It is unnecessary in the present day to go into any very minute investigations of the remote cause of scurvy; at the same time it may not be altogether useless briefly to review the external relations of the persons who have been submitted to its influence. The more obvious and interesting agents generally to be regarded in an enquiry of this kind, are the conditions of the atmosphere, the occupation of the individual, the nature and amount of his food, &c. &c. The winter has been unusually severe, and protracted. During the last six months, the temperature has been lower, with a lower range of atmospheric pressure, and a less amount of rain, than is the usual average of these months, while the winds have blown chiefly from the eastward instead of from the westward. That cold has some influence in the production of scurvy may be assumed, from its being a disease for the most part of late winter or early spring, and from its frequent occurrence in the colder latitudes of the north of Europe; but that cold is not the cause of the disease may also be inferred, from its not occurring at these periods or in these situations, excepting under The mean height of the thermometer and barometer, the prevailing winds, and amount of rain, from October, 1846, to March, 1847, compared with the averages of these months during ten years. certain conditions, and that under these conditions it occurs in warm weather, and inore southern latitudes. We therefore conclude that cold is not the cause of scurvy, but that when such cause may be in force, it greatly predisposes to it. That impure air was not the cause of the disease in these cases is evident, from many of those affected having been persons occupied much in the open air, or living in well ventilated rooms, as in the Union Workhouse, where the usual regard had been had to this particular. Doubtless the living in an impure air would tend to depreciate the general health, and thus render the system more susceptible of the influences of this disorder, but it cannot be esteemed as a cause. That scurvy is not produced by any peculiar occupation is evident, from its occurrence amongst persons engaged in various trades, as likewise in those following no particular calling. In fact it has been rather shown, more especially in the Crediton Union, by the extreme state of disease in the women and children there, that the want of occupation, and the absence of exercise thereby engendered, much predisposes to its attacks. We now come to the important question of food:First as regards amount, there has been, in the course of the above cases, the most satisfactory evidence offered that the cause of this disease can not be referred to a deficiency in this respect, as very many of those affected by it have been well off in means, and certainly those in the Crediton Union Workhouse enjoyed a diet which has been shown to be most ample; we must, therefore, look to kind and quality. It cannot fail to have been observed that the greater proportion of those afflicted have lived chiefly on fermented bread; that such bread is not the cause of scurvy, its long and universal use is sufficient evidence, at the same time the occurrence of the disease in those using it so freely, shows it is not, as has been supposed, prophylactic against it. The same may be said of rice, the poor generally not having eaten it, while its use in the union workouse has shown it incapable of preventing its occurrence. That salted provisions are not its cause is also certain, as by far the larger proportion of those affected have not eaten of them. It now remains to speak of the absence from the diet of the usual esculent, the potato. In this respect only has the food of all these people differed from that of other seasons, and it is here worthy of remark, that in the Crediton Union, there intervened between the last use of potatoes and the prevalence of the disorder referred to, a period of about six months, and experience has shown this to be the usual time, a diet devoid of fresh acescent principles takes to produce scurvy. It is a remarkable fact that the cases of scurvy which came under Dr. Heberden's obseration, at St. George's Hospital, in 1795, had lived chiefly on bread and butter.— Med. Trans." Vol, IV. ON THE RECENT OCCURRENCE OF SCURVY IN EXETER. As the recent failures in the potato crops have excited the enunciation of certain political opinions condemnatory of the employment of this esculent, it may not be useless briefly to refer to the conclusions which have been arrived at by able and competent authorities in reference to its anti-scorbutic properties. Sir Gilbert Blane, in his account of the diseases of the Fleet, in 1781, mentions that the potato, sliced up with vinegar, proved useful in preventing and curing scurvy; similar testimony is subsequently offered by Mr. Dalton. (Lancet, Sept. 22, 1842.) Mr. Berncastle, and M. Fontenelle have, however, shown that its usefulness in this respect is not destroyed by cookery as was supposed, the one having employed it boiled in the usual way, the other slightly baked. Dr. Baly, who has given a digest of these and other opinions, (Med. Gaz., Feb. 16, 1842,) adds his own valuable testimony to its being, as ordinarily cooked, an admirable preservative against scurvy." The facts from which Dr. Baly deduced this conclusion are most striking. As physician to the Milbank Penitentiary, he observed, that scurvy was unknown amongst the convicts whose diet contained a fair allowance of potatoes, (5lbs., together with an onion weekly,) while it was of very frequent occurrence amongst the military offenders, whose diet was almost wanting in this respect, (only lb in the week,) and that since these latter have been allowed the larger amount of potatoes the disease has not recurred amongst them. Similar and equally conclusive evidence is deduced by Dr. Baly, from the occurrence of scurvy in other prisons of the kingdom. We may still proceed one step farther, and show to what peculiar principles the antiscorbutic qualities of the potato are due, and in doing so I shall quote the summary given by Dr. Baly. "A glance at the chemical analysis of the potato, at once explains its antiscorbutic virtue. The various fruits, succulent roots and herbs, which have the property of preventing and curing scurvy, all contain, dissolved, in their juices, one or more organic acids,—such as the citric, tartaric, and malic acids. Sometimes these acids exist in the free state, but more generally they are combined with potash and lime, or with both these bases. Now, potatoes have been submitted to most elaborate chemical examination by Einhoff and Vauquelin; and by both these chemists they have been found to contain a vegetable acid in considerable quantity. According to Einhoff this acid is the tartaric, combined with potash and lime. According to Vauquelin it is the citric, partly in combination with those bases and partly in the free state. The farinaceous seeds, as wheat, barley, oats, and rye, which are destitute of antiscorbutic property, contain no organic or vegetable acids." From all that has been now stated we must come to the conclusion, that the recent occurrence of scurvy in Exeter is due to this one cause-a deficiency 285 of food containing acid principles; and that the potato has hitherto been the means whereby these acid principles have been supplied. We may farther conclude, that the peculiar symptoms of this disease are not developed until after the system has been deprived of food of this nature for some months; that the persons most liable to be affected by it are those naturally of weak constitutions, or who are submitted to inactive and depressing circumstances; and that protracted cold weather greatly predisposes, on the one hand, by depreciating the powers of the system; and on the other, by checking the growth of fresh vegetables, and rendering such as are raised deficient in proper juices. From all that has now been stated of this disease,from its symptoms, its predisposing and remote causes, has any light been thrown on its nature or proximate cause? We see evidently that it primarily consists in a peculiar state of anæmia, and that this anæmic state, unattended by loss of appetite or irregularity in the alvine secretions, is accompanied by a general dusky pallor, weak pulse, breathlessness, and a disposition to syncope-a condition of the system early followed by, and complicated with, low feverishness and tendency to local deposits, causing swollen red gums, stiffness and swelling of the joints, together with petechiæ, hæmorrhage, and nodes, a series of phenomena distinctly indicating the proximate cause of this disease to be a disordered state of the blood, and which disordered state it would appear, from the investigations of Mr. Busk,* mainly consists in the amount of fibrin, albumen, and salts and water, exceeding the proportion of health, while that of the hæmatosine falls below it. In accordance with the above indications of the nature and origin of this disease, the mode of treatment pursued has mainly been the use of acids, and much benefit has resulted therefrom; otherwise the use of potatoes, if they could be procured good, and other vegetables, has been enjoined, together with oranges, cider, vinegar, pickles, &c., in fact, such treatment as is usually recognized amongst us as adapted for the cure and counteraction of scurvy. It must not be understood from this that scurvy is stated to be solely caused by a deficiency of vegetable food. Scurvy is essentially a disease of depraved nutrition, and may be produced by a too restricted and exclusive use of any kind of food. In this paper I am strictly confining myself to the nature and origin of the disease now prevailing. of Practical Medicine." * Art. "Scurvy," by Dr. George Budd-" Cyclopædia ON A FEW POINTS CONNECTED WITH THE OF PERICARDITIS. By E. J. SHEARMAN, M.D., Rotherham. Pericarditis is a very frequent and a very dangerous disease: it attacks those persons most exposed to changes in temperature and climate, and least likely, from position in life, to be able to take precautions to prevent, or use remedies to cure such a disease. It is consequently of the utmost importance to society that such an affection should, if possible, admit of easy detection; and that its nature and treatment be plain and straightforward to medical practitioners in general. In Dr. Bartolomé's Essay on this subject, published in this Journal of the 5th of May, he remarks, "The diagnosis of pericarditis is not always easy; it has been mistaken by Corvisart, Andral, and Laennec, for other diseases;—that the "fibrous portion of the pericardium is that first affected;" and he advances a mode of treatment so contrary to that which I have been in the habit of considering as the one most approved of by all the late pathological writers on this disease, that I trust he will allow me to notice bis statement, with the laudable motive of searching for truth. I shall confine my remarks to pericarditis only, although I am perfectly aware that endocarditis, with all the resulting effects of valvular disease, atrophy, dilatation, and hypertrophy, are generally its conse. quences; but space will not allow these to be named. The following order may be as well observed :- involved, and its terminations. 2nd. The best mode of determining, by examination during life, the actual condition of the part. 3rd. The most approved method of treatment as described by the best authors of the present day. 1.-The Pathological Condition of the Part. Although the pericardium is composed of both fibrous and serous textures, yet the same arteries supply both, and it will depend upon the condition of the blood supplying the inflamed capillaries what the exudation corpuscles produce. Dr. Bartolomé says, " very probably pericarditis generally, if not always, first attacks the fibrous pericardium," then, afterwards, "the most common causes besides rheumatism, are blows, pressure, inflammation propagated along the lungs or pleura, &c." He gives no proof of the fibrous being the membrane first affected, and is "at a loss how to describe the first stage of the disease." But, if pericarditis arises from inflammation propagated along the serous membrane of the pleura and lungs, it is not very likely to affect the fibrous membrane first. I am not aware of any other author having laid any stress upon the fibrous membrane being immediately implicated. I have had a great many opportunities of examining the parts after death, having during the disease anxiously and narrowly watched its progress; and until I see by dissection that I am wrong, I shall feel inclined to agree in the opinions which I quote below. The same degrees of congestion, nervous and vascu-lar irritation, determination of blood, obstruction of capillaries from atonic enlargement, and adhesion of white corpuscles in the vessels; distension of blood in the arteries before, and emptyness of the veins beyond, impeded or arrested circulation at, and increased circulation around, the obstruction; with change in the whole quantity of blood by increase of fibrin and diminution of the secretions, exhaustion and depression either from excessive excitement or the presence of pus or other foreign matters in the blood,must attend this as well as all other inflammations. If the blood be excessive in red particles, as in very robust and healthy persons, there will be coagulating lymph, serum, and blood exuded; if deficient in red particles, as in anæmic, lymphatic and leucophlegmatic subjects, tubercular deposits will be formed; if fibrin predominate, the serous membrane will be: covered with a thicker and more adhesive layer of lymph, and of the most plastic character. But the blood may be so altered in quality, and the quantity of its salts and red particles so much increased, as may produce even osseous deposits. The fibrin may be so low in character as to allow only aplastic lymph to be secreted, in which case very slight, if any adhesion, would take place; and pus, curdy matter, yellow tubercle, &c., would be deposited. It might be enplastic and become highly organized; or cacoplastic, and susceptible of only a very low degree of organization, particularly in the chronic stage, thus giving origin to fibro-cartilage, grey tubercle, &c. It therefore depends on the character of the blood as well as upon the character of the membrane inflamed, what the product of inflammation will be; and this easily accounts for the various statements of many of the old authors,-of bony, bloody, purulent, curdy, fibrinous, and various other effusions having been found in cases of pericarditis. It is very evident that some of these products of inflammation are much more adhesive in their nature than others, and I have taken the opportunity of naming all, for the purpose of giving the greatest latitude possible to the difficulty this will give us in diagnosis. But it is well known that pericarditis, like rheumatism, is a disease of a highly inflammatory nature, and oftener attacks those whose blood is loaded with red particles and fibrin, than the weak and anæmnic; and those who have had the most extensive experience in examining such cases after death, agree in saying that adhesion of the pericardium is by far the most frequent result. The first and immediate effect of pericarditis is ON PERICARDITIS. effusion of a small quantity of coagulating lymph and -serum on both sides of the pericardium; this increases according to the activity of the attack, or the success of remedies. It may go on to such an extent as to bulge out the bag of the pericardium enormously, or it may stop short, and only produce so much mischief, as to impede the smooth motion of the heart in its natural capsule. There may be the other deposits mentioned before, but there must be both effusion of lymph and serum. 287 indebted for the first information of the diagnostic physical signs, are,-a singularity of manner and peculiar expression of countenance, strange aspect of distress in the deportment, palpitation, oppression at the epigastrium, catch in the breathing, dry cough, inability of lying on the left side; pain in the region of the heart, increased by inspiration, pressure between the ribs, or upwards under the diaphragm; stiffness, and pain in the left shoulder, extending into the arm, elbow or wrist; and delirium, often wild and furious, not dependant upon any disease of the encephalon. All these symptoms put together would not be enough to make us sure that this was pericarditis; for truth, in all its kinds, is most difficult to win, and truth in medicine the most difficult of all. Clinical observation, though never blind, was, until lately, always deaf; but now, with the aid of the ear, when, with even some of these symptoms, we find the attrition murmur, Dr. Latham says the disease cannot be mistaken for anything but pericarditis. Before the true attrition or friction-sound is beard, there is almost always, and generally for some days, a kind of clanging, harsh, churning, creaking, or crumpling sound heard over some part of the præcordial region, not conveyed to the aorta, pulmonary artery, or carotids. This is not constantly present, The general opinion amongst authors, without one exception, I believe, is, that after every case of pericarditis, the lymph unites the pericardium to the substance of the heart, and the cavity is thus either partially or wholly obliterated; and this is considered the most efficient care which the parts are capable of admitting. For some years I have had the opportunity of watching numerous cases of this disease, in the practice of our late lamented and talented associate, Dr. Favell, as well as in my own; and there are at least two specimens of his in existence, and one of my own, which he added to his collection, where, after the most positive, proofs of pericarditis having ́existed from acute rheumatism, verified by several medical gentlemen and students, the patients quite recovered under the specific influence of mercury, and died afterwards of some other disease. dissection, the pericardium in each case was found unadherent throughout, and the parts which had been inflamed are quite distinct and easily discerned from the rest, being of a much lighter colour, thicker, and raised from the surface of the uninflamed part of the membrane. This is a circumstance deserying notice, for - only be known by the it gives great encourcomont on the practitioner .. cxtent to which the præcordial region, and perhaps, some space beyond it, may be dull to arent vise disense very actively, with so goed a prospect pertussion. Thus, dulness sometimes occupies a part, sometimes the whole; of that region; sometimes it On པ In pericarditis there are the fluid products of inflammation as well as the solid: here is serum as well as lymph; and the signs of fluid effused within the pleura and pericardium are the same. The fact of its existence, and the measure of its accr within the pericardium, ca¬ degree and of perfect success. 411. The best 'Mode of detecting Pericarditis during Lift, | reaches beyond, as high as the second, and even the Dr. Bartolome remarks, "All authors seem to agree, | first left rib; sómétimes it extends beneath the whole 'that the most unequivocal sign is the presence of pain length of the sternum, except about an inch at the top, 'over the region of the heart, particularly if aggravated and even beneath the cartilage of the ribs on the right bby pressure." He lays great stress upon the quality of side. the pulse, as à diagnostic symptom, stating in one place ... that it is "the loose robbing polse of acute rheumatism, when the fibrous membrane alone is inflamed, but will vary in proportion as the serous membrane becomes affected;" and in another, that “it is the jerking immediately felt along the arteries, that distinguishes the pericarditic pulse from that produced by merely accelerated circulation." But he afterwards says, 66 we cannot form our diagnosis from the pulse alone." He mentions the "bruit de soufflet," which is pathognomonic of inflammation of the endocardium, but passes over very slightly the "craquement de cuir,” and “bruit de cuir," and does not notice the "bruit de frottement." This dulness to percussion is a most important sign, and hardly inferior to, or less diagnostic of, the pathological condition to which it points, than the attrition, friction, for to-and-fro murmur itself, which is caused by the rubbing of the two layers of membrane on each other, after they are covered with lymph. But there are two other physical signs of this disease which often but not always attend,-1st, an undulatory motion, visible to the eye, Letween the cartilages of the second and third, or the third and fourth rils, on the left side, or in both situations at the same time; 2nd, a vibratory motion, like the purring of a cat, felt just over the same places as the undulatory motion is seen. These two last signs sometimes attend disease of the The symptoms, as described by Dr. Watson, to semilunar valves of the aorta and pulmonary artery, whom, simultaneously with Dr. Stokes, we are and are therefore not pathognomonic. During the life-time of Corvisart and Laennec the physical signs of pericarditis were not discovered, and it is no wonder they speak with so much doubt about it. But since Dr. Watson, of London, and Dr. Stokes, of Dublin, distinctly ascertained that increased dulness | on percussion, and the peculiar friction to-and-fro sound, were pathognomonic of this lesion, no one who has once listened attentively to this sound can ever again mistake it, or misinterpret its meaning. In all acute cases of pericarditis I believe this friction-sound can be heard distinctly if listened for. The harsh churning sounds spoken of before are generally the precursors of this more distinct sign, but they are not always to be heard. The to-and-fro friction-sound is always evident, and if watched quite distinct. In cases where a very large quantity of serum is exuded, the friction-sound may only be heard during the first few hours or days of the disease, the fluid having so far separated the pericardium from the heart as to prevent its touching, at which time the dulness of percussion would be more marked. But under the influence of proper remedies, this fluid becomes absorbed in a few more days to such a degree, as again to allow the membranes to rub against each other, and then the friction-sound re-appears. I believe this very rarely happens, but I have certainly noticed it myself in cases which I have narrowly watched. The difference of density in the fluid in the pericardium does not alter the nature of this friction-sound, is conveyed immediately from the outer layer of the pericara, errears to proceed from a surface immediately under the ear. This sound is perfectly distinct from the systolic bellows-murmur of endocarditis; but when endocarditis exists at the same time, as is often the case, this bellows-murmur is heard as well, and frequently confuses, for a time, the frictionsound. I would recommend any one who is sceptical on this point to read Dr. Latham's late work on "Diseases of the Heart," in two volumes, 1846-47. I name this work above all others because Dr. Latham has taken his data from ninety cases of pericarditis, attended by himself in St. Bartholomew's Hospital, all of which were open to the observation of the medical staff of the hospital and students; and he is a physician of such decided talent and probity as to carry conviction to every unprejudiced reader. But there still may come a difficulty, which I will briefly allude to. In a case of pericarditis which has been apparently cured by treatment, and where most of the pericardium has become adherent; what will be the pathognomonic physical sign, should another attack of inflammation make its appearance? Here auscultation is not to be entirely depended upon. The impulse will be great, tumultuous. There may be some slight friction-sound if a very large part of the pericardium still remain un-adherent, but generally there is little or none. If the former attack was curedwithout adhesion, (a circumstance by no means impossible,) then I presume the very same physical signs which have been already described will beconie again pathognomonic. In most second attacks the endocardium, valves, and cavities become diseased, and during acute inflammation these sounds are often difficult to diagnose, unless the ear be well accustomed to such abnormal sounds. It may be well to mention a combination of sounds originating in disease of the semilunar valves from endocarditis, which sometimes simulates this frictionsound of pericarditis, and might mislead an ear unprac tised in auscultation. I allude to a direct as well as a regurgitant murmur existing in the semilunar valves of the aorta or pulmonary artery, and not unfrequently met with in the aorta. The character of this sound is different to the friction-sound, although the peculiarity is difficult to describe. The length of both sounds in the pericarditic friction sound is the same, but the systolic is longer than the diastolic sound in that origi-nating in the semilunar valves. A very little education of the ear will be found sufficient to distinguish the difference. The valvular sound is also heard louder at the top of the sternum than at the apex of the heart, and is conveyed by the vessels, whereas the intensity of the friction-sound is generally in the opposite direction, and is not conveyed by the vessels. We now come to III.-" The most approved Method of Treatment." Dr. Latham, in 1847, says, "In foreign practice no mercury is used from first to last, but all the power of common antiphlogistic remedies is brought to bear upon the disease, and thus its symptoms are mitigated or subdued, yet they return again and again, and are again and again mitigated or subdued, and so the patients are kept alive for a week or ten days, and then they die, in the great majority of cases." M. Bouillaud's treatment of pericarditis is of this antiphlogistic description; he never uses mercury; and in his treatise on it, he says almost every case is found on dissection to have the pericardium adherent. In inflammation of the pericardium the products or exudation of the inflammatory action are deposited in a shut sac. There is not only congestion, great nervous and vascular irritation, and determination of blood, with their usual consequences, but a large quantity of lymph and fibrin ere exuded, which, so far as I know of the remedies for inflammation, can only be checked, stopped, or absorbed, during the timethe system is under the specific influence of mercury. Bleeding, both general and local, is undoubtedly invaluable, and ought to be carried to such an extent as to cut off the supply of a certain quantity of blood to the part, and decrease the quantity of fibrin in the blood. Purging to a certain extent is necessary, but that will not absorb either the serum or lymph. Opium is of the greatest benefit, by soothing the excessive irritability. |