Dr. Willan has given the result of his experience of an epidemic scarlatina, from cases which occurred in his own practice in the year 1786. Of 251 cases, there were 152 of scarlatina anginosa, 42 of sore throats without eruption on the skin, and 39 of scarlatina maligna. Dr. Clark, in the description he has given of an epidemic scarlatina which prevailed at Newcastle in 1778, observed, that of 131 patients, 75 had the eruption with sore throat; in 33 the disease occurred with every distinguishing symptom of scarlatina maligna; 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 may only occur out of a large number of individuals affected. We find from the register of cases kept at the London Fever Hospital, that the mortality of scarlatina shews great variation. In the years 1822 and 1823, the disease appears to have been extremely mild, as none of the patients died during these years. In 1824, the mortality was one in 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 1832, the mortality was one in forty; and during the last year, the average has been about one in twenty-two. Of 644 cases treated at this hospital, the gross mortality was thirtyeight; of these there were thirteen males and twenty-five females. The following table exhibits the comparative ages of the fatal cases:— Males. Females. 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 individual case, as well as to the various circumstances with which it may be associated. It is also indispensably necessary that the treatment 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 sufficient merely to advert to it again. 1. In the scarlatina simpler, the symptoms are generally so mild, that it is only necessary to confine 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 surface with cold water, by which the morbid heat is rapidly dissipated, and the feelings of the patient are rendered more comfortable. It is seldom necessary 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 prudent to take away a moderate quantity of blood, with the view of subduing the vascular excitement, 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 circumstances require. It is necessary to watch every case of scarlatina, however mild at the beginning, as the character of the disease is often materially altered by the sudden accession of inflammation 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 bleeding from the arm, when there is much excitement at the beginning, is often useful in moderating the fever, and diminishing the tendency to visceral inflammation. General bloodletting has been strongly recommended by several continental physicians in this form of scarlatina, more especially when there is much cerebral disturbance. Morton employed it with success in the epidemic he has described; 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 vomiting and diarrhoea. 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 bear a large bleeding, and scarcely any a second. On the other hand, in some epidemics, evacuations of blood are less efficacious, or wholly inadmissible, 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 of the disease by bloodletting and other antiphlogistic measures at one season, does not warrant the practitioner 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 the colour of the rash was not intense, or did not appear at all, the swelling of the throat great, and the pulse firm. Dr. Willan, 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 bloodletting appeared to be indicated. Whenever it had been employed, great depression and faintness were the immediate consequences, the pulse becoming more weak and frequent, and often irregular. 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, but 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 employed with the greatest caution, and not unless some urgent circumstance arise to require its use. We have seldom had ocsion 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 cupping 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 skilfully 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 precludes their adoption. The inhalation of the vapour arising from warm water gives much more decided relief. The exhibition of emetics in the commencement of scarlatina anginosa as well as of the Edinburgh Medical Essays, vol. iii. p. 27. other forms, has been strenuously recommended by some physicians. Dr. Withering prescribed them not only in the beginning, but even in the later 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 symptoms 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 symptoms and feelings of the patient. Dr. Rush exhibited 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. Dr. The abatement in the symptoms which is generally 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 their doubts of the safety of this practice, from the fear of inducing debility and repelling the efflorescence. Hamilton, however, has adduced powerful arguments in support of it, and has illustrated his views by an appeal to the result of cases treated in public and private practice. No variety of the disease, as appearing in different epidemics, or in the course of the same epidemic, has hitherto prevented this distinguished physician from following out this practice to the necessary extent. The pungent heat of surface, violent headach, tutgescence of features, and full and quick pulse, the earliest symptoms in some epidemics of scarlatina, and which may have suggested and warranted the practice of bloodletting, are often quickly subdued by one or two brisk purgatives. Dr. Hamilton 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 fœces, 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 medicines 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 difference depends, it is necessary to adapt our practice in the use of purgatives to the nature of the prevailing epidemic. In the early stages, when there is nothing to contra-indicate the use of purgatives, a brisk aperient may be exhibited daily. We generally prescribe 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 bowels, 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 membrane of the intestines betrays signs of irritation or of inflammation. In such cases, the bowels 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 be selected; none is preferable to castor-oil suspended in mucilage, with the addition of a few drops of laudanum. The free application of cold is decidedly beneficial in the acute stage of scarlatina, and more especially, in the anginose form. The bed-chamber should always be properly ventilated by frequently renewing the air, and allowing a current of cool fresh air 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 refreshed. The sponging should be repeated when the skin feels pungently hot. The testimony of Dr. Bateman, 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 bloodletting in acute inflammation,) by which the functions of the animal economy are controlled with 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 indicated in this state of disease, and which we should scarcely à 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 countenance 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 followed by the same beneficial effects as at first."* Little confidence should be reposed in any of the ordinary saline remedies. We prefer the mineral acids, more especially the saturated solution of chlorine, prepared according to the directions given in the Dublin Pharmacopoeia, which contains about twice its volume of chlorine. Of this remedy a fluid dram and a half, mixed with eight ounces of water, and two drams 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, producing 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 acid 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 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 circumstances of unusual debility after a protracted illness. The moderate use of it in such cases tends much to assist the convalescence. When visceral inflammation arises in the progress of scarlatina anginosa, no time should be 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 FEVER,) 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. Practical Synopsis of Cutaneous Diseases. 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 commencement, and before it is fully formed, an antimonial emetic is generally very beneficial, more particularly when the bowels are afterwards evacuated either by the antimony, or by an active aperient. If, however, those means be insufficient to subdue the excitement, more over 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 require a cordial tonic plan of treatment. It then becomes necessary to support the sinking powers by animal broths, quinine, and a moderate allowance of wine. The volatile alkali has been strongly recommended in cases of malignant scarlatina; it was considered by Dr. Peart to be endowed with a specific power over the malignant scarlet fever and sore throat. He directed two drams of the carbonate of ammonia to be dissolved in five ounces of water, of which the dose was two teaspoonfuls 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 have tried this remedy repeatedly, but our experience of it does not warrant such an inference; nor do we deem it preferable to other diffusible stimulants. Capsicum is a remedy which appears to have been employed with much success by Dr. Stephens, in an epidemic scarlatina which prevailed at St. Christopher's in 1787, and of which an account was published in the second volume of the Medical Communications, and also in Duncan'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 be strained off, to which half a pint of very sharp vinegar is to be added. Of this mixture, the dose for an adult is one tablespoonful every four hours, the quantity being diminished in proportion for children. This remedy has been commended by several writers who have employed it successfully; but having never employed it, we cannot offer an opinion on it. When topical inflammations arise in scarlatina maligna, general bleeding is seldom admissible, unless they supervene in the be ginning 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 inflammation which arise in this malignant disease. With regard to the local treatment in scarlatina maligna, we may observe, that in the very beginning 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 treatment 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 frequently 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 employment. Acidulated bitter infusions, 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 chlorosodaic solution of Labarraque, in the proportion of f3xii of the solution to ƒzvß of water and 3iv of honey, as an excellent gargle. The same solution, in the proportion of vi to 3v 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 coryza.* Fumigations by the nitrous acid gas, (separated from pulverized nitre by the strong sulphuric acid,) or the nitro-muriatic acid gas, (chlorine,) (separated from a mixture of equal parts of pulverized nitre and of sea-salt, by the strong sulphuric acid,) have been strongly recommended by Willan. It is almost superfluous to state, that proper ventilation is most essentially necessary in this, as in the other forms of scarlatina. The admission of fresh air around the patient generally invigorates his powers, and often proves a most excellent tonic. Warm sponging, a tepid bath, or, if there be much cerebral disturbance, fomentations to the extremities, may be employed in addition to the other measures. 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 Bateman's Practical Synopsis of Cutaneous Diseases, edited by Anthony Todd Thomson, M.D. denominated scirrhus, cancer, fungus hæmatodes, and the several kinds of sarcoma, under the generic term of Carcinoma. The reasons for our grouping together under the term 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 meantime, 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 conceive, while they express in a concise and conspicuous manner those characters by which they are distinguished, justify our having brought them together under the same general denomination : 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 common to all of them, however much they may differ from each other in the subsequent periods. 3. They all terminate in the gradual destruction or transformation of the tissues which they affect. 4. They have all a tendency to affect, successively or simultaneously, several organs in the same individual. 5. They all possess, although in various degrees, the same reproductive character. 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 evidently 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 purgatives 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 anti--1. They are essentially composed of a solid phlogistic treatment of dropsy succeeding to scarlatina has been corroborated by many practical writers in other countries as well as our own; and though some still hesitate 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 be 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 measures. As to the employment of tonics, on the supposition that the dropsical effusion depends on loss of power or tone in the exhalents, we confess we are sceptical as to this being the pathological state of the vessels in any case of dropsy succeeding to scarlatina, and therefore we are disposed to place little or no confidence in this class of remedies. When the effusion has been removed by suitable measures, pure air, mild nourishment, and attention to the bowels will be found the best mode of invigorating the general powers. (A. Tweedie.) SCIRRHUS.-The term exippos, from oxi gos, marble, was given by the Greek physicians to certain tumours characterized chiefly by a great degree of hardness; but the application of the term scirrhus has for a considerable length of time been limited to tumours or portions of organs or tissues which present not only this character, but which terminate in the disease called cancer. Hence the state of induration to which the appellation of scirrhus is given is regarded as the first stage of cancer. We shall overlook for the present 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 VOL. III. : Specific divisions of carcinoma.-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 differences to which we allude are referable to two states of the carcinomatous substance to which the diseases in question 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 be 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 circumstances, it possesses in itself properties by means of which its subsequent arrangement and developement are effected, independent of the nutritive function of the organ in which it is formed, except 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 accomplish this object; it is 2 U |