and 
situation of the disease. Thus the function of 
digestion is not so frequently disturbed in the 
early as in a more advanced stage of the disease, 
nor is the disturbance so great in the former as in 
the latter case. This difference in the effects of 
carcinoma on the function of digestion may be 
explained on the following principles, viz. that the 
carcinomatous substance, when first deposited, acts 
merely mechanically, and therefore does not inter- 
fere with the function of digestion, unless it oc- 
cupies a great extent of the walls of the stomach, 
or prevents the egress of the digested food; 
whereas during its subsequent development, this 
substance undergoes those changes which we have 
already described, viz. softening, sloughing, and 
ulceration. The absence of irritation in the 
former case, and its presence in the latter, fur- 
nish an obvious reason why digestion is seldom 
disturbed in the one case, and more frequently and 



SCIRRHUS. 



99 



lo a greater degree in the other. The influence 
of carcinoma as to extent and situation, over the 
function of digestion, is very great. A carcino- 
matous tumour of from three to four inches in 
diameter, and projecting from one to two inches 
above the mucous membrane of the stomach, if 
situated at the small or large curvature, may be 
accompanied by but a very slight derangement 
of the function of digestion ; whereas a tumour 
not larger than a filbert, situated at the pyloric 
orifice, may disturb this function to an extreme 
degree. It is, indeed, very often in consequence 
of the mechanical operation of carcinoma pre- 
venting the egress of the food or chyme, that we 
are first led to detect disorder of the function of 
digestion, and to suspect the nature of the disease 
on which it depends. In such cases more or less 
of the digested food is retained ; the succeeding 
meal is partially or imperfectly digested ; the sto- 
mach becomes distended, and being irritated by 
the continual contact of its contents, rendered 
more stimulating by decomposition or fermenta- 
tion, contracts forcibly, and they are rejected by 
vomiting. Vomiting is an invariable consequence 
of carcinoma of the pylorus, accompanied with a 
diminution of bulk of the orifice of this part suf- 
ficient to interrupt or impede the exit of the 
chyme or indigested food. Perhaps the most fre- 
quent cause of vomiting is the mechanical obsta- 
cle occasioned by the carcinomatous substance in 
the pyloric portion of the stomach. This modifi- 
cation of the function of the stomach as a me- 
chanical effect, we have never observed in carci- 
noma of any other portion of this organ. Vomiting, 
however, frequently occurs, whatever may be the 
situation of the disease, in consequence of the 
irritation which accompanies the softening pro- 
cess, and the ulceration by which it is followed. 
Vomiting from irritation may, in general, be dis- 
tinguished from that occasioned by a mechanical 
obstacle situated at the pylorus. The former 
takes place however small the quantity of fluid 
taken into the stomach ; the latter, only when the 
quantity is considerable. Vomiting from irrita- 
tion is sudden, and accompanied by a disagreeable 
or painful effort; that from a mechanical obstacle 
gradual, and instead of being accompanied by 
pain, frequently affords relief from this state or a 
considerable degree of uneasiness. It is in this 
case a kind of passive act, the consequence of the 
great dilatation of the stomach, and sometimes of 
the inferior portion of the oesophagus also. The 
presence of dilatation of the stomach, which is 
easily detected by percussion, will enable us to 
distinguish vomiting from a mechanical obstacle 
from that occasioned by irritation. 

The periodical character of vomiting is, in the 
great majority of cases of carcinoma of the sto- 
mach, to be attributed to the presence of a me- 
chanical obstacle at the pylorus. The vomiting 
occurs at certain intervals, which vary with the 
extent of the obstacle, the quantity and kind of 
food taken, and other necessary and accidental 
circumstances, as the susceptibility of the patient 
and the state of those organs which exercise a 
sympathetic influence on the function of digestion. 
In some cases of this kind, the vomiting, after 
having continued for several weeks or months, 
disappears for a considerable time before it recom- 



mences, and in other cases ceases entirely. We 
have met with examples in both cases, referable 
to opposite physical conditions of the pyloric ori- 
fice. In both cases the vomiting depended on the 
pyloric orifice being obstructed by thickening of 
its walls, or the presence of projecting or pendu- 
lous tumours ; and the partial or permanent ces- 
sation of this symptom, to the patency of this ori- 
fice being restored, in consequence of the destruc- 
tion of the carcinomatous substance. The return 
of the vomiting in the former case was owing to 
the return of the disease in such a form as to 
obstruct anew the exit of the contents of the sto- 
mach ; and in the latter, the entire cessation of 
this symptom was to be attributed to the progres- 
sive extension of the ulcerative and sloughing 
processes, and, consequently, the complete removal 
of the obstructing cause. 

The quantity and quality of the matters vom- 
ited are variable. Both will be modified by the 
quantity and quality of the food and drink; the 
former by the capacity of the stomach, and the 
absence or presence of irritation ; the latter by the 
nature of the ingesta, the state of digestion, and 
the stage and variety of the disease. It is only 
at the early stage of carcinoma, or at least before 
softening and ulceration have taken place, that 
the vomiting consists of a watery or mucous secre- 
tion. At a more advanced stage, the rejected food 
is less altered by the digestive process than before, 
and is often accompanied by a quantity of gas of 
a disagreeable odour. In the great majority of 
cases, and always towards the termination of the 
disease, the contents of the stomach rejected by 
vomiting contain a substance resembling the lees 
of wine, a mixture of chocolate, or soot and water. 
This substance may appear in the form of little 
particles, patches, or streaks, among the other 
matters vomited, or it may be in such quantities 
as to give to the whole contents of the stomach a 
deep brown or black colour. Its appearance al- 
ways indicates the effusion of blood into the cavity 
of the stomach from hemorrhage, either in conse- 
quence of the softening of the carcinomatous sub- 
stance, or the sloughing of this substance and of 
the contiguous parts. It is on this account re- 
garded as a fatal symptom, and as indicating the 
speedy termination of the disease. (The cause 
of the black colour of the effused blood we have 
already explained in the articles Mortification 
and Perforation.) It is also at this period that 
the odour of the breath and the rejected matter is 
most offensive ; and that the appetite, if not pre- 
viously much affected, is entirely lost, perverted, 
or replaced by a morbid craving for peculiar kinds 
of food. There is only one other circumstance 
connected with vomiting to which we shall allude, 
viz. the rejection of the food taken the previous 
day or even at a later period, whilst the last meal 
is retained. This kind of choice, as it would 
seem, of the stomach between fresh and digested 
food, is not frequently observed. We do not 
recollect to have observed it except in cases of 
carcinoma of the pyloric portion of the stomach. 

The modifications of the special functions of the 
intestines produced by carcinoma are in many re- 
spects very similar to those which we have described 
as occurring in the stomach. We have already 
noticed the mechanical influence of the disease ir 



100 



SCIRRHUS. 



preventing the passage of the food and faeces, the 
accumulation of the latter, and the subsequent 
dilatation of the intestine. In no other respect 
does carcinoma interfere with functions of the 
intestines, except when it gives rise to great irri- 
tation or inflammation of the mucous membrane 
and subjacent tissues, or when it terminates in 
sloughing and ulceration. Diarrhoea is the con- 
sequence of the former, and hemorrhage a frequent 
attendant on the latter of these morbid conditions. 
The rejection of fsecal matter by vomiting is not 
often observed in carcinoma of the intestines. 
The stools sometimes present the same melanotic 
character as the matters rejected by vomiting in 
the last stage of carcinoma of the stomach. They 
also indicate the last stage of the disease in the 
intestines, coincide with the appearance of the 
hemorrhage, and depend on the subsequent dis- 
coloration of the effused blood. 

Carcinoma of the liver may occur without any 
appreciable derangement of the special function 
of the organ being observed. We are disposed to 
believe that a suspension of the secretion of the 
bile very seldom occurs in the disease. In the 
great majority of the cases of jaundice which we 
have seen to accompany carcinoma of the liver, 
we have found the ductus communis choledochus, 
the hepatic duct or its principal branches, much 
compressed or obliterated by the carcinomatous 
substance in the form of large tumours. The 
same mechanical operation of these tumours on 
the trunk of the vena porta or its larger divisions 
in the liver, prevents the return of the blood of the 
chylopoietic viscera to this organ ; hence that form 
of ascites which always accompanies this state of 
the portal vessels. 

There is often no apparent alteration in the 
quantity or quality of the bile, even in the most 
extensive forms of carcinoma of the liver. This 
fact is determined not only by the colour of the 
fffices during life, but by the examination of the 
organ after death ; the substance of the liver pre- 
senting no unusual colour, and the gall-bladder 
being filled with bile of the natural consistence 
and colour. 

There is no apparent modification of the secre- 
tion of the urine in carcinoma of one of the kid- 
neys, although the disease may be so extensive as 
to leave no trace of the natural structure of the 
organ. We have never found both kidneys af- 
fected. On the contrary, the sound one is gene- 
rally larger than natural, and appears to supply 
by its increase of bulk or energy the place of the 
other, as the quantity of urine voided in a given 
time is not sensibly diminished. 

The much more frequent occurrence of carci- 
noma after than before the cessation of the men- 
strual discharge, prevents us from estimating accu- 
rately the influence which this disease exercises 
on the ■■lion of the uterus and ovaries. 

Impregnation, however, has been known to take 
olace in carcinoma of the os uteri, and of one of 
the ovaries. For farther information on carcinoma 
of the female organs of generation, see Uterus, 
Diseases of. 

Only a few remarks are necessary on the modi- 
fications of function which accompany carcinoma 
of the spleen, pancreas, mesenteric and lymphatic 
glands, epiploon, and serous membranes in gene- 



ral. With regard to the spleen, we have only to 
remark that its cellular organization may be com. 
pletelv effaced by the presence of the carcinoma- 
tous matter, and consequently it is rendered inca- 
pable of receiving more blood than is necessary 
for the nutrition of its solid parts, and the growth 
of the disease. Carcinoma of the duodenal ex- 
tremity of the pancreas, in consequence of the 
compression of the duct which passes in this 
direction, gives rise to an accumulation of the 
secretion of this organ, and great dilatation of the 
duct throughout its whole extent. It is in conse- 
quence of the increase of bulk of the pancreas 
which accompanies such cases, that we are some- 
times led to suspect retention of the secretion of 
this organ. Diminished or suspended absorption 
are the occasional consequences of carcinoma of 
the mesenteric and lymphatic glands. Emacia- 
tion, when attributable to no other cause, may be 
regarded as indicating the modifications of func- 
tion alluded to, of the former glands, and oedema 
of some external part, of the latter, both of which 
are rare occurrences, particularly oedema. An 
accumulation of the secretion of serous mem 
branes, and a greater or less degree of obstruction 
to the motions of the contained organs, are the 
functional derangements which accompany carci- 
noma of these membranes and of the epiploon. 
The latter, when affected with carcinoma, is gene- 
rally drawn up in the form of a thick irregular 
mass, and fixed to the stomach along its great 
curvature; or it is sometimes split into several 
portions attached above to the stomach, and below 
to the uterus, ovaries, or walls of the abdomen, 
forming so many thick bridles, which not only 
interrupt the motions of the intestines, but some- 
times pull the stomach downwards, giving rise to 
an uneasy dragging sensation in the latter organ, 
and a sense of tightness or constriction in the 
former. 

The function of respiration may be interrupted 
to such a degree by the mechanical presence of 
the carcinomatous matter, as to terminate in fatal 
asphyxia. We remember one case in particular 
of this kind. It occurred in a young man about 
twenty-five years of age, who, six weeks previous 
to his admission into hospital, performed the active 
duties of a soldier. He complained only of diffi- 
culty of breathing; he had a slight cough, fol- 
lowed occasionally by the expectoration of a small 
quantity of mucus. The difficulty of the respira- 
tion rapidly increased, and terminated in asphyxia, 
without the occurrence of fever or emaciation. 
Both lungs were nearly filled with large masses 
of the medullary sarcoma. The remaining pul- 
monary tissue was compressed, but not otherwise 
altered. This case affords a striking example of 
the mechanical effects of carcinoma, and the rapid 
and extensive development of the medullary va- 
riety of the disease. Carcinoma of the heart has 
been seldom met with to any great extent, and so 
far as we know, no particular modification of 
function has been observed to accompany its pre- 
sence. We have already minutely detailed the 
changes effected by this disease in the capillary 
and venous circulation. 

The functional lesions which accompany carci- 
noma of the brain, cerebellum, and spinal cord, 
vary considerably with the seat of the disease re- 



SCIRRHUS. 



101 



lative to these organs individually, as well as to 
particular portions of them. But in neither of 
these respects does it give rise to any symptom 
which can be regarded as pathognomonic of its 
presence. As a foreign body, it gives rise some- 
times to a degree of compression sufficient to pro- 
duce partial or complete paralysis ; loss of memory, 
or difficulty of speech ; and derangement of the 
intellectual faculties. But these latter changes 
depend principally on the irritation and softening 
of the substance of the brain in contact with 
the carcinomatous mass. Even paralysis is 
more frequently produced by these subsequent 
changes than by compression. We have met 
with two cases of medullary sarcoma of the cere- 
bellum, characterized by a remarkable develop- 
ment of the function ascribed to this organ by 
Gall. Both patients, young men, were between 
18 and 19 years of age. The left lobe of the 
cerebellum in one of them contained a carcino- 
matous tumour, of the variety mentioned above, 
js large as a hen's egg ; in the other the tumour 
was less, and projected from the centre of the 
cerebellum into the fourth ventricle. We could 
not ascertain how long they had practised the act 
of pollution, but both were emaciated and weak 
when admitted into hospital. One of these pa- 
tients was left to himself, and died about two 
months after his admission, in a state of extreme 
debility. The other lived nearly three weeks. 
When warned of the fatal consequences which 
must soon follow the practice which had already 
reduced him to a state of great misery, he declared 
that although he was conscious of the nature of 
his situation, it was not in his power to resist the 
influence under which he felt himself compelled 
to act. His hands were secured, but without the 
desired effect. As a last resource, the whole of 
the prepuce was removed, yet in this mutilated 
state he attempted to gratify the fatal propensity. 
He died a few days afterward, having had several 
severe convulsive attacks. 

Paralysis of the superior and inferior extremities, 
of the muscles of respiration, of the bladder and 
rectum, have been observed in carcinoma of the 
spinal cord. It is hardly necessary to observe that 
the seat and extent of the paralysis depend on 
the portion of the spinal cord occupied by the 
disease. 

General Symptoms. — The general symptoms 
of carcinoma do not make their appearance before 
the last stage of the disease. Their severity de- 
pends much on the nature of the organ, and the 
extent to which it is affected ; but it is principally 
the irritation produced by the presence of the car- 
cinomatous substance during the period of soften- 
ing, sloughing, and ulceration, that determines the 
gravity of these symptoms. It is in this, the last 
stage of the disease, that the circulation and inner- 
vation become deranged, and that fever and a 
diminution of the nutritive function are first ob- 
served. It is likewise at this period, but more 
frequently a few days or weeks before death, that 
the skin assumes a pale earthy, or dull ochry tint ; 
that debility and emaciation make rapid progress ; 
and all the functions of the economy become im- 
plicated in the deteriorating influence of the dis- 
ease. It is this group of the general symptoms 
which constitute what is called the cancerous ca- 

i* 



chexia. The febrile symptoms, as well as the 
diminution of nutrition, in general are greatest 
when the seat of carcinoma is the uterus or sto- 
mach ; and least in those organs, as the brain and 
lungs, in the former of which softening, and in 
the latter compression, may terminate in death, 
Defore either of these symptoms has become con- 
spicuous. General dropsy does not often occur, 
and is never great. Ascites frequently accom- 
panies carcinoma of the liver, for the reasons 
which we have already stated. Dropsy of the 
inferior extremities occurs more frequently in car- 
cinoma of the ovaries and uterus than of any 
other organ. It is the consequence of compres- 
sion of the iliac veins, but it may also be occa- 
sioned by the extension of the inflammation which 
accompanies the ulcerative stage of the disease to 
these vessels. Compression of the vena cava by 
tumours in the liver, or by the enlarged mesen- 
teric glands, may also give rise to the same state 
of the inferior extremities. 

Diagnosis* — It is not until carcinoma has 
made considerable progress, that we are sometimes 
able to recognise its presence in internal organs, 
by means of a careful consideration of the local 
and general symptoms which we have enumerated. 
We have had frequent occasion to remark how 
little importance is in general to be attached to 
any one of these symptoms taken individually. 
But when the local signs, viz. the changes in the 
bulk, form, and situation of organs, occasioned by 
the disease; its relative frequency in different 
organs and in particular portions of the same 
organ, are taken in connection with the special 
and general modification of function which may 
be present in individual cases, the greatest pos- 
sible assistance is afforded us in establishing the 
diagnosis. The degree of facility with which this 
important object may be accomplished, will de- 
pend on the number of the signs and symptoms 
present, and the possibility of detecting them by 
the means of investigation in our possession. 
Thus it is more easy to detect carcinoma of the 
stomach than of the lungs, of the latter than of 
the brain ; because of our being able to ascertain 
the presence of the greater number of the local 
signs of the disease in the first case, only a few 
of them in the second, and none at all in the 
third. And when the sense of sight can be ap- 
plied with that of touch and hearing, the diag- 
nosis seldom presents much difficulty, as in lh» 
case of carcinoma of the os uteri and rectum. 

It is necessary to observe that too much reliance 
is not to be placed on the presence of those genera', 
symptoms which constitute the cancerous cachexia , 
for there are morbid conditions of the stomach and 
duodenum, associated with derangement of the 
biliary secretion, which give rise to a state of de- 
bility and emaciation, accompanied with discolora- 
tion of the skin, which so closely resembles tho 
cancerous cachexia, that the one is not to be dis- 
tinguished from the other. The difficulty of estab- 
lishing the diagnosis in such cases is likewise 
increased by the circumstance that the same 
chronic character prevails in both. There is, 
therefore, no possibility of distinguishing between 
carcinoma of the stomach and such morbid condi- 
tions of the same organ, unless the lopal phenomn 
na of the former be very conspicuous. 



02 



SCIRRKUS. 



It is hardly necessary to remark that the presence 
of carcinoma in an external part of the body is to 
be regarded as a diagnostic sign of great importance, 
in all cases of a doubtful character in which 
functional derangement of an internal organ has 
existed for some time. In such a case we should 
regard the frequent occurrence of vomiting after 
meals as indicating the existence of carcinoma of 
the pylorus, even should no tumour be felt in this 
situation, or dilatation of the stomach. If the 
presence of a tumour were detected in any part 
of the abdominal cavity, we should not hesitate to 
say that it was of the same nature as the external 
affection ; and the occurrence of paralysis, under 
the same circumstances, would justify us in attri- 
buting it to carcinoma of the brain or spinal cord. 

We shall not, in this general article, attempt to 
determine how far it may be possible to distinguish 
carcinoma from other diseases to which internal 
organs, considered individually, are subject. Be- 
sides, in the description which we have given of 
the signs and symptoms of carcinoma, we have 
already endeavoured to point out those which more 
especially characterize the presence of this disease 
in individual organs. 

Prognosis. — In no disease is a fatal termina- 
tion so universally admitted as in carcinoma. The 
possibility of the cure of carcinoma of internal 
organs has never been supported by substantial 
evidence ; and the examples are few indeed in 
which we are disposed to believe that the disease 
has been removed from an external part by surgi- 
cal or other means, without its recurrence in the 
same or some other part of the body at some 
other future period. 

Treatment. — A host of remedies have been 
•proposed for the cure of carcinoma ; the greater 
number of them have been tried in almost every 
form of the disease, but they have nearly all failed 
to justify the high praises formerly bestowed on 
their curative virtues. Some of them, however, 
have been found to retard, if not to arrest the 
progress of the disease; and, what is of great im- 
portance, to alleviate the sufferings and prolong 
the life of the patient. We shall notice those 
remedies only, the successful administration of 
which has been rendered evident in carcinoma of 
external organs, as under such circumstances the 
nature of the disease is less likely to have been 
mistaken. We shall speak first of those remedies 
which effect a salutary change in the nutritive 
function of the affected organ, and thereby retard 
or arrest the progress of the disease; secondly, of 
those best calculated to prevent, remove, or mitigate 
the local and general effects to which it gives 
rise. 

1. The remedies which retard or arrest the pro- 
gress of carcinoma consist of those which exercise 
a direct or indirect influence on the nutritive 
function of the affected organ. Among the former, 
or those which operate directly, the local abstrac- 
tion of blood by means of leeches, and compression, 
hold the first rank. The first of these means 
should be employed for a considerable length of 
time, at intervals of one, two, or three days, and 
the quantity of blood taken should be regulated 
chiefly by the strength of the patient. The dimi- 
nution of bulk of the original tumour which follows 
this mode of treatment, is sometimes very consider- 



able. In the great majority of cases the tumour 
is not entirely removed. It may be reduced from 
the size of a hen's egg to that of a nut, and in 
this state remain stationary for years w.thout 
Kivine rise to pain or any inconvenience whatever. 
The alternate use of local bleeding and compres- 
sion effect more rapidly the reduction of bulk just 
noticed than when either is employed separately , 
but the former should, as a general rule, be always 
employed so as to produce a certain degree of 
indolency in the tumour, before the latter is had 
recourse to. 

The beneficial effect of pressure, first employed 
by Mr. Young, (Cases of Cancer, &c. London, 
1816,) has been satisfactorily determined by M. 
Recamier, one of the physicians of the Hotel 
Dieu of Paris. The following are general results 
obtained by this physician: — 

1st. Of one hundred patients treated by M. 
Recamier for carcinomatous affections, sixteen ap- 
peared to be incurable, and underwent only a 
palliative treatment. Thirty were completely 
cured by compression alone ; and twenty-one, 
submitted to the same means, derived considerable 
benefit from it. Fifteen got rid of the affection 
radically, by means of ablation alone, or chiefly 
by ablation combined with pressure ; and six by 
means of compression and cauterization. In the 
twelve remaining patients, the disease resisted all 
the means employed. 

2d. Tumours similar, or at least analogous to 
those which degenerate into incurable cancer, are 
cured by methodical compression, and some othei 
internal and external remedies. 

3d. When a tendency towards resolution of a 
swelling of the mammary gland, which has not 
yet degenerated, has been produced for a considera- 
ble length of time by means of compression, the 
resolution of the swelling continues even after the 
compression is no longer employed : but if the 
swelling has degenerated, and, after having ob- 
tained a great diminution of its bulk, compression 
be laid aside, the swelling may resume its former 
bulk, and its degeneration proceed with greater 
rapidity than before. 

4th. Compression may assist in preventing the 
return of cancer after ablation. 

5lh. The resolution of chronic inflammation is 
greatly favoured by compression alone, or com- 
bined with local bleeding, &c. 

6th. Various tumefactions of the neck of the 
uterus are resolved by compressing this part by 
means of a pessary in the form of a hollow cone 
terminating in an open olive-shaped extremity. 

7th. It is reasonable to hope, that if compression 
were employed at an early period, that is to say, 
before the degeneration of those tumours suscepti- 
ble of this mode of treatment, the resolution of a 
greater number of them would be obtained, and 
the necessity of the ablation of cancer of the 
breast, so frequently followed by a return of the 
disease, when not encysted, be greatly diminished. 
(Recherches sur le Traitement de Cancer, par M. 
Recamier, t. i. p. 474.) 

Although compression and local bleeding can- 
not be employed in the treatment of carcinoma of 
internal organs, properly so called, we have thought 
it proper to notice the results which M. Recamier 
states he has obtained by their external applica- 



S C I It R H U S. 



103 



Hon, as encouraging to the physician, and as af- 
fording a strong presumption that the cure of this 
disease, even in internal organs, is not altogether 
beyond the resources of his art. 

It is also in consequence of a modification of 
nutrition in general, and consequently of that of 
the affected organ, that the beneficial effects of 
some general remedies, in carcinoma of external 
organs, are chiefly to be attributed. Some of these 
remedies appear to modify nutrition by effecting 
some unknown change in the composition of the 
blood, as aconitum, conium, and arsenic ; others, 
by acting on the capillary circulation and absorp- 
tion, as mercury, in alterative doses, and various 
preparations of iodine. 

The beneficial effects of tonics, as preparations 
of iron, the fixed and volatile alkalies, mineral 
waters, such as those of Plombieres, Bareges, and 
Vichy, and all other remedies which increase the 
vital energies, invigorate digestion, and promote 
absorption and secretion, may also be referred to 
a favourable change induced in the nutritive func- 
tion of the affected organ, by the introduction of 
these remedies into the circulating system. 

The salutary operation of these local and gene- 
ral remedies is much increased by a judicious com- 
bination of both, regulated according to the cir- 
cumstances of individual cases. But while em- 
ploying any of these remedies, it is of the utmost 
importance to regulate the diet and regimen of the 
patient in such a manner that neither of them may 
interfere with the operation of the remedy em- 
ployed. M. Recamier, in the work already referred 
to, has shown that the curative virtues of conium, 
for example, depend greatly on the quantity of 
food consumed by the patient ; that is to say, the 
operation of this remedy was more or less power- 
ful when only a small quantity of food was allowed, 
and hardly perceptible when the quantity was con- 
siderable. While using the conium, he therefore 
restricts the patient to a severe diet ; and in this 
way he says he has succeeded in curing several 
cases of carcinoma of the uterus, liver, spleen, 
mamma?, testes, and of the extremities. The fol- 
lowing are the principles of the treatment: — 

1st. The patient takes a dose of the extract of 
conium, evening and morning, two hours before 
the first and two hours before the last meal. The 
amount of the first dose is half a grain, which is 
gradually increased to six grains each time. This 
dose is continued for a fortnight in order that the 
organs may become habituated to its operation, 
and is afterwards increased to twelve grains each 
time, beyond which it is not necessary to carry the 
remedy because of its influence being, sufficient. 
The twelve-grain dose is continued for from two 
to three or four weeks. 

2d. After each dose of the conium, as well as 
<it meals, the patient uses a decoction of sarsapa- 
lilla, (composed of two ounces of the root to two 
pounds of water,) instead of water. 

3d. Only the third of the ordinary quantity of 
food is allowed, which ought to be very simple, 
and divided into three small meals. 

4th. If the conium disagree in one form, it 
should be given in another, or the aconitum may 
be used instead, but in lesser quantity than the 
conium. Towards the end of the treatment the 



dose of the conium is gradually diminished and 
the diet gradually increased. 

M. Recamier ascribes the success he has ob- 
tained in the use of the conium not only to the 
strict observance of these dietetic rules, but also to 
the method he has employed in the preparation 
of the extract. The plant is submitted to the ac- 
tion of the vapour of vinegar or alcohol, before 
the juice is expressed from it ; the juice is after- 
wards exposed to the heat of a sand-bath, and 
evaporated to the consistence of an extract. The 
extract thus obtained has not the nauseous odour 
of that usually employed, while it possesses all the 
deobstruent virtues, and sits better on the stomach 
than the latter. 

[The only class of remedies, that can be expected 
to afford any essential benefit, are those that are 
capable of inducing a new condition in the sys- 
tem, by modifying the function of nutrition; such 
as the various preparations of iodine, combined 
with a thorough change of every thing surround- 
ing the individual. The cachexia is the real mor- 
bid condition, and the cancerous affections in par- 
ticular organs are but so many evidences of it, as 
tubercles in the lungs are mere expressions or 
indications of another form of cachexia, equally 
possessing the whole system. Hence it is, that 
cancerous tumours on the external parts of the 
body are so apt to recur after they have been re- 
moved by the surgeon. Still it must be admitted, 
that in cases of scirrhous tumours, when they have 
been removed early, there has very frequently been 
no return of the disease. In such cases the ca- 
chexia has been less strongly marked, and time, 
apparently, has not been permitted for the local 
mischief to increase the morbid disposition. It 
would seem, too, that the particular species of 
cancer influences the probability of recovery 
There are few examples of permanent recovery 
after the removal of encephaloid tumours. 

Recent statistical inquiries by M. Leroy d'Eti- 
olles, offer no great encouragement to the surgeon 
to attempt to remove by the knife the local evi 
dences of systemic mischief. Of 2781 cases oc- 
curring in the practice of 174 surgeons, 1227 
happened in persons above 60 years of age. The 
cases of cancer of the uterus were about 30 per 
cent., those of the heart 24 per cent. Cancer of 
the mouth was in women only as 1 to 1| per 
cent. ; whilst in men, probably — he suggests — from 
the use of the tobacco-pipe, it was as much as 20 
per cent. Of 1172 patients not operated on, 18 
lived more than thirty years after the first appear- 
ance of the disease; whilst of 801 operated on by 
excision or caustic, the existence of only 4 was 
prolonged for a similar time. 14 patients operated 
on, and 34 not operated on, lived from twenty to 
thirty years; and 88 in the first category, and 
228 in the second, lived from six to twenty years 
after the first appearance of the disease. The or- 
dinary duration of life after this period, amongst 
persons not operated on, is said to be five years 
for men, and five and a half for women ; whilst 
among those operated on, it is no more than five 
years and two months for men, and six years foi 
women. Hence it would seem, that setting asidn 
the immediate danger from the operation, the re- 
moval of cancerous disease by the knife had but 
little influence in prolonging life. Further cbserva- 



104 



S C I R R II U S — S C O R B U T l T S 



tions are necessary, however, before these influ- 
ences can be regarded as generally applicable. 
(See on the whole subject of cancer the excellent 
Essay by Dr. Walshe, especially the Amcr. edit, 
by Dr. J. M. Warren.)] 

II. The remedies best calculated to prevent, re- 
move, or mitigate the local and general effects of 
carcinoma of internal organs, vary with the nature 
of these effects and the scat of the disease. The 
state of irritation and fever, and pain, at whatever 
period of the disease they may occur, may be 
greatly moderated by the use of the conium, aco- 
nitum, opium, hyoscyamus, the acetate or muriate 
of morphia ; whilst at the same time the use of 
all kinds of stimuli is to be avoided, particularly 
if the digestive organs be the seat of the disease ; 
and the patient himself kept as much as possible 
in a state of quiet of body and mind. If the os 
uteri be the seat of the disease, additional benefit 
may be derived from the use of leeches applied to 
this part, and also sedative injections. It is only 
in this latter situation that sloughing and ulcera- 
tion can be detected, and local remedies applied to 
remove some of the disagreeable effects of the one, 
or retard the progress of the other. The chloru- 
rets of lime and soda are, perhaps, the best reme- 
dies we can employ in this case, as they not only 
destroy the disgusting odour which accompanies 
this stage of the disease, but remove the putrid and 
irritating fluids which are then discharged. The 
retention of the contents of hollow organs, from 
compression or obstruction, is an occurrence which 
ought to be guarded against by regulating the 
quantity and quality of the food, for negligence in 
this respect may be followed by fatal consequences, 
if the obstacle be situated in the intestines. 

It is not in our power to prevent the occurrence 
of ascites from compression of the vena porta?, nor 
of oedema of the inferior extremities from com- 
pression of the cava in carcinoma of the mesen- 
teric glands, or of the iliac veins when the ovaries 
or uterus are affected with this disease. But the 
quantity of the effused fluid may be prevented 
from becoming so great as to affect the respiration, 
or give rise to painful distension of the integu- 
ments, by the use of those remedies usually em- 
ployed in dropsy from obstruction to the return of 
the venous blood. (See Dropsy.) 

When carcinoma has arrived at that period 
when the cancerous cachexia announces the ex- 
tension and fatal termination of the disease, the 
efforts of the physician must be directed solely to 
the mitigation of the sufferings of the patient. It 
would indeed be a valuable discovery — a remedy 
capable of removing pain without producing any 
injurious effects on the economy ; for if this symp- 
tom were removed, there are many cases in which 
carcinoma would run a much longer course, and 
give rise to comparatively little functional derange- 
ment. 

We have not in the course of this article alluded 
to the perforation of hollow organs from carcino- 
ma. With regard to this termination of carcino- 
Dia, we shall only remark that it most frequently 
lakes place in the uterus and stomach, the rectum 
and urinarv bladder, the transverse arch of the colon 
ai.d jejunum, and the peritoneum. The perfora- 
tion of the rectum, bladder, and peritoneum, is the 
consequence of the extension of the disease from 



the uterus; that of the transverse arch of the 
colon, the consequence of its extension from the 
stomach. (See Pkiwohatiow, Pekitowiti. 
Stomach and Utkiils, Diseases or.) 

Robert Carswell. 

SCORBUTUS. — This is the general appella- 
tion of nosologists for the disease long known in 
our own country by the name of scurvy. The lat- 
ter term, however, in professional as well as in 
popular use, has had an extended and very vague 
signification, embracing various morbid conditions 
of the skin which differ often essentially from each 
other, and are unallied to the subject of the pre- 
sent article. Illustrations of this remark might be 
adduced from various sources. As an instance, in 
the English translation of the Pentateuch the 
word scurvy is twice used synonymously with 
scabies in the Latin. (Lev. xxi. 20, xxii. 22.) 
This and similar applications of it we think may 
be traced to its early use in an adjective sense ; the 
substantive scurf having its literal prototype in the 
Saxon language, and referring, as is well known, 
to exfoliations of small particles of the cuticle; 
an occurrence not uncommon in the disease now 
called scurvy, but which has no title to a charac- 
teristic symptom. 

The word scorbutus, as Good observes, is nei- 
ther Greek nor Latin, nor belongs to any language 
whatever, but is an intolerable barbarism, deduced 
probably from the Sclavonic word ' scorb,' the 
identical disease of which we have to treat having 
been frequently endemic in Russia and other 
northern countries : it has gratuitously received a 
sort of Latin termination. It has also been re- 
ferred to ' schorbert' in the Danish language, and 
' scorbeck,' i. e. sore rnouth or ' scheurbuych' in 
the Dutch. Most authors, says Lind, have traced 
it to ' schorbock,' a griping or teazing of the belly, 
by no means a usual symptom, but so stated by a 
mistake in the etymology of the word. Scorbutus 
has also been called gingibrachium and gingipe- 
dum, from its affecting the gums, arms, and legs. 
It is probable also that the word ' stomacace,' (from 
croixarog and naKo;, disease of the mouth) and 
'sceletyrbe' (from okcXos, the leg, and rvp^rj, disor- 
der) have by the ancient writers been employed to 
designate this affection. It may be well also to 
mention here that ' scorbutus' has two derivatives, 
which have had the same extensive and corre- 
sponding misapplication as the original, viz. the 
terms scorbutic and antiscorbutic, the former re- 
ferring to a peculiar virus supposed to be the com- 
mon root of a large class of diseases, the latter to 
the substances employed for their removal, consti- 
tuting a very formidable and extraordinary cata- 
logue. 

To prevent misconception, it seems necessary 
for us to premise that the following discussion re- 
lates to a peculiar disease, distinct, so far as we 
know, from the papular, pustular, squamous, and 
other diseases of the skin which have been un- 
fortunately confounded with it ; a confusion which 
has given rise to evils of the greatest magnitude, 
as exemplified not only in the errors of the care- 
less and illiterate, but in their endless dissemina- 
tion with all the force of authority from the written 
doctrines of the respected and erudite. It may 
not be without its use to mention, that from the 



SGORB UTUS 



105 



confusion of terms above adverted to, the best me- 
dicine for the prevention and cure of scorbutus 
was for a very long period overlooked and ne- 
glected, to the immense sacrifice of human life ; 
and from the same cause it is stated that on the 
recommendation of Boerhaave, mercury was em- 
ployed by the medical officers of the imperial 
army of Hungary in 1720, in the treatment of 
four hundred soldiers suffering from real scorbu- 
tus ; every one of whom having been subjected 
to a course of this medicine died in consequence. 
(Elements of Medical Logic, by Sir Gilbert Blane, 
M.D. p. 217.) 

Scorbutus, or true scurvy, is a disease which 
pervades the whole of the human frame, and is 
characterized by general debility, fcetor of the 
breath, sponginess and turgidity of the gums, livid 
subcutaneous spots, particularly at the roots of the 
hairs, ecchymoses, spontaneous hemorrhages, and 
frequently contraction of the limbs. Cullen has 
placed it in the class Cachexias and order Impeti- 
gines, and has thus defined it : " In regione 
frigida post victum putrescentem, salitum, ex 
animalibus confectum, deficiente simul materia 
vegetabili ; asthenia, stomacace, in cute maculfe 
diversi coloris, plerumque livescentes, prtesertim ad 
pilorum radices." Masjin Good has arranged it 
in his class Hxmatica and order Dysthetica, as 
one of three species under the generic name 
Porpln/ra ,■ including under it every variety of 
petechial eruption not depending on fever. The 
first species, viz. << P. simplex — petechial scurvy," 
he has defined " spots numerous but small and 
flea-bite shaped, chiefly in the breast, arms, and 
legs, paleness of visage." The second « P. he- 
morrhagica — land scurvy," in which the spots are 
circular, of different sizes, often in stripes or 
patches irregularly scattered over the thighs, arms, 
and trunk ; occasional hemorrhage from the mouth, 
nostrils, or viscera ; great debility and depression 
of spirits. In the third species, viz. : " P. nautica 
— sea scurvy," the spots are of different hues in- 
termixed with some which are livid, principally at 
the roots of the hairs, teeth loose, gums spongy, 
and bleeding, breath fetid, debility universal and 
extreme. The first and second species having 
been particularly discussed in the article Pdrpuha, 
in conformity with the usage of modern writers, 
require no further comment in this place, than that 
they have been so distinguished from the circum- 
stance of their having frequently occurred in 
young persons living in the interior of the coun- 
try, and previously enjoying good health with all 
the necessaries and comforts of life, but who, 
nevertheless, having failed to derive benefit from 
the diet and regimen usually found adequate to 
the cure of sea-scurvy, have not unfrequently 
been recovered by opposite means; circumstances 
which appear to indicate some essential differences 
in the pathological conditions under which they 
occur. This opinion has been further strength- 
ened by the blood drawn from the veins being 
also dissimilar; under the former circumstances 
being livid and very loosely coagulahle, and under 
the latter having the usual appearances character- 
istic of an inflammatory disease. It is to be re- 
marked, however, that the scurvy as it is developed 
at sea is a form of disease in its characters pre- 
cisely similar to that which was commonly termed 

Vol. IV.— 14 



land-scurvy long prior to the distinction of Mason 
Good above adverted to ; the only difference being 
that of the situation of its occurrence and the 
class of persons (mariners) who have been most 
frequently its victims. In our own country, 
though now happily a rare disease, it was formerly, 
even in the inland parts, of great frequency ; and 
in other northern states, particularly on the shores 
of the Baltic, where the products of vegetation, 
at least in their fresh state, have formed a very in- 
significant portion in the diet of its inhabitants, it 
is now even occasionally endemic. Its former 
frequent occurrence in besieged towns and garri- 
sons, under the combined circumstances of defect 
in the quantity and quality of food, fatigue, anxi- 
ety, disappointment, and exposure to the united 
influence of a cold and damp atmosphere, further 
prove that any particular influence from the sea is 
not essential to its generation. A memorable in- 
stance in point presents itself in the account of 
the siege of Thorn ; where we find that between 
five and six thousand of the garrison, besides a 
great number of the inhabitants of the town, 
were cut off by the disease, when the Swedes, 
who were the besiegers, were altogether exempted 
from it ; and it is further remarkable that no 
sooner were fresh vegetables admitted to their use 
than the mortality subsided, and the disease dis- 
appeared. (Lind on Scurvy, Part III. ch. ii. p. 
395.) 

Considerable discrepancy of opinion has pre- 
vailed as to the origin of scorbutus; whether it 
be of recent date, or referred to in the earliest pro- 
ductions of medical literature. It has been con- 
tended, chiefly by the continental writers, though 
some of high estimation in our own country have 
coincided in the opinion, that the ancient physi- 
cians were acquainted with it, although it has not 
been accurately described by them. On the other 
hand, there are authors of great celebrity, amongst 
whom are to be found Friend, Lind, and Trotter, 
who have maintained that the Greeks, Romans, 
and Arabians never could have witnessed it ; con- 
sidering it indigenous to the colder regions of the 
globe, and chiefly incidental to the privations 
consequent to long voyages, which from their ig- 
norance of the compass and the science of navi- 
gation generally, they never undertook. Sieges, 
however, and seasons of dearth have been com- 
mon to every period and country, the former of 
much longer duration in ancient than in recent 
times ; and though experience has determined 
that the climates, or at least the vegetable pro- 
ductions of tropical latitudes, and their consequent 
use in the diet of the inhabitants, would in gene- 
ral insure its prevention, we have abundant proof 
that its existence is not incompatible with high 
temperatures. The ancient physicians, too, it is 
contended, have left us details more closely coi- 
responding to the symptoms of scorbutus in our 
present acceptation of the word than any other 
disease with which we are acquainted. Thus 
Hippocrates, in his description of disorders of the 
spleen, has noted the occurrence of the following 
assemblage of symptoms. " The abdomen is dis- 
tended, and subsequently the spleen is enlarged 
becomes hard, and the seat of acute pain ; the 
complexion is changed and has a dusky (/ieAu$; 
pallid appearance, like the cc'our of a pomegri' 



106 



SCORBUTUS, 



nate ; a disagreeable odour is exhaled from the 
ears and gums; the latter recede from the teeth, 
and ulcers break out on the tibia; like nocturnal 
pustules or blotches, (o«co«i irep eirivvKrtSet ;) the 
limbs are attenuated and the bowels costive." 
Again, in his second book of Prognostics, he ob- 
serves that in those who have tumid spleens, the 
gums are diseased and the mouth emits a fetid 
odour, but those whose spleens are enlarged with- 
out any consequent hemorrhages are attacked with 
ill-conditioned ulcers in the legs and black scars. 
His description of the convolvulus sanguineus 
(EiXeoj atiiariTns) more nearly represents the scurvy 
than that of the <nr\r)v ncyas. " A bad odour is 
emitted from the mouth, the gums recede from the 
teeth, and blood is effused from the nostrils : but 
sometimes ulcers break out on the legs, and while 
some are healing others break out afresh, the skin 
about them is of a dark colour, thin and tender, 
and the patient is not disposed to walk or use any 
exertion." In the original the affirmative is as- 
serted, that the patient is disposed to exertion, a 
circumstance so inconsistent with ulcerations of 
the legs, hemorrhages, and other symptoms, that 
commentators agree that the negative particle (on) 
must have been omitted : this derives further con- 
firmation from some additional remarks of the 
same writer, referring to a former description of 
another kind of convolvulus for the remaining 
symptoms, in which it is said that the patient's 
legs are wearied, and if he walk they tremble. 
and if he should ascend an acclivity that he 
breathes with difficulty, the elbows being raised as 
if they were suspended, &c. ; the causes of which, 
he states, are heating food taken by persons using 
little or no exercise, and who, thus weakened, were 
suddenly forced to take long and fatiguing jour- 
neys in very cold weather; the ciAeoj, it must be 
remembered, being a term not confined by the 
ancients to express affections of the smaller intes- 
tines, but applied to denote also pains in the other 
parts of the abdomen. (Enquiry on Scurvy by 
Francis Milman, M. D. Lond. 1782, p. 179.) 
Cclsus has given a similar character of the ulcera- 
tions attending scurvy to that of Hippocrates: 
" Ulcera autem omnino non sanescunt, aut ccrte 
cicatricem vix recipient ;" and in another part 
seems to have translated the observations of Hip- 
pocrates : " At quibus magni lienes sunt, his, 
gingiva; malae sunt, et os olet, aut sanguis aliqua 
parte prorumpit ; quorum si nihil evenit, necesse 
est in cruribus mala ulcera et ex his nigra? cica- 
trices fiant:" (Lib. ii. c. vii.), and in another pas- 
sage, on tumefactions of the spleen, he has almost 
confirmed the conjecture above mentioned, ex- 
pressly observing, " in intenta ambulatione cur- 
suque dolor et qusedem difticultas est ;" and he 
thus proceeds : " hoc vitium quies auget, itaque 
exertione et labore opus est, habita tamen ratione, 
ne febrem ista, si nimium processerint, excitent." 
(Liv. iv. c. ix.) Aretams, (lib. i. c. 14,) Paul of 
.•Egina, (lib. iii. c. 49.) and Avicenna, (lib. iii. c. 
2,) as well as other Greek and Arabian physicians, 
have described the same chain of symptoms. 

It seems highly probable also that the true 
scurvy has been referred to both by Strabo and 
Pliny ; by the former of whom we are told that 
the Roman army, sent into Arabia under ./Elius 
Gallas in the reign of Augustus, underwent great 



hardships and fatigue from difficult marches 
sometimes in a marshy unhealthy country, and 
at other, from long and troublesome navigations, 
which Syllams purposely protracted. " Promde, 
savs he, « ad Album Pagum pervenit, jam exet- 
citu oris et crurum vitiis (qui morb. sunt ei regiohi 
peculiars) tacto stomacacen et sceletyrl.cn d.eunt; 
quorum ilia circa os, et circa crura rcsohU.o qua>- 
dam est ex aquis et herbis provcniens. (*tra- 
bonis Geograph. lib. xvi.) Pliny has left an ob- 
servation which seems to bear on the same point. 
He states that the Roman army under the com- 
mand of Caesar Germanicus, having encamped in 
Germany beyond the Rhine, near the sea-coast, 
met with a fountain of sweet water, by the drink- 
ing of which in the space of two years the teeth 
drop out, and the joints of the knees became para- 
lytic (compages genubus solverentur). The phy- 
sicians, he adds, called the disease stomacace and 
scelotyrbe, and discovered a remedy for it, viz. 
herba Brittanica, "a salutary medicine not only 
in disorders of the mouth and nerves, but for the 
quinsy, bite of serpents," &c. (Plinii Histor. 
Naturalis, lib. xxv. c. iii.) 

It has been denied, however, that the scelotyrbe 
was an indication of scurvy, because Galen has 
spoken of it as a kind of paralysis,* by which the 
patient is disabled from walking straight; but 
such an effect does not seem at all inconsistent 
with the detail of the symptoms. It has been 
argued, also, that the stomacace may have stood 
for aphthous and similar disorders of the mouth; 
and that other concomitant symptoms equally 
constant and remarkable, particularly the petechia 
and ecehymoses, could not have failed to elicit the 
notice of the early writers, if the disease they 
described had been scurvy. On the other hand, 
from the comparative rarity of the occurrence of 
scurvy in the southern climates, it is not to be 
presumed that the attention of the ancient phy- 
sicians should have been very particularly directed 
to it. There is, besides, a peculiarity in the com- 
bination of the symptoms, a difficulty in referring 
them to any other known disease, and an apparent 
identity of circumstances under which they hail 
been induced. It is likewise an established fact 
that in many instances the presence of scurvy has 
been acknowledged, and it has been expressly 
noticed, without the appearances which have been 
supposed to constitute the deficiency in the descrip- 
tion of the ancient writers. Thus Sennertus ob- 
serves, "In aliquibus nulla; erumpunt macula;; 
aliis tota crura violaceo pinguntur ut tibialia ejus 
coloris supcrinducta jurares." To cite another 
authority, Nitzeh, who had very extensive expe- 
rience of the disease as physician in the imperial 
Russian armies, and published an elaborate ac- 
count of it in the year 1747, has noticed the 
occasional appearance of the other symptoms of 
scorbutus without the petechia; which usuallv ac- 
company it. (See Lind on Scurvy, p. 423.) 

From a consideration of all the circumstances 
of the question at issue, it appears a reasonable 
conclusion that the conjecture of the antiquity of 
the disease is well founded, and that the slight 
diversity of the effects , if any, by which it has 

* Mason Good imagines that Galen referred to chorea, 



SCORBUTUS. 



1(1? 



been manifested at different periods, is to be ac- 
counted for by the infinity of varying circum- 
stances which exert their modifying influences on 
disease, rather than by any essential differences in 
the actual morbid condition under which it has 
been induced. It will be sufficient to mention 
the diversity of periods, of seasons, of climates, of 
localities, of occupations, of diet, besides number- 
less others of a moral nature. It is further corro- 
borative of the antiquity of scorbutus, though we 
mention it in continuation of its history, rather 
than with the view of dwelling on incidents from 
which no deductions of practical value are to be 
drawn, that with the revival of literature after the 
siege of Constantinople, we find an undoubted 
record of its occurrence. It is characterized in the 
most particular manner by the Sieur Joinville, 
from the appearances it presented in the Christian 
army under St. Louis IX. in Egypt, about the 
year 1260. They had only one sort of fish, viz. 
the bombette, and their religion would not suffer 
them to eat meat during Lent; circumstances 
which, together with bad air and great scarcity 
of water, were supposed to have induced the dis- 
ease. (Histoire de Louis IX. par le Sieur Join- 
ville. — Milman on Scurvy. Lond. 1782. p. 184.) 
In the year 1486, it is stated by Fabricius in his 
account of the antiquities of his own country, 
(Misnia,) to have been a new and unheard-of 
disease, spreading as supposed by contagion, and 
proving extremely dangerous. (Op. supra cit. p. 
186.) In 1497 it was the acknowledged occasion 
of dreadful havoc in the crew of Vasco de Gama 
in his passage of discovery by the Cape of Good 
Hope, (Hackluyt's Collection of Voyages, vol. 
iii. p. 225) ; and its destructive ravages have since 
been awfully pourtrayed in the narratives of the 
early English navigators, particularly in those of 
Cartier, Sir Francis Drake, Davis, Cavendish, and 
Dampier. Sir Richard Hawkins mentions that 
within his naval experience, he had known of 
10,000 men having perished by the scurvy ;* and 
from the same cause Commodore Anson, in the 
course of his voyage round the world, lost more 
than four-fifths of his men. 

Until the year 1796, scorbutus may be said to 
have been the universal scourge of our maritime 
connections ; and it is supposed to have destroyed 
more sailors than the various accidents incidental 
to a sea life, united with the terrific consequences 
of naval warfare. Happily, however, since the 
above-mentioned period it has been of very rare 
occurrence in our ships of war and naval hospitals; 
so rarely, that on the high authority of Sir Gilbert 
Blane, the year adverted to may be regarded as 
the era of its extermination. The accomplish- 
ment of this he attributes in an unqualified man- 
ner to the curative as well as preventive use of 
citric acid ; no instance of the disease having oc- 
curred in his extensive experience which resisted 
its influence. To such testimony, perhaps, it 
behoves us to yield our implicit assent; but, satis- 
fied as we are with the immense mass of evidence 
adduced in favour of the wonderful efficacy of the 
remedy referred to, we cannot but take into the 
account the co-operative influence of the great 

*The Observations of Sir Richard Hawkins, knt. in 
his Voyaffi; to the South Sea, A. D. 1593. — Purchas's 
Pilgrim, part iv. p. 1374. 



improvements in naval economy, successfully 
commenced with a view to the prevention of 
scorbutus by the justly esteemed navigator Cap- 
tain Cook, and brought to comparative perfection 
under the happy auspices of the enlightened and 
venerable director of the medical department of 
the navy, Sir Gilbert Blane himself. The records 
of medicine abundantly prove the prevalence, and 
even the great fatality of scorbutus on our own 
shores at a former period, although its appearance 
at the present day is most rare, as is well known 
to every practitioner of medicine. This salutary 
change is fully accounted for by the drainage of 
the country ; by the introduction of fresh vegeta- 
bles as a considerable proportion of the habitual 
diet of the people ; and those improvements in 
our national economy by which the use of fresh 
meats has been rendered available at all seasons 
of the year, and substituted for the dried and salted 
provisions formerly a principal article of sub- 
sistence throughout the winter. The want of 
fresh vegetables at former periods is plainly evinced 
by the historical fact, that as late as the commence- 
ment of the sixteenth century, the art of garden- 
ing was so little understood in our country, that 
Katharine of Aragon, queen of Henry VIII., to 
procure a salad, was obliged to despatch a mes- 
senger to the Netherlands for it ; and it was near 
the close of Henry's reign before the necessaiy 
vegetables for the purpose, as well as cabbages, 
turnips, carrots, and some other edible roots, were 
produced ; the small quantity of this kind of fooi 
previously used having been imported from Hoi 
land and Flanders. (Hume's History of England 
ch. xxxiii.) 

But to return to the general history of scor- 
butus. Krantz, the historian of Saxony, is sup- 
posed to be the first writer whose works are extant 
who calls it scurvy; and the next, Euritius Cordus, 
in his Botonologicon, published in 1534, wherein 
the chelidoniutn minus, called by the Saxons 
schorbock root, is extolled as a remedy. It is 
mentioned, also, in the same manner in the Me- 
dicina Herbaria of J. Agricola, published in the 
year 1539. But in an intermediate period, in 
1535, we find that the most decisive and deplora- 
ble effects of it were evinced in the crew of James 
Cartier in his second voyage to Newfoundland, 
when we are informed of the providential disco- 
very of a remedy (in previous use amongst the 
people of Stadacona,) viz.. the decoction of the 
bark and leaves of the ameda or hanneda, after- 
wards gratefully designated by them " the tree of 
life."j In 1555, the History of Northern Na- 
tions, by Olaus Magnus, contained, amongst the 
diseases peculiar to them, a long description of 
scorbutus. Soon afterwards we find three cotem- 
porary physicians of eminence treating expressly 
of it, viz. Rousseus, Wiems, and Ecthius. The 
works of the two former, in the opinion of the 
learned Astruc, were not published until the year 
1580, and the epitome of Ecthius, which, accord- 
ing to Forrestus, was the transcript of a letter 



t"I am inclined to believe, from the description given 
by Cartier of the ameda tree, that it was the large 
swampy American spruce. Some have supposed it to 
be the sassafras, others the whitethorn ; but in nis third 
voyasre he mentions the whitethorn, and makes the 
ameda to be three feet in circumference." — Liud. on 
Scurvy, p. 178. 



109 



SCORBUTUS. 



dated 1541, not until 1583. In 1604 appeared 
a work on the subject by Engelanus, which for 
many years was regarded as the standard of pub- 
lic opinion. This was succeeded in 1624 by that 
of Sennertus, and in 1627 by the description of 
Vander Nege, drawn from personal observation 
of its extensive prevalence at the siege of Breda. 
In 1667 Willis published a systematic treatise 
on the disease, which, like that of Engelanus, 
continued for some time to be the prevailing au- 
thority. In 1708, however, it gave place to the 
observations of Boerhaave, and to him succeeds 
a long list of writers ; but, as of those who pre- 
ceded him, we shall mention such only as have 
been held in estimation, attaching the dates to 
their several publications. (Lind's Treatise on 
Scurvy. Lond. 1757.) Mead, in 1749 ; Russell 
and Huxham, in 1750; Addington, in 1753; 
Bisset, in 1755; Lind, in 1757; Macbride, in 
1767; Hulme, in 1768; Milman, in 1782; Trot- 
ter, in 1797; and Blane, first in his work on the 
Diseases of Seamen, published in 1785, and sub- 
sequently in a paper on the health of the navy, 
inserted in the sixth volume of the Medico-Chi- 
rurgical Transactions of London, in 1815, and 
transcribed in a pamphlet of the same title printed 
for private circulation in 1830. Besides the above 
mentioned, there are doubtless others which merit 
attention ; and much valuable information on the 
subject is to be found in the periodical miscella- 
nies, chiefly of a remote date. 

Symptoms. — The symptoms which constitute 
scorbutus having rarely if ever appeared except 
when there has been an obvious exposure of the 
subject of them to the concurring influence of 
several of those termed its predisposing causes, 
other indications of the approach of the disease 
will be confirmed, or the suspicion of it diminish- 
ed, in proportion as 1 such a connection of circum- 
stances can or cannot be ascertained. Of the 
predisposing causes the most uniformly present 
has been the combination of cold with humidity 
of atmosphere, either general or partial ; whilst at 
the same time the diet has consisted of food de- 
fective in its nutritious qualities, and particularly 
of provisions rendered dry and hard by the pro- 
cess of salting as usually adopted to preserve 
them for sea use, together with a total privation, 
or the use of a comparatively insignificant quan- 
tity of succulent vegetables in their fresh state. 
Under this privation, as it has frequently occurred 
at sea, a craving desire for them, particularly for 
such as are of an acid taste, and also for pure 
water, when the supply of that article has been 
scanty, has been so often observed to precede the 
disease, that practical authorities have considered 
such desires as premonitory symptoms. Their 
operation has been feelingly portrayed in the nar- 
rative of Lord Anson's voyage, on the occasion 
of the approach of his ships to the island of Juan 
Fernandez : the scenery of which having been 
depicted, the writer ouserves, " Such a scene, so 
beautifully diversified, must have been delightful 
to an indifferent spectator; but in the distressed 
condition of the Centurion's men, who were in a 
manner languishing for the land and its vegetable 
productions, a situation of mind which always 
attends the scurvy, it is not to be conceived with 
•what transport and eagerness they viewed the 



shore, and how impatiently they longed for it 
ereens the fresh water, and the other refreshment. 
Sen in Bight" And it is further observed, « that 
those only who have endured a long ser.es of 
thirst, and can readily recall the desire and agita, 
tion which the ideas alone of springs and brooks 
have at that time raised in them, can judge ol the 
emotion with which they eyed a large cascade of 
the most transparent water, which poured itself 
from a rock near one hundred feet high into the 
sea at a small distance from the ship." « Those 
who had been long confined to their hammocks 
now exerted all the strength they had left in 
crawling up to the deck to feast their eyes with 
the reviving prospect. Thus they coasted along 
the shore, contemplating the enchanting land- 
scape, which improved as they advanced; but 
the night closed upon them before they had dis- 
covered a proper bay. At four the next morning 
the third lieutenant was despatched with the cut- 
ter to discover the bay they sought for, and at 
noon he returned with the boat laden with seals 
and grass; for the boat's crew did not stay to 
search for better vegetables, as they well knew 
that even grass would prove a dainty, and indeed 
it was soon eagerly devoured." (Anson's Voyage 
round the World, 1740-4, ch. iii.) 

Another indication of the scorbutic diathesis, 
unnoticed by preceding writers, says Sir Gilbert 
Blane, is a soft indolent tumour, which arises 
under the skin on a part which has received a 
slight blow or contusion, so slight as not to break 
the skin. It most commonly appears about the 
elbow or forearm, and generally disappears with- 
out inconvenience, its contents being absorbed. 
(Observations on Diseases of Seamen, 1785, p. 
465.) Scratches and wounds which under other 
circumstances would scarcely elicit attention, are 
apt to proceed to troublesome ulcerations, and 
betray their real character with the further de- 
velopment of the disease. 

Amongst the more obvious symptoms, the ear- 
liest is usually a change of colour in the face, 
which, as well as the rest of the skin, becomes 
pale, and has a bloated appearance. When nar- 
rowly examined, it is seen that the lips and carun- 
cles of the eye, where the blood-vessels lie most 
exposed, are of a greenish hue. The countenance 
denotes the state of the mind, which is depressed. 
The patient complains of lassitude, and is averse 
to all kinds of bodily exercise ; the inability to 
use it is soon manifested by stiffness and feeble- 
ness of the knees, and excessive fatigue and breath- 
lessness or panting are the consequences. The 
gums soon become itchy, swelled, and are apt to 
bleed upon the gentlest friction. On inspection 
they present a livid red appearance, are soft and 
spongy, and become extremely putrid and fun- 
gous. The odour of the breath is, as may be 
supposed, excessively offensive, and hemorrhages 
are apt to occur from the gums, as also from other 
parts of the body. 

The skin at this time feels dry, and continues 
so through the whole course of the disease. If 
the patient be feverish, it is extremely rough, 
sometimes resembling that which is vulgarly called 
goose-skin. But most frequently it is smooth and 
shining, with suffusions of reddish, bluish, or ra- 
ther black and livid spots. These are of dilTerenl 



SCORBUTUS. 



109 



sizes, occupying spaces from the smallest possible 
to that of a handbreadth or more, increasing gene- 
rally with the progress of the disease. They are 
to be seen chiefly on the legs and thighs, often on 
the arms and trunk, but more rarely on the head 
and face. The legs are apt to be cedematous, the 
swelling at first being confined to the ankles, and 
conspicuous only in the evening, but gradually 
extending to the whole limb, and becoming less 
and less transient. 

Such are the most constant and essential symp- 
toms of the disease in its first stage; but a diversity 
is sometimes observed in the order of their appear- 
ance. Tlius, when there has been great debility 
from previous illness, the gums for the most part 
are first affected ; whereas, when the individual 
has been deprived of exercise in consequence of a 
fractured bone or other injury, the parts so affected 
become first scorbutic. As for example, if a pa- 
tient is suffering from a strain of the ankle, the 
iirst indication of scorbutus will be pain, swelling, 
and oedema of the leg, with the purple subcutane- 
ous spots and ecchymoses which more especially 
characterize the disease. It is remarkable, also, 
that if there have been previous disease, particu- 
larly rheumatism, chronic pains from bruises, and 
other effects of local injuries, these are apt to be 
renewed, and the disease on which scorbutus may 
have supervened to appear in a more aggravated 
form. (See Lind on Scurvy, chap, ii.) A strik- 
ing instance in confirmation of the preceding re- 
mark is mentioned in the account of Lord Anson's 
voyage. The individual spoken of had been 
wounded, about fifty years before, at the battle of 
the Bowie, but had speedily recovered, and had 
continued well for a great number of years pre- 
ceding an accession of scorbutus; but upon this, 
and during its progress, the same wounds broke 
out afresh, and appeared as if they never had been 
healed ; nay, what is still more astonishing, the 
callus of a broken bone, which had been com- 
pletely formed for a long time, was found to be 
destroyed, and the fractured part as if no consoli- 
dation had ever taken place. 

The subjects of scorbutus frequently suffer from 
shifting pains : some complain of them, according 
to a common expression, throughout their bones, 
being particularly severe in their limbs and lum- 
bar region, and in the joints and legs when they 
are swelled. But the most frequent seat of pain 
is the thorax ; a sense of constriction in it with 
stitches on coughing being usual symptoms. "I 
believe indeed," says Lind, "it will universally be 
affected urdess the bowels are very open. The 
pain shifts from one part ofgit to another, often to 
opposite sides, and is at first perceived upon 
coughing only ; but in a more advanced stage it 
commonly fixes in a particular part — most fre- 
quently in the side, where it becomes extremely 
severe and pungent, so as to affect the breathing — 
a dangerous symptom." As scorbutic pains often 
change their position, so they are always exaspe- 
rated by motion of the body, especially the pain 
of the back, which on such occasions proves very 
troublesome. 

The next thing observable is, that if any epi- 
demic should prevail at the same time with scor- 
butus, the subjects of the latter are in consequence 
predisposed to be attacked by it, even if there 



should appear to be no correspondence between 
the two diseases. Such a concurrence, however, 
Lind considers much more fortunate than when 
the new disease may be, as he terms it, of a putrid 
nature, as small-pox, measles, dysenteric fever, 
&c. ; " it is then," he adds, " that co-operating 
with the scorbutic acrimony, they produce most 
fatal and malignant symptoms." The head is 
seldom or never affected with pain, unless when 
fever is present, which may be considered altoge- 
ther an adventitious circumstance. When fevers 
supervene on scorbutus, they usually prove fatal ; 
but that species which at a former period was 
most destructive, more so even than the plague, 
was the petechial or gaol fever, of which we read 
in works of the last century, contracted in large, 
crowded, and sickly ships or prisons. According 
to the habit and constitution of the patient, there 
will be some diversity in the performance of the 
alvine function. In some patients it is natural, in 
others there is extreme constipation ; but generally 
the bowels are in a relaxed state, and the dejec- 
tions are extremely fetid. The appearance of the 
urine is very variable at different times, even in 
the same patient, except that it is generally high- 
coloured, and soon becomes rank and fetid. It is 
said, also, to turn blue vegetable infusions to a 
green colour. The pulse varies according to the 
habit of the patient and stage of the disease, being 
in general slower and more feeble than in health. 
After a time the patient is commonly deprived of 
the use of his inferior extremities, the flexor ten- 
dons of the ham being contracted and the joints 
swelled ; livid spots and ecchymoses are to be 
observed, particularly on the legs, and frequently 
hard and very painful swellings in different parts. 
" In some," says Lind, " I have seen, without any 
swelling, the calf of the leg quite indurated." 
There is great proneness to syncope upon exertion, 
and not unfrequently upon occasions of this kind, 
or any sudden exposure to a fresh atmosphere, 
scorbutic patients have instantly died. The ten- 
dency to profuse hemorrhages increases with the 
progress of the disease, and these are apt to take 
place from the nose, gums, lungs, intestines, &c, 
as well as from any ulcers which may be present. 

Besides the morbid appearances of the gums 
already mentioned, they are liable to be affected 
with deep ulcerations, the teeth most commonly 
are loosened and often fall out; but caries of the 
jaw rarely ensues, nor is this affection of any of 
the bones a usual consequence, but has probably 
been considered so from the occasional complica- 
tion of scorbutus with syphilis; as ptyalism has 
also from its synchronous occurrence when mer- 
cury has been exhibited for the cure of the latter 
disease. 

When scorbutus approaches its fatal termina- 
tion, the painful and livid swellings above referred 
to often break, and assume the fungous appear- 
ance characteristic of scorbutic ulcers The he- 
morrhages become more profuse and general ; the 
increasing dyspnoea is accompanied in some cases 
with pain under the sternum, but most frequently 
in one of the sides. In others, however, without 
any complaint of pain, the respiration becomes 
suddenly quick and laborious, and death unex- 
pectedly puts a peiiod to the disease. The mind 
throughout is depressed and anxious, nut at last, 



no 



SCORBUTUS. 



there is generally a total indifference and apparent 
torpor of every faculty. The appetite for food is 
rarely impaired, and death has even seized the 
sufferer in the act of eating. Nyctalopia is an 
occasional occurrence in the progress of scorbutus, 
though rarely noticed in the descriptions of it. 
Dr. Hulme recorded its appearance in his inaugu- 
ral dissertation printed in 1765; and Sir Gilbert 
Blane states that it had been reported to him by 
Mr. Telford. It was also a common occurrence 
amongst the scorbutic patients in the garrison of 
Gibraltar, during the siege of that place. (See 

NrCTALOPIA.) 

To the complications of scorbutus with other 
diseases is to be attributed the Protean character 
which has frecpuently been ascribed to it, and 
which, from a comparison of descriptions, it would 
seem to have manifested. The conjoined diseases 
have been most frequently such as are incidental 
to the same predisposing causes, namely, fevers, 
continued, intermittent, and remittent; rheuma- 
tism, diarrhoea, and dysentery. It has often also 
been complicated with syphilis, and occasionally 
with catarrh and ophthalmia. Besides these, 
numerous other diseases are mentioned by writers 
as having preceded its occurrence ; but scorbutus 
always exerts the predominating influence, and 
sometimes even has simulated the worst form of 
idiopathic disease, as phthisis pulmonalis,* the 
symptoms of which have subsided on the treat- 
ment appropriate to the removal of the former. 

Scorbutic ulcers are to be recognised by the 
following characteristics : instead of pus they ex- 
crete a thin, fetid, sanious fluid, mixed with blood ; 
their edges generally are of a livid colour, and as 
it were puffed up ; a coagulum is soon formed on 
their surface, which can with great difficulty be 
wiped away or separated from its subjacent parts. 
These are soft, spongy, and putrid. When, how- 
ever, the removal of this coagulum has been 
effected, the same appearance presents itself again 
after the lapse only of a few hours, and soon con- 
stitutes a soft bloody fungus of considerable size, 
formerly familiar to sailors, and commonly called 
by them bullock's liver, which in its boiled state 
fhe former resembles both in colour and consist- 
ence. " It often rises," says Lind, " in a night's 
time to a monstrous size, and although destroyed 
by cauteries actual or potential, or cut smooth 
with a bistoury, in which case a plentiful hemor- 
rhage generally ensues, at the next dressing it is 
as large as ever." 

Pathological Anatomy. — Although scorbu- 
tus, as we have already stated, was until the latter 
end of the last century a very fatal disease, and 
has been the subject of numerous dissertations, 
few accounts have recorded the post-mortem ex- 
aminations of individuals who have died of it. 
On this part of the subject the essay of M. Pou- 
part, from observations made at the hospital of St. 
Louis, in Paris, (Memoires de l'Academie des 
Sciences, 1699, p. 237; also Lind on Scurvy, 
p. 255,) is the most minute and explicit we pos- 
sess. Added to the external appearances of the 
body as described in the living subject of the dis- 
ease, extravasations of dark-coloured blood have 



* Medico-Chir. Review, for June, 1824. On scurvy in 
.us Majesty's ship Leander, on a voyage from Trinco- 
inalee lo the Cape of Good Hope. 



been found very generally under the integument* 
in the muscles, so as to render them hard and 
rigid, and in some of the glandular parts of the 
body, particularly the spleen. The brain was 
always in its natural state. Serous fluid was fre- 
quently found in the thorax, stated to have been 
of various colours, and so corrosive as to excoriate 
the hands which have been wetted with it. In 
some who had suffered from dyspnoea, and had 
died suddenly, the cavity of the chest and also the 
lungs were void of serum,- but there were adhe- 
sions of the pericardium to the latter, and of the 
lungs to the pleura costalis and diaphragm. In 
some who died suddenly without any obvious 
cause, the auricles of the heart, it is stated, were 
as large as a man's fist, and full of coagulated 
blood. The glands of the mesentery were gene- 
rally obstructed and swelled. Some of these were 
found partly corrupted and imposthumated. la 
the liver of some few, the extravasations were 
hardened. The spleen was three times bigger 
than natural, and fell to pieces as if composed of 
coagulated blood. Sometimes the kidneys and 
lungs were studded with imposthumes. The 
ligaments of the joints were corroded and loose, 
and instead of the synovial fluid there was only a 
greenish liquor, to the causticity of which the cor- 
rosion of the ligaments was attributed. The epi- 
physes were found entirely separated from the 
shafts of the bones, the cause in the living subject 
of a crepitating noise on motion, which was some- 
times distinctly audible. In some, the cartilagi- 
nous portions of the ribs were separated from the 
bone, and the bony part, at the point of separation 
from the cartilage, was carious to the breadth of 
four fingers. In some subjects, on squeezing the 
sternal extremities of the ribs, the spongy portion 
was separated in a corrupted state, leaving only 
the external and internal bony plates. In some 
were found abscesses of the glands of the groin 
and axilla. Dr. Mead tells us, that upon opening 
the abdomen of a scorbutic patient, he was struck 
with amazement at the monstrous size of the 
spleen, which weighed five pounds and a quarter, 
whereas the liver weighed but four pounds and a 
quarter ; but its bulk seemed to be its only defect; 
for it retained its natural shape and colour, and 
had not the least scirrhosity or other hardness. 
Its interior parts were as usual of a dark livid hue, 
with lax fibres and deep-coloured blood. (Medi- 
cal Works of Richard Mead, M.D. Dublin, 
1767, p. 421.) 

In the beginning of the disease, according to 
the observations made by the surgeons of Lord 
Anson's expedition, ^Ir.Etiriek and Mr. Allen,) 
the blood as it flowed out of the orifice of the 
wound might be seen to run in different shades 
of light and dark streaks. As the disease ad- 
vanced, it ran thin and seemingly very black, and 
after standing some time turned thick and of a 
dark muddy colour ; the surface in many places 
of a greenish hue, without any regular separation 
of its parts. In the third degree of the disease it 
came out as black as ink, and though kept stirring 
in the vessel many hours, its fibrous parts had 
only the appearance of a quantity of wool or hair 
floating in a muddy substance ; and when it 
issued from the body, as in hemorrhages, the ap- 
pearances of this fluid were the same as to colou. 



SCORBUTUS. 



Ill 



and consistence, whether it was discharged from 
the mouth, nose, stomach, intestines, or any other 
part. In dissected bodies, the blood in the veins 
was so entirely broken, that by cutting any con- 
siderable branch, the part to which it belonged 
could be emptied of its black and yellow liquor. 
The extravasated blood was also precisely of the 
same kind. 

Diagnosis* — The symptoms already detailed 
as characteristic of scorbutus, considered in con- 
nection with the circumstances under which they 
are stated to occur, or in other words its immedi- 
ate causes, are sufficient data to render it distin- 
guishable from every other disease; but in the 
present state of our knowledge a consideration 
of the latter is necessary to prevent it from being 
confounded with certain forms of purpura, viz. 
purpura simplex and purpura hemorrhagica ; both 
of which until a recent period were regarded as 
manifestations of the disease under discussion. 
Good, as already stated, has classed the three to- 
gether as species of the same genus, under the 
name Porphyra, Scurvy, — an arrangement which 
was sanctioned by the opinion of Willan, who 
viewed them as allied. A comparison of the 
symptoms alone would seem to warrant the con- 
clusion that they are constituted by diversities of 
degree only of the same morbid condition. But 
that this uniformity does not exist, particularly as 
regards purpura hemorrhagica and scorbutus, has 
been inferred from the successful issue of the 
treatment of the former by the pursuance of the 
antiphlogistic system, especially by the exhibition 
of purgatives, and in some instances even by 
bloodletting, when the occasional causes of the 
latter have not been found to exist, and the reme- 
dial measures appropriate to its removal had been 
resorted to in vain. In many instances a pletho- 
ric state of the system and a febrile disposition 
have pointed out the divergence from the line of 
symptoms which characterize scorbutus, and the 
peculiarity has been further marked by the nature 
of the diet and the previous condition of the pa- 
tient. But it must be acknowledged that it is 
often impossible to recognise the distinction be- 
tween purpura and scorbutus, or appreciate any 
difference in their occasional causes, except that 
amongst those of the latter the influence of a cold 
and humid atmosphere appears almost, if not 
always, essential to its production. When the 
state of the pulse and the condition of the patient 
have suggested the advantage of bloodletting in 
purpura hemorrhagica, the appearance of that fluid 
on being allowed to stand has been that of blood 
drawn in inflammatory diseases, presenting on its 
surface a thick and tenacious coat of coagulated 
lymph. The cruor has also been firm and cohe- 
sive, and difficult of diffusion when shaken in the 
serum, and altogether different, (as will be seen 
by comparison with the description already given,) 
from blood drawn in scorbutus. 

Prognosis. — Although scorbutus has "slain 
its tens <>f thousands" on land as well as at sea, 
and from its former fatality was not inaptly classed 
amongst pestilential diseases, the means of treating 
it have been so well ascertained and established, 
that for the most part, having citric acid at com- 
mand, and still more certainly an abundant supply 
of fresh and succulent vegetables, with the power 



of protecting the patient from a continuance of 
the operation of its occasional causes, its cure, 
may be much more certainly anticipated than that 
of any other disease in which the visible effects 
are as general and as threatening to the extinction 
of life. When deprived of the means above spe- 
cified, as formerly often happened at sea, and as 
is even now frequently the case as regards fresh 
vegetables, citric acid may in general be depended 
on as a very efficient antidote ; but without it the 
probabilities of arresting the progress of the dis- 
ease will be infinitely diminished, and the recovery 
of severe cases rendered hopeless.. 

The first favourable symptom in the advanced 
stages of the disease, when fresh fruits and vege- 
tables have been obtained, is a change from a con- 
stipated to a lax state of the bowels ; the skin 
becomes moist and soft ; some increase of bodily 
power follows ; a tranquil pulse together with an 
improvement in the appearance of any ulcers 
which may be present ; and a change in the aspect 
of the petechia? and ecchymoses, their livid colour 
gradually assuming a yellow hue from the centre 
to the circumference, the skin at the same time 
resuming its natural colour, is then observed. 

The most unfavourable symptoms are dyspnoea, 
stitches in the side, frequent faintings, a weak am) 
quick pulse, involuntary evacuations, and exces- 
sive hemorrhages. An unexpected and fatal ter- 
mination of scorbutus has occasionally, we have 
said, taken place upon any unusual exertion, or 
on sudden exposure to a fresh atmosphere. When 
complicated with other diseases, as dysentery or 
diarrhoea, the unfavourable aspect of scorbutus is 
rendered still more so, in proportion to their 
severity and the difficulties there may be to en- 
counter in checking their progress. Diseases, 
also, of an incurable nature, the tendencies to 
which have been previously established, may be 
developed by the presence of scorbutus, such as 
phthisis, and other organic lesions productive of 
hydrothorax, ascites, &c. But at the same time, 
in forming a prognosis, it must be borne in mind 
that phthisis itself and other organic lesions have 
been simulated by this disease, and that their 
symptoms have subsided when the peculiar affec- 
tion which constitutes scorbutus has been sub- 
jected to its appropriate treatment; and that the 
most unfavourable sequelae will sometimes disap- 
pear when solely consequent upon the disease 
under discussion. 

Causes. — The predisposing causes, or those 
which induce an aptitude in the body to be at- 
tacked by scorbutus when exposed to its usual 
excitants, are numerous, and vary in their nature, 
but concur to occasion debility whatever they may 
have been. Thus we find that preceding diseases, 
whether acute or chronic, have been very common 
precursors, and that persons recovering from fevers, 
or who have been previously weakened by fre- 
quent relapses, have been often subjects of it. 
Indolence and inactivity appear also to have con- 
tributed to produce the susceptibility. The pi 
sons in a ship's crew termed skulkers or sluggard 
have been usually the first attacked ; and it has 
been observed that those whose condition 01, 
board-ship exempts them from much exercise, 
have also been early amongst the number affected. 
We are told that in one of Lord Anson's ship;., 



112 



SCORBUTUS. 



the Centurion, out of fifty cases of scorbutus four 
only survived, and of the whole number of ma- 
rines attached to the squadron (seventy), all but 
i leven died of it. It has been observed also in the 
Dutch service, that if there were seven on board 
that had the scurvy, four of these were marines, 
though the number of the latter was, of course, 
proportionately much less than that of the sailors. 
Corpulent persons have appeared to be peculiarly 
prone to it, and on shore it has been observed to 
affect individuals of sedentary occupations more 
frequently than those engaged in the active duties 
of lite ; and where it has been endemic, very fre- 
quently to attack the sedentary mechanics whilst 
the rural population have entirely escaped. On 
the other hand, however, excessive fatigue, over- 
exertion, and want of necessary rest, induce the 
same predisposing condition. Thus, it has not 
unfrequently occurred after long and harassing 
marches, and at sea succeeded occasions of much 
laborious duty ; numerous instances of which 
might be adduced, if space were allowed us for the 
detail. 

But of all the predisposing causes, none has 
been observed to have more frequently, if not in- 
variably, excited its influence, than cold combined 
with moisture either from the atmosphere gene- 
rally, or from the equivalent influence of a humid 
apartment or damp clothes. When scorbutus 
made such havoc in Lord Anson's squadron on 
doubling Cape Horn, the weather had been very 
tempestuous, the wind cold and cutting, accom- 
panied with snow and sleet. At the siege of 
Azof, when the Russian army suffered from it 
severely, the same circumstances existed. In the 
account of his voyage round the world, La Perouse 
states that he was very fortunate in preserving his 
crew from scorbutus, an effect which he attributed 
entirely to maintaining a dry state of the atmo- 
sphere between the decks. Captain Cook's suc- 
cess in this respect seems to have uepended con- 
siderably on similar precautions. In Captain 
Parry's first voyage for the discovery of a North- 
West passage, the influence of humidity in this 
particular was very conspicuous. " Mr. Scallon," 
he states, " had been complaining for some days 
of pains in his legs, — first considered by the sur- 
geon as rheumatic, but which he was soon con- 
vinced by the appearance of the gums depended 
on scorbutus. This occurrence, so uncommon 
amongst the officers of a ship, led to a particular 
inquiry as to its cause, and it was discovered that 
Mr. Scallon's bedding was in so damp a state in 
consequence of the deposit of moisture in his 
bed-place, as to render it no longer questionable." 
In Captain King's expedition in 1826, the crews 
of the two ships which he commanded, viz. the 
Adventure and the Beagle, continued healthy 
until May 1828, when scorbutus began to show 
itself whilst in the straits of Magellan, notwith- 
standing they were plentifully supplied with 
lemon-juice, sugar, preserved meats, pickles, cran- 
berries, fish, wild fowl and wild celery. There 
was, however, excessive moisture of the atmo- 
sphere, and great mental depression prevailed in 
the crews from want of occupation, which in this 
instance would seem to have been excitants of 
the disease. 

Mental depression, indeed, appears on most 



occasions to have had a powerful influence in 
predisposing persons to scorbutus. During its 
endemic prevalence, the timid, the discontented, 
and the inactive, have been frequently the first 
attacked. From this cause probably it is that 
newly impressed seamen have been particularly 
liable to it, and that it has often shown itself 
among the inhabitants of besieged towns. Hy- 
pochondriacs and persons of a melancholic tem- 
perament have been so commonly its subjects, 
that the hypochondriacal disorder, the atrabilious 
habit, and scorbutus, have by many of the old 
writers been considered as different degrees of the 
same disease. (Enquiry into the source of Scur- 
vy, by Francis Milnian, M. D. 1782.) Amongst 
a variety of other debilitating circumstances con- 
ducive to scorbutus, exposure to the impure air 
of crowded apartments and the free use of ardent 
spirits have been so commonly its precursors, that 
they require to be especially perticularized. It 
has also been observed that individuals of un- 
cleanly habits, both with regard to their persons 
and clothing, have been more liable than others 
to the disease. 

Various opinions have been entertained as to 
the immediate or exciting causes of scorbutus, 
and, as frequently has occurred in reference to 
epidemic or endemic diseases, its propagation has 
been attributed to contagion. Sennertus, Boer- 
haave, and Hoffmann, are of the number of those 
who have advocated this opinion ; and in Sir 
Gilbert Blane's work, published in 1785, we find 
that it was not discountenanced by him. It has 
been so completely subverted, however, by subse- 
quent experience that it would be needless to dis- 
cuss the question. Its hereditary transmission 
has also been asserted, but of this there is no 
satisfactory proof or even plausible argument. 

At all times it has been an accredited opinion 
that its origin has been referable, with the con- 
currence of the predisposing circumstances al- 
ready mentioned, to an insufficiency of nutriment, 
or to some noxious qualities of the ingesta, and 
these for the most part included in the following 
particulars — in certain impurities in the water or 
other liquids used for drink ; in a preponderating 
proportion of farinaceous substances ill-fermented, 
or which have not undergone that process, or 
otherwise in a faulty state ; in the use of animal 
food in a state of putrefaction, decomposition, or 
hardened and changed in its nature by the process 
of salting, as for sea use ; simultaneously with 
privation or an insufficient supply of fresh vege- 
tables, or a scanty allowance of such dietetic 
drinks as contain their elementary principles. 

The connection of scorbutus with the use of 
such diet has to a certain degree been rendered 
obvious, by the successful issue of changes in the 
dietary of our own navy, determined on in con- 
sequence of the numerous facts corroborative of 
the supposed influence of the former system on 
the generation of this particular disease. The 
necessary concurrence of so many circumstances 
apparently essential to its production renders it 
impossible to estimate their individual operation, 
and this knowledge can be obtained only (if the 
opportunity should ever occur) by a more full 
and exact inquiry into the coexistent condition 
of the blood and other fluids of the body than 



SCORBUTUS. 



113 



has ever yet been made. From its former preva- 
lence principally amongst sea-faring people, an 
idea has been entertained that the large quantity 
of salt used in their food was exclusively an ex- 
citant of scorbutus; but Dr. Lind has shown that 
the daily use of considerable quantities of sea- 
water has in no degree aggravated it, and that an 
entire abstinence from salt or salted meat has had 
no mitigating effect on its symptoms. (Page 52.) 
It is certain also that scorbutus has prevailed 
where the operation of this article could not even 
have been suspected ; as, for instance, on the oc- 
casion of Lord Anson's ships leaving the coast 
of Mexico, when they were plentifully supplied 
with fresh meat. The soldiers in the Russian 
armies, who suffered from scorbutus at the siege 
of Azof, had no salt provisions. During a scarcity 
of corn it raged amongst the poor inhabitants of 
the colder districts of Italy near the Alps, who 
subsisted chiefly on the decoction of roots, and 
often passed whole days without any food at all. 
In the Transactions of the College of Physicians, 
Dr. Milman has related two cases of the disease 
appearing in a very severe form in individuals 
who had lived for three months on tea, without 
milk or sugar, or any other article of diet except 
bread. (Milman on Scurvy, ch. ii.) From its 
occurrence also in prisons, and so lately as the 
year 1819 in the Milbank Penitentiary, under a 
dietary of fresh animal and vegetable food com- 
bined, it may be inferred that the prejudicial effect 
of salted meat depends either on its being deprived 
of its nutritious qualities, or upon its being other- 
wise rendered indigestible. It is also somewhat 
corroborative of this view, that the direct effect of 
the addition of salt to blood out of the body is a 
change of its colour from black to red, the reverse 
of which is the consequence of scorbutus in the 
blood of the living body. With regard to diet, 
however, the most constant peculiarity which has 
apparently caused the occurrence of scorbutus, 
his heen a deficiency in the proportion or an 
entire privation of fresh vegetables, or rather, it 
should be said, of those which are of a succulent 
nature, — as an instance in point, may be men- 
tioned the occurrence of scorbutus in Porchester 
Castle and at Norman Cross, about the beginning 
of the late revolutionary war, before those ar- 
rangements were put into practice which after- 
wards so effectually secured the health of the pri- 
soners. Under similar circumstances it appeared 
in a prison-ship near Porchester Castle. (See a 
paper on the health of the Navy, by Sir Gilbert 
Blane, in the London Med. Chir. Trans, vol. vi. 
P- 502. 1815.) In these situations, however, it 
is to be remembered that there was a co-operation 
of several circumstances conducive to the disease, 
viz. deteriorated air, a dull uniformity of life, de- 
pression of spirils, want of exercise, &c. &c. It 
is scarcely necessary to observe that the saline 
effluvia in sea-air has been alleged as the cause 
of scorbutus. It is obvious that a circumstance 
so constantly prevailing at sea and on its shores 
could never have had so partial a consequence, 
and that the disease has almost entirely disap- 
peared, though the cause alleged remains the 
same. It has been moreover remarked that there 
are few artificers so healthy as those who prepare 
salt from sea-water, and are thus continually ex- 
Vol. IV r .— 15 k* 



posed to the impregnated vapour which rises in 
the processes of drying and purifying this article. 
(Lind, ch. i. p. 53. Stevens on the Blood, p 
311. Lond. 1832.) 

The hypotheses which have been promulgated 
in explanation of the physical condition on which 
scorbutus, or, in technical language, its proximate 
cause, depends, have accorded with the revolving 
doctrines of general pathology, but have been 
chiefly founded on those principles which refer 
disease to morbid changes in the fluids, or else to 
a corresponding condition of the properties of the 
living solids. For the most part, and up to the 
present day, scorbutus has been attributed to the 
former, even by those who have ably advocated 
the opposite opinions with regard to disease in 
general. Much further investigation, however, 
into the elementary components both of the solids 
and fluids of the body in their healthy and morbid 
state, and into the influences of external agents 
upon them, than has hitherto been made, is requi- 
site to clear up the difficulties of this intricate 
question. The peculiar opinions on the subject 
which from time to time have elicited attention, 
require to he noticed in this place ; hut it must be 
premised that the principles of treating the disease 
founded upon them have been very inadequate to 
the end in view, which has been achieved most 
completely by observation alone, or, in other words, 
by that enlightened empiricism, which suggests 
the right application of established facts in the art 
of therapeutics, although much knowledge may 
be wanting to elucidate the nature of the changes 
produced in the body by which the object is 
effected. 

The early writers on scorbutus have applied the 
general doctrines of the humoral pathology to the 
explanation of its various phenomena ; more espe- 
cially ascribing them to a putrid state of the blood, 
occasioned, as it was supposed, by defect in the 
function of the spleen, this organ at the period 
having been considered essential to the process of 
sanguification. Willis, (Tract, sec de Scorbuto,) 
consistently with his pathological speculations in 
general, referred scorbutus to a state of djjscrasy 
of the blood, which he fancifully described as of 
two kinds, under the terms of the sulphureo-saline 
and the salino-sulphureous; the former to repre- 
sent, a supposed superabundance of sulphur, for 
the correction of which he taught that the deplet- 
ing system was requisite, and above all things the 
avoidance of the hot and acrid antiscorbutics; 
whilst, on the contrary, in the salino-sulphureous, 
when the salts of the blood were supposed to pre- 
dominate, he considered the warmer medicines 
were proper, and such as contained a volatile salt, 
together with preparations of steel and other tonics. 
The dyscrasy of the blood, he further presumed, 
was the occasion of a corresponding state of the 
nerves, or, according to his system, of the liquor 
nervosus; which thus secondarily, he imagined, 
conduced to the manifestation of some of the 
symptoms. The opinions of Boerhaave (Opera, 
cap. De Scorbuto) on this subject appear to have 
been equally hypothetical : he contended that scor- 
butus was occasioned by that part of the blood 
which constitutes the crassamentum being inordi- 
nately thick and viscid, and the serous portion too 
thin, salt, and acrid. The acrimony of this flub' 



114 



SCORBUTUS. 



he imagined was either ac.d or alkaline, according 
to the nature of the food by the use of which the 
disease appeared to be induced : if, as at sea, it 
had consisted of suited meats, or of such as yielded 
little nutriment, as a consequence that there would 
be. an acid, or, to use his own phrase, a muriatic 
acrimony ; but if the food had been in a putrid 
state, that the acrimonious principle would be al- 
kaline. 

Although Hoffman exposed the fallacy of the 
humoral pathology in general, his views of the 
nature of scorbutus coincided for the most part 
with those of Boerhaave; and Cullen, who first 
and most successfully controverted the same sys- 
tem of pathology, admitted its influence in giving 
rise to this disease. Presuming from the appear- 
ance of the blood, from that of the secretions and 
excretions, and from the fetor of the breath, that 
a morbid condition of the blood does give rise to 
it, he contends that a putrefaction or a nearer ap- 
proach to it than is consistent with health, is a 
necessary consequence of living entirely upon ani- 
mal food, without a frequent supply of vegetable 
aliment, and thereby of producing and evolving a 
larger proportion of saline matter. In confirma- 
tion of this, he observes that every interruption of 
perspiration, that is, the retention of the saline 
matter, contributes to the production of scurvy, 
whether produced by the direct application of cold, 
or by any other circumstance which might weaken 
the force of the circulation, such as the neglect or 
want of exercise, fatigue, and despondency of 
mind. It will be sufficiently obvious, he adds, 
that if the preternaturally saline state of the blood 
in scorbutus be admitted, the throwing into the 
body along with the aliment an unusual quantity 
of salt may have a great share in producing the 
disease. Even (he proceeds) supposing such salt 
to sutler no change in the animal body, the effect 
of it may be considerable ; and this will be ren- 
dered still more probable, if it may be presumed 
that all neutral salts consisting of a fixed alkali 
are changed in the animal body into an ammonia- 
cal salt, which he apprehends to be that especially 
prevailing in scurvy. (First Lines of the Practice 
of Physic, by William Cullen, M. D.) Sir John 
Pringle supported a similar doctrine, that scurvy 
was the result of "a gradually accumulating pu- 
trefaction" in the blood, from the putrescency of 
salted food, which he deemed the chief cause of 
the disease. (Obs. on Diseases of the Army, Ap- 
pendix, p. xci.) 

The theory of fixed air, which was considered 
the principle of cement or bond of union on which 
the firmness, soundness, and cohesion of bodies 
depends, was advanced by Macbride in support 
of the opinions which referred scorbutus to 
a putrescent tendency in the blood ; the loss of 
that principle appearing to him to account for 
the altered state of this fluid, and the method 
of cure depending on its restoration, which he 
proposed to effect by conveying it to the body by 
the free use of the infusion of malt and essence of 
wort. Dr. Trotter differed from his predecessors 
in his application of the pneumatic doctrines of 
pathology to this disease, the remote causes of 
which, in his view, tended to deprive the blood of 
oxygen ; and to the restoration of this principle 
through the medium of the acid fruits he attributed 



their antiscorbutic efficacy. " We are of op.mon," 
he remarks, « that the citric acid is decomposed 
by the organs of digestion and assimilation, after 
which the oxygenous principle is blended with 
the circulating mass." This supposition Dr. Trot- 
ter considers as further confirmed by the black- 
ness of the blood discharged, and by the speedy 
change to a florid hue which the fungous ulcera- 
tions assume within a few hours after the acids 
have been administered. (On Scurvy, p. 141.) 
Dr. Beddoes adopted the same hypothesis, but 
extended it to the abstraction of oxygen from the 
wnole system, in explanation of the phenomena 
of the disease. 

Lind disputed the idea of putridity of the blood 
in scorbutus, and referred the primary changes to 
a relaxation of the tone of the animal fibres, a 
weakening of the powers of digestion, together 
with a stoppage of perspiration, the tendency of 
which, he admits, was to produce spontaneous 
putrefaction, the process of nutrition being sus- 
pended. (Lind on Scurvy, p. 234.) This view 
of the subject was followed up and most ably ad- 
vocated by Dr. Milman, in an essay remarkable 
also for the elegance of its composition, published 
in 17S2. "Whether," says he, " I consider the 
nature of the causes producing scorbutus, or the 
actual state of the blood in the disease, or the se- 
cretions which occur in its progress, they all con- 
cur to make me believe that it does not consist in 
a putridity of the blood. Nor does there appear 
to be any quality which can be discerned or de- 
fined in the blood of scorbutic persons by which 
the nature of their disease can be characterized."' 
The theory which Dr. Milman has substituted, it 
would exceed our limits to enter into in detail, 
but it consists of the following propositions : — that 
scorbutus is not a disease of the fluids, but of the 
solids; that its seat is in the muscular fibre; that 
its proximate cause consists of a gradual diminu- 
tion of the vital power ; and that the subsequent 
diminished cohesion between the particles of the 
muscular tibres, and the tendency of these to pu- 
trefaction, are links of the chain. In reference to 
the action of salt provisions, he considers, with 
Lind, that they tend to excite scorbutus not by 
their saline, but by their indigestible nature, and 
through defect of nutriment occasion an enfeebling 
of the vital principle productive of languor in all 
the functions of the body, and ulteriorly of a 
general disposition to putridity. (Milman on 
Scurvy, chap, vi.) This view of the proximate 
cause of scorbutus is supported by the argument 
that all its predisposing causes are of a debilitat- 
ing nature, and by the extraordinary influence of 
mental impressions in favouring its occurrence as 
well as its prevention and cure, such impressions 
being considered inadequate to the occasion of a 
sudden chaise in the chemical condition of the 
fluids. The agency of such impressions, how- 
ever, through the medium of the nervous system, 
is supported by numerous illustrations in the phe- 
nomena of health and disease. On the other 
hand, it must be acknowledged that those means 
which appear to contribute in general to the 
strength and activity of the solids, such as fresh 
animal food, soups, wine, bark, and a variety of 
other tonics and stimulants, have been found to 
exert very inferior powers over the disease in coin- 



SC0RBUT1 S. 



115 



parison with the vegetable acids ; which, never- 
theless, are well known to produce an attenuating 
effect on the body, and this not unfrequently 
whilst they are accomplishing its cure. 

Broussais contends that in scorbutus, whatever 
may be its cause, there is first an irritation of the 
internal membrane of the digestive canal ; 2dly, an 
imperfect assimilation of the elements, especially 
of fibrin and gelatin, either in the tissues formed 
out of thein, or in the blood which directs them to 
different parts of the body ; 3dly, that in conse- 
quence of defect of nutrition a diminished cohe- 
sion of fibre ensues, which accounts, in his view, 
for the imperfect contractility and fragility of the 
muscular fibre, for the rupture of vessels and the 
escape of their fluids, and finally, for the easy 
disorganization of the issues on the occurrence of 
scorbutus. (Treatise on Physiology applied to 
Pathology, Transl. Philadelphia, 1832.) 

We shall conclude this part of the subject by 
noticing some observations of Andral, which ap- 
pear to us to be most consistent with all the facts 
on which an opinion of the nature of scorbutus 
can be established. In the threefold respect of the 
vital phenomena, intimate structure, and chemical 
composition, no line of demarcation can be drawn 
with strictness and precision between the blood 
and the solids. Physiologically speaking, it is 
impossible to conceive that one of these two parts 
of the same whole could be modified without the 
other being so likewise. On the one hand, inas- 
much as the blood nourishes the solids, and as 
without its presence they cannot support life, the 
state of the solids cannot but be influenced bv the 
state of the blood. The chemist might as well 
say that the nature of a body does not depend on 
the nature of the elements that compose it. On 
the other hand, the solids, considered with respect 
to their relations to the blood, form but two classes, 
the one contributing to make the blood, such as 
those concerned in the processes of absorption, 
digestion, arterial circulation, and respiration ; the 
other contributing to unmake it, those, namely, 
concerned in the processes of venous circulation, 
secretion, and nutrition. No one solid, therefore, 
can undergo the slightest modification without 
producing some derangement in the nature or 
quantity of the materials destined to form the blood 
or to be separated from it. Physiology, then, 
leads us to the conclusion that every alteration of 
the blood must be succeeded by a modification of 
the solids. Viewed in this light, there is no longer 
any meaning in the disputes between the solidists 
and the humorists ; and the system appears to 
constitute but one great whole, indivisible in the 
state of health as well as in that of disease. With 
regard to scorbutus in particular, he observes that 
the causes under which it is developed epidemi- 
cally, the symptoms that characterize it, the re- 
markable state of the blood itself, and the nature 
of the lesions discovered on examining the bodies, 
all combine to prove that this divease depends on 
a primary alteration of the blood. (Andral's 
Pathol. Anat. translated by Tow.isend and West, 
vol. i. p. 641 and 678.) 

Prevention of Scorbutus. — The prevention 
of scorbutus in this and in some other countries 
in which it formerly prevailed having been com- 
pletely effected, or rather the disease having dis- 



appeaied in consequence of the dietetic consump- 
tion by all classes of persons of fresh vegetable 
food at every season of the year, of drinks which 
contain their elementary principles, of water in a 
pure state, of milk, of fresh animal food, and the 
disuse, as an article of daily subsistence, of dried 
and salted meats, together with the general drain- 
age of the country, the greater security, dryness, 
and warmth in the dwellings, the improvements 
in clothing, and greater attention to cleanliness, 
it would be superfluous to enter into a formal de- 
tail of measures for its prevention on land ; more 
especially as the process of civilization advances 
us so much the farther from the sources of this 
and other epidemic diseases. But, although im- 
provements comparatively as great have been ef- 
fected in our naval economy, and have been suffi- 
cient to lead to the general extermination of scor- 
butus, yet under particular circumstances the 
greatest vigilance has been frustrated by the supe- 
rior power of its occasional causes, and their 
unceasing operation at sea renders unremitting 
attention to certain prophylactic measures neces- 
sary to ensure security against its occurrence. 
These consist of the removal, if possible, or, at 
least, of the counteraction of the predisposing and 
occasional causes of the disease ; and in the daily 
use of a certain quantity of lemon-juice, the pre- 
ventive efficacy of which is well established al- 
though its operation has not been satisfactorily 
explained. The application of such preventive 
measures has for the most part been happily illus- 
trated in the narrative of the memorable voyage 
of Captain Cook. To his sagacity we are indebted 
for the first impulse to those regulations by which 
scorbutus is so successfully prevented in our navy. 
It will be remembered that the crew of his prede- 
cessor Lord Anson, in a similar voyage of disco- 
very, had experienced the most dreadful havoc 
from this disease, and the prevention of it seemed 
to present as great difficulty to himself as any 
circumstance of his projected voyage. The main- 
tenance of the general health of his men he dis- 
cerned was the main point of security, and to 
command this he was especially careful that they 
should not be subjected to excessive or unneces- 
sary fatigue, and as much as possible that they 
should be protected from the noxious influence 
of a cold and damp atmosphere. In the first place 
he instituted three instead of two watches,* by 
which eight hours of uninterrupted rest were 
allowed to his men for four of duty ; their strength 
was consequently more recruited, and they were 
also less exposed to the weather than if they had 
been at watch and watch, and if necessary they 
had dry clothes to change. The hammocks and 
bedding every fine and dry day were not only or- 
dered upon deck, but each bundle was unlashed 
and so spread out that every part was exposed to 
the air. Besides the ordinary modes of white- 
washing and scraping the decks, stoves were kin- 

* Dr. Trotter disputes the advantage of this arrange- 
ment. "We," lie observes, "who see things on the 
gpot, and are daily accustomed to reason on the disci- 
pline of ships, are clearly decided in favour of two 
watches j our most accomplished and intelligenl officer* 
have also from experience put it beyond dispute."— Mt 
dical ami Chemical Essays by 'I nomas Trotter, M.D., p 
'J"). We believe, however, that three watches are now 
the more general custom in our navy, at least in aa'e 
ships. 



116 



SCORBUTUS. 



died and carried successively through them, which 
not only served to dry the ship, but, by heating 
the impure air below and rendering it specifically 
lighter than the common air, to make it rise and 
pass through the hatchways. In the torrid zone 
he shaded his people from the scorching sun by 
an awning over the deck, whilst in his course 
within the Antarctic circle they were provided 
with coats of woollen stuff, furnished with hoods 
to cover their heads. He attended also particu- 
larly to their diet, taking care that there should 
be always a plentiful supply of water both for this 
purpose and for the promotion of cleanliness. He 
prohibited the custom of using the fat which was 
boiled out of the salted meats in lieu of other food; 
having observed that symptoms of indigestion 
were the common consequence, and the latter not 
unfrequently a preliminary of scorbutus. (Mil- 
man, p. 33.) Captain Cook begins his list of 
preservative stores with malt. " Of this," he says, 
" was made sweet wort,* and given not only to 
those men who had manifest symptoms of the 
scurvy, but to such also as were considered most 
liable to it." This article, although he did not 
consider it adequate to the cure of scurvy, he 
praised as one of the best antiscorbutic medicines 
known in his day. Sooins or sowens,-]- an article 
of diet well known in Scotland, was also consi- 
dered by him of great antiscorbutic efficacy, and 
was dealt out to his men in messes sweetened 
with sugar and flavoured with some French prize 
wine, which, though sour, was thought to improve 
the flavour. Captain Cook was provided with 
lemon-juice prepared for sea use, but the neces- 
sary quantity not being understood, it was ne- 
glected and erroneously underrated. But the arti- 
cle of most extensive use for the same purpose 
was sour kroute (sour cabbage), well known in 
German diet. Sour kroute or croute (Saures 
Kraut, German ; literally sour herb or pickled 
cabbage,) is prepared by slicing the soundest and 
most solid cabbages in the way cucumbers are 
used in this country. In this state they are put 
into a barrel in layers, hand high, and over each 
is strewed a handful of salt and caraway seeds ; 
in this manner it is rammed down, stratum super 
stratum, till the barrel is full, when a cover is put 
over it, and it is pressed down with a heavy 
weight. After standing for some time in this 
etate, it begins to ferment, and it is not till the 
/ermentation has entirely subsided that the head 
is fitted to it, and the barrel is finally shut up and 
prepared for use. Vinegar, as some have sup- 
posed, is not employed in its preparation. It was 



* Infusion of malt, proposed as a preventive as well 
as a remedy for scorbutus, was recommended by Dr. 
Macbride on the supposition that it would ferment after 
being taken into the stomach, and give out carbonic 
acid gas— its alleged remedial principle. Laying aside 
all regard to the theory on which it was suggested, expe- 
rience seems to have determined that it is a nutritious 
beverage, and that it has heen productive of considerable 
advantage in the objects for which it was proposed. It 
has heen used rather as an article of diet than medicine, 
and has been generally directed in the quantity of from 
one to lour pints daily. 

t This food is prepared by putting some oatmeal into a 
wooden vessel, pouring hot water upon it, and continu- 
ing the infusion till the liquor begins to taste sourish, 

e. till a fermentation coim-s on, which, in a place mo- 
derately warm, may he in the space of two days. The 
water is then poured off from the grounds, and boiled 
■town tG the consistence of a jelly. 



recommended to the use of the British navy by 
Dr. Lind, the great freedom of the Dutch from 
scorbutus having been attributed to the lice uso 
of it. The quantity allowed was two pounds 
weight to each man per week, besides a pound 
and a half to two pounds with every gallon of 
peas, for making soup. He was supplied also 
with portable soups, which, as far as possible, he 
made the vehicle of vegetable aliment ; and by 
such means, and by diminishing the quantity of 
salted provision, to his honour be it said, he pre- 
served his crew from scorbutus, although the pe- 
riod of his voyage had extended to three years 
and eighteen days, passed in all latitudes from 
52° N. to 71° S. It is still more remarkable that 
of a company of 118 men he lost but one, who 
there is reason to suppose was labouring under 
phthisis previous to his departure from England. 
The comparative exemption of our own navy 
from scorbutus during the last thirty-five years, 
is, we conceive, to be attributed in no small degree 
to the regulations enforced for the maintenance of 
the general health of the sailors, together with the 
improvements by which this object has been ad- 
vanced. A frequent inspection of the men's 
clothing is made, to ascertain whether there is a 
sufficiency for the purposes of personal cleanliness 
and of protection from the effects of the weather, 
both as regards their bedding and wearing apparel. 
The strictest attention is given to the ventilation, 
cleanliness, and dryness of ships. For what are 
called windsails (which were found to be imper- 
fect and inconvenient ventilators, from their use 
being inadmissible with hatches closed in bad 
weather when they are most wanted, and when 
the men were asleep, on account of the large 
volumes of cold air which they admitted) has 
been substituted a contrivance free from those ob- 
jections, borrowed from a French frigate : this 
consists of square wooden trunks (for which brass 
tubes have since been used) running from the 
hold or lower deck and terminating in the open 
air. A contrivance which has still more recently 
been preferred, is a funnel placed vertically near 
the middle line of the ship, before the foremast, 
leading through the forecastle-deck where there is 
neither hatchway nor ladder, and under which 
are the sleeping-places. The removal of all offen- 
sive substances by sweeping and scraping has 
been much more particularly attended to than 
formerly ; but instead of washing the decks, par- 
ticularly in cold or damp weather, the preserva- 
tion of dryness, so essential to comfort and health, 
as well as to the prevention of scorbutus, has been 
carefully studied, and rubbing with hot sand, 
scraping, and portable fires, have been generally 
substituted. By these precautions, also, the de- 
teriorating agency of moisture on the ship's pro- 
visions, as well as on other articles in common 
use, has been prevented, and thereby a source cut 
off, which otherwise might have been largely con- 
ducive to the generation of this disease. " This 
important point has been further promoted by 
having portable fires in iron stoves carried all 
over the ship. Formerly a prolific source of foul 
air and bad smells in ships were the putrescent 
matters absorbed and retained by gravel, sand, 
and other earthy substances used for ballast, for 
which are now substituted small masses or pigs 



SCORBUTUS. 



11? 



of iron ; and iron tanks, instead of the lower tier 
of water-casks, are placed over the iron ballast. 
The tanks adverted to are cubes of four feet in 
dimensions, each capable of containing about two 
tons of water : as they are not corruptible, like 
wood, they impart no bad quality to it, and by 
their durability insure an ample supply; whereas 
the decay of casks in long voyages and in remote 
parts of the world where they cannot be replaced, 
has occasioned the utmost distress. 

The improvement suggested by Sir Robert 
Seppings, Surveyor of the Navy, and explained 
by him in the " Philosophical Transactions" for 
1814, the object of which was to add to the 
strength, solidity, and durability of ships, has been 
highly conducive to the purity of the air in them ; 
first, by the obliteration of those cavities under the 
floor of the hold which used to be the receptacle 
of filth and vermin, and the perpetual sources of 
offensive and noxious exhalations; secondly, from 
commanding at all times the most perfect ventila- 
tion, the timbers of the frame which run up the 
side of the ship maintaining a constant communi- 
cation with the open air, with the hold and spaces 
between the decks; thirdly, by virtue of this new 
construction, a ship being less liable to leakage, 
together with the new method of ballasting, all 
the unwholesomeness and offensiveness belonging 
to bilge-water is done away. 

The promotion of the general health of seamen, 
and consequently the prevention of scorbutus, is 
further effected by the superior quality of all the 
articles of victualling ; by the plentiful supply, 
when in port or within reach of it, of fresh meat, 
succulent vegetables and fruits ; and when at sea, 
by the daily use of cocoa for breakfast, or of tea, 
coffee, sugar, &c. and a less proportion of ardent 
spirits. To these are to be added the more liberal 
allowance as to quantity of the diet at sea ; and, 
under circumstances particularly conducive to the 
generation of the disease, an increased allowance 
of farinaceous articles in lieu of the necessary 
diminution in the rations of salted meats. The 
former consist for the most part of biscuit, wheat- 
flour, oatmeal, peas, and pearl barley, and, as sub- 
stitutes for fresh vegetables, though of infinitely 
inferior antiscorbutic efficacy, dried raisins, cur- 
rants, prunes, preserved fruits, spices, pickles of 
various kinds, vinegar, molasses, and as much 
wine for each man as is equivalent to one-half of 
the allowance of spirits, the latter being suspended. 
(See Paper by Sir Gilbert Blane on the Health 
of the Navy.— Med.-Chir. Tr. vol. vi.) 

But to the general supply of lemon-juice, judi- 
ciously dispensed to ships of war since the year 
1795, Sir Gilbert Blane ascribes the complete 
eradication or rather the prevention of scorbutus. 
Usually, after ships have been a fortnight at sea, 
to every individual in them a fluidounce of lemon- 
juice mixed with an ounce and a half of sugar is 
served out daily, which, with the addition of water 
and of wine or spirits, affords a grateful beverage, 
the use of which is enforced when the neglect of 
it is suspected, or under particular apprehension 
of the invasion of the disease. It is in conse- 
quence of this prophylactic, Sir Gilbert Blane in- 
fers, that there are now many surgeons in the 
navy of long standing who have never seen a case 
of the disease ; and, as appears from the inspec- 



tion of a great number of journals, that it has 
either not appeared at all, or else in so slight a 
degree that it was speedily checked by an increase 
of the quantity of the antidote. No other remedy 
yet known can ward off, he observes, this dreadful 
scourge of mariners under the use of salt provi- 
sions for an indefinite length of time ; nor does it 
produce, he adds, any bad effects on the constitu- 
tion like some specifics in other diseases. The 
decisive superiority of lemon-juice has led to the 
disuse of a variety of articles formerly in repute 
for the prevention of scorbutus, such as sour 
kroute, infusion of malt, essence of spruce, elixir 
of vitriol, &c. Of the sour kroute we have already 
spoken ; and we have alluded to the use of the 
infusion of malt. " Although," says Dr. Trotter, 
" I have no idea of impeaching the veracity of 
those who established the credit of the malt pre- 
paration, yet I must beg leave to observe that in 
my own practice I have not seen it attended with 
any good effects. Lind speaks of it only as a 
very nourishing liquor, well adapted for scorbutic 
patients." The essence of spruce,* or rather 
spruce-beer, the form in which it has been com- 
monly used, seems to possess, says Sir Gilbert 
Blane, similar and equal antiscorbutic virtues 
with fermented malt liquor, as beer or porter; and 
it has this advantage, that the materials for pre- 
paring it can be readily carried about and used as 
occasion may demand. (Observations on Diseases 
of Seamen, p. 302.) The use of elixir of vitriol 
in the cure of scorbutus was of very early date, 
and, on the principle that what will cure will 
prevent, it was recommended to the use of the 
navy by Dr. Huxham, who states that it had been 
found " greatly serviceable." The assertion, how- 
ever, is not corroborated by general experience, 
and the converse of the proposition seems more 
applicable to the circumstance in question ; at 
most, probably, it had been useful in correcting 
the unwholesome qualities of impure water, foi 
which purpose it has been occasionally added to 
it in very minute proportion. 

We have yet to mention the necessity, in a pro- 
phylactic point of view, of regular exercise. Al- 
though often called upon for extraordinary exer- 
tion, it occasionally happens with seamen that 
there are long intervals in which systematic atten- 
tion to this branch of hygiene is especially requi- 
site. Independently of its direct influence on the 
maintenance of the general health, it may be made 
subservient to an equally important object in the 
prevention of scorbutus, viz. to occupation of mind t 
and in sailors, its diversion from those gloomy 
views to which, under suspension of duties, they 
are peculiarly prone; a fact which, however as- 
tounding it may at first appear, reflection will as- 
sent to be consistent with his condition. To 
separate, as his duties require him, under perilous 
circumstances, from those to whom he is linked by 
the bonds of affection ; to be peculiarly subjected 
to disappointment, and to unexpected delay in 
schemes to which the brightest hopes are attached •, 
to have been taught by reason and experience that 

* Captain Dall states that the essence of spruce a little 
diluted did wonders at St. Dominjro, both in prevention 
and cure. It acted as a purgative, anil was therefore 
carefully administered; it. sat on the stomach when 
every thing else was rejected. — Med. Naut. by T. Tm|. 
ter, vol. i. p. 349. 



118 



S C R B U T u s . 



the perils which he has no fear to encounter are 
frequent and more than ordinarily liable to frus- 
trate them; and in many instances the necessary 
system of moral discipline being wholly inconsist- 
ent with the physical condition, are circumstances 
sufficient to account for the state of mind above 
mentioned. The despotic system, formerly in 
force, of impressing seamen, doubtless had a pow- 
erful influence in predisposing them to disease. 
Their country, says Dr. Trotter, has taken ad- 
vantage of their situation, and their service is in- 
dispensable to the safety of its commerce and terri- 
tory. It is only therefore mild treatment that can 
reconcile an impressed sailor to his fate, and if he 
be so unfortunate as not to overcome it, some fatal 
disease, as scurvy, will be the consequence ; among 
people of this description it first makes its appear- 
ance. An officer, therefore, cannot too minutely 
study the genius and the temper of those he has 
to command ; but the good effects of it and the 
satisfaction he will experience, will more than 
repay his assiduity. 

In the narrative of Captain Parry's voyage al- 
ready referred to, it appears that that able officer 
was fully impressed with the expediency of amuse- 
ment as well as of exercise for the preservation of 
the health of his men, and was particularly aware 
of the antiscorbutic efficacy of occupations being 
afforded to them. The mode of their pursuance 
must depend on the circumstances which are pre- 
sent, and much of the advantage must arise from 
the ingenuity and address with which the means 
are devised. The narrative of Captain Parry's 
expedition to the Polar seas affords a happy illus- 
tration in point, many circumstances of it having 
been congenial to the production of scorbutus, but 
which, nevertheless, by salutary precautions, was 
most successfully opposed. Although some of 
these have been already discussed, their practical 
application with that of others is so advantageously 
set forth in the following passage, that no apology, 
we conceive, is necessary for transcribing it. " The 
commander finding himself shut in for a long and 
dreary winter, devoted his attention, with judicious 
activity and a mixture of firmness and kindness, 
to mitigate those evils which even in lower lati- 
tudes had often rendered an arctic winter so fatal. 
His provisions being very ample, he allowed the 
sailors weekly a pound of Donkin's preserved 
meat and a pint of concentrated soup, instead of 
a pound of salt beef; beer and wine were served 
instead of spirits ; and a certain allowance was 
made of sour krout, pickles, and vinegar. The 
sailors were also called together daily and made to 
swallow a quantity of lime-juice and sugar in 
presence of the officers ; their improvidence being 
such as to afford otherwise no hope of their spon- 
taneously imbibing this salutary draught. Their 
gums and skins were also regularly examined, in 
order to detect scurvy in its earliest symptoms. It 
was necessary to be very economical of fuel, the 
small quantity of moss and turf which could be 
collected being too wet to be of any use. By 
placing the apparatus for baking in a central posi- 
tion, and by several other arrangements, the cabin 
was maintained in a very comfortable temperature ; 
but still, around its extremities and in the bed- 
places, steam, vapour, and even the breath settled, 
lirst as moisture and then as ice ; to dry and re- 



move these annoyances became therefore a part of 
their daily employment." 

Exercise it is stated, was enforced on the men 
when they were prevented from leaving the vettel, 
by oblHng them to run round the deck to the 
tune of an organ ; this they did not at first en- 
tirely relish, but no plea against it being admitted, 
they converted it at last into a matter of frolic. 

To keep their minds agreeably occupied, schools, 
masquerades, and plays, were adopted ; in refer- 
ence to the latter it is observed that the very ex- 
pectation thus raised among the seamen, and the 
bustle of preparing a room, were extremely salu- 
tary, and when the North Georgian Theatre 
opened, with " Miss in her Teens," these haidy tars 
were convulsed with laughter, not a little excited 
perhaps by viewing their officers in the singular and 
novel position of stage performers. At all events 
the Arctic management was extremely popular. 
As the small stock of plays contained in one or 
two chance volumes was soon exhausted, original 
compositions were produced and afterwards formed 
into a collection. The officers had another source 
of amusement in the North Georgian Gazette, 
of which Captain Sabine became editor, and all 
were invited to contribute to this chronicle of the 
frozen regions. Even those who hesitated to ap- 
pear as writers enlivened the circle by severe and 
good-humoured criticisms. 

Treatment. — Recovery from scorbutus, to use 
an expression of Lind's, presents a remarkable in- 
stance of the quick diminution of the effect from 
the cessation of the cause ; an observation which 
has been so amply confirmed by experience that it 
may be regarded as a most important axiom in the 
therapeutic consideration of the disease. There 
are remedies, nevertheless, which expedite and 
even effect its removal under disadvantageous cir- 
cumstances, and this with a degree of rapidity 
which, considering its apparent ravages, seems 
most extraordinary and peculiar to itself, the more 
so from our knowledge of its nature being very 
imperfect, and the salutary operation of such re- 
medies by no means obvious. We reject theory, 
therefore, from our consideration of this part of 
the subject, in the spirit of the following remark 
of one who has well appreciated its importance in 
practical medicine : " Cujus autem rei non est 
certa notitia, ejus opinio certum reperire remedium 
non potest. Verumque est, ad ipsam curandi ra- 
tionem nihil plus conferre quam experientiam." 
(Celsus, lib. i.) 

It has been found an essential step to the relief 
of a person suffering from scorbutus that he should 
have the advantage of a dry atmosphere, both as 
regards the apartment which he inhabits, and the 
various articles of his bedding and wearing apparel. 
Next to this, to gratify the cravings of his appe- 
tite, an instinctive index, apparently, to the chief 
corrective of his disease by a satisfying supply of 
esculent fruits and fresh vegetables : « be they of 
any sort," says Lind, and all experience has veri- 
fied the remark, « they will for the most part prove 
effectual." At different periods, however, a spe- 
cific vinue in the cure of scorbutus has been at- 
tached to particular articles of the vegetable king- 
dom, and those which are succulent and possessed 
of an aromatic quality, especially the alkalescent 
plants of the class tetrad'/ namia, have been re- 



SCORBUTUS. 



119 



garded as powerfully antiscorbutic ;* but that 
their power in this respect does not depend on 
their alkalescent property is proved by the fact 
that the vegetables and fruits in which the acid 
principle abounds have been alike efficacious, and 
even in a still higher degree. Of the latter, those 
of the genus Citrus, and of the natural order Hes- 
peridfc, viz. the Citrus medica, lemons — C. auran- 
tium, oranges — C. acida, limes — C. decumana, 
shaddocks — particularly the three first, have ob- 
tained pre-eminent repute, even to the extent of 
being considered specifics — a denomination to 
which they appear to be as much entitled as me- 
dicines adapted to the cure of any disease. Their 
efficacy, however, having been gainsayed by a 
physician whose writings have attracted considera- 
ble notice, - )" and their claim to therapeutic estima- 

* Formula for the preparation of medicines for the 
cure of scurvy were formerly inserted in the Pharmaco- 
peias cif London, Edinburgh, and Dublin, under the titles 
ofSucci Scorhutici and Succi ad Scoruuticos; these were 
compounded of the juices of garden scurvy grass (coch- 
learia officinalis); hrooklime (veronica beccabunga); 
water-cresses(nasturtium officinale); and Seville oranges. 

these, of the infinite number of anti-scorbutics 
which have been in great popular estimation, and com- 
monly recommended by medical writers until within the 
last half century, the chief are the horse-radish (cochlea- 
ria armoracia); garden purslane (pnrtulaca oleracea) ; 
black and white mustard (sin apis alba et nigra); the 
biting stone crop (sedum acre); celandine (chelidonium 
minas); marsh trefoil (trifolium palnstre); common and 
Roman wormwood (absinthium latifolium et tenuifo- 
litim); fumitory (fnmaria purpurea); hemp agrimony 

mini cannabiniiml ; the garden radish (raphanus 
Bativus) ; the garden lettuce (laetuca sativa) ; the garden 
endive (cichonium endivia): common juniper (juniperus 
communis); dandelion (leontodon taraxacum); the com- 
mon onion (allium cepa); garlic (allium sativum); the 
leek (allium porum); squill (scilla maratima) ; the po- 
tato, sliced and raw in vinegar (solanum tuberosum) ; 
the fir (pinus abies) ; sorrel (rumex acetosa) ; &c. Bishop 
Berkeley wrote a treatise, in 1744, to insist on the cura- 
tive efficacy of tar water in scorbutus; and Alston, 
(17a0) another on the superiority of lime-water for the 
same purpose. 

t Dr. Stevens ; see his Observations on the Healthy and 
Diseased properties of the Blood. 8vo, London, 1832. Dr. 
Stevens's denunciation of the treatment of scorbutus by 
the administration of vegetable acids, seems to rest on 
the general effect observed of their admixture with the 
blood out of the body— viz. that of changing its colour 
from red to black, and by consequence, on the supposi- 
tion that in this as well as in some other diseases in 
which the latter quality has particularly characterized 
the appearance of that fluid, such means would be found 
not only to keep up but to aggravate the disease. Tins 
morbid appearance Dr. Stevens attributes to its priva- 
tion of its saline constituents, and hence in scurvy, and 
in other diseases in which it is in a black and vitiated 
condition, he asserts that " the natural saline waters, or 
tin' active non-purgative alkaline salts, act like a charm" 
(p. 30'J) — it being the property of these substances (con- 
trary to that of the vegetable acids) on their addition to 
black blood nut of the body to change its hue to red. On 
Hits principle Dr. Stevens explains the good effect attri- 
buted to the nitrate of potash in the treatment of scor- 
butus, anil on the same ground would administer the mu- 
riate of soda, to the excessive use of which its production 

irved in the text) has been commonly attributed. 
Dr. Stevens, however, in another place (p. 451), has 
stated that during a residence of twenty years in the 
West Indies only one case of scurvy had come under his 
notice, and that case, he asserts, was decidedly brought 
on by theexcessive use of citric acid which an American 
gentlemaiUhad been recommended to use as a preventive 
against yellow fever; consistently with his theory too, 
that on its being laid aside and the carbonate of soda 
substituted, the patient was completely cured in three 
weeks. "To those," he observes, "who are disposed to 
see the contrast betwixt the effects of the neutral salts 
and the citric acid in the treatment of scurvy, I would 
recommend the perusal of Mr. Cameron's paper on this 

Which they will find in the Medico-Chirurgical 
Review, for 1829"— more conveniently, perhaps, for that 
purpose inserted in our text, and which, if considered 
with that degree of candour which the cause of thera- 
peutic science demands, would only serve to prove what 
little credit is due to the following remark of his own, 



tion resting entirely on experience of their effects 
and deference to authority confirmatory of it, we 
conceive it necessary to enter into detail of evi- 
dence in support of the treatment of the disease 
by the remedial agents the efficacy of which has 
been denied. 

The earliest notice we can find in reference to 
this point is in the third epistle of Rousscus, 
dated 1564, wherein it appears that some Dutch 
sailors who were suffering from scurvy, and the 
cargo of whose ship on their return from Spain 
consisted of lemons and oranges, accidentally dis- 
covered that their use was the means by which 
they recovered their health. "And if people," 
observes Lind, (p. 160,) "had been less assidu- 
ous in finding out new remedies, and trusted more 
to the efficacy of these fruits for preventing this 
fatal pestilence to seamen, the lives of many 
thousand sailors, and others, especially during the 
last war, might in all probability have been pre- 
served. But some have been misled to recom- 
mend many other things, as of equal, if not su- 
perior, antiscorbutic qualities to these ; and have 
reduced them to a level with other acids, and 
many falsely supposed antiscorbutic medicines ; 
from whence the many unhappy disappointments 
hitherto met with in preventing this disease at sea 
seem to have arisen." 

In 1593, Sir Richard Hawkins experienced the 
antiscorbutic efficacy of lemon-juice in his crew, 
who were attacked by it in its virulent form within 
three or four degrees of the equinoctial line. In 
a work of considerable merit, entitled the Surgeon's 
Mate, or Military and Domestic Medicine, by John 
Woodall, master in surgery, dated London, 1636, 
we find an excellent disquisition on scurvy, and 
the following apposite remarks : " further expe- 
rience teacheth, which I have oft found true, that 
where a disease most raigneth, even there God 
hath appointed the best remedies for the same 
grief, if it be his will they should be discovered 
and used ; and note, for substance, the lemmons, 
limes, tamarinds, oranges, and other choice of 
good helps in the Indies, which you shall find 
there, do farre exceed any that can be carried 
thither from England, and yet there is a good 
quantitie of juyce of lemmons sent in each ship 
out of England by the great care of the merchants, 
and intended only for the reliefe of every poore 
man in his neede, which is an admirable comfott 
to poore men in that disease. Also I finde we 
have many good things that hcale the scurvy well 
at land, but the sea chirurgeon shall do little good 
at sea with them, neither will they indure. The 
use of the juyce of lemmons is a precious medi- 
cine, and well tried ; being sound and good let it 
have the chiefe place for it will deserve it, the use 
whereof is : It is to be taken each morning, twv, 
or three spoonfuls, and fast after it two houres, 
and if you add one spoonful of aqua vitx thereto 
to a cold stomack it is the better. Also if you 
take a little thereof at night it is good to mixe 
therewith some sugar, or to take of the syrup 

(p. 264.) " With respect to scurvy it would not be ditn 
cult to prove, from the writings of Trotter and others, 
that this disease, which at one period was so distressing 
in the British navy, was frequent and fatal almost ex' 
actly in proportion to the quantity of citric acid whic> 
was used as a preservative, and unfortunately also as n 
cure for the disease." 



120 



SCORBUTUS. 



thereof is not amisse. Further note, it is good to 
be put into each purge you give in that disease. 
Some chirurgeons also give of this juice daily to 
the men in health as a preservative, which course 
is good if they have store, otherwise it were best 
to keep it for need." In want of these he adds, 
" use the juice of limes, oranges, citrons, or the 
pulp of tamarinds, and in want of all these use 
oyle of vitriol], as many drops, as may make a cup 
of beere, water, or rather wine if it may be had, 
onely a very little as it were sower." In another 
place he writes, " And generally note that bitter 
and sower medicines prevail most to the cure of 
this griefe, amongst which you have that are ap- 
proved goode thereto, those that follow as chiefe, 
juyce of lemmons, of limes, of citrons, and 
oranges." In the account of his voyage to the 
East Indies, published in 1683, Dellou, a French 
physician, recommends for the prevention of 
scurvy, that each person on board should provide 
himself with the juice of citrons, lemons, and 
dried fruits, especially prunes. The same reme- 
dies we find recommended in the treatise of Mar- 
tin Lister, published in 1694. 

It is remarkable, however, that epidemic scurvies 
were allowed to rage in various parts of the world, 
and in none more than in the British navy, for 
more than a century and a half after Woodall 
had pointed out the usefulness of lemon-juice, 
without its being generally employed. So com- 
plete was this neglect, that in 1740, when Lord 
Anson proceeded on his circumnavigation, no 
provision of any kind appears to have been made 
against the disease, and we find Mr. Walter, the 
chaplain of the expedition, and discriminating 
historian of it, declaring that " in some instances 
the prevention and cure of the malady could not 
be effected by any management or remedies which 
could be made use of at sea :" (p. 113.) But it 
is mentioned that on nearing the island of Tinian, 
lat. 15°. 8'. north, and in 114°. 50'. west longi- 
tude from Acapulco, it was part of a very grateful 
account of it they obtained from a Spanish pri- 
soner, (hat it afforded plenty of lemons, limes, 
sweet and sour oranges, cocoanuts, and bread-fruit. 
Wc are informed also that on making shore their 
sick amounted to 128, and notwithstanding the 
extreme debility of the greatest part, twenty-one 
of them dying on the day of their arrival and the 
ollowing day, yet during the whole two months 
n which they staid there, they did not lose above 
ten more, and that the remainder reaped such 
benefit from the fruits of the island, and " in 
particular {hose of the acid kind, that within a 
weelc most of them were so recovered as to be 
able to move about without assistance." 

The calamities of this unfortunate expedition, 
and the sufferings they underwent, created a ge- 
neral interest, not only with medical men, but 
with the public at large, on the cause and nature 
of the disease, and the most likely means of con- 
trolling its ravages. 

The stamp of correct observation founded on 
most extensive experience, which Dr. Lind's 
treatise on the subject, published in 1753, has 
been always acknowledged to bear, renders his 
testimony of the highest worth. " The result of 
all my experiments was," says he, "that oranges 
and lemons were the most effectual remedies for 



this distemper at sea. I am apt to think oranges 
preferable to lemons, though, perhaps, both gran 
together will be found most serviceable. In 
another case, » I cannot omit upon this occasion 
observing what caution is at all times necessary in 
our reasoning on the effects of medicine, even in 
the way of analogy, which would seem the least 
liable to error. For some might naturally con- 
clude that these fruits are but so many acids, for 
which tamarinds, vinegar, sp. salis., elixir, vitriol. 
and others of the same tribe would prove excel- 
lent succedaneums. But upon bringing this to 
the test of experience, we find the contrary. Few 
ships have ever been in want of vinegar, and for 
many years before the end of the late war all 
were supplied sufficiently with el. vitriol. Not- 
withstanding which the Channel fleet often put 
on shore a thousand men miserably overrun with 
this disease, and many hundreds besides died in 
their cruises. Upon those occasions tar-vvalcr, 
salt-water, vinegar, and el. vitriol, especially, with 
many other things, have been abundantly tried to 
no purpose; whereas there is not an instance of 
a ship's crew being ever afflicted with this disease 
where the before-mentioned fruits were properly, 
duly, and in sufficient quantity administered." 

Again, says this observer, " in seemingly des- 
perate cases the most quick and sensible relief was 
obtained from lemon-juice, by which I have re- 
lieved many hundred patients labouring under 
almost intolerable pain and affliction from this dis- 
ease, when no other remedy seemed to avail." 
Finding the acid to operate violently upon the 
stomach and bowels of those who were much 
weakened, he recommended the addition of wine 
and sugar, as constituting the best antiscorbutic, 
and was in the practice of ordering about four 
ounces and a half of lemon or lime-juice, and two 
ounces of sugar, to be put into a pint of Malaga 
wine, which he thought sufficient for any weak 
patient to take in twenty-four hours. Dr. Trotter, 
however, states as the result of his experience that 
any such preparation was unnecessary, and that 
the happiest effects were produced by allowing the 
patients to suck the juices immediately from the 
fruits themselves. 

In another place Dr. Li»d says, " summer fruits 
of all sorts are here in a manner specific, viz., 
oranges, lemons, citrons, apples, &c. ;" he more- 
over devised a method of preserving the juice of 
the two first-mentioned, so as to render them 
available at all times and in all climates, whether 
in the midst of the ocean or under the arctic circle. 

The testimonies of Sir Gilbert Blane and Dr. 
Trotter in favour of the antiscorbutic efficacy of 
these fruits are equally strong, and when we con- 
sider the extensive opportunities of observing this 
disease which fell to the lot of these three eminent 
physicians, their qualifications for forming correct 
opinions, and the immense mass of evidence ad- 
duced by them in support of the remedies in ques- 
tion, the conclusion is irresistible that their adapta- 
tion to the removal of this disease is established 
on as firm a basis as that of any article of the 
materia medica to any disease whatever. The late 
venerable and talented director of the medical de- 
partment of the navy, has in the year 1830 con- 
firmed the opinion he gave to the world of these 
remedies in 1785, by the triumphant fact that the 



SCORBUTUS. 



121 



scurvy has been prevented, subdued, and totally 
rooted out of the navy by the general use of lemon- 
juice, supplied for the first time at the public ex- 
pense in the year 1795, and which operated so 
speedily that in less than two years afterwards it 
became extinct and has remained so. (Brief State- 
ment of the Improvement of the Health of the 
Navy, by Sir Gilbert Blane, M. D., London, 1830.) 
Of all the articles either for medicine or diet he 
had observed for the cure of scurvy, lemons and 
oranges are of much the greatest efficacy. They 
are real specifics, if anything deserves that name ; 
but upon what principle their superior efficacy 
depends, and in what manner they produce their 
effect, he acknowledges that he was wholly at a 
loss to determine, the only sensible effect being a 
small increase of some of the secretions. In an- 
other place he says that he has never seen the 
scurvy resist the juice of these fruits, and in the 
perusal of several hundreds of surgeons' journals 
that he had met with only two cases which seemed 
to resist it. " It is sui generis — nil simile nee se- 
cundum." " It may be affirmed with truth that 
it performs not only what no other remedy will 
perforin in this disease, but what no known remedy 
will effect in any known disease whatever." (Me- 
dico-Chirurgical Transactions, vol. vi., p. 500. 
London.) 

Dr. Trotter, in his account of the health of the 
fleet in 1795, remarks, " from the middle of March 
to the 12th of June, upon comparing notes from 
the reports of surgeons, it appeared that not less 
than three thousand cases of scorbutus (the sub- 
jects of which were unfit for duty) had been 
cured on board ship by the fruit or preserved juice, 
and that twice that number with slighter symp- 
toms were relieved by the fruit, the juice, and sa- 
lads." (Medicina Nautica, vol. i. p. 134.) Mr. 
Moffat, surgeon to H.M.S. Triumph, 1796, in 
which scurvy had prevailed to a considerable ex- 
tent, reported to Dr. Trotter, " that the scorbutic 
cases as usual yielded to the lemon-juice in every 
instance. So general," he adds, " was the ten- 
dency to it, that almost every case of contusion 
or ulceration was attacked with the disease, nor 
could their cure be accomplished without a few 
doses of the acid." (Ibid. p. 157.) In p. 151, 
vol. i. of the Medicina Nautica we find the fol- 
lowing entry: — "Jan. 2, 1796. This day the 
squadron under Rear-admiral Harvey arrived at 
Spithead, after an absence of eighteen weeks from 
England, bringing three thousand soldiers from 
Isle Dieu. This squadron had been repeatedly 
supplied with refreshments from Plymouth and 
Cork. The scurvy appeared nevertheless in all 
the shipf:, but was quickly cured by lemon-juice." 
In the report of Mr. Kenning, surgeon, of the In- 
vincible, dated June 8, 1795, (Med. Nautica, vol. 
i. p. 411,) in which ship there had been in all one 
hundred and sixteen cases of scorbutus, it is stated 
thai of twenty-eight attacked in the month of 
April, the worst were supplied with three lemons 
and one orange daily, the others with two lemons, 
and that in every instance after the third day, and 
sometimes sooner, they began to recover, and 
were shortly well. In May fifty-six fresh cases 
were treated with the same remedies with equal 
success. In the latter end of the month the fruit 
was all expended, but there still remained a few 

Vol. IV.— 16 l 



gallons of lemon-juice, which lasted until the 2d 
of June. Patients continued to apply, and two 
of those that had been recovering before the le- 
mons were expended, got worse in the short inter- 
val from the 2d to the 5th day, the day on which 
a fresh supply of lemons was received. Their 
complaints were soon checked by the fresh fruit, 
but not so fast by the juice, though it was given 
in some cases to a pint per day." In Lord Brid- 
port's squadron, which (in 1795) had suffered 
severely from scorbutus, there was not a case in 
which lemon-juice was given where it did not 
produce a cure in the space of a few days. (Ibid, 
vol. i. p. 417.) 

Dr. Baird, surgeon of the Hector, a ship in 
which scorbutus prevailed to a considerable extent, 
gives the following account : " I began with giving 
the lemon-juice in the quantity of an ounce and a 
half daily, and encouraged by the material change 
I perceived in about four days, I increased it to 
three or four ounces per day, always taking care 
to join a sufficient quantity of sugar to prevent it 
from irritating the bowels ; in twelve or fourteen 
days the worst of them were able to return to 
duty, every symptom being then removed, except 
some slight degree of stiffness in the hams, which 
gradually wore off." " When I consider," he 
adds, " the alarming progress which the scurvy 
was making among the Hector's ship's company 
previous to the administration of lemon-juice as a 
preventive, the sudden check given to it after- 
wards and its powerful effect in very bad cases, I 
think I shall not be accused of presumption when 
I pronounce it, if properly administered, a most 
infullible remedy, both in the cure and prevention 
of the disease." (Ibid. vol. i. p. 426.) 

Mr. Walker, surgeon of the Hannibal in 1795, 
writes, "during our late cruise, numbers were 
afflicted with the disease (scurvy) ; the citric acid 
to the quantity of three ounces per day cured 
many, and always stopped its progress. It was 
given with wine in the following manner : 
R Vin. rub. ^ii. 
Succi lim. .^i. 

Sacchari, i^ii. m. fiat haustus ter 
die sumendus." (Ibid. vol. i. p. 407.) 

Dr. Trotter himself remarks that the superior 
efficacy of the acid fruits in the cure of scurvy is 
so well ascertained, that it might seem superfluous 
to add any fresh remark to what is so fully admit- 
ted. These articles are certainly more beneficial 
as they approach to the nature of the citric acid, 
which is that abounding in the lime, lemon, &c. 
Our summer fruit in this country, such as the 
apple and gooseberry, lose their acidity as they 
come to maturity, so that in their immature state 
they contain most of that principle valued in the 
cure of scurvy. "In all cases of scurvy," he 
adds, " which I have attended, I have remarked 
the longings and desires of the patient for acids, 
which also have been mentioned by some of the 
earliest writers on the disease, and more or less by 
others since that time. It is one of the strongest 
instincts in naUTe we are acquainted with. — 
Having repeatedly ->bserved the scorbutic slaves 
throw away the ripe, juavas, while they devoured 
the green ones with much earnestness, I resolved 
to try if there were any difference to be remarket 1 
in their effects. For this purpose I selected niim 



122 



SCORB 



blacks, affected in nearly a similar degree with 
scurvy. To three of these I gave limes, to three 
green guavas, and to three ripe guavas. They 
were kept under the half-deck, and served by my- 
self twice or thrice a day. They lived in this 
manner for a week, which was about the time we 
left the coast of Africa, and it is to be remarked 
that the three negroes restricted to the ripe guavas 
continued in much the same situation, while the 
others were almost well." 

Whenever the fresh fruit, i. e. oranges and 
lemons, can be procured, they should be preferred 
to their juice prepared by evaporation for sea use 
according to the methods devised by Dr. Lind, and 
to the crystallized citric acid obtained according to 
Scheele's formula by combining the fresh vegetable 
acid with lime, and then precipitating by means 
of sulphuric acid. (See Pharm. Lond.) The 
former by keeping is somewhat liable to spoil, 
though as stated by Mr. Moffat, a naval surgeon 
of experience, he found it fully adequate to the 
purpose of the fresh juices at the end of fifteen 
months. The crystallized acid, reduced to the 
strength of lemon-juice by solution in from sixteen 
to eighteen parts of water, is, however, an excel- 
lent substitute for the fresh juice. This solution 
should not be prepared long before it is required 
for use, being apt to undergo decomposition, but 
in its recent state it has proved equally efficacious, 
according to the testimony of Dr. Trotter and 
others, with the fruits themselves. (Med. and 
Physical Journal, vol. iv. p. 154.) Although all 
the esculent fruits and fresh vegetables have been 
found effective in the cure of scorbutus, and par- 
ticularly, as we observed before, those in which 
an acid principle prevails, it seems impossible to 
estimate their relative powers in this respect. 
The vegetable acids which have had trial, viz. 
the acetic and tartaric, appear to have exerted 
little if any power over the disease, nor have we 
any proof that the sulphuric, the nitric, and the 
muriatic acid, though frequently tried, have been 
at all beneficial. 

Mr. Patterson, a surgeon in the navy, published 
a treatise in 1794, in which he infers that a solu- 
tion of nitrate of potassa in vinegar is preferable 
to lemon or lime-juice as an antidote to scorbutus ; 
its good effects he ascribes entirely to the oxygen 
contained in the former. At first he used a solu- 
tion of two ounces of nitre in one quart of the 
ship's vinegar, and gave half an ounce of the solu- 
tion, to some twice, to others thrice in the day, 
and as frequently bathed I he local affections with 
it. From the good effect it produced, which was 
unattended either by nausea, colic, or diarrhoea, 
he was induced to increase the dose of the above- 
mentioned solution to an ounce, and to repeat it 
as before. At length, instead of two, he dissolved 
four ounces of nitre in a quart of vinegar, and 
used it in the same quantities and manner as be- 
fore. He adds, " some patients cannot bear the 
solution without the addition of water, whilst 
others without the least inconvenience bear it un- 
diluted. The discharge by stool, or the presence 
of gripes and nausea, guide me with respect to in- 
creasing or diminishing the dose ; but, at the same 
time, it is not a slight degree of nausea, colic, or 
diarrhoea that renders an alteration in the quantity 
of the medicine necessary. To a great number 



IT IS. 

"o7 scorbutic patients eight ounces of this strong 
solution, containing one ounce of nitre, have, in the 
course of the day, as long as such a quantity was 
necessary, been administered to each with the 
greatest success. Also, a circumstance no less 
curious than pleasing, large and frequently re- 
peated doses of this medicine have been given in 
cases of scorbutic dysentery, and instead of in- 
creasing I have always found it remove the dis- 
ease. °Sometimes, notwithstanding the free use 
of the nitric vinegar, I have known constipation 
take place to a considerable degree, in which case 
I have found intermediate doses of the potassae 
supertartras necessary and highly advantageous. 
This very constipated state generally occurred 
where the disease was far advanced ; but in a few 
particular cases in delicate habits, and where the 
disease was not far advanced, I perceived even 
small doses of the nitric vinegar ruffle the sto- 
mach and intestines ; to prevent or remove which, 
I have found two, three, or four grains of camphor 
with each dose of the medicine very effectual." 

The beneficial effect of the nitrate of potash in 
scorbutus has been more recently testified by Mr. 
Charles Cameron, surgeon in the Royal Navy, in 
a letter, dated December 10, 1829, to the Com- 
missioners for Victualling. The Fergusson, he 
states, sailed from Ireland on the 16th of Decem- 
ber the preceding year, with two hundred and 
sixteen male prisoners, amongst whom scorbutus, 
in several instances combined with dysentery, pre- 
vailed to a considerable extent. Before reaching 
Rio Janeiro, their state was such that he had rea- 
son to fear he should lose several, and others were 
fast approaching the same lamentable condition. 
Having on several occasions experienced the ex- 
cellent effects of a " solution of nitre," as recom- 
mended by Patterson, he was induced to employ 
it. "From the moment I commenced the use of 
it," he observes, " many, although almost hopeless 
cases, began to improve rapidly, and before we 
accomplished one-third of our voyage, I found 
the health of the sick improve so fast under the 
new treatment, that I did not think it necessary 
to go into any port, and on our arrival at Sydney 
the general health of the prisoners was much 
better than when they embarked in Ireland. I 
am willing," he adds, " to ascribe much of this 
favourable change to the effect of climate, but I 
feel assured that a solution of nitre in vinegar or 
lemon-juice is the best remedy ever proposed in 
the treatment of scurvy." 

Two of the patients who recovered exhibited 
symptoms of the last stages of phthisis, and ex- 
pectorated large quantities of purulent matter. 
With regard to the patients in general, he says, 
the most distressing symptoms which they com- 
plained of in the early stages of the disease were, 
a sense of oppression and sinking at the pit of the 
stomach, which a few doses of medicine invariably 
relieved or totally removed. Mr. Cameron's pre- 
paration consisted of eight ounces of nitre dis- 
solved in so much vinegar as made the solution 
amount to sixty-four ounces. Sometimes equal 
parts of vinegar and lime-juice were used, a little 
sugar was generally added to render it more 
palatable, and about four drops of ol. menth. pipe- 
rita;, diffused in a small portion of alcohol, was 
added to the whole, which rendered it more grate- 



SCORBUTUS. 



123 



ful to the stomach. An ounce of this solution 
was a dose, and from three to eight doses, accord- 
ing to the stage of the disease and the severity of 
the symptoms, were given at equal intervals during 
the day, from six o'clock in the morning till eight 
at night. Mr. Cameron, at the conclusion of his 
letter, observes that he has previously tried nitre 
in several bad cases of scurvy, where neither vine- 
gar nor lemon-juice could be obtained, and, ex- 
cept that sometimes it did not appear to sit so 
easy on the stomach, with the same beneficial 
effects. 

With the view of restoring the supposed defi- 
ciency of oxygen to the scorbutic system, it has 
been proposed to impart it to the body through 
the medium of the lungs ; but the attempt which 
was made in cases of the disease as it appeared in 
the voyage of La Perouse round the world, was 
wholly unsuccessful. 

From the salutary effect in cases of scorbutus 
produced by vegetable matter in general, peculiar 
efficacy has been ascribed to particular articles, 
the use of which accident or analogy from time to 
time has suggested ; it may be that future disco- 
veries will determine their relative title to the esti- 
mation in which they may have been held, and 
the precise principle on which it depends, but the 
superiority of lemon-juice as an expeditious and 
certain remedy being well established, other arti- 
cles of the vegetable kingdom, and the drinks pre- 
pared from them, are to be regarded rather as use- 
ful auxiliaries, and may be selected from those in 
popular repute as the inclination or particular 
habit of the patient may dictate. It will be no in- 
considerable advantage also to introduce them to 
use according to the dietetic form most grateful to 
the taste, instead of prescribing the nauseating 
compounds which until the last half century were 
supposed to possess especial virtues conducive to 
the removal of this disease.* 

[Of late, the antiscorbutic effect of raw potatoes 
has been frequently deposed to.] 

Beer, porter, simple infusion of malt, cider, 
perry, spruce- beer, various wines made from the 
subacid fruits, and even pure water, will present 
useful and agreeable beverages to scorbutic pa- 
tients. The Lisbon diet drink (decoctum sarsse 
compositum) and the compound decoction of 
guaiacum, have also been found serviceable for 
the recovery of patients from this disease. Of 
the dietetic vegetable substances, those which have 
been commonly preferred and considered to be 
most especially adapted to the removal of scor- 
butus, have been the various subacid fruits, and 
the several herbs used in salads, a form in which 
v.ith their usual additions, vinegar and mustard, 
they have been considered especially efficacious. 
Dr. Trotter, in his Medicina Nautica, has adduced 
numerous instances of their efficacy, and the 
oopular favour they elicited serves to corroborate 

* " A vpgetable substance called nopal, the stalk of the 
cirtus opuntia, which keeps well at sea, has been lately 
discovered in India to bo an extremely salutary article 
of diet, and to resist scurvy: but the author read in the 
surgeon's journal of one of the East India Company's 
ships, that in spite of the use of this and of spruce-beer 
Bt the same time, sixteen cases of scurvy arose, in one 
of « hich it was so severe as to prove fatal."— Paper by 
Sir Gilbert Wane, on the Health of the Navy; Medico- 
Chir. Tr. vol. vi. p. 501. 



the opinion entertained of them by professional 
writers for this particular purpose. 

Another agreeable method of supplying the 
system with vegetable aliment, and which has 
been advantageously adopted in scorbutus, has 
been the combination of it with fresh animal mat- 
ter through the medium of broths and soups, as 
well as in the ordinary forms in which they are 
commonly prepared for dinner use. Lind states 
that milk is useful to scorbutic patients, with 
whom it generally agrees, but that whey, " by 
reason of its more diuretic and cleansing quality, 
is preferable." 

" Thus," says the last-mentioned writer, " we 
have numberless instances of people after long 
voyages, miraculously, as it were, recovered from 
deplorable scurvies without the assistance of many 
medicines, for which, indeed, there is no great 
occasion, provided the green herbage and fresh 
broths keep the belly lax, and pass freely by 
urine, sweat, or perspiration." 

Since scorbutus has become a very rare disease, 
the materia medica has been enriched by the ad- 
dition of some valuable articles, the general pro- 
perties of which suggest their adaptation to the 
purposes of its treatment ; these are the chlorides 
of lime and soda, and the sulphate of quinine. At 
sea, the chloride of lime will doubtless be advan- 
tageously applied to the preservation of water and 
to the correction of such as may be putrescent, to 
the prevention of unwholesome exhalations, and 
to the general purification of the air. Solutions 
of it as gargarisms and lotions for ulcers give 
promise of considerable advantage, and from the 
little experience already had of its internal use, 
encouragement is given to its further trial. Dr. 
Robertson informs us that he has used the chlo- 
ride of soda in one instance — with the benefit he 
anticipated. (See Dublin Hospital Reports, vol. 
v. 1830.) With some other remarks with which 
he has been so kind as to favour us on this dis- 
ease, he observes, — » I had occasion, in the year 
1831, to see a case resembling scurvy in all its 
phenomena, (indeed, had it occurred in a seafaring 
person instead of a person living in a midland 
county, I should have pronounced it a well- 
marked case of that complaint,) where the liquor 
chloridis soda?, given in doses of half a drachm in 
conjunction with the decoctum lichenis Islandici, 
had a strikingly beneficial effect. The patient was 
speedily brought by it from a state of cachexia 
threatening death to a very tolerable degree of 
health and enjoyment. Were it ever my fortune 
to treat scurvy extensively again," he adds, <• I 
should trust chiefly to quinine or the chloride of 
soda internally, and to the chloride of lime pro- 
perly diluted as a topical application ; with, of 
course, a liberal supply of vegetable matter where 
it could be obtained." 

The costive state of the bowels which occasion- 
ally prevails to an extreme degree must be coun- 
teracted by aperient medicines, or, if need be, by 
the stronger purgatives. In many instances the 
advantage derived from the operation on the alvine 
canal of a single dose has led to their frequent 
repetition, and the most beneficial results have 
ensued. Lind was favourable to the combination 
of medicines of this class with diuretics, or to tne 



124 



SCORBUTUS. 



use of such as embraced the twofold property. 
Selections have accordingly been made from the 
supertartrate, acetate, and sulphate of potash, the 
tartrate and sulphate of soda, and the sulphate of 
magnesia, dissolved in the infusion of senna, of 
tamarinds, or of prunes, with the addition of some 
aromatic tincture, and further combined if requi- 
site with jalap, rhubarb, aloes, scammony, colo- 
cynth, or some of their preparations. 

The complication of inflammatory disease with 
scorbutus in constitutions naturally robust and 
not much debilitated, will sometimes require vene- 
section and the general adoption of the antiphlo- 
gistic treatment, according to the nature and degree 
of the supervening disease ; but diarrhoea, dysen- 
tery, pneumonia, and other morbid conditions 
which have been coexistent with it, have not un- 
frequently resisted modes of treatment peculiar to 
them, and have disappeared together with scor- 
butus when the remedies appropriate to the latter 
disease have been had recourse to. 

In reference to the concurrence of scorbutus 
and dysentery, Dr. Trotter observed that they 
frequently disappeared together, and readily yielded 
to a diet of fresh meat, citric acid, and esculent 
vegetables ; without requiring any of those reme- 
dies more particularly adapted to the last-men- 
tioned disease, as it occurred under other circum- 
stances. (Med. Nautica, vol. i. p. 377.) The 
same remark has been illustrated by Sir James 
M'Gregor, in his reference to a case of severe 
ophthalmia, which appeared conjointly with slight 
symptoms of scorbutus where the latter disease 
was endemic. It resisted a variety of applications, 
both external and internal, for five months, when 
the acid of limes was thought of, which in twelve 
days effected a cure. (Edin. Med. and Surg. 
Journ. vol. i. p. 283. 1805.) 

In some cases of apparent phthisis accompany- 
ing scorbutus, we find in the observations of Mr. 
Cameron, already cited, that the disappearance of 
both forms of disease was evidently effected by 
the remedies appropriated to the removal of scor- 
butus alone. 

It has been commonly observed, that however 
promising and speedy recovery from scorbutus 
may be, to prevent its recurrence it is necessary 
for a considerable time to persevere in the coun- 
teracting regimen, and to avoid as much as possi- 
ble the predisposing and occasional cause of the 
disease. When fresh vegetables can be procured, 
and the object is not to cure, but to guard against 
a relapse, the use of acids will be advantageously 
suspended. Practical authorities have expressed 
opposite opinions as to the general effect on the 
constitution of their continued use, but on the 
whole there is good reason to believe that, when 
long continued, they have produced injurious 
effects on the digestive organs. 

Great care should be taken that scorbutic pa- 
tients be not too suddenly exposed to an atmos- 
phere differing in its temperature or other qualities 
(except in point of dryness) from that which they 
have breathed for some time previously. Any 
sudden exertion should also be avoided, for nume- 
rous instances might be adduced in which inatten- 
tion to these particulars has been immediately 
followed by death, in cases in which it was not in 
the least to be expected. We read in the narra- 



tive of Lord Anson's voyage, that in the removal 
of his crew from the Centurion to the island of 
Juan Fernandez, twelve of them died on being 
exposed to the fresh air ; and on the first breaking 
out of the disease many of the people, though 
confined to their hammocks, were cheerful, talked 
in a loud strong tone of voice, and eat and drank 
heartily, but on being only moved in their ham- 
mocks from one part of the ship to another imme- 
diately expired. Others, trusting to their seeming 
strength, resolved to get out of their hammocks, 
but died before they could reach the deck, and it 
was common to see the men drop down dead upon 
a violent effort of duty. 

The local affections which are manifested in 
scorbutus are often extremely distressing, but, it 
must be remembered, are always secondary to the 
constitutional disorder, increasing in malignancy 
with its progress, and manifesting a contrary dis- 
position whenever a salutary change has been 
effected in it : this correspondence, too, takes place 
with an almost incredible degree of rapidity, and 
such as is rarely, if ever, exemplified under any 
other circumstances of disease. The constitu- 
tional disorder, therefore, should be the first object 
of regard in the cure of every local lesion which 
depends on scorbutus : a contrary procedure only 
can account for the numerous and complicated 
formulae which are to be found in the early treatises 
upon it, all of which, it may be inferred from ac- 
cumulated experience, will be nugatory whilst 
their immediate cause is allowed to continue 
uncorrected. Local applications, however, with 
the contemporaneous use of constitutional reme- 
dies, are not unproductive of advantage. To re- 
lieve the spongy and rotten state of the gums anil 
of the mucous parietes of the mouth and pharynx, 
astringent gargles, particularly those containing 
sulphate of alum, have been found very service- 
able. Two drachms of this substance, or more, 
may be dissolved in half a pint of water or of a 
decoction of cinchona for the purpose. Lind re- 
commends also the tincture of cinchona, which 
may be used alone, or mixed with port wine or 
camphor mixture. The tinctures and other pre- 
parations of myrrh, of kino, of catechu, may like- 
wise be selected from the class of astringents for 
the same purpose, and will be advantageously 
diluted with water or with camphor mixture, to be 
sweetened and inspissated with honey. In the 
advanced stages, the mineral acids have been found 
more efficacious ; water, barley-water, the infusion 
of roses, or other vegetable substances acidulated 
with the sulphuric or muriatic acids, and made 
agreeable with the addition of honey or simple 
syrup, will form convenient gargles. " The quan- 
tity of the acid," says Lind, " must be proportioned 
to the greater or less degree of putrefaction. The 
fungus must be often removed, or if needful be cut 
away ; and by frequent gargarizing the mouth 
kept as clean as possible. Where the ulcers ap- 
pear deep and spreading, they are to be checked 
with a touch of vitriol, or sp. salis, either by itself, 
or diluted according as the patient bears it." 
Analogical reasoning leads us to infer that a solu- 
tion of chloride of lime is peculiarly adapted to 
the purposes of this disease, whether in the form 
of gargle for the mouth, or as an immediate appli- 
cation to ulcers in other pans. To the latter the 



SCORBUTUS— SCROFULA. 



125 



astringent applications already mentioned as use- 
ful in the corresponding condition of the mouth 
and gums have been advantageously employed. 
« Sulphate of alum, in the proportion of two 
drachms to a quart of water," says the experienced 
and talented writer of the Medical Topography of 
New Orleans, Dr. Robertson, of Northampton, 
(Edin. Med. and Surg. Journal, vol. xii. p. 146,) 
in his observations on ' the Sloughing Scorbutic 
Ulcer,' as it appeared extensively in that place, 
" was upon the whole an admirable local remedy, 
and seemed to possess wonderful powers in stop- 
ping the ravages of sphacelus, and giving a healing 
tendency to spreading ulcers. In the same cases 
equal parts of basilicon and oil of turpentine 
(melted and applied warm to the ulcer), mixtures 
of lime-juice, or rum and water, charcoal cata- 
plasms, common poultices, bark decoctions, and 
bark in powder, were employed ; but though they 
kept the sores cleaner, they were often of no avail 
to arrest the sloughing process." Several of the 
early writers, and Lind amongst the number, 
particularize the unguentum JEgyptiacum* as 
adapted to the ulcerations of this disease. Mr. 
Murray, a naval surgeon, in a communication to 
Dr. Lind, observes," I have applied a strong tinc- 
ture of bark lately to scorbutic ulcers, and have 
found it highly beneficial. The powder of the 
hydrargyri nitrico-oxydi sprinkled on the fungoid 
ulcerations, and the ointment of this substance, 
after the sloughs have been removed and the ulcers 
cleansed by carrot and other detergent poultices, 
have also been of some use ; but no permanent 
benefit is to be anticipated from any other treat- 
ment than a diet of nutritious food of which fresh 
vegetables constitute a considerable proportion, the 
efficacy of which will be materially augmented by 
including amongst them the acid fruits or their 
juices, such as lemons, limes, shaddocks, apples, 
pears, gooseberries, &c. whilst at the same time 
the patient is secured from the influence of the 
predisposing and occasional causes of the disease." 
The latter remarks apply also to the eedematous 
swellings of the legs and the rigidity of the ham- 
strings, for which local relief also is often de- 
manded. Frictions with warm flannels, (which 
for this purpose were formerly medicated with the 
fumes of benzoin, amber, and warm aromatic 
gums,) have answered this end, and have been 
advantageously followed up by gentle compression 
with bandages. But in extreme cases, warm 
fomentations, local steam-baths, or, as Lind has 
recommended, sweating the limb " by burning of 
spirits," (the local vapour-hath of the present 
day,) with some of the various other contrivances 
in common use for the promotion of heat locally, 
are better calculated to alford relief. 

An important part of our duty would be unper- 
formed were we to limit ourselves to the detail of 
those means by which scorbutus has been success- 
fully treated, for we know not what additional 
light may be reflected on the obscure parts of this 
subject by a knowledge of such as have been found 
unsuccessful. The cost of the experience, too, by 
which it has been gained forbids its waste, and in 



* Gray, in his Supplement to the Pharmacopoeias, gives 
the following as the formula for this ointment :— Rough 
verdigris ppd. v. oz. honey xiv.oz. vinegar vii. oz. ; boil 
te a proper consistence. 



practical medicine it must be acknowledged that 
a beacon is often of not less use than a guide. 
In the first place, " it is to be observed," says 
Lind, (page 216,) "that this disease, especially 
when advanced, by no means bears bleeding, even 
although the most acute pains upon the mem- 
branes, a high degree of fever, and dangerous 
hemorrhages would seem to indicate it. The pa- 
tient generally dies soon after the operation. Nor 
does it bear strong cathartics, which are often 
injudiciously administered in its commencement. 
From blisters there is danger of a gangrene. As 
to vomits, though I have never had any great ex- 
perience of their effects, yet by the observation of 
others squill vomits have been found serviceable. 
2dly. Persons in the advanced stages of this dis- 
ease are not, without great caution and prudence, 
to be exposed to a sudden change of air. On 
such an occasion they are to be given a glass of 
generous wine well acidulated with lemon or 
orange-juice, which is likewise the best cordial in 
their fainting fits. The sloth and inactivity be- 
longing to the disease are not to be mistaken for 
wilful idleness. This," continues Lind, " has 
proved fatal to many, some of whom, when obliged 
by their officers to climb up the shrouds have been 
seen to expire and fall from the top of the mast. 
3dly. After a long abstinence from green vegeta- 
bles and fruits, scorbutic persons should be tfeated 
like those nearly starved to death; that is, not 
permitted for a few days to eat voraciously, or 
surfeit themselves ; otherwise they are apt to fall 
into a dysentery which often proves fatal. 

"Lastly, medicines of the fossil or mineral 
kind, such as steel, antimony, and especially mer- 
cury,-)- do manifest harm. Opiates occasion an 
unaccountable depression of spirits, with a sense 
of oppression on the chest, and when absolutely 
necessary, as in fluxes, should be of the warmest 
kind," (i. e. we presume combined with aromatics 
and cordials.) 

W. Kerr. 

SCROFULA. — The term scrofula is derived 
from the Latin scrofa, a hog ; and x°'P as ' l ' le cor * 
responding word in Greek, plainly acknowledges 
a similar origin, (x ot P 0{ ' a pig : ) but whether this 
etymology has arisen from the filthy condition in 
which scrofulous children are often found, or from 
the hog being subject to a similar disease, or from 
the appearance presented by scrofulous glands 
lying in clusters under the skin, or from the tumid 
throat and neck of such subjects, is not so easy to 
determine and seems of small importance to in- 
quire. It is sufficiently evident, however, that a 
strong association existed in the minds of the 
Greeks and Romans between scrofula and tho 
animal in question. Another term by which this 
malady has been designated is struma. Celsus 
very distinctly describes the disease as it affects 
the absorbent glands under this name ; and adds 
that it occurs also in the female breast, \mong 

t Sir Gilbert Blane stated to the select commlttet of 
the House of Commons appointed to inquire into tho 
state of the Penitentiary at Milliank in 18^3. that if h 
had found, when he was in office as commissioner, a 
navy surgeon who by his journal had administered a 
particle of this medicine in the treatment of sea scurvy, 
he should have felt it his duty to move that such surgeo'n 
be struck off the list.— Edin. Med. and Sure. Jouru vn 
xxii. p. 142. 



126 



SCROFULA. 



modern nations the French have named the dis- 
ease les ecronelles,* probably a corruption of 
scrophules ; the Germans der Kropf, from the 
swelling under the chin; and the English the 
king's evil. This last term commemorates the 
imaginary virtues of the royal touch, to which, 
from the time of Edward the Confessor till the 
reign of Queen Anne, multitudes of cases of scro- 
fula were submitted, and very many of them were 
supposed to have been cured. A similar practice 
existed in France, with equal belief in its success; 
and miraculous powers for the cure of scrofula 
were likewise claimed for different Romish saints, 
for the heads of certain noble families, for the 
seventh son, and for many consecrated springs in 
different parts of Christendom. 

It may be truly asserted that no original tem- 
perament, complexion, or frame of body, confers 
complete immunity from scrofula ; yet a little ob- 
servation will convince us that individuals pos- 
sessing certain characteristics are more frequently 
the subjects of this malady than others. The 
scrofulous constitution is often indicated by a fair 
complexion, light silky hair, long shining eye- 
lashes, large, watery, and often blue eyes, with 
dilated pupils, and a red patch on either cheek, 
contrasted with a dazzling whiteness of the skin, 
which is itself usually thin, smooth, and readily 
irritated by slight causes. Thus scrofulous indi- 
viduals are more liable to chilblains, which appear 
often on their hands ; and in such persons the ap- 
plication of a blister is generally followed by an 
eruption of pustules on the skin around, and the 
formation of successive crusts. The insertion of 
a seton, the wounds of leeches, and even simple 
venesection sometimes produce the same effect: 
so great, indeed, have we known the irritability 
of the skin in scrofulous children, that washing 
with scented soap has caused the immediate ap- 
pearance of a papular eruption. Scrofulous'per- 
sons often present the look of florid health and a 
full habit ; but the soft parts are flabby, and easily 
shrink away under fatigue, privation, or disease; 
and when the operation of these causes is com- 
pletely at an end, such individuals are restored 
with the same rapidity to their former plethoric 
condition. The scrofulous habit is, in short, cha- 
racterized by a deficiency of what has been termed 
ttamina, and enduring tone. Children who pos- 
sess this constitution are familiarly known as fever- 
ish children ; a very slight irregularity of diet or 
exposure to cold or moisture throwing them im- 
mediately into a state of febrile excitement. Their 
frames possess an undue proportion of irritability, 
and they are peculiarly prone to attacks of inflam- 
mation. The mucous membranes of the scrofu- 
lous, like the external integument, are also deli- 
cate, and their vessels readily give way and pour 
out blood : thus bleeding from the nose is a com- 
mon occurrence in persons of this constitution ; 
and in them hemorrhage is more frequent from the 
urinary passage* and ramifications of the wind- 
pipe. The conjunctiva in scrofulous individuals 
is very liable to inflammation, and the mucous 



secretions are very abundant and often acrid, and 
the membranes themselves frequently become 
thickened : hence arise excoriations of the nostrils 
and of the upper lip, which becomes in conse- 
quence chapped and swollen ; and the half-open 
mouth is a common characteristic of scrofulous 
persons, owing to the partially obstructed state of 
the nasal passages. Most scrofulous persons are 
of small stature, and have slender limbs; nor is it 
very uncommon in such individuals to find some 
member or organ imperfectly developed, defective 
in its power, or curtailed of its proportion : yet 
multitudes of scrofulous persons are met with of a 
very different description — individuals remarkable 
some for their lofty stature and apparent strength, 
and others for the surpassing symmetry and beauty 
of their persons. 

The moral and intellectual qualities of the 
above, which is the largest class of scrofulous sub- 
jects, correspond with, and in all probability are 
derived from those of their bodies : the temper is 
quick and irritable ; the desires and passions are 
ardent; the perception is keen, the imagination is 
predominant over the judgment ; and the mind is 
characterized by a want of firmness and solidity, 
and an inability to persevere steadily in the pur- 
suit of any one object. To this observation, how- 
ever, there are many brilliant exceptions, where 
the strumous constitution is seen combined with 
mental qualities of the highest order. 

In a second class of persons who are disposed 
to scrofulous disease, the complexion is dark, the 
skin harsh, and the habit indolent ; the counte- 
nance is swollen and pasty, and all the functions 
of the body are sluggish and imperfect : the nerv- 
ous energy is feeble, the feelings are obtuse, and 
the moral and intellectual powers occupy a very 
low rank. Scrofulous cases of this character are 
not by any means uncommon in Britain, although 
far more rare than those first described; but ex- 
treme instances are frequent in some districts of 
Switzerland and France ; and in these human 
nature appears reduced almost to the level of the 
brute creation, assuming forms which awaken feel- 
ings of humiliation and disgust. Scrofula, which 
is always tedious and difficult of cure, becomes 
still more obstinate and unmanageable when it 
makes its appearance in those of a dark com- 
plexion and sluggish temperament. 

[The writer's experience leads him to say, that 
scrofulosis occurs quite as frequently in the dark 
complexioned. The negroes of the south are very 
subject to it, and in its most severe forms. (Guer- 
sant, art. Scrofule, in Diet, de Med. 2de edit. 
xxviii. 207. Paris, 1844.)] 

This disease exhibits itself under a great va- 
riety of symptoms, according to the part of the 
body which it happens to affect : hence the diffi- 
culty of framing any definition of it which is ai 
once accurate and comprehensive. 

The most certain evidence of the existence of 
scrofulous disorder is afforded by the production 
of a soft, brittle, unorganized matter, resembling 
curd or new cheese, which is found mixed with 



membrane of the intestines is readily irritated and the purulent contents of scrofulous abscesses oi 
diarrhoea in duced. In such subjects the mucous deposited in rounded masses of different degrees 

of firmness, and varying in bulk from the size of 



* Tn some parts of Scotland the disease is called by the 
tommon people " the cruels " an evident corruption of 
ne French woul 



a millet-seed to that of a hen's egg: sometimes it 
is contained within the natural cavities and canaU 



SCROFULA, 



127 



of the body, sometimes it is enclosed in cysts, and 
occasionally it is diffused, as if by infiltration, 
through the natural texture of a part. To the 
rounded masses of this substance, which, as they 
enlarge, often acquire the irregular form of a 
tube ous root, the name of tubercle has been as- 
signed, and the substance itself has been named 
tuberculous matter. We venture to assert that 
the presence of tuberculous matter is a satisfactory 
proof of the existence of scrofula ; but we do not 
by any means maintain that scrofula cannot exist 
without the deposition of this substance. The 
researches of pathological anatomy have satisfac- 
torily shown that scarcely any living texture of 
the human body is altogether exempted from tu- 
berculous deposits. This morbid production has 
been observed on the free unbroken surfaces of 
mucous membranes, within mucous follicles, and 
forming the contents of lymphatic vessels the 
tunics of which were themselves sound, (Andral, 
Precis d'Anat. Patholog. torn. i. p. 419, and torn. 
ii. p. 116) : granules of tuberculous matter, some- 
times insulated, sometimes clustered together, have 
also been detected within the clots of blood con- 
tained in the cells of the spleen. (Andral, op. cit. 
torn. ii. p. 431. Carsvvell's Illustrations, &c. 
Fstsric. 1, plate iii.) The history of tubercle cer- 
tainly entitles us to consider it as a morbid secre- 
tion ; but when it is thus found lying free within 
a healthy lymphatic vessel, or enveloped in the 
coagula of the splenic cells, we are led to suspect 
that in such cases it has probably been formed by 
some change in the constitution of the lymph or 
blood, from an alteration in the proportions of 
their ingredients, or the addition of some coagu- 
lative substance, or the withdrawal of something 
which these fluids usually contain. The cellular 
tissue has been hitherto considered as of all others 
the most common seat of tubercle ; but Dr. Cars- 
well has stated that it is far more frequently met 
with in contact with mucous surfaces; and he 
has certainly adduced very strong arguments in 
support of this opinion, which he has also illus- 
trated by most beautiful engravings. (See Fas- 
cic. 1.) 

For a particular history of this substance in its 
etiological, pathological, and chemical relations, 
we must refer the reader to the articles Tubehcle 
and Tubbhcoiab Phthisis, and content our- 
selves, in this place, with noticing such circum- 
stances as have more especial reference to the 
subject of the present article. 

According to Dupuy, (De l'Affection tubercu- 
leuse,) all the domestic animals of France, not 
excepting the dog, as well as those imported from 
warmer countries, are subject to tuberculous de- 
posits : his researches further show that this dis- 
ease in the inferior animals is much more fre- 
quently combined with the presence of vesicular 
worms than it is in man. He has traced the con- 
version of the cysts containing these animals into 
collections of tuberculous matter, and has thus 
given a degree of support to the opinions of Dr. 
Baron, who maintains that all tuberculous disease 
Originates from vesicular worms or minute serous 
cysts. But although we admit that such adven- 
titious cavities often become, at least in the inferior 
animals, the nests in which the matter of tubercle 
is deposited, the assertion that all tubercles arise 



in this manner may well be disputed when we 
find that such cysts or vesicular worms, or traces 
of them, are by no means always co-existent with 
tuberculous disease, and that they often attain a 
very great magnitude without exhibiting any 
symptoms even of incipient transformation. 

Opinions directly opposed to each other have 
been held by writers of great eminence as to the 
immediate cause of tubercles ; one party ascribing 
their origin in every case to inflammation, (Brous- 
sais, Examen des Doctrines Medicales, torn. i. 
Alison, Edin. Med. Chir. Trans, vol. i. and iii.) ; 
another as exclusively asserting that they are in 
no instance dependent on inflammatory action, 
and that when inflammation co-exists, it does so 
as the consequence, and not the cause, of tube.r- 
I cles.* After carefully reviewing the discussions 
on this question, we have come to the conclusion, 
that on some occasions tubercles have been found 
, where no symptom of previous inflammation 
[ could be recollected, nor any trace of it dis- 
covered on inspection after death, (Andral, Precis 
d'Anat. Pathologique. Lombard, Essai sur les 
Tubercules) ; while in other instances the deposi- 
tion of tuberculous substance seems to have been 
distinctly connected with the development of in- 
flammatory action. But as inflammation often 
occurs without the formation of 'tubercles, it is 
obvious that this alone is not sufficient for their 
production, and that the addition of something 
else is required to that end. Inflammation, there- 
fore, may be viewed as an occasional cause of 
tubercles, producing this effect only in frames of 
a scrofulous disposition. 

Some organs are more liable to tuberculous 
deposits than others, and the liability differs at 
different periods of life : the organs which are 
most frequently affected with tubercles in children 
are not those in which they are oftenest met with 
in adults. In children the disease tends more to 
implicate several organs at once ; and in them it 
is more common to find the lungs unaffected, 
although tubercles be discovered in other parts of 
the body. (Lombard, op. cit.) The existence 
of tubercles in the foetus is certainly rare, but it 
has been proved beyond question by the dissec- 
tions of Langstaffe, (Lloyd on Scrofula,) Lom- 
bard, West, Orfila, ( Velpeau, Thesis ad aggreg. 
p. 10,) and Chaussier, (Proces verbal de l'Hospice 
de la Maternite, 1812, p. 62) : they continue in 
frequent from birth till two years, after which they 
are often met with ; and during the fifth year 
their occurrence appears to be much more com- 
mon than at any period before puberty. From 
eighteen till forty, tubercles very frequently occur; 
affecting, 'however, chiefly the lungs, intestines, 
and some parts of the lymphatic system. 

* O. L. Bayle, Recherches sur la Phthisie. — Laennec, 
Auscult, Mediate.— Oendrin, Hist. Anatom des Inflam- 
mat.— Lobstein, Anat. Pathnlog. torn. i. This able advo- 
cate of these opinions admits the production of what he 
terms miliary granulations on the surfaces of inflamed 
serous and mucous membranes, hut denies their identity 

with tubercles. In this mannei he eudeav ■< to get 

aside the arguments drawn from such cases as those of 
Dr. Alison, and also the results id' the experiments of 
Cruveilhier and others, who produced the appeal ance ol 
myriads of small tubercles by injecting mercury into th» 
bloodvessels and lungs of animals ; each minute elohint 
being found enclosed within an effusion of tuberculous 
like matter. These experiments we have always cor 
sidered as anything hut conclusive: for where" is tl><< 
evidence luat the effused matter is truly tuberculous ' 



128 



SCROFULA 



These results are drawn from the researches of 
pathological anatomy ; but to sneak merely from 
symptoms, independent of the verifications of dis- 
section, scrofula has been observed by us in the 



here to state that M. Dupuy has expressed strong 
doubt8 f the contagious nature of glanders, an 
has asserted that he knows of no well-conducted 
experiment in favour of this doctrine, but some 



form of enlarged axillary glands within the first against it. He is disposed, on the contrary to 
fortnight after birth: it is not usual, however, for refer glanders to hereditary transmission, and to 



the absorbent glands to be affected till the period 
of the first dentition ; the occurrence is still more 
frequent during the second. At puberty the dis- 
ease often disappears spontaneously, and after this 
age external scrofula is very rarely observed to 
originate ; but instances are not wanting in which 
persons well advanced in life have been attacked 
for the first time by scrofula, more especially 
among those who have been long confined in 
prisons or workhouses. To show the various 
ages at which the disease may develop itself, La- 
louette (Traite des Scrophules, Paris, 1780) states 
that in a scrofulous family one daughter was at- 
fected at fourteen, another at sixteen, a third at 
twenty-six, and the father at sixty-six. Cases 
have occurred to the writer where scrofula has 
appeared in youth, undergone an apparent cure, 
and again manifested itself in advanced life, when 
it proved fatal. 

In former times it was believed that scrofula 
was communicable from one individual to ano- 
ther ; and the 'occurrence of the disease in many 
members of the same family, and its diffusion 
among the inhabitants of particular districts, 
seemed, through a loose mode of reasoning, to 
afford ground for this opinion. Positive experi- 
ments have been made by Kortum, (De Vitio 
Scrofuloso. Lemgov. 1798,) Goodlad, (On the 
Lymphatic System,) Hebreard, (Dissertat. sur les 
Tumeurs Scrofuleuses,) Le Pelletier, (Sur la Ma- 
ladie Scrofuleuse, p. 16,) and others, to propagate 
the disease by rubbing in scrofulous matter, and 
by inserting it under the skin of animals, and 
even of the human subject ; while Pinel, Alibert, 
and Richerand, (Nosograph. Chirurg. torn. i. p. 
161,) have carefully watched the effects of allow- 
ing scrofulous and healthy children to associate 
together without restraint ; but in no instance was 
there the least reason for believing the malady to 
be communicable by any of these modes of infec- 
tion. The observation of British practitioners 
fully corroborates the opinion of the non-conta- 
gious nature of scrofula, although the writers of 
this country have not directed so much attention 
to the subject ; because a belief in the contagion 
of scrofula was abandoned by our physicians long 
before it ceased to be current among those of the 
continent. 

In this respect scrofula differs remarkably from 
that form of tuberculous disease in animals which 



various unfavourable circumstances in the rearing 
of horses, similar or analogous to those winch arc 
admitted as predisposing to scrofula, such as cold, 
damp, and shady pastures, insufficient nourish 
ment, and the debilitating effects oi castration. (De 
l' Affection Tuberculeuse.) 

Daily observation must convince us that a scro- 
fulous "constitution is often transmitted from pa- 
rent to child ; therefore the disposition to the dis- 
ease may be truly said to be hereditary ; nay, the 
dissections already referred to prove the actual de- 
velopment of scrofula even before birth, in the 
progeny of a strumous mother. Like other here- 
ditary gifts, it may miss one generation and re- 
appear in the succeeding ; just as some individuals 
are observed to resemble in external appearance 
their grandfathers more than their fathers. 

A striking example of the hereditary nature of 
scrofula was lately presented to the writer hy a 
family respecting whom he was consulted. The 
father was a tall, thin, and sickly man, who suf- 
fered much every year from winter cough ; the 
mother a person of full relaxed habit, with a look 
of florid health, and in fact not often affected with 
illness. Of nine children to whom she had given 
birth, two females and six males had died with 
phthisical or mesenteric symptoms, between the 
ages of three and fifteen months ; the survivor 
was a boy nearly twelve years old, who enjoyed 
moderately good health. The last of these little 
victims of transmitted disease died just as he had 
completed his third month, after having suffered 
under symptoms of phthisis. On inspecting the 
body, the lungs were seen mottled with many 
yellow spots, and when cut into they exhibited 
myriads of tubercles, varying from the size of a 
small mustard-seed to that of a pea : all of them 
were opaque, and many converted into pus. The 
glands at the root of the lungs were enlarged, in- 
durated, and some of them converted into ab- 
scesses, the walls of which were lined with firmly 
adherent fibrin, and their contents were a thick 
purulent fluid. The mesenteric glands were en- 
larged, hardened, and many of them contained 
softened tuberculous matter. The spleen con- 
tained some small granules of a white colour and 
cheesy consistence. There was a good deal of 
subcutaneous fat, but none in the omentum. A 
very few weeks after the death of this child, the 
father, who had been eager to learn whether his 



has been named glanders : for this last is not only offspring drew their fatal disease from himself or 



communicable from one animal to another, but 
also to man.* It would be curious to inquire 
whether glanders in man is itself communicable 
to other human beings : that it is so is by no 
means improbable, for it has been proved by expe- 
ment to be capable of being communicated from 
man to the inferior animals. (Coleman, in Tra- 
vcrs on Constitutional irritation.) It is proper 



from their mother, declined rapidly in strength, 
and fell a victim to phthisis. 

Scrofula is supposed by most writers to be of 
more frequent occurrence among females than 
males; and Le Pelletier (Sur la Maladie Scrofu- 
leuse,) has stated, as the result of a comparison 
of the cases in the Parisian hospitals, that the 
proportion of strumous females to males is as 
live to three. In all inquiries into the relative 
prevalence of disease in the two sexes, it must be 



* Eliotson, in Lonil. Med. Cliir. Trans, vol. xvi. p. 171. 
Travtrs, On Constitut. lrritat. 2d edit. p. 398. Schilling 

««d Weiss, in Rust's Magazin. fur die gesammte Heil- rpmUofioA c 

kunde 1821. Also Remer, in Hufeland's Journal, March recoliecle d that the female population, especially 
1822. 



| of large towns, considerably exceeds the malf , Find 



SCROFULA. 



129 



hence it is to be expected that a great number of 
scrofulous females will apply for medical relief. 
But on reviewing the matter carefully, and refer- 
ring to an examination of hospital patients made 
for another purpose, we are convinced that the 
disease is really more frequent in the female sex. 
Dr. Cullen was of opinion that scrofula was oftener 
transmitted from the father than the mother, which 
he conjectured might arise from the circumstance 
that more scrofulous men than women enter the 
married state; but he has nowhere explicitly as- 
serted that males are more liable to the disease 
than females. (First Lines. Sci-ofula.') 

We proceed now to pass briefly in review the 
various parts and organs of the human body in 
which scrofula most commonly appears, and to 
point out the modifications of this disease induced 
by the different properties and textures of the 
parts affected. 

The first which presents itself is the common 
integument ; and here several forms of cutaneous 
disease are distinctly referable to the class of 
scrofulous affections. The three species of porrigo 
named favosa, larvalis, and furfurans, together 
with eczema impetiginodes and rubrum in their 
chronic forms, may be fairly enumerated among 
strumous diseases ; at least if we are entitled to 
draw any inference from the facts that these erup- 
tions are found in combination with the generally 
admitted symptoms of scrofula, and are as often 
benefited by anti-strumous remedies as the symp- 
toms just mentioned are usually observed to be. 
Eruptions of this description, when they affect 
the scalp, ears, and face, are very apt to occasion 
swelling of the glands at the back part of the 
head, on the sides of the neck, and under the 
jaw ; at first from simple irritation, or perhaps 
the absorption of morbid fluids ; afterwards, the 
swelling becomes permanent, from the deposition 
of tuberculous matter. Other causes of an irrita- 
ting or inflammatory kind, as dentition and expo- 
sure to cold, are known to produce such glandular 
tumours, terminating like the others, where the 
habit is strumous, in the deposition of the same 
curdy substance. Thus we have a second order 
of parts more deeply seated than the skin affected 
with scrofula, often from the causes stated above, 
and sometimes, it would seem, spontaneously. 
The absorbent glands, indeed, are the parts of the 
body which have long been regarded as the peculiar 
seats of scrofula, and their enlargement and indu- 
ration are still considered as affording more une- 
quivocal evidence in the living body of the presence 
of that disease than any other circumstance except 
the discharge of tuberculous matter. A lymphatic 
gland, when first affected with scrofula, is soft and 
fleshy, and its size is increased ; the texture, as 
proved by inspection, then becomes firmer, and 
the colour paler than in health : as the disease 
proceeds, portions of the gland are observed to 
have altogether lost their flesh-colour, and acquired 
a degree of semi-transparency, and a texture ap- 
proaching to that of cartilage ; at length a deposi- 
tion of soft white or yellowish curd-like substance 
is found to have taken place, and the true scrofu- 
lous tubercle is now manifest. (Abercrombie, 
Edinb. Medico-Chir. Trans, vol. i. p. C83.) 

The size to which strumous glandular tumours 

Vol. IV.— IV 



attain is in some instances enormous. The lower 
jaw and upper part of the neck are occasionally 
seen hung round with such voluminous swellings 
as completely to deform the countenance ; and we 
have seen, in the case of a strumous middle-aged 
male, both groins occupied by vast glandular 
tumours, the larger of which equalled in size the 
half of a child's head at birth. These inguinal 
swellings were firm, nodulated, and without pain ; 
they had commenced only six months before as 
clusters of hard kernels, which by degrees enlarged 
and coalesced into the enormous morbid masses 
now described. It has been stated by a very able 
and accurate observer that scrofulous glands 
always possess a higher temperature than the 
healthy parts in the vicinity ; but the trials which 
we have made, and they were often repeated, did 
not detect any greater heat in such swellings, 
unless when they were actually inflamed. 

Scrofulous glands are commonly supposed to be 
obstructed and impervious to the fluids which are 
naturally transmitted through them, but it is 
certain that they are in many instances capable of 
being injected with mercury from the intrant lym- 
phatic, (Soemmering, De Vasis Absorbentibus, 
sect. 37, p. 90) ; and hence we may infer that, 
though partially changed, some portion of them 
may still give passage to their proper fluids. 

Scrofulous tumours do not uniformly originate 
from the degeneration of lymphatic glands, but 
arise in many cases from the deposition of tubercu- 
lous substance in the subcutaneous cellular tissue, 
in different parts of the body, quite independent 
of any absorbent gland : their resemblance, how- 
ever, to glandular swellings is such as to deceive 
the inexperienced ; nay, they were named even 
by Wiseman, the first surgeon of his day, adventi- 
tious glands. When these scrofulous tumours 
are cut into, they are found to be composed of 
cysts varying in size and density, usually lined 
with a fibrinous exudation, and filled with tubercu- 
lous substance, sometimes crude, at others soften- 
ed, or converted into curdy pus. 

Absorbent glands affected with scrofula, and 
cysts of tuberculous matter in the cellular tissue, 
may remain for a long time without exciting any 
irritation ; but their tendency is to become soft by 
the secretion of purulent fluid from the internal 
surface of the cavity, which is soon followed by 
inflammation of the integuments. Ulceration suc- 
ceeds, and the morbid contents are discharged 
from the body, sometimes by one, at others by 
many small apertures: but a cure does not follow; 
either fistulous openings remain, discharging a 
thin glutinous fluid mixed from time to time with 
curdy particles, or an indolent ulcer succeeds, or 
both may result from the expulsion of tuberculous 
matter. The contents of scrofulous glands and 
tumours on the surface of the body occasionally 
undergo the cretaceous transformation ; after re- 
maining long indolent, suppuration at last takes 
place, and masses of earthy substance, sometimes 
of considerable bulk, are extracted from their 
cavities. On macerating these calculous concre- 
tions in water, we have found them to separate 
readily into a multitude of gritty particles like 
dried mortar. In some instances, strumous gland? 
are converted into prominent spongy tumours of a 



130 



SCROFULA. 



red colour, and covered by a silky cuticle, which 
frequently breaks, and gives issue to small super- 
ficial collections of purulent matter. 

Scrofulous ulcers are characterized by their 
flabby and often pale granulations, and the thin 
unhealthy integument which usually overlaps their 
margins. This undermined skin is of a purplish 
or livid hue ; showing the languor of its capillary 
circulation, and its proneness to be destroyed by 
gangrenous erosion. Such ulcers, though usually 
productive of little uneasiness, sometimes become 
exceedingly irritable and painful, requiring the 
employment of powerful narcotics to give relief to 
the patient. The thin discharge which scrofulous 
sores yield often concretes upon their edges into 
straw-coloured crusts, under which the ulcer, if 
small, sometimes heals. Scrofu < us cicatrices pos- 
sess a peculiar wrinkled and puckered appearance, 
with small portions of projecting skin, and even 
complete bridges admitting a probe to pass beneath 
them ; features by which their real origin, long 
after a cure, may be readily discovered. These 
appearances of scrofulous scars seem to be pro- 
duced by the great attenuation and irregular de- 
struction of the integument, and the slow and in- 
terrupted mode in which such ulcers heal ; and 
they may always be in a great measure prevented 
by careful and judicious surgical treatment. 
When scrofulous cicatrices are cut into and ex- 
amined after death, the affected glands are found 
wasted away, no vestige of them being left ex- 
cepting a few bands of condensed cellular tissue 
attached to the cicatrized integument. The heal- 
ing of a scrofulous ulcer is often followed by the 
advance of other tumours to suppuration, or per- 
haps the formation of new ones in some adjoining 
or distant part of the body. Thus one train of 
evils succeeds another, till the constitution of the 
patient begins to yield to the debilitating effects 
of the irritation and discharge, or the disease 
fastens on some organ of greater importance in 
the economy, and life is at length destroyed by 
hectic fever, colliquative perspirations, and diar- 
rhoea. 

Another form in which scrofula sometimes 
attacks the integument is that of lupus, the usual 
seats of which are the lips and nose ; but we have 
also seen it affecting the genitals. Scrofulous 
lupus commences by the appearance of small red 
button-like prominences, which usually remain 
indolent for some time, then become excoriated 
and form eroding ulcers, with pale shining spongy 
granulations and encrusted margins; or, perhaps, 
the work of destruction goes on under a thick in- 
crustation, which drops off from time to time, to 
show the ravages which have been committed. 
The progress of the disease is sometimes hastened 
by the formation of sloughs, especially when the 
parts are cartilaginous ; and in this way perfora- 
tions are made into the nostrils, and sinuses 
scooped out within the thickness of the lips. In 
lupus of a well-marked scrofulous character, the 
face usually becomes swollen and raised into 
pallid flabby prominences, which deform the coun- 
tenance, and give to it a very sickly and disgust- 
ing aspect. See the article Noli ?ie Tangere. 

Scrofulous individuals are subject to the forma- 
tion of large chronic abscesses, which sometimes 
arise with great rapidity, as if from a sudden de- 



position of fluid rather than as the consequence 
of regular suppuration. The usual scat of such 
abscesses is in the cellular tissue connecting the 
lar-e muscles, or within their sheaths, and under 
fasciae ; and their contents are at first a serous 
effusion, afterwards sero-purulent fluid, with curdy 
flakes; and more rarely a thin pus. In such 
cases, sloughing of the cellular tissue is not un- 
common; spongy masses of it, like wet tow, 
coming away along with the discharge, or plug- 
ging up the lancet puncture. These abscesses 
are" named by French writers abets froid and 
abces par congestion,- and their origin is usually 
the irritation of some diseased joint or bone in 
their immediate vicinity. It does not appear that 
abscesses of this description result from the soft- 
ening of tuberculous matter previously deposited, 
but that the curdy flakes are thrown out from the 
internal surface of the abscess during the forma- 
tion of its more fluid contents. 

The lymphatic system has been generally con- 
sidered as the primary, and by some the only seat 
of scrofula ; and in all treatises on the diseases of 
the absorbent vessels, this malady occupies a pro- 
minent station. In almost every case of advanced 
scrofulous disease of the mesenteric glands, the lac- 
teals connected with them will be found affected, 
and more or less filled with tuberculous matter; 
but the absorbents in other situations have not 
been very often observed to be the seats of stru- 
mous disease. Several well-authenticated cases, 
however, are recorded, in which tuberculous mat- 
ter was found deposited within these vessels, and 
that in such quantity as completely to obstruct 
them.* 

The following instance of scrofulous affection 
of the lymphatic, vessels occurred to the writer 
A gentleman, after applying an astringent lotion 
to a simple excoriation of the cervix glandis, was 
affected with indurated swelling of the prepuce, 
and the appearance of hard tortuous cords within 
the integuments of the penis, which after a few 
days could be traced all the way to the pubes. A 
glandular swelling took place in one groin, which 
after a considerable interval suppurated, burst 
spontaneously, and at length healed. No per- 
ceptible benefit accrued from a slight mercurial 
and purgative plan of treatment ; but amendment 
commenced under the use of sarsaparilla and 
iodine, and the disease wholly disappeared after a 
tour of several weeks' duration, since which the 
individual has continued to enjoy good health. 

The inflammation of the superficial lymphatics 
in the horse, is believed by the best writers on 
veterinary medicine to constitute the disease named 
farcy, (Percival, Lectures on the Veterinary Art, 
vol. iii.), and M. Dupuy (De la Maladic Tuber- 
culeuse) regards the small tumours termed farcy 
buds as tuberculous deposits. 

The sublingual and submaxillary glands are 
often the seat of scrofula ; the parotid more rarely, 
but a chronic swelling of that organ is occasion- 
ally seen in scrofulous subjects of a dark com- 
plexion. Tumefaction of the tonsils is seldom 



; t.f •f•o < r 5" :r • Med, cal Records ami Researches, vol. 
i. 1st and 2d Lnses.-Paletta, Exercitat Patholoe p 109, 
.1, l — ltevtamd, Hist. Anat. MM. vol, ii obs 770,771, 
iila.—Ouo, Sultene beobaclituiif'. Tlicil ii No Tl — An- 
tral, Precis d'Anat. Patholog. t. i pp. Iumbo. 



SCROFULA. 



131 



absent, when the strumous constitution is strongly 
marked : this exists from an early period of life, 
and is perhaps in some instances congenital. The 
tonsils so affected jut out in rounded tumours from 
between the arches of the fauces : they are pecu- 
liarly prone to inflammation, and when it occurs, 
the swelling is often such as to threaten suffoca- 
tion, especially when stimulant astringent gargles 
have been incautiously employed. The inflamed 
tonsils become speedily spotted with aphthous 
crusts, which are succeeded by superficial ulcera- 
tions, always indolent, and sometimes ending in 
brown excavated ulcers, which we have known to 
exist for weeks without any remedy being used, 
and then to yield rapidly to cinchona. 

Scrofula occasionally attacks the tongue,* the 
disease alternating with strumous eruptions, espe- 
cially in the face : it sometimes assumes the form 
of aphthous ulcerations and fissures of the mar- 
gin ; but its most characteristic features are small 
knots or nodules superficially imbedded in the 
substance of the organ, varying in size from a 
grain of small shot to that of a horse-bean. They 
cause no uneasiness unless when firmly pressed, 
and then the pain is slight and pricking. The 
mucous membrane covering them is red and pro- 
minent, and soon breaks in the centre, giving rise 
to an ulcer, which spreads and destroys by sloughy 
erosion, with much pain, profuse salivation, furred 
tongue, and fetid breath. The ulcers under proper 
treatment become clean, contract, and heal ; but 
the hardness remains, fresh nodules form in other 
parts of the organ, and the same train of suffering 
is gone through after a longer or shorter interval, 
according to the state of the patient's health and 
the regularity of his mode of life, until a decided 
improvement be produced on the constitution by 
time, change of climate, or the employment of 
remedies. 

The mucous membranes are frequently affected 
with scrofulous disease : allusion has just been 
made to the aphthous exudations and superficial 
sores which appear on the tongue and tonsils of 
strumous individuals ; in other instances there are 
small blisters and excoriations on the inside of the 
lips and cheeks, and on the fauces, and that wholly 
independent of any syphilitic disease, or the pre- 
vious exhibition of mercury. The pituitary mem- 
brane in scrofulous subjects is easily irritated, and 
the secretion of mucus is usually copious and often 
acrid : nay, in some instances the morbid condi- 
tion of the part proceeds so far as to induce small 
ulcerations, constituting one form of ozcena. If 
the progress of this affection be not arrested, the 
fine long laminae within the nostrils become in 
part denuded, and at length necrosed ; and it is 
from the decomposition of dead osseous substance 
that the horribly offensive odour is produced which 
renders this malady so peculiarly disgusting. To 
those around the patient it is always so ; but he 
himself is sometimes unconscious of the odour, in 
consequence of the diseased condition of the pitu- 
itary membrane, and the loss of smell resulting 
from it. The most frequent cause of ozcena is, 
without doubt, syphilis ; but it occurs chiefly in 
those syphilitic cases where the habit is strumous, 
and it is met with also as the effect of scrofula 

* Mr. Russel has alluded to this affection, hut without 
(lesciihing it. See Russel on Scrofula. 



alone. It has not been ascertained whether ozcena 
ever originates from the deposition of minute tu- 
bercles on the pituitary membrane; but that this 
sometimes occurs is far from improbable. In the 
glanders of horses, which is an analogous affec- 
tion, the existence of tubercles in the lining mem- 
brane of the nostrils has been satisfactorily shown 
by Dupuy to form a leading feature. (De 1' Affec- 
tion Tuberculeuse, pp. 30 & seq.) 

Scrofulous children are more liable than others 
to inflammatory affections of the windpipe, and 
to that fibrinous exudation on its mucous surface 
which occurs in croup; yet this cannot properly 
be classed among strumous diseases. 

But the ultimate terminations of the respiratory 
mucous membrane are frequently the seat of scro- 
fula : some eminent pathologists, indeed, are of 
opinion that the air-vesicles of the lungs are the 
usual situations in which tuberculous matter is 
originally deposited in cases of scrofulous phthisis. 
Dr. Alison informs us that he has repeatedly found 
tuberculous matter in the air-vesicles, these minute 
cavities being partly filled with air and partly with 
this substance, (Edin. Medico-Chir. Trans, vol. 
i. p. 427) ; and the dissections of Dr. Carswell, 
(Illustrations of the Elementary Forms of Dis- 
ease, Fascic. 1,) which he has so happily per- 
petuated by his drawings, appear to us to have set 
this point completely at rest. M. Gendrin, how- 
ever, asserts that the substance effused into the 
air-vesicles is nothing more than the product of 
common inflammation, and not at all tuberculous ; 
but he candidly admits that Laennec expressed a 
contrary opinion while the subject was before 
them, and he is ready to acknowledge that inflam- 
mation is a powerful occasional cause of the pro- 
duction of tubercle. (Hist. Anatom. des Inflam- 
mations, torn. ii. pp. 310, 601.) 

The digestive mucous membrane is subject 
through its whole extent to scrofulous disorder of 
function, and in its intestinal portion at least to 
extensive scrofulous transformations. A feeble 
action of the stomach is an almost uniform ac- 
companiment of well-marked strumous disease ; 
and the mucous lining of the alimentary canal is 
in such cases either torpid or unduly irritable, the 
food remaining lodged as a source of oppression 
and disturbance, or being hurried rapidly forward, 
and expelled before it has had time to afford ade- 
quate nourishment to the system. Tubercles are 
met with in the walls of the intestinal tube in 
children, and still more frequently in adults : 
Louis states that in his examination of more than 
350 phthisical subjects above the age of fifteen, 
he found tubercles in the small intestines of one- 
third, and in the large intestines of one-ninth of 
the whole. (Recherches sur la Phthisic) 

The subsidiary organs of digestion and assimi- 
lation suffer also from scrofula ; but the spleen 
and the pancreas are more frequently the seats 
of tubercles than the liver ; yet the last of these 
organs is more or less functionally deranged in 
almost all strumous cases, which the chalky and 
various-coloured motions of such patients suffi- 
ciently demonstrate. The great irritability of the 
mucous tunic of the intestines in many scrofu- 
lous cases, and the tubercles which so often form 
within the mucous follicles and walls of the tube. 
naturally lead to ulceration, and hence arise manv 



132 



SCROFULA. 



cases of disease of the mesenteric glands. At 
first they become merely swelled, but ultimately 
tubeiculous deposits take place within their sub- 
stance, constituting what has been named mesen- 
teric consumption, or tabes mesenterica. For a 
full account of this affection, we refer the reader 
to the article Tabes Mesenterica. 

Scrofulous disease of the mucous membrane of 
the female genital organs is of frequent occur- 
rence, and forms the most obstinate description of 
leucorrhcea, producing languor and debility, disor- 
dering and sometimes putting a total stop to men- 
struation, and in very many cases preventing con- 
ception. The morbid discharge in this disease is 
interrupted on the appearance of menstruation, 
and is increased in quantity before and after that 
occurrence. It varies in character from an opaque 
white mucus to a greenish yellow or blood- 
streaked purulence ; and the surface which fur- 
nishes it is not limited to the vagina, but appa- 
rently extends throughout the whole internal 
lining of the uterus. It does not appear that 
lubercles have been detected in the vagina, but 
scrofulous ulcers have been seen there, probably 
arising from the destruction of tubercles, while 
the cavity of the uterus itself and the Fallopian 
tubes were found filled with tuberculous matter. 
(Carswell, Op. cit. pi. ii.) Tubercles have also 
been found imbedded in the walls of the uterus, 
and still more frequently in the ovaria. (Meckel, 
Handbuch der Pathol. Anat. B. ii. Theil. ii. s. 
386. Louis, Recherches sur la Phthisic Lom- 
bard, Essai sur les Tubercles.) 

In men, scrofulous disease of the mucous mem- 
brane of the urinary channels and cavities is not 
un frequent; and it is an affection particularly 
obstinate and unmanageable. The writer has 
known it to continue in the urethra for five years, 
at the end of which time it came under his care. 
The urethral membrane was then so soft and 
spongy that the most cautious attempt to intro- 
duce an instrument occasioned a profuse hemor- 
rhage: after a lengthened treatment, the discharge 
at last yielded to tonics, the cold plunge-bath, and 
astringent injections. Chronic, or mucous cystitis, 
s often of a scrofulous character, (see Cystitis;) 
and there is ground for believing that the same 
affection passes up along the ureters, and even 
extends itself within the chambers of the kidney. 
Tuberculous deposits have been found within the 
coats of the bladder, (Louis, Op. cit. Lombard, 
Op. cit. Dclaroche, Bulletin de la Societe de 
Med. t. 13 14,) and lining the interior of the 
ureters, (Laennec, Auscult. Med. t. i. p. 556. 
Louis. Also Carswell, Op. cit. pi. ii.); very fre- 
quently also in the cavities and substance of the 
kidneys, and sometimes in the renal capsules. 
(Bui/lie, Morbid Anatomy.) The glands of Cow- 
per, the prostate, vesiculse seminales, and testicles, 
have all been found the seats of tuberculous de- 
posits. They occur most frequently in the pros- 
ate gland and testicles, particularly in the latter ; 
and the symptoms to which they give rise render 
them objects of considerable importance to the 
practical physician as well as to the surgeon. 
See PnosTATE Glaxd, Diseases of. 

The changes produced in the testicle by scro- 
fula vary considerably, according to the degree of 
attending i'nfammation, and the rapidity with 



which the disease has formed. We have, most 
commonly, a hard solid enlargement of the organ, 
usually affecting first the large head of the epidi- 
dymis, slow in its growth, and obstinate in resist- 
ing the operation of remedies. It may remain 
indolent for some time, but at length abscess 
forms, the scrotum inflames, adheres, and gives 
way, discharging a curdy substance mixed with 
pus. The disease now extends to other parts of 
the epididymis and to the body of the testicle) 
sinuses form under different parts of the inflamed 
integument ; and fistulous openings take place, 
which give issue to a thin, ill-conditioned fluid, 
mixed with curdy particles. At other times a 
more rapid inflammation occurs, and an abscess 
forms, which on bursting discharges scrofulous 
pus; a fistulous opening succeeds, the gland 
wastes away, and at length nothing remains but 
a small, shrunk, and hardened mass. On dissect- 
ing a strumous testicle, the natural fabric of the 
organ is found more or less indurated by the de- 
position of dense organized substance ; tuberculous 
matter is discovered in different spots, in the tubuli 
seminiferi epididymis, and sometimes even in the 
vas deferens. Small scrofulous abscesses are also 
occasionally found disseminated through the sub- 
stance of the gland. (Sir A. Cooper, On the 
Testis. Carswell's illustrations, pi. ii.) This 
disease is much more common after puberty, when 
the actions of the testicle are awakened, and it has 
become exposed to numerous causes of irritation 
and injury ; but we have known it occur at a very 
early age, in the case of a child which exhibited 
other strong marks of the strumous constitution. 
In almost every instance only one testicle is at- 
attacked at first, but after a time the other is usu- 
ally affected ; and it is not uncommon for both to 
continue suffering from the disease at the same 
time. Andral has well remarked the frequency 
of scrofulous affection of the testicle, and has 
pointed out the palpable omission of Louis, who 
has assigned no place either to the testicle or the 
bones in his enumeration of parts in which scro- 
fulous deposits have been found. 

Another organ which is subject to scrofula is 
the mamma; scrofulous disease of which occurs 
both before and after puberty, but much more fre- 
quently after that period, and often during the ex- 
citement of the first lactation. Scrofula of the 
mamma appears under different shapes, and in its 
earlier stages is not always easily distinguished 
from disease of a more formidable character. Some- 
times a hard lump forms in the breast, and re- 
mains nearly quiescent for several years ; at others 
the whole gland is affected with scrofulous en- 
largement ; but in every case of the disease its ten- 
dency is to suppuration, and the purulent matter 
discharged is more or less mingled with curdy 
flakes : instances likewise occur in which large 
masses of tuberculous substance come away. 
(Lloyd, On Scrofula.) In the progress of such 
cases the integuments become inflamed, assumft 
a livid colour, and are extensively detached from 
the parts beneath ; new abscesses and apertures 
form, and the adipose and glandular tissues are 
traversed by many fistulous passages, while the 
contiguous parts are condensed and hardened. In 
strumous disease of the breast, there is always an 
enlargement of the gland instead of that conlrac- 



SCROFULA, 



133 



lion which occurs in one form of carcinoma : the 
tumour is tender when squeezed, never possesses 
the stony hardness which exists in the disease 
just named, and there is never, we believe, re- 
traction of the nipple. 

The mucous membranes of the eye and lachry- 
mal passages are peculiarly liable to scrofulous 
disease ; its influence on the latter is indicated by 
the long-continued discharge of puriform mucus, 
varying in its colour and consistence ; while stru- 
mous inflammation of the conjunctiva constitutes 
a very large proportion of all the inflammatory 
affections to which this organ is subject. Beer 
asserts that in Vienna nine-tenths of all the cases 
of ophthalmia in children are of a scrofulous cha- 
racter, (Jos. Beer, Lehre, &c. b. i. s. 588) ; and 
Benedict of Breslau estimates the proportion in 
that city as high as ninety-five in the hundred. 
(Handbuch, &c, b. ii. s. 165.) The eruption 
of the minute vesicles, (phlyctenular) or pus- 
tules, which occurs in scrofulous inflammation 
of the conjunctiva, seems to approximate it 
to other diseases of the same class, when nume- 
rous crops of very small tubercles are seen on the 
investing membranes of various organs ; but it 
does not appear that true tuberculous matter has 
ever been detected in any part of the eye.* Scro- 
fula likewise attacks the margins of the palpebrae 
and Meibomian follicles, causing the appearance 
of vesicles and ulcerations named ophthalmia tarsi; 
and it is believed by Mr. Todd to occasion chronic 
enlargement of the lachrymal gland. (Dublin 
Hospital Reports, vol. iii.) 

The organ of hearing, like that of sight, is the 
frequent subject of scrofula, which in many in- 
stances is productive of early deafness, and, there 
is reason to believe, is the cause of that imperfec- 
tion of hearing which is sometimes seen to per- 
vade several members of the same family. The 
lining membrane of the external auditory passage 
is in most instances the seat of the disease, which 
is usually marked by profuse watery, then mucous, 
and at length purulent discharges, forming what 
may be named strumous otorrhcea. It is in gene- 
ral unattended with danger, but it rarely exists 
without producing a greater or less imperfection 
of hearing. In some instances, however, the dis- 
ease spreads more deeply ; the membrane of the 
tympanum becomes inflamed and is perforated, 
the small bones of the ear are discharged, and irre- 
mediable deafness ensues ; or perhaps caries of the 
petrous portion of the temporal bone takes place, 
and the result is fatal. (See Oralgia and Otitis.) 
Strumous otorrhoea has been known to alternate 
with other mucous discharges, such as leucorrhcea 
and chronic cystitis, (Lallemande, Recherches sur 
PEncephale, lettre quatrieme) ; and its disappear- 
ance has been followed by enlargement of the 
cervical glands, swelling of the testicle, and vari- 
ous diseases of the eyes and skin, (ltard, Mala- 
dies de TOreille.) Like other scrofulous affections 
it sometimes resists all remedies, and at length 
disappears at puberty. 

The synovial membranes of joints are un- 
doubtedly much more liable to disease, in scro- 

* Strumous disease of that organ seems to exist also 
among animals. M. Dupuy considers the specific oph- 
thalmia of horses as one of the consequences of the tuber- 
culous affection. 



fulous subjects, than others; inflammation is more 
readily excited, and effusion of fluid into their 
cavities is more easily induced. In such persons 
we frequently observe several joints affected at 
the same time. In a case of six years' duration 
lately placed under the writer's care, the .left hip- 
joint, the right knee, and the joints of the right 
great toe were all suffering under disease, with 
displacement of the head of the femur and shaft 
of the tibia; there were, besides, many ulcers and 
sinuses around the joints, and indurated cervical 
glands : this patient had a strongly marked stru- 
mous countenance. The secretion of scrofulous 
pus into synovial cavities is not uncommon, but 
the existence of tubercle within the substance of 
the membrane itself appears to be of rare occur- 
rence. Dr. Craigie states his belief that tubercle 
has been found in the synovial membrane of the 
hip-joint. (Elements of Patholog. Anatomy, p. 
810.) There is indeed a remarkable change of 
structure, which takes place slowly in the synovial 
membranes, particularly that of the knee-joint, 
and which, as it occurs most frequently in the 
scrofulous, some may be inclined to regard as of 
scrofulous origin. This morbid alteration of tex- 
ture, which was first accurately described and 
illustrated by Mr. Brodie, (Pathological Observa- 
tions on the Joints,) consists of the conversion of 
the synovial membrane, and afterwards of the 
adjacent soft parts, into a pulpy substance of a 
light brown colour, intersected by white mem- 
branous threads, and traversed by minute red 
vessels. But there is another affection of the 
joints, in which the characters of scrofula are 
unequivocally exhibited ; in this the disease 
originates in the cancellous structure of the 
bones, which is found to contain deposits of 
tuberculous matter: and the cartilages and syno- 
vial membranes are affected secondarily by the 
spreading of the inflammation. 

In scrofulous persons the bones are more slen- 
der throughout; their cortex or outer wall is 
much thinner, and their interior more soft and 
vascular than the bones of persons of sound and 
vigorous constitution : in the inferior animals 
affected with tuberculous disease, according to 
Dupuy, (De l'Affection Tuberculeuse,) this pecu- 
liarity is still more strongly exhibited. Scrofulous 
children sometimes fracture the thigh or leg merely 
by falling on the carpet ; and in other instances 
the bone does not snap across, but bends like a 
piece of tin ; and the injury may be remedied by 
straightening it as we do a rod of that metal. The 
effects of scrofula on the bones are considerably 
different, according to the comparative density of 
their texture; but in all instances the process of 
disorganization appears to commence by an in- 
crease of their vascularity, or a greater or less 
degree of inflammation In the dense fabric of 
the bones of the skull and the shafts of the long 
bones, scrofula is a frequent cause of necrosis ; 
while in the spongy heads of bones, the small 
bones of the hand and foot, and the bodies of the 
vertebra;, this disease manifests itself, first by in- 
creased vascularity and softening of the cancellated 
structure while the firm exterior remains entire 
and unchanged ; then a deposit takes place of » 
clear yellow fluid, which is succeeded by or pro- 
bably converted into a soft cheesv enbstanrp. or 



134 



SCROFULA, 



true tuberculous matter. (Brodie, Patholog. Ob- 
serv. on the Joints. — Lloyd, On Scrofula.) This 
alteration in the texture of the bones is slow in its 
progress, and its existence is not indicated by any 
decided symptoms until it is considerably ad- 
vanced. A dull and deep-seated pain gives the 
first warning of the disease, the soft parts then 
become swelled, the motions of the neighbouring 
joint are restrained and painful, and abscesses 
now form around it, containing a scrofulous pus ; 
the investing cartilages and synovial membrane 
next suffer, effusion takes place into the articular 
capsule, and perhaps a high degree of inflamma- 
tion is induced by the escape of tuberculous mat- 
ter or a portion of necrosed bone into the cavity 
of the joint. In the progress of the disease the 
destruction of the head of the bone or edge of the 
socket, and of the ligaments which preserve the 
bones in their places, enables the more powerful 
muscles to draw the lower one from its situation, 
and produce what is named secondary luxation. 
The writer has repeatedly observed dislocation of 
the tibia produced by the separation of the epi- 
physis from the shaft of the bone ; the leg being 
in this manner completely displaced, although the 
articular surfaces of the knee-joint were in proper 
apposition. 

Not only the bones but also their investing 
membrane of periosteum is subject to tubercular 
deposits,* giving rise to swelling, inflammation, 
suppuration, detachment of the periosteum from 
the bone, and ultimately to necrosis, or absorption 
of the osseous tissue, which is replaced by dry 
tuberculous substance without softening of the 
bone. To this form of tuberculous disease we 
would refer some of those cases which have been 
named osteo-steatoma. This morbid deposition, 
which we have seen lying in contact with the 
bone in large angular masses, bears a striking 
resemblance to suet or adipocire ; but its nature is 
truly that of coagulated albumen, for it emits, 
under a strong heat, the odour of burnt cheese or 
horn, and produces no greasy stain when rubbed 
on paper. 

Scrofula manifests itself by unequivocal proofs 
both in the bodies of the vertebrae and the fibro- 
cartilaginous substance which is interposed be- 
tween them. The former become more vascular, 
are softened by the partial absorption of their 
earthy and saline constituents, and afterwards 
receive a deposit of yellow, cheesy, or true tuber- 
culous matter. These changes naturally lead to 
caries and destruction of the bone, which yields 
to the superincumbent weight; and the spine 
bends at an angle more or less acute according to 
the number of vertebrae which are diseased. The 
bend is in general directly forward ; but when the 
sides of the vertebrae have suffered most, the curve 
is of course lateral. (Brodie, Opus cit. p. 289.) 
In the progress of this disease the soft parts around 
become affected, and collections of purulent mat- 
ter form, which, passing down in front of the 
spine and along the course of the psose muscles, 
ultimately make their appearance under Poupart's 
igament at the upper part of the thigh, and some- 
times on both sides, nearly at the same time. On 



*Otto has found tubercle within the tissue of the 
i-tnosteum. See Compend. of Pathol. Anat. translated 
'iv South vol. i. p. 240. 



other occasions the matter points in the loins or 
near the anus ; and in some rare instances it has 
burst into the spinal canal, with an immediately 
fatal result. 

When chronic disease has thus been producing 
such extensive disorganization in the osseous sub- 
stance of the spinal column and in the soft parts 
around, it is not to be expected that the membranes 
of the spinal cord, the medullary substance itself, 
and the nerves which branch from it, should es- 
cape injury ; accordingly we find that the first 
symptoms of canes of the spine are, a feeling of 
weight and aching in the part, itching and numb- 
ness, pains shooting round to the front of the 
trunk; and, when the disease is farther advanced, 
pains and twitchings of the limbs, succeeded by 
palsy of all the parts below the affected vertebrae, 
and of the sphincters of the bladder and rectum. 
The nervous symptoms are not always limited to 
the parts below the seat of the disease : in some 
cases we have pains of the arms, although the 
disease be situated in the middle dorsal vertebras. 
(Copland, on Diseases of the Spine.) On in- 
specting the contents of the spinal canal, where 
death has occurred during the existence of caries 
of the bones, effusions of serum or plastic lymph 
are found between the osseous surface and the 
dura mater, and sometimes they are found firmly 
adherent ; plastic lymph and pus are also dis- 
covered within the arachnoid, or the membranes 
are found glued together. Tuberculous deposits 
have been observed within the substance of the 
spinal dura mater, and between that membrane 
and the arachnoid ; most commonly connected 
with scrofulous disease of the bones, but some- 
times wholly independent of it. (Ollivier, De la 
Moelle Epiniere, t. ii. pp. 760-764.) The me- 
dullary substance itself has in such cases been 
found softened or attenuated ; sometimes entirely 
destroyed for a short space, and the vacuity filled 
up with a sanious pus. 

When scrofulous disorganization of the bones 
has been effectually checked, it is astonishing to 
mark the efforts made by nature to repair the loss 
and support the fabric by new osseous growths : 
we have even occasionally seen them formed in 
the vicinity of the disease, even although its 
activity was still unabated. 

Scrofulous affections of the spine often com- 
mence in the intervertebral substance, which be- 
comes soft in the centre, and is then destroyed by 
ulceration and absorption ; the disease afterwards 
extending to the bodies of the vertebrae. There 
is no reason to doubt that ulceration of the inter- 
vertebral substance is in most cases of a scrofu- 
lous nature ; yet it must be admitted that tubercu- 
lous matter has very rarely been observed in this 
texture ; partly, perhaps, because it has not often 
been carefully sought for. Andral states that he 
once met with a mass of tubercles within the sub- 
stance of the intervertebral cartilages. (Precis 
d'Anat. Patholog. t. i. p. 424.) 

Lateral curvature of the spine has been sup- 
posed by some writers to be in almost all cases 
produced by strumous disease of the bodies of 
the vertebrae. Certain it is that scrofulous indi- 
viduals are most liable to lateral curvature of the 
spine; but this may with more propriety be 
ascribed to a general debility and relaxation of the 



SCROFULA. 



135 



frame, and of the muscular and ligamentous sys- 
tem in particular, than to any positive softening 
of the osseous texture. Were the bones softened 
from scrofula in every case of lateral curvature, 
how is it possible that so many cures should be 
effected, or that such multitudes of females should 
be met with in comparatively good health, yet 
having permanent lateral flexure of the spine 1 
Scrofulous disease of bones in other cases re- 
quires powerful counter-irritation to check its 
progress ; but in this form of spinal disease, rest 
in the horizontal posture, friction, a regulated ex- 
ercise of the muscles, and attention to the general 
health, are sufficient, in a great majority of in- 
stances, to accomplish a cure. Lateral curvature 
of the spine not unfrequently precedes angular 
projection from caries : hence it has been inferred 
that the latter is but the second stage of the 
former disease : of this, however, there is no 
proof; nor is it at all unnatural that a feeble in- 
dividual, whose spine sinks readily into a serpentine 
bend, should afterwards become the subject of a 
more formidable disease, affecting the bones them- 
selves. The vertebra? after death, in cases of 
serpentine curvature, are most commonly found 
free from disease,* which would seem to show 
that scrofulous softening of the bones is rarely the 
cause or this deformity ; for it is highly improba- 
ble that so great a change in the texture and 
form of the vertebrae should be repaired without 
leaving behind it some traces of its previous ex- 
istence. 

The serous membranes in different parts of the 
body often exhibit decided marks of scrofulous 
disease, myriads of minute tubercles or tubercu- 
lous granulations being found adhering to their 
surfaces or imbedded in their tissue ; and some- 
times enveloped in the false membranes connect- 
ing them, which have formed during inflammation. 
Thus the pleura, the arachnoid, the pia mater, the 
peritoneum, are frequently found affected with 
scrofula ; and a few instances are recorded where 
tubercles have been observed in the pericardium. 
(Baillie, Morbid Anatomy, p. 9.) When this 
disease attacks the membranes of the brain, its 
symptoms are usually the same as those of acute 
hydrocephalus ; and its termination takes place 
by effusion within the skull or spinal canal, to 
which sometimes is superadded softening of the 
medullary substance. The children of scrofulous 
parents are well known to be more prone than 
others to cephalic disease ; and in this manner 
the whole offspring of such individuals are some- 
times cutoff in succession during infancy. When 
tuberculous disease affects the peritoneum, it 
seems, whether originally induced by inflamma- 
tion or not, to produce, after a time, that state : 
dropsical effusion then follows. As the disease 
proceeds, the fluid is absorbed, and the opposite 
surfaces, loaded with tuberculous matter, become 
glued together, obliterating the cavity of the peri- 
toneum, and fixing the floating viscera in their 
places. We have seen this disease in a boy of 
twelve years pervading the whole trtink, gluing 
the contiguous viscera to each other, to the pa- 



rietes of the chest and abdomen, and to the dia- 
phragm, filling up the anterior mediastinum, and 
presenting numerous white cheesy tumours within 
the substance of the viscera themselves. The 
heart alone was free from disease. A separation 
of the lowest part of the sternum, which was 
much softened, had taken place, and the point of 
the ensiform cartilage was directed forwards and 
upwards ; a consequence apparently of the swell- 
ing of the abdomen, and the restraint imposed by 
the strong adhesions on the motions of the chest 
in respiration. Such cases are always compli- 
cated with scrofulous disease of the mesenteric 
glands, and usually with ulceration of the coats 
of the intestines, which have thus been perforated, 
allowing a free communication through* the ad- 
herent sides of the contiguous tubes. In some 
cases it has appeared that the ulceration had com- 
menced in the peritoneal surface; {Gregory, 
Lond. Med.-Chir. Trans, vol. ii. p. 269;) while 
in others the mucous lining of the bowel seems 
to have been the first eroded. (Howship, Prac- 
tical Observations in Surgery and Morbid Ana- 
tomy, p. 269.) The same result will follow from 
both processes ; but certainly the ulceration from 
within outwards is what we consider most likely 
to happen from the greater proneness of mucous 
membranes to that state. 

The frequent occurrence of scrofula within the 
central organs of the nervous system has been 
satisfactorily ascertained. Wiseman, whose know 
ledge on this subject greatly surpassed that of mos* 
of his contemporaries, appears to have suspected 
the fact ; but it was reserved for modern patholo- 
gistsj" to show how frequently tubercles are formed 
within the encephalon and spinal cord. Before 
the age of two years they are not common ; but 
from this period onwards till puberty they are of 
frequent occurrence. Their most usual seat in 
the brain is the upper part of the hemispheres ; 
and in the spinal cord they occur much oftener in 
the cervical than in the dorsal or lumbar portions : 
according to the most accurate observers, they are 
very often enclosed in cysts. (Andral, Precis 
d'Anat. Pathol, torn. ii. p. 841.) It is singularly 
deserving of notice that tubercles have been re- 
peatedly found in the nervous centres where no 
symptom dining life had induced any suspicion 
of their existence ; and the scalpel has as fre- 
quently been unable to disclose any deviation 
from healthy texture in the substance immediately 
surrounding them. 

The thyroid gland was long believed to be pe- 
culiarly subject to scrofula ; and the chronic en- 
largement of that organ, named bronchocele, was 
at one period regarded by the best writers of their 
day as a distinctly scrofulous disease; (Sennertus, 
Mcdicina Practica. — Laurentius, Hist. Anat. cor- 
poris humani ;) nay, it is remarkable that even in 
recent times the introduction of iodine as a gene- 
ral anti-strumous remedy originated in the sup 
posed connection of bronchocele with scrofula. 
But on reviewing the history of the two diseases, 
we shall find so many points of difference as to 
convince us that they are altogether distinct and 



* Sknic, Diseases of the Spine. We have lately ex- t Leveilli. Becherches sur les Tubercules du Cervau, 
amined a number of preparations with a view to this ]824, a thesis.— Gendrin, Sur les Tubercules duCervau 1 1 
point, and the result fully corroborates the assertion of I de la Moelle Epiniere, 8vo. — OUivier, Sujr la MoeWi 
.Mr. i^haw. I Epiniere. 



136 



SCROFULA. 



independent. (See article Broschocele.) In 
support of this opinion it may be sufficient here 
to state that hronchocele is of rare occurrence in 
the large manufacturing towns of Britain ; while 
scrofula prevails throughout their population, cut- 
ting off thousands in infancy, and scattering among 
the survivors the germs of debility and protracted 
disease. The thyroid body, though rarely the seat 
of true scrofula, is not wholly exempt from it, 
more than one instance of its occurrence having 
come under our observation. The disease com- 
mences with a moderate degree of swelling, which 
is followed by the formation of a small indolent 
abscess : this after a time bursts spontaneously, 
discharging a thin pus mixed with curdy flakes ; 
the apertures remain fistulous for a considerable 
time, while the tumefaction of the gland subsides. 
The lungs have long been known to be particu- 
larly liable to scrofulous deposits ; and so rare is 
it to find tubercle in any other situation without 
also finding it in the lungs, that Louis states he 
never met with an instance in all his numerous 
dissections excepting once, in the case of a man 
who had died of fever. (Recherches sur la 
Phthisie.) Scrofulous disease of the lungs con- 
stitutes what has been named tubercular phthisis ; 
to the article on which, the reader is referred. 

[Scrofulosis is very analogous to, although not 
identical perhaps with, tuberculosis. They both 
occur in persons who have like habits and general 
appearance ; but there is this difference, as regards 
at least tuberculosis of the lungs, that it is most 
frequently developed after puberty, — the period 
when the tendency to scrofulosis is usually dimin- 
ished or arrested. Moreover, scrofulous disease 
manifestly exists where there is no reason to be- 
lieve in the existence of tuberculous matter. (Scro- 
fula, its Nature, Causes and Treatment, by W. 
Tyler Smith, M. D. p. 6. Lond. 1844.) A person 
having scrofula, however, in early life, would 
seem to be more liable to tuberculosis at an after 
period. Some recent observers, however, argue 
strenuously for the identity between scrofulosis 
and tuberculosis. MM. Rilliet & Barthez (Traite 
Clinique et Pratique des Maladies des Enfans, 
iii. 5. Paris, 1843,) affirm, that having examined 
the bodies of a large number of scrofulous chil- 
dren, at the Hopital St. Louis, they met with no 
instance in which tuberculous deposits did not 
exist in some part or other. Many affections, 
commonly termed scrofulous, as ophthalmia, they 
consider of a secondary nature, accidentally com- 
plicating the original scrofulous or tuberculous 
habit, but not essentially scrofulous in their na- 
ture. They propose to banish the term scrofula 
from medical nomenclature, as being vague and 
apt to mislead, and to substitute for it the term 
tuberculization. M. Bredow, of St. Petersburg, 
( Ueber die Scrofelsucht, Berlin, 1843,) seems to 
entertain a similar view ; bat he proposes to re- 
tain the word scrofula, to designate tuberculous 
disorganization of the lymphatic glands; and the 
terms tubercle and tuberculous disease for the 
same affection existing in other organs. (Dr. West, 
Brit. 4 For. Med. Rev. April 1844, p. 565.)] 

The heart has been found affected with scrofula 
but rarely: Dr. Otto, (Compendium of Pathologi- 
cal Anatomy, translated by South, p. 290,) of 
ttreslau. a very learned and able pathologist, never 



once met with a case of this sort ; yet several 
, its occurrence are on record from Fubii- 
cius Hildanus, (Observ. Chirurg.) and Needham, 
(Wiseman's Surgery, vol. i. p. 404 ; at the apex 
of the heart,) down to Andral, (Audrul A Bayk, 
Revue Med. Franc;, et Etr. 1821,) Lobstein,* and 
Macmichael.f Tubercle of the heart never occuri 
except when the system is strongly imbued with 
strumous disease; and its existence in this situa- 
tion does not appear to have been indicated by any 
peculiar diagnostic symptom. 

The occurrence of scrofulous disease in the 
voluntary muscles appears to be not less uncom- 
mon than in the heart : instances, however, have 
been met with of tuberculous deposits in these or- 
gans, both in the human subject and the monkey.} 
The effect of scrofula in modifying the symp- 
toms of a large proportion of the diseases to which 
the human frame is subject, has been long known 
to medical observers, and meets us daily in the 
course of our practice. Inflammatory affections, 
in a particular manner, exhibit the effects of this 
influence ; losing the acuteness of their character, 
and becoming tardy and indolent, difficult of cure, 
and requiring for its accomplishment the use of 
stimulants and tonics. Frequent and striking ex- 
amples of these facts are presented to us by many 
of the early consequences of syphilitic infection, 
and by the extensive tribe of ophthalmic diseases. 
Injuries of the soft parts, particularly where there 
has been much loss of blood, also often afford un- 
equivocal evidence of the presence of a strumous 
habit : hence it is common for persons who are 
jealous of the imputation of scrofula to declare 
that their wounds are always readily healed. So 
strong sometimes is the modifying power of scro- 
fula, that the writer has known the stump of a 
strumous girl's arm, which was removed on ac- 
count of an extensive laceration, to discharge dis- 
tinct curdy matter at the second dressing. 

Scrofula appears to possess a certain degree of 
connection with several other diseases. Some con- 
genital affections, such as hare-lip, spina bifida, 
and external hydrocephalus, are more frequently 
met with among scrofulous children than others; 
and it is worthy of remark that in many cases of 
congenital peculiarity or defect, the same have 
been observed in ancestors, or near collateral rela- 
tives of the patients. 

Of all the diseases allied to scrofula, perhaps 
the most closely connected is rickets, (see art. 
Rickets ;) yet the distinction between the anato- 
mical characters of the two diseases is sufficiently 
well marked. In rickets the whole texture of the 
bone is softened, though not exactly in the same 
manner in both species of that disease; but in 
scrofula, tuberculous matter is deposited in the can- 

* Anat. Patholog. At the apex of the heart, as large 
as the [joint of the thumb, and apparently formed in the 
substance of a false membrane. 

t Lond. Med. and Phys. Journal, 1826, p. 119. The ta- 
in the heart were connected with others in the 
lungs; yet they niny have been Originally distinct. 

| Otto, Opus cit. p. 2.r.>, in the Bterno-mastoid of a girl 
—in the muscles of tin; neck and thigh of acromion! 
monkeys.— Laennec, Auscult. Mediate, torn. i. p.556. In 
the Bterno-mastoid of a phthisical man. Lombard Onus 
cit. Intercostal Muscles.— Reynaud, Archive Gen de 
Medecine, toin. xxv. 1831, pp. 148.301. This wnter'liHS 
given a very interesting account of the tuberculous aflec 
tions, particularly phthisis, occurring in monkevs at the 
Jardin des Plantes. ' 



SCROFULA. 



13; 



eellous structure, the outer wall remaining entire, 
or becoming necrosed: or tubercle invades the 
none from the periosteal surface, the osseous sub- 
stance being removed by absorption. Encepha- 
loid or medullary tumours may also be enumerated 
among the affections connected with scrofula ; 
they occor chiefly in individuals of a strumous 
habit, and the materials of which they are com- 
posed bear, in their last stage of softening, a con- 
siderable similitude to those of tubercle.* There 
is a fungous tumour, occurring in the lips and 
cheeks of young scrofulous subjects, which we 
have repeatedly met with ; in its external charac- 
ters it bears a very close resemblance to encepha- 
loid; but it is formed with much greater rapidity, 
and admits of cure by a well-directed alterative 
and purgative treatment, and the application of 
leeches, astringents, and escharotics. It is the 
opinion of some experienced practitioners, that 
carcinoma occurs more frequently in persons of a 
strumous constitution than others ; and our own 
observation inclines us to entertain a similar be- 
lief. The concurrence of scrofula with urinary 
calculus has led to the supposition that the two 
diseases are intimately connected ; but it does not 
appear that they are in any way dependent on 
each other: the same causes, however, are likely 
to induce both. (See art. Calculous Diseases.) 
The greater sensitiveness of most scrofulous 
individuals renders them more prone to diseases 
of the nervous class : hence an aggravated form 
of hysteria is more frequent in such persons ; and 
we think with Dr. Cheyne, that epilepsy affects 
strumous subjects oftener than others. (See Epi- 
lepsy.) The diseases of the mind claim an alli- 
ance with scrofula, which has not attracted the 
attention of writers on this subject so much as it 
seems to merit. An eminent physician of great 
knowledge and experience in the treatment of in- 
sanity has stated to us his belief that more than 
one-half of those who are subject to mental de- 
rangement are of a scrofulous constitution, having 
some manifest indication of its existence in their 
persons. With the view of elucidating this sub- 
ject, we examined all the paupers of a lunatic 
establishment. Of forty-four females, exactly one- 
half presented indurated or enlarged glands of the 
neck or throat, and several had extensive scrofu- 
lous cicatrices. Of forty-six males, twenty-eight 
had no decided symptoms of scrofula, though 
several of these had the strumous aspect ; sixteen 
presented the marks already mentioned in refer- 
ence to the females ; and two belonged to families 
known to be afflicted with scrofula in an aggra- 
vated form. All of these ninety lunatics were 
adults, and not one of them exhibited any active 
symptoms of scrofulous disease. It has been 
remarked to the writer by the physician already 
referred to, that he has often observed active scro- 
fulous symptoms to alternate with attacks of ma- 
nia. In several cases he has known the purulent 
expectoration of phthisis to cease during the urgent 
symptoms of insanity ; and, on the other hand, 
reason has been seen to return before the pulmo- 

*The earliest distinct account of encephaloid as it 
affects tlie extremities, is to be found in Ruysch, Obser- 
vat. Anatomico-Chirurgic. X". SI, when he describes it 
under the title of Die spongj or ossivorous tumour, and 
latit was known to the Germans under the name 
of schwamm, and to the Dutch under that of been eter. 
Vol IV.— 18 «' 



nary disease proved fata! — soothing the feelings 
of affectionate relatives, and shedding a calm over 
the last days of the consumptive lunatic. In ac- 
cordance with what has just been stated, the seve- 
rity of the symptoms of scrofula does not appear 
to promote the development of mental disease, 
but rather to impede it; for in families eminently 
scrofulous, we have sometimes observed the indi- 
vidual least afflicted with that malady to be the 
victim of insanity ; while those who suffered most 
from scrofula possessed sound minds; as if the 
local irritation, or the drain from the body afforded 
some protection against mental derangement. It 
has often been remarked by medical writers, and 
the observation of every physician must confirm 
the accuracy of the statement, that precocity of 
mental development, and superior genius, are in 
a great majority of instances the accompaniment 
of the scrofulous constitution. 

Causes. — In considering the causes of a dis- 
ease so deeply rooted in the constitution as scro- 
fula is universally acknowledged to be, it is neces- 
sary to direct our attention to circumstances very 
remote in the history of those who are its subjects. 
The foundation of a scrofulous habit is frequently 
laid during the foetal state, by the transmission of 
that peculiar organization of the frame from pa- 
rents who themselves possess it. Nothing, indeed, 
can be better established as the result of general 
observation than the hereditary nature of scrofula. 
This peculiarity of constitution may also be com- 
municated to the foetus by some defect of energy 
in one or both of the parents, arising from extreme 
youth, or very advanced years, or great disparity 
of age, or that premature decay which is induced 
by a life of dissipation, or the debilitated states 
resulting from protracted illness; or, on the part 
of the mother, repeated miscarriages, and by defec- 
tive nourishment and other similar causes. Va- 
rious occurrences, likewise, may take place during 
gestation — such as accidents, frights, prolonged 
disease, mental distress, — which interfere with the 
proper development and growth of the embryo, 
and entail upon the child that feebleness of con- 
stitution which, if not identical with scrofula, 
leads to its appearance on the application of causes 
not adequate under othei circumstances to pro- 
duce that disease. The writer was recently called 
upon to examine a boy of six years, labouring 
under a complication of scrofulous ailments ; the 
history of whose case may serve to illustrate the 
influence of injuries received by the mother during 
gestation. In this instance the mother was a tall 
and rather slender woman, apparently enjoying 
good health ; the boy was puny for his age, h«i 
movements were quick and restless, his articula- 
tion very imperfect, and his mind in a state ap- 
proaching to idiotcy : the lips were seamed with 
the scars of former ulcers, the conjunctiva: relaxed 
and injected, the tarsi inflamed, ulcerated and 
almost without cilia; the countenance pale and 
bloated; the skin dry and scaly; many of his 
teeth were gone, and most of those which remained 
were in a state of decay ; the cervical glands were 
indurated, but not much enlarged. The last pha- 
lanx o( one thumb was double, and each extremity 
of the fork had a perfect nail. He had always 
been a very sickly child, had had repeated suppu- 
rations in the groins, and was then labouring 



133 



SCROFULA. 



jnder chronic diarrhoea, part of his food passing I 
undigested. During the time that his mother was 
pregnant with him she had suffered many severe 
falls, the first towards the end of the third month. 
Scrofula is also observed to originate in the 
healthy offspring of healthy parents under certain 
circumstances, the principal of which are habitual 
exposure to cold and damp, privation of free air 
and light, and want of healthful exercise. In- 
stances are recorded where persons previously in 
good health have been affected with scrofula after 
being confined in the dungeons of a prison, and 
there scantily fed. (Pinel, Nosog. Philos. t. iii. 
pp. 380, 385.) The influence of such causes in 
producing tuberculous disease in the inferior ani- 
mals has been made the subject of experiment by 
Dr. Jenner, (Jenner, in Beddoes on the Med. Use 
of factit. Airs), Dr. Baron, (Delineations, &c, pp. 
25 et seq.,) and others ; and the results have satis- 
factorily shown both the great extent of that in- 
fluence, and the power which we possess of re- 
moving the factitious disease by replacing the 
animals in healthy situations, and supplying them 
abundantly with wholesome food. The operation 
of cold and damp, as causes of scrofula, is greatly 
augmented even by a slight local injury. 

A moist, cold, and variable climate, like those 
of Great Britain and Holland, is particularly 
favourable to the development of scrofula ; in 
proof of which it is sufficient to adduce the great 
prevalence of the malady in both of those coun- 
tries. A very cold or a hot climate, on the other 
hand, serves rather to protect us against scrofula ; 
the former, dry and bracing, invites to exercise 
and promotes digestion, and thus strengthens the 
system ; while the latter favours the excretions, 
particularly that of the skin, and preserves the 
body from those sudden changes of temperature 
which in our island so often lay the foundations 
of scrofulous affections. But when an individual 
whose constitution has been formed in a warm 
climate is removed to a cold and variable one, the 
occurrence of scrofula is exceedingly frequent ; 
convincing proofs of which are every day afforded 
by those natives of warm climates who reside in 
our island, as well as by the diseases of birds, 
monkeys, and other animals which have been 
brought to us from warmer latitudes. (See Rey- 
naud, on the Diseases of Monkeys at the Jardin 
des Plantes. Archives Gen. de Med. t. 25.) In- 
deed it is not necessary for the inhabitants of 
warm climates to leave their native countries to 
experience the effects of a cold and variable atmo- 
sphere in the production of scrofulous disease : 
it is sufficient for them to ascend their own moun- 
tains, when they will be exposed to the same 
influences, and suffer the same evil consequences 
as if they had removed to a more northern cli- 
mate.* The information communicated by Dr. 
Ferguson regarding the diseases of the black 
troops in different situations in the West Indian 
islands, illustrates this point in a very interesting 
and satisfactory manner. (Alison, in Edin. Me- 
dico-Chir. Trans, vol. i. p. 398.) 



* In every latitude there is a point of elevation above 
the plains wherethe thermometer never sinks below 33° 
Fan. Even at the equator iliis exists at a height of 
J5.20T feet. See Suppl. to Encycl. Brit. art. Climate; also 
Humboldt. Geogranhv of P'ants. 



Amon- the causes which appear to give rise tu 
scrofula in children, are .ho practices of rearing 
them by the band and suckling them too long- 
two extremes, both of which often lead to the 
same result, the imperfect nourishment of the 
child The former of these is a fruitful source of 
scrofula in England, the latter in Scotland, where 
it is usual among the labouring classes for ch.ldren 
of sixteen and eighteen months to be still at the 
breast : in some instances we have known them 
suckled for upwards of two years. A similar 
injurious effect will be produced by allowing the 
same wet-nurse to suckle several children in suc- 
cession, which we have known to be pursued as 
far as three, when debility and symptomatic 
amaurosis forced the woman to resign her charge. 
Imperfect nourishment of the child, and consequent 
tendency to scrofula, is also likely to be induced 
in those cases where the wet nurse menstruates 
regularly during lactation. It is an opinion pro- 
fessed by Wiseman and other writers of great 
ability and experience, that a scrofulous wet-nurse 
may occasion the disease to appear in the child to 
whom she gives the breast ; and the idea appears 
consistent with reason, not on account of the exis- 
tence of any scrofulous poison, capable of being 
imbibed by the infant, but because it is natural to 
suppose that the milk of a scrofulous female will 
not afford the same substantial nourishment as 
that of a woman in sound and vigorous health. 

[When a close investigation is made, it will b' 
seen, that infants of the scrofulous habit display evi- 
dences of imperfect formation — Dr. Stokes says— 
of arrest of development. Their development re- 
sembles, in some respects, that of the fcetus prior 
to the seventh month of intra-uterine existence: 
the abdomen is prominent; the liver large; the 
head large ; and the extremities small. The writer 
has always entertained the view, that the condi- 
tion of the system is such as to require an in- 
crease of the plastic powers ; and a radical error 
appears to him to have been incurred by those 
who apply to all scrofulous inflammations the 
rigid system of regimen and therapeutics which are 
adapted for ordinary phlegmasia. These views 
have been strengthened by the observations of 
recent histologists. It has been remarked by 
Gerber, (General Anatomy., by Gulliver, London, 
1842,) that "albuminous or unorganized tuber- 
cles (which with great propriety are called scrofu- 
lous tubercles.) can only be produced from exuda- 
tions abounding in albumen, poor in fibrin," and 
such exudations, it need scarcely be said, are more 
likely to take place from blood itself defective in 
the fibrinous or essentially plastic element.] 

Another case of this disease is confinement in 
ill-ventilated apartments ; for the deficiency of 
pure atmospheric air cannot be long endured, 
especially during youth, without the most injuri- 
ous consequences. While the frame is building up 
and the constitution acquiring that character which 
is to distinguish it through life, all the processes 
of the economy are peculiarly active, and any 
defect of what is to perfect the' animal fluids and 
give energy to the nervous power, is felt with 
greater force, and is productive of much more 
injury than at an after period. Ill-aired apart- 
ments are in general imperfectly light, and the 
want of this vivifying influence of light favours 



SCROFULA. 



139 



the formation anJ development of scrofula; for the 
human body requires a certain exposure to light 
for the proper performance of its function, little 
less perhaps than plants, although in them the 
loss of colour renders the effects of seclusion more 
strikingly manifest. The experiments of Edwards 
on the spawn of frogs and on tadpoles clearly 
demonstrate the agency of light on the formative 
processes of living organization. He found when 
the light was excluded that the eggs were never 
fully hatched, and that tadpoles did not undergo 
their transformation at all, or did so after a con- 
siderable delay ; but their size increased, although 
they were kept in darkness. (De l'lnfluence des 
Agens Physiques sur la Vie, p. 398 et seq.) In 
accordance with the results of these experiments, 
it has been observed that monstrous births are 
exceedingly frequent among the miserable occu- 
pants of the dungeons under the fortifications of 
Lille. (London Medical Gazette, Sep. 29, 1832.) 
We may in part ascribe to the deficiency of light 
the prevalence of scrofula among the inhabitants 
of collars and of narrow alleys, where the beams 
of the sun never gain admittance. We are even 
inclined to think that the custom now so general 
among the wealthier classes in this country of 
sitting in darkened rooms during the day is far 
from being conducive to vigorous health; and 
where the young are concerned, we do not hesi- 
tate to say that it must be injurious. It is a 
custom borrowed from the luxury and effeminacy 
of warmer latitudes, and one which is calculated 
to enervate the body and induce a tendency to 
strumous disease. 

In a great metropolis like London, where the 
moving crowds of human beings and the number 
of carriages are such that children cannot be 
allowed to go abroad in the streets, they grow up 
feeble and often scrofulous ; while in villages and 
even in some populous towns, where they are 
almost constantly at play in the open air, they 
prove healthy and vigorous. The mischievous 
effects of the want of air, and sun-light, and 
healthful exercise, may be seen among the rich as 
well as the poor, though not to the same extent. 
The confinement, mental fatigue, and anxiety to 
which female children in particular are so unre- 
mittingly subjected during their education, prove 
fertile sources of scrofula in boarding-schools, and 
even in the families of the higher classes: bodily 
health is too often sacrificed to the idol of accom- 
plishment, and the intellectual powers, perhaps 
originally of excellent quality, are forced into a 
state of extreme culture and morbid precocity, 
destructive of all genuine soundness and vigour. 

Acute diseases, especially those accompanied 
with cutaneous eruptions, as small-pox, measles, 
and scarlet-fever, are often observed to have the 
effect of producing the development of scrofula ; 
and the more tedious the convalescence, the more 
frequently do symptoms of this disease ensue. 
Various other causes of debility prove the means 
of developing scrofula — as long watching, pro- 
tracted anxiety of mind, severe study, especially 
in the young, habits of dissipation, excess in sexual 
indulgences, solitary vice, profuse discharges of 
all kinds, repeated syphilitic disease ; the abuse 
of mercury, of nircotics, of warm bathing, and 
of powerful evacuants. Different local irritations 



have the effect of causing the neighbouring 
lymphatic glands to swell, and where a strumous 
tendency exists, to become the seats of tubercu- 
lous deposits, as we see exemplified in the con- 
sequences of difficult dentition, and of the in- 
flammatory affections of the mucous membranes 
of the respiratory and alimentary canals. Too 
great indulgence in sleep, has been enumerated 
among the causes of scrofula, and excess in this 
particular will certainly debilitate and thus dis- 
pose to the disease ; but we are inclined to believe 
that the indulgence in sleep which appears to in- 
duce scrofula is, in fact, usually occasioned by that 
feeling of weakness and exhaustion which is 
among the earliest symptoms of the approaching 
development of the disease. 

[Nature. — The pathology of scrofula, and the 
definition of the term, are differently expressed by 
different authors. Some define it to consist essen- 
tially of inflammation of the lymphatic ganglions, 
especially of those of the neck. This acceptation, 
however, is too incomprehensive, and expresses 
but imperfectly the grand characters of the disease. 
Although inflammation of the ganglions, and 
chiefly of the cervical, is very common in scrofu- 
losis, it is often absent ; and it can only be re- 
garded as a functional expression of the morbid 
diathesis. The disease, as has been shown, often 
expresses itself elsewhere, as in coxalgia, white 
swelling, vertebral caries, &c. &c. Scrofulosis is 
a morbid condition of the whole system of nutri- 
tion ; and hence, ought to be classed amongst the 
cachexia — the inflammation and enlargement of 
glands, like the eruption in variola, rubeola, &c. 
being merely attendant phenomena. The lymphatic 
ganglions are liable to simple inflammation from 
ordinary irritation. A thorn, run into the finger, 
may cause enlargement of the ganglions in the 
axilla ; inflammation or irritation of the mucous 
membrane of the intestines may give rise to 
mesenteric ganglionitis, owing to the extension of 
the irritation to the lymphatic ganglions that are 
seated between the irritated part and the centre 
of the lymphatic system. In like manner, nutri- 
tive irritation, occurring in one of a scrofulous 
diathesis, may occasion inflammation of the same 
glands ; but, being general in its influence, scrofu- 
losis may express itself in various other forms 
besides ganglionitis. With some, it has been a 
question, whether it be not dependent upon a 
morbid state of the blood. This is not probable, 
inasmuch as the disease, or rather a tendency to 
it, must exist prior even to the formation of blood. 
An impulse to it must be present in the materials 
furnished by one or both parents at a fecundating 
copulation ; which impulse may persist and be 
developed at an after period of the individual's 
existence. This tendency may not be received in 
sufficient force from the parents to be developed 
in their immediate progeny; but, like facial re- 
semblances, may be strongly exhibited in the 
grandchildren. Some writers, among whom is 
Dr. Stokes, (Lectures on the Theory and 1'. 
of Physic, 1st Amer. edit. p. 311, Philad. 1837,) 
place scrofulosis in the system of white vessels , 
in which, according to them, the lymphatics exe 
cute the function of veins. This view, howevc:. 
implies a something which probably has no ex 
istence — white blood. The want of colour in cm 



HO 



SCROFULA 



tain of the tissues, as in the conjunctiva and 
serous membranes, is probably due to the thin 
stratum of red blood circulating in their vessels, 
which renders the colour inappreciable. A very 
thin stratum of any coloured liquid, viewed by 
transmitted light, appears to be colourless ; but if 
the quantity of liquid be increased, the colour 
becomes manifest. This is what occurs in in- 
flammation of the white tissues : the quantity of 
red blood in the vessels is increased sufficiently to 
render its colour perceptible — not that there is an 
enlargement of arteries, destined in health to con- 
vey white blood, so that they now admit red cor- 
puscles, as supposed by some. There would, in 
fact, seem to be no white arteries, and, conse- 
quently, no white veins. Were such vessels to 
exist, they would be liable to constant obstruction 
from the red corpuscles. The function executed 
by the lymphatics would seem to be to break 
down the old tissues and convert them into lymph 
— a fluid essentially the same in every part of the 
lymphatic system — which eventually enters the 
circulation. They are engaged in the great pro- 
cess of assimilation, or in the decomposition and 
renovation of the tissues. Scrofulosis, then, must 
be regarded as a peculiar morbid condition of the 
whole system of nutrition.] 

Treatment. — The treatment of scrofula natu- 
rally divides itself into the preventive and cura- 
tive, the former of which is the more generally 
successful, and obviously the more important. 
All children are liable to become scrofulous, and 
those more especially whose parents or near rela- 
tives are the subjects of this disease. Hence par- 
ticular attention is required to prevent the forma- 
tion of the strumous constitution in children, and 
the development of the disease in those who may 
from birth be marked by this peculiarity of organ- 
ization. Indeed, it will not be undeserving of our 
care to influence as far as we can the sound and 
perfect formation of the embryo, by more than 
ordinary attention to the health of the mother 
during her pregnancy, wherever there is reason to 
apprehend the existence of a scrofulous disposition. 

When the child of a scrofulous father is born, 
the infant, unless the mother is free from all traces 
of the disease, ought to be consigned to a wet- 
nurse of sound and robust constitution, having an 
abundant supply of milk. This alone ought, for 
some months, to be sufficient for the nourishment 
of the child ; but after a time, should it appear 
delicate, a little isinglas jelly may be allowed in 
addition, or liquid yolk of egg, or beef-tea, to- 
gether with some preparation of wheaten meal or 
flour, or pure starch. Daily immersion in cold 
water, and gentle friction of the whole body will 
be found of great utility. The child ought to be 
warmly clothed, to be carried about in the open 
air as much as possible, and the apartment in 
which it sleeps ought to be kept at a steady mode- 
rate temperature, and perfectly well ventilated. 
All rooms occupied as nurseries for children ought 
to be spacious and lofty, never situated in a sunk 
floor nor in an attic, and, if possible, considerably 
above the level of the ground — directions which 
will lie readily understood, when it is recollected 
that low rooms are ill ventilated and often damp, 
while those in the attic story are particularly liable 
10 variations of temperature. 



As the child grows up, a similar plan of man 
agement will be found to avert, as fur as il 
accomplished, the formation of a scrofulous habit, 
and the development of the disease in those who 
exhibit that tendency. A plain and nutritious 
diet, containing a larger than usual proportion of 
animal food, warm clothing, daily exercise in the 
open air, the cold plunge-bath, cool and well-ven- 
tilated rooms, moderation in the pursuits of plea- 
sure, of study, and of business ; strict temperance 
and virtuous habits; may be said to comprise all 
that is most likely in our mode of living to give 
protection throughout life against the occurrence 
of scrofulous disease. To those in affluent cir- 
cumstances who can be removed to a climate more 
genial than that of Britain, such a change, if 
judiciously made in early life, will confer a still 
greater security from scrofula. (£);•. James Clark, 
On the influence of Climate. See also art. Cli- 
mate, in this work.) 

When a well-marked strumous tendency ex- 
ists, the management of the mind urgently de- 
mands our attention ; and attempts ought to be 
made at a very early age to correct whatever is 
deficient or excessive in its operations. Children 
who are of a dull and apathetic character ou»ht 
to be roused by presenting to them objects which 
are likely to interest and enliven, while the ardour 
of others in the pursuit of knowledge should be 
cautiously repressed ; and when the genius gives 
promise of unnatural precocity, means should be 
used to retard the unfolding of the mind, and 
allow the faculties to mature themselves by slow 
degrees. The moral feelings, in an especial man- 
ner, require a strict control for the purpose of 
giving them a just direction, and preserving indi- 
viduals of a sensitive character from indulging in 
those extravagant manifestations of sensibility 
which, if permitted, are apt to endanger the 
soundness of the mind. 

Before proceeding to consider the cure of scro- 
fula, it will be necessary to direct our attention tj 
the different conditions of those who are afflicted 
with this disease. It is frequently engrafted on a 
feeble and attenuated frame ; but it exists also in 
combination with a plethoric habit, perhaps deceiv- 
ing with a false show of strength ; the first of 
these forms being often exemplified among the 
poor, the second among the rich, although not by 
any means uniformly so. Hence a broad line of 
distinction arises between the methods of treat- 
ment adapted to such different types of the dis- 
ease. In the former a generous diet and stimulat- 
ing remedies are required; in the latter spare 
living, moderate evacuants, and local depiction 
are necessary : both, however, demand the em- 
ployment of those tonic means which tend to 
communicate vigour to the constitution, and which 
increases that power of resisting the occasional 
causes of disease and repairing the injuries of the 
frame ; a power which it is the remarkable 
characteristic of the scrofulous constitution to be 
devoid of, or to possess in a very imperfect degree. 

To consider in detail, the method of treating 
each of the extensive class of strumous affections 
would involve us in the repetition of what will be 
found under various specific heads of disease, and 
swell the present article far beyond its due limits. 
It will be sufficient, after premising a few general 



SCROFULA, 



141 



remarks, to pass in review the chief of the numer- 
ous remedies which have been held in estimation 
for the cure of scrofula ; pointing out, as we pro- 
ceed, the particular circumstances under which 
they have appeared to produce most benefit. 

The management of scrofulous patients, in 
respect of air, exercise, clothing, and diet, must 
be conducted upon the principles already laid 
down, but varied according to the exigencies of 
each individual case, still keeping steadily in view 
the improvement of the constitution. 

On the subject of diet it is deserving of notice 
that, besides those varieties before alluded to, a 
very nourishing food may be prepared by boiling 
a small bag filled with suet in cow's milk. We 
have made trial of it on the recommendation of 
Dr. Paris, (On Diet, 2d edit.,) and found it to 
answer remarkably well in cases of scrofulous 
marasmus when almost every other article of diet 
caused irritation of the bowels, and passed through 
undigested. It bears a near resemblance to goat's 
milk, but has the advantage of being more as- 
tringent. 

Some eminent writers have not hesitated to 
state their belief that air, exercise, and proper 
clothing and diet, comprise the best and only 
method of controlling and removing scrofula. To 
such an opinion we cannot subscribe, although 
we fully acknowledge the vast importance of 
attending to these particulars, and the natural 
progress of cases of external scrofula towards a 
cure, after the age of puberty. An amusing in- 
stance of the effect of air and exercise alone in the 
cure of a scrofulous sore in the leg is afforded by 
the case of a young nobleman, who, after suffer- 
ing under a variety of regular treatment, had a 
hole cut in his stocking, and was sent to range 
the fields, when a crust soon formed, and the ulcer 
healed. It is worthy of remark that this indivi- 
dual became afterwards insane. 

1. Evacuunts. — Although it be true, in a 
general sense, that scrofula is a disease of debility 
rather than of strength, and that profuse dis- 
charges, whether natural or artificial, prove among 
the most powerful of its exciting causes ; yet in 
the early stage of many scrofulous diseases, and 
sometimes during their progress, a cautious em- 
ployment of evacuants is found to be productive 
of the best effects; but it is only by a careful 
study of the existing symptoms of inflammation 
in each individual case that we are enabled to 
make use of depletory means with confidence and 
success. In strumous persons the occurrence of 
inflammatory symptoms is to be watched with 
unceasing care, and above all those of the respira- 
tory mucous membrane, as well as of the serous 
membranes of the head and abdomen : a well- 
timed venesection in such cases may be the means 
of cutting short symptoms which would speedily 
induce the eruption of a crop of tubercles ; on the 
I ltd consequences of which, whether slow or 
rapid in their progress, it is unnecessary to en- 
large. Leeches arc often preferred from the 
timidity of patients and their friends, and some- 
times perhaps from the indolence of medical 
attendants; but their effects are frequently irritat- 
ing and exhausting, and, even in children, far 
inferior to those of the lancet. Cupping is also 
preferable to leeching, the ease and rapidity with 



which blood can be taken by this method placing 
it nearly on a level with venesection. The de- 
traction of blood from the vicinity of parts suffer- 
ing from scrofula, or in danger of becoming the 
seats of scrofulous affections, is in very many 
cases necessary ; and in these both leeches and 
cupping may be employed, but under the guidance 
of a wise discretion, for which no general rules 
can be given. To promote the efficacy of san- 
guineous depletion, and supply its place when 
circumstances render it unsuitable, the tartrate of 
antimony may be exhibited in small doses, as a 
nauscant and diaphoretic ; and it will sometimes 
be necessary to have recourse to this remedy 
during the progress of the tonic plan of treatment 
when it appears, as often happens, to be pro- 
ducing too much excitement. The tartrate of 
antimony or ipecacuan is also used, with excellent 
effects, in emetic doses, for the purpose of pre- 
paring the stomach for the reception of tonic 
medicines in many scrofulous cases. 

Long-continued nausea, whather produced by 
sea-sickness or by the persevering use of tartar- 
emetic, has a powerful effect in dispersing indolent 
tumours, and has been successfully employed for 
that purpose. Two cases of this nature, and one 
of presumed tuberculous phthisis, cured by the 
use of nauseants, have been communicated by 
Dr. Jenner ; and he has expressed a hope that by 
such remedies we shall be enabled to affect the 
absorption of tubercles. (Baron's Inquiry, pp. 
158, et seq.) All that we know of the action of 
the absorbents leads us to believe that they are 
capable of removing tubercles ; and that such an 
operation, to a certain extent, does really take 
place, is proved by the changes which that sub- 
stance undergoes in its progress to the cretaceous 
transformation. If tuberculous masses of long 
standing are thus changed, what reason have we 
to doubt that the soft curdy matter of which they 
are at first composed is often absorbed and carried 
back into the circulation, to be converted into 
some less noxious constituent, or altogether ex- 
pelled from the system ? 

The action of strong purgatives is sometimes, 
though rarely, required in scrofulous diseases ; but 
the neutral salts combined with the administration 
of mercurials are very useful, as we shall presently 
point out. Moderate aperients, and those which 
tend at the same time to improve the powers of 
digestion, are required in the treatment of almost 
all scrofulous cases. Rhubarb and soda, and rhu- 
barb and magnesia are well adapted to such cases; 
and as a mild evacuant, when the bowels are 
loaded, castor oil is very serviceable. 

2. Mercurials. — Of all the remedies employed 
in the treatment of scrofula, perhaps none have 
enjoyed a greater reputation than mercurials ; but 
it is only from their purgative and alterative effects 
that they prove beneficial, and not when they pro- 
duce that powerful influence on the frame which 
so rarely fails to ensue from their free exhibition. 
In the forms of calomel and blue-pill, mercury 
enables us to relieve the bowels from those morbid 
accumulations which are so apt to collect in stru- 
mous cases, and to restore to the liver its healtny 
action, which is rarely preserved, at least for any 
length of time, during the existence of scrofula. 
The success of a mild alterative plan of treatment. 



142 



SCROFULA. 



aided by the use of saline purgatives with senna, 
has been admirably illustrated by Mr. Abernethy 
(On the Constitutional Origin of local Diseases) ; 
and more exclusively in reference to the disease 
now before us by Mr. Lloyd. (On Scrofula.) 
Other mercurial preparations are also employed 
with benefit in different forms of scrofula : thus 
the hydrargyrum cum creta will be found very 
serviceable when the secretion of bile is faulty or 
deficient, whether combined with a torpid or re- 
laxed state of the bowels, as in the early stages of 
mesenteric disease. The internal use of corrosive 
sublimate is also valuable, particularly in scrofulous 
ulcerations and leucorrhoeal discharge ; provided it 
be administered cautiously and in minute doses 
such as the eighth of a grain three times daily. It 
seems to act rather by stimulating the mucous 
membrane of the alimentary passages, and pro- 
moting perspiration, than by any influence it exerts 
over the secretion of the liver. Mercury has like- 
wise been employed in the form of ointment, 
rubbed on the skin for the relief of scrofula, and, 
according to the report of Mr. Brandish (On the 
Use of Caustic Alkali in Scrofula, &c), with the 
most beneficial effects. It was his practice to use 
it in small quantities, continued nightly for months, 
but never during the cold season ; it is proper to 
add that he avoided the full operation of the 
mineral, and combined its employment with the 
internal exhibition of liquor potassae, with a gener- 
ous diet, and the occasional use of vegetable tonics. 
Of this practice in cautious and experienced hands, 
we are inclined to think favourably, although it 
must be admitted that medical opinion in the pre- 
sent day is adverse to the employment of mercu- 
rial frictions in scrofulous cases generally. But 
the local application of camphorated mercurial 
ointment to diseased joints and indurated testicles 
is now acknowledged to be in very many instances 
highly efficacious. (Scott, Observations on the 
Treatment of Chronic Inflammation, &c.) 

As a sequel to the subject of mercurials, it will 
not be out of place to mention another remedy, 
less hazardous in its operation, but not of less ap- 
proved efficacy in scrofula, — namely, sursaparilla. 
We find it recommended by Wiseman (Vol. i. pp. 
410 et seq), and after a period of neglect it has 
been again restored to merited favour. It is a mild 
tonic, and well adapted to those cases where the 
skin is in a harsh and unkindly state : it proves a 
restorative to the stomach, and is found very use- 
ful in the chronic diarrhoea of strumous children. 
The decoction is the usual form in which this 
drug is exhibited, but the bulk of this preparation 
often renders it objectionable, particularly for chil- 
dren ; and in most cases, both of children and 
adults, a much more concentrated preparation, 
such as the solid or fluid extract, will be found to 
possess many advantages. Powdered sarsaparilla, 
conjoined with soda, is an excellent form, though 
much less palatable than the extracts : it has been 
given with marked benefit in scrofulous disease of 
the tongue. 

A feeble digestion, and prevailing acid condition 
of the stomach and alimentary tube, are the fre- 
quent concomitants of scrofulous disease ; hence 
the employment of the alkalies and alkaline earths, 
but particularly the former, has been attended with 
very beneficial effects in its treatment. All the 



alkalies have been used with advantage in scro- 
fula ; but the liquor potassa; is that which in our 
hands has proved the most decidedly useful. The 
dose must be large, as Mr. Brandish has shown— 
from half a drachm to a drachm and a half three 
times daily, for an adult; given in malt tea, mild 
ale, or infusion of hops. (Brandish, Op. cit.) 
Carbonate of soda is generally more agreeable to 
patients, and may be given freely with good effect, 
especially when combined with sarsaparilla, cin- 
chona, or bitters. The volatile alkali (carbonate 
of ammonia) has also been administered in scro- 
fulous cases ( Charles Armstrong, on Scrofula), arid 
with excellent results. But its stimulant anil dia- 
phoretic properties render it suitable only for cases 
in which there exist torpor, languid circulation, 
impaired appetite, and a dry husky state of the 
skin, such as we often meet with among the poor, 
and in that form of the disease so well character- 
ized by Alibert (Nosologie Naturelle), under the 
designation of scrofule nornie, 

A considerable number of the remedies which 
have enjoyed reputation in the treatment of scro- 
fula, have belonged to that class which increase 
the secretion of urine. The alkalies which we 
have just considered are of this description ; and 
besides these, we may enumerate the muriate of 
lime, the muriate of barytes, and nearly all the 
mineral waters to which scrofulous patients are in 
the habit of resorting. These saline remedies not 
only promote the secretion of urine, bnt act gently 
on the bowels, and thus, especially when conjoined 
with the exercise and free air enjoyed at a water- 
ing-place, increase in a remarkable degree the 
powers of digestion, and so prove beneficial to the 
scrofulous invalid. In their specific effects we 
have no confidence. Muriate of barytes is now 
very rarely prescribed ; and muriate of lime almost 
as seldom, excepting in the combined form in 
which it is furnished by nature at various mineral 
springs. 

The opinions which we have already expressed 
regarding the nature of scrofula may have pre- 
pared our readers to look for the most valuable 
remedies in this disease under the head of tunics. 
Even inflammation, which in most cases requires 
depletory measures, is, when combined with scro- 
fula, and thus rendered indolent in character, often 
successfully treated by tonic remedies; this is 
especially true of those inflammatory affection) 
which are attended with little or no constitutional 
disturbance, as in strumous inflammation of the 
conjunctiva, where the efficacy of cinchona has so 
long been acknowledged. This admirable drug 
is, without doubt, the most efficacious of all the 
tonics used in scrofula, and, from the concentrated 
form in which it can now be exhibited, the most 
generally available. The virtues of cinchona in 
strumous diseases were first brought into notice 
by Dr. Fordyce, (Medical Obs. and Enquiries, 
vol. i. p. 184; see also Fothergill, ibid. p. 303,) 
and from that time until now it has enjoyed more 
or less favour. Sulphate of quinia has now very 
generally superseded it, having become a remedy 
of every day prescription. It is one, however, 
which requires to be carefully watched and imme- 
diately intermitted when it produces, as it often 
does, a degree of feverishness. Other vegetable 
tonics and bitters have been administered with 



SCROFULA 



143 



advantage in scrofula, such as calumba, gentian, 
and hop; and in Germany, coffee made from 
roasted acorns 1ms found many advocates, although, 
as Benedict (Handbuch der Practish. Augen- 
heilkunde) informs us, it often proves consti- 
pating and induces a feverish state. 

[Of late, different preparations of the leaves of 
Juglans Regia, walnut tree, and especially the 
extract, have been highly extolled by M. Negrier 
as anti-scrofulous remedies. (Archiv. General. 
de Med. x. 399, Paris, 1841.)] 

Of the metallic tonics used in scrofula, iron is 
that which has been found the most beneficial. 
The best forms of exhibiting it are the vinum 
ferri, the muriated tincture, and the subcarbonate 
in powder : the chalybeate mineral waters also 
have often proved eminently serviceable in this 
disease. 

Arsenic is a metal of much more questionable 
efficacy; but we have known it productive of 
great benefit in allaying the pain attending stru- 
mous affections of the bones and periosteum. 
Gold was given by Lalouette in scrofula, and its 
use has lately been revived by Chrestien as a 
remedy for syphilis. [From recent trials, it would 
not seem to be possessed of such efficacy as to re- 
commend it to great confidence.] 

In the advanced stages of scrofulous affections, 
one of the most permanent and exhausting symp- 
toms is profuse perspiration ; for the purpose of 
checking which, the mineral acids, particularly 
the sulphuric and nitric, have been given with 
great benefit : their use, however, is apt to cause 
irritation of the bowels, and thus we are forced to 
alternate them with opium, or altogether to aban- 
don their employment. The root of the tormentil 
has been recommended as a substitute, but it 
seems to possess very feeble powers of repressing 
either perspiration or diarrhoea. The mineral 
acids are also useful in restoring the tone of the 
stomach, and thus they frequently prove of great 
service in the treatment of scrofula. 

Scrofula as a chronic disease, often accompanied 
with febrile action of the stomach, and indeed, of 
all the assimilative organs of the system, seems 
naturally to require the exhibition of stimulating 
remedies. In regard to dietetic stimulants, ani- 
mal food, as we have already stated, is proper in 
a large proportion of strumous cases, and in some 
ale and wine may be given with great advantage. 
Of these, ale is the more nutritious and less heat- 
ing, and when sound and well seasoned with 
hops, it proves in many cases a valuable auxiliary 
to the medicinal treatment of scrofula, — an opinion 
which is not given on theoretical grounds, or the 
mere authority of others, but from what we have 
had frequent occasion to observe. Bitter tinctures 
have been prescribed in this disease, and that of 
Peyrhile, which contains also a proportion of 
alkali, was long a favourite among the French. 
Its effects, however, are known to have been often 
injurious, because too stimulating ; and in the pre- 
sent day it is seldom or never employed. 

Iodine, a powerful stimulant of the alimentary 
mucous membrane, and of the whole absorbent 
system, has lately been added to the catalogue of 
anti-strumous remedies; and as yet it can scarcely 
be said that a just estimate has been formed of its 
real virtues. The evidence contained in the writ- 



ings of numerous authors, and the results of our 
own experience, prove satisfactorily that iodine 
possesses a very considerable efficacy in removing 
scrofulous swellings of the lymphatic glands; and 
there is some reason even to believe that it is 
capable also of inducing the absorption of tuber- 
culous deposits. (Gairdner, On Iodine, pp. 52 
& seq. ; also, Baron's Inquiry.) This remedy is 
successfully employed both internally and locally, 
in each of which modes it increases the action of 
the absorbents ; and in the latter it likewise often 
induces suppuration of strumous tumours, and 
thus hastens their removal. After attracting for a 
time the attention of the medical profession, iodine 
was beginning to experience a degree of neglect, 
when the appearance of M. Lugol's Memoirs re- 
stored its reputation. (Lugul, Memoires sur 
1'Iode, Paris, 1829, 1830; and Dr. O'Shaugh- 
nessy's Translation, with Appendix.) His exten- 
sive series of experiments in the employment of 
this substance have placed in a very clear and 
convincing light the powers which it possesses of 
controlling and even curing scrofula. The trials 
which we have made of it serve to confirm the 
representations of M. Lugol ; but we are ready to 
admit that his strong partiality in its favour may 
in some instances, perhaps, have led him a little 
beyond the limits of legitimate induction. For 
farther information regarding the employment of 
iodine in scrofula, we beg to refer to M. Lugol's 
last memoir, where a full account will be found 
of his most improved method of administering this 
powerful drug. Iodine, like arsenic and some of 
the mercurial preparations, is apt to cause pain of 
stomach, and in some instances headach ; and 
when taken in excess, to produce an inflamma- 
tory condition of the alimentary mucous mem- 
brane, diarrhoea, and even bloody motions. The 
first of these symptoms is relieved by wine of cin- 
chona, but the others require that the remedy be 
discontinued ; and when resumed, that the dose 
be reduced. In cases where iodine has produced 
debility and loss of appetite while manifestly re- 
ducing the scrofulous swellings, we have obtained 
a return of health and continued diminution of the 
tumours, by administering in its place sulphate of 
quinia with extract of sarsaparilla and aromatic 
sulphuric acid. The evidence of many practi- 
tioners, whose veracity and correctness of observa- 
tion are above suspicion, proves that iodine, when 
long continued in full doses, frequently produces 
great weakness and emaciation ; but M. Lugol is 
disposed to throw doubt on this opinion, and he 
even asserts that in his experience, thin females 
have not become emaciated, nor corpulent ones 
lost flesh. It ought to be remarked in explanation 
of this discrepancy, that the doses which he pre- 
scribes are usually small, always moderate, and 
much diluted ; and that he endeavours to accom- 
plish by long perseverance what others have at 
tempted by rapidly pushing the remedy to it. 
utmost limit. In these particulars, we conceive 
consists the superiority of M. Lugol's mode of 
treatment. It is proper to state here, that he als. 
avails himself in the treatment of scrofula, of the 
auxiliary means of air, exercise, warm clothing, 
and good diet ; and employs, besides, baths ol 
watery vapour, of iodine, and of sulphureous 
water. 



i« 



[The general condition of the system in scro- 
fulosis might appear to suggest more especially 
the iodide of iron, in which eutrophic and tonic 
properties are combined. Accordingly, it has been 
extensively used, and with valuable results. Of 
this, a grain may be given three times a day, and 
the Jose may lie gradually raised to three grains. 

Codliver oil — oleum jecoris aselli — which has 
been found to contain iodine, has been given 
largely in various forms of scrofulosis, and there is 
much testimony in favour of it. One writer, 
Schenck, (Huff-land's Journal der Praktisch. Heil 
hunde. May, 1838,) esteems it as certain a remedy 
in scrofula and rickets, as cinchona is in intermit- 



SCROFULA. 

"other modes of stimulating the scrofulous pa- 
ti en( are afforded by electricity and galvanism: 
hitherto these have been employed principally as 
local remedies for the dispersion of strumous swell- 
inns and with excellent effects; {Underwood, 
Surgical Tracts.— Birch, on the Medical Applica- 
tion^ Electricity ;) but they will be found equally, 
if not more beneficial, as general means ot exalt- 
ing the nervous energy, and improving the tone 
of the whole frame. 

Like all diseases occasionally attended with 
pain, scrofula requires at such times the use of 
narcotics, and, among these, opium under various 
forms of preparation certainly holds the first place. 



tent fever. The writer has had no experience j Hyoscyamus, belladonna, and conium, are also 

used with advantage ; and the last obtained at one 
period, through the writings of Dr. Stoeck, a parti- 
cular celebrity for its anti-strumous virtues. It has 
both as an internal and external remedy a consider- 
able power of relieving pain ; but none which we 
have observed of a truly discutient nature. 

Topical Treatment. — Of the local treatment 
of scrofula, it may be supposed that the physicians 
ought not to speak ; but, although this branch of 



with it. Recently, skateliver oil has been recom- 
mended as preferable to codliver oil. In Holland 
and Belgium, the oils obtained from the livers of 
Raia clavata and It. batis have been used in place 
of the latter, on account of their being less dis- 
agreeable to the taste, and even more efficacious 
as a therapeutical agent. It is said by MM. Gi- 
rardin and Preisser to contain a per centage more 
of iodide of potassium ; and in point of purity and 



other properties, appeared to be superior to it. the subject falls immediately within the province 



(Edinb. Med. and Surg. Journ., Oct. 1842, p. 
504.) 

Dr. Ure has suggested the use of codliver as a 
diet for those for whom the oil is considered to be 
indicated. {Pharmaceutical Journ., Nov. 1, 
1842, or Braithwaite's Retrospect, vi. 104, Lond. 
1843.) 

Bromine, whose properties resemble those of 
iodine, has been given in the same cases, but it pos- 
sesses no advantage over the other, and is by no 
means as easily attainable.] 

The use of baths in the treatment of strumous 
affections is of great value, the kind of bath made 



of surgery, we may yet he permitted to state 
nerally our views regarding this matter. Long 
observation of scrofulous diseases has convinced 
us that much active surgical interference is usually 
injurious, and that mild and soothing modes of 
treatment are, on the whole, more generally suc- 
cessful. Thus the laying open of sinuses, the 
cutting away of undermined integument, and the 
application of strong escharotic ointments, often 
exasperate instead of improving the case ; while 
small counter-openings, moderate pressure, brush- 
ishing the integuments around ulcers and fistulous 
openings lightly with nitrate of silver; and the 



choice of being determined by the existing state ! application to strumous sores of bread-and-water 



of the patient. Sudden immersion in cold water, 
and especially sea-water, has long been an ap- 
proved remedy in scrofula ; but when the strength 
of the patient is so reduced that no kindly glow 
follows, and when there is decided feverishness, 
the cold plunge bath is not admissible. In such 
cases the warm-water bath, and still more that of 
vapour, will be found highly soothing and resto- 



poultices, astringent washes, lime-water, and the 
black mercurial lotion, proves very serviceable. 
When a scrofulous ulcer is highly irritable and 
painful, the bruised fresh leaves of the hemlock 
applied as a poultice seldom fail to give relief. In 
ulcers of the tongue, carrot pulp and Peruvian 
balsam are the best applications. 

Indolent scrofulous tumours, when the health is 



rative. To weak scrofulous invalids, the well- little reduced, may be dispersed or made to sup- 



managed application of steam has very often 
proved signally beneficial. A greater degree of 
excitement m&y be communicated to the cutane- 
ous surface, when the general torpor of the system 
or the indolence of the diseased parts demands it, 
by the employment of warm saline water, or im- 
pregnating the water or steam with irritating 
gases, such as sulphuretted hydrogen, carbonic 
acid, (see the Remarks of Prof. Osann on the Ga- 
seous Baths at Eger. Osann und Trommsdorf Die 
Mineral Guellen, etc., Berlin, 1822,) chlorine or 
iodine. The use of baths of every kind ought al- 
ways to be followed by friction, and this alone is 
a valuable mean of restoring the healthy actions 
of the skin, and furnishing a substitute for that 
bodily exercise which the condition of the scrofu- 
lous patient often disables him from using. In 
cases of abdominal obstruction and affections of 
Ihe spine and joints of the extremities, the great 
benefit derived from friction is attested by all who 
have seen it carefully practised. 



purate by continued pressure or by blistering, 
which can be employed when the situation of the 
swelling will not admit of pressure. As soon as 
suppuration has taken place, and the matter ap- 
proaches the surface, it ought to be evacuated by 
a small puncture, which will hasten the cure and 
diminish the chance of an unseemly scar. When 
the parts continue inflamed and hardened, poul- 
tices of bread and water, or rags dipped in cooling 
lotions, are the best applications ; but when the 
discharge is considerable, finely carded cotton 
with gentle pressure checks the profuse secretion, 
and gives comfort to the patient. In those sudden 
depositions of fluid which sometimes occur in 
strumous cases, it is not always prudent to make 
an opening as soon as fluctuation can be detected; 
for by a little delay and soothing means we have 
not unfrequently known the fluid to be wholly 
absorbed. 

[When the strumous swellings are very indo- 
lent, along with the internil remedies, and re- 



SCROFULA — SEDATIVES, 



145 



gimen inculcated above, many local applications 
may be rmule use of to discuss them. Chlorinated 
lime has been applied with advantage in the form 
of ointment, as well as the aqua chlorini. Iodine 
has been used advantageously in the form 
of tincture, applied repeatedly by means of a 
camel's-hair pencil. The ointment of iodine, of 
iodide of potassium, of the ioduretted iodide of 
potassium, and of the iodide of lead, have likewise 
been used with advantage, rubbed on the part 
night and morning, and the iodo-hydrargyrate of 
potassium has been prescribed both internally and 
externally. An ointment of veratria has likewise 
been strongly recommended, but it has not been 
much employed.] 

The eczematous and impetiginous eruptions 
which occur in scrofulous individuals are greatly 
benetited by astringent applications, such as the 
liquor suhacetatis plumbi and liquor aluminis 
compositus ; and when these diseases have proved 
obstinate, the unguentum picis will often com- 
pletely remove them. This last application we 
have found particularly efficacious in those crops 
of psydracious pustules and extensive exfoliations 
of the cuticle which are so frequently seen on the 
fingers of scrofulous females and delicate children. 

The tumid upper lip, so distinctive of scrofula, 
and often amounting to a deformity, may be 
grently reduced or altogether removed by the re- 
peated application of nitrate of silver. When the 
ulcerated fissures of the lip are very painful, relief 
will be obtained from the hemlock poultice, and 
nitrate of silver can be afterwards had recourse 
to. 

Strumous enlargements of the tonsils were 
formerly treated by excision, and cases requiring 
this procedure do sometimes occur: the practice is 
as old as Celsus, and is still a favourite with the 
Baron Dupuytren; Dr. Hosack of New York 
has also lately borne testimony to the safety and 
advantage of this operation, [and it is now fre- 
quently — perhaps too frequently — practised.] 
When it is not absolutely demanded, the employ- 
ment of iodine, leeches to the throat, the light ap- 
plication of nitrate of silver to the tumours, and a 
gargle of oak-bark, will generally prove sufficient, 
if not for a complete cure, at least to keep the 
swellings within moderate bounds. 

Scrofulous diseases of the bones and joints 
require, in their first stage, local depletion, and at 
a more advanced period counter-irritation by 
croton oil, blisters, tartar-emetic ointment, caustic 
issues, or rnoxa. The warm-water douche and 
careful friction are also eminently useful in indolent 
cases. A very successful plan of managing dis- 
eased joints has of late been made public by Mr. 
Scott, (Observations on the Treatment of Chronic 
Inflammation, &c.,) — consisting of the applica- 
tion of camphorated mercurial ointment, pressure, 
and complete rest of the affected articulation with- 
out confinement of the patient. 

When all hope of recovering a diseased portion 
of the body is at an end, the question immediately 
presents itself whether such part ought not to be 
removed by an operation, and the patient thus 
freed from what is in itself useless, perhaps burden- 
some, the cause of constant irritation, and in many 
cases of exhausting discharge. Scrofulous bones 
and joints are peculiarly of this description, and 

Vol. IV.— 19 n 



the question of their amputation is seldom deter- 
mined without the concurrence of the physician. 
It has been asserted that amputation in such cases 
merely puts off the evil day, ar.d that the patient, 
at no distant period, is destroyed by scrofulous 
disease of some other and more important organ ; 
but the futility of this opinion is daily attested by 
the numerous living instances, not only of those 
who have suffered amputation for scrofulous affec- 
tions in early life, but of multitudes of others who 
have survived with contracted and distorted limbs 
from the ravages of the disease. In considering 
the propriety of amputation, it is necessary to de- 
termine how far the continuance of the affection 
brings the patient's life into hazard, and whether 
he has still sufficient strength left to undergo the 
operation. It is truly surprising to observe how 
small a degree of vital force is adequate to carry a 
patient safely through an operation under such 
circumstances ; but it must be remembered that 
amputation, severe as it certainly is, removes the 
very sources of irritation and exhaustion which 
are rapidly undermining life. This operation is 
nugatory when another joint, or a vital organ, as 
the lungs or bowels, is already the seat of incurable 
disease ; and in such cases unquestionably it 
should not be performed. Great caution, however, 
is required in making our final decision ; for every 
practitioner of experience has seen instances 
where the symptoms of visceral disease appeared 
almost to preclude hope, and yet have yielded on 
the removal of the local irritation, and a cure has 

been the happy result. TIT „ 

Klv W. Cumin. 

SEDATIVES, from sedare, to calm. These are 
medicines which directly depress the energy of 
the nervous system, and diminish pretematurally 
increased action. They exert an immediate in- 
fluence over the nervous system, by which its 
energy is either greatly weakened or wholly de- 
stroyed. They thus have a twofold action, first, 
upon the nervous system, and, secondly, through it 
upon the muscular: if the dose be large, the indi- 
vidual quickly loses his 'volition and becomes 
vertiginous; the nerves of sensation cease to 
respond to ordinary impressions ; consciousness 
fails ; syncope supervenes, and in a few seconds 
life is extinct. 

With the exception of Dr. Young (Introduction 
to Medical Literature,) and Dr. Billing,* medical 
authors in general have confounded sedatives with 
narcotics. There is no doubt, however, that the 
distinctive characteristics of both classes are well 
marked, and that the boundaries of each may be 
readily traced. The only circumstance, indeed, 
which has prevented the distinction from being at 
all times perceived, is the transitory nature of the 
excitement which follows a large dose of a narco- 
tic, and the rapidity with which the symptoms of 
diminished sensibility and mobility supervene, as 
if they were induced without any previous in- 
creased action. In the operation of every narcotic 
the depressing effect, therefore, is preceded by in- 
creased action; and both the degree of the col 
lapse and the rapidity of its appearance depend 
on the extent of the previous excitement. In 

* First Principles of Medicine, p. 44. [The separation 

is made by the writer in his Qcneral Therapeutics Plntii 
delphia, 183U & 1843.] 



146 



SEDATIVES. 



small or moderate doses, narcotics augment the 
force and increase the frequency of the pulse, pro- 
mote the secretions, and elevate the powers both 
of the body and the mind, and if these doses be 
repeated at proper intervals, this excitant effect is 
maintained ; but, if the dose be not repeated, the 
transitory nature of this excitement becomes con- 
spicuous, and a state of depression or collapse fol- 
lows, in which languor, dullness of sensation, and 
sleep ensue. 

Such are the effects of a narcotic. The admin- 
istration of a sedative, on the contrary, whatever 
be the dose, is not followed by any perceptible 
quickening or augmentation of the pulse, but by 
an immediate diminution both of its force and 
frequency, and by a general feeling of depression, 
too decided to be overlooked. I- is, indeed, evi- 
dent thai this effect is exactly th« opposite of that 
of an excitant : and if the dose be large, not only 
is the sensibility diminished, but the whole power 
of the sensorium is at once completely paralyzed. 
We are perfectly aware that Magendie and others 
regard the sedative influence of one of the most 
efficient of this class of medicines, the hydrocya- 
nic acid, as that of transient excitement, followed 
by an immediate state of collapse ; but the result 
of our own experiments on living animals is ad- 
verse to this supposition : the instantaneous dimi- 
nution of the general powers of the system, the 
prostration of strength, the stupor, numbness, 
sleepiness, vertigo, and depression of the animal 
spirits, all indicate an immediate influence on the 
nervous energy. With these observations in view, 
and with the experiments of Mr. [Sir B.] Brodie 
on some poisonous substances before us, we may 
venture to assert that it is upon the nerves of sen- 
sation chiefly that direct sedatives operate. 

When sedatives are taken into the stomach, if 
they do not destroy life, their influence is much 
weakened after a certain time has elapsed, and 
soon afterwards it altogether ceases. It may, 
however, be maintained in the same manner as 
that of narcotics, by the repetition of the dose at 
moderate intervals ; but the impression becomes 
weaker after each renewal of it, until it is almost 
lost, unless the dose be greatly augmented. If 
these statements be correct, it is evident that seda- 
tives operate directly on the nerves of sensation, 
and that this effect is not the result of a stimulus 
rapidly exhausting the excitability of the nerves, 
but of a direct impression of a peculiar kind on 
the nervous system, which instantaneously de- 
stroys the susceptibility of the nerves for receiving 
impressions from external stimulants. 

Owing to the ideas which we acquire in early 
life, the effects of excitants are connected with 
mechanical impressions, and, therefore, the mind 
has less difficulty in admitting the hypothesis that 
every instance of collapse must be preceded by a 
previous state of excitement, than that something 
is either abstracted from the nerves, or that some 
alteration takes place in these organs, which di- 
minishes their faculty of receiving impressions. 
It is true that no organic change can be detected 
in the nerves of animals killed by sedative poisons, 
and we are equally unable to affirm from inspec- 
tion that any thing has been abstracted from them, 
•et that some change has occurred is undoubted, 
as they arc no longer susceptible of being excited. 



Whether we can assume that the sedative effect 
is immediate, not secondary, is questionable: but 
we imply its direct character from the local effect 
of powerful sedatives where they are applied in 
small quantity to a limited portion of the surface 
of the body ; as for example, if the finger be held 
over the mouth of a bottle of hydrocyanic acid, it 
is numbed, and it continues so for a considerable 
time without any extension of this effect to the 
rest of the body. When the quantity is larger, 
their influence ceases to be partial, and is extended 
over the system : and when it is very large, the 
same rapid destruction of life follows as when the 
sedative is taken into the stomach. Sedatives con- 
sequently differ from many of the other classes of 
medicines, in their effects being more regulated hy 
the extent of the dose than by the state of the 
body. Upon the whole we conceive that there 
are sufficient reasons for separating sedatives from 
narcotics, and allotting to each a distinct place in 
the arrangement of the materia medica. 

Let us examine their influence, as physiological 
agents, on the different organs of the living sys- 
tem. 

1. On the Digestive Organs* — No sensation 
in the stomach is experienced when a sedative is 
taken into it, except occasionally that of nausea: 
the influence of the sedative is rendered obvious 
rather by the change which follows in the state of 
the digestive function than by anything which can 
be referred to the condition of the organ itself. 
If the viscus be morbidly irritable, the influence 
of the sedative is acknowledged by the diminished 
susceptibility of the gastric nerves, by the improve- 
ment of digestion from the lessened irritability fa- 
vouring the formation of a more healthy, because 
more slowly secreted, gastric juice. 

In this respect, when the dose is moderate, the 
direct influence of the sedative is local and con- 
fined to a certain set of nerves, although the gene- 
ral system ultimately benefits by the change thus 
affected, a fact daily illustrated in the administra- 
tion of hydrocyanic acid in dyspepsia ; whereas 
the influence of narcotics is invariably propagated 
over the system, even when they are administered 
in small doses. 

If the dose of the sedative, however, be in- 
creased, the impression then extends to the brain, 
and is manifested by slight vertigo, transient in- 
sensibility, sinking of the pulse, failure of thff 
muscular energy, particularly in the thighs, gene- 
ral lassitude, and mental depression. If the dose 
be larger, but within the limit of a poison, it must 
be admitted that sensations, for example weight 
and an obtuse pain in the forehead, are super- 
added, which seem to indicate previous excite- 
ment ; but that this has not existed is highly 
probable, since we know that coma may proceed 
from inanition as well as from increased action in 
the brain, and that stimulants are frequently re- 
quisite to relieve symptoms closely resembling 
those requiring venesection and depleting reme- 
dies. Taken into the stomach, therefore, sedatives 
operate directly upon the nerves of that organ, 
and, within a certain limit with respect to dose, 
the effect which follows is strictly local. 

2. On the Circulating and Respiratory 
Organs — When the influence of a sedative ex- 
tends to the general system, the action of the 



SEDATIVES. 



147 



heart and arteries is diminished, out not in the 
ratio of the impression on the nervous system. 
Sehubarth asserts that the heart loses its con- 
tractility, but the experiments of Coullon, (Re- 
searches, &c. p. 146,) with which those of the 
author accord, lead to an opposite opinion. In 
poisoning by hydrocyanic acid, the heart contin- 
ues to pulsate, and the intestines continue to dis- 
play their peristaltic and vermicular movements 
after the death of the animal, and they do not 
lose their contractility for some time ; at least such 
is the case when hydrocyanic acid is taken, and it 
is probable that the same occurs when other seda- 
tives are employed. As far as relates to the 
lungs, if sedatives be applied directly to them 
either in the form of gas or of vapour, the effect 
is both more rapid and more decisive than when 
they are swallowed ; the respiratory function is 
almost instantaneously suspended ; no change 
takes place in the blood, which retains its venous 
character, and, on examining the organs, nothing 
is perceived which can authorize the idea of ex- 
citement having existed : death, in fact, is the 
result of the complete destruction of muscular 
irritability. When taken into the stomach, the 
action of sedatives on the lungs is greatly modi- 
fied ; the blood, however, remains dark-coloured 
and retains its fluidity. 

3. On the Nervous System. — It is unne- 
cessary to repeat that the nerves are the organs on 
which the influence of sedatives is chiefly and 
directly exerted ; but little is known with regard 
to the nature of the impression, except that it is 
different from that of any exciting agent; and 
after the most minute inspections of the brain, the 
spinal cord, and the nerves, in cases of death from 
poisoning by sedatives, no other conclusion has 
been arrived at. Whatever may be the impres- 
sion, it is assuredly not that which is followed by 
excitement. 

4. On the Secerning System. — Sedatives 
produce effects which, to an ordinary observer, 
might seem almost at variance with the foregoing 
opinions : thus, salivation has occasionally fol- 
lowed the employment of hydrocyanic acid; 
(LonJ. Med. Journ. Feb. 1823, p. 128.) and the 
secretion of urine is not unfrequently greatly 
augmented by whatever produces a sedative effect 
on the system. But such results do not necessa- 
rily imply previously increased vascular action in 
the salivary glands and the kidneys : thus we 
know that in the lowest condition of the nervous 
excitability in fatuity, salivation is one of the most 
ordinary attendants, and under the influence of 
fear and other depressing passions, nothing is 
more common than a sudden and copious secre- 
tion of urine. Upon the whole, we have suffi- 
cient reason for concluding that there are powers 
which can destroy excitability and life without 
causing previous excitement, or, at least, without 
any signs of its being discoverable. This is not 
the result of the administration of narcotics, and 
therefore we feel authorized in forming a distinct 
class of sedatives. 

In treating of sedatives employed as therapeuti- 
cal agents, we may arrange them under two 
heads ; 1. direct, or those which operate by their 
immediate influence on the nervous system ; and, 



2. indirect, those which operate through the me- 
dium of the vascular system. 

1. The first and most powerful of the direct 
sedatives is hydrocyanic acid* This acid, as 
prepared for medicinal use, is one-sixth only of 
the strength of the concentrated acid, but it dif- 
fers from it in no other particular. It is colour- 
less, limpid, and has a penetrating odour, which 
causes headach, nausea, and fainting, when in- 
haled in considerable quantity by the nostrils. 
This odour has been erroneously compared to that 
of the peach-blossom, — an error originating from 
the odour of the volatile oil, which is, in some 
instances, as in the peach kernels, blossom, and 
leaves, and in the bitter almond, mingled with this 
acid. The odour of the free acid, when well ex- 
amined, cannot be confounded with that of the 
peach- blossom.j - 

The pure acid is extremely volatile, and even 
the diluted or medicinal acid is so much so as to 
be greatly weakened when not carefully preserved. 
It is also spontaneously decomposed when it is 
not kept in a cool place : the best method of pre- 
venting this decomposition is to place the bottles 
containing it in water, or in porous jars saturated 
with moisture. In prescribing hydrocyanic acid, 
it is essential to know that it is decomposed by 
the aqueous solutions of chlorine and the oxides 
of antimony, and is precipitated by nitrate of 
silver and sulphate of copper. These substances 
are, therefore, incompatible in prescriptions with 
hydrocyanic acid, but it may be combined with 
the salts of iron if no alkali be present. This acid 
is the active principle of laurel-water, the distilled 
water of the leaves of the prunus lauro-cerasiis ; 
cherry-water, distilled from the bark of the cluster 
cherry, prunus padus ; the kirsch-wasser of the 
Germans, which is a spirit distilled from the fruit 
of the same species of prunus; and the oil of 



* This name is a compound of v$G>p, water, and cyan- 
ogen, (a compound substance, named from Kvavos, blue, 
and yivvadi, to produce,) signifying a produce of blue, as 
it gives the blue colour to the ferrocyanate of peroxide 
of iron, or Prussian blue. 

t The plan of this work forbids any detailed account 
of the various methods proposed by Vauquelin, Gay 
Lussac, Robiquet, Pessinau, Fiantwain, and others, for 
preparing the medicinal hydrocyanic acid ; but it may be 
useful to describe the following processes, by which any 
practitioner can readily prepare it for himself. 

1. Put into a wide-mouthed phial a solution of one 
part of bicyanide of mercury, dissolved in eight parts 
of distilled water, and pass through it a stream of sul- 
phuretted hydrogen gas, extricated in another phial trom 
a mixture of equal weights of sulphuret of iron, and 
strong sulphuric acid, diluted with two parts of water. 
The gas must be passed as long as any sulphuret of mer 
cury in the form of black powder is formed; the fluids 
then filtered, and any excess of sulphuretted hydrogen 
removed by agitating the solution with a little carbonate 
of lead, and filtering a second time. 

2. Put into a phial twenty-two grains of cyanuret ot 
potassium, and pour over it a solution of fifty grains of 
pure tartaric acid in six iiuidrachrns of distilled water, 
and eight of rectified spirit After agitating the phial 
occasionally, secure the stopper, and set it aside until 
the precipitate falls to the bottom . then decant the clear 
acid. The acid thus formed should contain one grain of 
hydrocyanic acid in every fluidrachm, which is easily 
ascertained by adding in small quantities to a given 
portion of it peroxide of mercury finely levigated, as 
long as agitation enables the acid to take it up. By di- 
viding the weight of the peroxide dissolved by four, the 
quotient expresses the quantity of real acid contained 
in the diluted acid. No heat should be employed. TSee 
the form for the preparation of hydrocyanic ac ; d, »n rile 
Pharmocopceia of the United States.} 



148 



SEDATIVES. 



bitter almonds, now occasionally employed as a 
medicine, and very generally in confectionary.* 
But along with the acid in these and similar pre- 
parations, there is a volatile oil, the odour of 
which, as we have already stated, is very distinct 
from that of the hydrocyanic acid, is stimulant, 
and possesses poisonous properties nearly equal to 
those of the acid.j- It is, however, not a direct 
sedative, but resembles a narcotic in its operation : 
thence the effects of the oil of bitter almonds and 
laurel-water differ considerably from those of free 
hydrocyanic acid. 

Concentrated hydrocyanic acid cannot be em- 
ployed as a medicine.:): The same circumstance, 
the powerful influence of this acid on the nerves 
of sensation, which renders it so awfully formida- 
ble when it is taken in doses sufficient to produce 
its poisonous effects, renders it in the hands of 
the prudent and well-informed practitioner, when 
its dose is judiciously regulated, its administra- 
tion properly timed, and its effects are carefully 
watched, a remedy possessed of powers which 
cannot be obtained from any other substance, and 
it is therefore extensively employed. 

The use of hydrocyanic acid is indicated in 
diseases connected with a state of excessive or 
morhid sensibility, and those depending on a 
highly irritable state of the nervous system. This 
general statement is not solely influenced by the 
opinion which we maintain of its direct sedative 
power, and were the assertion that it produces at 
first a transient excitement capable of demonstra- 
tion, it would not affect in any degree the ad- 
ministration of the acid ; for as this excitement is 
said to be of a very transitory nature, it need not 
be taken into account in estimating the sedative 
powers of the remedy. In idiopathic fever, hydro- 
cyanic acid has been rarely if ever employed : it 
has, however, been supposed to act beneficially in 
hectic, moderating the force of the circulation and 
suspending the night-sweats which always accom- 
pany this symptomatic fever ;§ but, in reference 
to phthisis, the eulogy bestowed by some practi- 



* Hydrocyanic acid is found in the leaves and kernels 
of almost all the plants of the natural order Amygdaleffi, 
and in the pips of some of the Pomaces and Auranti- 
aceie ; it is formed when copaiba is distilled with diluted 
nitric acid. 

f When the volatile oil of bitter almonds is redistilled, 
the first portion which comes over smells strongly of 
hydrocyanic acid, and affords indications of its presence 
when tested ; but it smells very faintly of the peach- 
blossom : the second portion exhales a more powerful 
odour of the peach-blossom than the first, hut less of that 
of the hydrocyanic acid. The first portion operates as 
a powerful direct sedative in the same manner as free 
hydrocyanic acid ; the second, besides operating prima- 
rily as an excitant, produces violent convulsions when 
it poisons. What remains in the retort, if the distilla- 
tion have been carried far enough, crystallizes on expo- 
sure to the air, and absorbing oxygen, acquires all the 
pioperties of an acid: this is completely inert on the 
living system. Vogel has suggested that these changes 
depend on the process, and he supports his opinion by 
the fact that a quantity of bitter almonds, which, ii 
niade into an emulsion, may be swallowed with impuni- 
ty, when distilled would yield a product more than suffi- 
cient to destroy the life of one individual. 

t For an account of its poisonous influence on the 
animal system, as well as that of the diluted acid, the 
oil of bitter almonds, and laurel-water, with the modes 
of detecting these poisons and of counteracting their 
effects, we must refer ou' readers to the article Toxi- 
cology. 

§ Historical and practical Treatise on the Internal Use 
ni the Hydrocyanic Acid, &c. By A. B. Granville, M. D. 
»cc. p. 5'J, 1820. 



tioners on this acid has not been merited. Neither, 
with the exception, ,,.,ha P s, of phren.tis is ileal- 
culated for the relief of the diseases classed bj 
nosologists under the title Phlegmasia: even in 
phrenitis we have had no experience of its utility, 
but knowing that the inflammation of the mem- 
branes of the brain morbidly augments the general 
sensibility, as illustrated by the impatience of light 
and of sound, we are disposed to recommend its 
employment as an adjuvant to other remedies in 
this state of the brain. In pleurisy it has been 
found beneficial in moderating the cough, one 
source of exasperation of the inflammation of the 
serous membrane; but beyond this it has no 
pretensions to be regarded as a remedy in this 
disease. 

In the exanthemata, except as an external ap- 
plication, hydrocyanic acid holds forth no prospect 
of benefit. In the state in which it is found in 
the bitter almond, it was employed as an external 
sedative so early as the time of Cclsus in several 
external diseases; his formula in a painful pustu- 
lar disease, which he describes as peculiar to in- 
fants, is the following: "lapidis, quem pyriten 
vocant, partes octo, cum quinquaginta amaris 
nucibus miscetur, adjiciunturque olei cyathi tres." 
(De Medicina, lib. v. c. 28, § 16.) But even as 
an external application, the volatile oil of bitter 
almonds requires to be used with much caution, 
and Coullen has recorded the case of a child killed 
by the leaves of the prunus lauro-cerusiis, applied 
to a sore on the neck. (Researches, &c.) The 
free acid has been recommended by the aulhor of 
this article in the proportion of f.giii to f.^viof 
bitter almond emulsion, as a lotion in impetigo or 
running tetter. In such cases also, when the irri- 
tability is very considerable, it may be combined 
with the acetate of lead according to the following 
formula : 

R. Acid, hydrocyan. f.^iv. 

Acet. plumbi, gr. xvi. 

Alcoholis, f.5i. 

Aquae destillatne f.^viiiss. M. 
This lotion not only soothes the irritability of the 
diseased surface, but also disposes the skin to 
renew its healthy action, and is productive of the 
greatest comfort to the patient : it has been found 
very useful in prurigo inveterata, in the various 
forms of psoriasis, and several other skin diseases 
attended with itching and tingling. 

In passive hemorrhages no advantage can be 
expected from hydrocyanic acid ; but in active 
forms of the disorder, much confidence may be 
placed on the internal use of it. In hemoptysis, 
by rapidly augmenting the dose from three minims 
(the medium dose) to twelve minims, or until the 
pulse begin to afford indications of the deleterious 
influence of the medicine, we have seen the most 
happy results in the absence of any organic affec- 
tion. In phthisis, as we have said, the powers 
of hydrocyanic acid have been much overrated; 
nevertheless as a palliative it is not without its 
value. In small doses frequently repeated, it di- 
minishes the hardness and frequency of (he cough, 
and lessens the general hectic tendency : but more 
is not to be expected from it in this respect than 
from some of the narcotics. It has, however, one 
advantage over narcotics, namely, that, besides 
moderating the cough, it frequently favours sleep 



SEDATIVES. 



149 



without exciting those sweats which are too often 
augmented when opium is employed. At the 
same time, as its tendency is to lower the powers 
of the system, it is in the early stages only of this 
disease that it can be regarded as likely to prove 
beneficial even as a palliative. Its employment 
in phthisis, in the combined state in which it is 
found in laurel-water, is, indeed, of no recent date, 
most of the old works on consumption enumerat- 
ing laurel-water amongst the means to be em- 
ployed for soothing the cough. From some ex- 
periments made by M. J org, at Leipsig, we might 
infer that it would prove injurious in the early 
stage of the disease, as well as in every inflamma- 
tory affection. This physician exhibited the cherry 
laurel-water in doses progressively increased from 
five to twenty-five, and finally to one hundred and 
twelve minims. He states that the symptoms 
were those of concentrated action of the brain, a 
sensation of weight in the head, drowsiness and 
torpor of the intellectual functions, lassitude, re- 
tardation of the pulse, and headach, preceded by 
a dull pungent pain of the head, chiefly in the 
region of the optic nerve. It also was attended 
with symptoms not unlike those of bronchitis. 
M. Jorg refers these symptoms to plethora of the 
cerebral vessels, but they may depend on paralysis 
of the brain itself. These observations are at va- 
riance with our own experience. We have found 
the laurel-water and also free hydrocyanic acid 
almost specific in that affection of the trachea 
which has been termed phthisis trachealis, and 
which is often as fatal as tubercular phthisis. The 
natural combination of hydrocyanic acid in the 
bitter almond emulsion is also an excellent vehicle 
for the administration of the compound powder 
of ipecacuanha in the above-mentioned disease. 

In affections of the mucous membrane, hydro- 
cyanic acid is a much less equivocal remedy than 
in the diseases already mentioned. In chronic 
catarrh, and under certain circumstances in dysen- 
tery, sufficient proofs of its efficacy have been 
recorded. In the latter disease, when given at the 
same time with full doses of calomel, to the extent 
of four or five minims for a dose, in the bitter 
almond emulsion, and repeated at short intervals, 
it allays irritation and improves the secretions and 
excretions of the intestinal canal. On the same 
principle its power of allaying irritability, and 
thereby favouring a slower and consequently more 
healthy secretion of the gastric juice, the author 
of this article was induced to recommend its em- 
ployment as a sedative in dyspepsia. (See Gran- 
ville's Historical and Practical Treatise on the 
Internal Use of the Hydrocyanic Acid. First 
Edition, 1819.) Dr. Elliotson prosecuted this 
suggestion, and laid the results of a very extended 
trial of its powers in St. Thomas's Hospital before 
the profession. (Numerous Cases illustrative of 
the Efficacy of Hydrocyanic or Prussic Acid in 
Affections of the Stomach, &c. 8vo. 1820.) In 
dyspeptic affections it may be combined with the 
decoction of Iceland liverwort, infusion of calum- 
ba, or the extract of sarsaparilla ; or it may be 
administered in water, from three to five minims 
for a dose, with the addition of f.gi of tincture of 
calumba or of any simple bitter. In pyrosis it 
affords relief on the same principle, by allaying 
the morbid irritability of the stomach. 



It is in spasmodic affections, however, as may 
be readily conceived, that the sedative powers of 
the hydrocyanic acid are most conspicuous. In 
spasmodic asthma, even when the pulse is small, 
irregular, and often not easily distinguished, we 
have seen it act almost instantaneously, relieving 
the oppressed state of the pulmonary circulation, 
and restoring the free action of the respiratory 
organ. In hooping-cough, also, this acid displays 
the most striking influence when early resorted to 
and judiciously administered. After emptying the 
stomach with an emetic, and purging briskly, it 
may be immediately administered three or four 
times a day, in doses of one or two minims, ac- 
cording to the age of the patient, in f.giss of the 
bitter almond emulsion, sweetened with a few 
drops of syrup of tolu. It is seldom necessary to 
change the prescription, except to increase the 
dose of the acid, until the cough ceases, which 
generally occurs in less than a month or six weeks 
after commencing the use of the remedy. It is 
requisite to confine the patients to a graduated 
temperature, and to restrici them to a milk and 
vegetable diet. 

[The writer has often used hydrocyanic acid in 
hooping-cough, and endeavoured to observe its 
effects carefully ; but the results have not been 
such as to enable him to place much reliance upon 
it. It certainly has not answered, in his hands, 
in the very cases mentioned by Dr. Thomson, 
half as well as narcotics employed so as to pro- 
duce a sedative influence.] 

In epilepsy, chorea, hysteria, and tetanus, the 
results of the trials of hydrocyanic acid have been 
of a description which do not admit of any deci- 
sive opinion of its value in these diseases. In 
hydrophobia it has been tried both in this country 
and on the continent ; in few instances it appeared 
to allay the violence of the paroxysms ; (see 
Transactions of the Medico- Chirurgical Society 
of London, vol. xiii. p. 298 ;) but, as may be sup- 
posed, the effect was transitory, and in no instance 
has it warded off the fatal termination of the attack. 

The essential oil of bitter almonds has been 
proposed as a substitute for hydrocyanic acid, on 
the plea that the strength of the medicine can be 
more certainly determined, and that it is less likely 
to suffer decomposition than the free acid from the 
influence of air, light, and variations of tempera- 
ture. Twelve minims of the volatile oil of bitter 
almonds, dissolved in a fluidrachm of olive oil, 
and formed into an emulsion with mucilage, are 
regarded as equivalent to four minims of the or- 
dinary medicinal hydrocyanic acid. An objection, 
however, to the use of this oil is the excitant pro- 
perty of the volatile oil with which the hydro- 
cyanic acid that it contains, is mixed ; it also 
produces an uncomfortable effect on individuals 
of a peculiar idiosyncrasy. Some people cannot 
eat even a single bitter almond without suffering 
severely from nettle-rash, attended with vomiting 
and vertigo ; a circumstance, as we have already 
stated, depending on something in the kernels 
independent of the hydrocyanic acid, which is 
further demonstrated by the fact that the sweet 
almond sometimes causes the same inconvenience, 
although no hydrocyanic acid has been detected 
in it. 

A more useful substitute for the hydrocyann- 



150 



SEDATIVES. 



acid than the volatile oil of the bitter almond, is 
the cyanide of potassium, which, although it 
does not hold a place in any of the British phar- 
macopoeias, yet possesses sedative properties equal 
to those of the free hydrocyanic acid. In solution 
it is a hydrocyanate ; but in this change it loses 
none of its sedative properties. One part of the 
cyanide and eight parts of water form a solution 
which may be administered in the same doses as 
the hydrocyanic acid ; and in this state it has 
been successfully employed in neuralgic affections 
by Dr. Buttigny and Dr. Lombard of Geneva. 
They have also used in the same disease an oint- 
ment compounded of five grains of the cyanide 
and one ounce of lard. The cyanide has also 
proved useful in rheumatism.* 

In closing our account of this powerful seda- 
tive, candour obliges us to notice some experi- 
ments and facts which have been published on 
the opposite side of the question, with regard to 
the mode in which its influence on the nervous 
system is effected. The author of this article 
supports the opinion that it operates directly on 
the nervous system, whilst Magendie, Orfila, and 
others contend that it is previously absorbed. The 
only experiments we shall notice are those of Dr. 
Krimer of Aix-la-Chapelle, who found that when 
it is applied directly to the neurilema of the nerves, 
or to the surface of the brain and spinal cord, it 
displays no activity. He also supposes that he 
has ascertained that it does not kill, even when 
applied to the tongue, until it is evaporated by the 
heat of the mouth, and is absorbed into the pul- 
monary circulation ; destroying life first by di- 
minishing the action of the heart and arteries, 
and then by extinguishing the energy of the 
spinal cord. Dr. Krimer found that when the 
arteries and veins of a part are tied and the nerves 
left free, if the acid be applied to a wound it pro- 
duces no effect; but the instant the ligatures are 
removed, it displays its power : on the other hand, 
also, death occurs when the nerves are divided if 
it be introduced into the vessels. When all the 
vessels of the stomach, says Dr. Krimer, are tied, 
although the nerves remain entire, hydrocyanic 
acid when introduced into the stomach does not 
produce its usual effect; but it operates imme- 
diately when placed on the tongue, and in thirty- 
six minutes it can be detected in the blood by re- 
agents : such is the case, also, when it is inhaled, 
without the vapour coming in contact with the 
nerves of the tongue. 

Notwithstanding the apparent conclusiveness 
of these experiments, we cannot accord with the 
inferences deduced from them. For instance, we 
cannot conceive how the acid can be taken into 
the pulmonary circulation, and yet not act on the 
nerves in its vicinity ; and an assumption is made 
respecting pulmonary absorption, which requires 
to be proved. On these accounts, and from hav- 
ing witnessed the instantaneous effect of this acid 
when taken in large doses, we see no reasons 
sufficient to alter our formerly expressed opinion 
regarding its mode of action. 

Tobacco is another sedative of great power. The 
experiments of Mr. [Sir B.] Brodie have rendered 
it pr liable that there are two efficient principles in 

* A method of obtaining tins cyanide in a state of 
ft eat purity has been lately discovered by Mr. R. Lamins. 



tobacco , one an empyreumatic volatdc oil, which 
operates directly on the brain and the nerves of 
sensation, or on the sensibility of the system , the 
other a saline substance, (nicotina,) which appears 
to influence chiefly the motor nerves, confining its 
sphere of action particularly to the heart, which it 
renders insensible to its natural stimulus, the 
blood, and thereby causing death. In whatever 
manner this volatile oil is procured, its effects are 
so powerful on the animal economy, that, when 
it is applied to an abraded surface, or introduced 
into the rectum.it causes almost instant death.f 
When tobacco is infused in boiling water, this 
volatile oil is partially taken up by the liquid, and 
produces the sedative effects which always more or 
less result from the exhibition of tobacco enemataj 
but the greater part of the influence of the tobacco 
clyster is due to the nicotina, which, in the to- 
bacco, is probably combined with some acid that 
increases its solubility. The sedative influence 
of nicotina is such that the action of the heart 
ceases even before that of the diaphragm, — an 
effect directly the opposite of that which occurs 
from the administration of hydrocyanic acid. The 
influence of both the components of tobacco is 
evidently directly sedative, without even the most 
transient stimulant effect, whether the infusion be 
introduced into the stomach or into the rectum. 

It is remarkable, with the knowledge which the 
profession possesses of the sedative influence of 
the tobacco clyster, that it should ever have been 
employed in cases of suspended animation : it is 
indicated and has been successfully used in cases 
of incarcerated hernia. If one drachm of the 
dried plant infused in a pint of boiling water and 
strained, be thrown into the rectum, great muscu- 
lar debility, partial insensibility, and sometimes 
cold clammy sweats almost immediately super- 
vene; relaxation of the spasms follows, during 
which the gut is replaced. But occasionally the 
aid thus afforded to the taxis is not unattended 
with hazard ; and in certain states of the system 
of some individuals which are not obvious, but 
greatly influence the action of the remedy, it is 
evident that it must not be inconsiderately re- 
sorted to, nor indeed at all whilst the least chance 
of any other means proving useful remains.t 
When it does not succeed, and the operation must 
be performed, the patients do not recover so well 
as those who have not been subjected to its use, 
The sedative influence of tobacco has also been 
taken advantage of, in smoking the plant for the 
relief of spasmodic asthma, violent tooth-ache, and 
some painful affections of the face. 

[Digitalis, classed by Dr. Thomson under 
Narcotics, (q. v.) is more worthy of a place 
among sedatives. It is an important agent with 

t This oil is gradually deposited in the wooden 
stems of the pipes of the Hottentots, who employ it for 
destroying serpents. Mr. Barrow mentions having wit- 
nessed its effects when applied to the tongue of a poison- 
ous snake; the reptile stretched itself out, became stiff, 
and died in an instant. 

t When the tobacco clyster produces deleterious effects, 
they should be immediately obviated by throw ins into 
the rectum a strong infusion of nut-galls, or any otoM 
™me ~ ? / 0ma,n,ng a lar « e Proportion of tannin and 
destrnWnf'f as , l ° , combil,e with the nicotina, ami by 
monin 5 Sf J ls f olubility, to render it inert. Brandy, am- 
e?ed hv ,Pn tl ' e ,, i;n,n : ,lan,s - Bhould al "> '"' <"imini 
lined for Am-?- h ' aml a " artificial respiration mail 
hi \„ a ° rsnme ,,me - or «"" 1 the sedative influence ol 
the medicine begins to disappear. innuencei 



SEDATIVES. 



151 



the contra-stimulant school. Colchicum, veratrum 
alburn, veratrum, viride, cimicifuga, and perhaps 
ergota might likewise be considered, with pro- 
priety, under this head, as their main action is 
one of sedation.] 

The hydrosulphuret of ammonia, although less 
frequently employed than either hydrocyanic acid 
or tobacco, is a most powerful sedative, depressing 
the action of the heart and arteries by operating 
directly on the nervous system. In very moderate 
doses, namely five minims in a tumbler of water, 
it causes nausea and vomiting ; and, when the 
dose is increased, drowsiness and vertigo super- 
vene. It was employed and strongly recom- 
mended by Mr. Cruickshanks in diabetes mellitus, 
for destroying the ravenous appetite and morbid 
action of the digestive organs which always ac- 
company that disease ; but it has been very little 
used. 

Two gaseous compounds of hydrogen, sulphu- 
retted hydrogen and carburetted hydrogen gas, 
exert a powerful sedative influence on the animal 
economy, which proves rapidly fatal to animal 
life, if breathed, even when largely diluted with 
air. The former is noticed here rather with the 
view of alluding to the share which it has in 
causing the depression that always occurs in those 
febrile affections in which it is extricated largely 
in the intestinal canal, than to refer to its thera- 
peutical properties, although its employment in 
phthisis has been suggested. There is undoubtedly 
a copious evolution of it in all low fevers, and its 
direct sedative influence on the intestinal nerves 
is the chief cause of the collapse which attends 
these diseases ; to obviate this, is therefore, of 
much consequence, and the influence of chlorine 
in decomposing this gas by forming muriatic acid 
in combining with the hydrogen whilst the sul- 
phur is deposited, points out an easy and effectual 
method of doing so. Either the aqueous solution 
of chlorine, or of the chloride of soda, should be 
administered in these cases. The presence of the 
gas is detected by the extremely offensive odour 
of the faces; and still more decidedly by holding 
slips of paper covered with carbonate of lead over 
the vessels containing them. If sulphuretted hy- 
drogen be exhaled, the carbonate will be immedi- 
ately blackened. 

The second of the above-mentioned gases, car- 
buretted hydrogen, has been employed for medi- 
cinal purposes, as a sedative in phthisis ; but its 
use requires much caution, as even when diluted 
with twenty or thirty times its bulk of common 
air, it cannot be respired for more than a minute 
or two without causing nausea, dizziness, and 
other symptoms of dangerous nervous depression. 
Although so destructive to animal life that it can- 
not be taken into the lungs undiluted without 
producing instantaneous death, yet to no gas does 
the system become so soon habituated ; conse- 
quently the degree of dilution which is at first re- 
quisite, may be gradually reduced with impunity. 
The trials, however, which have been made of it 
as a remedy in phthisis are as yet far from suffi- 
cient to determine accurately its influence in that 
disease. 

2. The indirect sedatives operate on the nervous 
system through the medium of the blood, either 
by altering the properties of that fluid so as to 



unfit it for affording the requisite stimulus to the 
brain and nervous centre, or by extracting it in 
quantity sufficient to bring the brain into a similar 
state from defect of stimulus, or, as it were, from 
inanition. 

The first of the sedative agents belonging to 
this division of the class which requires to be no- 
ticed, is carbonic acid. gas. The influence of this 
gas in causing suffocation when it is attempted to 
be breathed undiluted, as it never enters the lungs, 
but causes a constriction of the muscles of the 
glottis, so that no air can enter the lungs, and no 
change take place in the blood passing through 
them, is supposed to be negative ; thence the ques- 
tion, whether this gas is positively or negatively- 
sedative 1 But although this gas is never admit- 
ted into the lungs in attempts to respire it, and 
therefore may be regarded as negatively sedative, 
yet there are facts which demonstrate its positive 
sedative properties. Thus, if the body of an ani- 
mal be immersed in an atmosphere of carbonic 
acid gas, whilst atmospherical air is freely admit 
ted to the lungs, sedative symptoms occur, such 
as weight in the head, dimness of sight, singing 
in the ears, vertigo, &c. ; and that it even exerts 
a local influence on the nerves, was demonstrated 
by an experiment of Dr. Priestley, who, having 
excited pain in a blistered hand by immersing it 
in oxygen, relieved the pain instantly by plunging 
the hand into a jar of carbonic acid gas. It is 
also a well-known fact that the pain of a cancer- 
ous ulcer is allayed by directing upon it a stream 
of carbonic acid gas which has passed through 
water ; and it is to the presence of this gas in the 
carrot and other fermenting poultices, that they 
are indebted for their sedative properties. On 
these accounts, although we have arranged cai- 
bonic acid gas among the indirect sedatives, yet it 
in some measure belongs also to the former divi- 
sion of direct sedatives. 

Carbonic acid gas was at one time much em- 
ployed as a sedative in phthisis: Dr. Percival in- 
troduced it as an antiseptic, and from the result 
of thirty cases concluded that it abates the hectic 
and improves the expectoration ; (Percival's Es- 
says, vol. ii. p. 308 ;) and Dr. Withering, who 
also looked upon it merely as an antiseptic, found 
that similar effects resulted from its administration. 
Favourable opinions of it were given by Dr. Dol- 
son, (Medical Commentary on fixed Air. London, 
1779,) Dr.Hulme, Dr. Beddoes, and Dr.Fenwick 
of Durham : on the contrary, the experiments of 
Dr. Muehry, (Inaugural Dissert. Gott. 1797,) who 
gave it a fair trial in five cases without material 
benefit, and our own experience, have led us to 
place little confidence in it, even as a sedativi 
When it is employed, it should be largely diluted 
with common air; the best proportions are four 
parts of the air to one part of the gas. 

The only other indirect sedative which requires 
to be noticed is bloodletting. It is scarcely neces- 
sary to remark that a certain quantity of the cir- 
culating fluid is required to be present in the blood 
vessels, in order to support the energy of the 
brain and nervous centres ; and, therefore, *hat 
when this proportion is diminished, the result is i 
sedative effect on the svstem. In man the aver- 
age quantity of blood in proportion to the weigtii 
of the body, in a healthy adult subject, is as on% 



152 



SEDATIVES. 



to five ; when a greater relative proportion exists, 
a diseased state of the body, plethora, takes place ; 
when a smaller, the body becomes emaciated. If 
blood be suddenly abstracted from the vessels, a 
series of phenomena occur which demonstrate a 
diminished state of vitality ; and if the quantity 
taken away be greater than a certain proportion 
of the whole, then death almost immediately en- 
sues. But these effects do not depend altogether 
upon the quantity of blood contained in the ves- 
sels or abstracted from them, but partly upon other 
circumstances, which ought always to be kept in 
view when bloodletting is intended to operate as 
a sedative. 

If these phenomena depend on the state of the 
vascular system in health, it is evident that a pow- 
erful effect must result, in disease, from the ab- 
straction of blood, whether this be effected by 
opening a vein, by cupping, or by leeches. The 
immediate depression of the vital powers which 
follows this abstraction must have been early ren- 
dered obvious, from the effects of hemorrhages 
arising from the accidental rupture of vessels ; 
and thence artificial means were adopted to dimin- 
ish excitement by opening a vein. The syncope 
which succeeds is much regulated by the habit of 
the patient, the nature of the disease, and the 
manner in which the blood is abstracted ; but as 
a particular inquiry into the morbid effects of 
bloodletting and the methods of obviating these 
are given in detail in other parts of this work, we 
think it unnecessary to enter into minute details, 
referring the reader to the articles Bloodletting, 
Fever, Inflammation, and Plethoba. 

A. T. Thomson. 

[Under the head of sedatives may be included 
a set of therapeutical agents, now much used, in 
Italy more especially, but also adopted in France 
and in Great Britain, — rarely in this country ; — 
agents which, by removing excitation, might be 
termed sedatives, but which, by their propounders, 
have been called contrast imulants, and the theory 
which suggests them, the theory of contro-stimu- 
las or contra-stimulus, — the new medical doctrine 
of Italy, — La nuova Dottrina, <Vc. 

Prior to the termination of the last century, the 
doctrines of Brown were universally embraced in 
Italy, and they continued in vogue until Kasori, 
on the occasion of a petechial fever making its 
appearance in Genoa, subjected the prevalent 
views to considerable modification ; and, as in 
most similar cases, ended by embracing views dia- 
metrically opposite. Kasori maintained that most 
diseases, to which mankind are liable, are owing 
either to an augmentation of excitability, or to an 
excess of stimulus; and he conceived that there 
are certain medicinal agents which possess a pecu- 
liar debilitant power, and which act upon the ex- 
citability of the frame in a manner directly opposed 
to that in which stimulus acts upon it. To this 
power he gave the name controstimulus. 

The mode in which the ditferent contra-stimu- 
lants have acquired their reputation, appears to 
have been as simple as it must frequently have 
been fallacious. Every agent which succeeded in 
'^moving a sthenic disease, could do so only, it 
was presumed, by diminishing the excitability, 
or removing the stimulus. Accordingly, it was 



a contra-stimulant. Substances were therefore 
classed together, which bore no relation to each 
other, either in their immediate properties, or in 
their 'secondary effects— as regarded the physiolo- 
gical phenomena they induced. We find, in the 
lists, emollients— as milk and gum ; astnngents- 
as acetate of lead ; tonics— as gentian, simarouba, 
iron, and, according to some, even cinchona ; ex- 
citants— as turpentine, squill, and arnica; emetics 
— as tartrate of antimony and potassa, and ipeca- 
cuanha ; narcotics — as stramonium and bella- 
donna; acrid poisons — as arsenic, nux vomica, 
cantharides ; and a host of other animal, vegetable, 
and mineral substances, which had no kind of 
analogy to each other. It has been properly ob- 
served, that this manner of considering the effects 
of medicines tends essentially to bring together 
the most dissimilar substances, as well as to sepa- 
rate such as are closely allied, and, consequently, 
to confound all. 

In the case of this theory, however, as of every 
other, the practice built upon it has added valuable 
facts to therapeutics ; and not the least of these is 
the knowledge, that tartrate of antimony and po- 
tassa may be administered in large doses in in- 
flammatory affections, not only with impunity, 
but with marked advantage. This potent emetic 
may be given to the extent of ten or twenty grains 
or more, in divided doses, during the day, without 
either producing vomiting or purging; or, if the 
first doses prove emetic, a tolerance is soon ac- 
quired, and the subsequent doses may be followed 
by no marked effect, except the diminution of the 
febrile symptoms. At other times, the urinary 
and cutaneous depurations appear to be largely 
augmented, and rapid emaciation succeeds to its 
administration. The contra-stimulant physicians 
maintain, that the exaltation of the vital manifes- 
tations in febrile and inflammatory diseases, en- 
ables the system to bear the large doses of this 
and other contra-stimulants, and they say that the 
tolerance vanishes with the disorder that commu 
nicated it ; but this assertion is not confirmed by 
experience. There is certainly a greater resist- 
ance to the action of these agents, as there is lo 
bloodletting, when all is exaltation, but the power 
of resistance does not cease, although it is dimi- 
nished, when the exaltation cease.--. Some indi- 
viduals, too, never possess the necessary tolerance; 
so that with them the tartrate of antimony and 
potassa does not produce its contra-stimulanl 
effects; and it would seem that there are, also, 
what the French term medical constitutions ur 
epidemic conditions, which forbid its employment. 
Thus, according to Bricheteau, (Clinique Mtdi- 
cale de l'Hopital Neckar, Paris, 1S35 ; or the 
writer's translation in the Amer. Med. Lib- 
Philad. 1838,) although it was so successfully 
used in 1831, it could not be beneficially admi 
nistered at the end of 1832, and the beginning of 
1833. Not until the autumn of this last year. 
could it be resumed advantageously. On one 
occasion it was given in the hospital," by an 
de garde, during the choleric epidemy. ' The most 
violent symptoms supervened, and the patient dW 
of cholera morbus, no sign of which existed before 
the tartrate was taken. 

Of the different phlegmasia;, acute rheumatism 
and pneumonia are those that are considered lo 



SEDATIVES.— SEX, (DOUBTFUL.) 



153 



have been most successfully combated by this 
agent, ill a large dose. (See art. Inflammation, 
vol. ii, p. 795.) "Emetic tartar," says M. Bri- 
cheteau, " should generally he preceded by blood- 
letting ; and commonly it is advisable not to have 
recourse to the former, unless the latter is insuffi- 
cient, except in cases in which bloodletting is 
contra-indicated or impossible, owing to some 
special circumstances, — as happened to me once 
in the case of a rickety individual, who had no 
veins proper for phlebotomy. The medical con- 
stitution of the season is, also, occasionally op- 
posed to the abstraction of blood : in such cases, 
the tartrate of antimony and potassa is a valuable 
agent. Recourse may, likewise, be had unhesita- 
tingly to tartar-emetic at the very first, when the 
patient is exhausted by age or other causes, and 
appears to be too weak to bear the abstraction of 
blood ; or in cases where a positive refusal is 
given to the proposition for phlebotomy." " This 
agent," he adds, "must also be of great advantage 
and of convenient employment in country situa- 
tions, where the physician can rarely pay his 
visits at an early period. It may be practicable, 
by this method, and with the aid of an intelligent 
person, to regulate the treatment of a case of 
pneumonia or of rheumatism for several days after 
having premised a copious abstraction of blood, if 
it be considered desirable." The fact, however, 
referred to by Bricheteau — that it is not every 
one who presents the necessary tolerance — would 
render this agent by no means as easy of applica- 
tion by the laity as he presumes. 

Granting — and it would seem it must be 
granted — that the tartrate of antimony and po- 
tassa is a sedative agent, it becomes interesting to 
inquire into the mode in which such agency is 
exerted. It is, as is well known, one of our best 
suppurants, when we are desirous of establishing 
a centre of fluxion on some part of the cutaneous 
surface, with the view of removing an internal 
disease. Experience, too, has sufficiently shown 
that, when given in large doses, it produces pus- 
tulation in the mouth and fauces, if not lower 
down in the alimentary tube. In a case which 
occurred under the author's care in the Baltimore 
Infirmary, this effect of the antimonial was sig- 
nally evidenced. Bricheteau — who has adminis- 
tered it largely as a contra-stimulant — says its 
local action is exerted more particularly on the 
mouth, tongue, and pharynx, where false mem- 
branes and pustules are occasioned by it ; but these 
lesions, he thinks, are by no means common. 
The oesophagus, he says, never participates in 
them, and they are more frequent in the intestinal 
canal than in the stomach : and in the former, the 
lower part of the small intestines, and the com- 
mencement of the large, exhibit themselves more 
sensible to the action of the antimony than other 
portions of the tube ; but it cannot be said that 
sufficient opportunities have occurred for testing 
the effects of the remedy, and for separating the 
morbid appearances which have presented them- 
selves, and which may have proceeded from other 
causes. Bricheteau is of opinion, that the lesions 
which may be referred, with the greatest proba- 
bility, to the use of the tartrate of antimony and 
potassa, — although he admits they are frequently 
owing to other inappreciable causes, — are, injec- 
Vot. IV. — 20 



tion or infiltration of the submucous tissue of the 
intestines, and softening of the mucous membrane. 
In the mouth, considerable inflammation — either 
pustular or ulcerous — is sometimes observed, 
which speedily disappears after the discontinuance 
of the antimony. 

The contra-stimulant virtues of tartrate of anti- 
mony and potassa may, then, be dependent upon 
its revulsive properties ; this revulsion being pro- 
duced in the lining membrane of the alimentary 
canal ; so that when it is accomplished, the ex- 
cited actions, going on elsewhere, may become 
diminished, and more or less nervous and vascular 
concentration takes place towards the seat of the 
artificial revulsion. Rasori thought that the re- 
medy lessens stimulation, or augmented excita- 
bility, directly : Laennec maintained that it in- 
vigorates the action of the absorbents; whilst 
Vaidy, — a French practitioner, who embraced the 
precepts of the followers of the " Nuova Dot- 
trina," — is of opinion, that its influence extends 
immediately to the circulation of the blood, restor- 
ing its harmony, and subduing the febrile excite- 
ment. Begin [Traite de Therapeutique, Paris, 
1825) asserts that none of these hypotheses can 
stand the test of attentive inquiry, and that they 
are not founded on well-observed facts. "They 
are all in contradiction to experiments made on 
living animals, which prove that tartar-emetic, 
whilst it stimulates, and tends to inflame the mu- 
cous coat of the alimentary canal, from the cardia 
to the lower portion of the rectum, irritates the 
nervous system, and produces more or less inflam- 
matory engorgement of the lungs :" and he adds — 
" this remedy acts chiefly as a revulsive in the 
treatment of pneumonia, and we shall have occa- 
sion to develop this truth, when treating of the 
revulsions produced on the gastro-intestinal sys- 

ROBLEY DUNGLISON.] 

SEX, DOUBTFUL, [Sexual Ambiguity.'] 
Among the freaks of nature, there is none which 
has given rise to more erroneous ideas or more 
barbarous practices than those varieties in the 
formation of the organs of generation, which have 
given origin to the term hermaphrodite. This 
word, derived from 'Epp/j, Mercury, and 'A<ppo&irri y 
Venus, conveys the notion of an individual par- 
taking of both sexes, and capable of both beget- 
ting and conceiving. The ancients believed in 
the possibility of such a combination in the hu- 
man body ; and enactments existed, both in Greece 
and Rome, ordering the destruction of infants 
born with confusion of the sexual organs. At 
Athens all the unfortunate beings considered to 
be hermaphrodites were thrown into the sea, and 
at Rome into the Tiber. In modern times it is 
admitted that no such phenomenon ever existed 
in the human species as a perfect hermaphrodite, 
although there are numerous instances of preter- 
natural structure which gives the appearance of a 
double sex. In the lower orders of organized bo- 
dies, hermaphrodism is common; thus in vegeta- 
bles it is so prevalent as to have led some to sup- 
pose it to be an attribute of the order ; and the 
more nearly the other classes of beings approach 
the vegetable, the more common is this combing 
tion of sex among them. Of this zoophytes, mol- 
lusca, acephali, and gasteiopodes are example* 



154 



SEX, (DOUBTFUL) 



In these animals two kinds of hcrmaphroJism 
exist: in some it is absolute, that is, the animal is 
capable of impregnating itself, as in some of the 
bivalves, as oysters and mussels ; hut in others, 
as the univalves, this power is not possessed, but 
a union of two individuals is necessary, both, 
however, becoming impregnated at the same time. 
We look in vain for any such admixture in the 
higher orders of animals, though some extraordi- 
nary approaches towards it are recorded. Accor- 
ding to Sir. E. Home (Phil. Trans. 1799,) and 
J. Hunter (Anim. Econ.,) such combination is 
most frequently met with in neat cattle, the indi- 
viduals so circumstanced being known by the 
name of free martins. In these, however, the 
testes and ovaria are always too imperfect to per- 
form their functions. Instances are not wanting 
in the human species in which, either from mal- 
formation of the genital organs in one or other of 
the sexes, or from a real attempt at mixture of the 
two in the same individual, considerable difficulty 



;lnsc . L„ deriding on the proper sex. Th.s , ,h, 
point to which the present article .» more I»««,c-„- 
larly directed, and it should be recollected that il 
is one of material importance ; for upon the opinion 
pronounced by medical examiners may depend 
the employment in life of an individual, the right 
of inheritance to property, and the judicial dec 
sions concerning impotence and sterility. 

fin an able article by Dr. J. Y. Simpson, (Her- 
Maphroditish, in Cyclopedia of Anatomy and 
Physiology, ii. 685, Lond. 1839,) hermaphroditic 
malformations, considered as a class, are divided 
into two orders — spurious and true, — the spurious 
comprehending such malformations of the genital 
organs of one sex as make these organs approxi- 
mate in appearance and form to those of the opposite 
sexual type ; and the true comprising all cases in 
which there is an actual admixture or blending 
together, upon the same individual of more oi 
fewer of both the male and female organs. The 
following is Dr. Simpson's classification : 



CLASSIFICATION OF HERMAPHRODITIC MALFORMATIONS, 



fin 



the Female. 



'Spuriou 



"I 



Hermaphroditism. \ 



( From excessive development of the clitoris, &x. 

/ From prolapsus of the ulerus. 

L From extroversion of the urinary bladder. 

In the male < From adhesion of the penis to the scrotum. 

( From hypospadic fissure of the urethra, &c. 
restes on the right and ovary on the left side, 
left and ovary on the right 



Lateral. 



_ , \ External sexual organs female; internal mail . 

iransverse j External sexual organs male; internal female. 

( Ovaries and an imperfect uterus with male vesiculae 

I s?minales, and rudiments of vasa deferentia. 
Vertical or Double <( Testicles, vasa deferentia, and vesiculae seminales, 

I with an imperfect female uterus and its appendages. 

[ Ovaries and testicles coexisting on one or bothsideo, &c 1 



Sir E. Home (Loc. cit,) considers that all the 
monstrous productions hitherto noticed and de- 
scribed as hermaphrodites may be reduced to one 
of the four following classes: — 1. malformations 
of the male ; 2. malformations of the female ; 3. 
males with such a deficiency in their organs that 
they have not the character and general proper- 
ties of the male, and may be called neuters ; 1. 
where there exists a real mixture of the organs 
of both sexes, although not sufficiently complete 
to constitute the double organ. 

1. Malformation of ttie Urinary and 
Generative Organs of tlie Male. — Cases of 
this class usually depend upon imperfection of the 
scrotum and urethra ; there is no deficiency of the 
natural parts, nor addition of foreign parts, but the 
confusion of sex arises from the scrotum being 
split along the middle line, each half containing a 
testicle, and resembling one of the labia majora 
of the female. The deep slit between these paral- 
lel folds of skin very much resembles the vulva, 
and the similarity is heightened by the circum- 
stance of the urethra being usually split likewise 
in these cases, and opening in the perineum, 
which having a red and tender appearance, is 
easily mistaken for the vagina. In consequence 
of the urethra terminating at the perineum, the 
penis is imperforate ; and thus, if it be of small 
size, it may be supposed to be the clitoris. It is 
this malformation of the male organs which more 
than any other has given origin to mistakes 
respecting the mixture of the sexes. The case 
of the negro described by Cheselden (Anat. of the 
Human Body, p. 314,) was of this kind. In 



him the scrotum was divided into two separate 
bags, with a deep slit between them, representing 
the labia majora and commencement of the vagina 
Over these hung down the penis ; the imperfec- 
tion of the scrotum extended to the canal of tl.o 
urethra, — a circumstance appropriately compared 
to the fissure of the hare-lip being continued 
through the bony palate. The penis was united 
by its under surface, through its whole length, to 
the folds of skin containing the testicles, resem- 
bling an enlarged clitoris, to which resemblance 
sence of the urethra contributed. The 
urethra opened with a large aperture in the peri- 
neum, between the divisions of the scrotum, and 
from its size was mistaken for a vagina. Chesel- 
den describes another case similar to the preceding, 
which he met with in the person of an European. 
Persons afflicted with such malformation as we 
have described have not only been taken for 
females but have been married as such. Adelaide 
Preville was married, and lived the last ten yean 
of her life in Paris, and died in the Hotel Dieu 
of that city. Giraud discovered by examination 
of the body after death that it was of the mascu- 
line sex, and except a false vagina, which con- 
sisted in a cul-de-sac placed between the rectum 
and bladder, this individual presented no resem- 
blance to a female. (Recueil periad. de la Soc. de 
Med. Paris.) There is a very remarkable case 
related by Marc, (Diet, des Sciences Med. t. xxi.p. 
91 et Jour, de Mud. Chirurg. et Pharm. Paris, Feb. 
1806,) in which an individual after having passed 
for a female for many years, was at length disco- 
vered to belong to the male sex, and was restored 



SEX, (DOUBTFUL) 



155 



by public ordinance to his proper station. On 
the 19th of January, 1792, the cure of the parish 
of Ber certified the birth of a girl, and gave her 
the name of Marie Marguerite. This child arrived 
at the age of 14 without having particularly at- 
tracted the attention of the parents. It shared 
the bed of a younger sister, and grew up among 
other young persons with whom it was associated 
by education, exercise, and childish amusements. 
At this time Marie complained of pain in the 
right groin, where a tumour soon manifested 
itself The village surgeon took it for a hernia, 
and applied a truss. This instrument gave too 
much pain to be borne, and was soon laid aside. 
The tumour descended and the pains ceased. 
Some months afterwards, the left groin was affect- 
ed in a similar manner, and on the supposition of 
the tumour in it being also a hernia, a double 
truss was put on, which was as speedily thrown 
off as the former. At 16 years of age an offer of 
marriage was made, but refused by the parents as 
an unsuitable match for their daughter. Three 
years afterwards another proposal was made and 
broken off after having been accepted of. Never- 
theless, as Marie advanced in age, the graces of 
her person began to disappear ; her clothes did not 
fit as well as before ; her air and carriage had some- 
thing extraordinary ; from day to day her tastes 
changed and became more masculine ; indoor oc- 
cupations seemed to interest her less, and she pre- 
ferred field-work to her former duties. These 
masculine dispositions, and the report of the 
surgeon that Marie had been hurt in such a man- 
ner as to prevent her ever marrying, did not pre- 
vent a third lover from aspiring to her hand. 
This match was much desired by the friends on 
both sides ; but the parents of Marie, knowing 
that she was not formed as other women, and 
recollecting that she had never menstruated, did 
not wish to deceive the son of an old friend, and 
determined on having a medical examination of 
their daughter. Worbe was requested to perform 
this office. The surprise of all was great indeed 
when he declared Marie to be a man. She (or 
he) shed tears at the announcement, and was for 
some months before she could be reconciled to 
the idea of not being a woman. At last he took 
the resolution of petitioning the authorities to 
alter the registry, and declare him of the male 
sex. A commission was accordingly appointed 
consisting of three medical men, to inquire into 
the circumstances of the case, who reported that 
on examination they found the scrotum divided 
through its whole extent, each division containing 
a rounded body, which they recognised as true 
testicles. Between these parts a fleshy prolonga- 
tion was observed, having a cleft at its extremity, 
!>ut imperforate, covered by a process of skin, 
which was in reality the prepuce. The penis 
was but little developed ; and beneath it, at about 
an inch and a half from the margin of the anus, 
an opening was discovered, caused by the abrupt 
termination of the urethra in the perineum. As 
to the rest of the body they found nothing remark- 
able, except a considerable development of the 
!>reasts, resulting, as they imagined, from the form 
of clothing usually worn. They therefore gave 
it as their opinion that Marie belonged to the 
male sex ; and the authorities declared it to be so, 



and ordered that the registry of birth and baptism 
should be altered. Dr. Worbe states that in 1816, 
this individual was 23 years of age, hair and eye- 
brows auburn, a light beard appearing on the 
upper lip and chin, the sound of the voice mascu 
line, height four feet eleven inches French mea- 
sure, skin very white, constitution robust, and 
the limbs round but muscular. The form of the 
pelvis did not differ from that of a male, the 
knees were not inclined inwards, and the hands 
and feet were large and strong. A year had not 
elapsed from the time of his metamorphosis when 
he was considered as one of the best farmers in 
the canton. On being questioned with respect to 
what he felt when sleeping with females, whether 
he had not desires different from those of others, 
and if curiosity had not prompted him to discover 
what opportunity permitted him so easily to observe, 
he answered, blushing, " quelquefois, mais je 
n'osais pas." 

Dr. Schweikard (Hufeland's Journal, t. xvii. 
No. 18.) has published the history of an indivi- 
dual who up to the age of manhood was esteemed 
to belong to the female sex. He had been bap- 
tized as a girl, and regarded as such, until to the 
astonishment of all he demanded permission to 
marry a girl then pregnant by him. He sub- 
mitted to an examination, when it was found that 
the penis was situated lower than ordinary, not 
quite two inches long, and a little less bulky than 
usual. The imperforate glans offered a slight 
curve towards the lower part ; the inferior sur- 
face of the corpora cavernosa was deprived of 
urethra, but presented a channel or groove along 
its middle line. Behind and under the corpora 
cavernosa, between their root and the anterior 
superior part of the scrotum, a prominent oval 
opening was remarked ; this was the orifice of 
the urethra, through which the urine flowed, and 
in consequence of its vicinity to the penis, the 
stream was conducted along the under surface of 
that organ so as to appear to issue from its orifice. 
The scrotum, situated below this opening, con- 
tained the right testicle only, that of the left being 
probably retained in the abdomen. In all other 
respects the physical constitution of this individual 
was perfectly masculine. According to his ac- 
count, the desire for women and the secretion of 
semen were observed at puberty. He had fre- 
quently performed coition, and had, besides a 
child born before marriage, two other children 
well formed, born in wedlock. This case was 
evidently only an instance of hypospadias, of 
which malformation we have already spoken in 
the article Impotence ; and it is a further con- 
firmation of the opinion there advanced, that per- 
sons labouring under it are not to be considered 
as incompetent to procreation. It is most pro- 
bable that the semen during the act of coition was 
conducted along the penis, as the urine is stated 
to have been, at least so far as to enter the vagina. 
A case similar to that just mentioned is detailed 
by Dr. Wageler. (Annales de Med. Politique de 
Kopp. v. 129.) 

The malformation of which we have now 
spoken is that which most frequently causes mis- 
takes in the male, but by a careful examination 
of the individual the obscurity must be easily re- 
moved. There are other degrees of vmoerfectior. 



156 



SEX, (DOUBTFUL) 



which are sometimes observed, but can never lead 
to much confusion. One of these consists in a 
close application of the penis to the anterior sur- 
face of the scrotum, by a continuation of the skin 
of the latter over the former. In such a case the 
penis is bound down in its unnatural situation, 
and the urine passes downwards ; the erection of 
the organ cannot take place; it may become 
turgid, but never erect, and intromission is of 
course impossible. A case of this description oc- 
curred to Mr. Brand, (Vide Brewster's Edinburgh 
Encyclop. art. Hermaphrodites, and Beck's Med. 
Jur. by Darwall, p. 45,) in the person of a child 
seven years of age, who had been baptized and 
brought up as a girl ; he found a malformation 
of the male sexual organs consisting of the pre- 
sence of such an unnatural integument. By a 
slight incision he liberated the restricted part, and 
proved to the parents that they had mistaken a 
boy for a girl. 

Another form of lusus which has given rise to 
mistake of sex, is that in which the urinary blad- 
der, or rather the rudiment of it, opens directly 
above the pubis, through a deficiency of the ab- 
dominal muscles and integuments at that part. 
In these cases the bladder can scarcely be said to 
exist ; all that appears of it is a red fungous mass 
protruding through the integuments, consisting 
of the mucous lining of the viscus, with the uterus 
opening on it together with the vesiculae seminales 
and vasa deferentia. The penis is always very 
short, scarcely exceeding two inches, and, from 
deficiency of the urethra, imperforate. The testi- 
cles arc generally well formed, but are sometimes 
retained in the abdomen. Persons with this mal- 
formation are observed to vary in their sexual 
appetites ; some being totally deficient in sexual 
desire, others exhibiting it in a tiifling degree, 
while others have it strong. It may readily be 
supposed that persons constructed in this manner 
are impotent ; but it sometimes happens that the 
vasa deferentia open in a small tubercle at the 
root of the penis, in which case it is possible that 
impregnation may be effected by the individual. 
It is only by such a disposition of parts we can 
explain the pregnancy of a young girl in Lin- 
lithgow in Scotland, stated to have resulted from 
her sleeping with a young person, who from a 
malformation, such as we have described, was 
supposed to be a female. (Vide Piscottie's His- 
tory of Scotland, p. 104.) It is plain that if the 
seminal ducts opened externally above the pubis, 
such an event could not have taken place. 

2. Malformation of the Female Genera- 
tive Organs. — There are two sorts of malforma- 
tion in women which may lead to error in judging 
of the sex. The first consists in excessive dimen- 
sions of the clitoris. Although hypertrophy of 
this organ occurs most frequently in warm coun- 
tries, it has also been observed in cold. Sir E. 
Home doubts that it ever takes place in these 
latitudes, and also is of opinion that even in those 
situations where it is most frequently observed, 
the enlargement never proceeds to such a length 
as to lead to any serious doubt. There are, how- 
ever, some instances on record in which the in- 
crease in size was such as to cause the clitoris to 
esemble and be mistaken for the male organ. 
Columbus notices an instance in which it was the 



size of a finger. Haller observed one case in 
whirl, he states that it was seven inches in length; 
and it has been said to reach the extent of twelve 
inches. (Diet, des Sciences Med. art. Clttoru.) 
However, notwithstanding any excessive dimen- 
sions of the clitoris, an attentive observer will 
readily discover the difference between the genital 
organs of a female with such a development, and 
those of a male. Thus, for instance, in a celebrated 
hermaphrodite exhibited in Paris and London in 
1777, named Marie Auge, the clitoris was found 
to resemble perfectly the male organ, but it was 
unprovided with a urethra, and imperforate: it 
was situated above the other parts of generation 
which presented no peculiarity, except an unusual 
contraction of the vagina. Schneider met with an 
instance in a child of two years old still more likely 
to mislead ; he examined it after death, and found 
neither labia majora nor minora, nor the usual 
cleft between them ; the clitoris was an inch and a 
half long, resembling a penis, with a well-formed 
glans and prepuce, but it was imperforate, a small 
spot occupying the situation at which the male 
urethra terminates. Some lines below this organ 
there was an opening, by which the urine was 
transmitted ; but this passage seemed also des- 
tined to perform the functions of a vagina, for it 
led direct!}' to the uterus, and was of a length 
proportionate to the age of the subject ; the vagi- 
nal ruga? were distinct, and at the upper part of 
the orifice a small opening was observed which 
led to the bladder, and was in fact the orifice of 
the true urethra. In Sir E. Home's (Loc. cit.) 
paper on hermaphrodites he gives an account of a 
Mandingo negress whose clitoris was two inches 
long, and of the thickness of an ordinary thumb: 
at first view the extremity seemed formed like a 
glans, but on more minute examination it was 
found imperforate, and not so round as a true 
glans, but more pointed ; the clitoris was capable 
of erection, during which state its size inc 
to three inches. The other parts of generation 
were well formed, the urethra was situated just 
beneath the clitoris, which obstructed the flow ol 
urine so much as to compel her to raise it when 
about to evacuate the bladder. Her person was 
very masculine, the mamma? were little developed, 
the voice was rough, and the countenance resem- 
bled that of a man. Beclard (Jour, de Med. Chir. 
et Phar. Mars, 1815,) has given a very detailed 
account of a female who was exhibited in Paris, 
in 1814, as an hermaphrodite, from which wo 
extract the following. Marie Madeline Lefort 
was the name of the individual ; she was then 
sixteen years of age, and in the general form of 
her body resembled a male ; the voice was mas- 
culine, a beard appeared on the upper lip and 
chin, the breasts were developed, and the limbs 
were slightly hairy. The external genitals pre- 
sented a rounded mons veneris, covered with hair. 
but the symphisis pubis was elongated as in the 
male ; beneath it protruded a conoid-shaped body, 
twenty-seven centimetres in length, when flaccid, 
but more when erect ; this was surmounted by an 
imperforate glans, covered for three-fourths of its 
extent by a prepuce. Inferiorily this enlarged 
clitoris was furnished with a canal, which, how- 
ever, did not run the whole length, but was 
pierced in the middle line with five small holes ; 



SEX, (DOUBTFUL) 



157 



capable of admitting a small probe. Beneatb and 
behind the clitoris, there was a sulcus, bordered 
on each side by a narrow and short labium, which 
on being handled gave no sensation of containing 
any body like a testicle. This sulcus or fissure 
was very superficial, being blocked up by a dense 
membrane, but which gave, when pressed by the 
finger near the anus, the idea that it was spread 
over a cavity. At the anterior superior part, near 
the clitoris, this membrane was pierced by a round 
opening, which readily admitted a moderate-sized 
catheter. The external abdominal rings were very 
small, and gave no indication of containing testi- 
cles. The urine was passed partly through the 
opening in the membrane described, and partly 
through the small cribriform openings in the canal 
extending along the under surface of the clitoris. 
This was taken from her own account, as she 
found it impossible to void urine in the presence 
of the examiners. The bladder could not be 
reached by a catheter introduced through the large 
opening, but the instrument could be easily passed 
upwards and backwards, and in this manner it 
glided along the posterior surface of the membrane 
closing the vagina, which, being felt between the 
point of the instrument and the finger, seemed 
about twice as thick as the skin. She had men- 
struated regularly from the age of eight years, and 
on one occasion when Beclard examined her 
(luring menstruation, he observed the fluid to pass 
through the opening already described, and the 
catheter then introduced was withdrawn full of 
menstrual blood. She considered herself a woman, 
and preferred the society of men, and was per- 
suaded that a trifling operation would render her fit 
for matrimony. This individual belonged decidedly 
to the female sex ; she had many and the most 
essential of the female organs of generation, the 
vagina and uterus, the latter organ moreover per- 
forming its natural function with regularity ; and 
those characters of the male which she exhibited 
were only of a secondary class, such as the pro- 
portions of the limbs and body, shoulders and 
pelvis, the size of the larynx, tone of voice, deve- 
lopment of hair, and the prolongation of the 
urethra beyond the symphisis pubis: this, how- 
ever, was not complete, for the canal did not ex- 
tend to the extremity of the mimic penis. 

The second kind of malformation of the female 
generative organs likely to mislead as to the sex 
of the individual, is a protrusion of the internal 
parts. The uterus when prolapsed has at times 
assumed so close a resemblance to the penis that 
it has actually been mistaken for it by medical 
men of the highest character. The following 
case came under the observation of Sir E. Home, 
who has given the particulars in his paper on 
hermaphrodites. " A French woman had a pro- 
lapsus uteri at an early age, which increased as 
she grew up. The cervix uteri was uncommonly 
narrow, and at the time I saw her (when she was 
about twenty-five years old) projected several 
inches beyond the external opening of the vagina: 
the surface of the internal parts, from constant 
exposure, had lost its natural appearance, and re- 
sembled the external skin of the penis; the orifice 
of the os tincae was mistaken for the orifice of the 
urethra. This woman was shown as a curiosity 
in London, and in the course of a few weeks 



made four hundred pounds. I was induced by 
curiosity to visit her, and on the first inspection 
discovered the deception, which, although very 
complete to a common observer, must have been 
readily detected by any person intimately ac- 
quainted with anatomy. To render herself still 
more an object of curiosity, she pretended to have 
the powers of a male : as soon as the deception 
was found- out, she was obliged to go away." 
There is in the Philosophical Transactions the 
history of an hermaphrodite which seems to be 
exactly similar to this, as is fully proved by the 
menses flowing regularly through the orifice of 
the supposed penis. The French physicians 
were, however, so perfectly convinced of her 
manhood, that they made her change her dress 
and learn a trade. To this she readily submitted, 
and the account says she could perform very well 
the functions of a man, but not those of the other 
sex. 

3. Males with such a deficiency in their 
organs that they have not the character 
and general properties of the male, and 
may he called Neuters. 

This form of hcrmaphrodism usually takes 
place in individuals originally intended for the 
male sex, and is nothing more than the effect pro- 
duced by atrophy, or absence of the testicles, — a 
circumstance to which is frequently joined a de- 
fective development of the penis. The genital 
organs do not appear to grow with the rest of the 
body, but continue in the same state as at birth. 
In many the characters of both sexes seem mixed ; 
in others there is a slight predominance of one or 
the other, discoverable chiefly by moral circum- 
stances, such as the kind of life, habits and pur- 
suits of the individual. An instance of this kind 
of deformity occurred to Hufeland at Koningsbcrg. 
An individual named Marie Dorothee Duriee, 
aged twenty-three years, was examined by him 
and Mursinna, who both declared the sex to be 
female, while Stark and Martens were of opinion 
that the same person belonged to the male sex. 

A marine soldier, aged twenty-three years, i.. 
the year 1779 was admitted a patient into the 
Royal Naval Hospital at Plymouth, under th« 
care of Sir E. Home. He had been there only 
a few days when a suspicion arose of his being a 
woman, which induced Sir E. Home to examine 
into the circumstances. He proved to have no 
beard, his breasts were fully as large as those of 
a woman at that age ; he was inclined tc be cor- 
pulent ; his skin uncommonly soft for a man ; his 
hands fat and short ; his thighs and legs very 
much like those of a woman ; the quantity of fat 
upon the os pubis resembled the mons veneris ; 
the penis was unusually small as well as short, 
and not liable to erections ; the testicles were not 
larger in size than we commonly find them in the 
foetal state ; and he had never felt any passion foj 
women. In this case the testicles had been im- 
perfectly formed, and the constitution was deprived 
of the influence which it naturally receives front 
them. The two following cases show a still 
greater degree of imperfection in the male organs: 
they are mentioned by Sir E. Home. 

A woman near Modbury, in Devonshire, ttio 
wife of a day-labourer, had three children ; the 
first was considered to be an hermaphrodite; the 



158 



SEX, (DOUBTFUL) 



second was a perfectly-formed girl ; and the third 
an hermaphrodite similar to the first. In the year 
1779 the eldest was thirteen years of age, and of 
uncommon bulk, which seemed to be 
almost wholly composed of fat ; he was four feet 
high ; his breasts as large as those of a fat wo- 
man ; mons veneris loaded with fat; no penis; a 
prepuce one-sixth of an inch long, and under it 
the meatus urinarius, but no vagina. There was 
an imperfect scrotum with a smooth surface, with- 
out a rapha in the middle, but in its place an in- 
dented line ; it contained two testicles of the size 
they are met with in the foetus. The younger 
one was six years old, uncommonly fat and large 
for his age : the external parts of generation dif- 
fered in nothing from those just described except 
in the prepuce being an inch long. Both were 
nearly idiots. The immense accumulation of fat, 
and the uncommon size of these children, accords 
with the disposition to become fat so commonly 
met with in the free martin. 

4. Where tliere exists a real mixture of 
tlie Organs of ooth Sexes, altliougH not 
sufficiently complete to constitute the Dou~ 
ble Organ. — Cases of this description which 
most nearly approach the absolute hermaphrodite 
are less common than those we have mentioned. 
A remarkable instance is mentioned in Dr. Bail- 
lie's Morbid Anatomy, (3d edit. p. 410.) The 
person was twenty-four years of age, and bore the 
name and dress of a woman, had the breasts of a 
female, and no beard, and yet had a very mascu- 
line appearance. The clitoris and meatus urina- 
rius had the natural appparance, but there were no 
nymphs, and the labiu j/udendi were unusually 
pendulous, resembling a split scrotum, and con- 
tained a testicle each. The vagina was found to 
terminate in a cul-de-sac, two inches from the ex- 
ternal surface of the labia. She had no partiality 
for either sex, and had never menstruated. 

The Memoirs of the Academy of Dijon con- 
tain the following case, communicated by M. Ma- 
ret. (Mahon. t. i. p. 1*J0, and Beck by Darwall, p. 
43.) Hubert J. Pierre died at the hospital in Oc- 
tober 1767, aged 17 years. Particular circum- 
stances had led to a suspicion of his sex, and these 
induced an examination after death. His general 
appearance was more delicate than that of the 
male, and there was no down on his chin or up- 
per lip. The breasts were of the middle size, and 
had each a large areola. The bust resembled a 
female's, but the lower part of the body had not 
that enlargement about the hips which is usually 
observed at his age. On examining the sexual 
organs, a body four inches in length and of pro- 
portionate thickness, resembling the penis, was 
found at the symphisis pubis. It was furnished 
with a prepuce to cover the glans, and at its ex- 
tremity, where the urethra usually opens, was an 
indentation. On raising this penis, it was ob- 
served to cover a large fissure, the sides of which 
resembled the labia of a female. At the left side 
of this opening there was a small round body like 
le, but none on the right. However, if the 
abdomen was pressed, a similar body descended 
through the ring. When the labia were pushed 
iiside, spongy bodies resembling the nymphs were 
seen, and between these and at their upper part 
the urethra opened as in a female, while below 



these was a very narrow aperture covered with a 
semilunar membrane. A small excrescence, placed 
laterally, and having the appearance of a carun- 
cula myrtiformis, completed the similarity of this 
fissure to the orifice of the vagina. On further 
examination the penis was found to be imperfo- 
rate ; the testicle of the left side had its spermatic 
vessels and vas deferens which led to the vcsiculae 
seminalcs. By making an incision into the semi- 
lunar membrane, a canal one inch in length and 
half an inch in diameter was seen, situated be- 
tween the rectum and bladder. Its identity with 
a vagina was, however, destroyed by finding at its 
lower part the verumontanum and the seminal 
orifices, from which, by pressure, a fluid, resem- 
bling semen in all its properties, flowed. The 
most remarkable discovery was, however, yet to 
be made. The supposed vagina, together with 
the bladder and testicles, was removed. An inci- 
sion was made down to the body noticed on the 
right side. It was contained in a sac, filled with 
a limpid and red-coloured liquor. From its upper 
part on the right side, a Fallopian tube passed off, 
which was prepared to embrace an ovarium placed 
near it. It seemed thus proved that the body in 
question was a uterus, though a very small and 
imperfect one, and on blowing -into it, air passed 
through the tube. 

In April 1807, an individual was exhibited at 
Lisbon, uniting the organs of both sexes in the 
highest degree of perfection that has probably 
been ever seen. This person was twenty-eight 
years of age, and possessed of the male organs, a 
penis, or what represented one, capable of erec- 
tion, covered by a prepuce, and pierced for a third 
of its length by a canal, and testicles. The air 
and appearance were masculine, the colour dark, 
and a light beard covered the chin. The female 
organs were labia, vulva, and vagina, well formed, 
but very small ; the larynx and voice were femi- 
nine, and so were all the dispositions ; she men- 
struated regularly, and was twice pregnant, but 
was prematurely delivered each time, once at three, 
the other at five months. (Diet, des Sc. Med., art. 
Hermaphrodite.) This, if the account respecting 
the testicles be correct, is the nearest approach to 
a true hermaphrodite with which we are acquainted 
in the human subject. 

In the Memoirs of the Royal Academy of Sci- 
ences of Paris (An. 1720) there is a very accu- 
rate description by M. Petit, of a similar mixture 
of organs. The person had wholly the character 
of a man, but was of a delicate constitution; he 
was a soldier, and died of his wounds. The ap- 
pearance of the penis is passed over ; but the scro- 
tum not containing testicles drew M. Petit's at- 
tention, and in the dissection he found testicles in 
the situation of the ovaria, attached to two pro- 
cesses, continued from an imperfect vagina, but 
having vasa deferentia, which passed in the usual 
manner to the vesiculm seminales; the vagiiw 
communicated with the urethra between the neck 
of the bladder and of the prostate gland. 

[A number of cases in which there was a mix- 
ture of the organs of the two sexes are now on 
record. (Simpson, op. cit. See also, Guy, Prin- 
ciples of Forensic Medicine, p. 36. Lond. 1843; 
and the writer's Human Physiolo^u, 5th edit, il 
351. Philad. 1844.)] 6S 



SEX, (DOUBTFUL). — SMALL-POX. 



159 



With respect to the formation of such monsters 
as we have spoken of, Sir E. Home was of opinion 
that the only mode in which it can be explained 
is by supposing the ovum, previous to impregna- 
tion, to have no distinction of sex, but to be so 
formed as to be equally fitted to become a male or 
a female foetus ; and that it is the process of im- 
pregnation which marks the distinction, and con- 
duces to produce either testicles or ovaria out of 
the same materials. The following circumstances 
are in favour of this opinion. The testicles and 
ovaria are formed originally in the same situation, 
although the testicles even before the foetus has 
advanced to the eighth month, are to change their 
situation to a part at a considerable distance. The 
clitoris in foetuses under four months is so large 
as to be often mistaken for a penis, and serves to 
explain an erroneous opinion at one time main- 
tained in France, that the greater number of mis- 
carriages between three and four months have 
been remarked to be males ; which mistake arose 
from the above circumstance. The clitoris origi- 
nally appears, therefore, equally fitted to be a cli- 
toris or a penis, as it may be influenced by the 
ovarium or testicle. In considering this subject, 
it is curious to observe the number of secondary 
parts, which appear so contrived that they may be 
equally adapted to the organs of the male or 
female. In those quadrupeds whose females have 
mammae inguinales, the males have also teats in 
the same situation ; so that the same bag which 
contains the testicles of the male is adapted to the 
mammae of the female. In the human species, 
which has the mamma! pectorales, the scrotum of 
the male serves the purpose of forming the labia 
pudendi of the female, and the prepuce makes the 
nymphx. The male has pectoral nipples as well 
as the female ; and in many infants, milk, or a fluid 
analogous to it, is secreted, which proves the ex- 
istence of a glandular structure under the nipple. 
This view of the subject throws some light on 
those cases where the testicles are substituted for 
the ovaria; since, whenever the impregnation fails 
in stamping the ovum with a perfect impression 
of either sex, the part formed will neither be an 
ovarium nor a testicle, sometimes bearing a greater 
resemblance to one, sometimes to the other ; and 
may, according to circumstances, either remain in 
the natural situation of the ovaria, or pass into the 
situation proper to the testicle, whether it is the 
scrotum of the male or the labia pudendi of the 
female. [On the causes of hermaphroditic mal- 
formation, see J. St. Hilaire, Hist, des Anomalies 
dt I'Organiz.ii. 58; and Simpson, op. cit.] 

Menus of ascertaining the true sex of a 
supposed Hermaphrodite. — We say sup- 
posed, because, as has been already stated, we do 
not acknowledge the existence of a true herma- 
phrodite in the human species. Some cases no 
doubt have occurred in which it was very difficult 
to assign the proper sex ; but even the most per- 
fect of these complications of the genital organs 
did not give the individual in whom they existed 
the power of double copulation. Thus in the 
case of Hubert Pierre it is not easy to decide to 
which sex he really belonged: again, we must 
admit that great diiliculty existed in coming to a 
conclusion when wc find such men as Hufeland, 
Mursinna, Stack, Martens, and Metyger disagree- 



ing. From these and other cases thar might be 
quoted, we must agree that cases do occur in 
which the greatest difficulty must be felt, and the 
greatest caution should be used in forming an 
opinion. These cases of great difficulty all belong 
to the last class of malformations : in the other 
classes the solution is not so difficult. In pro- 
ceeding to make an examination for the purpose 
of ascertaining the sex of an individual, the great- 
est care should be taken not to mistake appear- 
ances, and these should be all accurately noted 
down. The different openings that present them- 
selves should be all explored with appropriate 
instruments, (taking care not to inflict any wound 
or cause pain,) in order that their direction may 
be ascertained. An accurate inspection of the 
whole body should be made, to elicit any predomi- 
nance of the constitutional characters of either sex 
that may exist. These examinations should not 
be made hurriedly, but should continue for a 
length of time, and be frequently repeated, before 
a positive opinion is given ; for the tastes, habits, 
and propensities of the individual must be taken 
into account, as well as the physical conformation 
in doubtful cases. It is of importance to be in- 
formed whether a discharge of blood has ever 
escaped from any of the openings, and if repeated, 
whether it has been periodical ; as that circum- 
stance alone will be sufficient to decide us in 
coming to a conclusion. In the case of young 
children, it is best to wait until the parts become 
more fully developed, as it has happened that in- 
stances of confusion of sex when young have at 
the age of puberty taken a decided leaning to one 
or the other sex. Above all, it is necessary to be 
most cautious in believing all that is stated by the 
individual or the friends, as, from interested mo- 
tives, they may misrepresent facts in such a way 
as to lead us into error. 

T. E. Beatty. 

SMALL-POX. — The most approved authoi* 
concur in the belief that the disease known to us 
by the name of small-pox or variola, was not de- 
scribed by any of the writers of antiquity. From 
their silence, therefore, respecting a disorder so 
fatal, and possessing such very peculiar characters, 
we may reasonably presume that its origin was 
subsequent to their times, and that the world had 
existed some thousand years before it was visited 
with this dreadful pestilence. Etymology comes 
here in aid of history. The first authentic pas- 
sage in which the words variola and pocca occur 
is to be found in the Bertinian Chronicle of the 
date 961. (Moore's History of Small-pox, p. 87.) 
There being no term for the disease in the Greek 
or Roman authors, variola was coined in the mid- 
dle ages from the Latin varus, a pimple, or varius, 
spotted, and for several succeeding centuries was 
applied to designate measles as well as small-pox. 
From variola are derived the Italian vaiuolo, and 
the French verole. The term poc is of Saxon 
origin, and signifies a bag or pouch. The Anglo- 
Saxons early adopted this word, which was vari- 
ously spelt, and became pock, pocks, and pox. 
The epithet small in England, and pclitc .v. 
France, were added in the fifteenth century. 

From very early times attempts have been majh' 
to prove the antiquity of smnll-oox, and even in 



160 



SMALL-POX. 



our days this doctrine has found supporters. Dr. 
Baron, of Gloucester, the latest writer on the sub- 
ject, entertains the opinion that small-pox is to be 
traced in the earliest writings of the Hebrews and 
Greeks; that it was seen by Hippocrates, and 
commented upon by Galen. According to this 
author, the account of the plague of Athens, as 
given by Thucydides, " presents as accurate an 
account of the leading symptoms of variola as 
could possibly be expected from any historian not 
medical." (Life of Jenner, p. 177.) In this 
opinion Dr. Baron is countenanced by Salmasius, 
Hahn, and more recently by Dr. Willan, in a pos- 
thumous dissertation "On the Antiquity of Small- 
pox." Rhazes, an Arabian physician, and the first 
acknowledged writer on this disease, laboured to 
prove that Galen had seen it, but with all his en- 
thusiasm for his master, he acknowledged and was 
surprised at the unwonted brevity and inaccuracy 
of his description. This alone may be considered 
as decisive of the question ; but we may further 
state that Friend and Mead, authors of the highest 
repute, after devoting great attention to the sub- 
ject, agreed that there was no foundation for such 
a notion. We shall be fully justified, therefore, 
in adhering to the generally received opinion that 
small-pox is a disease of modern origin. 

The first notices of a disorder which exhibits 
the well-marked features of small-pox, are to bs 
found in the historical writings of Procopins (De 
Bello Gothico, lib. ii.) who flourished during the 
reign of Justinian the First. The obscurity of its 
origin, the difficulty of its cure, the universality 
of its devastations, and above all, the complete 
immunity from second attacks which are mentioned 
as characteristic of this epidemic, bespeak it to 
have been truly small-pox. It began A. D. 544, 
at Pelusium in Egypt, from whence it spread to 
Constantinople. This corresponds closely with 
tire era commonly assigned in medical books to 
the first appearance of small-pox, viz. A. D. 569, 
the year of the birth of Mahomet. In that year 
an Abyssinian army, under Abrahah the viceroy, 
appeared before Mecca, and was unexpectedly 
compelled to raise the siege. Several circumstances 
concur to render it probable that the sudden retreat 
of the army was owing to the breaking out of 
small-pox, and the dreadful mortality which it oc- 
casioned. Bruce, in his travels (Travels to dis- 
cover the Source of the Nile, vol. i. p. 514), met 
with a manuscript account of this war, which 
confirms this story, and strengthens the opinion 
that small-pox first appeared in Egypt and Arabia 
about the middle of the sixth cerrtury. 

A further question has been raised and keenly 
agitated, whether the small-pox really beiran in 
Egypt, or was conveyed to the shores of the Red 
Sea from India. Attempts have been made to 
establish the existence of this disease in China 
and Hindostan at very remote periods. Mr. Moore, 
in his history of small-pox, advocates ibis opinion. 
He finds in the mythology, the religious institu- 
tions, the sacred and historical records, the medical 
works, and uniform tradition of those countries, 
abundant proofs that small-pox existed there at a 
period antecedent even to Hippocrates. (Moore's 
History of Small-pox, p. 35.) He then enters 
into an investigation of the circumstances which 
may have prevented the spread of the infection 



from Asia to Europe and Africa. It must be ac- 
knowledged, however, that the facts on which Mr. 
Moore relies in support of this opin.on rest on 
vcrv questionable authority; and as the opinion 
itself has not met with many supporters, it is not 
nccessarv in a practical work like the present to 
bestow on it more particular examination. 

The small-pox, and with it the measles, cer- 
tainly burst forth in Arabia under circumstances 
most fatally favourable to their dissemination. It 
was in the year 622, when Mahomet be<, an to 
collect the wandering tribes of Arabs whom he led 
forth, inflamed with religious zeal, against the 
neighbouring nations. To the devastations of 
war were now added the ravages of a new and 
most intractable disorder. But if we owe the in- 
troduction of small-pox to the Arabian armies, it 
is to the physicians of the same nation that we 
are indebted for the earliest accounts of it. Rhazes, 
an Arabian physician, wdio practised at Bagdad 
about the beginning of the tenth century, is the 
first author who treats expressly of small-pox. 
He quotes, however, several of his predecessors, 
of whom the most ancient is Ahron, a physician 
of Alexandria, who is supposed to have flourished 
about the year 622, the era of the Hegira, when 
Mahomet first went forth as a conqueror and a 
prophet. The treatise of Rhazes " De Variolis et 
Morbillis," deserves especial mention for the accu- 
rate description which is given of the several kinds 
of small-pox. His theory of the disease, however, 
is childish and scarcely intelligible, and his treat- 
ment lamentably deficient. He abounds, indeed, 
with directions for the management of every 
symptom, and more especially for that of the pus- 
tules in their several stages, which is very compli- 
cated, consisting of fomentations, fumigations, dry 
powders, ointments, and other applications chiefly 
intended to prevent pitting. In most of those in- 
stances his prescriptions are harmless, but this 
merit does not belong to his recommendation of 
free bloodletting and of the most powerful nar- 
cotics in all stages, and even in the confluent 
forms of the disease. Avicenna, another Arabian 
physician, gives also a very full and excellent ac- 
count of the symptoms of small-pox, and he im- 
proves upon the treatment suggested by Rhazes, 
by restricting bleeding to plethoric habits, and to 
the three first days of the disease. Both Rhazes 
and Avicenna concur in the opinion that measles 
and small-pox are only modifications of the same 
disorder. Avicenna considered measles as a sort 
of bilious small-pox. 

Hali Abbas, a third Arabian author on small- 
pox, deserves to be mentioned as having made an 
approach to the doctrine of contagious origin. 
The theory of small-pox adopted by him, as by 
all the Arabian physicians, was founded on the 
commotion and putrefaction of the humours of 
the body ; but Hali observed that one of the 
accidental causes which excited the movement of 
the distempered humours to the skin was being in 
the same place with persons affected with the 
small-pox, or breathing air contaminated with the 
pestilential vapour of small-pox pustules. All 
the Arabian authors believed in the occasional 
occurrence of small-pox twice in the same person. 

1 he successes of the Saracen arms in Spain 
and Sicily, during the eighth century, contributed 



SMALL-POX 



Joubtless to the gradual extension of small-pox 
through the different countries of Europe, but on 
this subject very little is known. We read that 
on several occasions a pestilence of fire raged, the 
body dissolving away as if burnt, with an intole- 
rable fcetor of the putrid flesh. It is reasonable 
to suppose that some at least of these epidemics 
were the small-pox: others may have been the 
true Egyptian plague with buboes. 

The researches of antiquarians lead to the be- 
lief that small-pox reached England early in the 
tenth century (907). There is preserved in the 
British Museum a curious Anglo-Saxon manu- 
script, supposed to have been written in that cen- 
tury, containing an exorcism or supplication 
against the small-pox. (Moore's History of Small- 
pox, p. 94.) Nicasius was the saint especially 
addressed on these occasions. All that we read 
serves to show how great were the terrors in- 
spired by the small-pox in every period of its 
career. 

The discovery of America by Columbus, which 
so wonderfully extended the boundaries of human 
knowledge, was the occasion also of scenes of 
desolation at which the heart sickens. Among 
all the calamities incident to that event none can 
surpass the introduction of small-pox into that 
continent, which took place in 1517, twenty-five 
years after its discovery. It is stated, on the 
authority of the Spanish historians, that in a very 
short time after the infection reached Mexico, 
three millions and a half of people were destroyed 
by it in that kingdom alone. Among the victims 
was the emperor, the brother and successor of the 
brave but unfortunate Montezuma. (Robertson's 
History of America, vol. iv. b. viii.) 

From the revival of learning to the present 
period, no subject has attracted the attention of 
physicians, b ith speculative and practical, more 
than small-pox. Every medical writer has treated 
of it, and some have devoted themselves exclu- 
sively to its study. It would be vain, therefore, 
to attempt more than a brief allusion to those who 
have distinguished themselves in this department 
of medical inquiry. 

The humoral doctrines which prevailed in the 
schools during the sixteenth century led to the 
universal adoption of the hot or alexipharmic 
mode of treating pestilential and malignant dis- 
eases, including small-pox. Sennertus gives the 
following account of the practice pursued in his 
time (1628). The great object was to expel the 
noxious humour by perspiration, to accomplish 
which various decoctions of warm seeds are di- 
rected, containing mithridate, hezoar, and other 
drugs, denominated alexipharmic and sudorific. 
" While using these, every attention is to be paid, 
especially in winter, to prevent the admission of 
cold air. The patient is therefore to be tended in 
a warm chamber, and carefully covered up, lest 
by closing the pores of the skin the efforts of 
nature should be impeded, the humours driven 
upon internal organs, and matters which ought to 
be expelled retained within the body, to the im- 
minent danger of the patient, and the certainty 
of increasing restlessness, fever, and other symp- 
toms." (De Variolis et Morbillis, t. vi.) 

Such had long been, and such was the state in 
which Sydenham in 1667 found the theory and 

Vor.. IV. — 21 o* 



practice of small-pox. Bad as that practice was 
it yet had the support of all the learning and all 
the prejudices of the age. It required, therefore, 
talent and boldness successfully to oppose it 
Sydenham began by separating for ever small-por 
from measles, with which, from the days of 
Rhazes, it had been so strangely yet so obstinatel) 
associated. He divided small-pox into two kinds 
the distinct and confluent, traced with the greates' 
accuracy the usual course of both, and adder 
many important remarks to the detail of symp 
toms given by others, particularly with referenct 
to prognosis. Of the intimate nature or essenc< 
of small-pox he professed his ignorance in com 
mon with the rest of mankind, but adds immedi 
ately afterwards his suspicion that it consists of f 
specific inflammation of the blood and othei 
humours, and that the inflamed particles, when 
duly digested and concocted, are expelled from 
the body in the form of little abscesses. The 
chief merit of Sydenham consists in his criticisms 
on the prevailing treatment of small-pox. These, 
though worded with the most scrupulous care, 
and an anxious wish to avoid hurting the feelings 
of his professional brethren, yet exposed him to 
much obloquy, and he was calumniated as an in- 
novator and a homicide. He introduced what is 
now called the cooling regimen, including fresh 
air, light bed-coverings, and abstinence from wine 
and all cordial and sweating medicines. The 
remedies on which he chiefly relied were mode- 
rate bleedings, acidulated drinks, and opiates. 
His principal faults consisted in the timid em- 
ployment of purgatives, and his fondness for 
blisters. 

Boerhaave, who was born when Sydenham 
was at the height of his fame (1668,) entertained 
the highest admiration of him, and was contented 
to adopt almost without alteration the description 
and treatment of small-pox given in his works. 
But Boerhaave has the great merit of first, putting 
prominently forward contagion as its direct excit- 
ing cause. He acknowledges " that as the first 
man who suffered from small-pox must necessarily 
have received it without contagion, so may it still 
be occasionally engendered by causes of which we 
are ignorant. Nevertheless, as a general law it 
may be stated that the contagion once generated 
multiplies itself without any assignable limit, as 
the smallest spark may spread the widest confla- 
gration." (Van Swieten's Commentaries, vol. v. 
p. 18.) 

The theory and treatment of natural small-pox, 
placed thus, by the combined labours of Syden- 
ham and Boerhaave, upon their proper footing, 
underwent no important changes during the last 
century; the attention of authors was then di- 
rected almost exclusively to the new discovery of 
inoculation, of which we shall treat more fully in 
a subsequent page. 

We now proceed to give a description of small 
pox, and have to remark, in the first place, how 
singularly diversified are the appearances which 
it presents. A variety of causes contribute to 
this, but none more remarkably than the previous 
habit or condition of the body with reference ti- 
the contagion of small-pox. It will be usetui, 
therefore, to begin by considering the disea** 
under three different aspects : — 



.62 



SMALL-POX. 



First, as it occurs, casually and for the first 
ame, to those who have undergone no preparatory 
process. This is called the casual or natural 
small-pox. 

Secondly, as it occurs to those who in early life 
have undergone the process of vaccination. This 
is called the mitigated or modified small-pox. 

Thirdly, as it occurs to those who have been 
inoculated with the variolous virus : the inocu- 
lated small-pox. 

Natcual Small-pox. 

This disease is characterized by a long train of 
phenomena, some of which are peculiar to it, while 
others are common to it with other acute disorders. 
From very early times it was observed that these 
admit of a division into three stages. Such an 
arrangement is strictly natural, and admits of no 
improvement. These are, the stages of incuba- 
tion, maturation, and decline ; and they will re- 
quire separate investigation. 

I. Stage of Incubation. — Under this head 
ia included the whole period that elapses from the 
reception of the variolous germ, or virus, into the 
human body, until the appearance of eruption. 
Rayfear (Treatise on Diseases of the Skin, trans- 
lated by W. B. Dickinson, p. 108, London, 1833) 
subdivides it into the two stages of incubation and 
invasion, the former comprising the interval be- 
tween the reception of the germ and the sickening ,■ 
the latter extending from the sickening to the ap- 
pearance of eruption. In very many cases, how- 
ever, this distinction cannot be made, the two 
periods running into each other by insensible de- 
grees. 

The reception of the variolous poison into the 
human body casually by the mode of infection, 
(that is, through the medium of respiration,) takes 
place in most instances imperceptibly and without 
symptoms. Occasionally, however, the patient 
experiences at the moment of imbibing the germ 
of disease some unpleasant sensation, such as a 
disagreeable odour, or a feeling of giddiness, or 
sickness at stomach, or, what is perhaps more 
common still, an inward sense of alarm or fright. 
The duration of this stage is subject to some va- 
riety. Fourteen days may be stated as the ave- 
rage period that elapses from exposure to conta- 
gion to the appearance of eruption. The extremes 
may be set down as one week and three weeks. 
This interval is passed differently in different 
cases. Sometimes the patient, during the whole 
or greater part of this period, has been weak, lan- 
guid, low-spirited, and inactive, with impaired 
digestion and unquiet nights. He has felt poorly, 
without any assignable cause. In the greater 
number of instances, however, no uneasiness what- 
ever is experienced until the eleventh or twelth 
day after exposure to contagion, when an unex- 
pected and perhaps severe rigor announces the 
commencement of the initiatory, or, as it is some- 
times called, the eruptive fever. This is accom- 
panied in some cases with severe pain or weakness 
of the back, so that the patient has dropped down ; 
in other cases with acute pain of the epigastrium, 
aggravated on pressure, and hence sometimes 
mistaken for gastritis; with nausea, vomiting, gid- 
diness or headach. Children are often very 
drowsy at this period. The nervous system some- 
times participates in a more marked manner. 



There is extreme prostration of strength. The 
patient staggers in his walk, and the expression 
of countenance is anxious and haggard : children 
have an epileptic fit: adults become delirious. 
These more urgent symptoms generally indicate 
the approach of a severe form of the disease. Of 
this there can be no doubt, when, in addition to 
the symptoms already enumerated, we observe 
such as denote that the fluids of the body are im- 
plicated in the mischief which is going on— that 
is to say, when petechia: appear in different parts 
or large patches of subcutaneous ccchymosis, with 
hemorrhage from the nose, mouth, stomach, bow- 
els, or uterus. Under these circumstances death 
has been known to take place prior to any unequi- 
vocal appearances on the skin. Here the real 
nature of the disease must always remain in some 
degree doubtful, but it can often be inferred by 
tracing carefully the history of the case. It will 
be found to have succeeded exposure to small-pox 
contagion within the reasonable limit of time, or 
it may in its turn have communicated contagion 
to others. Several well-marked instances have 
occurred, rendering it almost certain that conta- 
gious emanations are thrown off from the lungs 
and skin even at this early period of the disease. 

The duration of the initiatory or eruptive fever 
of small-pox has been a fruitful source of discus 
sion among authors. Prior to the time of Syden 
ham the object of physicians was to shorten the 
period as much as possible, and to promote an i 
early eruption, which they attempted to effect by 
powerful diaphoretics. Sydenham, on the other 
hand, maintained that the more tardy the eruption 
the lighter was the subsequent disease. This ob- 
servation is not borne out by the results of our own 
experience ; and it is not improbable that Syden 
ham's judgment might have been in some degree 
warped by his anxiety to dissuade from that heat- 
ing regimen of whose injurious effects he was so 
well convinced. The fact appears to be that the 
period of the initiatory fever is most remarkably 
uniform. The eruption in a vast majority of 
cases shows itself at the end of forty-eight hours 
from the occurrence of rigor or headach, whether 
the subsequent disease be mild or malignant, con- 
fluent or distinct: in other words, one^omplete 
day intervenes. Sometimes, from accidental cir- 
cumstances, (such as great weakness of constitu- 
tion,) this period is protracted to seventy-two 
hours, but never, so far as we have observed, is it 
shortened. This may be looked upon as a re- 
markable law of the variolous disease, and a most 
important means of distinguishing small-pox from 
other exanthemata, particularly scarlatina, lichen, 
and measles. In the two former disorders, the 
duration of the premonitory symptoms is less than 
in small-pox ; in measles it is greater. 

II. Stage of Maturation. — The eruption of 
small-pox shows itself in the first instance in al 
most all cases on the face and wrists, and thence 
gradually extends over the rest of the body. In 
a very few cases only has it been first observed on 
the inferior extremities. It consists of minute 
papula; sensibly elevated above the general sur- 
face of the skin. In some instances the eruption 
is fully developed over the whole body in. the 
course of twenty-four hours. In other cases, two 
and even three days elapse before the process is 



SMALL -POX. 



163 



lompleted on the legs and feet. When the papula? 
are few in number, and separate from each other, 
the disease is called distinct ,• when the eruption 
is close set and profuse, confluent. To the inter- 
mediate varieties the old authors gave the name 
of contiguous or coherent, but the term semicon- 
fluent is preferable. We apply it to designate 
those cases where the eruption is confluent in one 
part and distinct in another, as well as those 
where the papulce are numerous without actually 
running into each other. 

Arrangement and structure of the pock. — 
This branch of the subject has excited much at- 
tention at various times, and in particular was 
investigated diligently by Cotugno, (better known 
under his Latin name of Cotunnius,) an Italian 
physician, in the year 1771. (De Sedibus Vario- 
larum. Vienna, 1771.) When the papulae are 
few in number, they will not be found indiscrimi- 
nately diffused over the body, but arranged in 
groups of three or five, and assuming a crescentic 
or semicircular form. When two groups coalesce, 
a complete circle of papula may sometimes be 
observed. The papulse have their seat in the 
true skin ; and upon the third or fourth day from 
their first appearance are converted into vesicles, 
containing a thin transparent lymph. These 
vesicles are very curiously organized, being divided 
into six or eight cells tied together in the centre, 
which for several days is depressed. This central 
depression, or umbilicated form of vesicle (as it 
is sometimes called), is very characteristic of 
small-pox. It is exhibited only in one other dis- 
ease — cow-pox. The specific matter or poison 
of small-pox is secreted by the parietes of the 
minute cells, and the progress of inflammation in 
the papula is denoted by the inflammatory circle 
(called areola) which about the fourth day begins 
to surround it. As the colour of this areola 
changes to a bright crimson, the lymph in the 
vesicle is converted into a thick opaque matter, of 
a white or straw colour. This distends the cells, 
and gradually increasing in quantity, breaks down 
the central band, in consequence of which the 
pustule acuminates. In favourable cases this 
proces^ is usually completed in seven, or at 
furthest in eight days : occasionally it occupies 
only five or six days. 

During the maturation of the pustules there is 
always some degree of fever present, varying, of 
course, in violence, with the quantity of eruption, 
the habit of the patient, and the circumstances in 
which he may happen to be placed. If the habit 
of body be good, the season mild, the apartment 
cool, the diet duly restricted, and the mind free 
f rotn anxiety, there will be very little fever, even 
-hough several hundred pustules are in the pro- 
cess of maturation. There is generally more or 
less tenderness of the skin present. Occasionally 
this tenderness is excessive, and productive of the 
greatest distress. 

Confluent form of small-pox. — When the 
eruption is very copious over the whole or greater 
part of the body, this, its regular or normal pro- 
gress, undergoes several important modifications, 
which are next to be described. In some cases, 
indeed, the confluent small-pox runs the same 
course as the mildest forms of the distinct disease. 
The vesicles are small, and each is surrounded by 



a minute areola, while the constitutional excite- 
ment is moderate. Such a form of small-pox 
may be characterized as the confluent superficial. 
The most familiar instances of it are presented 
when the disease is taken after vaccination, but it 
is sometimes witnessed among persons wholly 
unprotected. 

Analysis of the symptoms of confluent small- 
pox. — 1. The first peculiarity of confluent small- 
pox, as generally met with, is, that from a very 
early period it involves not only the cutis vera, 
but the subjacent cellular membrane in extensive 
and often violent inflammation. The eye-lids are 
swollen, and by the fifth day the patient is unable 
to see. The scalp is tense and tender. The pa- 
rotid glands participate in the increased action of 
the surrounding cellular membrane, and salivation 
takes place, with great turgescence of the cheeks. 
The limbs are tumid, and an erythematous red- 
ness often occupies such parts as are free from 
variolous papula?. In the most aggravated cases, 
buboes form in the groin, often with intense pain. 
The skin being almost wholly occupieff with vesi- 
cles, there is no areola. The pustules do not acu- 
minate, but appear flat and doughy, and upon the 
face especially they coalesce into ane large sore, 
which discharges a copious thin ichor. The con- 
stitutional symptoms accompanying this kind of 
small-pox are very severe. The pulse is rapid, 
with extreme debility, restlessness, and total want 
of sleep. 

2. The second peculiarity of the confluent 
small-pox is, that the eruption occupies not only 
the skin but the mucous expansions of the mouth, 
nose, pharynx, larynx and trachea to below its 
bifurcation. The tongue is also occupied with 
vesicles. The precise structure of the mucous 
vesicle has not been determined with the same ac- 
curacy as that of the cutaneous vesicle; but it 
runs a course in all respects similar. This com- 
plication of mucous inflammation adds immea- 
surably to the danger of the disease, besides that 
it modifies some of the other symptoms. Heat 
of the mouth, pain of the throat, difficulty of 
swallowing, hoarseness, dyspnoea, and more or 
less mucous expectoration, are the first symptoms 
that it occasions. These increase in severity until 
the eighth day, from which time a copious secre- 
tion takes place from all the structures so affected. 
In a large proportion of cases the swelling occa- 
sioned by the inflammation so narrows the open- 
ing of the larynx, and the effused matter so blocks 
up the air-passages, that suffocation is produced. 
Before this takes place, however, the respiration 
has been impeded to such a degree as materially 
to interfere with the due oxygenation of the blood. 
Hence arises a long and frightful train of symp- 
toms, among which we may particularly enume- 
rate gradually increasing dyspncea, coldness and 
paleness of the extremities, lividity of the areola, 
especially in parts distant from the centre of cir- 
culation, a swelled and purple tongue, great rest- 
lessness, and a low muttering delirium. 

Cases of the confluent form of small-pox are 
sometimes met with, which are altogether devoid 
of mucous complication, but they are very rare. 
The extent of mucous and of cutaneous inflam- 
mation, however, are not always and necessarily 
proportioned to each other. A case may be vet v* 



l&i 



SMi LL-POX, 



confluent on the surface, with but few vesicle.-' in 
the throat. 

3. A third circumstance influencing materially 
the character of the symptoms in the confluent 
variety of small-pox, is the early and deep impli- 
cation of the brain and nervous system. This 
fortunately is but a rare occurrence. The chief 
symptom by which it is character'zed is early and 
violent delirium, (the delirium ferox of old au- 
thors,) attended in many cases with such a strong 
disposition to self-destruction that the utmost care 
should always be taken to guard against the pos- 
sibility of accident. Variolous delirium is accom- 
panied with redness of the conjunctiva, contrac- 
tion of the pupil, and a wild expression of coun- 
tenance. It generally shows itself at the very 
commencement of the initiatory fever, but is some- 
times delayed until the second or third day from 
the appearance of the eruption. Excessive rest- 
lessness, anxiety, and despondency may be viewed 
as lighter evidences of the same specific affection 
of the brain. Nothing indicates its absence so 
certainly as a calm and collected manner, with a 
succession of quiet nights, and a confident hope 
of recovery. Variolous delirium is always most 
violent in the early periods of the disorder. When 
the areola begins to form, still more when external 
inflammation is fully developed, delirium for the 
most part ceases. Cases of confluent small-pox 
complicated with delirium are extremely danger- 
ous. A large proportion of them terminate unfa- 
vourably, sometimes by affection of the head, 
(coma,) sometimes by acute inflammation of some 
other internal part, especially the pleura, brought 
on or determined by the general derangement of 
the nervous system. We have stated, as a gene- 
ral rule, that th<? peculiar affection of the brain 
and nervous system now adverted to, is associated 
with a full confluent form of eruption, but occa- 
sionally it is found to accompany, and of course 
very materially to aggravate the danger of distinct 
and semi-confluent cases. 

4. The fourth circumstance which characterizes 
and modifies the phenomena of the confluent 
forms of small-pox, is the implication of the fluids 
of the body, — in other words, the concurrence of 
thai state of the blood called by the old writers 
dissolved or putrescent. To these, the most ag- 
gravated of all cases, the terms malignant or 
petechial small-pox are generally applied. They 
are thus distinguished. From the earliest period 
of the disease, petechias are observed in different 
parts of the skin. Sometimes the extent of sub- 
cutaneous ecchymosis is immense. As the vesicles 
advance to maturation, they fill, not with pus, but 
with a thin ichor tinged with blood. Hemorrhages 
break forth from all the mucous structures of the 
body. The gums bleed often very profusely. 
There is epistaxis, spitting of blood, vomiting of 
blood, and the passage of blood by stool. Fe- 
males suffer from violent menorrhagia, and abor- 
tion never fails to occur to such as are pregnant. 
There is bloody urine in some cases. All this 
occasionally happens without delirium, or any 
other well-marked evidence of cerebral affection. 
More commonly, however, these conditions, viz. 
disturbed brain and dissolved fluids, are found asso- 
ciated together. From this appalling variety of 
«mall-pox, recovery is scarcely ever met with. 



Death usually takes place between the fifth and 
seventh days of the eruption. 

Complications.— Such are the ordinary phe- 

nomena of the natural small-pox in its distinct 
and confluent forms, when it occurs to persona 
previously in good health and of sound constita- 
tion. But it must be remembered that this dis- 
order may attack those who may be labouring, at 
the time of seizure, under some other disease, 
such as pneumonia, hooping-cough, hepatitis, or 
consumption; and further, that these and other 
disorders may come on, unexpectedly, at any 
period, early or late, during the progress of small- 
pox. An infinite variety of accidental symptoms 
may thus be superadded to those regular symp- 
toms now enumerated. Besides which, small-pox 
may occur to persons of a weak habit, or in con- 
stitutions exceedingly exhausted, and unable to 
cope with a disease of such severity. It may 
occur, for instance, to those who have but recently 
recovered from a severe typhous or scarlet fever. 
Under these circumstances, we observe a very 
tardy eruption; collapse without advance of erup- 
tion ; or in cases somewhat more favourable, an 
abundant formation of large blebs, containing a 
thin ichor, with a very tedious and hazardous 
period of convalescence. To this latter form of 
the disease the old writers gave the name of the 
watery or bladder pock. 

III. Stage of Decline. — If the maturating 
stage of small-pox exhibits great diversity of 
symptoms, so also, even in a more eminent de- 
gree, does the stage of decline. The mildness 
and rapid progress to recovery which some cases 
present, contrast strongly with the severity, obdu- 
racy, and varied dangers of others. 

In the distinct and mild form of small-pox the 
pustules burst and discharge their contents on the 
sixth, seventh, or eighth day. A scab succeeds, 
cicatrization commences, and in vigorous consti- 
tutions is completed in about eight or ten days 
In the very mildest cases of all, which approach 
to the character »f chicken-pox, there is very little 
discharge of matter, but. the pustules harden, and 
the small portion of pus which they do contain is 
apparently absorbed. This variety of th#disease 
has been called the dry or horny pock, and it is 
the most common form in which small-pox shows 
itself after previous vaccination. 

In cases of greater severity, as well in the truly 
confluent as in tho.-e which we have distinguished 
as the semi-confluent variety, where the eruption 
is copius, but where the vesicles do not actually 
coalesce except in a few places, the decline of the 
disorder is attended with some remarkable phe- 
nomena, of which the most important are pitting 
and secondary fever. Cicatrization is tedious and 
ultimately effected with such a loss of substance 
in the true skin as occasions pits and scars, which 
continue during the remainder of life. From the 
great vascularity of the face, there is always greater 
confluence and a higher degree of inflammation 
there than in other parts. Hence, pitting is 
chiefly met with in the face, disfiguring and often 
completely altering the countenance of the suf- 
ferer. 

Secondary fever.— The febrile symptoms sub- 
side entirely in all cases where the' pustules have 
maturated kindly over the whole body; but in all 



SMALL-POX 



165 



severe cases, that is to say, where the cellular 
membrane and glands which it envelopes have 
become involved with the skin in inflammation, 
the fever, so far from subsiding on the ninth or 
tenth day, when the maturative stage has closed, 
is aggravated. The surface of the skin at this 
time becomes hot and dry, the tongue white, the 
pustules hard and scaly, the pulse increases in fre- 
quency, the patient is tormented with a great, 
sometimes inextinguishable thirst. Secondary 
fever is now said to have set in, and the variety 
of symptoms observed during its progress almost 
baffles description. The following attempt to 
enumerate some of the leading phenomena of se- 
condary fever will serve at least to point out the 
character of this very singular condition. 

1. In a large proportion of cases, secondary 
fever is accompanied with some form of inflam- 
matory action on the surface. An efflorescence 
identical with that of scarlatina occupies the trunk 
and extremities. Trails of erythematous redness 
appear in several parts, or a genuine erysipelas 
attacks the head, trunk, or limbs. In other cases 
the cutaneous and cellular inflammation is more 
circumscribed, leading to the formation of ab- 
scesses, often of great extent, of boils and car- 
buncles, and ulceration of those parts which are 
especially liable to pressure, such as the elbows, 
hips, and sacrum. In those situations sloughing 
sores are often met with, which from their extent 
and depth bring life into danger. In some cases 
the scalp is the part which receives the violence 
of the fever. Abscesses form there, or a diffuse 
cellular inflammation takes place, which is fol- 
lowed by purulent infiltration. Lastly, in a few 
instances the whole surface is occupied with pus- 
tules of ecthyma cachectiaim, accompanied with 
fever of the hectic kind, which is with great diffi- 
culty subdued. 

2. Secondary fever is accompanied in a certain 
proportion of cases with ophthalmia. The sub- 
ject of variolous ophthalmia is one of great extent 
ind importance. In the early periods of the dis- 
ease it is not uncommon to observe a considerable 
degree of conjunctival inflammation, and some- 
times a pustule forms at the edge of the cornea ; 
but it is reserved for the decline of the disease to 
exhibit the aggravated form of this affection. In 
some desperate cases an intense form of ophthal- 
mia sets in about the tenth day, which rapidly 
involves all the structures of the eye, and in the 
course of a few days destroys its entire organiza- 
tion. In other cases the sloughing is confined to 
a portion of the cornea, and this is followed by 
a slaphylomatous protrusion of the iris. It is rare 
to observe more than one eye involved in this very 
destructive form of inflammation, but still in all 
countries, and from the earliest periods at which 
we read of this disease, a large proportion of the 
blind have been found to owe their misfortune to 
the secondary fever of small-pox. 

3. Another frequent occurrence in the progress 
of secondary fever is gangrenous inflammation of 
the genitals. This shows itself in the first in- 
stance on the scrotum or prepuce, runs on rapidly 
to mortification, and in almost all instances ends 
in the loss of life. 

4. The destructive effects of secondary fever, 
however, are by no means confined to the surface 



of the body. It frequently happens that without 
any obvious cause some internal organ receives 
the violence of the febrile shock. Acute inflam- 
mation is set up, and the result is in almost all 
cases suppuration. The pleura is the part pecu- 
liarly disposed to suffer under these circumstances. 
Variolous pleurisy comes on about the eleventh or 
twelfth day of eruption, for the most part very 
suddenly, and proceeds rapidly to empyema. Wo 
have seen it prove fatal in thirty-six hours. In 
general, the pleuritic symptoms are violent and 
well marked. The pain of side is excruciating, 
and the shortness of breath equally unequivocal; 
but sometimes there is a latent form of pleurisy. 
The patient dies without making any complaint 
of the side, and on dissection one of the cavities 
of the thorax is found gorged with a sero-purulent 
fluid. In all cases of secondary fever, a strict 
attention to the respiratory organs, with such aid 
as the stethoscope can afford, should never be 
omitted. In a few cases the substance of the 
lungs is the seat of an intense form of inflamma- 
tion, tending to abscess. Children are sometimes 
attacked with symptoms indicating laryngitis or 
croup. 

5. Affections of the abdominal viscera are very 
uncommon. Inflammation of the liver and of the 
mucous membrane of the bowels have been no- 
ticed, but they are among the rarest forms of in- 
ternal disease observable in the progress of small- 
pox. 

6. The brain sometimes suffers during the pre- 
sence of secondary fever. Phrenitis with delirium 
occurs in children ; and in adults of plethoric habit 
a state of coma or lethargy is not unusual. But 
what is most worthy of attention in this respect, 
is that singular state of the nervous system which 
accompanies the destruction of large portions of 
skin, and which is so well known to surgeons as 
a consequence of extensive burns and scalds. It 
is characterized by severe and repeated rigors, 
succeeded by general tremors, low delirium, a 
weak and rapid pulse, a dry brown tongue, and 
collapse of the features terminating in death. 

7. The evils attending secondary fever are ag- 
gravated by the concurrence of the strumous habit. 
Nothing develops it more certainly than protracted 
small-pox. Accordingly, in scrofulous constitu- 
tions we see secondary fever complicated with 
strumous ophthalmia, characterized as well by its 
complete intolerance of light and abundant secre- 
tion of tears as by its obstinate resistance to every 
kind of remedial treatment. Irritable ulcers form 
under the lower eyelid, and around the knee, 
ankle, and elbow-joints, and are found very diffi- 
cult to heal. Glandular enlargements of the neck 
take place, which sometimes suppurate, but oftener 
continue indolent and of stony hardness. Chil- 
dren frequently suffer from otitis. 

8. To all this must be added the danger of con- 
tracting during the stage of decline, common fever 
of the typhoid or erysipelatous kind. At the 
Small-pox Hospital, it is not uncommon to find 
even the milder cases attacked during apparent 
convalescence, with fever, irritable stomach, scfre 
throat and erysipelas of the face or extremities 
This superadded disease has in many instances 
brought life into hazard, and in some has proved 
fatal. The great peculiarity of it is the concur 



166 



SMAL 



rcnce of severe inflammation of the tonsils and 
subjacent cellular membrane with erysipelas of the 
head, neck, or back. It appears to have its origin 
in that vitiation of the air which is almost insepa- 
rable from the very nature of an hospital, and 
which any accumulation of malignant cases, more 
especially in a disease like small-pox, must neces- 
sarily tend to augment. This form of disease 
might be appropriately designated hospital fever. 
When it has once shown itself, there is abundant 
reason for believing that such a fever, whether 
exhibiting anginose or erysipelatous symptoms or 
their combination, is truly contagious. 

Prognosis. — The following are the chief 
grounds on which the prognosis in small-pox 
should rest. 

1. Confluence is always unfavourable, because 
it necessarily occasions a large drain on the sys- 
tem ; but if the pustules acuminate well, and the 
areola on the extremities be of a good, that is, 
crimson, colour, a reasonable ground of hope 
exists. Confluence on the face is more to be 
dreaded than in any other part. When the vesi- 
cles on the trunk of the body are flat, when the 
eruption on the face is white and pasty, when the 
extremities appear of a clarety or livid colour, 
little or no hope of recovery can be entertained. 

2. With reference to prognosis, great attention 
is due to the state of the larynx. Hoarseness, 
with copious spitting, occurring at an early period 
is very unfavourable, as indicating the extent of 
mischief in that important organ. On the other 
hand, a natural tone of the voice is a favourable 
sign, and with a good constitution gives a fair 
ground of hope, even though the eruption be full 
and confluent. 

3. Quiet nights, composure of mind, a collected 
manner, and confident hope of recovery are good 
omens, because they indicate the comparative free- 
dom of the brain and nervous system from all 
serious complication. Patients who from an early 
period of the disease are restless, delirious, moan- 
ing, and desponding, rarely recover. There is 
not a worse symptom in children than grinding 
of the teeth : very few recover in whom it is ob- 
served. 

4. In estimating the danger of confluent and 
semi-confluent cases, the age of the patient merits 
particular attention. Persons above forty years 
of age seldom recover from any of the severer 
forms of small-pox. Infants also are in danger 
even from a moderate quantity of eruption. In 
both cases the reparative process is attended with 
great exhaustion of nervous power, the result of 
which is that the brain, larynx, or some other 
important organ loses its tone, takes on acute 
inflammation, and by its disorganization life is 
destroyed. The most favourable age for taking 
*mall-pox is from the seventh to the fifteenth 
year, when the powers of life are in the greatest 
vigour, with the least chance of plethora. 

5. The habit of body is rikewise to be taken 
into account. In the middle periods of life the 
danger of small-pox is much increased by its con- 
currence with a plethoric habit. Great weakness 
of constitution is equally a source of danger. Of 
the additional risk which a strumous habit entails, 
we have already had occasion to treat. 

fi Every thing indicating a dissolved or putres- 



L-POX. 

^cTnt state of the fluids is of course most unfavour- 
able, such as petechia, menorrhag.a, and ep.staxis. 
Recovery from the petechial or malignant form of 
small-pox, indeed, is so rare as scarcely to enter 
into calculation. . 

Mortality of Small-pox. — It is commonly 
stated that one-fourth of those who are attacked by 
small-pox in the natural way perish. The records 
of the Small-pox Hospital indicate a somewhat 
higher proportion. The deaths during the last 
fifty years at that institution have averaged thirty 
per cent., the extremes being eighteen and forty- 
one per cent. The days of greatest mortality, or 
critical days, as they are called by the old authors, 
have been much commented upon, and in all ages 
it has been observed that the eighth (counting 
from the day of eruption) is the day of greatest 
danger. The following table, extracted from the 
register of the Small-pox Hospital for the years 
1828 and 1829, illustrates this fact, while it shows 
at the same time that small-pox proves fatal at 
various periods, from the third to the thirty-eighth 
days of eruption. From this table it also appears 
that nearly two-thirds of the total number of 
deaths take place during the second week of erup- 
tion. 

Table of the critical days in Small-pox, shoiving 
the period of eruption, at which 168 cases 
proved fatal. {From the Records of the 
Small-pox Hospital for 1828 and 1829.) 



There died on the 

3d day of eruption. 
4th 



1st week. -\ 5th 

6th 

I 7th 

r 8th 

I 9th 

| 10th 

2d week. ■< 11th 

12th 

13th 

lUth 5. 



• n 

5 
10 

5 
11J 

27^1 
15 

11 
16 

11 
11 



y 3a 



99 



3d week. 



4th week 
and 

after. 



(-15th 

| 16th 

J 17th 

*) 18th 

I 19th 

L20th 

f-22d 

23d 

24th 

25th 

27th 

28th 

29th 

31st 

32d 

35th 

l38th 



21 



Total. 



U 

3 

1 
2 

fl 

3 
1 
1 
1 
1 I 
1 | 
1 
I | 

2j 

168 



16 



[Prior to the introduction of vaccination, ac- 
cording to Dr. Gregory, (Tweedie's Library of 
Practical Medicine, 2d Amer. edit. ii. 324, Philad, 
1842,) the deaths by small-pox were, to the 
total deaths in town and country, in the ratio of 
16 to 100, or about one-sixth. Of those attacked, 
the mortality is usually stated at 1 in 4. This 



SMALL-POX. 



167 



•according to Dr. Stewardson, was the mortality at 
the Small-pox Hospital of Philadelphia during the 
years 1840, '41, and '42, — a much smaller propor- 
tion than in the epidemic of 1823 and 1824, de- 
scribed by Drs. J. K. Mitchell and J. Bell, {North 
American Med. and Surg. Journal, vol. ii. 1826,) 
in which more than one-half the unprotected cases 
died. In an epidemic small-pox, which visited 
Malta and Gogo in 1830 and 1831, the mortality 
amongst those not vaccinated was, according to 
Dr. John Davy, 1 in 4.7. (Notes and Observa- 
tions on the Ionian Islands, <fc., Lond. 1842.) 

The numerical method has not, however, been 
extensively and rigorously applied to this subject. 
The mortality seems to vary in different places ; 
thus, from primary small-pox in London it has 
been estimated by Dr. George Gregory at 36 per 
cent. ; whilst in Germany, according to Heim, it 
was only 20 per cent. From accurate statistical 
accounts, taken by the Kegistrar-General of Eng- 
land, it would appear that, in 1837, there were 
only five diseases more fatal in England; and that 
the deaths by it throughout England and Wales 
amounted to about 12,000 annually. Since then, 
the number has fluctuated from 16,268 in 1838, 
to 9,131 in 1839. (Mr. W. Farr, in Third Re- 
port of Registrar-General, 1841.) 

At times, during special epidemic influences, 
the mortality from small-pox is terrific] 

Causes of death in Small-pox. — It may 
not be irrelevant to recapitulate the several causes 
of death in small-pox. 1. Prior to the maturation 
of the pustules, that is, between the second and 
seventh days of eruption, patients die of malignant 
fever ; of that peculiar condition of the fluids and 
nervous system to which the name of acute ma- 
lignancy may properly be given. 2. Between the 
eighth and thirteenth days of eruption, the chief 
cause of death is to be found in affection of the 
throat, and consequent suffocation. 3. In the 
state of secondary fever, that is, between the four- 
teenth and twenty-first days of the eruption, death 
may take place in three ways — either by violent 
febrile excitement with effusion on the brain ; or 
by sloughing, gangrene, and destruction of large 
portions of the surface ; or lastly, by supervening 
pleurisy, peripneumony, or laryngitis. 4. At a 
still later period, that is, after the third week from 
the appearance of eruption, death may take place 
from mere exhaustion, or from erysipelas and 
superadded fever. 

Blorbid Appearances, — It has been remarked 
from the earliest periods that the internal organs 
do not suffer in small-pox so extensively or so 
frequently as might be expected. In a large pro- 
portion of cases, the condition of the surface is 
the sole cause of death. In the throat, however, 
some very characteristic appearances present them- 
selves, provided death has taken place between the 
seventh and twelfth days of the eruption. The 
pharynx, larynx, and trachea are then found 
covered with a copious, viscid, puriform, or puru- 
lent secretion of a grey or brownish colour, thrown 
out by the numerous vesicles which had formed 
upon the mucous membrane of those organs. 
The mucous membrane itself appears thickened, 
pulpy, and in the worst cases black and sloughy. 

There is no point wherein pathologists have 
more widely differed than in this, whether the 



specific inflammation of small-pox invades the in 
ternal parts 1 The phenomenon has been asserted 
as a matter of fact by some, while others have, 
with equal confidence, denied it. Cotunnius (De 
Sedibus Variolarum, passim) made a vast number 
of dissections with a special view to ascertain 
whether any of the viscera were the seat of vario- 
lous pustules. His conclusion is, that they are 
exclusively confined to the skin, and those mucous 
membranes which are in direct contact with the 
external air. There can be no doubt that this 
opinion of Cotunnius is strictly correct. Inflam- 
mation may originate from accidental causes in 
any internal organ during the progress of small- 
pox, and its effects will be seen after death ; but 
these are not to be confounded with, or mistaken 
for, the specific effects of small-pox on the skin, 
and mucous expansion of the throat and chest. 

When death has taken place in the third week 
from the appearance of eruption, the pleura will 
sometimes be found inflamed, and coated with 
layers of coagulable lymph, while in the coire- 
sponding cavity of the thorax, purulent matter or 
a sero-purulent fluid will be collected, often in 
enormous quantity, compressing by its bulk the 
lung of that side into a small space. Occasion- 
ally a portion of the lung itself is found infiltrated 
with pus. 

In some cases, where great determination of 
blood to the head has been indicated during life 
by swelling of the head and face, delirium, head- 
ach, and high fever, the blood-vessels of the brain 
and its meninges are found turgid, with more or 
less of effusion into the ventricles. 

Nothing is more worthy of notice than the 
freedom of the abdominal viscera from all traces 
of disease in those who die of small-pox. Among 
the numerous dissections made at the Small-pox 
Hospital, we have never been able to detect vario- 
lous pustules on the mucous membrane of the 
intestinal canal. Ulceration of the bowels indeed 
sometimes takes place in children during the vio- 
lence of the secondary fever, but differing in no 
respect from that which occurs in other and more 
familiar forms of hectic fever. 

[See, on this subject, Dr. Petzholdt, in Brit, 
and For. Med. Rev. v. 479.] 

Pathology. — For more than a thousand yeais 
after the first appearance of small-pox, this dis- 
ease was considered by physicians to have its 
origin, like other fevers, either first, in some state 
of the atmosphere, or secondly, in some vitiated 
condition of the humours of the body. A large 
portion of the community at the present day are 
of the same opinion, and confidently believe tin! 
the small-pox is, to use their own expression, 
bred in the blood. The pathologists of the last 
century, however, from the time of Boerhaave, 
reasoning from the very peculiar train of symp- 
toms observed in small-pox, and from the com- 
paratively recent date at which it became known, 
adopted the notion that this disease is in all cases 
the product of a specific poison or contagion, re- 
ceived into the blood from without. Such is stilt 
the general opinion of the best informed phy- 
sicians. It cannot indeed be denied, that great 
difficulties are experienced in tracing the source 
of contagion in numberless cases, and that tin. 
doctrine of spontaneous origin admits of being 



163 



SMALL-POX. 



supported by some ingenious and plausible argu- 
ments ; but the weight of evidence is decidedly in 
favour of the invariable origin of small-pox by 
contagion. How the variolous poison was first 
generated is wholly unknown. A tradition has 
been handed down by the Arabian physicians 
(See Baron's Life of Jenner, p. 522,) that it was 
originally derived from the camel, but no substan- 
tial reasons for such an opinion have ever been 
advanced. 

The peculiar miasm or morbid matter of small- 
pox is receivable into the human body in three 
modes: first, by the lungs through the medium 
of the respiration : this is called the mode of in- 
fection. Secondly, by application of the matter 
to the unbroken surface of the skin or mucous 
membrane of the nose. This is properly denomi- 
nated contagion, although the terms infection 
and contagion are generally made synonymous. 
Thirdly, by application of matter to