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LECTURES
ON THB
ERUPTIVE FEVERS?
AS HOW IN THB COURSE OF DELIVERY AT
ST. THOMAS'S HOSPITAL, IN LONDON.
* « V «# «4
•# <• « « «
• ••
?.T
• • •
FELLOW OF THK S0«^ COLLEOB OT^^^t^^CUVS OF LONDON ; PHYSICIAN TO TBS
SMALL FOV^ND VACCINATION HOSl'lTAL^AT HI6HOATE ; CORRESPONDING
or THE NATIONAL INSTITUTE 0^ WASHINGTON, ETC.
. *
''9IBSX AMERICAN EDITION,
WITH NUMEROUS ADDITVDlfS AND ^Mp(0USMIfS '^T THE AUTHOR, COMPRISING
HIS LATEST VBWsi
WITH NOTES AND AN APPENDIX,
EMBODYING THE MOST RECENT OPINIONS ON EZANTHEMATIC PATHOLOGY ; AND
ALSO STATISTICAL TABLES, AND COLORED PLATES.
BY
H. D. BULKLEY, M.D.,
PHYSICIAN OF THE NEW YOBK HOSPITAL; FELLOW OF THB NEW YOBK COLLEGE
OF PHYSICIANS AND SUB6E0NS, ETC., ETC.
S. S. &, W. WOOD, PUBLISHERS,
361 PEARL STREET.
MDCCCU.
V.
• • ••
• • I
• •
• • •
• •
• •
• • •
Entered
1
i
aeq^rding to Aot of
Congrefli in the year 1851, by
S. S. & W. WOOD.
in the Clerk's Office of the District Court for the Southern District of New York.
^^^^^^^^^t^0<^^a^f^t^0^t^f^0^^^^^^f^^^^tm
^t^^^^^Jkm^i
ROIIRT CRAIOHIAD, niMTIR,
118 rUtTOH BTBRIT.
-82.
85\
TO
SIR CHARLES MANSFIELD CLARKE, BART.
MJ>^ F JUS.
Mt dear Sm Charles,
The dayi are gone by when dedications could be relied on
as passports to public favor ; but I hope it will never be out of fashion to
make a public profession of gratitude, esteem, and respect. I am proud to
acknowledge myself as your pupil, and to avow that from you I learned,
not only the science of physic, but the art of lecturiiig.
The position which you occupy in society sufficiently attests your skill
and acquirements ; but the esteem and regard of your brethren, which no
one ever enjoyed in a higher degree, have been earned by still higher
qualities of mind, by great urbanity, and an untiring readiness to promote
the professional advancement of your juniors.
I have yet another reason for prefixing your name to these pages. They
treat of diseases which occur for the most part in that early period of
human life, to the management of which your thoughts have been in a
great degree directed. In submitting my ideas to your judgment, I feel that
I am subjecting them to their severest ordeaL
I am, my dear Sir Charles,
Ever very faithfully yours,
GEORGE GREGORY.
SI Wfynontli Btn&t^
lluchlO»]Ba
PREFACE.
The following short course of Lectures on the Eruptive
Fevers was delivered in the Theatre of St. Thomas's Hospi-
tal, between the 18th January and the 8th February, 1843.
It was thought that the experience which twenty years of
official connexion with the Small Pox and Vaccination
Hospital had given to the author might contribute something
towards that extended and improved system of medical
education now pursued in that school.
The Lectures are published in the same form as that in
which they were delivered, with the exception of certain
portions necessarily omitted in the oral delivery, in order
that what was calculated for thirteen lectures might be com-
pressed into eleven.
The author is very conscious of one imperfection of the
present volume. He is fully aware that the conversational
tone adapted for the lecture-room does not suit the closet so
well as the gravity of a didactic style ; and that many, who
might be inclined to look with favor on the matter, may
very reasonably object to the manner.
The author would anticipate one other criticism. Those
who are in possession of the " Library of Practical Medi-
cine " will at once perceive that a chapter in the first volume
of that work has here been laid heavily under contribution ;
but as, in so doing, the author only borrows from himself on
points where later experience has suggested no improvement,
he trusts to obtain the kind indulgence of the reader. Should
,^r-^
Tiii FSSFACE.
of the four epidemic diseases, small pox, measles, scarlet
fever, and hooping cough, in the cities of New York, Phila-
delphia, Boston, Providence (R. I.), Lowell (Mass.), Baltimore,
and Charleston (S. C), and in the State of Massachusetts, as
could be obtained ; and also some more extended remarks on
various topics treated of by the author, which the editor
considered more appropriate to this portion of the work.
To enhance still further, as was hoped, the interest and
value of the work, plates of the vaccine disease as it appears
in the cow and on the hands of those inoculated from this
source, copied from the beautiful and faithful illustrations of
this affection by Mr. Ceely, of Aylesbury (Engl.), in his work
on the varioleB vaccinae, have been annexed.
The editor is happy to acknowledge the aid which he has
received in constructing his statistical tables from the valu-
able labors of Dr. Emerson, of Philadelphia, Dr. Joynes, of
Baltimore, and Dr. Parsons, of Providence. The other and
principal items in the tables have been derived from public
documents.
H. D. B.
43 BUeeker Street,
March 6, 1851.
CONTENTS.
^^^^^^^^^^^s^*^^^*^^*^
LECTURE I— CHARACTER AND AFFINITIES OF THE ERUP- ^"**
TIVE FEVERS, 1
Mutual Relation of Diseases 2
Varieties of Cutaneous Disease, 4
Exanthematio Mortality, 5
General Character of the Exanthemata, 10
Exanthematous Fever, 11
Specific Eruption, 15
Alleged Identity of the Exanthematic Poisons, 16
Law of Suspension, 18
Affection of Mucous Surfaces accompanying Exanthema, . . .18
Structures Secondarily Implicated 20
LECTURE II.— CHARACTER AND MANAGEMENT OF THE
ERUPTIVE FEVERS, 22
Law of Universal Susceptibility, 22
Law of Non- Recurrence, 23
Contagious Origin, 25
Modes of Miasmatic Access, 26
Theory of Zymosis, 29
Quarantine, 30
Epidemic DifTusion, 31
Management of the Exanthemata, 36
Influence of Medicine over the course of Eruptive Fever. . • .39
LECTURE HI.— EARLY HISTORY AND PHENOMENA OF SMALL
POX, 41
Pestilence of Proeopius, 42
First appearance of Small Pox in England, 43
Introduction and Progress of Inoculation, 46
Variolous Incubation, 49
Initiatory Fever, 50
Characters of Variolous Eruption, 53
Maturative Stage, 56
Implication of the Mucous Membranes, 57
Implication of the Cellular Membrane, 59
Secondary Fever, and its Consequences, 59
Implication of the Nervous System, 61
Petechial Small Pox 62
Small Pox with Gangrene, 63
Variolous Ophthalmia, 64
Implication of Internal Organs, 65
Appemraoces on Diaaecxion, 66
4(
LECTURE IV.— STATISTICS AND PATHOLOGY OF SMALL
POX. ^
DiBguosis of Small Poi, ™
Buti.ucB of Small Po» '*
Pioponion of Mild lo Severe tnd F»ul C«ee» '4
FerJoda of ihe DiwaM »t which De»ih occura, 76
Direct Cauwa of Death ID Smill Pox, 76
pMbolofly of SmMlI Poi, 77
Qut^-tion >.lS|„..m,i]]-m. Origin, ^9
^T™!^'. ■■■'""' ''''t'""'""'''*"*^" '.'.'.'.'.'.'. S3
I I ' •... I. I I, of Small Fox B4
fiuwrliijbiljt)' of t^maH Poi 86
I ... I .'I .-ini.il Poi lo the Fomus in Utero 91
LECTl'liK V.-MAXAi-iKMiiNT OF SMALL POX 93
Early opinioiiB fonceiiiing ilier Minagemvnt of Small Foi, . . .94
SoutcMof danger in Small I'ol 95
Treilmeiit duriog the Inittilory Fever 97
« during the MaluittUve Slagf lUO
oflheMuoouBComplieaUon 103
Lop«l,of Ihe PuJlul™ 102
in the Secondary Fever ' . - .105
of ihe Sequela of Small Pm 106
" Exieruul, -daring Secondarr FcTtr 107
InocuialioD of Small Fox 108
Kesulis of Inoculation 110
Ahulition of Inoculalion, 113
LECTURE VL RUBEOLA, OR MEASLES 114
Chpraclera of Rubeola, 114
Early ll.-iurv ,.t' Rubeola, 115
Incubaiiv.: .<K-.,^K-. 117
Charatlrn ol' iliu liiilialory Ferer 113
Rubeola »ine Caurrho, 191
Maluratioti of Meaalea, 1S3
Rubeotous Pneumonin 136
Oilier Sequelc of Meaalea, I2S
Walignant Meaele* 129
Cnncrum OtI*, 131
Diagnoeia, 134
Recurrent iMeafles, 137
Inuculaiion ofMwuIca, .' 138
Bluli'-lics ol' Meaalea, . 140
Treatment of Men E.(es, 142
LECTURE VH— HlSTOftV AND PHENOMENA OF SCARLET
FEVER 146
Early Hitlory of Scarlet Fever 147
Division of «e«rloi Fevet into Species 151
Scatlatinn Mills 151
" AnginoM, 153
Atleetion of the Throat 156
Iniplicalion of ihe EyB 158
Ccrrbral Compiication 159
Afleeaon of ihe Heart. 160
Aiietna A1alit;na Pmrida 161
Sequelot of ^uxrlel Fever, 164
ScaTlatlntl Dropaf, 167
OQHTBllTSk xk
fan
LECTURE Vni.— PATHOLOGY, STATISTICS, AND TREAT-
MENT OF SCARLET FEVER 172
Statistics of Scarlatina, 174
Per Ceotage of Mortality, 176
Diagnosis of Scarlatina from Measles, 179
Pathology of Scarlatina, 180
Laws of the Scarlatinal Miasm, 183
Recurrence of Scarlatina, . 184
Management of Scarlatina, . . . . . . .* . .186
Employment of Emetics, . . 188
" Cold Affusion, 189
** Blood-letting, 190
" Purgatives, 194
" Stimulants, 195
Management of Scarlatinal Dropsy, 198
LECTURE IX.— ERYSIPELAS 203
Etymology of Erysipelas, 204
Ancient Opinions concerning it, 205
Modem Views of Erysipelas, 207
Its Origin from Hospital Miasm, 208
Development of Ochietic Miasm, 210
Contagiousness of Erysipelas, 213
Sources of Erysipelas, not Miasmatic, 215
Incubation, 217
Phenomena of erjrsipelas, 220
Its Extension to Internal Structures, 224
Statistics of Erysipelas, 226
Treatment, 228
LECTURE X.— HISTORY, PHENOMENA, AND PRACTICE OF
VACCINATION, 237
Early History of Cow Pox 238
Announcement and General Adoption of Vaccination, .... 240
Susceptibility of Cow Pox, 243
Phenomena of Vaccination, 244
Constitutional Symptoms accompanying Cow Pox, .... 246
Anomalies and Varieties, 248
Concurrence of Cow Pox with Small Pox, 251
Modified Cow Pox, 254
Surgery of Vaccination, 255
Preservation of Vaccine Lymph, 261
LECTURE XL—PATHOLOGY AND RESULTS OF VACCINA-
TION 262
Theory of the Identity of Small Pox and Cow Pox, .... 263
Variolo- Vaccine and Retro- Vaccine Lymph, 266
Equine Origin of Cow Pox, 268
Doctrine of Antagonism, 270
Results of Vaccination, 272
Variolous Epidemics since 1800, 274
Statistics of Small Pox after Vaccination, 277
Per CenUge of Mortality, 285
Actual Amount of Vaccine Security, 287
Recurrence to the Cow for Primary Lymph, 287
Re-vaccination, 289
LECTURE XII.— VESICULAR ERUPTIONS 292
Varicella, its early History, . . 292
Appearance and Progress of Varicella, 296
121 0OSTEST8.
Diagnoofl of Varicella and Modified Cow Pox, .... 299
Question of its Identity with Variola, 300
Hebfes 302
Herpes Zoster, 303
IVeatment of Herpetic Eruption, 308
Miliaria, 308
Appearances of Miliary Eruption, 310
Cau«e of Miliary Eruption, 312
PlHPHIOUS A2«D FOMFHOLYX, 314
Pemphigus, Chronic form of, 314
Acute form of, 315
Gangrenosus, 315
LECTURE Xin.— NOX-CONTAGIOUS EFFLORESCENCES. . . 317
Lichen, 317
Diagnosis of Lichen Fcbrilis, 330
Strophulus, or Infantile Lichen, 321
Syphilitic Lichen, 322
Lichen Tropicus, 323
Urticaria ; its Characters, 324
Causes of Urticaria, 325
Roseola : its several Varieties, 327
Roseola Eianthematica 327
Erttuema : Local forms of, 329
Erythema Nodosum, 331
Connexion of Fever, Efflorescence, and Specific Exanthem, . . 332
APPENDIX 333
Table of average Exanthematic Mortality in New York, Philadelphia, and
Boston, 333
Table of Exanthematic Mortality in New York from 1805 to 1850, inclusive, 335
PhUadelphia from 1807 to 1846, " 337
Boston from 1811 to 1850, " 338
Providence (R. I.), from 1842 to 1849,
inclusive, 340
Lowell (Mass.), from 1839 to 1850,
inclusive, 340
" " " Baltimore, from 1836 to 1849, inclusive, 341
" " " Charleston (S. C), from 1822 to lt<49,
inclusive, 342
" " " Massachusetts (exclusive of Suffolk Co.)>
from 1841 to 1848, inclusive, . 343
Co-existence of febrile exanthemata, 344
Secondary occurrence of small pox, 346
Communication of small pox to fa>tus in utero, 348
Means to prevent pitting in small pox, 351
Influence of inoculation on mortality, 353
Pathology of scarlatinal dropsy, 355
Treatment of scarlatinal dropsy, 357
On epidemic erysipelas, and the form popularly known as " Black TongiSe," 358
On mortality by small pox after vaccination, 365
On Re-vaccination, 370
<( it €t
*t tt II
J
ON THE
ERUPTIVE FEVERS.
t^^^^^^^^0^^^lm^^0^l^^^0^^t^^^*^^^^^^0S^^^*^
LECTURE L
CHARACTER AND AFFINITIES OF THE ERUPTIVE
FEVERS.
Mutual relation of diseases. Importance of the skin in the animal economy.
Varieties of cutaneous disease. Exanthematic mortality throughout Eng-
land, and in the metropolis. General character of the exanthemata. Of
exanthematous fever, its uniformity and steadiness of course. Fever not
essential to exanthemata. Symmetrical disposition of exanthematous
eruptions. Alleged identity of the exanthematic poisons. Law of sus-
pension. Affection of mucous surfaces accompanying exanthemata.
Structures secondarily implicated. Variety and occasional severity of
such complications.
If there be any group or class of disorders which admits
of being considered apart from and independent of
others, it is undoubtedly that association of complaints
called the exanthemata, or eruptive fevers. The reason
is this. There are many pathological principles which
are best exemplified in the phenomena of the exanthe-
mata, and some which are nearly peculiar to them.
Nevertheless, while I acknowledge this, I would at the
same time impress upon you the great principle, that
there are no diseases strictly isolated fi^om others ; they
are links in a chain —
" All are but parts of one stupendous whole .^'
They must be viewed in conjunction, if we would hope
1
2 MUTUAL RELATION OF DISEASES.
to form just, enlarged, and legitimate views of the cha-
racter and pathological affinities of each.
Let us ask ourselves, what would be the conduct of
a judicious traveller, when he first sets foot in an inte-
resting district of country ? Would he not lofik out
for some elevated point, some pinnacle or cloud-capt
tower, from whence he may survey the general aspect
of the country, trace the course of the rivers, and the
direction of the mountains, — from whence he may note
how the district is indented, on the one hand, by the
countries he has already traversed, and how it loses
itself, on the other, in those portions of the country
which he has still to explore ?
That which would be a pradent course iq the tra-
veller would be an equally prudent course with us. You
have studied some portions of the great field of patho-
logy ; others remain for future investigation. Let it be
our business now to take a general view of the exanthe-
mata, in relation to other branches of patholc^ical
study. It can be but a bird's eye view that I lay
before you, but such a sketch, loose and imperfect as it
must necessarily be, will prove useful to us, I had
almost said essential, in the further prosecution of our
design.
Let us, then, consider the relation in which the
exanthemata stand, 1. to each other; 2. to other forms
of fever ; 3. to other diseases of the superficies ; 4. to
other diseases arising from morbid poison ; 5. to the
diseases of other structures.
On the structure of the skin, or dermoid tissue, I
have no intention to enlarge. That subject has been
already brought before you in the lectures of Mr.
Grainger. You will remember what was said of the
PlIVaiOLOGY OF THE SKIN.
epidermis, of ihc corion or true skin, and of the rauci-
form tissue, called rete mixcosam, interposed between
ihein. You will bear in mind what you were taught
regarding the blood-vessels and nerves of the skin.
But though I shall pass over in silence the anatomy
of the skin, I must detain you for a few minutes while
I direct your attention to some points in its physiology.
The skin, yon know, is the great organ of transpiration.
By means of tlie skin, the body loses every twenty-four
hours not less than thirty ounces of matter, — very nearly
two pounds.
[Very Uifferent results have bceii arrived at by tbose who h«ve made
experiments for the purpose of nacprtaining the amount of nmlter
thrown off from the skin. M. Seguin fixed the quatiOly, taking the
aventge of his experiraenla, nt eleven grains per minute, in a grown
penQii, or more than two pounds in tweutj^-four houre.
Dr. Willirtm Wood, of Newjiort (England), makca it abf<ut forty-fivti
ounce*, or nearly four pounds every twenty-four hours. (Eniag on
Structure anil Fanetimu nf Skin. Edinb,, 1832 : quoted by Dimglisoii.
PhysiolosTP. 1850.)]
The skin is exposed to the atmosphere, and to the
moisture which the atmosphere contains, and to all its
other inflnencps. It must he, and it is, fitted to bear
the extremes of temperature which the meteorologist
registers. You are aware that there are at least a
hundred degrees of difference between the iicals of
Calcutta and the snows of Caubul. Tlio skin, too,
is exposed to various injuries, for by the sweat of
man's brow he is to earn his daily bread. It is also
supplied with abundant means for the repair of those
physical injuries. Its numerous blood-vessels are
endowed with a strong disposition to heal by the first
intention (adhesive inflammation), or failing that, by
the second intention, bv which is understood the pro-
cesses of abscess, granulation, and cicatrization.
4 VARIETIES OF CUTANEOUS DISEASE.
If you wish to satisfy yourselves of the unmense
importance of the skin in the animal economy, observe
the effects of bums and scalds. See how a severe bum
affects the heart, and the brain, and the lungs ; I may
now say, also, the duodenum ; for the inquiries of Mr.
Curling have lately added this viscus to those which
severe injury of die skin disturbs and disorganizes. A
man may lose one half of his lungs by slow ulceration,
and he may yet live for months, nay, for years. But if
one half, or one third, or even one fourth of the skin of
the body be destroyed, the system rapidly gives way,
and death ensues.
The skin may be considered as the fourth in the
series of important organs. First come those of the
enceplialon, then those of the chest, then the abdominal
organs, and lastly, the superficies. This portion of our
frame, the superficies, is subject to various diseases
originating from internal and obscure causes. They are,
1. The acute febrile affections bringing life into
hazard. We call them the Exanthemata, from the
Greek av^o^, a flower. Hence egav^^w, to bud forth or
effloresce. Of these greater exanthemata there are
four: — Small Pox, Measles, Scarlet Fever, and
Erysipelas.
2. The acute febrile affections not bringing life into
hazard, — the lesser Exanthemata. They are divisible
into two sections. 1. Vesicular affections, of which
there are four: — Vaccinia, Varicella, Herpes, and
Miliaria. 2. The simple efflorescences, not leading to
fluid effusion ; of which there are also four — namely,
Lichen, Urticaria, Roseola, and Erythema. These
twelve forms of eruptive fever will constitute the sub-
jects of the present series of lectures.
3. The chronic cutaneous affections of a mild or
EXANTHEMATIC MORTALITT. 5
benignant character, formerly characterized as being
boni moris : such as Lepra, Psoriasis, Ichthyosis, Impe-
tigo, Elephantiasis, and MoUuscum.
4. Chronic cutaneous affections, mali mo7'is, bearing
a malignant character, such as Cancer, Lupus, and
Fungus haematodes. Complaints of this latter kind are
exclusively surgical. The physician is consulted in all
the others.
I have said that the greater exanthemata are those
which bring life into hazard. The first point, there-
fore, to which I have to call your attention, and which
strikingly displays the relation of the exanthemata to
each other, is exanthematic or epidemic mortality :
what is its amount 1 — what proportion do deaths by the
exanthemata bear to the deaths by all other diseases ?
Is this proportion constant or fluctuating ? Is it alike
in town or country t I will tell you.
Upon an average of years, 350,000 persons die
annually throughout England and Wales, and 46,000
in the metropolis. The mortality by the four great
epidemic maladies (small pox, measles, scarlatina, and
hooping cough) is very nearly 40,000 in England and
Wales, and about 5000 in the metropolis, averaging
one in nine of the total mortality, or eleven per cent.
This is a very large proportion. That four diseases
only should absorb one ninth of the total mortality of
this and probably of all other countries, may well excite
our surprise.
[The average mortality by these four great epidemic diseases in
New York, during the forty years from 1806 to 1845 inclusive, was one
in about thirteen (12f) of the whole mortality, or nearly eight per
cent., and in Philadelphia, during the thirty years from 1816 to
1845 inclusive, one in thirteen and a half, or seven and one third per
\
EXANTHEMATIC MORTALITY.
cent. Iq both these cities, the proportion was one third more during
the last two decennial periods (from 1826 to 1S35) than during the
period from 1816 to 1825. In Boston, the deaths by these diseases
from 1831 to 1840 inclusive, amounted to one in nearly nine and a
half, or over ten and a half per cent., and from 1841 to 1845 inclusive,
one in about eight, or a little more than twelve per cent. See Table
A in Appendix.]
If the exanthemata are considered independent of the
hooping cough, considerable fluctuations will be per-
ceived, the mortality by them falling sometimes as low
as six per cent., at times rising to near thirteen ; but a
very important principle comes into play here, which
serves to equalize the amount of epidemic mortality.
This curious doctrine had long been surmised, but was
never proved until the statistical inquiries of recent
times showed its correctness. We may, for want of a
better name, call it the law of vicarious mortahty, by
which is understood, that whenever one epidemic
diminishes, another increases, so tliat the sum total of epi-
demic mortality remains, on an average of years, nearly
the same.' The following table exempUfies this : —
Table exhibiting (he amount of Epidemic Mortality in England and
Wales, during the years 1838, 1839, 1840.
Small Pox ....
Meiu*iles .....
Scarlet Fever ....
Totiil mortality by the Exan- )
theniata . . . .\
Hooping Cough ....
Total of Epidemic Mortality
Total Mortality throughout J
Enj^land and Wales . /
Year
1838.
Year
1839.
Year
1840.
16,268
6,514
5,802
9,131
10,937
10,325
10,434
9,326
19,816
28,584
9,107
30,393
8,165
39,576
6,132
37,691
38,558
45,708
342,529
338,979
359,561
1
EXANTHEMATIC MORTALITY.
We learn from this table, that every year is dis-
tinguished by some master epidemic. In 1838, small
pox was the ruling epidemic throughout England. In
1839, measles and scarlet fever struggled for the mas-
tery. In 1840, scarlet fever was so general, and so
fatal, that the mortality by it exceeded by one fifth the
ravages of small pox during an epidemic season (1838),
and more than doubled the mortality by that disease in
1839.
The following table, exhibiting die amount of epi-
demic mortality in the metropolis during a period of
five years, shows that the same general principle applies
to town and country, but is less manifest in the smaller
population.
Table showing the amount of Epidemic Mortality in England during
Five r"i?ar«— 1888 to 1842.
Small Pox .
Measles
Scarlet Fever
Total Mortality by the ;
Exanthemata . . \
Hooping Cough .
Total of Epidemic Mor- )
tality . . . )
Total Mortality through- )
out Ix)ndon . . )
Year
1838.
Year
1839.
Year
1840.
Year
1841.
Year
1842.
3,817
588
1,524
634
2,036
2,499
1,235
1,132
1,954
1,053
973
663
3*0
1,292
1,224
5,929
2,083
5,169
1,161
4,321
1,069
2,689
2,278
2,876
1,603
8,012
6,330
5,390
4,967
4,479
52,698
45,441
46,281
45,284
45,272
From this table we learn that in 1838 small pox was
the great epidemic in London as in the country. In
1839, measles and scarlet fever were both on the
increase, while small pox had sunk from 3817 to 634.
In 1840, scarlet fever predominated. In 1841, hooping
8 EXANTHEMATIC MORTALITY.
cough doubled its numbers, and shot above all the rest ;
while scarlet fever sank to the low point which small
pox had reached in 1839. The year 1842 has been
remarkable, first, for the extreme infrequency of small
pox, one death only throughout this great metropolis
being attributed to it for each day of the year ; and
secondly, for the uniform rate of mortality occasioned
by its three great rivals.
pn Appendix B, will be found tables showing the amount of
epidemic mortality in the cities of New York, Philadelphia, Boston,
Providence, Lowell, and Charleston (S. C), and in the State of Massa-
chusetts (exclusive of Suffolk County), during different series of years in
the different cities, from 1805 to 1849 inclusive.
It may be seen by reference to these tables, that scarlet fever was the
predominating disease in the first three of these cities during the five
years referred to by our author, except in Philadelphia during 1841,
and in Boston during 1840, in both which years small pox exceeded it
in mortality — tliat small pox increased nearly four-fold in New York in
1840, and in Philadelphia in 1841, and nearly two-fold in Boston in
1840 — and that in 1838, when it was the great epidemic in London,
the* whole number of cases in New York and Philadelphia was only
about one third of that of scarlet fever, and in Boston only 3 to 106 of
that disease.
It will also be seen that there was a great increase of mortahty by
small pox in New York in 1834, '5, '6, "7, and in Philadelphia in 1833,
'34, while there was no epidemic visitation of it in Boston until 1839.
In New York and Philadelphia, scarlet fever predominated in 1840,
as it did in London ; while in 1841, hooping cough was less prevalent
in each of these three American cities than the other diseases, consti-
tuting in Philadelphia a proportion of only 6 to a total epidemic
mortality of 407 ; the next year, however, in the same city, reaching to
197 out of an epidemic mortality of 697.
In Baltimore, small pox and scarlet fever were both rife in 1838,
and the latter was the predominating disease until 1842, during which
year measles took the lead.
The same fact with regard to both scarlet fever and measles will be
found in Charleston, the former prevailing extensively in 1838, when
the number of cases of measles was only about one seventh ; while in
EXANTHEMATIC MORTALITY. 9
1842, the number of cases of scarlet fever was just one half that of
measles.]
Everything teaches us that when one avenue to death
is closed, another opens, —
Noctes atque dies patet atri janua Ditis.
You will perceive from all this, that vaccination,
great as its merits are (and no one more fully appre-
ciates them than I do), does not, and cannot do all that
its too sanguine admirers promised. The blessings of
vaccination are met and counterbalanced by the law of
vicarious mortality. How and why is this? The
explanation is easy. The weak plants of a nursery
must be weeded out. If weakly children do not fall
victims to small pox, they live to fall into the jaws of
tyrants scarcely less inexorable. Scarlet fever and
measles are both advancing in respect of mortality, and
the increase of deaths by hooping cough since this
century set in is quite extraordinary.
These statistical considerations are both curious and
instructive, but they are not to diminish our zeal in
behalf of vaccination, or our efforts to lessen the sum of
human misery.
[The subject of vicarious mortality is one of much interest, and one
which has not received the attention it deserves. Statistics prove that
the per centage of deaths under five years of age is rather on the
increase than the contrary, in cities at least ; or, at any rate, remains
about stationary, and that at a high point in the scale, notwithstanding
the many lives acknowledged to have been saved by vaccination ; and
it is no less true, that the mortality by scarlet fever, measles, and
hooping cough has increased, both in this coimtry and in Europe,
within the last twenty years.
It must necessarily be the case that the lives saved from small pox
increase, by just so many, the number of those who are exposed to
other causes of death ; and if the susceptibility to each exanthem be the
10 CHARACTER OF THE EXANTHEMATA.
same, the balance of life among those who suffer most by these dis-
eases would naturally remain the same, so far as this cla<*s of causes is
concerned, supposing them to prevail with equal fatality at all times.
But other elements must enter into the calculation. The diminution in
the number of victims of small pox and the increase of mortality by the
other exanthems, at any particular period, will be governed also to a
certain extent by the absence of epidemic prevalence of the former, and
the existence of such a prevalence of the latter. It is, therefore, neces-
sary to examine the subject in several points of view, and also to extend
the investigation over a long succession of years, before conclusions
deser\nng of confidence can be reached. Even a limited view of the
subject would require more space than could with propriety be devoted
to it in this connexion, and we reluctantly dismiss it with this passing
notice.]
Dr. Haygarth once inquired what would be the pro-
bable effect of a complete annihilation of small pox.
He entertained some extravagant idea of effecting this
by a plan of universal inoculation. The result of the
calculation was, that in fifty years more than one eighth
would be added to the population. On a population of
sixteen millions (which we now nearly reach), the
increase in fifty years would therefore be two millions
and a half. In this calculation, the doctrine of vica-
rious mortaUty, though not left out of consideration,
was, it is plain, prodigiously underrated.
The general character of the exanthemata is derived
from the following sources : — 1. From the presence and
course of the accompanying constitutional disturbance.
2. From the course of the local or cutaneous affection.
3. From the law of universal susceptibility. 4. From
the law of non-recurrence. 5. From the law of con-
tagious origin. 6. From the law of epidemic diffusion.
Fever, eruption, universal susceptibility, non-recurrence,
contagion, epidemic diffusion — these are the topics
CHARAOTER 01* THE EXARTBEHATA.
which in the course of this and the succeeding leclure
are to occupy our thoughts. They will be found to
involve a great variety of ioiportaut and some very
carious considerations, ail equally necessary to a due
understanding of the exantliomata.
]. The exantlieniata are usually described as fevers
to which eruption is essentially linked. The old
authors used ihe phrases febris variolosa, febris ruheo-
losa, febris anginosa, and eryslpelatosa, wheu speaking
of these disorders. As the doctrines of fever have not
yet been formally explained to you, I may premise that
by fever we mean a general disturbance of the whole
system, affecting principally the heart, lungs, brain, and
secreting organs, but extending, more or less, to every
structure and function of the body. The four leading
features of fever are — 1. Rigors, succeeded by or alter-
nating with flnslios. 2. Frequency of pulse. 3. Las-
situde and debility. 1. Diminished and depraved
secretion. Wheu a man has a hot skin, a frequent
pulse, a furred tongue, and a feeling of weariness, we
say that he has an attack of fever. The lesser symp-
toms are, restlessness, disturbed dreams, wandering
pains, especially of the back aud limbs, tlnrsr, and loss
of appetite.
Fever is of several kinds, types, or characters. We
distinguish four great types of fever, the inflaunnatory,
the nervous, the gastric, and the malignant, in which
respectively the heart, the brain, the intestinal canal,
and the blood itself are more directly and severely im-
plicated. The true character of exauthematons fever is
innammatory. This it exhibits in nineteen twentieths
of the cases of small pox and measles. The low or
nervous form offerer occasionally characterizes scarla-
J
12 EXANTHEMATOUS FEVER.
tina and erysipelas. The putrid, petechial, or malignant
form of fever is occasionally witnessed both in small
pox and scarlatina. In these cases the blood is literally
poisoned. It loses its ordinary powers of coagulation,
bursts through its containing vessels, and appears in the
form of petechiae and haemorrhages. It is a curious
circumstance that the vaccine poison, mild as it is to
the greater number of mankind, may yet in the same
manner poison the blood. I have lately attended a
case of petechial cow pox — an occurrence hitherto
unrecorded. It is far from an improbable supposition,
that in the worst of these cases the vitality of the blood
is actually destroyed, and that death takes place in
consequence of the circulation of blood, the vital pro-
perties of which are extinct.
Exantliematous fever is divided into stages. I shall
have to speak to you of four stages — the incubative,
eruptive, maturative, and secondary. The incubative
stage, commonly called the period of breeding, is of two
kinds, the silent and the overt ; that is, it is sometimes
attended, sometimes unattended by symptoms. The
processes of eruption and maturation have Ukewise their
respective fevers, called the eruptive and maturative
fever. The term secondary fever expresses that renewal
or exacerbation of febrile vsymptoms which happens
when the specific fever ought, normally, to subside. It
is commonly applied to small pox, but I shall have
occasion to show you that each exanthema has its stage
of secondary fever, characterized by a certain group of
symptoms. Here we trace another important bond of
connexion among the exanthemata.
Nothing is more striking than to witness the uni-
formity in the character of exanthematous fever, under
rra dhiformitt and stkadinebs. 13
every possible variety of external circumstHiice. Neither
age, seasop. climate, nor habit of body, affects materiaUy
the phenomena of small pos and measles. The
description of the exanthemata handed down to us from
the Arabians, corresponds perfectly wiili the appear-
ances which we now witness: tlie European and the
negro, the infant and the aged man, the strong and the
feeble, suffer alike. The chief modifications of exanihe-
niatoHs fever are the result either of idiosyncrasy or of
a habit of body artificially engendered.
The peculiarly steady conrse of exanthematous fever
enables us to predict the result, or, as wc commonly
say, to prognosticate, in eruptive fevers, with a certainty
which it is not permitted us to do in any otiier tribe of
diseases. Even the nurses at the Small Pox Hospital
are rarely deceived.
The notion that "fever precedes the specific action
of the exanthematous poisons" has prevailed iu ail ages,
and still iiolds its ground. You will find this doctrine
distinctl)- laid down in I'r. Williams's work on the
morbid poisons. He calls fever the primary effect of
the pobon; affection of the skin and mucous mem-
branes he calls the secondary effect of the poison ; and
the inllammation of internal organs its tertiary effect.
Having mentioned the work of Dr. Williams,* senior
physician of this hospital, I should be doing injustice to
my own feelings were I not to say that, in my judgment,
it is the best specimen of elaborate research, of lucid
and terse description, and of sound patholog)', which
has appeared in this country — honorable aUke to the
author, to this hospital, and to the age in which we
■ Elctnenu of Mcdiolne. Od Morbid Puisona. By Roborl WilUimt, H.D.
London, lUil. S toI«. Bvo.
14 FEVER NOT ESSENTIAL TO EXANTHEMA.
live. It is a work, which better than any other that I
know, portrays the style of reasoning on matters of
patholopjy prevailing in this country at this time, and as
such will be quoted in after ages. It should be in the
hands, not of the student, for he cannot appreciate its
merit, but of every practitioner in this country, who will
find in it rich stores of curious anecdote and useful
instruction.
High as the authority of Dr. Williams is, I shall
occasionally venture to dissent from him, and shall do
so on the present occasion. Dr. Williams, I have told
you, upholds the ancient maxim that fever precedes the
specific action of exanthematic poisons. The doctrine
that I teach you, however, is, that exanthema may take
place without fever, that the febrile state is not essential
to the development of exanthem. For observe,— cow
pox, varicella, inoculated small pox, and the mildest
type of scarlatina, frequently display themselves without
initiatory, without eruptive, nay, even without matura-
tive fever. But further, I shall have occasion to show
you, that the less the amount of fever the more perfectly
is the eruption developed, and the more normal is the
course of the disease. Any tunmltuous febrile action
disturbs the regular progress of an exanthem. Witness
scarlatina with excessive angina. There is here literally
no eruption at all. We call the complaint angina
maligna. Witness the recession of the eruption in
malignant measles. Witness the ill-developed eruption
of petechial small pox. This consideration is strictly
practical. It shows the extreme folly of the old notion,
that raising a fever by means of w^arm baths, heated
rooms, and cordial alexipharmics, promoted eruption.
It shows you the merits of Sydenham and of Sutton,
BTMMETRT OF BXANTHBMATA.
who, in consecutive centuries, did so mncli to improve
the practice in small pox. It shows )oti that the
violeuce of initiatory fever must often be subdued by
active purgatives, by leeches, or even by venesection,
to give the disease any chauce of running a safe course.
As. then, there may be eruption without fever, the
question may reasonably be asked — May there not be
the specific fever of an exanthematous poison without
eruption ! Has a man ever gone through small pox
and measles without exhibiting eruption 1 In all ages
this doctrine has obtained some supporters. Sydenham
encouraged the notion that in epidemic years a variolous
fever was to be met with whicli showed no eruption.
Burserius, Vogel, Dellaen, Frank, Hedland, and others,
have, in later times, avowed their belief in this Irish
mode of undergoing small pox. Some couuteuance is
given to the doctrine by the phenomena of cynanche
maligna, but it is very questionable pathology, %\hich I
cannot undertake to advocate.
[Dr. Watson ngrves in opinion wilb onr author on the subject of the
''variola sine variolis." (Pniet. Phytic, 3d edit. 147, p. 670.) Bui a
recfiit epidemic of ineasli* iti Pnris Bi'<^in« lo hnve natisficil iIiosb wlio
observed it as to tlie occurrence of Uie constitutional Bymptoioa of lie
dise&so without the eruption.]
2. T he second character of the exanthemata is
derived from the presence of eruption. Here 1 must
advert, for a few moments, to a doctrine recenUy brought
forward under the title of the symmetry of diseased
action; by which is understood the fact, that in disease
both sides of the body are affected alike. This doctrine
always reminds me of the Unes on Dutch gardening,
where
Grote nods At grove, ench al!-;y has its bruthur,
And half the garden just reflects the other.
16 SYMMETRY OF EXANTHEMATOU8 ERUPTION.
In the case of this symmetrical disposition of disease,
we are all, I suspect, pretty much in the same state as
the Bourgeois Gentilhomme, who found out that he had
been speaking prose all his life without knowing it. We
knew the facts, but we had never reasoned concerning
them. The chief illustrations of the symmetry of disease
are to be found in the phenomena of rheumatism, in the
mode of decay of the teeth, in the growth of certain
tumors ; but, better than all, in the aspect of exanthe-
matic eruption. In the corymbose form of small pox,
the patches, or corymbi, will be found to correspond
on the two sides of the body in the most singular man-
ner. Once I had a patient at the Small Pox Hospital,
who exhibited confluence in the highest possible degree
on each hand and wrist, but in no other part of her
body.
[For striking illustrations of the symmetrical arrangement which
patches of eruption assume, with many curious facts and much ingenious
reasoning on the subject, see Paper on the subject by Mr. Jame^s Pfiget,
and esj)eciaily a more extended one by Dr. William Budd, in Medico-
Chirurg. Transactions^ vol. 25.]
In all the exanthemata, the parts of the body nearest
the centre of circulation are more affected than those at
a distance. This is strikingly exempHfied in the erup-
tion of post-vaccine small pox, which is often confluent
on the face, and wholly undeveloped on the extremities.
In general, the distinctive characters of exanthema-
tous eruption are strongly marked, but difficulties in
diagnosis do occur. Small pox is sometimes mistaken
for chicken pox. Measles is not always readily distin-
guished from lichen.
When the exantliemata first invaded the world, their
identity was universally beUeved. Rhazes and Avi-
EXAKTHBMATIC IDENTITY.
cenna taught that small pox and measles were the same
disease. Kven so late as 1640 this doctrine prevailed
all over Europe. Measles atid scarlatina continued to
be confounded until about one hundred years ago ; nor
has the bias in favor of exantheinatic identity, which
our ancestors displayed, altogether subsided. Dr.
Thomson, of Edinburgh, labored to prove that chicken
pox is identical with small pox. Dr. Baron, Mr. Ceely,
and others, who would be justly offended by the impu-
tation of confounding scarlatina with measles, or measles
with small pox, contend nevertheless strenuously for the
identity of small pox and cow pox.
That the disorders termed exanthemata bear a cer-
tain pathological relatioo to each other cannot be
denied, but this principle is probably not more applica-
ble to siuall pox aud cow pox thau it is to small pox
aud measles, to small pox aud chicken pox, to measles
and scarlet fever. The epoch of the dilTusion of small
pox and measles gives a certain countenance to such a
doctriuc. The relationsliip may possibly consist in
some modification of the elements which compose the
morbid miasm, and may be analogous to that which
subsists between the nitrous oxyde, the nitrous acid, and
the nitric acid. Such a relationship, however, if admit-
ted, is very different from the absolute idpullly for
which Dr. Thomson and Dr. Baron contend.
Nothing certaiu is known regarding the primary
sources of the exanthematic poisons. The analogy of
cow pox would lead us to conjecture that all (I mean
the variolous, rnbeotous, and scarlatina!) were originally
derived from cattle. Such an idea was entertained long
before the discovery of vaccination. Dr. Layard, in
1780, distinctly avowed his belief that the lues bovilla
18 LAW OF SUSPENSION.
was of the same nature as small pox. Navier (a French
author), in 1753, traced the relation subsisting between
scaflatina and the distemper of homed cattle, and came
to the conclusion that scarlet fever was origmally com-
municated from cattle to man.
In some cases the body receives at one and the same
moment the germs or miasms of two exanthemata, and
though they occasionally proceed pari passu, the more
usual law is that of suspension. Generally the lesser
exanthem is suspended by the greater. Measles is sus-
pended by small pox. Cow pox is held in abeyance by
measles ; but instances of the reverse proceeding are on
record.
[For cases illustrating the co-existence of two febrile exanthcroala
in the same individual, and the 8US{>ension of one by another, Bee
Apj>endix C]
The connexion of exanthernatous eruption with a
Uke affection of those mucous expansions or tissues
which are in contact with the atmospheric air, and
exposed to its direct influences, claims your especial
attention. It is a feature in the eruptive fevers of the
highest importance both in theory and practice. A
V reason may be found for this connexion in the similarity
of the structure and offices of skin and nmcous mem-
brane. The epithelium of the one corresponds with
the epidermis of the other. The result is, that all such
mucous membranes are susceptible of the changes of
efllorescence, papula, vesicle, and pustule. Small pox,
measles, and scarlatina, alike exhibit, in their early
stages, affection of mucous surfaces, — either of the nose,
month, fauces, larynx, or trachea. Erysipelas some-
times betrays the same tendency, and this strong dispo-
sition of the morbid poisons to affect the throat is still
BEOONDARV AFFECTIONS. 19
further exemplified in the pheuomena of hydrophobia
and lues venerea.
In some cases, the akin receives the whole violence
of the poison ; sometimes the mucous membrane to the
exclusion of the skin ; and in a third set of cases, both
structures suffer. The blood, too, may be primarily
afl'ected by the poison, even before the developmeat of
fever (illustrating the principle, that the eruptive nisus
is independeut of fever). But other organs occasion-
ally suffer, when the miasm is very virulent, or the
body in an unhealthy slate. Here we trace an import-
ant bond of connexion between the eruptive and other
kinds of fever.
[In vAriola, rubeola, and Karlatina, Andral and Gavarret found the
composition of (he blood very similar to what it is in continued fever.
Some analyses gave negative results, while in others the tendency of the
blood wa9 mora towards hyperinosis than hypinoais.
The maximura of fibrin amounts to only 4.4, against which there ia
a miiiimum of 1.1. In ihe majority of cnsea, it does not difibr much
from Lveanu's normal average 3.
The blood eorpnscles are increased in a l^s degree in variola and vario-
loid, tbmi in scarlatina and rnbeoU. (Simon's Vhetnislri/, vol. i. 298.)
Andral says that he has never met wiUi the bufl| unleaa there was
some phli?gmasinl complication, either in inflammatory fever, in slight or
severe typhoid fever, in measles, in scarlatina, or in variola. (PaOiolog.
Hamaloloyij — translated by Drs. Meigs and StiUfe, p. 50.)]
In typhus fever, rheumatic fever, and remittent fever,
we observe the implication of internal structures.
These most serious aggravations of eruptive malady,
whether denominated secondary or tertiary, may occar
at all periods of the exantheni. They may accompany
the first burst of eruption ; — they may develope them-
selves gradually during the niaturative stage, or period
of concoction, hut they prevail chiefly towards the
t
20 SECONDARY AFFECTIONS.
decline of the disorder, and in the course of secondary
fever.
I know of no exanthem which does not show
secondary complications, no organ or structure which
may not thus be dragged, as it were, into participation
with the primary malady.
In small pox we see the eye, the salivary glands, the
brain, the pleura so affected. In measles we see the
lungs, the larynx, and the mucous membrane of the
bowels, secondarily affected. In scarlet fever the variety
is still greater. The eye, the ear, the heart, the liver,
the kidney, and the peritoneal surface of the bowels,
are each, in their turn, the seat of superadded disorder.
In certain cases, the morbid poison acts as directly on
these internal structures as it does upon the skin ; but
this is not a normal course of exanthematous disorder.
The brain is especially liable to suffer in small pox,
the lungs in measles, and the kidney in scarlet fever.
When we consider the peculiar offices of the kidney
and skin, we shall be at no loss to account for the
implication of the kidney in a disease which suspends
the function of the skin so completely as does scarlatina.
Some of these internal complications, or superadditions
to exanthematous malady, are explicable on other prin-
ciples, especially those which occur after the climax or
crisis ; when the virulence of the poison has, for the
most part, expended itself. Thus, some are attributable
to season, some to plethora, some to local weakness,
the legacy of a prior ailment ; some to the coincidence
of a typhoid or hospital miasm. The theory of a few
cases must be sought for yet deeper, and may be found
in that obscure law of the animal economy which, in
other diseases, probably through the medium of the
veins, tends to the formation of purulent depots.
VARIETY IN THE COMPLICATIONS. 21
k
These secondary or superadded effects of the poison
vary very much in violence. The pleuritic complica-
tion in the secondary fever of small-pox, the pneumonia
consecutive of measles, and the dropsy supervening in
the latter stages of scarlatina, absorb every other con-
sideration, and prove, in themselves, the direct causes
of death. But other affections of the surface may take
place besides the specific affection belonging to the
miasm. Thus we may have small-pox followed by
scarlatina — measles by erysipelas and gangrene — scar-
latina by phlegmasia dolens. Some complications,
again, are purely accidental, and this happens much
more frequently in adult than in infantile life. In
infancy the exanthemata occur for the most part uncom-
plicated ; but as life advances, the probability increases
of some accidental complication. Thus, for instance,
small pox in the adult may be complicated with apo-
plexy ; measles with phthisis; scarlatina with pregnancy.
In infancy we sometimes meet with hooping cough
complicating and thereby aggravating each of the erup-
tive fevers. Painful dentition, in like manner, may be
superadded to exanthematic disease, and contribute its
share to the sufferings of the patient, and the result of
the malady.
LECTURE 11.
CHARACTER AND MANAGEMENT OF THE ERUPTIVE
FEVERS.
Law of universal susceptibility. Law of non-recurrence. Exceptions to
this law. Of contagion. Miasm or morbid poison. Modes of its access
to the body. Inoculation. Theory of Zymosis. Absence of predispos-
ing causes. OfFomitea. Quarantine. Epidemic diffusion. Theories of
epidemic influence. Laws of epidemic visitation. Management of the
Exanthemata— during the period of invasion — of maturation and decline.
Ineiiicacy of tonics in the secondary fever of the Exanthemata.
Employment of saline diaphoretics — of opiates. Influence of medicine
generally on the course of eruptive fevers.
The eraptive fevers derive their third character from
the law of universal susceptibility.
No principle is more generally recognised than that
small pox and measles necessarily and unavoidably
occur to every man once in the course of life. The
notion can be traced back even to the Arabians. Avi-
cenna distinctly announces the fact, and strives to
account for it Willis says, that the escape of a man
living to the ordinary period of human Hfe from small
pox and measles, is as rare as the falling into them
twice. Both the one and the other he describes as
vara et intcsitata eventa, Diemerbroeck is the only
author I know who distrusted the doctrine of universal
susceptibility, and he was doubtless influenced by the
fact that he himself reached the age of seventy without
ever experiencing an attack of small pox, though so
continually exposed to the contagion. In the palmy
days of inoculation, it was found that very few chil-
dren were permanently unsusceptible, though, of course.
LAW OP CirrvERSAL SUacEPtlBILlTY. 23
from temporary causes, the operation occasiouall}' failed
of saccess. Dr. WoodviQe, my predecessor at the
Small Pox Hospital, estimated the proportion of unsus-
ceptible children at one out of sixty. The proportion
of unsusceptible adults was consiilerablj higher, perhaps
one in twenty.
There are still some countries in the world not yet
visited by the exanthemata. Small pox, measles, and
scarlet fever, are to tliis day unknown in Australia and
Van Diemen's Land.
All the exanthemata have sprung up since tlie com-
mencement of the sixth century. The dates of the first
appearance of each exanthem will be duly investigated,
as constituting an interesting branch of medical chro-
nology. That a "nova febrium cohors" should thus
invade the earth need not surprise us when we reflect
that, within our own times, two have started into exist-
ence — Vaccinia and Asiatic Cholera, — the mildest and
the most malignant of human maladies, the Alpha and
the Omega in the catalogue of nmrbid poisons. How
many more of what Gray describes as
"The painful fumily of deatb.
More Lideous Uiaa tlieir queen,"
lie concealed in the womb of time it is not for us to
say, hut we may reasonably conjecture from what we
know of the origin and succession of epidemic mala-
dies, that nature has not yet exhausted her store of
wide-wasting pestilences, and that others remain to
afford occupation for the pathologists and physicians of
succeeding ages.
The fourth peculiarity of the exanthemata is derived
from the law of non-recurrence. It was formerly held
24 LAW OF NON-RECURRENCE.
that scarce any one had small pox or measles a second
time. This doctrine was sedulously inculcated during
the greater part of the last century, when the philan-
thropic mind was laboring to encourage the practice of
inoculation.
Dr. Mead of London, the elder Monro of Edinburgh
(two of the best practical physicians of the last century),
doubted the possibility of small pox recurring. De
Haen, De la Condamine, and Dr. Heberden, spoke of
it as a possible but most unusual event. Times are
changed. Vaccination has taken the place of inocula-
tion, and now, to screen the obvious defects in the pro-
tective power of the cow pox, pathologists have wheeled
round, and many, in their zeal, would fain persuade us
that the recurrence both of small pox and of measles is
far more frequent than our forefathers were willing to
admit The friends of vaccination, says Dr. Baron,*
were compelled to prove that the small pox occurred a
second time, and in so doing were accused of drawing
upon their imagination. To determine the truth in a
matter of such interest may profitably employ a few
minutes of our time.
Imnmnity from second attacks of the same disease is
a very extended and a very important principle in
pathology. It does not merely apply (as the world
would have us to believe) to small pox, measles, and
hooping cough, but to all diseases whatever which origin-
ate from a poison or miasm — which are, as we say, of
miasmatic origin. It belongs, therefore, to scarlet fever,
yellow fever, typhus fever, and Egyptian plague. It
belongs, in a certain limited degree, to fevers of paludal,
terrestrial, or, as we sometimes say, of endemic origin —
* Baron's Life of Jenner, vol. i. p. 226.
ORIGIN FKOM CONTAGION.
that is, to ague and remitting fever ; for ibese fevers are
curable while the patient is still resident in the
unhealthy locality, and a certain time elapses before the
constitution is susceptible of a second seizure. So also
with gout and rheuniatisni, fevers of internal origin. It
is well known that these diseases recur again and
again, and at length rivet themseivcs on tlie system.
Nevertheless, we congratulate a friend, with perfect
justice, when we hear tliat he has had a fit of the gout,
because we feel sure that for a certain time he will be
free from similar attacks. In all cases, therefore, the
susceptibility of a disease is more or less exhausted fay
once undergoing it, A gradation in this respect may
easily be traced from rheumatism and gout (where the
law obtains least) through ague and every variety of
endemic fever, whether remittent or continued, up to
plague, scarlet fever, typhus, yellow fever, measles, and
small pox. The law of non-recurrence is more strik-
ingly displayed in measles and small pox than in any
other known disorder. Nevertheless, exceptions occur
even here, of which due mention will be made in future
parts of the course.
We now approach the fifth characteristic of the
exanthemata — contagious origin.
The diseases of tlie human body arc divisible into
two great classes — those of constitutional and tiiose of
accidental origin. This distinction is very obvious in
surgery. Cancer, fungus haematodes, stone in the
bladder, white swellings, psoas abscess, aneurisms, — all
arise from internal causes, and are of constitutional
origin Again, fractures, dislocations, sprains, wounds,
bums, scalds, and contusions, are the result of external
and accidental causes. In a community where there
26 ACCESS OF CONTAGION TO BODY.
were no railroads, no runaway horses, no high scaffold-
ings, no deep mines, no cotton mills, and no careless
servants, a sui^eon might practise for many years
without ever meeting with any disorders but those of
constitutional origin.
Now the same distinction holds good in physic.
There are medical as well as surgical accidents. Drop-
sies, inflammations, haemorrhages, apoplexy, palsy, and
jaundice, are all constitutional maladies, arising from
such internal causes as the following : — Advancing age,
scrofula, original weakness of constitution, the gouty or
rheumatic diathesis imprinted on the individual at birth
and descending to him from his parents.
The second class of medical disorders are those of
accidental origin — the results of overfeeding, of intem-
perance, of exposure to cold, of excessive fatigue, but
above all, of those deleterious agents received into the
body from without, which we call miasms or poisons.
The most interesting disorders belonging to this class
are the exanthemata ; but, besides them, we enumerate,
as associated with them, the venereal disease, gonor-
rhoea, hydrophobia, hooping cough, plague, and some
others of lesser moment These all originate from the
miasms of an animal body laboring under disease, and
we therefore call them the true morbid poisons. Ague,
remittent fever, dysentery, and cholera, arise from ter-
restrial miasm. In Dr. Williams's work, however, you
will find all these diseases treated of under the general
appellation of the " morbid poisons !'
The contagion, infective miasm, or materies morbid
obtains access to the human body in three modes. First,
by the inhalation of air tainted by the breath or perspi-
ration of a patient. This is called the mode of infec-
INOCULATIO^.
tioD. Small pox, measles, plague, typhus, scarlatina,
and erysipelas, are thus comumnicatcA Experiments
have been made to determine the limit of infective
distance, but nothing very satisfactory is known con-
cerning it. It probably varies from a few feel to many
yards.
2, Miasms gain access to the body, secondly, by solu-
tion in the fluids, or humors, and subsequent appUcalion
to the unbroken surface. It is thus that psora, tinea
capitis, gonorrhoea, and the venereal disease, arc com-
municated from man to man. We call this mode
contagion, "a cff«/«c/« corporis." Remember that the
matericsmorhi must be dissolved. " Corpora non agunt
nisi solula," was a dogma of the old chemists. It is
equally true of the animal body. Fluidity is essential
to all the great processes going on witliin the animal
economy, a principle which those who vaccinate from
points and glasses are very apt to forget. The germ of
disease is conveyed in the fluid form in the interior of
the frame, where it mixes with and taints the blood, the
most complex, the most perfect, and the most essential
to life of all the animal fluids.
Strongly impressed with the importance of these
tilings, the ancient physicians professed themselves
humoral pathologists, and the current of modern disco-
very is running rapidly into the same channel. Witness
the importance attached to the condition of the urine in
disease, and observe with what interest all microscopical
observations on the blood and its secretions are now
received.
3. Certain of the morbid poisons are not admitted
into the frame unless (srill after solution in the animal
fluids) they are applied to an abraded or wounded sur-
28 INOCULATION.
face. Hydrophobia, vaccinia, and farcinoma (or glan-
ders), are received in tliis mode. Small pox and plague
may thus be excited artificially, and the process is, as
you know, called inoculation.
One of those curious points in pathology which is
now attracting the attention of Continental physicians,
is the direct communication of disease by means of the
blood, and not by the secretion derived from the blood.
It is very reasonable to suppose that such may be the
law of nature. All infection is probably direct from the
blood. The injection of the blood of a glandered horse
into the veins of a healthy horse communicates that
disorder. Measles has been communicated by inocula-
tion with the blood in so many instances, and by so
many experimenters, and recently in the Austrian terri-
tories on so large a scale, that no doubt can exist as to
the possibility of thus exciting the disease. I have often
noticed that if the vaccine vesicle be punctured so deeply
as to bleed, the lymph is equally effective as when per-
fectly colorless and pure. All these things point to an
important principle — the direct communication of dis-
ease by means of the blood. Whether the resulting
disorder be thereby rendered milder, as in the ordinary
process of inoculation from secreted humor, or not, is a
question for our future consideration.
Each specific miasm has its respective laws — its
period of latency, of development, and of decline. With
reference to the period of incubation, the morbid miasms
are divisible into three classes : —
1. Those of rapid incubation — viz., chicken pox,
plague, scarlatina, and gonorrhoea. In these instances
the latent period is less than a week.
2. Those of mature incubation, the period extending
THEORY OF ZYMOSIS.
from ten to fourteen days. In this class come small
pox, measles, and hoo^iiiig cougli.
3. Those of ;firfio«.s incubation (extending from fonr
to six weeks). In this class we place hydrophobia,
secondary syphilis, and endeniial remittent
From the earliest period at which the existence of
morhid poisons became known, the analogy of vegetable
formentatiou has been adduced to explain their 7/wdtts
oj}erandi. Tiie doctrine of a fermentative process going
on during the incubation of small pox and measles, was
distinctly announced hy Sydenham, Willis. Dienier-
broeck, and Morton, Liebig has lately ^ven increased
interest to this portion of pathology, hy reviving the
hypothesis of fermentation, and investing it with a sci-
entific character. " The phenomena attending the
transformation of organic vegetable compounds afford,"
he says. " not merely an analogy, bnt a correct explana-
tion of the changes taking place in tlie animal economy
by the agency of morbid poisons." Nothing, however,
can be clearer than that in this notion, whether correct
or not, Liebig is anticipated by Diemerbroeck, who
flourished two htmdred years ago. " Out of an infected
body," says he, " flow forth continual streams, which,
being received by other bodies, presently feniient with
the blood, and excite the latent and homogeneous seeds
of the same distemper, disposing them into tlie idea or
character of the same disease."
Mr. Farr, in his fourth report, recently submitted to
parliament, proposes to call all those diseases which
have the properly of comnmuicating their own action,
and eflbcting analogous transformations, zymotic dis-
eases (from ^uf"^. to ferment), and the action itself)
zymosis. Zymotic diseases will comprehend all those
30 QUARANTINE.
now associated by the tedious periphrasis of " epidemic,
endemic, and contagious maladies." The terms appear
to me to be judiciously chosen, and I shall employ
them in these lectures. Zymosis, you will remember,
is applied to a process of the aniinal economy ; fer-
mentation to the mutual action of vegetable principles.
One very remarkable character of the zymotic
miasms is, that they operate upon the healthy body
without the aid of predisposing causes. A man in the
most perfect health contracts small pox or measles, and
this state of body is the best possible for insuring the
success of inoculation and vaccination. Almost all
cases of vaccination which progress unfavorably, may
be traced to some previously unhealthy condition of
the humors or secretions. A characteristic feature,
then, of the exanthemata is ''absence of predisposing
causes^
All miasms of animal origin are capable of attaching
themselves to fomites, and (provided they be excluded
from the air) of retaining their communicating property
for a considerable length of time. This great law of
nature is the foundation of that important practical
measure — quarantine. It is a law of universal applica-
tion. Tinea capitis spreads by means of hats, combs,
and brushes ; Egyptian ophthalmia by towels and
sponges ; small pox and typhus by clothes and bedding ;
plague by personal apparel and old rags. Some would
persuade us that merchandise, which, ex necessitate ret,
could never have been near the chambers of the sick, or
handled by others than by men in health, may also com-
municate contagion ; but I believe this doctrine to be
opposed to every principle in sound pathology.
Reasoning chiefly from the well established fact that
QUARANTIHE. 31
medical men very seldom communicate the seeds of
disease, Dr. Ha^'garlh discredited the doctrlno of com-
munication by fomites. That fact, though it will not
hear out Haygarth in his speculations, sufficiently proves
how exceedingly volatile contagious miasms are, and
how short an exposure to the air deprives ihem of
noxious quality. The term of forty days, originally
judged necessary for the security of the community, is
founded on utter ignorance of the laws of morbid poi-
sons. As the incubative stage of plague never exceeds
seven days, so one week of quarantine is, in strictness,
sufficient, and two weeks should satisfy the uioi-t scru-
pulous auxiety.
[The CommissioD of the French Academy of Modicinc, apiwintej in
1844 to report on the subject of Plague and Quaranlitiea, say that at n
distance from countries where it is endemic, and IwyorKl or iiuay from
epidemic fwi, the pliigue has ne»er broken out in i>ersoiiFi who Lave
been exposed to its influence after an isolation of eight Jiiys.]
The period of quarantine, too, may safely commence
from the departure of tlie ship from the suspected port.
This great improveuient in commercial intercourse is
now sanctioned by the British Government.
You will lake notice, that all fomites or harborers ol
contagion are substances of a rough surface or downy
texture. Wool, cotton, leather, every kind of apparel,
the dust accumulated on walls, floors, and ceilings, are
those against which it behoves you to be most on your
guard. By universal consent it is admitted that money
and ail metallic substances are incapable of harboring
contagion.
6. The sixth and last character of the exanthemau
is drawn from their occurrence as epidemics. This
term is derived from the Greek words .=«■ and Jr,pc, and
32 THEORY OF EPIDEMIC INFLUENCE.
simply expresses the fact of the spreading of a disease
among the people without reference to the precise fnode
of communication. Some diseases therefore are conta-
gious but not epidemic, as ophthahnia, gonorrlioea, and
porrigo. Some are epidemic but not contagious, as
catarrh, diarrhoea, and pneumonia.
Lastly, some diseases are botli epidemic and con-
tagious, as small pox, measles, scarlet fever, typhus
fever, plague, and probably also cholera. These are the
diseases which, rising occasionally like a mist out of
the earth, shed desolation on nations, to disappear as
rapidly and insensibly as they arose. The origin of all
such disorders is necessarily obscure, but the obscurity
has proved no stumbling-block in the path of medical
theorists. In ancient times their appearance was attri-
buted to the direct agency or influence of the sun, moon,
and stars (whence the term injluenza, applied to the
least energetic among them). Sydenham connected
them with some supposed movements going on below
the earth's surface, in ipsis terne visceribus. Some
modern pathologists attribute them to the condition of
the surface itself; some find, or pretend to find, their
source in mysterious changes of the atmosphere ; others
in heat, imperfect ventilation, or some bad quality of
food. Dr. Holland looks with favor on the animalcular
origin of epidemic maladies, while Diemerbroeck can-
didly avows his belief that this is one of those mysteries
which nature for ever intends to keep to herself.
The present most approved theory of epidemic
influence attributes everything to the atmosphere, but
neither the thermometer, nor the barometer, nor the
hygrometer, nor the electrometer, aids us in our re-
searches. The best prospect of attaining to truth in
EPIDBHIO INFLUENCE.
this recondite branch of pathology is afforded by the
increasing fondness for statistical researches. Their
improvement and extension to eastern countries, where
all wide-spreading epidemics seem to originate, may
perhaps discover order where all is now confusion and
vague conjecture.
Seven maladies are acknowledged on all hands as
genuine epidemics. These are Small Pox, MEAaLEs,
Scarlet Fever, Hooping Cough, Typhus, Cholera,
and Influenza. The Registrar-General of England
admits, in his Statistical Reports, four other disorders
into the category of epidemics, namely : — croup, thrush,
diarrhoea, and dysentery. Their claims to this distinc-
tion are not, however, so generally conceded. At any
rate, on the same grounds, pneumonia might lay claim
to the title of an epidemic.
Although we make no pretensions to a knowledge
of the ultimate cause of epidemic visitation, yet there
are certain laws, having reference to the diffusioa of
epidemics, which are sufficiently established.
It is seldom lliat two diseases are epidemic at the
same time in the same district When the yellow
fever raged with such violence at Gibraltar in 1804, it
was remarked that all other diseases declined ; and well
they might, for in that fatal epidemic, out of a civil
populatiou of 14,000 persons, 28 only escaped an attack.
We may hence learu why, during the presence of an
epidemic which proves fatal at a high per centage, the
sum total of annual mortaUty is often not sensibly
augmented. The reason is obvious. Other diseases
fall off, and if men die of cholera, or children of small
pox, they are not left to be ihe prey of pneumonia or of
hydrocephalus, of asthma or of croup.
34 EPIDEMIC VISITATION.
There are some exceptions to the law that only one
epidemic can rage at one and the same time. In 1839,
both small pox and measles were epidemic in England
and Wales.
. [Small pox and scaiiet feTer were both epidemic in New York in
1840, '41, '42, and '43 ; and in 1840 and '41 measles was also epi»
demic, so that the three diseases were epidemic together daring the two
last mentioned years.
Measles and small pox were also both epidemic in Philadelphia in
1828 and 1824; and in 1885, small pox, measles, and scarlet fever,
were all epidemic, as was also the case in 1845.
Measles and scarlet fever were both epidemic in Baltimore in 1887,
and small pox and scarlet fever in 1838, and again in 1845, in that ci^.]
^ On the succession of epidemic maladies we have as
yet no details that can be relied on, but this branch of
the subject invites inquiry, and promises results both
curious and useful. We may safely leave it in the
hands of Mr. Farr, whose laborious investigations have
already done so much to elucidate the truth, conducted
as they have been with great judgment, and guided by
sound views of pathology. The notion once enter-
tained of the recurrence of epidemics in cycles of five,
seven, or ten years, has been disproved by modem sta-
tistics, the cultivation of which will probably serve to
dispel many other long-established opinions, or rather
prejudices, in physic.
[Epidemic diseases seem to be more fatal among the uncivilized than
the civilized. In an epidemic of Rubeola among the Crees (a tribe of
North American Indians) in the summer of 1846, as reported by Dr.
Smellie {Monthly Journal of Medical Science^ December, 1846), in 145
cases treated in their camp, 40 were fatal.
Small poz bas sometimes swept off an entire tribe of Indians, as was
die case with the Mandans (another North American tribe), and has
been raging with great fatality among some other tribes of these Indiana
daring the past and present year.
EPIDEMIC VISITATION. 35
Thpse races aacrib© epidemics to spells exerted by their onemieM, or
regard litem as direct viditaLiona of the Great Spirit, and abattdou all
ho|>e of recovery as soon ae attacked,
They seem also to differ in the degree of their mortality among
blacka, small po>, meoBJes, and liooping cough, being more fklal to ibem
tiiati to wbilei, while scarlet fever would seem to ba more &(al to
In Chwleston (8. C), the mortality by small pox during the period
from 1S22 to 1848 ioclusive, was 49 among the white population and
154 among Uie blacks. Within the same period, 289 whites and 163
blaoka died with scarlet fever, and 45 whites and 97 blacks died with
nieaslee; and 100 whites and 257 blacks with hooping cough, — the
population of the whites being 12,828, and of the blacks 17,461, in
1830; and 13,000 whiles, to 16,200 blacks, in 1840. (Cmsut of
Charlalmt, by Drs. Dawson and De Saussure. 184D.)]
It iias always been observed that epidemics are unu-
sually severe when they first appear in any counlry, or
are renewed after any long interval of time. When
cholera first invaded Jndia, in 1817, it raged with an
intensity which may have been equalled, but never has
been surpassed. When the cynauche maligna first in-
vaded Naples, in 1618, — when small pox first appeared
in America (1518), — when the putrid sore throat first
invaded America in 1735, and London in 1747, — the
ravages of each disorder were terrific. It seems, then, to
be a law of the animal economy, that the susceptibility
to any morbid poison is great in proportion as it has
been Uttle accustomed to the impression.
[These diseases bare different modifications in the same places in dif-
fereut y^iun, and also different modificatioufl in different place* Uie home
year.
On examination of the tables in the Appendix, it will be s^n that
durinc; the five years from 18-18 to 1812 inclusive, the pro|H>rtk>n of
deaths by scarlet fever to the whole mortiility, was that of one to about'
thirty (2D, 87) in London, and one to twenty-five in New York ; while
tho propordoD of deaths by the four epidemic diseaseG together, was thak
38 IXAIITHEMATIO DEBILITY.
developed ; but you are not to set this down as an uni-
versal law. The truth is, not many of the exanthemata
last long enough to induce real debility. What men
call debility is, in nine cases out of ten, secondary fever.
If the theory of debility be adopted, and beef tea, wine»
bark, and tonic medicines, be administered, you feed
the fever, and make bad worse. Not long ago, I saw
peritoneal inflammation occasioned by acting on this
false notion of exanthematic debility. Secondary fevers
must be reduced, like other fevers, by purgatives, diure-
tics, and low diet. You cannot safely stimulate in
secondary fever.
To no disease does this principle apply more strongly
than to scarlet fever. I have seen this exanthem fol-
lowed by true debility ; but febrile or apparent debility
is far more common. The circumstances which indi-
cate real debility in the several exanthemata will be
mentioned hereafter.
Much of what applies to the treatment of common
fever applies also to the exanthemata. These points
will be more fully detailed to you hereafter ; but I may
select two general principles as illustrative of my mean-
ing:—
1. One of the chief features of fever, both in a theo-
retical and practical aspect, is the general diminution
of secretion observable all over the body. The secre-
tions of the mouth, the stomach, the mucous membrane
of the intestines, the kidney, the Uver, and the skin, are
alike checked during the presence of fever. Whatever
therefore encourages secretion aids and assists in the
expulsion of fever. We employ, therefore, diuretics and
diaphoretics,— calomel, with James's powder, or the
antimonial powder, saUne draughts, saUne purgatives*
INFLUBNOE OP HIDICIHB.
jaiap with cream of tartar, senna with the sulphate of
magnesia.
2. On tlie very same principle, we avoid opiates as
far as possible, for all opiates confine the secretions.
Opium given to a man in health, per se, occasions a
state of ephemeral feverishness, like wine. Opium
locks up the bowels, diminishes the urine, causes (hirst
and a dry tongue. But it does more when the system
is already laboring under fever of any intensity. It then
disturbs the circulation very materially. It occasions,
or at least aggravates, congestion in the larger vessels,
whether in the head, chest, or belly. We often see
opium in fever producing piles. In all exanlhematous
fevers, therefore, let opium be avoided, or administered
with such correctives as this evU tendency of the medi-
cine nafurally suggests.
When all is done, you will not fail to remark how
small a proportion the strictly therapeutical and practical
parts of the course bear to the descriptive and patholo-
gical portions ; it will often remind you of Falstaff's
ka'porth of bread to his two gallouH of sack. Remem-
ber, however, that in the e.\act proportion in which wc
improve the two latter, we diminish not the importance,
but the extent, of the former. In the early periods of
medicine, when descriptions of disease were imperfect,
and pathology was in its infancy, and statistics were
unknown, physicians arrogated to themselves a power
of controlling, by drugs, the course of diseases (and
especially of exanthcmatic diseases), which we now
know to be wholly unwarranted. Pages and chapters
were devoted to objects quite unatlaiuable ; presenting,
indeed, an imposing, but a vain parade of learning. In
tliis respect we have improved upon our predecessors.
40 INFLUENCE OP MEDICINE.
We are not ashamed to acknowledge that many diseases
must ran their stated course, and that others will ran
their coarse, in defiance of all the efforts of medical skilL
In the management of the exanthemata, be satisfied
with steering the ship. Do not attempt to quell the
storm. Trophilus, an ancient Greek physician, being
asked who was the most perfect physician, replied, " He
who knows best how to distinguish that which can
from that which cannot be done."
EARLY HISTORY AND PHENOMENA OF SMALL POX.
PBslilenee of ProcopiuB. Firet nppearance of small po< in England anil
America. Of tlie sweating syateai. Introduction and progresH of inocu-
lalion. Abandonment of lliat procena. Of the period of incubulion Id
small pox. DiflgnoBU of the initiatoiy fever. Characters of the variolons
eruption. Maturativo stage. lmpli<ntion of the muroua membraneH.
Implication of the cellular membrane. Secondary fever, nod ita coune-
quences. Implication of the nenrous system. Of the petechial form of
small pox. Of Hmoll pox accompanied with ^ngrene, ophthalmia, and
affection of internal organs. Of the variolous pleurisy. Of the abdominal
complications. Appearances on dissection.
Small Pox is the most remarkable of all tbe eraptive
fevers, and though I once proposed to begin with the
simple efflorescences, and proceed thence to small pox,
the most highly developed form of exanthematic disease,
yet I find that otlier and more imporlaat objects will be
gained by beginning with small po.v. A brief sketch of
the early history of this disease will be quite essential
to a due understanding of the subject
The Greeks and Romans knew nothing of small
po.'c. It is very true that Hahn in former times, and
Dr. Willan and Dr. Baron in our own, have labored
diligently to prove the contrary. Mr. Moore, too, has
been no less anxious to convince us that small pox was
known in China aud Hindostan even before the time
of Hippocrates ; but 1 am very incredulous on these
points, and am borne out in this scepticism by the
opinions of Dr. Friend, Dr. Mead, and many other
physicians of great learning, and equally indefatigable
in research.
42 PESTILENCE OF PR0COPIU8.
In the writings of Alexander Trallianus, who lived
in the first half of the sixth century, we have a brief
description of the whole circle of medical science as it
existed in his days. No allusion to any complaint
exhibiting the character of small pox is there to be met
with.
The first notice of a disease that looks like small pox
is to be found in a chapter of Procopius, " De Belle
Persico" (lib. it cap. 22), where he describes a dreadful
pestilence which began at Pelusium, in Egypt, aboat
the year 544, and spread in two directions, towards
Alexandria on the one side, and Palestine on the other.
This disease, he says, was accompanied by buboes and
carbuncles. So far it resembled Egyptian plague ; but,
on the other hand, Procopius distinctly states that it
raged independent of all season ; that it spread into
Persia and thr ugh the whole interior of Asia, and did
not confine itself to the shores of the Mediterranean
and Red Seas ; that it spared neither age nor sex ; that
it affected the whole human race alike ; that it was a
new disorder, so little understood by the physicians of
those days, that many recovered whom they had given
over as hopeless, and many died whom they had pro-
nounced safe. It is stated, also, that it was peculiarly
severe in pregnant women. All this looks very Uke
small pox.
Whether this epidemic was or was not small pox
may be doubted ; but certainly, within a short time
afterwards, very unequivocal traces of small pox are to
be met with in the countries bordering on the Red Sea,
for we read of caliphs and caliphs' daughters being
pitted. Mr. Bruce, the celebrated Abyssinian traveller,
wishes to fix the first epidemic of small pox to the
era 522, which corresponds sufficiently near to the date
of this plague described by Procopius.
Small pox had cerlainly been known for several cen-
turies before it was described. Rhazes (910) is the
first author who mentions it: his description is clear
and full, his tlieory childish in the extreme, and his
practice very bad. Avicenna and Hali Abbas, the
Arabian physicians who succeeded Rhazes, also men-
tion variola, adding some facts to those already
described.
From the east small pox travelled to the west,
whether slowly or quickly we have no means of ascer-
taining. It appears to have reached England towards
the close of the ninth rentury. The word variola is to
be found in several Latin manuscripts preserved in the
British Museum, of date decidedly prior to 900. Exor-
cisms to ward oif the dangers of this new plague are to
be found addressed to St, Nicase. The term variola,
the diminutive of varus, a pimple, is obviously of monk-
ish origin. The monks, you know, were llie deposito-
ries of all the little medical learning of those times.
The term pock is of Saxon orlgiu, and signifies a bag
or pouch. The epithets amc// in England, and petife in
France, were added soon after the introduction of the
grand or great pox in 1498.
If America (discovered in 1492) gave us, as people
confidently say it did, the great pox, we more than
returned the compliment by introducing to her acquaint-
ance the small pox. This pestilence reached the
American Continent about 1527, devastating in the
first instance Mexico, and spreading afterwards with
fearful virulence over the whole of that vast country,
[■■ Acconling to Humboldt, variola was introduced into Mexico in
44 FIRST APPEARANCE OF SMALL TOX.
1520, bj a negro slave ; and, from this period, it exercised its ravaget
throughout that extensive region at regular intervals of 17 or 18 years;
and notwithstanding European vessels frequently introduced the vims
anew subsequently, it never became epidemic except at those very
marked intervals of time.** (Forry. i^. Y. Joum, Med^ March, 1844,
p. 156.)
Webster (Hint. Epidemic Diseases, vol. i. p. 292) says that "in 1638
the Indians in Massachusetts were invaded by the small pox, which
swept them away in multitudes."
He speaks of it as having first occurred in Boston in 1649, and sub-
sequently in 1666, 1678, 1689, 1702, 1721, 1730, 1752, and 1764.]
The ravages of small pox, great as they are in tempe-
rate climates, are far greater in tropical ; severe as they
are in the white skin, they are far severer in the black
and colored races.
[In the year 1752, when this disease prevailed as an epidemic in
Boston, the mortality was about fifty per cent greater among the
blacks than among the whites, when taken in the natural way ; and
more than three times as great, when taken by inoculation. (Vital
Statistics of Boston, by L. Shattuck. Amer, Jour, Med, Sci,, Jan. 1841,
p. 372.)
The statistics of Charleston (S. C), already quoted, show the same
fact of the greater fatality of the disease among the blacks than the
whites.]
Skipping over 120 years, the era at which I shall
next pause is 1640, when the mode of treating fevers
by the hot or sweating system had attained its acme.
We have a splendid picture of this practice in the
writings of Diemerbroeck, a Dutch physician and pro-
fessor. I must treat you to some few traits of this
.system, premising that it was especially applicable to
small pox.
" Keep the patient," says Diemerbroeck, ** in a cham-
ber close shut. If it be winter, let the air be corrected
by large fires. Take care that no cold gets to the
THE SWEATING 8TSTK1I.
patient's bed. Cover him over with blatikets. Red
blankets have always been preferred — not that the color
is material — bat because, in the limes of our ancestors,
alt the best, tliickest, and warmest blankets, were d}*ed
red. Never shift the patient's linen lill after the four-
teenth day. for fear of striking in the pock, to (he irre-
coverable ruin of the patitmt. Far better is it to let the
patient bear with the stench, than to let him change his
linen, and thus be the cause of his own death. Never-
theless, if a change he absolutely necessary, be sure that
he puis on the foul linen that he put oiT before he fell
sick, and, above all things, take care tliat tliis supply of
semi-clean linen be well warmed. Sudorific exputsives
are, in the meantime, to be given plentifully, such as
treacle, pearls, and saffron."
This is an abbreviated sketch of the system of expel-
ling the peccant humors in fever by perspiration ; and
such was the condition in which Sydenham found the
practice of medicine in 1667. He had an Augeao
stable to cleanse when he undertook the task of reform.
Unless you have .well studied the writings of physicians
during the first half of the seventeenth century, you can
form no just estimate of Sydenham's merits. He was
violently attacked by his contemporaries for the system
which he quietly substituted, but truth ultimately pre-
vailed, and before the end of the century the new or
cooling plan of practice was fully established. Syden-
ham had other merits in regard to small pox. He
desiTibed die disease admirably, and was the first who
separated small pox from measles.
JJoerhaave, who flourished about the year 1700, was
a devoted admirer of Sydenham. He deserves mention
as the author who first excluded all commou causes
46 IKTftODCCnCMI AMD FEOGKBSS
from the edoiogj of smaO pox, and maintained that it
was propagated bj a specific contagion or miasm alone.
This brings ns to the next great epoch — that of ino-
eolation. It was at Constantinople, abont the year 1 700,
when inoculation for the small pox was first practised.
Dr. Emanuel Timoni, Mr. Kennedj, and Dr. Pjlarini,
in 1714-15, made the profession in England acquainted
with the discovery, but no attention was at first paid to
it It was reserved for a ladj — Ladj Marj Wortley
Montague— to introduce this splendid improvement into
medical practice. Her son was inoculated at Constan-
tinople in 1717, and her daughter was reserved to be
the first person ever inoculated in England. This event
took place in 1721.
[Inoculation was first advocated in this oountrj by the Rev. Cotton
Mather, and first practised, at his suggestion, by Dr. Z. Bovkton, on the
27th of June, 1721, in Boston, upon bis only son, about thirteen yean
of age, and two negro servants, and was entirely successful. During
that year and the early [>art of 1722, he [performed it upon 247 persons
himself. Tlie opposition which the introduction of the practice met^
and which was carried so far as to endanger his life, the courage and
energy as well as perseverance with which he carried di rough to final
triumph his bold and humane undertaking, and his eventual reward in
the amount of good accomplished, in the acknowledgments of those who
bad l>een his persecutors, and in pecuniary returns, are interesting mat-
ters of historic record. (See Thacher^s American Medical Biography ;
Boston, 1828, p. 28 ; also under head of his life in same work.)]
In the following year, after successful trials upon six
condemned criminals in Newgate, the Princess of
Wales submitted her own daughters, the Princess
Amelia and Caroline, to the new process. Both passed
through the small pox favorably. The anxiety of the
Princess of Wales on this occasion admits of easy ex-
planation.
dueen Mary, wife of William the Third, died of
OP INOCULATION.
confluent small pox of ihe worst sort, at the age of 32,
on tUe 28tli December, 1G94. In 1721, George the
First had but recently come to the throne, and the direct
succession of the Hanoverian line was of the otmost
consequence to the court and the nation. Q.ueen
Mary's death had made a deep impression, which an
interval of 25 years had not banished from the recollec-
tions of the people, Hence doubtless arose the ex-
treme anxiety of the Princess of Wales to fly to the
novel expedient of inoculation.
The first ten years of its career were singularly
unfortunate. It fell into bad hands. It was tried on
the worst possible subjects, and practised in the most
injudicious manner. The consequence was, that it
soon fell into disrepute. The pulpit, too, sounded the
alarm, and in trulh, conducted as inoculation then was,
it was a very questionable improvement.
A new era arises in 1746, when, the practice being
better understood and appreciated, the Small Pox Hos-
pital was founded, to enable the poor to participate in a
benefit hitherto confined to the rich. In 3 754, the
College of Physicians put forth a strong recommenda-
tion of inoculation. About the same period, Mead and
De la Condamine wrote treatises in favor of it, the
former in London, the latter in Paris. At length, in
1763, the practice was undertaken by an exceedingly
clever man, Mr. Robert Sutton, who, >vith his two sons,
inoculated with admirable skill and wonderful success.
In 1775, a dispensary was opened in London for the
gratuitous inoculation of the poor at their own houses;
but the iustilution failed, chiefly through the opposition
of Baron Dimsdale. The Small Pox Hospital then
took up the plan of promiscuous inoculation, which
48 DEFINITION OF SMALL POX.
was carried on to an immense extent between the
years 1790 and 1800.
In 1798, Dr. Jenner announced the discovery of
vaccination. On the 5th of May, 1808, the inoculation
of out-patients was discontinued at the Small Pox Hos-
pital. On the 20th June, 1822, inoculation was discon-
tinued to in-patients. On tlie 23d July, 1840, the
practice of inoculation, the introduction of which has
conferred immortality on the name of Lady Mary W.
Montague, which had been sanctioned by the College
of Physicians, which had saved the lives of many kings,
queens, and princes, and of thousands of their subjects,
during the greater part of the preceding century, was
declared illegal by the English parliament, and all
offenders were to be sent to prison, with a good chance
of the treadmill. It is even provided that an attempt to
produce small pox by inoculation, even though unsuc-
cessful (including, of course, the testing of vaccinated
subjects at all ages), is an offence at law ! Such are
the reverses of fortune to which all sublunary things are
doomed.
We define small pox to be a disease, the product of
a morbid poison or miasm, which, after a certain period
of latency, developes eruption on the surface, passing
through the stages of pimple, vesicle, pustule, and scab^
with certain other, concomitant or succeeding affections,
which runs a stated course, and having exhausted itself,
removes from the constitution the susceptibility of a like
attack.
Small pox. is divisible into varieties. The terms
confluent and distinct express two of the most remark-
able, but others are equally important. I shall speak
PERIOD bF INCUBATION. 49
to you here of conflnent, seuii-coDlluent, corymbose,
distinct, and modified small pox — of superficial, cellu-
lar, and tracheal small pox — of the benignant, niahg-
nant. and petechial small pox — of simple and compli-
cated small pox.
Every kind and variety of small pox is divisible into
iuee stages — incubation, maturation, and decline.
1. Of the period of iucuhation. This is the latent
or dormant period of some autliors, and it includes the
whole period tbat elapses from the reception of the
variolous germ to the development of eruption. The
first few days are passed, in many instances, without
symptoms of any kind, hut in other cases there are
obvious evidences of some morbid process going for-
ward. At the moment of receiving the miasm, the
patient experiences, perhaps, an unpleasant odor, or a
feeling of sickness, or of giddiness, or of inward alarm.
As the incubation advances, his nights are restless, bis
spirits low. He is oppressed with languor and lassi-
tude. With respect to the period of incubation, a large
accumulation of facts enables me to fix it at twelve
days of apyrexia and two of fever — fourteen in all.
One example may suffice.
Mrs. Joseph, wife of Mr. Joseph, surgeon, of Great
Marylebone street, registrar of biribs and deaths for the
Kectory district of Marylebone, was sitting in her parlor
on Monday, June 7, 1841, when a nurse called to
register the death of a child who had died the preced-
ing day of small pox. The nurse had just left the
dead body. Mrs. Joseph's suspicions were sufficiently
excited to induce her to have her baby vaccinated
immedialely, but she never thought of herself. On
Saturday, June 19 (thirteentli day from exposure to
50 CHARACTER OF ERUPTIVE FEVER.
the miasm), Mrs. Joseph sickened. On Monday, June
21 (being that day fortnight on which the child's death
had been registered), small pox appeared in her.
The incubative period admits of some latitude. The
extremes may perhaps be stated at ten and sixteen
days.
With regard to the initiatory or eruptive fever (con-
stituting the last two days of the incubative period), it
may be remarked, that on the twelfth or thirteenth day
from imbibing the germ, rigors occur, followed by the
usual evidences of pyrexia — a quickened pulse, heat of
skin, pains of the back and limbs, scanty and high-
colored urine, and restlessness. How can you prognos-
ticate that the fever then breeding is variolous ?
(1.) By the sickness at stomach. This is often very
intense, continuing for two or more days, and often
accompanied by tenderness of the epigastrium on pres-
sure. There is irritability of the stomach here, but not
inflammation, for the vomiting is uninfluenced by
bleeding, and yields when the eruption shows itself
[Heberden says, " if the vomiting be continued after the eruption is
completed, the patient's life is in great danger, even though the small
pox be not confluent," — Commentaries^ p. 355.]
(2.) By the pain of the back and loins. This, too.
Is often very intense, so that men carrying a load have
dropped down in the street The most remarkable
case of the kind which I ever saw was the following :
— Mrs. Delahay (Little Marylebone Street), at the full
time of her first confinement, began to complain, No-
vember 23, 1837. The pain of the back was very
severe, with very little intermission. Yet the os uteri
scarcely dilated at all. Mr. Jordan, who attended her,
seeing some peculiarity in the case, requested my assist-
CHARACTER OP EHUPTITE FEVER.
ance. The pain of the back was agonizing, and she
continued to suffer from it during the whole of the 23d,
the OS nteri contiouing unahered. She was put into
the warm bath, took 200 drops of laudanum, and was
bled to thirty ounces. At one a.m. on the morning of
the 24th, she was delivered of a dead child, but pain
still continued. On ihe evening of the same day, con-
fluent small pox appeared, when the pain of the back
ceased. She had been well vaccinated in early hfe.
The peculiarity of this case consisted, you will per-
ceive, in the incubative stage of small pox concurring
with the completion of ntero-gestation. The infant's
life was destroyed by the intensity of the fever.
[Lumbftr pain is one of the moat common precursory Bymptotna of
vnririla, and ofl«n of a groat degree of severity, and is not met with in
either BcarlHtinn or rulMola, or at least to an atnouut at all marked, and
ita presence often BBsists mnterially in the diagtiosis of this diseiiM.
Beberden lays, " an excruciating pain in the luins has never failed to
be succeeded by a bad sraall pox, and the more violent tile pain, the
greater has been the danger ; it 'm much safer to have it between the
sbonlders." — (Comnuntarieg, p. 354.) I have, bowever, seen a mild
attactt of varioloid follov severe pain in tlie back, and the reverse of
this is also true.]
(3.) Encephalic symptoms accompany the initiatory
fever of small pox in certain cases. Adults complain
of severe headache. There is stupor or doHriuu). The
face is flushed. The carotid and temporal arteries
beat strongly. The patient is supposed to he on the
eve of a severe cerebral affection. Somnolency or an
epileptic fit is often noticed in children.
(4.) Syncope and e.tcessive prostration of strength
are the leading features in some cases. I have seen
syncope occur on the seventh day after inoculation.
Occasionally, even in strong habits, the effect of ihe
52 DURATION OF ERUPTIVE FEVER.
miasm is so thoroughly poisonoas that the coantenance
turns pale, the pulse is feeble, the extremities become
cold. The patient is brought into a state o{ collapse.
(5.) Great anxiety of the praecordia, deep sighing,
and dyspnoea (symptoms indicating thoracic conges-
tion), are occasionally noticed.
[** A great shortness of breath coming on about the fifth day of the
eruption, scarcely leaves any hopes that the patient will sun'ive."—
Heberden — Commentaries^ p. 357,]
Sometimes the one, sometimes the other of these
groups of symptoms predominates during the brief
period of eruptive fever. In addition to the evidence
which they afford, the suddenness of the seizure, the
previous good health of the patient, the circumstance of
prior exposure to the contagion, or having previously
undergone small pox, will assist in the diagnosis. In
adults, the fact of prior vaccination is not to throw you
off your guard, for the initiatory fever is just as severe
after vaccination as it is in the unprotected.
The eruptive fever of small pox acknowledges the
tertian type. Forty-eight hours elapse from the rigor
to the first appearance of eruption. Sydenham believed
that the more time nature occupied in finishing the
separation of the inflamed particles, the greater was the
chance of ultimate safety to the patient ; and accord-
ingly he never interfered at this period. Before his.
time, the theory and practice were different. It was
thought that nature was struggling to effect the separa-
tion, that she required assistance to do this effectually,
which assistance was afforded to her in the shape of
heating diaphoretics and alexipharmics.
The duration of the eruptive fever is never less than
forty-eight hours. It may be protracted, by weakness
CRABACTBA OF THE ESUPTIOff.
of habit, to seventy-two hours, anil the full development
of eruption over the whole surface may even occupy
three couiplete days. Minute papulx sensibly elevated
abave the surface of the skin show themselves, iu the
first instauce, on the face, forehead, and wrists. In a
few instances only does the eniption commence on the
lower extremities. It often happens that two or three
large papulae precede the general eruption, and advance
to the slate of vesicle, before the surface is extensively
occupied.
[Tlie first pustules are usually seen on the upper lip, cheeks, and
forehead, but tliey are often found on the velum palati sooner than on
any other part. Hence it is always important to enamine the inside of
the mouth and the throat, when this disease is suspected, to aid in the
diagnosis. Sometimes the paria are inflamed witliout any perceptible
eruption; at other times, both inBamroation and papulx can be
plainly seen.]
In a large proportion of cases, the outbreak of erup-
tion affords great relief to the general constitutional dis-
turbance. The fever moderates, the sickness abates,
the dorsal pains diminish, the head is relieved. From
all this, you will perceive that such symptoms depend,
not on inflammation, hut on vas ular distension.
Something may be learned by attention to the
arrangement of the papulfe. They are not thrown
together confusedly and without order, but are arranged
in groups of three or five. Crescents and circles may
be traced very distinctly when the eruption is not too
copious. This constitutes an important diagnostic
between variola and varicella.
The external character and internal structure of the
variolous pimple and pustule have excited much atten-
tion. Cotuguo, in Italy, commenced the investigation.
54 ORGANIZATION OF THE PUSTULE.
which John Hanter, Dr. Adams, and, in more recent
times, Bousquet, Gendrin, Mr. Judd, Dr. Petzholdt, and
others have continued.
[To the names quoted by our author of those who have investigated
the structure of the small pox pustule, may be added that of Dr. Simon,
who has given a minute description of its peculiarities in his work on
diseases of the skin, a full abstract of which may be found in the Brit,
and For, Med. Ckir, Rev., April, 1849, p. 349.]
The organization of the variolous pustule is very
curious. Inflammation begins at a spot called the
phlyctidium. Its seat is in the cutis vera. From the
central point, or stigma, the inflammatory action pro-
ceeds by radiation on the surface, penetrating to a
greater or less depth in different cases. Beneath the
epidermis, and constituting the greater part of the
phlyctidium, is found a substance, or disc, of the con-
sistence of pulp or thick mucus. This is not considered
as any part of the skin altered by disease, but as the
product of a specific action of the vessels. John Hunter
and Adams called it the variolous slough. At the
height of suppuration this substance is swollen, and
moist like a sponge. The floor of each phlyctidium
presents the papillated structure of the skin, elevated,
and marked with fissures. The vesicle is divided, like
the substance of an orange or poppy-head, into nume-
rous cells (twelve, or more). It is, as we say, multilo-
cular. A filament of cellular tissue binds down the
central portions of cuticle to the lower surface of the
phlyctidium, and gives to the vesicle, in its early stages,
that umbilicated form, that depression of its centre,
which, though not peculiar to the variolous eruption, is
so important as a diagnostic mark between it and genu-
ine varicella. The fluids (lymph and pus) which at
MATUEATIVE STAGE.
different periods distend its cells, desiro}' at length tlie
filamcutous attachment of the stigma to tlie cuticle, and
that which was at first a depressed or uiiibilicated vesi-
cle, becomes at last an acuminated pustule. It bursts,
discharging a well formed purulent matter, of a yellow-
ish color and creamy consistence.
2. The inflammation of the phlyctidium is accompa-
nied by a kind of erythema, or specific inflammation,
called tlie areola, extending to some distance beyond
the margin of the vesicle. The color of the areola is
always to he carefully noted, for reasons which will
soon be e.\plaincd. On the subsidence of this inflam-
matory areola, the ripened pustules, having burst and
discharged their contents, are succeeded by scabs, which
dry up, and, in a healthy state of constitution, fall off ui
four or five days. In mild cases, where the full process
of pustulation is not gone through, many of the vesicles
shrivel, and form only tubercles, or imperfect scaly
crusts. On the lower extremities, this premature desic-
cation of the vesicles is often very general.
In severe cases, the infiammation of the corion does
not cease with the completion of the pustulating process.
Portions of the cutis vera are then actually destroyed
and slough away, the result being that, when cicatriza-
tion is at length completed, tlie skin presents the ap-
pearance of pits or fovcie, with a diffused clarety hue of
the surface. This tint wears off in the course of three
or four months; but the depressions are permanent.
From the great vascularity of the face, there is always
most risk of such disfigurement there.
Nurses will talk to you of a five, six, seven, eight,
nine, and even ten days' pock. They are quite right
When the disorder is perfectly normal in its course, not
66 MATURATIVE STAGE.
interfered with by any peculiarity of habit either con-
genite or acquired by previous vaccination, — when the
constitution is sound, with sufficient strength of system,
and a good, but not over-abundant supply of blood, —
lastly, when there is not too copious a crop on the sur-
face, the pock maturates in seven days. In severe cases
of a semi-confluent or corymbose kind, the process of
maturation occupies eight days. In bad confluent
cases, nine or perhaps ten. On the other hand, after
vaccination, or when there is some originally favorable
diathesis present, the pock will maturate in six, or some-
times imperfectly in five days. This five-day pock
constitutes the mild, mitigated, or modified form of
variola, now so familiar to us, as occurring in those who
in early Ufe had been well vaccinated. But this variety
of the disease, though formerly less frequent, was yet
well known to all the old authors. Van Swieten
describes it under the title of variola verrucosa and
cornea (stone pock, horn pock, and wart pock).
A certain amount of fever accompanies the matura-
tion of the pock even in its mildest aspects. The actual
amount depends mainly on the quantity of eruption, but
something is attributable to the habit of tlie patient,
whether irritable or otherwise. A quiet condition of
mind is always favorable to small pox. Something de-
pends, too, upon season, something on diet, and the
temperature of the room in which the patient lives.
The corymbose, or partially confluent form of small
pox (where the vesicles are grouped into clusters, leav-
ing intermediate spaces of unoccupied skin), is always
attended with severe and irregular fever.
The maturative process is often accompanied by an
exceedingly tender state of the surface. This happens
chiefly in women, and in men of delicate skin. It is a
very farorable sign, tliougii productive of much tempo-
rary inconvenience. The variolons matter, when
abundant, gives off a peculiar, faint, and sickly odor.
Kecovery may be retarded, even in the distinct small
pox, by weakness of habit, by cold, and ihe excitation
of scrofulous disease. Ecthymatous eniption may then
occupy the surface ; the skin maybe left dry and scaly;
the scabs may be adherent. All this is owing to the
setting up of a low form of secondary fever.
I nmst next draw your attention to the implication
of certain of the mucous structures in the progress of
small pox. In a lai^e proportion of confluent, and in
some semi-confluent cases, the mucous membrane of all
those parts to which the atmospheric air gets access
(the nose, month, and trachea), is occupied with erup-
tion — sometimes distinct, more generally confluent.
The early symptoms occasioned by tliis mucous com-
plication arc as follows: — Numerous white points appear
on the tongue, palate, and velum pendulum. Hoarse-
ness and alteration of voice indicate that the same con-
dition exleitds to the nmcous membrane of the larynx
and trachea. There is great pain in swallowing, and
in bad cases cough and dyspncea. The cough is at
first dry and tearing. As the disease progresses, there
is expectoration. About the eighth day, a copious
viscid secretion takes place from all the atrected stnic-
tures.
The nlterior effects of this mucous implication are
far more important than any local mischief \vhich it
occasions. The oedematous thickening of the larynx
and the swollen condition of the tracheal membrane,
have by the eighth day maierially impeded the free
M
58 IMPLICATION OF THE MUCOUS MEMBRANE.
access of air to the iangs, and the consequences appear
in every part of the circulating system. There is no
crimson areola, for the blood is not well arterialized.
The vesicles on the extremities never acquire any
inflammatory areola, by which alone the surface can
be cicatrized. On the trunk the areola is dark or
claret-colored. The vesicles do not acuminate. They
lie flat, and present much of the same appearance which
is displayed after death. Sometimes the superficial
inflammation partakes more of an erysipelatous than of
a phlegmonous character. The results are large watery
blebs, from which flows out a thin ichor. Consequences
still more serious happen in the succeeding twenty-four
hours. The brain becomes affected. A low muttering
delirium is observed, as the waves of ill oxygenated
blood begin to circulate. The tongue swells and exhi-
bits a purple hue. Restlessness and great anxiety suc-
ceed. The patient tries to get out of bed. The
bladder loses its contractile power, and may be felt dis-
tended at the brim of the pelvis. The extremities
become cold. Dyspnoea increases, and the patient
dies !
[According to M. Louis, fifteen twentieths of all that die of variola,
perish from asphyxia consequent upon affections of the larynx and air
passages generally.
For an interesting paper on this subject, with cases confirmatory of
this remark, by Charles R. King, M. D., see N, Y, Journ.of Med. and
Surgery, April, 1840, p. 269.
The present state of our knowledge respecting cedema glottidis, sug-
gests the inquiry, whether this state of the parts in variola may not be
the cause of the sudden fatality of a certain number of cases, and if this
be the case, whether the operation proposed for its rt^lief by I>r. G.
Buck of this city, might not be practised with benefit. For an account
of this operation, with illustrative plates, see Trans. Amer. Med. Asso-
ciation^ vol. i. p. 135.]
CONSEQUENCES OP SECONDARY FEVER. bH
The implicatiou of the cellular membrane in the
progress of small pox must next engage our attention.
In the distinct small pox the skin continues movable on
the subjacent textures, hut ia all bad cases, confluent,
semi -con fluent, and cor^'mbose, the inflammatory actiOD
dips deeper, and invades the cellular membrane. The
skin DOW becomes swollen and tense. This cellular
complication is sometimes universal, sometimes partial.
The scalp is very often affected. Enormous intumes-
cence takes place, followed by diffuse pustulation, or a
succession of small and most troublesome abscesses. The
cellular membrane of the throat is peculiarly liable to
take on this action. The salivary glands participate in
the inflammation, and salivation \vlth great turgescence
of die neck follows. Occasionally the tongue becomes
involved. Glossitis is superadded to other evils, and
few, if any, survive, when matters have proceeded to
this extremity. Supposing, however, tliat neither the
cellular nor laryngeal inflammation is in sufficient
intensity, on the eighth or ninth day, to destroy the
patient, then secondary fever sets in, to be known at all
times by the occurrence of rigors, followed by a hot and
dry state of the surface, and a thirst unquenchable.
3. In the progress of secondary fever you must be
prepared for all sorts of troubles. The skin, already
weakened and prone to inflammation, is sure to suffer
first. The elbows, legs, scrotum, knees, back, and hips,
take on a mixed erysipelatous and phlegmonous action.
Tbe result is either boils and abscesses, or enormous
imposthumes, or carbuncles, and gangrenous destruction
of large portions of tbe skin, according to the severity of
each case. On the 17th July, 1829, 1 saw at the Small
Pox Hospital an exact counterpart of the pestilential
60 MODIFIED VARIOLA.
babo and carbuncle on the groin of a small pox patient
Sometimes the whole surface of the body is covered with
a vivid scarlatinal rash. The face always suffers severely
in this aggravated form of cellular small pox, and the
patient (if happily he escapes) passes through a tedious
process of convalescence. In 1828 I saw a woman
whose face was not simply pitted, but scored and seamed,
She informed me that she was twelve years in recovering,
and I could well believe it. The disposition in inflamed
parts, during the secondary fever of small pox, to termi-
nate in suppuration, appears to be universal, and almost
uncontrollable. In some few cases the larger joints fill
with purulent matter.
Confluent and semi-confluent cases of small pox,
though very frequently, are not necessarily accompanied
with cellular complication. There is a form of the dis-
ease called the confluent superficial^ where the eruption
passes through all its regular stages, but the inflamma-
tory action never extends beyond the outer layer of the
corion. This is sometimes confounded with the modi-
fied small pox, but the progress of eruption is very
different in the two cases. The confluent superficial
small pox appears in the unvaccinated. The pustules
maturate equally and regularly. The confluent modified
small pox, on the other hand, never appears except in
the vaccinated, and the advance of the pustules is not
only imperfect, but it is unequal on the same portion of
surface. On the arm, for instance, at one and the same
time, you will perceive some pustules fully maturated,
others of smaller size desiccating after the escape of a
minute portion of pus, while part of the eruption has
become tuberculated without purulent formation, and
with little or no surrounding inflammation. This ine-
IMPLICATIon OF THK NERVOUS BYSTEH.
61
quality of aspect is the great cliaracleristic of modified
variola.
I must next draw your attention to tlie implication of
tlie brain and nervous system in tlie plienomena of small
pox. Children grind tlieir teetli, and squint. Cerebral
intlammation supervenes and the child dies, either in an
epileptic fit, or with evident signs of hydrocephalus.
Adults become delirious, and octasioually it is of that
severe kind called delirium feroz, accompanied with
great wildness of the eye, and sucli strong tendency to
self-destruction that the utmost precautions do not over-
step the necessities of the case. Variolous delirium
depends more on some peculiarity of temperament, on
some highly irritable condition of the nervous system,
than it does on inflammation. Thomas Weston became
a patient of the Small Pox Hospital on the 17lh of July,
]8:?9. For several jears his thoughts had been alisorbed
in religious matters. He would often say that he was
better prepared to die then than he could he if bis life
were lengthened. When it was announced to him that
his complaint was small pox, he expressed no wish to
recover. The eruption was uioderate in quantity — not,
per se, threatening danger. He had been vaccinated in
early life. Delirium set in early, and he died on the
eighth day of the disease. A peculiar nervous affection
often supervenes on the tenth day, when tlie skin is
extensively occupied by the confluent eruption without
nervous complication. It is identical with that which
is familiar to surgeons as the consequence of extensive
burns and scalds. General tremors, low delirium, a
quick and tremulous pulse, a dry tou^^ue, collapse of the
features, cold extremities, and subsultus tendinum, are
62 PETECHIAL SMALL POX.
the symptoms of this nervous complication, and the pre-
cursors of a fatal event.
The implication of the fluids next demands notice.
It happens occasionally, though happily not often, that
the miasm of small pox poisons die blood, alters its
crasis or coagulating properties, and leads to haemor-
rhages from every open surface. The evidences of this
condition of the fluids are often perceptible from the
first hour of initiatory fever. At other times they are
not noticed until the eruption has begun to develope
itself, or even later in the maturative stage. The erup-
tion has a livid or dingy aspect. The expression of the
countenance is highly anxious. If blood be drawn from
the arm, a loose layer of fibrine is thrown up, beneath
which you find fluid red blood. Haemorrhage takes
place from the nose, mouth, lungs, stomach, bowels, and
kidney. Petechiae and patches of ecchymosis (called
vibices) appear intermixed with the variolous papulae.
The variolous vesicles fill with blood, instead of serum.
The aspect of body in some cases of aggravated pete-
chial small pox is wholly changed.
In February, 1842, 1 saw, in consultation with Dr. L.
Stewart, a lady in small pox, whose whole body was of
the color of indigo, and whom I at first believed to be a
native of Africa. She conversed with me in the most
tranquil manner, and died a few hours afterwards,
proving that the nervous system is not necessarily, nor
is it even usually, implicated in the petechial form of
small pox.
When adult females are thus attacked, menorrhagia
is almost always observed, and if they be pregnant,
abortion or premature delivery takes place. The fcetos,
as you might naturally expect, dies in utero.
PETECRIAL SMALL FOX— GANGRENE.
[Heberden says [Commenlaries, p. 35E) that in the worat cases of
emtill pox, the menstrual discharge has come on out of its regular course
two days before the small po* liaa begun to show ilaelf, and has con-
tinued to flov in an excessive manner, and that it has sometimei
appeared before ita regular lime, ti^tlier with the eruption ; but that
more commonly it has begun as soon as the eruption nss completed,
and continued from one day to five. The discbarge does not check the
progre-M of the small pox, nor depress the patient's strength, and
requires no interference from art. The pn^oais, however, is entirely
di9i;rcnt. and of a very serious character, when there is a complication
with purpura, attendetl with hemorrhages from other parts, Socb cases
are almost always fatal.
The period at which miscarriage tatiea place is usually at the time of
suppuration of the pustules, which is about the seventh or eighth day
from the Rntl enip^on, a day or two afU.-r whieh death more commonly
occurs. A case, however, is related byDr. Marrotte{ffaz. <i«s Hdpitaax,
Sept. 5, 1S46), in a woman 26 years old, who aborted in the fourth
month, five days after the complete desiccation of the variolous pustules,
and without any external cause. The ftetus presented no trace of erup-
tion, which is moat usually the case, A small proportion pass ihrougi
the disease without miscarrj'ing.]
This variety of small pox was known of old by the
uaine of ibe black pox (variolae nigrfe), and appears to
have been more frequent in former times than it is now.
Death may take place in consequence of this remarkable
condilion of the blood before any unequivocal signs of
small pox are developed. More commonly, the erup-
tion, confluent iu character, displays itself, but never
makes much advance. Nature apparently gives up the
struggle as hopeless. The patient is carried oJT very
unexpectedly, perhaps on the fourth, or from that to the
sixth day.
There is something not very well understood in the
coDcurrencc of gangrene with small pox. It is not
necessarily connected with the petechial state, nor with
affection of the nervous system, nor with debility. It
64 OPHTHALMIA.
often occurs where the fever is of a truly inflammatory
type, and where no previous symptom gave evidence of
unusual danger. It is more generally found attendant
on the irregular or corymbose small pox than on the
purely confluent cases. The chief seats of variolous
gangrene are the scrotum, feet, and back, but I have
seen it also on the breast 1 cannot doubt but that in
certain cases the gangrenous disposition is something
superadded to the small pox by the condition of the air
which the patient breathes.
Small pox is often accompanied with ophthalmia. It
has been stated that this arises from the formation of
pustules on the cornea and conjunctival membrane.
This is erroneous. If these structures had been sus-
ceptible of the specific variolous eruption, every con-
fluent case must necessarily have ended in total blind-
ness ; but, happily, Nature has arranged it otherwise.
Conjunctival inflammation, iritis, inflammation still
deeper seated, may indeed arise, especially when exten-
sive crusts put a stop to all perspiration, and when
secondary fever rages in the blood, and devastates
internal organs. But there is no specific inflammation
of the eye in small pox.
The ophthalmia by which so many eyes have been
lost is a sequela of the disease, generally coincident
with some great destruction of surface in a distant part.
In some cases, variolous ophthalmia, setting in on the
tenth day of the disease, advances so rapidly, that in
forty-eight hours the whole eyeball is irremediably
injured. I have seen the whole eye converted into
one large abscess. More usually, the inflammation runs
into some of its less violent and more familiar conse-
quences. An ulcer forms at the outer edge of the cor-
AFFECTIONS OF INTERNAL ORGANS.
65
nea, by which tlie aqueous humor escapes, or at which
staph) lorn ato us protrusion of the iris takes place ; or
the aqueous humor becomes clouded, or specks form on
the cornea, from wliich blindness more or less com-
plete, more or less permanent, results.
Although, at present, we are not in a position to
affirm it positively, yet many facts concm' to render it
almost certain, that this secondary affection of the eye
in small pox is connected with and dependent upon
some altered condition of the blood — certain matters
being retained within it which ought to have been
chminatcd.
It would be unreasonable to believe that such a fever
as I have described should rage, expend its whole viru-
lence on the skin, and never affect the great internal
organs of the chest and abdomen. Sronchial infiam-
mation is sometimes present daring the wliole course of
the complaint, especially in the winter season, bat it
docs not materially complicate the phenomena. In
Lascars, and all natives of tropical climates, attacked
by small pox in a cold chmate, this frequently happens,
and may of itself prove the cause of death. Sometimes,
even among our own people, the substance of the lungs
becomes involved in Indannnation, and its usual conse-
qneoces. But the great peculiarity deserving of your
notice is the frequency of variolous pleurisy. It occurs
between the twelfth and twentieth day. It is a pera-
cutc form of inflammation, remarkable for its sudden
invasion, rapid progress, and invariable termination by
empyema. The symptoms are very unequivocal.
Intense pain, a hard, wiry, and incompressible pulse,
shortness of breathing, and a dry state of the surface,
L
66 APPEARANCES ON DISSECTION.
betoken but too forcibly the state of the pleura. Blood-
letting is almost powerless in this disease. Death usu-
* ally happens on the third, or, at furthest, on the fourth
day, from the invasion of thoracic symptoms. The
heart occasionally becomes involved. Syncope, palpi-
tation, and a sense of exhaustion, are the evidences of
this complication. I have seen such symptoms con-
current with phlegmasia dolens of the leg, indicating an
inflammatory condition of the blood-vessels. These
cases prove fatal very rapidly.
Small pox is singularly exempt from all abdominal
complication. Children sometimes fall into a state of
mucous enteritis, with frequent, slimy motions, and
emaciation ; but nothing occurs here to warrant me ia
detaining you.
The appearances, on dissection, peculiar to small
pox, are confined to those which the larynx and tra-
chea exhibit. The lungs, indeed, sometimes display
the usual evidences of inflammation — vascular engorge-
ment, purulent infiltration, and hepatization. The
thorax of one side may be found replete with a sero-
purulent fluid (resembling a mixture of cream and
water), the result of acute pleurisy, and the pleura itself
may be seen injected with blood, and covered with a
dense layer of coagulable lymph ; but all this occurs
equally in other diseases. The condition of the larynx
and trachea, however, in small pox, on the eighth day,
is unique. The mucous membrane, if then inspected,
appears covered with a copious, viscid, puriform secre-
tion, of a grey or brownish color. On detaching this,
the membrane itself is seen deeply congested with
blood, thickened, pulpy, and, in the worst cases, black
APPEAUANCES ON DISSECTION,
67
and sloughy, exhaling a uiost offensive odor. Tlicse
appearances may be traced to the third division of the
bronchial tubes.
Much discussion has taken place regarding the
occurrence of variolous pustules on the gastro-cnteric
mucous membrane. Cotugno, Wrisberg, Iteil, and
others, who have paid great attention to the subject,
concur in opinion that this structure is not capable of
developing them. Sir Gilbert Blane, again, reports a
case where the mucous membrane of the bowels pre-
sented the appearance of ulcerated spots, which he
compared to variolous pustules. The experience of
the Small Pox Hospital is in favor of the old doctrine.
Inflamed, enlarged, aud ulcerated follicles, wilh pete-
chial patches, may indeed be noticed in a few rare
cases ; but such appearances are in all respects the
same with those observable in typhoid fever.
[PathologUto seem to be divided in opinion as to llie existence of
true varioloiia paslules on tlio niucoua luembraue of ihe intes^nnl canal,
Louis, Gerhurd, MM. BurtheE and Rilliet, Petzholdt, and Chaptnan,
uniting with thwo mentioned by our author in denying ll<at tliey are
evor prewnt there, and saying that a follicular eruption, not untrequenlly
ibund both at the beginning and end of the small intestine, and more
rsrely in the lai^ intestine, has given riae to llie error.
Dr. George Patterson, however, of Edinburgh, lately reported a case
of a boy, five years old, in which pustules and superficial incrustations
were found in the lower part of the intestines, and the statement is
corroborated by Dr. W. T. Gairdner, who made tlie pcntriuorleni exami-
nation with Dr. Patterson. The whole case was so well characterized,
that he considered it as an unequivocal instance of varioloid eruption in
the coloD.
M. Rostan is also quoted aa authority in favor of their having been
found throughout the whole intestiniil tract.]
In like manner, the brain presents, in small pox, no
morbid phenomena different from those which other
types of fever display.
LECTURE IV.
STATISTICS AND PATHOLOGY OF SMALL POX.
Diagnosis of small pox. Statistics of small pox. Mortality by small poz
in the la,«t century, and throughout England and Wales, since 1837.
Proportion of mild to severe and fatal eases. Periods of the disease at
which death takes place. Direct causes of death in small pox. Patho-
logy of small pox. Question of spontaneous origin. Of miasmatic
origin exclusively. Circumstiinces that determine the character of the
disease. Epidemic diffusion of small pox. Laws by which it is governed.
Susceptibility of small pox. Of recurrent or secondary small pox. Case
of Louis XV. Communication of small pox to the foetus in utero.
In the present lecture I propose to bring before you, in
one view, the several considerations which reflection on
the phenomena of small pox is calculated to elicit
Everything that relates to diagnosis, statistics, and the
origin of the disorder, comes therefore now to be inves-
tigated. To distinguish one disease, however, from
another, it is obviously requisite that the course of both
should be known. We are therefore hardly in a situa-
tion yet to enter with advantage on this topic of inquiry.
Nevertheless, that nothing may be omitted which can
contribute to your practical benefit, I will say a few
words on the diagnosis of small pox.
The diseases with which, after the occurrence of
eruptive fever, small pox may be confounded, are
measles, febrile lichen, varicella, and secondary syphilis.
J. The papula; of small pox are firmer than those of
measles. They feel granular under the finger. In
measles, too, there are accompanying cough and watering
of the eyes. Furtlier, in small pox, forty-eight hoars
elapse from rigor to eruption ; in measles, seventy-two.
DIAGNOSIS OF SHALL POX.
2. Febrile Uchen is the disease from which small
pox, at its onset. Is \vith most difficulty distiuguisbed.
The aspect of eruplion is in both cases nearly aUke.
The surest and safest grounds of diagnosis are based ou
the interval which has elapsed from rigor to eniptioa,
and the mode in which ihe eruplion has developed
itself. In febrile lichen, tweniy-fonr hours elapse from
sickening to eruption ; in small pox, as you know,
forty-eight Small pox almost always appears first on
the face. The eruplion of lichen is developed, from the
first, uniformly over the head and trunk. Besides
which, your judgment will be materially aided by
inqnirles into the prior history of the patient, and the
character and course of incubation.
pn febrile lichen, the gastric derangemeDt would probably be greater,
aldiougli witbout vomiting, there would be no puis in die back, and
the itching would be so marked as to form a prominent symptom.
The early appearance of piutules on the velum and palatine arehea has
abo assisted me in the diagnosis. At the same time I would add, that
tbU form of lichen, presenting such a resemblance to small pox as to
give rise U> uncertainty in the diagnosis between the two diseases, has
seldom come under jny observation, and cannot be of very frequent
occurrence amongst us.]
3. The diagnosis of small pox and chicken pox
requires attention to uiiuutia:, and cannot be given until
a later period of the course, when the plienumcna of
that mild disorder will be duly submitted to you.
4. There is a form of secondary syphilis, in which
an eruption appears on the face and tnink very similar
to the distinct small pox. This syphilitic eruption
passes through the several grades of papula, vesicle, and
pustule. It is preceded by a febrile attack of variable
duration. The diagnosis is to be effected bj» careful
inquiry into the whole history of the case, and close
70 STATISTICS OF SMALL POX.
observation of the progress of the disease. To those
accustomed to the look of small pox, there is something
in the general aspect of a syphiUtic patient, in the
absence of all febrile anxiety, which would at once
indicate that the generating miasm was not variolous.
The march of the disorder would convert suspicion
into certainty. The pustular syphilitic eruption runs a
tedious course, exceeding ten days. The pustules are
developed, not simultaneously, as in small pox, but in
successive crops.
[Dr. Watson mentions one patient under his care, in whom " the
papulsc of small }>ox were, at the ouUet, so intermingled with the
appearances and sensations of urlicaria, that he doubted, for twenty*
four hours, what the true character of the eruption might be." — {Prac,
ofPhys,, p. 978; 3d edit, 1847.)]
From the earhcst periods, much attention has been
paid to the statistics of small pox. The absolute num-
bers carried off by it, and the relative numbers of those
who die to those who are attacked, have alike been
made the objects of inquiry. The old bills of mortality,
which can be trusted to more in plague and small pox
than in any other disorder, give 199,605 as the total
amount of deaths by small pox in London during the
last century, of whom 97,546 perished in the first half,
and 102,119 in the second half During the last quar-
ter of the last century, from 1775 to 1800 — that is,
prior to the discovery of vaccination, — the proportion
of the mortality by small pox to the total mortality, was
as 8 to 100 in London, and we may reasonably con-
clude that the same proportion existed throughout the
country^ Sir Gilbert Blane and others fancied that
this ratio was steadily augmenting in consequence of
MORTALITY OF SMALL POX.
71
the spread of inoculation, but I shall show you after-
wards that this notion was unfounded.
All authors have remarked, that the greatest mor-
taUty by small pox takes place in the early periods of
life. Dr. Haygarth computed, that at Chester, in 1795,
one half of the deaths among children below ten years
of age was due to small pox. The same law holds
good at present. From particulars to be found in Mr.
Farr's first and second reports, I have drawn up the
following table, which shows that out of every nine
persons who now die of small pox in England, seven
are below the age of five years.
Apes of 9162 persons who died of Small Pox in England^ during the
years 1837 and 1838.
Under the age of 5 years, .
Between the ages of 5 and 15,
15 and 30,
30 and 70,
Upwards of 70 years of age.
u
(t
ii
u
7340 deaths.
1668 "
528 "
210 "
16 «
Total 9762
[Ages of 758 persons who died of Small Pox in New York^ during the
years 1840 to 1844 inclusive.
Under 5 years, 411 deaths.
Between 5 and 10 years, . . . . 75 "
" 10 and 20 " 52 "
" 20 and 30 " 121 "
" 30 and 40 " 59 "
« 40 and 70 " 34 «
" 70 and 80 " 2 "
Unknown, 4 **
Total 758
72 MORTALITY OF SMALL POX.
Ages of b2^ perscns vcho died
in
Philaddphia
</
the »anu diseam
during i
\h€
fame years.
Uniler 5 years,
. 315 <
deaths.
Between 5 aad 10 years, .
. 61
u
" 10 and 20 " .
. 30
u
" 20 and 30 ** .
. 58
u
" 30 and 40 " .
. 41
u
" 40 and 70 **
. 24
u
Total 529
In Ireland, during the ten years ending June 6, 1841, of 58,006
deaths from this disease, 40,038 wore in those under five years of age.
The statistics of Manchester, Liverpool, Edinburgh, Glasgow, Perth,
and Dundee, for 1830, show that the rate of mortality by small pox
during tliat year was from 85 to 89 per cent of those under fire yeais
old.
The following table by Dr. Watt, of Glasgow, showing the per
centage of deaths by tliis disease at different ages to the whole number
of deaths in the cities of Glasgow, Edinburgh, New York, and Phila-
delphia, is not without interest in this }^K>int of \'iew : —
Glasg.
Edinb.
.V. F.
Fhila.
Under 2 years,
57.76
53.24
34.11
34.39
u 5 u
85.72
82.68
58.66
57.14
" 20 "
95.12
95.23
72.74
77.24
Above 20 "
4.87
4.76
27.25
22.75
It will bo seen by this, that the proportion of deaths by small pox in
New York and Thiladt'lphia, under two years of age, is above 23 per
cent less than in Glasgow ; while there is a corresponding increase in
the proportion of deaths at tbe higher ages ; while the proportion of
deaths at the early ages is the same in these two American cities- Dr.
W. considers it highly probable that inattention to early vaccination
may Ix; the immediate cause of a greater mortality at tlie higher ages
in Amcricji tlmn in Great Britain. {^Auur, Jour, Med. Sciaice, April,
1845— p. 515.)]
When the registrar-general of England first began
his labors (July I, 1837), it was found that, notwith-
standing ihc benefits of vaccination, there were still
only four diseases which stood before small pox with
MORTALITY OF SHALL POK.
reference to the actual amount of mortality. Those
still uiorc fatal complaints were — consumption, convnl-
sions, typhus fever, and pneumonia. In the second
half of 1837 there died, throughout England and
Wales, by small po.\, 5811 ; and in the metropolis, 763.
The year 1838 was remarkable for the epidemic preva-
lence of small pox throughout this country. In that
year there died by small pox in England and Wales
no less than 16,268 persons, of whom 3817 died in
London. In 1839, a marked diminution took place.
The deaths over the whole country amounted only to
9131, and in the metropolis to 634, which, as com-
pared to the total mortahty in that year, is little more
than 3 in 100.
At the Small Fox Hospital, the admissions, from
1776 to 1800 (a period of twenty-five years), were
7017 — and the deaths 2277, being at the average rate
of thirty-two and a half per cent From 1801 to 1825
(a like period), the admissions were 3743, and the
deaths 1118, being at tlie average rate of thirty per
cent, of those attacked. Since 1825, the proportion of
deaths to admissions has experienced a further diminu-
tion. At the present time the deaths do not exceed
twenty-five per cent, and in some years they have
lallen as low as twenty per cent., or one in five. Tak-
ing the world throughout, and making allowance for
the character of cases which are usually sent to a
hospital, we may state the average mortality by small
pox at one in six of those attacked. Now this is
exactly the calculation made by Dr. Adams thirty-five
years ago, when he said that small pox occasioned very
nearly a double decimation.
The proportion of severe to mild cases is a subject
74 PROPOKTION OF SEVEBB CASES.
which merits attention. The following tahle, which
exhibits an anal^'sis of the cases admitted into the Small
Pox Hospital during four years, with tlie deaths in each
respective class, will show, at one view, the numbers
admitted, the comparative severity of the cases in the
respective years, and the amount of mortality.
TahU exhibiting Ihe proporlion. of Severe lo Afild Ca»et, admitted into
the Small Pox Hospital, in. the Ytan 1837, 1838, 1839, and
1841.
'"'■rr.'. '"
183
1S36-
IMS.
1841,
rx:^
^l-'
-.-
J'u;.
0,^.
^,i.
a-L
^
Dtad.
t>»d.
ConflucDl C«sai . . .
Semi-confluent . , .
Conflucnl li. ^mi-coD- )
ducnt Mudilied , , \
Distinct i. Varicelloid
Total . - . .
104'
4a
3
1
351
lao
154
ITO
la
5
48
31
18
48
as
i
134
71
38
99
4
1
a
637
267
143
373
304
8
3
339
46
GS4
m
145
a:
34a
74
1420
335
In tiic foregoing table it will be perceived that the
vaccinated and unvaccinated are classed together, the
object of the table being to show the proportion which
the mild Ijear to the severe cases, without reference to
the cause of such discrepancies. It will also be seen that
the conlliicnt and semi-confluent cases taken together
exceed tlie half of the admissions; that nearly one half
of the conlluent cases prove fatal, and about one in ten
of the semi-confluent cases. Tliedeatlisiu the remain-
ing classes are to be looked upon only as accidental and
superadded events.
The next table that I lay before you carries the
analysis still further, and shows ihe comparative severity
of the cases, as they occurred among vaccinated and
unvaccinated subjects. This table 1 have given for one
year only, 1838, the year of epidemic prevalence.
OOHPABATIVE MORTALITY.
75
Table exhibilitiff the Comparative Mortality of the several varirtioa of
Normal and Abnormal Small Pox, oeeurrinp at Ike Small Pox
ffoipilal, daring the epidemic fif 1838, diatinffuisking the vaeei-
iiatedffmn the unvaccinaled.
.c™,. ..„„„.
Vbco
Dnled.
Admilled.
Died.
Admilled,
Died.
Confluent
Semi-confluent ....
Distinct
Total Normal . .
Confluent Modified . .
Semi-confluent Modified .
Varicelloid
Total Abnormal , .
295
18
19
149
8
42
20
21
4
392
157
US
25
2
1
1
38
28
114
4
1
1
i
180
6
398
157
298
31
This table shows how remarkable is the power of
vacciuatioti in altering the proponion of severe to mild
cases. It will be seen that among 396 unprotected
cases, there were onlj' 23 which were mild in their
aspect ; while out of 298 vaccinated subjects, there were
no less than 134 which presented, from the onset, favor-
able appearances, independent of GG, which displayed
modification during the maturatlve stage.
The next point which merits attention is the period
of disease at which death takes place. Small pox may
prove fatal at any period from the first invasion of fever
to the fortieth day. Death may even take place prior
to the development of eruption, but such cases are rare.
In all countries it is observed that the second week is
that which exhibits the greatest amount of mortality,
and the eighth day the day of greatest danger. The
76
FATAL PERIODS.
subjoined table, extracted from the records of the Small
Pox Hospital for 1828-9, shows the period of eruption
at which 168 patients died. The dates of their decease
prove satisfactorily that no importance can be attached
to the doctrine of critical days in the fever of small pox.
Table exhibiting the Days on which 168 Ctisea of Small Fox proved
fatal, at the Small Pox Hospital, 1828-29.
Dajrs.
Fatal
Cases.
Days.
Fatal
Cases.
Days.
Fatal
Cases.
3d
1
13 th
11
24th
3
4th
5
14th
5
25th
5th
10
15th
7
27 th
6th
5
10th
5
28th
7th
11
17th
3
29th
8th
27
18th
3
31st
9th
15
19th
1
82d
10th
U
20lh
2
35th
nth
16
22d
3
3 8 th
1
12th
1
11
23d
1
39th
Wc may otherwise arrange these cases by saying,
that there died
((
ii
i(
((
i(
u
(i
((
During the 1st week (3d day to the 7th), 32 Patients.
2d week (8th to 14th), . . 99
3d week (15th to 21st), . . 21
4th week (22d to 27th), . . 9
5th and Cth weeks, ... 7
It may be useful, in connexion with these statistical
details, to recall to your recollection the principal cir-
cumstances to which the fatal event in small pox is more
immediately attributable. 1. Prior to the maturation
of the pustules (that is, during the first week), small pox
proves fatal by that general derangement of the whole
system, and more especially of its fluids, which we
usually designate by the term, acute malignaricy. No
marked lesion of any internal organ would be traced on
DIRECT CADBES OP DEATH.
dissectioD. 2. During the second week of eruption, the
chief cause of death will be found in the specific affec-
tion of the trachea and larynx, and consequent asphyxia.
3. During the third week, when secondary fever has
begun its work of devastation, death may happen, either
by effusion on the brain (hydrocephalus), or by super-
vening pleurisy, pneumonia, or laryngitis, or lastly, hy
gangrenous destruction of portions of the skin. During
the 4th and subsequent week, death may he the direct
consequence of erysipelas, or of some other complaint
excited by the small pox, or engendered by that debility
which small pox, in any of its severer forms, so frequently
entails.
[M. Trousseau remarked, in speaking of a p«-se of death from discreta
Tariola, that the exflctness of a rule given hy Sydenham, an<l repeated
after liim by Von Swieten & Stoll, was verified in it, vii. that when
there is no tumefaction of the face and eyelid?i in variola, death takes
place on the 9th or lOLh day if tlie disease U discrete, and on the 13th
or 14th if it is confluent. (Clin. de» B6p. det EafanU ; quolrd hy Lon-
don Laiii-et. American Republication, May, 1848, p. 441;.)]
The phenomena and statistics of small pox being now
described, I proceed to explain to you its causes, — to
unfold what is known regarding its origin and mode of
propagation, and the circumstances nnder which It com-
monly displays itself. This we call the pathology of
the disease, by which is understood everything that can
be learned concerning a disease by reasoning upon
acknowledged phenomena.
For more than a thonsand years after tlie first appear-
ance of small pox in Egypt, its causes were sought for
in the condition of the blood, or in those circumstances
of the body, or of the atmosphere which surrounds the
body, which were beheved, and justly too, to give rise
80 SPONTANEOUS ORIGIN.
that the variolai vaccina} originate spontaneously. lie says that it is
not doubted by the farriers of that place, and that, in all the cases he
has observed, he could never discover the probability of any other
source. (Observations on Variol® Vaccinae. Trans. Provinc. Med, and
Surg, Assoc,^ vol. viii. p. 300.)
K the cow pox thus frequently originate, analogy would seem to offer
strong reason in favor of a similar origin, at least occasionally, of the
human small pox, which so closely resembles it
It must be acknowledged respecting them all, and especially with
reference to measles, scarlet fever, and hoojnng cough, that they some-
times occur in such a manner and under such circumstances as almost
to exclude the idea of contagion.
A striking instance of a case of variola without obvious contagion, is
given by Dr. Banks, of Lawrenceville (111.), in \)[iQ Philadelphia Medical
JSxaminer, new series, vol. v. p. 519, from which it is quoted in the
Brit, and For, Med, Chir, Rev,^ April, 1850, p. 533. The case pre-
sents several points of interest. The editor of the Examiner refers also
to two other cases, where the idea of contagion seemed to be out of the
question.]
To understand, therefore, the origin and propagation
of small pox, you must view it, not only as a contagious,
but as an epidemic disorder. And first, of the conta-
gious origin of small pox.
Contagious emanations are given off from the human
body at every stage (.f small pox, from the first invasion
of fever to the throwing off of the latest scabs. Heber-
den and Haygarth believed that for the first few days,
fiid during the initiatory fever, a patient seldom, if ever,
communicated the infection ; but this notion is erro-
neous. I have even been tempted to think that in the
very earliest periods of the disease the communicating
power is most energetic.
[Heberden fixes the probable time of communication at the sixth day
of the eruption. Chapman (Eruptive Fevers) agrees with Heberden,
but thinks it probable that, as in tlie instance of the vaccine affection,
the contagion may exist in the vesicle as well as in the pustule.
PREDISPOSING CAUSES.
frl
Prof. A. Clark, of this cily, from a cnrefiil esnminalion of llie caaea
vhich have occurred at the New York Ilospltal for a series of years, is of
the opinion ibal the disease is not communicated until the eruption hai
reached tlie vesicular form.]
The dry scabs of small pox retain a conlaglons
property for a great length of time. Ejtperience, too,
has taught us that death does not destroy the energy of
the purulent secretion, A child has been successfully
inoculated with matter taken from the dead body. A
confluent case will taint the air and spread infeciion for
at least len or twelve days after death. The know-
ledge of this fact has induced the Secretary of State to
issue orders that the bodies of those dying of small pox
are not to be admitted into the schools of anatomy.
The circumslances that determine the quantity of
eruption and the general character of the disease are
not well known, though many attempts have been made
to throw light on this obscure branch of exantheuiatic
pathology. Notliing is belter ascertained than that the
disorder produced bears no necessary relation to the
disorder producing. A confluent case shall give origin
to a varioloid, and a uiiid distinct, nay, even a varicel-
loid, or highly modified case, shall generate in another
person malignancy and confluence. The predisposition
to the reception of the variolous germ is an interesting
branch of this inquiry. Persons in the best health take
small po.v, and, upon the whole, are more apt to take
the disease than those who are out of health, just as we
find it most easy to vaccinate successfully the ruddiest
and finest children. The state of mind generally said
to be most favorable to the reception of the virus is a
dread of the disease. There is probably some truth in
this statement, but you will meet with exceptions to the
82 PREDISPOSING CAUSES.
rule, almost as numerous as the illustrations of it.
Change of air decidedly predisposes the body to receive
infection. But this is a law of the animal economy of
very wide application. It is this same principle, applied
io endemic fevers, which leads to the phenomena of
seasoning and accUmatization. You know that a regi-
ment arriving in the West Indies, or the crew of a ves-
sel first entering the Bonny or Calabar, are almost sure
of suffering from the remittent fever of those climates.
The quantity of eruption in any particular case is
sensibly influenced by the state of the surface at the
precise moment of development Whatever tends to
augment the cutaneous circulation, such as the warm
bath, abundant bed-clothes, strong diaphoretic and su-
dorific medicines, cordials, wine, heat of the apartment,
all concur in favoring confluence. The proved effect
of heat in promoting, and of cold in repressing eruption,
formed the keystone of the Suttonian practice of inocu-
lation. Small pox is almost always confluent, and fre-
quently fatal, when it occurs to a woman in child-birth.
Much may in this case be attributed to heat.
All local irritants, such as bHstcrs, mercurial inunc-
tion, and plasters, favor confluence in parts to which
they have been applied. Active purgatives, taken dur-
ing the incubative stage, lessen the quantity of eruption
by causing derivation of the fluids from the skin to the
bowels. A plethoric state of body equally disposes to
confluence, while it adds to the general severity of the
disease, and is the main cause of cellular complication.
Extreme weakness of frame delays the eruption, and
dangerously represses that inflammatory process which
is essential to the repair of the injury inflicted by the
poison on the skin.
HIASHATIO DRIQIir. 83
Lastly : it may be remarked that (here exists in cer-
tain individuals, and not unfreqiiently in members of
the same family, a pocuhar irritabihty, under the inflii-
eoce of the variolous conlagion, just as sonic persons
sufTer severely from the smallest doses and the mildest
preparations of mercury. The petechial form of smalt
pox has for its cause this idiosyncrasy, or peculiarity of
habit Such constitutions receive small pox with alarm,
develope it with difticulty, and sink under its elimina-
tion. On tlic oiber hand, oiher persons imbibe the
morbid germ mildly, nourish it without siifTering, and
eliiiiiuate it safely and kindly.
The miasm of small pox belongs to every part of the
body. It is given off both by the lungs and by tlie skin.
The breath, the secretions, the matter of the pustules,
the scabs, all contain it. It attaches itself to fomites,
more especially the clothes of the patient, the bedding,
and the bed furniture. These, if closely wrapped up,
and secluded from the air. will retain the miasm, and
^ve it out in an active state at great distances of time.
But free exposure to the air greatly diminishes or alto-
gelher destroys this infecting property; for the conta-
gion, whatever be its inllmate nature, is very volatile. .
The medical attendant, therefore, who goes into the
open air after visiting a small-pox patient, is seldom
found to communicate the disorder. Very absurd stories
have been gravely told regarding the time during which
fomites may retain their active powers. A physician at
Plymouth describes a case of small pox originating in
contagion brought from London in a periwig. Another
doctor assures us that he knew a maid-servant who took
small pox by washing tlie floor of a room two years
after any small pox patient had been in it.
84 EPIDEMIC DIFFUSION
Experiments were made in 1832, by direction of the
Royal College of Physicians of London, for the purpose
of determining the power which a high temperature and
chlorine gas are said to possess of destroying the activity
of variolous contagion ; but the results were unsatisfac-
tory. The sphere of contagious influence has been
much questioned. Dr. Haygarth's opinion was that it
was very limited, not extending more than a few feet
from the patient's body. On the other hand, an Ameri-
can physician, corresponding with Dr. Haygarth, affirms
that the contagion, on one occasion, crossed a river
1500 feet wide, and affected ten out of twelve carpen-
ters at work on the other side ! It is undoubtedly very
difficult to fix the distance at which the variolous poison
ceases to be energetic ; but it is almost certain that the
constitution of the air, in epidemic years, permits a very
wide diffusion of the germ.
Variolous matter may be diluted with water without
its properties being in any degree altered. Dr. Adams
first established this fact, which has since been corrobo-
rated by the analogous experiments of M. Bousquet
with regard to cow pox.
We must now view small pox as an epidemic disor-
der, as one that spreads in particular seasons, and in
certain districts, without our being able to ascertain why
that district, or season, is subject to such a visitation.
The great epidemics of the last hundred years, in Lon-
don, have been those of 1757, 1781, 1796, 1825, 1838,
and 1844, the respective intervals between which have
been 24 years, 15 years, 29 years, 13 years, and 6 years.
Epidemic visitations, whether of small pox, or of any
other alhed malady, acknowledge alike the law of rise,
culmination, and decline. They advance gradually.
attain ihoir crisis or height, and ihen gradually decline.
Mr. Farr has, wirh his usual ingenuity, traccil the laws
which appear to govern each of these stages of epidemic
progress, and he arrives at the conclusion that epidemic
decline is always less rapid than its advance.
[It may Dot be uninleresting to slate more particularly the taw of the
riw and decline of small pox to which our author alludes. Mr. Farr
aya "it appears probable that the small pox increases at an accelerated
and iheD at a retarded rate ; lliat it declines first at a bliglilly accele-
mted, then at a rapidly accelerated, and lastly at a retiirded ral«, until the
dj»ease attains the minimam intensity and remains stationary." The
came law is said to apply also to measles, scarlet fever, and hooping
cough, in London.]
Sydenham remarked that when a small pox epidemic
is mild, il begins about the vernal equinox (March 25) ;
hot when of an extended and dangerous kind, it begins
in the month of January, These observations are not
confirmed by modem statistics. The last epidemic
which the metropolis experienced began in November,
1837, reached its acme in June, 1838 (being a period
of eight months) — then slowly dechned, and ceased
entirely in January, 1839, extending tlms through a
period of fifteen months. The epidemic of 1796 fol-
lowed a course very similar in all respects.
Some epidemics are local, some are very extended.
Small pox broke out in Norwich in 1319, and destroyed
63U persons in that city between the months of May
and October. It did not spread to other parts of the
country. The epidemic small pox, the most remark-
able for its extensive diffusion which perhaps ever
occurred in the world, was that which began in Swe-
den, in 1824, — reached England in 1825, spread to
France in 1826-27, and ceased, in Italy, in 1828-29.
86 EPIDEMIC DIFFUSION OF SMALL POX.
The effects of this epidemic were very remarkable, and
will be noticed hereafter, when the results of vaccina-
tion are laid before you. Mr. Farr, in his second
Report (1840), has given a very interesting table, show-
ing the rise, culmination, and decline of the variolous
epidemic of 1838, in each of the great districts of Eng-
land. From this table it appears that the epidemic
commenced in Liverpool in 1837, spread through the
southwestern counties to the metropolis, diverged to
Manchester and Leeds, raged in the eastern counties
during the first half year of 1839, and then returned to
its old haunts in Lancashire, after making a sweep
around the island. From this fact alone we might
learn, what innumerable other observations teach us,
that the miasm of small pox is very indifferent to sea-
sons, that the frosts of winter and the heats of summer
are alike congenial to it.
Small pox will sometimes spread in a cold and moist
state of the air, sometimes wjien the atmosphere is clear,
bright, or frosty. Nothing, in fact, has ever been
observed, either with respect to the temperature, the
moisture, the winds, or the general character of the
atmosphere, which can throw light on the sources of
epidemic visitation. It is worthy of remark, that the
mortality by small pox always increases in years of
epidemic prevalence. Small pox is then not only more
abundant, but more severe than when it occurs as a
sporadic malady. The difference in the rate of mor-
tality may amount to ten or even twelve per cent.
The susceptibility of small pox next claims our
attention. All mankind, with few exceptions, are bom
with a susceptibility of small pox. The European, the
SUSCEPTIBIHTV TO BUALL POX. 87
cegro, and the Hindoo, in tliis respect, at least, are on
a par. This susceptibility, unless ahered by vaccina-
tion, remains equally strong at all ages. Children,
indeed, are the especial victims of small pox, but this ia
merely because the disease is usually contracted on the
first occasion of exposure to the miasm. There died
in London of small pox during the two years 1840-41,
223G persons, of whom 2060 were under, and only 226
ahove 1.5 years of age. Nevertheless, to this law there
are occasional exceptions. Persons have been known
to go through hfe, e.vposed frequently to the contagion,
yet never take it. Prior to tJie discovery of inocula-
tion, and indeed after it, many thousands of mankind
attained a good old age without ever experiencing an
attack of small pox. Vet persons exhibiting this natural
onsusceptibility, have nevertheless, late in life, received
the disease by inoculaliou. A lady residing in Salis-
bury was successfully inoculated for small pox in 1804,
at the age of eighty-three, and lived several years after-
wards. She had brought up a large family, many of
whom she bad attended in an attack of small pox, but
had never taken it herself A (cw persons pass through
life apparently insensible to the variolous vims, whether
casuallv or by inoculation; but such cases are rare.
This very estimable privilege has been said to attach
to particular families, hut there is no foundatioD for the
notion.
The great discovery of modern times is, that an
onsusceptibility, or at least a deferred susceptibility of
small pox, may be given to man artificially. We may
80 alter and modify the state of his blood that he can-
not take it. I need hardly tell you, that this expedient
is vaccination. The security which it affords may be
88 RECURRENCE OF SMALL POX.
permanent through life, or only temporary; but observe,
— this is no more than happened to a few favored indi-
viduals, by an inexplicable idiosyncrasy, before Jenner
was born, or vaccination dreamed of.
If there are people in the world who cannot be made
to take small pox, this is more than compensated by
those who have the bad luck to fall into it twice.
Cases of secondary or recurrent small pox have been
described in all ages, from 1{ hazes down to our own
times. They were never very common — rar(z aves
always — but they have occurred, and they may occur
again. You must not, however, give credit to all that
you hear said nowadays on the subject of secondary
small pox. One gentleman, in reply to the queries of
the Provincial Medical and Surgical Association,
informed us, that in his own practice he had attended
between eighty and ninety cases of recurring small
pox ! He even goes further, and avers that he knows
two families where small pox occurred a third time.
Contrast with this the opinions of Dr. Mead, Dr. He-
berden, Dr. Monro, De Haen, and other practical men
of the last century, who hesitated very much about the
possibility of genuine small pox recurring. Remember
that De la Condamine, in 1754, estimated these cases
at one in ten thousand ; others, at one in five thousand.
At the Small Pox Hospital, very few persons ever pre-
sent themselves who affirm that they have previously
undergone small pox ; and of the few who do, but a
very small fraction can stand the test of rigid scrutiny.
In one of the last cases that occurred, a medical man
who witnessed the first seizure had misgivings as to the
true nature of the case. No instance is recorded of
the same person having been admitted twice into the
RErrilRRENCE OF SMALL PUX, 89
Small pox Hospital. You may ask me why I am thus
incredulyus on the subject of recurrent small pox 1 It
is not that I have any theory to support, but it is
because I know there are so many sources of fallacy.
Sometimes the first case is incorrectly reported ; some-
times the second. It is very rare that the same medi-
cal maD sees and reports both the seizures. I have
seen three cases of pustular syphilis so like small pox,
that a careless observer, — nay, even a very careful
observer, were he only to see the case once, might
easily be deceived. But it is not only tiie pustular
forms of syphilis which gives rise to mistakes. Lichen,
and, above all, varicella, are fruitful sources of error.
I was ouce called in to see a case of alleged secondary
small pox, which, on investigation, proved to be
ecthyma. I have evenseen psora mistaken forsmall pox!
Id Dr. Baron's Life of leaner (vol. i. p. 278), it is
remarked, " that when Jenner's discovery was first
announced, it had escaped the attention of medical men
that small pox occurred a second time so frequently, as
it has since been proved to do, botli by recent experi-
ence and past history." "Such an impression," adds Dr.
Baron, " led to a too confident announcement of the
never-failing eflicacy of vaccination," It is scarcely
conceivable that Jenner, who for thirty years had been
studying small pox closely, should have been so ill-in-
formed on one of the most curious points of variolous
pathology as is here alleged. It is difficult to believe
that a principle of such importance shonld have escaped
observation at a period when men's minds were so
strongly drawn to the subject, and have attracted notice
only when small pox was comparatively rare. The
probability, therefore, is, that Jenner was correct in his
90 CASE OP LOUIS XV.
early views of the permanency of the protection which
one attack of small pox afforded, and that the ardor of
his followers in their support ( f vaccination led them
to overrate the frequency of recurring or secondary
small pox.
With this impression strong upon my mind, I cannot
go far into the history and peculiarities of recurrent
small pox. I may, however, state to you, that some
pathologists connect the phenomenon with a peculiar
proneness in the system to suffer under the variolous
virus. They argue thus, from observing that all well
authenticated cases of second small pox have been of
persons who in the first instance took it severely.
Another class of pathologists explain the circumstance
by supposing that the first attack had not been in suf-
ficient intensity to absorb the whole amount of suscep-
tibility. They argue thus, from having noticed that
the fii-st attacks have been inild. This question I can-
not undertake to decide, — tantas componere lites.
The most remarkable case of recurrent small pox on
record is that of Louis XV., king of France, who died
of it in the year 1774, at the age of sixty-four, after
having, as it is alleged, undergone that disease casually
in 1724, when he was fourteen years of age. I have
been at some pains to investigate this case, which cre-
ated a great sensation at the time, has been quoted over
and over again, and to which great importance has
been attached. After careful inquiry into dates, the
character of the incubative stage, and the course of the
eruption, I convinced myself that his Majesty never
had small pox in early life, and that the primary attack
was varicella.
COMMUNICATION TO THE P(ETUS. 91
[For Temnrks on the occurrence of small pox a second time in tba
■aniQ individual, itnd elatistics showing i\» comparative frequency, Bee
Appendix D.]
Among ihe pectiliarities of small pox, the possibility
of its occurriiig simultaneonslj with other exantheiiiatit
must not be oDiittcd. Measles and small pox have
appeared together, and run their respective normal
courses, uninfliicneiug each other. At the Small Fox
Hospital, I have seen many unequivocal cases of the
concurrence of small po\ and scarlatina anginosa.
Small pox and cow pox may co-exist, as I shall after-
wards more fully explain. Sometimes each disorder
runs its natural course. Occasionally one or other
malady is modified either in aspect or progress.
[For inslances of co-existence of small pox with other eianlhemala,
see Appendix C, hefuro referred to.]
There remains only one topic connected with the
pathology of small pox, on which 1 would wish to
address you ; and that is, the commuuicability of the
disease to the fcetus in utero. Dr. Jcnner, Dr. George
Pearson, ami others, have collected many curious facts
on this subject, aud I am desirous to acquaint you with
some of the most interesting of them. To do full jus-
tice to the subject would lead me into a wide but
unproiitable path.
It does not necessarily happen that a pregnant woman
taking small pox conveys the disease to the child.
Several iustances to the contrary have occurred at the
Small Pox Hospital. An opinion was entertained by
Dr. Mead (but erroneously), that in cases where a
woman undergoes small pox williout aborting, the infant
would remain through life unsusceptible, having, in fact,
passed through tlie disease iu utcro. Dr. Jenner has
92 COMMUNICATION TO THE FCETUS.
detailed two cases which prove very satisfactorily that
a foetus in utero may contract small pox, provided the
mother be exposed to the contagion, although she her-
self does not take it. An infant born under these cir-
cumstances sickened for the small pox five days after
birth, and twelve from exposure to contagion.
In a large proportion of cases, small pox communi-
cated by the mother to the foetus destroys the infant's
life. The child is often still-born.
[For particulars of the cases reported by Dr. Jenner, referred to by
our author, and a record of other cases and references on the subject,
see Appendix K]
In the neighboring museum of Guy's Hospital there
formerly was, and perhaps is still, a foetus preserved,
whose skin is covered with variolous pustules. Mr.
Heaviside's museum contained a similar case.
[A very well marked and well preserved specimen of the same kind
is to be seen in the Museum of the College of Physicians and Surgeons,
of this city.]
The earliest period of foetal life at which I have ever
seen traces of variolous eruption is four months.
It is very seldom that a pregnant woman dies of
small pox without aborting, or giving birth to the child.
This seems to be a very general law of nature, applica-
ble to all severe maladies, whether acute or chronic. A
pregnant female, if consumptive, lives to give birth to
her child, though she herself may sink, exhausted, within
a few hours afterwards. It is apparently a provision of
nature, giving to the offspring, under all circumstances,
the best chance of life. The principle is illustrated in
the history of scarlet fever, not less remarkably than in
that of small pox.
LECTURE V.
MANAGEMENT OF SMALL POX.
H noliona formerly entertained on tliis Bubjcct. Souflfs of danger
in sm.tll \iox. Trentment during tho iiiiliaiory fever. Question pa lo Ibe
employment, of blood-letliDg. Trentment during the maturalive stage.
TrvKtment or Ibo mucous implication. Local treatment of the pustules.
Hsruigcinent of the petechial form of small pox. Treatment in Iho
•ecendory fever. Controversy ns ti> the employment of purgatives in
email pox, Treulment of the sequels of amall pox. Extvmiil Ireatment
during secondary fever. Inoeulailon nf small pox. Mode of practice,
Plienomenn of inoeulailon. Results of inoculation. AboUfion of inoeu-
TiJE power of medicine over small pox is not so striking
as it is over inflaniinatiotts, over bowel complaints, over
agues, or many other types of fever, IS evertheless,
metliciue does exert a certain amount of influence over
the course of this disease. Wliether it does so, bow-
ever, or not; whether the amount of that influence be ,
great or small ; in either case llie management of small
pox must be carefully investigated by yon — first, lest by
your measures you may do mischief, and make bad
worse ; secondly, because the world expects you to do
something for the benefit of your patient, and vvliat that
something is you must be taught, reuicmberlng always
that improper treatment may do harm, though ibc very
best may not do good.
It is a melancholy reflection, but too true, that for
many hundred years the efforts of physicians were
rather exerted to ibwart nature, and to add to the ma-
lignancy of the disease, than to aid her in her efforts.
Blisters, heating ale.xipbarmics, large bleedings, opiates.
ERRONEOUS NOTIONS OF SHALL POX.
oiotments, masks, and lotions to prevent pitting, were
idle great measures formerly pursued, not one of which
■■can be recomuieuded. Wliat tliink yoa of a prince of
' the royal blood of England (John, the son of £dward
the Second) being treated for small pox, by being put
into a bed surrounded with red hangings, covered with
red blankets, and a red counterpane, gargling his throat
with mulberry wine, and sucking the red juice of pome-
granates T Yet this was the boasted prescription of
f John of Gaddesden, who took no small credit to him-
lelf for bringing his royal patient safely through the
disease. We may smile at this ; but if either he, or
Gordonius, or Gilhertus. were to rise from their graves I
and inquire whether this is one wbit worse than Mes-
merism, or at all more absurd than homoeopathy or
hydropathy, we should, I fear, look a little foolish. Let
ns, then, avoid the errors of our ancestors, without
reproaching them.
Even physicians, in more recent times, have enter-
tained very erroneous notions regarding the powers of
medicine in the treatment of small pox, and the objects
which ought to be kept in view. They imagined that
certain drugs possessed a power of promoting the erup-
tion of small pox, and not only of promoting it, but of '
procuring a favorable sort. They arrogated to them-
selves a like power of controlling secondary fever, and
preventing its necessary consequence — pitting. We
pretend to no such power. We know that the system
has imbibed a morbid poison, which, somehow or other,
must be got rid of; and consequently we study to place
the system in the most favorable circumstances for the
safe elimination (or concoction) of the morbid matter.
We propose to ourselves, therefore,
SOURCES OF DANGER. 95
1. To moderate the violence of febrile excitement
whenever we meet with it.
2. To check and relieve local determinations of blood,
at whatever period of the disease they arise.
3. To support the powers of the system when it flags,
either from the malignity of the poison or the long
continuance of the disorder.
4. To combat, by appropriate means, concouiltaut
disease.
You will bear in mind what I told you in a preceding
lecture of the various sources of danger in small pox.
As it is very important, in undertaking the management
of the disease, to keep these in view, I will recall the
principal circumstances to yonr minds. Danger in
small pox depends — 1. on the quantity of eruption;
2. on the condition of the mucous membranes; 3. on
the state of the fluids; 4. on the slate of the brain and
nervous system ; 5. on the age of the patient ; 6, on
his habit of body ; 7. on the circumstances in which he
is placed.
1. Distinct small pox is a disease of littlp or no
danger. Confluence is always unfavorable, especially
on the face ; nor is the danger always apparent. A
confluent case shall sometimes appear to progress favor-
ably, when, unexpectedly, a fit of convulsion occurs, and
the patient sinks. The drain upon the system which
excessive pustulation occasions is another source of
danger; nevertheless, if the pustules on the extremities
acuminate well, and exhibit a crimson areola, a good
ground of hope exists. If, on the other hand, the vesicles
on the trunk and extremities be flat, with a clareiy
areola, white the eruption on the face is white and pasty,
no reasonable hope of recovery can be entertained.
96 SOURCES OF DANGER.
2. The condition of the mucous membrane of the
trachea is equally important. Hoarseness at an early
period of the disease is always to be looked upon with
suspicion. A natural tone of voice is a good omen,
even though the eruption be full and confluent, with a
disposition to cellular complication.
3. The condition of the fluids in small pox is a fea-
ture of the utmost importance in guiding your judgment
as to the probable result of the case. Everything which
indicates putrescency and a dissolved state of the blood
is highly unfavorable. Petechia;, mucous haemorrhages,
menorrhagia, and vesicles filled with blood, preclude
the hope of benefit even from the most judicious treat-
ment.
4. A tranquil state of the nervous system is peculiarly
favorable, and the circumstance to which recovery in all
severe confluent cases is mainly attributable, duiet
nights, composure of manner, a contented disposition,
and confident hope of recovery, are among the most
pleasing signs that can occur, llestlessncss, a succes-
sion of sleepless nights, constant moaning, and despond-
ency, afford little prospect of eventual recovery. Chil-
dren who grind their teeth seldom recover.
5. Age is a point of great moment in estimating the
degree of danger in confluent and semi-confluent cases.
The extremes of life arc those on which small pox
always falls the heaviest. Persons above forty years of
age seldom recover even from the semi-confluent small
pox. Children are in danger from an amount of erup-
tion that can scarcely be called semi-confluent In
both, the process of cicatrization is attended with great
exhaustion of nervous power, the result of which is
often the setting up of acute inflammation in an internal
i
aoDRCES OP OAHOBE.
organ essential to life — either the brain, the larynx, or
the lungs. The most favorable age for taking small
pox is from the seventh to the fourteentli year, when
the powers of Ufe and reproduction are in their fullest
vigor.
6. The habit of body is also to be taken into account.
Small pox is always aggravated by its concurrence with
a state of plethora. Conslhutional debility is equally
to he dreaded. In the strumous habit, the sequels of
small pox are peculiarly severe, and' often threaten the
loss of life when the first dangers have been passed.
7. The probability of recovery must depend, lastly,
on the circumstances in which the patient is placed, —
on the possibility of applying remedial measures effec-
tively, on the treatment which may have been pursued
tD the early stages, and other contingencies, which
scarcely admit of enumeration. In hospitals, the risk
of contracting erysipelas, and falling imder the influ-
ence of hospital miasm, must never be lost sight of.
In private life, again, the anxieties of friends may
prompt a more stimulating regimen than prudence
would dictate; and thus may local congestions and
inBammations be excited, from which the hospital
patient is exempt.
With respect to the initiatory fever of small pox, it is
cither known or not known that small pox is approach-
ing. If it be not known, then the case is necessarily
treated as one of common fever, to which ordinary mles
apply. On the other hand, if it be known, or strongly
suspected, that the variolous poison is circulating, then
the question arises, should tliere he any corresponding
difference of treatment ! Are you, on that account, to
TEEATHIIIIT m tNlTIATOKr FEVER.
or the
refrain from bleeding, or to practise it ? — i
gative. or to withhold it t It is always desirable
ascertain. If possible, the fact of variolous origin, for the
same reason that it Is better for a man to work in
light than in the dark, hut the diSerences in treai
are not material, as you will soon perceive.
In the initiatory fever of small pox, tlie antiplilogist^
treatment is to be pursaed, except in a few special
cases. The surface is to be kept moderately cool. A
brisk cathartic, composed of four grains of the chloride
of mercury, vrith eight of the compound extract of colo-
cynth, may be given with great propriety, when there
is considerable tumult of the general system. Saline
draughts may be taken frequently in a state of efferves-
cence, with the addition of a pill containing three grains
of James's powder, lint if there be present pain of the
back, or of the head, or of the epigastrium, more urgent
than these measures can effectually control, blood may
be taken from the arm.
It has often been said, that blood-Ietling, in the fever
of invasion, interrupts the process of nature, repels the
eruption, or so retards it, and so weakens the constitn-
tion, that the due concoction of the pustules is never
effected. It is undeniable that a man may be bled
unnecessarily and too largely in small pox, but a mode-
rate bleeding does no hann, and, if the fever runs high,
often does great good. If the pulse be sharp, or very
full, if the headache be severe, with accompanying epi*
staxis, blood-letting is not only useful, but absolutely
indispensable; for the eruptive process is often impeded
by the quantity of blood in the body, and the violence
of the arterial excitement Huxham justly said, "that
you should bleed in the onset of these fevers, for the
EUFLOYHERT OP BLOOD-LBTTING.
same reason that jou draw off part of a fenneiitmg
liquor, — to prevent tiic splitting of tlie vessel. By
drawing off some blood, you prevent the overdistending,
inHaniiug, and rending tlie vessels of the human body."
I can give yon no rules as to the quantity of blood to
be drawn. Consider the circumstances of each case,
and be guided by them. Your object is to unload and
relieve the lungs, the hver, or the brain. Whenever,
therefore, these organs are gorged, and their functions
impeded by a load of stagnant or inflamed blood-
when intense headache, extreme irritability of the sto-
mach, oppressed breathing, with a full laboring pulse,
give evidence of such general or local congestion, draw
blood, and let the quaniity drawn be such as to relieve
the urgent symptom. In some cases, when headache
predominates, witli suffusion of the eyes, leeches applied
to the temples, afford all the relief which is required to
take off the strain from the vessels. It is under these
circumstances that active purgative pills, followed by a
laxative draught, are so useful in diverting the fluids
from the head and surface to a mucous membrane
which is never implicated in the ordinary march of the
disorder.
Some writers, in their zeal for blood-letting, have
tried to persuade themselves that it is the only measure
which can be relied on to lessen confluence, and to
(ffeveot the development of pustules in the mucous
membrane of the throat and trachea. This opinion 13
altogether erroneous. Bleeding has no effect on the
quaniity of eruption, whether cutaneous or mucous.
The most confluent eruption has succeeded to the most
vigorous employment of the lancet. To bleed, there-
fore, merely because small pox is anticipated, with the
4
TU
TKBATHENT DOBINCT THE
Tiew, thereby, of prevcuiiug confluence, is uselessly to
expend that power which will be required for the
repair of injury to the surface. You will keep tliese
general principles before you, and take care ihat iu
your efforts to diminish internal congestion you do not
materially impah constitutional power.
If the stomach, durmg the initiatory fever, remains
very irritable, rejecting everj-thing that is taken, even
the sahne effervescing draughts with laudanum, which
you will naturally feel disposed to try, I recommend
you to apply mustard poultices to the epigastrium and
to the feet, and to promote eruption hy the pediluvium.
Again : if the circulation at this period be languid,
if the pulse be small and feeble, the skin pale, and the
extremities cold; if the patient lies on his back, sunk
and exhausted, let liini have immediately warm brandy
aiid water, cover him with bedclothes, apply mustard
poultices to tlie centre and extremities of the circulat-
ing system, and give thirty drops of laudanum, to be
repeated in four hours, if necessary. This cordial
plan of treatmeul must often be continued for several
days, when the eruptive uisus is accompanied with
depression, and nature appears so obviously unequal to
the effort.
While the pustules are in process of maturation, a
variety of measures may be pursued, which, without
interrupting the salutary and necessary process of ptis-
tulation, lessen the patient's sufferings, and prevent sub-
sequent difficulties.
If the eruption proceeds favorably, you would not do
more than lessen thirst by saline draughts, and occa-
sionally reheve the bowels by a dose of castor oil. If
HATURATITB 8TAOI.
101
the maturation of a large crop of pustules excites much
fever, it will be prudeut to employ more active purga-
tivps, such as calomel with colocynth, the compound
powder of jalap, or the iafusion of scDua witli salts, all
which cause a drain from the blood-vessels, and dimi-
uish arterial action. Place the patient in a large and
cool room, and cover him lightly with bedclothes.
Remove all flannel coverings which may usually be
worn next the skin. If the surface be very tender,
apply to it some cooling lotion, such as the decoction
of bran, wiili some spirit of rosemary. In all cases,
even of moderate intensity, it is proper to cut the hair
close, and so to maintain it during the whole course of
the diseasa The head is thus kept cool ; delirium is
relieved or prevented ; the risk of cellular inflammation
of tlie scalp diminished, cleanliness enforced, and an
opportunity afforded for the employment of evaporating
lotions, should more urgent symptoms arise. Opiates
may be occasionally administered at bed-lime, when
there is much cuticular irritation, or great distress from
want of sleep.
The diet of the patient should consist of tea, bread
ami milk, arrow-root, rice milk, and roasted apples.
Grapes, oranges, and ripe subacid fruits, are grateful to
the patient, and useful adjuvants to the antiphlogistic
remedies. Lemonade, apple water, tamarind water,
toast water, and milk and water, must be tbe ordinary
beverages. ^Sydenham permitted his patients to drink
small beer — an indulgence which may still be granted.
To that able physician we are indebted for this, the
cooling system of treatment in small pox. How
strongly does it contrast with the plan of stopping up
every nook and cranny, by which a breath of fresh air
102
TKEATHENT OF THE PUSTULES.
could gain admission, and drenching the unbappj suf-
ferer with treacle posset and symp of saffron !
One of the first objects which, in cases of more
nrgcncy, will attract your attention, is the condition of
the throat. Gargles of intusum rosie compos, afford
some relief When the difficulty of swallowing is very
great, and the tonsils much swollen, leeclies applied to
the throat, followed by poppy water fomentations, are
serviceable. Under these circumstances.some physicians
counsel you to apply to the throat, by means of a camel
hair pencil, a strong solution of lunar caustic (twelve
grains to the ounce), with the view of checking the
advance of the nmcous vesicles. 1 have not adopted
this practice, from a conviction that it would not afi'ect
the tracheal Inflamtnatiou, from which alone danger is
to he apprehended.
[Of Iftte yesn, the solution of nitrate of silver lias been applied to tba
posterior fauces and inside of the glottix, and even within the larynx, of
much ^BHter strength than that mentioned by our author ; and pei^
baps the iotroduction of a very strong Bolution of the ciyBtallixed nit
(sny 40 (o 60 graioB to Sj ; of distilled traler) l>eyoTid the epiglottia, hj
meauB of a sponge attached to a piece of wlialebone, or of steel properly
curved at the end, might modify the condition of the mucous mem-
brane of the larynx and tracliea, and relieve the patient of a comjilicaticni
which is very apt to compromise his life. This appiicatJon is said to
have been attended with suceem., ,
Cldoniretted lotions are also highly recommended for the throat and
nasal passages in severe cases of the confluent form.]
Three measures Iiave been pursued, having for their
object to diminish action on the surface of the body
during tlie maturatlve stage. The 6rst was that of
opening all the pustules, as fast as they ripen, by a gold
needle. This was the Arabian practice ; but it is as
useless as it is troublesome. The second is a modem
TREATHBNT OF THE FUBTULBS.
103
invention, that of appl)'iug lunar caustic to tlie pustules,
so as to destroy theiu at an early period of their growth.
As a partial appUcation — say, to vesicles forming near
the eye, — I can recommend tliis measure; but I cannot
advise you to employ it to any large surface covered
witii continent or semi-conllnent vesicles. The pain
which such au application occasions is very great, and
must, of itself, add largely to the danger of the patient
In the distinct form of small pox, the remedy would be
worse than the disease.
The latest mode of treating the surface during the
maturative stage of small pox is that of applying mer-
curial plasters, containing calomel or corrosive muriate
of mercury, or covering the whole surface with mer-
curial ointment. In the French hospitals at the present
lime, the latter mode is iu fashion. Tiie reports which
have reached me of its success, however, are not very
flattering. I have seen all tliree plans fairly tried at
the Small Fox Hospital. The ointment and calomel
plasters were inefficient. The plaster of corrosive
sublimate converted a mass of confluent vesicles into
one painful and extensive blister, but I am still to learn
what benefit the patient derived from the change.
Throughout tlie whole period of maturation, you will
look carefully to the state of the internal organs. In a
very large proportion of cases these are unaffected, but
bronchial in 3 animation, and even poeunionia, maj
aapervene, which you will meet by the usual remedies.
lo cases of delirium, carefully restrain the patient,
exhibit active purgatives, and wait until the full matura-
tion of the pustules shall have relieved the tension within
the head.
The petechial form of small pox admits of no essen-
104 HANAOEHEIfT OF THE PCTECIIlAL PORK.
tial relief from mediclDe. 1 can scarcely say that 1
can palliate even the most pressing symptoms. ActiM
pm'gatives are inadmissible. I have tried ihe inflnence
of mercury, but it is of no value here. The loss of a
little blood from the arm has appeared to me more
effectual than any other measure. The infusion of
roses and acid is prescribed more in conformity with
general usage, than with a view to any real benefit
The citrate of ammonia in etfervesceuce, witii port
wine and brandy, nmst be given when the powers of
life appear to fail, but tlie hccmorrhagic diathesis is often
accompanied by a liot skin and an excited circulation.
[Cases of tliis fona of diseMS occasionnlly recover under tbe free dm
of siimulants, when the hsuraotrhage from internal organs is not very
profuse, Dor very protraot«d. Soma sink at once without hiemorrhagd)
and without reaction enough to develope the variolous eruption.
In other oases, where petechia exist, or apota of purpura even of eoti-
uderahle estent, aud the prostration is not gtenl, and no liiemorrtutge
takes place from internal oi^ans, the prognoeis a very much less
unfavorable, I have seen varioSoid with this coinplieatioo pass favoN
ably through its stnges without interruption, the piA'pura lUsappcaring
in the coursu of a few days.]
The decline of the mild form of small pox requires
little else than attention to the state of die bowels, and
care lest too great indulgence of the appetite should
light up feverish excitement. A warm bath is always
advisable before the patient ml-ves again in society.
Vapor baths, when they can be procured, arc very
vicealile in promoting a more healthy state of
surface.
The dlfRcuhies id the management of small pox
begin with the setting in of secondary fever. Tlie com-
plications are then so numerous, the struggle betwei
TREATHBEtT IN SBCOKDART FEVER.
105
tlie disease aud the constitution so close, excitement
and exhaustiou tread so near upon each otiier, lliat it is
scarcely possible to assist you witli any mies admitting
of precise applicatioa. I shall satisfy myself, therefore,
with some remarks on the chief points which will
attract your notice, first treating of internal, and then of
external remedies.
One of the most remarkable dispntes which ever
arose in physic was that regarding tlie propriety of
using purgatives during the secondary fever of small
pox. Sydeudani, with all his boldness, never wholly
divested himself of the early prejudices which tlie Ara-
bians had inculcated against purgatives in small pox.
Morton inveighed bitterly against their use, while Dr.
Friend, with the trne spirit of a reformer, advocated
their free employment, especially during the secondary
fever.
In 1708 a young nobleman took confluent small pox.
Dr. Friend was called in wirh two physicians of the old
school. The arguments in the consulting room were
long and stormy. The patient died, in spite of the
purgatives which Dr. Friend's pertinacity had at length
induced his colleagues to agree to. A paper war suc-
ceeded, and from words the parties came to blows. Id
June, 1719, Dr. Mead and Dr. Woodward met io
Cheapsidc, drew their swords, and, after a few passes,
Mead came off victorious. This display effectually
settled the dispute, and purgatives are now as fi'eeiy
employed in the secondary fever of small pox as in
ague or in typhus. They are of the greatest service
when the skin is hot and dry, when scarlatinal rash
covers the body, or innumerable abscesses give evidence
of the excited state of the cutaneous vessels.
106 TKEATMBIfT III SECO!fDAKT FEVER.
pTofase postnladon demaDds tliat the strengtb of the
systcoi should be supported by uourishing diet, an allow-
ance of ale, porter, or wine, and cardial medicines. In
the great depression which sometimes succeeds the
destraction of large portions of the surface, wheu sub-
sdHus tcndiaam, geueral tremors, a feeble pulse, and a
dry tongue, attract observation, wine mnst be liberallj
adniiiiislered. with beef-tea, and a mixture containing
citric sther and the carbonate of ammonia in camphor
jolqt.
In the progress of secondary fever we sometimes
witness the access of rery acute seizures, such as phre-
nitis, apoplexy, pcripneumony, and pleurisy. Blood
may be taken freely from the arm in many of these
cases. In others, leeches aiTord the only palliative
which medicine can suggest. Blisters are, from the
condition of the surface, seldom, il' ever, applicable.
Syncope, palpitation, coM extremities, and other evi-
dences of deficient power, and cardiac implication,
demand the administration of wine and ether.
Erysipelas, succeeding small pox, must be treated with
reference to the accompanying state of the circulation.
For the most part, it is best combated by purgatives
and saline medicines. Sometimes, wine and die decoc-
tion of iiarl( are indicated. Ophthalmia is one of the
most serious evils which the secondary fever of small
pox gives rise to. The loss of blood, which the inten-
sity of the symptoms appears to warrant, would be
followed by great and perhaps irremediable esbaustioiL
In some caseH, therefore, the eye must be sacrificed to
save the patient's life. Leeches, cupping-glasses to the
temples, active aperients, calomel, pushed so as to affect
the mouth, with warm fumentations, are the remedies
k L
M
EXTERNAL TREATKEHT.
107
OD which you must mainly rely. In a more chronic
form ol' the complaint, blisters to the temples a0brd very
decided benefit.
When small pox has called into activity the dormant
seeds of scrofula, when irritable sores, irritable ophthal-
mia, enlarged joints, and ecthymatous pustutation, com-
hiiie to weaken an already debilitated frame, your
utmost efforts will be called into requisition, but often
with doubtful success. The best remedies are occa-
sional warm baths, a course of sarsaparilla, and mode-
rate doses of blue pill and rhubarb, to insure due action
of the liver. The remedy of most uuqnestionahle
efficacy is change of air. It imparts tone to the lan-
guid vessels of the surface, converts an ecthymatous
Burface into healthy granulations, improves the appe-
tite, and gives tone to the retina. The influence of an
altered air on the diseased actions of the body is better
displayed in the sequel® of small pox than m any other
known disorder.
A few words on external treatment will conclude this
division of the subject. When pustulation is profuse,
benetit is obtained by covering the surface liberally with
some simple dry powder. Starch powder, hair powder
(well dried), and the powder of calamine, arc alike
available for this purjHJse. Cold cream, and mild
unguents, such as the ung. cetacei, with a proportion of
oxide of bismuth, are useful when tliere is much cuta-
neous irritation wilh a dry surface. Fomenlalions and
poultices are the only local means of treating those
abscesses and erythematous Inflammalions which so
harass the patient and so fearfully peril life in the later
periods of secondary fever.
All the attempts made by the use of masks to prevent
108
INOCULATION IN SHALL POX.
pitting, cud in disappointnieoL The only effcctnal
means of lessening such disfigurement are those which
allay cutaneous action. Purgative medicines, low diet,
and free exposure of the face to a cool air, are the sole
measures on which your reliance ought to be placed.
[Other means besiiioa tliose menlioned in the text have been used for
preventing pitting, either by causing the abortion of the pustules in their
fbrmieg stage, or drying them up after maturation, and upon authority
which would seem to render them worthy of notice.
For the different applications wbicb liavc been recommended, i
manner of using them, their modus operandi, &c., see Appendix F.]
Inoculation having been abolished by act of parlia-
meut in this country, any lengthened details concerning
it would of course be superfluous, and very much out of
place. Nevertheless, a measnre so remarkable in its
consequences, and which, for the better part of a cen-
tary, was the object of general attention, to which
every individual in this kingdom above the age of
forty-two now trusts as his security from a loathsome
pestilence, must not be passed over without a short
comment.
Inoculation is performed by introducing into the arna,
at the insertion of the deltoid, by means of a lancet, a
minute portion of variolous matter. The thin lymph
of a fifth-day vesicle is to be preferred to the well-con-
cocted purulent matter of the eighth day, but both are
efficient. One incision only is to be made. A minute
orange-colored spot is perceptible, by aid of the micro-
scope, on the second day ; on the third or fonnh day a
sensation of pricking is experienced in the part. The
punctured poiut is hard, and a minute vesicle, whose
centre is depressed, may be observed, surmounting an
inflamed base. On the fifth day, the vesicle is well
HODB OF PRACTIOE. 109
developed, and the areola commences. On (he sLvth
day, tlie padcDt feels stiffness in the axilla, with pain.
The inoculated part has become a bard and inHamed
phlegmon. The sutijacent cellular membrane has
become involved in the Inflammatory' action. On the
evening of the seventh, or early on the eighth day,
rigors, headache, a fit of syncope, vomhing, an offensive
state of the breath, alternate heats and chills, languor,
lassitude, or, in the child, an epileptic paroxysm,
announce the setting in of fever. The constitution
has taken alarm, and sympathizes with the progress of
the local disorder.
On the appearance of febrile symptoms, the inflam-
mation of the anil spreads rapidly. An areola of
irregular shape is soon completed, which displays within
it minute confluent vesicles. On the tenth day, the
arm is hard, tense, shining, and very red. The pustule
discbarges copiously, and ulceration has evidently pene-
trated the whole depth of the corion.
On the eighth day, spots of variolous eruption show
themselves in various, and often in the most distant,
parts of the body. In a very large proportion of cases,
the eruption is distinct aud moderate. Two hundred
vesicles are counted a full crop. Sometimes not more
than two or three papula: can be discovered, which
perhaps shrivel and dry up without going through the
regular process of maturation. At other times, the
eruption is full and scnii-confluent, passing through all
the stages of maturation, and scabbing, and cicatriza-
tion, with as much perfection as the casual disease can
display. Between tliese extremes every possible variety
may be observed. The truly confluent erupliou with
affection of the mucous membranes is very rare, and
J
110 KOOS or PBACTICB:
t)iat liiiplicatioD of the fluids and of the uervous system,
which together constitute the extreme of variolous
maliguit)', is nearly, if not entirely unknowD. Secon-
dary fever, therefore, is not cominou, at least in any
intensity.
The rules laid down for the safe conduct of inocula-
tion were priucipally the following; — It should be per-
formed exclusively in persons free from actual hodily
disease, and neither plethoric uor scrofulous. It may
be safely practised at all ages, heginning at the third
month. It is improper to inoculate during pregnancy,
on account of the dauger to tlie child in utcro. It may
be practised iu all seasons and in all climates. It
proved not less successful among the negroes in Jamaica,
than in the inhabitants of St. Petersburgh, Perfect
health being the best coudition for receiving and safely
eliminating the poison, everything that tends to dimi-
nish plethora, to lessen cutaneous action, to render the
bowels free, to preserve the blood in a cool, pure, and
uoniial condition, was found useful. Laxative medi-
cine, a moderate diet, alistinence from all fermented and
spirhuous liquors, cool chambers, gentle exercise in the
open air, light clothing, — all contributed, in their several
degrees, to the successful result. The autimonial aod
mercurial medicines, which the Suttons laid much stress
upon, were useful only to secure the co-opcrutioD of
the patient in matters of more necessity, especially diet
and exposure to the open air.
You will naturally wish to know what was the prac-
tical result of inoculation. 1 will tell you in a few
words. Its influence in lessening the mortality of small
pox was something quite extraordinary, and scarcely
credible. With ordinary precautious in the choice and
RBSULTa OF IROCHLATKm.
preparation of subjects, not inore tban one in five hun-
dred cases will terminate unfavorably. Tlie ill success
which attended the early inoculations, between the
years 1722 and 1730, arose entirely from bad manage-
ment, from the most culpable negligence in the choice
of subjects, and an utter ignorance of all the principles
by which the practice of inoculation should be governed.
Had not the discovery of Jenner interfered to interrupt
its extension and improvement, inoculation would have
continued to this day increasing yearly in popularity.
It cannot be doubted that improvements in medical
science generally would have shed additional lustre on
this practice.
Since the introduction of vaccination, it has been the
fkshiou to decry inoculation, and to impute to it mis-
chief of which il was not guilty. The great objection
made to inoculation, and that which recently induced
Parliament to abolish it ahogothcr, under lieavy penal-
ties, was, that it disseminated the virus, and multipUed
the foci of contagion. Dr. Watkinson and Dr,
Schwenke, in 1777, and more recently. Dr. Adams,
broke the force of this argument, by pointing out how
important a part epidemic influence plays in the diffu-
sion of variola. Had they lived in our times, how
strongly would they have fortified iheir arguments !
We saw, in 1838, an epidemic small pox raging Id
London, where inoculation had long been discontinued.
The admissions into ihe 8mail Pox Hospital in that
year exceeded those of 1781 and of 17£)G. Inoculation
was abolished throughout England and Wales in 1840,
and the act has been most rigidly enforced; yet, during
the two last years, small pox has visited every county
of England.
RESULTS OP INOCULATION.
Sir Gilbert Blanc has attempted to prove bys
ihe evils of iDoculatlon. lie has shown that the pro-
portion which the mortality by small pox in London
bore to the general mortality, increased during the last
century from 78 to 94 per thousand, but many circum-
stances must receive attention before we are Justified in
drawing conclusions from this fact. The population
increased prodigiously in the interval, more indeed than
would suffice to explain the increased iiiortahty by small
pox. But, further, the general mortaUty diminished.
CoDsetiuently, tliough the actual mortality by small pox
had remained stationary and uninfluenced by popula-
tion, its ratio to the total mortality would appear to
augment. Thirdly, Dr. Adams has shown that a cor-
respondent increase took place in scarlet fever alid
hooping cough, whicli are not communicable by inocu-
lation. Lastly, a different mode of calculation would
exhibit a very different result. The sophism consists
in arranging your figures so as to include or exclude
years of epidemic prevalence. If, for instance, we
divide tlic last ninety years of the 18lh century into
three periods, we shall find that the recorded deaths hy
small pox were as follows : — 1711 to 1740 (when there
was no inoculation), 65,383; 1741 to 1770 (when
inoculation was coming ioto general use), 63,308 ; 1771
to 1800 (when inoculation was almost universal), the
deaths were only .57,268 : so that, by this showing,
inoculation diminished the mortality by 8115 lives!
Statistics are very useful, and deservedly carry great
weight witb them; but they may be enlisted, with a
little management, on both sides of an argument.
[For remarks on tJie influence of inoculation upon mortality, seo
Appendix G.]
ABOLITION OF INOCULATION. llo
One subject only remains for our consideration, and
that is. the question wiiether any circumstances would
still warrant us in recommeudiiig inoculation on scien-
tific principles ? Concurring most cordially in opinion
that the practice of inoculation by unqualified persons
ought to have been put down (uot in 1840, but forty
years before that) by stringent legislative enactments, I
still remain of opinion, that under several circumstances
it is the duty of a medical man to recommend inocula-
tion. These circumstances do not, indeed, often occur;
hut the legislature would hardly wish to control and
fetter, even in a single case, the deliberate judgment of
a physician, acting for the benefit of his patient. I will
name to you four of these cases; — 1. When a person
has been found, from peculiarity of habit, unsusceptible
of vaccination. 2, When new sources of vaccine
lymph are introduced, and it becomes of importance to
ascertain that the new virus is efficient. 3. When
young persons (between the ages of ten and twenty),
vaccinated in early life, are proceeding as cadets to
India. 4. When small pox unexpectedly breaks out in
a country district, at a lime when (even with the
facilities of a penny post) vaccine virus is not to be
obtained.
Other cases, equally strong, might be put ; but what
I have said will probably sufiice to show that a clause
(duly guarded against abuse) permitting qualified medi-
cal practitioners to inoculate under circumstances of
urgency, would have been an useful addition to the
Vaccination Extension Bill. That it was not so added
was DO fault of mine.
^^
4
LECTURE VI.
RUBEOLA, OR MEASLES.
Characters of rubeola. Its early history. Its supposed identity with small
pox and scarlatina. Incubative stage. Characters of the initiatory fever.
Rubeola sine catarrho. Maturation of measles. Exacerbation of the
rash. Decline of measles. Rubeolous pneumonia. Other sequelae of
measles. Abdominal inflammation. Malignant measles. Appearances
on dissection. Cancrum oris. Prognosis in measles. Diagnosis. Patho-
• logy of measles. Recurrence of measles. Inoculation of measles.
Statistics of measles. Treatment during the early stage. Employment
of blood-letting in the pneumonic complication. Treatment of malignant
measles. Treatment of the several sequelae of measles.
Rubeola,. or measles, the roiigeole of the French, the
morbilli of Sydenham and other old authors, is an exan-
thematous disease, characterized by the following
symptoms : — A fever, with catarrhal implication, which,
at the end of seventy-two hours, throws out an abundant
eruption, consisting of minute confluent papulae, sUghtly
elevated above the surface of the skin, and subsiding in
three, or at furthest, in four days ; the catarrhal symp-
toms, in all normal cases, declining on the appearance
of eruption, but sometimes, especially in severe and
irregular cases, continuing, or merging in those of pneu-
monia. The disorder, for the most part, occurs to all
mankind once in the course of life ; but having been
undergone, the constitution remains for ever after
unsusceptible of the same disease.
No complaint j)ossessing these very striking features
is to be found recorded in the writings of any Greek or
Roman author. Dr. Willan (in his Miscellaneous
Works, 1821) struggles hard to prove that such a dis-
HISTORY OF RUBEOLA.
115
case was known to iliem ; hut his researches have
made no converts. The opinions of Friend and Mead
are still adopted, and we are constrained to believe that
the measles is a disease of comparatively modern origin.
All our best medical historians concur in the behef
that measles began to spread flirongh the world about
the same time as small pox. and that it had its origin In
the same countries whence the variolous miasm arose.
The shores of the Red Sea, the coasts of Arabia and
Abyssinia, first experienced the assaults of this malady,
and probably abont the fifth or sixth century. Constan-
dne Africaous dates the origin of measles two or three
centuries after small pox; but I know not on what
grounds. The first distinct allusion to measles is found
in the writings of Rhazes, the Arabian physician already
mentioned as the fl«c^or^^Wnc^^,t on small pox. Khazes
is supposed to have flourished early in the tenth century
(910). His successors. Hall Abbas and Avicenna, the
two most distinguished authors of the Arabian school,
described measles under its Arabic name, Hasba, or Al
hasbet. The term j-uheola was introduced subsequently
by the Latin translators of Hali Abbas, and by some
appears to have been appropriated to that variety of
exauthema now called scarlatina.
The term morbilli was employed from a very distant
period also, and seems to have included every variety of
exanthema, accompanied by efflorescence, lu this sense
morbilli was used by Morton at the close of the seven-
teenth century. Sydenham carefully restricted the term
morbilli to measles.
It is not only curious but instrucllve to trace the
gradual expansion of men's minds in the diagnosis of
the exanthemata. All the Arabian authors were im-
116 IDENTITY OF MEASLES AND SCARLATINA.
pressed with the belief that small pox and measles
were pathologically associated. Avicenna pronounced
measles to be a bilious small pox. In 1640, Daniel
Sennertus proposed as a subject of inquiry, why the
disease in some constitutions assumed the form of small
pox, and in others, that of measles.
Diemerbroeck, in a posthumous work, published in
1687, asserts that the two diseases are only different
degrees of the same malady. " Differunt morbilli a
variolis accidentaliter, vel quoad majus et minus."
" The matter by which measles is generated," says he,
" is not so thick as in the case of small pox. It is
drier, and somewhat choleric." (Choler, or bile, was
the dry humor) This author held that such as had
had small pox were generally exempt from the measles,
" though, 'tis true they can challenge no absolute immu-
nity. Therefore," he adds, " measles is chiefly met with
in young persons."
Sydenham, who was the contemporary of Diemer-
broeck, and a much bettor physician, devoted much of
bis attention to measles. He described with great
accuracy the epidemics of 1670-74, and his opinions
concerning measles display singular acuteness. He
permanently separated small pox from measles, which
was a great step in pathology. The belief in the
identity of measles and scarlatina, however, still pre-
vailed. Twenty years after the time of Sydenham,
Morton viewed measles and scarlatina as the product of
the same miasm, and averred that they stood to each
other in the same relation as the distinct and confluent
small pox. Hence, by many authors of that age scarla-
tina was called morbilli confluentes. Even so recently
as 1779, Dr. Withering speaks of measles as being
IMCUBATIVE STAGE.
nearly allied to scarlatina. By this time, however,
physicians had become sensible that the two diseases
arose from different miasms. This conviction was
forced upon them hy observing that patients who had
gone through measles were equally with others subject
to scarlatina.
Having brought down the history of measles to our
own time, 1 proceed to describe to you its phenomena.
I shall first make you acquainted wiih measles as it
occurs in healthy habits, and in its simplest and most
asnal form. This constitutes the morhilli regulares of
Sydenham.
Measles is the product of a miasm or morbid poison,
which in this country is invariably received by the mode
of infection. It has, of course, its breeding or incubative
period. The term latent period is improper, because
ihe miasm, often from the very first, gives evidence of
its activity. Sometimes the entire incubative stage is
marked by languor, lassitude, a sense of mal-aise (or
dis-ease), and occasionally a characteristic cytiiptom,
such as cough. I once attended a lady, wlio for a fort-
night had a cough which baffled us all, but terminated
at length by a copious eruption of measles. At other
times, the first eight or ten days of incubation are passed
without any sign of ill health.
The early authors, biassed, no doubt.'by their preju-
dices in favor of exanthematic identity, taught that the
initiatory sympioms of measles were the same as those
of small pox. This, as a general rule, cannot be admit-
ted. With regard to the duration of such symptoms,
authors are more agreed. Heberden says that from ten
to fourteen. Burns that from twelve to fourteen days.
118 CHARACTER OF THE
usually elapse from exposure to contagion to the appear-
ance of rash. Dr. Willan considers sixteen days as the
extreme limit. The first week being usually passed
without symptoms, the child (for the greater proportion
of your measly patients will he children under seven
years of age) then droops. Catarrhal symptoms super-
vene. Chills, flushes, disturbed nights, some degree of
delirium or drowsiness during the day, with weight on
the forehead, are then observable. Pain of the back is
a frequent symptom. The pulse is quick. The tongue
is white.
From the occurrence of rigors to the appearance of
rash, seventy-two hours elapse. The initiatory fever of
measles aflfects the quartan type. Two complete days
intervene. The rash comes out on the fourth day from
the setting in of fever, and the eleventh or twelfth from
the imbibition of the poison. The following cases will
illustrate the ordinary process of incubation, and the
anomalies occasionally witnessed : —
Case 1. — Miss M. D., aged seven years, residing in a
retired situation at Woodgrecn, was brought to London
on Tuesday, January 10, 1843, to attend a juvenile
party. One of the children whom she there met, sick-
ened for the measles on the following day, and before
the end of the week tw^o others of the party had been
seized. On the morning of Tuesday, January 24,
being fourtcert days from exposure. Miss M. D. began
to complain of languor, headache, sneezing, and cough.
The eyes were suff'used. On Friday, the 27th, measles
appeared on the face. The full incubation extended
here to (;igliteen days. This young lady was attended
by Dr. Munk, of Finsbury-placc.
Case 2.— On Tuesday, February 14, 1831, Mrs. D.,
INITIATORY FEVER.
119
aged '26, went to Cainberwell in a hackney coach. The
coarbmaa appeared ill as he let down the steps. At
dinner, Mrs, D, fell sick and poorly, and so continued
al! the rest of the week. On Tuesday, February 21
(eighth day), she complained of rigor and violent pain
of the back. Her husband, a surgeon, imagined she
was passing a calculus. This pain continued all
Wednesday and Thursday, On Thursday, the 23d
(tenth day from exposure), I first saw her. The symp-
toms were backache and headache. The eyes were
suffused ; the pulse 130. On Friday, the 24th, at ten
A,M., seventy-two hours exactly from the first rigor,
measles appeared. Eleven days of incubation.
Case 3. — Eliza Finch, aged four months, residing al
Pentonville, was vaccinated by me at the Small Pox
Hospital, May 15, 1832. May 17, the child began to
droop. Bilious vomiting, very severe, with drowsiness,
succeeded. Much blood passed by stooL The head
was very hot. Vomiting continued all that and the
four following days. It ceased on the 22d, On the
24th the other febrile symptoms yielded a little. On
the 25th (nine days from the invasion of symptoms, and
eleven from the probable reception of the germ), measles
appeared, and went through its course regularly.
[Of 38 pntjonts in the wnrilj of MM, ItiUiul and Bartbez, (lie eruptioD
^peared in fuiir instances, in from 4 Ui 5 il;\ys • ia eight, from 9 to
la days; in twenty, from 15 to 25 days; Hud in six, from 28 to 58
dayi.
In an epidemic in the Necker Hospiul (PBris), in 1843, in tLe senice
of U. Bouchut, the period of iricubatioii varied from 12 to !9 dajB-
This period varies witli the natural prediapositidn of the patient aa well
M with accidental causes, {ifrd. Ohir. Rev^ Oct. 1845. p. 408.)
With regard to tbe last six cases mentioned by MM. KiUiet & B..
the question may pyrbap? be asked, whellier they were not nitlier (msl-s
120 INITIATORY FEVER.
of more recent infection from fumites or fresh exposure than instances of
prolonged incubation.]
The leading features of tlie initiatory fever of measles
are, I have said, catarrhal. I must describe them to
you more in detail.
1. There is sneezing. I have seen both adults and
children sneezing every five minutes, and really ex-
hausted by it. In the case of Robert Woodland, whom
I attended in June, 1830, the sneezing ended in epi-
staxis. You know that sneezing indicates a gorged and
irritable state of the Schneiderian membrane.
2. l*he eyes are red and watery. There is epiphora^
the great diagnostic on which nurses are wont to rely.
While the measles are breeding, you will be sure to find
the window-blinds down, and the curtains of the bed
close drawn. The slightest ray of light is painful.
There is irritability of the retina, sometimes attended
by inflammation of the conjunctival membrane.
3. There is a loud, dry, hollow cough {tussis sicca).
The violence of this cough, on some occasions, will
astonish you, as it did me many years ago, while attend-
ing a young Irishman, Mr. Webb, at Islington. It was
not only loud, but incessant. The trachea and bronchi
participate in the same kind of action (whatever be its
nature) which takes place in the nose and eyes.
4. There is hoarseness {raucedo). The larynx is
also implicated. In fact, the mucous stnictures gene-
rally of the head and chest receive the first impetus of
the poison. We are not justified in saying that the
action developed in them is inflammation. The mem-
branes arc probably only in a state of congestion with
increased irritability — a state which plethora, bad
RUBEOLA SINE CATARRHO. I
mauagement, a cold season, or a bad habit of body,
may convert into inflammatiou.
Ever since measles was separated from scarlatina,
authors have described au exantheniatic disorder, allied
in aspect to rubeola, but not exhibiting any initiatory
catarrhal symptoms. Such a complaint has been called
rubeola sine catarrho, or incocta. By some it is called
the bastard, spurious, or imperfect measles. Much
attention has been paid to it in Germany. Dr. Willan's
opinions on it seem to guide the pathologists of this
country. He considered it as a species of measles,
arising from the true rubeolous poison ; but he added,
"persons receiving the miasm in this form are pecu-
harly liable to a second attack of measles."
This last admission seems to me nearly decisive of
the (juestioiL 1 beheve that by farlhc larger proportion
of such cases are cases of febrile lichen. I should he
inclined to lay all the stress on the duration of the ini-
tiatory feve-. If this extends to 72 hours, the disorder
is measles, whether catarrhal symptoms be present or
not. On the other haod, if a rash of a rubeolous charac-
ter succeeds a brief period of febrile commotion (24 or
48 hours), the disease is not measles, and tlie child will
fall into true measles at some subsequent period of its
life. It is worthy of note, that no author who has
treated of this bastard or imperfect measles mentions it
as occurring after the true measles.
[The casos whicli v?6 have much more frequeiiUjf seen oonfuunde<]
with in«i»les, axul irLich probably ounstitute the largest share of " rube-
oU sine catarrho," have been those of Koscola, between the cutiiiieona
developments of which and of Rubeola there is often great reaeiiiblanoe.
The question is often asked, whether measles can exist wilhoul the
eruplioa.
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MATURATION OF UEA8LES. 123
Pltoi]i,'lil perhaps lo be nieutii.ned in ibis counexiou, tbaUa iiinUar
rednes'* in these ptirts somutinies occurs in RoseoU,]
When closely examined, the eruption is found to con-
sist of a congeries of minute papula, close set, or con-
Buent, and for a short time perceptibly elevated above
the level of the snrronnding skin. This elevation, or
roughness, is most perceptible on the forehead. On
the Umbs it is scarcely to be delected. The color of
the measly ernption is a diugj' red, very different from
the bright scarlet hue of its rival. Hence the French
name llougeole, or fievre rouge. The difference in
color may easily be traced to the tracheal and bronchia!
complicalion so generally present in measles, which,
extending partially into the substance of the lungs,
gives a venous character to tlie blood. In .scarlet fever,
on the other hand, the lungs are unaffected, while there
is intense arterial action. The eruption, therefore, par-
takes strongly of tlie character of arterial blood.
The development of eruption is often accompanied
with a very moist state of the surface. This is the
Dornial mode of development, and of course always to
be desired. Few, if any cases, that begin thus, end
unfavorably. The same thing is true of all exanthema-
tic disorders. In a hot and dry state of the surface,
eruption is difficult, partial, and imperfect.
By Willan and others, the patches of measly eruption
are said to assume a crescentic arrangement. I have
often been disappointed in my search for this appear-
ance, and am inclined to think there is some little fancy
called inti play in this description.
On tiie second day of eruption (the fifth from the
occurrence of rigors), the eyelids often swell, from the
extension of cutaneous action to the subjacent cellular
124
EXACEKBATION OF THE RASH.
tissue, . Although I have never seen such a thing, I
have yet heard of children blinded bj measles during,
the space of four days. The progress of measly era]
tion, in all normal cases, is steadily from above dowi
wards. On the second day of eruplion, the trunk and
upper extremities are occupied. On the third, it has
extended to the lower extremities, by which time it has
nearly disappeared from the face. On the sixth day, id
has faded over ihe whole surface. 'fl
[Bnnliez ii Rilliet say tliat there is a period of incn^asa id nieaa^H
whieli lulls one or two days, and n period of decrease which lasts thf^^|
to fiftci^n dajs, the eruptiou being staUonaty but a very short tid^H
(Mai. do eri/anU). The eruplion has most ooRimonly disappeared at d^|
end of sin dnvB ; but not unfre'juonUv reoiHiaa until the serenib, M^H
sometimes even liii^n to tbe DiDth or teolli duy.] ^|
Some modiiications occur even in the most regal^f
measles. One of the most familiar is an abundant crojfl
of miliary vesicles on the arms and trunk, filled with a^
thin transparent lymph, and of such size and distinct-
ness as to create a suspicion of the disease being small
pox. We may well believe that tlie frequency of this
event led originally to the idea of identity. Measles of
this kind has been called rubeola variolodes, or the
nirles. Pathologists have reasoned themselves into the
belief that this symptom is owing to a peculiarly inflam-
matory state of the cutaneous capillaries, but it will
be observed in mild cases, unaccompanied with high
fever.
Another anomaly merits notice, the reappearance or
exacerbation of the rash after having reached or passed
its regular crisis. Dr. Willan first noticed this circum-
stance. He records two cases of the kind in his ■• Re-
ports of the Diseases of London.'' Frank, of Vienna,
^
I
m
DECLINE OF MEASLES. 125
has observed the sauie thing. Dr. Conolly recites a
like case, where the renewed eriiptiou was so copious
and itiTeose on the face as to make it impossible to
recognise the features. Some years ago, a case in
every respect similar occurred at Brompton to Dr. Sey-
mour and Mr. Chinnock. Ten days elapsed in this
instance before the reuewal of the exanthematic action.
By most authors, it is staled that the decline of
measles ts attended with desquamation of the ciiticio,
the scales being so minute that the body appears as if
sprinkled over with fine bran. That this is perceived
in some cases is Duquestionabte, but in many no such
destruction of cuticle takes place. The cause of
desquamation Is the intense heat of skin which dries up
and kills the minute fibrils connecting the cuticle with
the corioD. Desquamation does not form that striking
feature of measles which it does of scarlatina and erysi-
pelas, because tlie heat of surface seldom attains the
requisite degree of intensity.
In the perfectly regular measles, the cough, hoarse-
ness, and other mucous symptoms, begin to abate on the
first appearance of eruption. I have seen the cough cease
instantly, as if by magic. Let me pause for a moment
to illustrate, by this means, the mode in which blisters
relieve a teasing winter cough. The principle is exactly
the same. The skin and tracheal membrane arc analo-
gous or homophysic structures, and irritation set up in
the one, whether by nature or by art, relieves irritation
(and even inflammation) in the other.
The sequela;, or dregs, of measles require from you
as much study as the earlier periods of the complaint.
I have described the normal progress of measles in per-
fectly healthy subjects. 1 am now to trace its effects
126 RUBEOLOUS PNEUMONIA.
■
on weakened and scrofulous constitutions. Generally,
in such habits something occurs early to give cause of
uneasiness. The initiatory fever has been severe. The
eruption has been retarded twelve or twenty-four hours.
It has receded and returned. Epistaxis, or an epileptic
fit, or diarrhoea, has occurred to interrupt the normal
course of the disease, and warn you of impending
danger. Above all, in such constitutions the catarrhal
symptoms do not subside on the outbreak of eruption.
The cough continues. The child becomes restless.
Careful observation detects dvspncea. The stethoscope
gives signs of impeded respiration. Instead of the
febrile symptoms subsiding on the sixth day, and the
child expressing its desire to get up and have its toys,
the litde sufferer continues to droop. Its hands are
hot ; its nights unquiet. It is thirsty, and the urine is
scanty. Secondary fever has set in.
During the progress of secondary fever, inflammatory
action, sometimes acute, but more commonly of a lower
subacute kind, arises in one or more of the structures
which were the seats of primary irritation — namely, the
eyes, the glands of the neck, the larynx, the trachea, or
the lungs. ^Scrofulous ophthalmia, scrofulous enlarge-
ments of the glands of the neck, with succeeding ulcer-
ation, laryngitis, croup, but above all, pneumonia, are
the sequclcB of measles. Of the laryngeal and croupy
affections 1 have nothing to offer differing from the usual
phenomena of those disorders arising idiopathically.
The danger is alike in both cases. Measly pneumonia,
from its extreme frequency and frightful devastations,
deserves a closer attention.
Pneumonic complication occurs both in the progress
of the eruption and during its decline. It is a slow,
RUBE0L0U3 PNEUMONIA.
127
creeping, iusidious form of inflatumatioii, wliicli too
often iLrows rlie practilioiier off his guard. No positive
complaint is made. Tlie child droops, and appears
weak and exhausted. Imagining that the disorder has
weakened his patient, the practitioner directs some mild
tonic. Meanwhile, pneumonic engorgement (or pneu-
monia in its first stage) creeps on. The lungs hecome
more and more congested, and at length .solidified. A
convulsive fit now takes place. Alarm is taken, and
leeches are applied, but the mischief is irreparable.
Dyspnoea increases, The child becomes drowsy, the
feel cold. The pulse sinks. Fluid effusion now takes
place from the bronchial membrane. Another and
another fit succeeds. Rattles are heard in the throat.
The child dies !
[Pueuinoniu torm», as our nutlmr remi)rk<<, one of die most frcqueut,
aa well ik the most dnngt^rous com pi rent ions of measlta, HQil dttnnndi
that tlie disease shuulil be narrowly watched, botti during its progress
and its decline. Its cuurEe is eonietinies more marked tlian stated here.
When occurring during its prijgress, there is pereistencB and increaae of
cough, eon ti nuance naJ |)erhapB exacerbation of fever, either without
any abatement, or after it has been less for one or two days, inereased
dyepncea, with more or less lividity nf the countenance, ubilu the
Btethoscofic signs, at least in children of five years and ujiwards, will
oRcn clearly indicate tlie change which is taking place in the lungs.
Bomelimes the patient will have been unattended unlit didncss, or
peTCUasion and bronchial respiration, shuw that it has reached tlie second
Stage.]
Such is the usnal course of rubeolous pneumonia.
Sometimes the inffammaiion is of a different kind,
which runs on to the rapid development of tubercles,
and the formation of small abscesses. The child ema-
ciates, heconies consumptive, and dies. This series of
changes may occupy a month or six weeks. The for-
130
HALIONANT MEASLES.
intensity, sometimes giving a decided character to the
epideniic. In 1745, measles of this kind appeared in
Plytnouth, and found an able historian in Dr. Huxbaui.
In 1763, occurred the celebrated epidemic of malignanl
measles described bj Sir William Watson with such
accuracy, thai the disease was long known as Watson's
measles. In 181G, a similar epidemic prevailed in
Edinburgh. In 1S39, it was observed at Hertford
among the children of Christ's Church Hospital, who
are tbere educated. Tlie characteristic features of
malignant measles are — J. Severity of the initiatory
fever. 2. Irregularity in the course of the symptoms,
especially in the appearance and aspect of the eruption.
3. Severe implication of the brain. 4. Implication of
the abdominal viscera. 5. Concomitant disorganization
of the blood, leading to petechias and btEUiorrhagea.
The eruptive fever is severe, and attended with
QDUSual symptoms. The fever is typhoid, not iuflam-
matory. The eruption appears too early or too late.
It perhaps recedes after having shown itself, and par-
tially reappears. The stomach is irritable; vomiting is
both severe and protracted ; tbere is delirium, with
wildness of eye, or coma; the belly is tender; there is
purging of unhealthy stools ; tlie extremities are cold,
the pulse small and wavering; on the surface appear
petechiEe or ecchymosed patches of eruption ; the fauces
assume a livid, or dusky red color; blood passes by
stool; there is much oppression at the pnecordia, and
abundant niuco-serous discharge from the chest, indi-
cating the congested condition of the lungs and their
mucous membrane. In these almost hopeless circum-
stances, children may (He in forty-eight or sixty hours,
asphyxiated by the coudiliou of the air-passages ; others
APPEARANCES ON DISSECTION.
131
die of coma or convulsion ; some are worn out more
slowly by diarrhoea and bloody slook.
The appearances presented on dissection of those
who die either of the malignant measles or of the tho-
racic complication already described, present features
which might readily be anticipated from the character
of tlie symptoms. Tlie bronchial memhrane is spongy ;
abundant serons efTusion escapes Irom the lungs on
pressure; portions of their substance are consolidated;
the larynx is (Edematous. Abscess and purulent infil-
tration are rare. In the abdomen appear patches of
nlccraiion, with or without enlarged mesenteric glands.
In the ventricles of the brain, you will occasionally find
e0usion of serum.
I have, lastly, to speak to you of that truly frightful
combination, measles with the tendency to gangrene.
This is sometimes witnessed in children of the upper
ranks who are of extremely weak habit, but all the
worst cases appear in the half-fed children of the lower
ranks, inhabiting damp cellars, and inhaling an impure
air. The measles, having superadded to it such sources
of constitutional debility, proves too much for the sys-
tem. The first evidence of the gangrenous dispositioa
will probably be a sloughy state of leech-bites or blis-
tered surfaces, if leeches or blisters had been applied,
with small ragged nlcers on the inside of the cheek,
exhaling an offensive odor ; soon after which the trae
cancnini oris begins to show hself. A hard round
spot, Uke a marble, occupies the inside of the cheek, or
a small black point appears at tlie corner of the mouth.
A tooth drops out. In twenty-four hours, gangrene has
spread so as to occupy a large portion of the inner and
some part of the outer cheek ; at length the whole
.132
PROGNOSIS IN MEASLES.
^^eek is eaten away, and the nose and eye are invaded.
Happily, however, death puts a period, though not
always an early period, to this distressing scene.
Cases of recovery from cancruni oris are seldom seen,
except in adults. The aflectioD is not peculiar to the
latter stages of measles. I have seen it following small
pox, and occurring in the progress of infantile remitting
fever ; hut there is something in the rubeolous miasm
peculiarly depressing to the vital power, and hence can-
Lcnim oris is much more common after measles than
rafter any other exanlhcmatic malady. Mercurial pre-
IparatioDS have often, but unjustly, been accused of occa-
l^oning or at least favoring the disposition to cancrum
|:oris. It often, however, appears where no sacli drug
fhad been administered, and is, in truth, entirely depend-
I ent on constitutional debility.
The prognosis in measles is easily laid down. The
I cause of death in the great proportion of cases is pneu-
' monia. All symptoms indicating pulmonic cougestion,
' and its con sequences, whether affecting the chest, head,
f or belly, such as coma, convulsions, or vomiting, are pe-
culiarly to be dreaded. It has generally been remarked
that measles does not fall with such severity on pregnant
and parturient women as the other exanthemata. In-
deed, the mortality by measles among adults is very
' low. In hot countries measles is not viewed with alarm,
evidendy from the abseuce of thordcic complication.
The following are the observations of authors regard-
ing the proportion of deaths to recoveries ; — lu one of
Sir W. Watson's epidemics, the deaths were as high as
I ten per cent. Dr. Plome estimated the proportion at
eight per cent. Mr. De la Garde states that, at Exeter,
in 1824, he lost eight per cent. Dr. Percival, of Man-
STATISTFCS OF HEABLES.
Chester, lost niuety-one out of 3807, which is one iu
forty, or two and a half per cent. Dr. Adams states, as
the generally received opinion in his time, that commii-
nibus anitUi, measles dues not prove fatal to more than
three per cent. I have given (page 6) a table of the
deaths by measles during three years. It will be seen
that in 1839, there died, throughout England and
Wales, by measles, 10,937 persons: this, at three per
cent., would make the total attacked, 364,566, about
the number of those born who attain the age of three ,
years.
Mr. Farr's Fourth Report gives tables of the deaths,
by measles, throughout England and Wales, for three
years and a half, on a very extended scale. The fol-
lowing abstract presents an interesting picture of the
prevalence of the disease in this country, and of its
varying intensity : —
Table exhibiting Hie Deaik.1 by Measles IhroUffhouC England and Wala,
telthia Fauflem Quarterly Periods, exiaidinff from UtJulg,\&Zl.,
to aUt Decemher, 1840.
QDIITCELT FEEIOIM. IS37.
1838.
1839,
le-io.
Inn.. Fib.. Miircb . . .
April, May, June ....
Jnly, August. Seiit . . .
Oct, Nov., Dec . . .
Total Deaths . .
2302
23»2
2022
1512
1037
1943
2074
3204
2767
2802
28:16
2641
1739
2110
47S4
6514
10,037
9326
We learn from this table that the average annual
deaths by measles in England is about 8500, which is
nearly one-fortieth part of the total mortality. Season
would appear to have less influence on the mortality of
meastes than might have been anticipated.
[From n tab!« exIiiUiting the months during whicL death tooV [ilwM
i
DUflHOBIS OF HBASLES.
aeasles, within quarterly perioOa, in ihe eity of New York, from 3
1, 1830, to Dec. 31, 1844, inclusive, embradng a period oT fifteen yeai^
Rnd 2104 death!!, we find that the roorlality was grenteat during tho
months of Jftnuury, February, and March, and least during thi.' nionLh»
rf October, November, and December, the numbers being nspectively,
during these two quarterly periods, 610 nnd 984; tlie numbers during
I the quarcerly periods of April, May, and June, and of July, August, and
Soptember, being respecIJvely 574 and 530.]
The diagnosis of measles need not detain ns. Fi
scarlatina it is to be distinguished — 1. By ibe charai
and duration of the eraptive fever; 2. hy the character
and general aspect of the eruption ; 3. by the state of
the throat. In a subsequent lecture, these points will
be stated more in detail. From lichen febrilis, measles
is distinguished by attention to the initiatory stage.
This stage is four days in measles; in lichen, tweni
four hours.
[Chomel adds to the above dingnoslic marks of measles mentioned
anthora,
1, Spots like those of ecchymosis under the skin, which he saya
' not rare, and are peculiar to measles, and seen in some of il
forms.
S. Sputa of a peculiar character, which he describes as consistiDg
Opake, nummular masses, of a greyiab rolor, floating in an abundance
I of liquid, and resembling the sputa of the second stage of phthisis. But
ID phthisis, the fluid in which they float is cleiir and transparent, wh3o
in raeaales it is dull, cloudy, aud lactescent.
M. Chome! considers this an important diagnostic mark, affording aid
in epidemics when the eruption dues not make its appearance, and
when the eruption is suddenly suppressed. Tiiis mark can only bo
eervioe in adults, as infanta do not eject the sputa.]
The real difficulties of diagnosis arise out of the c
currence of ttvo exanthemata. Measles has been knon
to co-exist with small po.\. Mr. De la Garde has l
corded an intercsliug case of this kind which occun
I
DIFFICULTIES OF DUGIfOBIB.
at Exeter in the epidemic of 1824. Dr. Russell has
detailed like cases occurring at Aleppo, Many years
ago I attended, with the late Mr. Corbett, a case which
exhibited the combined character of measles and scarla-
tina. There was an eruption of measles, with the
sloughy throat of scarlatina. I have put on record the
particulars of a family invaded at the same time by
the miasms of scarlatina and measles; one child took
measles first, and scarlatina afterwards; the other took,
scarlatina first, and measles afterwards. The character
of the eruptive fever in each of the four seizures, indi-
cated the nature of the disease which was to follow.
Dr. Russell, discoursing on the reciprocal influence
of small pox and measles, informs us that he carefully
watched above 300 cases in which these diseases suc-
ceeded each oliier, at a time when they were both epi-
demic at Aleppo (1765). He noticed that the measles
rarely succeeded small pox iu less than 20 days from
the first appearance of the eruption. Several cases,
however, were observed where small pox succeeded
measles before the total disappearance of rubeolous rash
from the extreniiiies — that is, on the 11th or 13th day
of tiie eruption, lie adds, " so little did the quality of
the first disease influence that of the second, that a
mild distinct small pox was often observed to follow the
worst kind of measles, and vice versa."
Willan relates the case of a young man, aged eighteen
inoculated for measles and cow pox on the same day ;
the cow pox took the lead, measles following at the end
of sixteen days. I described (page 119) a case very
analogous ; but there measles had the start, and after
sixteen days, cow pox bad its turn. It is singular that
136
PATHOLOGY OF MEASLES.
in each case sixteen days should be the period of sus-
pension. This, I am persuaded, was not accident
The pathology of measles (by which I understand
all specidations regarding the causes of the disease) af-
fords much curious matter for inquiry. That measles
b the product of a specific miasm, and is never gene-
rated de novo, is now tlie universally admitted doctrine.
Historical facts countenance this opinion. Measles
never gained footing at St. Helena until 1808. For
ftventy-five years it was ahsenl from the island of Ma-
deira ; and wben, in 1808, it did invade the island, it
found almost the whole population susceptible ; in four
months it destroyed 700 lives. Australia and Van
Diemen's land are to this day exempt from measles.
They have, indeed, what is called Van-Diemen's-Land
measles, which is a species of febrile lichen, affording no
protection against the measles of this country.
[Ad aiiiilo^Dus fiict to the one sUilcd respecting Mndeira, is recorded
as liHving occurred at Tliorshnven, the capiUil of the Faro Islands. A
writer in the London Med. 6az. (July 10, 1846, p. 83) says, " letters
lately received from Thorshaven cnilain the intelligence that the mea-
sles, which had not appeared in that i»lnii<l since 1T8I, and which, in
that cliniale, always assumcH the charneler of a terrible ejiidemic, Iiad
broken out there. Of the 800 inhabitants of that town, more than 700
had been attacked hy it, and from 10 to IS persons daily fell victims to
it. The only pcr!(ons spared were the native old men who liad the dis-
ease in 1781, and the foreigners who had been attacked by it in foreign
parts."
These facts, interesting as they are, cannot be quoted in favor of cither
side of the ques^on as to the origin ofineafiles, being deficient in proof
M to the importation of the disease. We have already slated (j»age 80)
lensons for beli'^ving in the possibility at least of the occurrence of this
eiantbem independently of contagion. Dr. M. F, Cogswell, in a letter
to Dr. K n. Smith, June, 1799, records two such cases [Med. Repoa.,
1709, vol. ii. p. 281), and we have also given the authority of Dr.
ithority of Dr. |
Lha same side. To tlie.se, we may
of lha probability of such an origin.]
The statistical details already given show how uni-
versal is the susceptibility of this contagion. The re-
currence of measles has been recorded, but the well
authenticated cases are few. Dr. Gaillie has put on
record seven, of whom five were brothers and sisters.
Four had recurring measles at the interval of sis
months; one at the interval of twenty-one years. Dr.
Websler has published three similar cases, where the
intervals were respectively two years, four years, and
si.? years. Two cases are recorded by Dr. Home.
In all speculations on the recurrence of measles, it
should be remembered that one form of lichcnous erup-
tion closely resembles measles in its outward aspect,
and. consequently, that the periods of incul>atioii, access,
and decline, are of more value in diagnosis than the
character of the eruption.
[DeUils of the cases reported by Dr. John Webster, referred to b
Hit author, may be found in the Medico- Chirarg. Trans., vo!, x\ii. j
Dr. Joeepb Moore also gives a cage of a femnte infant, 22 i
attacked with ineaslra in the latter part of May, and n<:ain i
iuly, both passing througli their regular stages (tfft/ico-CAiVii
■il- Tri
vol. X
., 18;
Rayer states that he met with three very remarkable instnnccs of the
Mcurrence of measles during the interval between the first and second
•ilitioD» of his work on Diseases of the Skin, and quotes seventl aiithon
«bo have met with such a recurrence (Mai. de la jitau, I. i. p. ISO).
Bateman admitted tlie powiibility of such a recurrence, although Ko-
aemtuin met witli but a single instance of it in a practice of fgrty jtars.
Dr. Van Diezen relates an instance of thrirt successive attacks in a
ehild three years old, at Antwerp. The first attack was in February,
the BMond Uie following March (commencing the 4Ui), nnd Uie third
138 INOCULATION OF MEASLES.
on tho 12t1i of April. Desquamation took place each time. {Bullet
Gin^r, de Th6r., Sept 15, 1848, p. 239.)]
The inoculation of measles was first thought of by
Dr. Home, of Edinburgh, in 1758. He inoculated with
the blood, applying cotton dipped in tlie blood of a
measly patient to a wound in the arm. We read, that
febrile symptoms appeared on the sixth day, of a mild
character, and that no secondary complications ensued.
Early in this century, Mr. Wachsel, of the Small Pox
Hospital, inoculated a lad, Richard Brookes, with fluid
taken from some of tlie measly (or miliary) vesicles, and
the inoculation was successful. In 1822, Professor
Spcranza, of Mantua, inoculated himself and six boys,
in tlie manner recommended by Home, with complete
success. In other trials, it does not appear that the
resulting disorder was at all mitigated.
The latest recorded experiments are those made in
1SI2, in Hungary, by Dr. Katona. We are informed
that he failed in 78 cases only out of 1112 (seven per
cent.), and that the resulting disorder was mild, contrast-
ing favorably with the severity of the reigning epidemic.
No deaths occurred among the inoculated. The in-
fecting blood was drawn from the surface most eiflo-
resced ; we further learn, that a red spot with surround-
injj areola followed. On the seventh day, rigors
oeeurred, with the usual catarrhal symptoms. On the
ninth or tenth day, eruption manifested itself, which
(l(M*linod on the 14th. On the 17th day from inocula-
lion [1\\\ or sometimes 8th from eruption), the patient
WHS (M>nvaK\seent.
Theso (^xpcTiments certainly merit more attention
ihfin th(\v have yet received in tliis country. I have
STATISTICS OF HSASLEB. 139
lately been inclined to think, that the child, whose case
I detailed (page 119) as having undergone cow pox
after measles, received the germ of measles and of cow
pox at the same time ; in other words, that, unknown to
me, the child that furnished the lymph was incubating
the measles, with the zuma or poison of which the vac-
cine matter had become impregnated. When the case
occurred, I presumed that the germ of measles had been
received b; accidental infection.
[The cotntnunication of smnll pox to the foatiis in ut<?ro is a well
estabtbhed foci — such commuuication in tlie case of messlos \> not well
known. Id iLis point of view, the following is not without interest,
takeD from Dr. West's Report on Progress of Midwifery, ic., in Brit,
and For. Med. Rev., Oct. 1845, p. 549.
" Dr. Hcilrick relates the hislorv of a woman, who, having been at-
tacked by inettsles at the end of her pregnancy, gave birth, on the fourth
day of the disease, to a female child, who was covered with the eruption
of measle*, and was suffering from catarrh, cough, sneezing, inflamed
eyea, iic, but recovered in a few days."]
This brings me to the infective nature and epidemic
diffusion of measles, which must detain us for a short
time.
It has been rendered highly probable, more especially
bj a case recorded by Dr. Williams of this Hospital,
that the blood throws off infective emanations during
the eruptive fever, and prior to any eruption. The in-
fective distance is unknown. It was formerly held,
that measles sets in in January, reaches its crisis at the
vernal equinox, and ceases in the summer solstice.
Modern statistics overthrow all these long- established
notions The quarterly deatlis by measles in London,
in 1841, were 168— 147— 260— 408,— total, 973, In
1842, they approximated still closer, being 308 — 334 —
140
STATISTICS OF MEASLES.
311 — 340, — total, 1293. No such law of epidemic
culmination and decline is here apparent. In fact, the
recurrence and duration of epidemics is, in Kurope,
wholly irrespective of season. In Bengal, however, the
prevalence of measles (or Haceni) is governed by dif-
ferent laws. There the disorder never originates except
in the cold season. It begins about the middle of that
division of the Indian year, and continues till the hot
season is estabUshed. Season affects too, there, (he
character of the symptoms. In the hot months the
eruption is more vivid and more elevated, and the
internal organs comparatively but little affected. In
tlie cold season, the affection of the mucous tissues is
best developed.
Measles is undoubtedly increasing in severity, if not
in quantity, in this country. In 1748 only ten deaths,
and in 1754 only twelve, are recorded in the bills of
mortality as having arisen from measles; whereas the
weekly average of the last four years is thirty, and the
annual average, 1560.
1 me )
[Measles in the adult differa but littlo in ils character as eiliibit«d
in^Dta and cKiUr^n. M. L«vy, who has written an iotercgting pHperon
the disease in that cliisi, tbinka that the mortality is less in proportioD
among ndults ibun amons cbilJren. He explains this by a greater
resistance of the orgauisin of the adult ; n less liability lo lobular pneii-
monia ; & greatj^r facility of clinical examination, and greater certuio^
in treatment n«i says 'that tnen from 18 to SO yeare of age do not
bear bleeding belter than cbihiren, as it might be supposed they (rould.
The iuHaminatian, as he remarks, is not of a simple and legitimate
characler, but apjiroachea congestion in its nature ; and is freiquAotl]'
accimpanitid by nervous erethism or prostration of strength. Tliii
remark iti true of different epidemics.
For an analysis of the paper of M. Levy, see Medieo-Chirufff,
Oct 1847, p. 477.
dieo-Chirurff, J8w » I
STATISTICS OF MEASLES. 141
Death by measles would seem to be very rare in proportion in chil-
dren during the earlier months.
Dr. Otto never saw a child under four months of age have measles.
The greatest number of deaths occurs between the ages of two and five
years, as is seen by the following tables :
Ages of 978 persons who died of measles in New York during the
eight years from 1837 to 1844 inclusive, and of 414 who died in Phila-
delphia of the same disease, during nine yeai*s from 1837 to 1845
inclusive : —
New York.
Philadelphia.
One year and under,
. 178
77
Between 1 and 2 years, .
. 298
. 121
" 2 and 5 " .
. 402
. 1C5
" 5 and 10 " .
. 74
. 41
" 10 and 20 " .
11
3
" 20 and 30 " .
. 10
o
" 30 and 40 " .
o
1
" 40 and 50 " .
2
1
Unknown,
1
Total, . . . .978 . .414
The annexed tablo, by Dr. Watt, of Glasgow, similar in its nature to
the one respecting the mortality of small pox in tho same cities, on page
72, shows the percentage of deaths by this disease at ditlerent nges to
the whole number of deaths by that disease, in the cities of Glasgow,
Edinburgh, Xew York, and Philadelphia : —
Glassj;ow.
Edinburgh.
New York.
Ph
iiladelphia.
Under 2 vears, .
52.7(5
60.25
47.48
45.70
'* 5 **
88.08
92.30
00.00
80.83
" 20 "
00.35
00.G7
98.27
00.43
Above 20 years, .
0.04
0.42
1.72
0.50
As Dr. W. remarks, "the t«)tal amount of d'^aths in eaeh uf those
towns was very <litrerent, and y<*t it will boohsorved that the proportion
of deaths at different ages, to the whole deaths by mea.>h'S, is very
neariy the same in each of these towns, the variation b.ing chietly at
ages under two years." [Proceed in f/s of Philos. aSV. nf (r!its(/o(f\ June
8, 1844 — taken from Amvr. Jour. Med. Sci., Aj»ril, 1845, p. 515.)
Mea^les would aj>poar toln* mueh less fatal among hlaeks than among
whites in this city. During the eight years in New York, extending
TREATmNT IN THE lAXLT ITAOE.
7 to 1 84* inclusive, the per centage of deaths to tim popalation I
'OS among the whites in tbe proportion of about one
utd nmong bhuks in tliat of about one in lOOO.
In Charleston (S.C), on tlio contrary, as will be seen by the statis^cs I
I OH pitf^ .IS, tbe tDnrtiilrty by mea-^leR was twice as gr«at anioD^ biac
ua AinoDg whitefl, during tbe Beriw of years there mentioned.]
If I have rightly laid down the pathology of measlesi,!
the principles of treatment will flow naturally from it, 1
and in truth there never has been any serious difference J
of opinion on this suhject of late years. In regular i
measles, an autiphlogistic method of treatment has been [
advised. The only doubt that can be raised is as to I
the extent to which such measures should be carried, I
aud the period to which they should be protracted.
Moderate warmth is desiral)le during the initiatory
fever, to encourage eruption, and thus reUeve niDcoas
congestion. This may, however, be carried too far.
On the 1.5th June, 3 830, I attended R. W. (letatis 5), j
who was kept so hot by blankets, flannel vests, a large!
fire, and the closure of all doors and windows, that the^
cliihl was nearly comatose. Perspiration was flowingfl
from his skin. There was dyspntra and epistaxis. Thel
blood was goi^ing the bead and chest. The loss ofm
some blood from the arm, a total change of regimen, 1
and lotions of vinegar and water, soou set matters toM
rights, aud the measles ran its regular course. I
On the appearance of eruption, your object is simplyl
to avoid occasions of aggravation. Let the patient he I
confined to bed, take occasionally some castor oil and I
a simple s;dine draught, with synipof tolu and some an- M
timonini wine, every fonr hours. A saline powder,!
HDch as three grains of potassie salphas, with five of!
tUKur, may be given to children of very tender years, arm
143
the mistura amygdalie with nitre. To allay the cough,
a httle syrup of poppies may be taken, especially at
night.
If, after the completion of emption, cough should
remain, try what a mustard poultice, or the acctum
cautharidis, or a blistering plaster, will do. If the cough
still continues, mischief is brewing, which neglected,
will lead to more serious consequences. Therefore
apply one, two, or more leeches, according to the age
of the child; and if the symptoms indicate confirmed
pneumonia, take away some blood, from the arm if you
can, — if not, from the jugidar vein. Do not attempt to
combat measly pneumonia by purgatives, nor by calo-
mel and opium. Tartar emetic, pushed in the first
instance to full vomiting, and tlien given in more mode-
rale doses, is sometimes sufficient, but it cannot generally
be relied upon.
Pt U important Lo bear in mind llist dyspnrmi, severe coiigii, and a
deep color of till? face, do not alwaya with certainty indicat*> inflammntory
■flection of either the bronchinl tubes or of the longs thentsi-ltes. The
tympUiras may all be produced by a congested Btatc of the mucuua
Membrane of tlie respiratory passnges, as a part of the disease, anal<^ua
to (iist state of hyperemia upon wliich the eruption on the skin depends,
and rottj rapidly disappear as the eruption bceoines de\'eloped over the
snrliice. The continuance of tliese symptoms after the eru/ilion is iwff
out, is indicative of more serious trouble, as our auihor remarks.]
Id the malignant measles, with cold exlremities,
diarrhoea, and receding eruption, no plan of treatment
is very successful. Diarrhoea must he restrained by
one, two. or three grains of Dover's powder, given along
with half a grain of calomel, every four hours. The
child should be put into a warm bath, and mustard
poultices apphed to the feet and epigastrium. Ulisters
LECTURE VIL
HISTORY AND PHEXOMENA OF SCARLET FEVER.
First notices of scarlatina. Epidemics of the 17th and 18th centuries. Ef-
fects of the muism. Division of scarlatina into species. Incubative stage.
Phenomena of scarbtina mitis. Phenomena of the scarlatina anginosa.
Character of the accompanying fever. Character of the eruption. Con-
comitant affection of the throat. Implication of the eye and larynx^
Cerebral complication. Affection of the heart. Phenomena of the angina
maligna putrida. Scarlatina with colbpse. Sequelae of scarlet fever.
Sloughing of the cellular membrane of the neck. Desquamation ; debi-
lity ; mucous enteritis ; dropsy. Phenomena of scariatinal dropsy, and
consecutive convulsion.
The extent and severity of scarlet fever at the present
time are such as to demand from you the most patient
attention and dihgent study. It is obviously an in-
creasing malady, and seems likely, in after times, to
occupy that painful pre-eminence among the fatal dis-
eases of early life which small pox formerly enjoyed.
By whom the term scarlatina was first used is not
well known; perhaps by Sydenham, for I cannot find
anv traces of the word before his time. The mild vari-
etv of the disease described bv him existed in the East
at a verv earlv date, but vou woidd in vain search for it
in the writina^s of the ancient Greeks and Romans. It
probably invaded the world soon after small pox and
measles had made their debiii, for the Arabian physi-
cians describe a species of measles, which, from the
extent of desijuamation, we may be assured was scarla-
tina. In the ages which succeeded, scarlatina continued
to be confounded with rubeola.
FIBST NOTICEa OF SCARLATINA.
147
In til e year 1610 an epidemic angiaa, with scarlet
eruption, raged in Spain, from which country it passed
over, in 1618, to Naples, theu governed by a Spanish
viceroy. We naturally look therefore to Spanish and
Italian authors for the first description of the anginose
or malignant scarlet fever. The early Spanish writers
are Ludovicus Mercatus (1G12) and Michael Heredia
(!G:?6). The latter is peculiarly full and clear in his
descriptious. The Italian authors are Sgambatus "(k
pestUente faucium affcctu Neapoli steuietUe" (1620) ;
and CEtius Clems " de nioibo siran guia/orio" (163G).
Sennertus noticed the same disease in Germany aboat
1625. Dieuierbrocck of Utrecht, in 1640, described
under the title of purpura, a disease which he believed
to be a variety of measles, but which was obviously
scarlatina. The milder type of the same disorder was
seen by Sydenham in London between the years 1670
and 1675. He describes it as a disease more in name
than in essence, and fatal only through the officiousness
of the physician. He was ignorant of any connexion
existing between it and the angina putrida maligna of
the Continental authors of that day.
Scarlet fever, in its mild form, first reached Edin-
burgh in the year 1680. Sir Robert Sibbald, physician
to King Charles II., for Scotland, says, " It is so recently
introduced, and so little understood, that I cannot ven-
ture to ofi'er any observations either on its theory or
treatment." Morton described scarlatina as it appeared
in London in 1089 and the three following years. It
was a severer epidemic than that witnessed by Syden-
ham, but Morton was so fully convinced of its intimate
relation to measles, that his details cannot be trusted.
Id 1747-8, London experienced a severe scarlatinal
150 DIVISION INTO SPECIES.
1. The phases, modifications, or types of the disease ;
2. the mode of its propagation ; 3. the amount of mor-
tality which it occasions ; and 4. the treatment adapted
to its varied aspects.
I have explained to you that the fever now to be
treated of does not originate (under common circum-
stances) from any spontaneous movements in the blood
or humors of the body. A zuma, ferment, or poison^
must have access to the body, before the blood is set in
motion, so as to develope the phenomenon now called
scarlet fever. The effects produced by that poison may
be exerted on the skin alone, and then the accompany-
ing fever is slight ; or it may develope a more serious
kind of ardent fever, and then the skin and throat will
both exhibit appearances. It may so seriously affect
the whole system as to produce intense fever, in which
case the throat receives nearly the tvhole shock, the
skin being only partially affected. Nay, in some
extreme cases, the nervous system shall be so com-
pletely depressed and subdued by the virulence of the
miasm, and the mass of blood so thoroughly poisoned
and disorganized by it, that all the ordinary appear-
ances of scarlatina are masked. Petechia?, coma, and a
slongliy state of the throat, alone appear. liifc rapidly
yields under snch an attack.
From this rude sketch of the effects of the scarlatinal
miasm, you will see that a gradation exists in nature
from the mildest to the most malignant, and that the
external appearances vary with the character of the
fever. A division of scarlatina into species has been
made, but remember that it is artificial. Nature creates
genera and individual cases, but species are the imper-
fect arrangements of man. With this reservation, I
SCARLATINA HtTIS.
151
sliall avail myself of the threefold division now in gene-
ral use, and sliall treat of the two extreme links in the
long chain of phenomena, and the intermediate variety
— that is, I shall describe to jon, 1. Scarlatina initis;
2. Scarlatina anginosa ; 3. Angina maligna.
The poison of scarlatina, whatever aspect it stibse-
qucnlly assumes, has a very short period of incubation.
It invaded my own family in 1839, Rigors occurred
to one member of it on the last Saturday in April. On
Sunday, languor and lassitude, with dryness of skin,
were the chief symptoms. At six o'clock on Monday
morning, eruption appeared. On the following Satur-
day, at two P.M., my eldest daughter sickened, so that
the incubative period coald not have exceeded seven
days, and was probably only six. Withering says that
he has known patients begin to complain as early as
the third day from exposure to the contagion, and I
cannot contradict the assertion, though I never saw
incubation so rapid as this. Wc may fairly state the
incubative period as varying from four to eight days.
1. In the mildest form of scarlatina, it often happens
that the first symptom is the rash. No febrile disturb-
ance whatever has preceded. More commonly, there
is a certain amount of fever, the symptoms not present-
ing any marked characters. Rigors, beat of surface,
vomiting, restlessness, thirst, languor, lassitude, muscular
debility, and headache, are the chief complaints. On
ihe succeeding day, the rash appears. Some authors
would persuade us that the rash may be delayed to the
third or even the fourth day from llie rigor. These
observations, however, made when the diagnosis of
measles and scarlatina was yet in its infancy, cannot be
trusted to.
162
SCABLATINA HITIS.
Tbe efflorescence in scarlatina mitis is first perceive!
ou the trunk, arms, and thighs; very often nothing"
appears ou (he face, when these parts are covered with
eruption. In less than twenty-four hours, it spreads
over (he whole \)ody. Everything is rapid about scar-
latina — rapid incubation — rapid eruption — rapid course.
6ome(itnes the redness is continuous ; but much more
generally it is distributed in patches of no definite
shape. The color is a bright scarlcl, precisely that of
the bmled lobster. When closely examined, it is found
to consist of innumerable small red points, or dots. In
the greater number of cases, the finger passed over the
surface is not made sensible of elevation or roughness.
Sometimes, especially on the breast, and parts kept
very warm, the feehng of papula is given. This, how-
ever, can only occur when there is fever, and sufficient
force in the heart's action to distend the cutaneous
Capillaries. In the mild fonn of scarlatina I am now
describing, this will not often happen. The redness
of scarlatina, like that of erysipelas, disappears on
pressare.
[Tbe color of scarlet fever has long beeD described as unifonnlj spread
over tbe surfnce, as if the part had been rubbed over with the juice of
nspberries — but tbis requires some moditicntion. It is not uniform u
to lint, but is composed of a bright red layer, on which arc ecAttered
great numbers of very small points of a deep red color, which give ths
eruption a markedly jniob^d aspect. These two shades of redness vary
in inlt^nsity in diffureul cases, and the predominance of intensity of the
one or ihe olber gives tbe surface a brighter or a deeper tint. Towards
tbe dose of the eruption, the more uniformly difiiised layer gradualty
bAe», while the red points retniu more of their original color, and this
gives tlie surbce, during this slate, a punctated appearance, the dislribo-
tion of which is rr>gul3r, and has been compared, as far iis nrrangument
of the points is concerned, to the granite of painters. This npp<>nranca
aotaetinies exists during the whole course of the disease- lu measles,
on the contrary, besides the decided diff.Ten n hu h fiots a a
alwnys irre^lnr, witlioui Fiymmetrr, and dilfi- n )i!if ze d 1 a
tioa. This is eajiecially evident during the dei.1 f I nip n
Hence, rej^ulnrily is a characteristic mark of eca lu u ad (nik
of measles.]
For twenty-four hours tlie child is restless, and rofusos
his food. On the third day yoii will find him sitting
up whh his toys. The rash is receding. In two days
more, ilie httle patient is convalescent. I have often
examined the throats of children affected with the
scarlatina niitis, and not seen the slightest trace of
angina. The poison, therefore, may circulate w-jthoot
any throat affection. Well might Sydenham call this
a disease in name only; it is net'crtheless worthy of
your study, in order that you may trace (he steps by
which it ascends into the malignant cynanche.
2. I now come to the scarlatina anginosa, the primi-
tive type of the disease, or that from which all the other
varieties diverge. It is, as might hence be presumed,
by far the most frequent form in which the miasm
developes itself. Scarlatina anginosa is a disease which
more than any other that I know of will call into play
yonr pathological learning, and all yonr therapeutical
skill. It is a disease wliich may be materially aided by
medical art. It is a disease in the management of
which medical men are more apt to differ tliau perhaps
any other. It is, lastly, a disease which, from its
rapidity, leaves you little time for reflection. You must
have studied it well beforehand, and determined how to
act in cases of emergency.
A dry detail of the successive symptoms that will
meet your observation in the course of scarlatina angi-
nosa, varied as they are by season, habit of body,
154 CHARACTER OF ACCOMPANYING FEVER.
climate, and epidemic character, would profit you bat
little. I shall rather direct your attention to the struc-
tures and organs affected, and thus associate symp-
tomatology and pathology. Remember, that in this
complaint you have four classes of symptoms — 1.
General fever or pyrexia ; 2. affection of the skin and
cellular membrane; 3. affection of the mucous mem-
branes ; 4. affection of one or more of the great viscera
— the brain, lungs, or heart.
(J.) The accompanying pyrexia may be, as I have
already said, either inflammatory or typhoid. In the
majority of cases, the inflammatory character prevails,
the heat of skin being more remarkable than in any
other known malady ; it gives to the hand the feeling
of scorching. The heat indicated by the thermometer
often rises to 104, and Dr. Currie says he has seen it
at 112. The body is living in a furnace of its own
making. Let not this circumstance pass unnoticed by
you. The human body is prepared for a heat of 96.
Its functions then flourish ; but it will not bear to have
its internal heat much lowered, nor materially raised.
A heat of 105, 108, or 110, no system can long with-
stand ; it burns and dries up everything; it kills the
cuticle and the hair, injures the delicate structure of the
eye and car, deranges the liver and the brain. I attri-
bute a large share of the evils of scarlatina anginosa to
the intensity of the animal heat. The blood is not
always buffy in scarlatina, ahliough the skin be so hot,
and the pulse rapid ; there is febrile tumult, but not
inflammation. Inflammation may supervene, but the
pulse will then be not merely frequent, but hard and
incompressible.
[It may probably with wifcty bo said that, at the present time, and
CHARACTER OF THE ERUPTION.
fcr aereral years past, in this country, tlie type of sc«rlatina hRs been
dnndedly lyplioid in ila character. It is comparatively rare that we
find that great beat of skin described by our author, as wt-11 as by
oUien, as acconipnnying this disease. The temperature, even in this
forni, i» not unfrequently about natural, and Bometimea even below tbis
stjuidard. With this temperature of the skin, an nnginuse affection of
the worst kind is very often associated.]
The true cbaracter of the pulse in scarlatina is rapid,
seldom less than J20; the tongue is white; and as the
mucous covering of ihe tongue is affected, like other
mucous surfaces, %vith eruption, so the red and elongated
papillae protrude through the fur, or diseased secretion
of the month, presenting that peculiar appearance called
the strawberry tongue. Sometimes it is purely red.
The other febrile symptoms are the same in kind, but
exceed in severity those of scarlatina simplex. The
headache is more pungent, and often accompanied with
delirium. Muscular pains are severe, and the back of
the neck is often very stiff There is a feeling of ten-
sion and fulness in the fingers, evidently from the force
of the blood impinging on the extreme capillaries.
(2.) But to pass to the affection of the skin and sub-
- jacent cellular membrane. The rash is vivid in color.
I once saw it elevated in circular patches, and some
physicians called it urticaria rubra febniis ; but it
was genuine scarlatina, with sloughy throat. Nothing
is more desirable than that the eruption should be
accompanied by a moist state of the surface. There
is ibea, as we might reasonably expect, niucli less risk
of visceral congestion. The determination of blood to
Ihe skin is sometimes so great, that miliary vesicles
appear interspersed among the patches of efflorescence
(especially on the breast). This variety has been called
scarlatina varioloides. With ordinary care, however,
156 CHARACTER OF THE ERUPTION.
this will never happen. It is attributable to the nimia
diligentia either of the nurse or of the doctor, of which
Sydenham complains. Very often the rash recedes for
a few hours, and then recurs. Sometimes it appears
only partially, as on the thighs ; white blisters some-
times accompany or succeed the rash.
It is very common to see the cellular membrane,
especially that of the neck, taking on a kind of inflam-
matory action. The fingers stiffen ; the neck swells ;
the parotid glands enlarge ; tlie jaws are with difficulty
opened.
[MNf. Baitliez and IlilHet mention six to eight days as the ordinary
duration of the eruption of scarlet fever in its normal form. They say
that it requires a longer jieriod to develope itself than that of measles ;
and jtersists longer at its maximum, that is, 24, and even 48 hours.
They have seen the eruj)tion of scarlet fever last only five days, and have
also seen it l:ust seven, eight, or even ten days ; but never beyond ten
days. (J/i/Z. dcs Enfants, t. 2, p. 5*78.)]
(3.) The condition of the mucous structures of the
nose, mouth, palate, and larynx, will demand a much
more extended investigation.
Sometimes the very first intimation of the real nature
of the disease is given by a feeling of roughness of the
throat, and some pain in deglutition. On examining
the fauces, the palate, uvula, and tonsils appear red and
swollen ; and should the fever be active, portions of
coagulated lymj)h will be seen efliised. These are
often mistaken for ulcers; but in many most severe
cases of anginose scarlatina there is no actual breach of
surface — only excessive engorgement, with efliision of
lymph.
Deglutition is now so painful, that the patient will
rather suffer tliirst than attempt to quench it with the
AFFECTION OF THE THROAT. 157
certainty of excessive pain. Be on your guard when-
ever excessive pain occurs, wheilier it be Iq pleurisy,
jaundice, enteritis, or scarlaiiiia. Remember that death
may be the conseijuence of excessive pain (as in cru-
cifixion, or the torments of the Inquisition), or, if not
deatb, at least serious mischief. In tlie case of angiaa,
excess of pain is followed by extension of ioilamQiation
to the celhilar membrane subjacent to tlie ear, and to
the brain.
It is often difficult to examioe the state of the throat
from the exteut of cellular inflamuiation, but you may
always form a good judgment of what is going forward
there by taking as your guides the pulse, and the
degree of pain iu deglutition. That actual ulceration
does lake place in a certain proportion of cases is uude-
DJahle, hut the former is the more frequent pathological
condition. I remember seeing a young lady many
years ago (Miss E. H.), of exceedingly full habit, where
the determination of blood to tiie throat was so exces-
sive that respiration became impeded; the pulse began
to give way ; and timely scarifications alone saved the
patient's life.
AVhile all this is going on in the throat, the mucous
membrane of the nose becomes involved. An acrid
sanies, or ichor, begins to flow from the nostrils. The
membrane itself appears red and swollen. The sense
of smell ceases. Inflammation next extends along the
Eustachian tube to the inner and outer ear. An acrid
discharge, sometimes of a purulent character, distils
from the ear. Tiie ear is painful. The inflamniation,
if intense, may destroy the interior structure of tlie ear.
The ossicula auditus may slough away, the tympanum
fill up with granulations, and total deafness ensue.
158
IMPLICATION OF THE EYE.
Bat this is not all, nor a tithe of the mischief which
may take place wiiile the scarlatinal poison is in pro-
cess of concoction, and struggling, like a giant in prison,
to work its way out. The eve may become affected,
and two things may here take place, both requiring
your attention. The eye itself may take on inflamma-
tion, and this, if neglected, may go on to actual destruc-
tiou of one or both eyes. lu 1832, at the late Sir
David Berry's, I played a game of chess with Mr. Sey-
mour, who lost both eyes by this disease. He had been
seized with an intense form of scarlatina anginosa, at a
village in the west of England, where ihe medical man
wanted knowledge to guide him in the required treat-
ment. This young man ought to have lost thirty
ounces of blood from the arm. He was never bled at
all The poison, raging uncontrolled, destroyed both
eyes.
But further; the inflammatory action may lay hold,
not of tlic eye, but of the cellular substance within the
orbit in which the eye lies imbedded, 1 have never
seen this described, and have seen but one case of it,
that of Mr. Hobson, Surgeon, of Great Marylebone
street The ear was here first affected, then the cellu-
lar membrane of tlie orbit. The eye was saved only
by the most vigorous measures — bleeding, cupping,
physicking, and starving, continued for many weeks, so
difficult was it found to subdue an inflammatory dispo-
sition once sot up in this structure. Had it been small
pox instead of scarlatina, where the disposition of
vessels to pustulation is so strong, nothing could have
prevented abscess, I was assisted in the management
of this most difficult case by the late Dr. Warren, and
Mr. Alexander of Cork street.
CELLULAR COMPLICATION.
159
^^^^PTbe extension of inHammaiioD lo tbe larjnx is next
to engage nur attention. This, too, has received but
little notice from authors. In November, 1842, 1 was
called in to witness the sudden extension of the angi-
BOse inflammation to the larjnx. The croupy respira-
tion was soon succeeded by convulsions, and the child
rapidly sank.
(4.) So much for tbe implicatioa of structures situate
near to tbe fauces, and suffering by virtue of their jiroxi-
mity to the primary seat of disease. I must now advert
to the more serious iinpUcation of deep-seated and vital
organs. Mr. Dry, of Tottenham Court-Road, a man
in tbe prime of life, of good constitution, took scarlet
fever in November, 1842, When I first saw him, the
rash was abundant, and the throat was evidently the
seat of intense inflammation, aiibongh from cellular
complication it was diliicult to examine it. Above all,
the brain was affected. The patient had got out of
bed, and was crouching down in a comer of tbe room
in a state of high delirium. The eye was suffused.
The skin was cooled down by exposure to tbe cold air.
The state of delirium continued many days, but was
idtimately subdued.
Sometimes affection of the brain shows itself with
less of violence. My eldest girl, during her illness, cou-
tlnnally repeated tfie Lord's prayer. These more
urgent symptoms will sometimes show iheuiselves very
unexpectedly. Never, therefore, be tlirown off yoar
guard l)y the apparent mildness of the symptoms for
the first two days. The third is tbe day of danger,
when the rash begins to subside, and when tbe poison,
stjl) active and driven from the exterior, vents its fury
160 IMPLICATION OF THE HEART.
on some internal organ. In a few hours, irreparable
mischief may be done.
The lungs are sometimes the seat of inflammatory
engorgement. I attended, many years ago, in Broad
street. Golden square, a young man with scarlatina, where
urgent dyspnoea and distress about the praecordia indi-
cated a gorged state of the lungs or great vessels about
the heart. Timely venesection saved his life. That
an affection of the heart, particularly of its interior
structures, often complicates the phenomena of scarlet
fever, I cannot have the least doubt Mr. Snow pub-
lished cases of complication of pericarditis with this
disease several years since, and Dr. S. S. Alison has
more recently directed attention to the subject Mr.
Snow conceives the pericarditis to be the result, not of
the fever, but of the renal disease which succeeds to it,
and which may give rise to pericarditis, wholly inde-
pendent of the previous occurrence of scarlatina. This
complication has also been mentioned by Dr. Golding
Bird and by several other writers. The intensity of
the febrile action, the highly oxygenated character of
the blood, and the increased temperature at which it
circulates, would lead us to expect such complication.
The frequency of consecutive dropsy corroborates the
same pathological doctrine. I may mention one
strongly marked case, though, in so doing, infandum
rcnovo dolorem. A lady was seized w ith scarlatina at
the period of parturition. The labor was long and
severe. She perspired profusely. The heart labored
violently. The next day scarlatina appeared. The
heart, exhausted by the preceding efforts, gave way,
and in about fifteen hours from the appearance of erup-
ANGINA MALIGNA PVTRIDA.
161
tion, became engorged. A friglitfu! feeling of suffocation
sapervcned, and tlie pulse for a few minutes was imper-
ceptible at the wrist. This feeling subsided, but the
heart never regained its natural condilion. Dyspnoea
increased, and iu twenty-four hours more, the LIueness
of countenance and iucipient delirium showed that the
lungs were implicated, and that waves of ill-oxygenated
hlood were permeating the brain. Twelve bours longer
of this semi-asphyxiate state closed the sad and painful
scene.
3. The angina maligna putrida (the ulcerous sore
throat of Fotherglll, the cynanche maligna of Cullen)
next claims your attention. Bear in mind, that in
nature, tlie type last described slides into this, the fever
gradually losing its inflanmiatory, and assuming more
and more the typhoid character.
The initiatory symptoms of the malignant scarlet
fever are distinguished from those of the other varieties
only by their intensity. An irritable state of the sto-
mach and bowels, vomiting, and diarrhtca, are frequeat
occurrences. Headache, pain of tiie back, prascordial
oppression, and stJlTness of the neck, are present in con-
siderable severity, with great dejection of spirits. The
pulse is small and fluttering. The eyes appear heavy
and suffused. There is great debility. The patient
lies on his back and talks in a whisper.
The poison first localizes itself in the throat, which,
on inspection, appears stcolkn and livid. A disagree-
able foetor is perceived in the breath, which rapidly
increases. Ash-colored slonghs occupy the tonsils.
Ulceration and often extensive gangrene destroy a large
portion of the mucous membrane. The voice becomes
hoarse and hollow, and respiration is performed with a
162 SCARLATINA WITH COLLAPSE.
noise like that of one strangling. Hence the Spanish
name for tlie disease, garotillo. The throat is clogged
with a viscid phlegm. The nostrils pour forth an abun-
dant and acrid sanies, followed by excoriation of the
lips and ulceration of the angles of the mouth.
Delirium, often of a very fierce and unrcstrainable
kind, seizes the adult I have seen two patients in this
disease in the most raging phrensy — jumping out of
bed, naked, and literally dying on the floor of the
chamber. No spectacle more awful can be witnessed
in Eg}'ptian plague.
[Dr. Cathciirt Lees mentions (Dublin Med, Press, July 3, 1850) a
peculiar form of delirium resembling delirium tremens, and successfully
treated by opium, >ihich he thinks has not been sufficiently noticed by
authors on this subject. In one case, in a very old person, in ^hich he
was unwilling to give opium, stimulants were used with success.
The lato Dr. T. F. Cornell, of this city, described two forms of
delirium in scarlet fever which had come under his observation requiring
stimulants : one form in which they should be gradually but pirscvirhtf/If/
administered, and another in which they should be freely triven from
the Ix'Lriniiinir, and cites ciises in illustrati<»n.
lie also fully nrognised as a third form, that d<'pending upon an
intlainniatory state of the brain, and requiring antij»hloi;istic treatment.
Kcw York Jour. Med. ami Surff.^ Jan. and Aj>ril, 1841.]
In some instances the bronchi become congested, and
diflicult breathing is added to the other troubles. In
another class of cases, the mucous membrane of the
stomach and intestinal tract receives a large share of the
febrile impetus. Diarrha^a (scarcely to be restrained),
witli hiccup, distension of the abdomen, ischuria renalis,
and an extreme sense of exhaustion, characterize this
most formidable variety of the disease. In the most
aggravated of all the cases, an a'dcmatous condition
of the extremities, a bloated and cadaverous aspect of
SCARLATINA WITH COLLAPSE. 163
countenance, excoriation of the arms and buttocks, a
hard, dry, and brown tongue, precede the fatal event
All the circumstances conspire to show the awful
derangement taking place in the nervous and cu-culating
system through the intensity of the generating poison.
The blood collecls and stagnates in the mucous mem-
branes of the whole body (thoracic and abdominal), as
well as in the liver ; and that blood is of the most
depraved and vitiated quality. Such blood permeating
the brain, hver, and heart, destroys their functions, and
death ensues. You may examine the body, but the
precise cause of death is not thereby manifested. You
will find probably great destruction of ihe throat by
sloughy ulceration or gangrene — turgescence of all the
mucous membranes — engorgement of the substance of
the lungs, or liver, or both — effusion of a bloody sanies
into one or more of the great serous cavities, but the
condition of the blood is the real cause of death. The
palicnt dies of acute malignancy.
It is encouraging for you to know that bad as these
cases are, nature does not always give way under them.
Dr. Huxham relates an extraordinary instance of reco-
very under circumstances apparently the most hope-
less. You will naturally ask, what becomes of the
skin during this burst of gangrenous angina with
cerebral complication, gastro-enteric inflammation, and
hepatic congestion l I will tell you. In some cases
Aere is considerable efflorescence, but tlie color is no
Ifinger scarlet. It is livid. It appears and recedes. It
b accompanied with itching, and occasionally petechia
appear, interspersed among the more vivid patches of
eruption.
There are cases, very sad ones, occurring both to
adal&i and children, wbere uo afibction of the skin takes
place at all. Some years ago, I attended, with Dr,
Neviuson, Mrs. Mason, of Great Marylebone street, and
her two growu-up daughters. In each of the three
cases the nervous system was utterly prostrated, or in
the state of coi/apse. There was no violence, no deli-
rluiu, no rash, no struggling for breath ; but the pulse
was small, tlie skin cold, and the whole system depressed
by tlie intensity of the poison. Neither wine, nor
brandy, nor capsicum, could put life into iheui. They
sank, one after another, without any attempt to rally.
It was difficult to believe tlie disease scarlatina, hut the
eldest son took it in the usual form, recovered, and pat
that matter beyond doubt.
I proceed next to describe the sequel* of scarlatina,
as well of the mild as of the anginose and ulcerous
kind. The very mildest form of scarlatina simplex is
not free from tlie risk of some unpleasant sequels.
That which is most usually seen is a febricula, with
swelled glands of the neck, and discharge from the ear.
The skin is hot, the tongue white, and the alvine secre-
tions depraved.
1. When there has been any serious anginose affec-
tion, the cellular membrane of tlie neck \vill often take
on inflammation. Erysipelatous redness of the neck,
with great hardness and sweUing, are perceived. The
cellular tissue sloughs, and this sloughing, if extensive,
brings hfe into hazard, especially in infants, where the
vis vitsE is low. The danger is less in adults. On the
15lh December, 1842, I attended, with Mr. 8quibb, a
chdd who died in this state, with accompanying coma,
who had struggled successfully through the lirst period
of the disease. Suppuration of the cellular membrane
SKQDELf OF 80A&LET FETER.
165
of the ueck is often so extensive that long and deep
incisions into the neck are required to afford the neces-
sary vent to the sloughs. I ouce saw ahscess extend to
the body of the parotid gland.
[Eleath m slso sometimea caused by hicniorrbage from abscess of the
neck following amrtet fever.
A case of ulcerarion of ihe internal jugular vein, with a description of
Ihp paHa aft«r death, is given by Mr. Barret, in London Lancet {Amer,
Repub.), June, 1847 ; and also a case of ulceraiioa of the same vein
and of a branch of the subclavian, in a child eight years old, by Dr. R.
J. Hale, in London Jour. Med., Aug^ 1850, p. 720.
An interesting otse of an abscess opening behind the ear in icarbt
fever, in which profuse biemorrhage was first restrained by cotnpresfling
the artery with the finger, and al^rwnrda by applying creosote, and
with final Bucce^, u contained in the prise essay on this disease, by Dr.
P. W. Elkworth, of nartford (Conn.), publish^-d in Boston Med. aitd
Suri/, Jour., 18iB, in which paper refi-'rence is aUo made to a case of
alceratina of one of the jugular veins, which proved fatal, in the same
nei^botbood.
Abscesses sometimea form in different p.irU of the body, besides the
neck, as a sequel of this disease.]
2. Dest|uamation of the cuticle is quite pathogno-
monic of scarlatina. It is hardly ever absent. In all
bad cases, the hair comes off too, as indeed it does after
all long fevers, accompanied (as all long fevers are)
with dryness and great heat of skin. The nails are
sometimes thrown off, and some cabinets contain gloves
of cuticle and uaiL It is a curious speculation whether
this destruction of parts ends with the cuticle, whether,
in feet, portions of other structures may not be killed in
like manner as the cuticle, and regenerated during the
convalescence.
When scarlet fever attacks a child between the ages
of 3 and 7, while the second set of teeth is in process
of formation, it very frequently happens that their
168 SCARLATINAL DROPSY.
proportion of such cases, the urine is loaded with alba-
men, and of low specific gravity.
This circumstance has induced some pathologists in
recent times to connect scarlatinal dropsy in an especial
manner with an affection of the kidney, congestive or
sub-inflammatory ; and undoubtedly this is an import-
ant addition to the pathology of scarlatina. Dr. James
Miller, in a work entitled, " The Pathology of the Kid-
ney in Scarlatina," considers renal implication as an
important feature in certain cases, even from the outset.
He believes that the scarlatinal miasm fixes itself, occa-
sionally, on the kidney as it does on the mucous
textures of the throat, and that the development of this
renal complication gives a character to the subsequent
phenomena, leading more especially to dropsy and con-
vulsion. These cases he proposes to distinguish by the
title of Renal scarlatina. The occurrence of bloody
urine in certain cases of scarlatina proves that the
blood-vessels of the kidney are sometimes highly con-
gested. In a case seen by me in 1848, and recorded
in the first volume of the London Journal of Medicine
(p. 451), the left kidney ultimately took on inflamma-
tory action, and an abscess was found, after death,
imbedded in its substance. The frequency of dropsy
as a sequel in scarlatina, and its rarity in the secondary
stages of small j)ox and measles, admits of a satisfactory
explanation on the pathological principle so ably illus-
trated by Dr. Miller.
[Albumen is not always pro^ont in scarlatinal dropsy, as our author
intimates. In 00 cases out of 100 in an epidemic in Berlin, in 1840,
in which the urine was tested, I>r. Philipp never detected the presence
of albumen by heat alone, and in only a few cases by nitric acid.
Dropsy invariably occurred in cases which were not carried ofi* early,
JITIHAL DaOPBT^ 169
and began to appear, in a more or less eevere form, from llie twelflJi dny
bi the fourth or fifth week after dcsquaiiiiilion had comraenced. Not
one CA»e of dropsy proved fatal. {Brit. i»d For. Med. Hev., Jan,
1841.)]
Scarlatinal dropsy may assume any of Uie usual forms
— anasarca, ascites, Iiydrothorax. Anasarca is infinitely
the most common, perhaps in the proportion of ten to
one. Sometimes the three are associated. We may
then rest assured that the heart has become impUcated
iu the course of the disorder, and that some serious
impediment to the free course of the blood exists within
or about the heart — probably a deposition of lymph
about one or more of the valves of the heart, which
careful auscultation will detect. These cases may
nearly be despaired of I have seen simple ascites suc-
ceeding scarlatina, depending upon inflammalion of the
peritoneal coveriug of the liver, and yielding to leeches
and saline purgatives,
[Dropsy may auperveoe in scarlet fcver in two diflerent ways : —
1, Suddenly, distending the cellidar Bubatance of the whole body,
«nd extending even to the cavities, within twenty-four or tliirly-sii
boars, with fever, and almost entire auppression of urine, and very rapid
pulse. Tljis furm occurs quit« as often, and perhaps mom so, after mild
Attacks of the disea»e.
2. Qraduaily, with little or no fever, first showing itself by puffinesa
about the eyes, or swelling of the whole ^e, or of the ankles, or of all
theso parts at the same time.]
The anasarca succeeding scarlatina is cnrable in a
large proportion of cases — a circumstance which ren-
ders it probable £hat tlie condition of the heart, kidney,
or other viscera giving rise to it, is one of congestive
rather than of pure inflammatory action.
It was a favorite notion of physicians in times past,
that scarlatinal dropsy depended on (feiiVeVy of the capil-
170 8CARLATI1IAL DROPBT.
lanes, and was to be combated by tonics and wine.
This doctrine mnst have been encouraged by the resnlts
of practice, or it never could have enjoyed such popa-
larity ; and this is true. I have seen weakly children
become anasarcous after scarlatina, and recover by the
aid of wine and bark. But very many cases so treated
would be exasperated. The urine would become still
scantier, still deeper colored. The oppression of the
breathing would augment, and they wocdd die at length
with the thorax full of water.
Hydrothorax succeeding scarlatina in the adult, still
more commonly in children, may advance without
attracting attention. Some years ago, a gentleman
having passed through scarlet fever, b^n to conva-
lesce, but his recovery was neither rapid nor satis&c-
toiy. Symptoms were not uigent, and attracted no
particular notice. He walked out one morning to his
club-house. On returning, he fell, and was car-
ried home a corpse. His chest was found full of
water.
Therefore, watch carefully the secondary fever of
scarlatina. Watch the period of convalescence, even
though no fever developes itself. Convince yourselves
that the kidneys secrete urine of healthy, and not of
albuminous quality. If fever hangs about the patient,
and ill-defined symptoms harass him, keep your eye
and ear upon the chest, so that you may early detect
any unusual murmur indicative of cardiac disease, or
any evidences that the lungs are congested, or the
pleural sac distending with fluid. See that the pulse
be soft and the tongue clean, ere you take your leave.
" Aliter male consules nomini tuo" as BagHvi observed
160 years ago. Without aid judiciously administered.
SCARLATINAL CONVULSIONS.
171
a system suffering under the secondary fever of scarla-
tina will not regain its healthy action.
[For A summary of the views of different pathologists in relation to
dropsy following scarlet fevtr, see Appendix H.]
6. The last of the sequelae of scarlatina, and happily
the rarest, is convulsion. Not more than one out of
eighty cases will be found thus affected. Convulsion
may accompany the development of fever, or it may
he deferred, and occur unexpectedly, when a hasty
observer might consider convalescence as confirmed.
The period of its accession, therefore, may vary from
the third to the fortieth day from the invasion of fever.
The pathology of scarlatinal convulsion has not yei
heen iuvestigated with all the accuracy which is desir-
able. It appears to be owing, in some cases, to disor-
ganizing processes going on in the brain. In others, it
perhaps depends on the condition of the blood which
the heart is propelling towards the brain. Scarlatinal
convulsion is accompauied by a buffy state of the blood
and inordinate action of the heart. Convulsion some-
times succeeds to dropsy, and the two affections are
pathologically allied. The occurrence of convulsion in
scarlatina always betokens great danger. I have notes
of seven cases, five of which died, and two recovered.
[Dr. Robert Barnes has called attention to a muco-puruleiit discbarge
from the vagina in sicBrlatina, which Le considers as iraporttint ia rela-
tion to forensic medicine, and which he Rupposea to be of rare occur-
rence, {lond. Med. Oai., July 12, 1850.)
I>r. J. R. Cormack has published a paper on this affeetiun in tlie
utne Journal (August, 1650), in which he states lliat it is lei^ utici>m-
mon than has been supposed, and that, in an epidemic of searlet fever
in 1849-40, in 23 female patients under hix care, all of whom were
cleanly and well nursed, there were 12 cases of well marked vnginilis.
Of these 23 paUents, two only were above fourteen years of age, and
172 BBQUBLIS or 80ABUT FBTIR.
dme were req>ectivdj 26 and 28 yean of age, and both married, and
both of these had acute vagiiiitis much more severe than any of the
difldren. He says that he was so much impressed with the importance
of averting or preventing this aflfection, that, in every female patient, he
directed careful ablution of the parts, at least twice every twenfy-lbur
boon. He regards it as ^ a not unlooked fer extension of the exanthe-
matous inflammation of the skin, analogous in its nature to what is
often met with in the mucous linings of the nose, ear, air passages, and
intestinal canaL"
Wiy neA, or contraction of the stemo-deido-mastoid muscle, is
another, and occanonally very trouUesome sequel of this disease. Ji
aometimes goes off spontaneously in a few days, and at other times lasts
for months, and even for years, and can then only be relieved by an
operation.
Dr. Golding Bird alludes to peculiar pains, at first nght apparently
of a rheumatic character, limited almost entirely to the lower limbs, as
fidlowing scarlatina — not constant, but apparently of a spasmodic or
cramp-like character. {Ou^i Hiup. jBep., April, 1845.)
The frequency of occurrence of sequehe in scarlet fever is said by Dr.
Bird to be in the inverse ratio of the severity of the attack.]
LECTURE VIII.
STATISTICS, PATHOLOGY. AND MANAOEMEN'T OF
SCARLET FEVER.
Statistical details showing tlie prevalence of scarlotinn In Englnnd, the
proportion of Bevere to mild cubcb, and the per tentsge of moimlily.
Diognobls of scnrklina from measles. Pathulony of scnflnlino. Laws of
the scarlntinol tnitmm. Question of spontaneoua origin. RecDirence of
BcarlaliQfi. Cause of the diversity iif its sspetti Munagvtnent of gcarla-
tinii. General principles. Employment of emetics. Cold affusion.
Blood-letting, general and topical, pargutivo medicines, stimnlonts, and
Gordliila. Bark. Local treatment of tlie angina, Miinugemi?ul of scurln-
tiool dropsy.
Scarlet fever is ondoubtedly an increasing malady in
this country. The delails of its ravages, however, in
the last centnry, are not well known, for the deaths by
scarlet fever are mixed np in the old liills of mortality
with measles and quinsy. Still the uuited nnuiber was
small, and bears no couiparison with the results of recent
observation. The amount of mortality occasioned bv
scarlet fever tlirougbout England at the present time
is really appalling. Mr. Farr, in his tliird and fourth
Reports, has given a most instructive series of tables
showing the deaths by scarlet fever (in each of the 324
districts into which England and Wales have beea
subdivided) for three years and a half, divided into
fourteen quarterly periods, extending from July 1, 1837,
to December 31, 1840. The general results of this
gigantic investigation appear in the following brief
summary : —
174
STATISTICAL DETAILS OF SCARLATINA.
IkMe ukowing the Dtalhi by Scarlet Fever ikroughout England and
WaU$^ within Fourteen Quarterly Periodic extending from 1st
July, 1837, to SUt December, 1840.
QUABTEBI.T nEBtOM.
1837.
1838.
1839.
1840.
Jan., Feb., March . . .
April, May, June . . .
July, August, Sept • . .
Oct, Nov., Dec ....
Total Deaths . . .
1033
1487
1880
1104
1260
2058
1655
1620
2529
4521
4537
4370
4874
6035
2520
5802
10,325
19,816
From this table we learn that the ravages of scarlet
fever have (on the whole) progressively aagmented
from the first to the last of these periods, and that the
year 1840 exhibits an increase over 1837 of four to
one. It further shows that the greatest mortality by
scarlet fever takes place in the last three months of the
year, and the smallest mortality in the months of April,
May, and June. This is exactly what Dr. Willan had
remarked nearly fifty years ago, when watching the
visitations of epidemic scarlet fever in London. Never-
theless, you will perceive that the influence of season
on the mortality of scarlet fever is not very striking.
[An examination of the months in which 4334 deaths by scarlet fever
took place in New York, within sixty quarterly periods, during the fifteen
years from 1830 to 1844 inclusive, shows that Hy far the greatest num-
ber of deaths occurred during the months of January, February, and
March, and the smallest number during the months of July, August,
and September, the numbers corresponding with these ]>eriod8
respectively being 1600 and 665 ; the numbers during the quarterly
periods of October, November, and December, and of April, May, and
June, being respectively 1084 and 986.]
You are not to suppose that the above table exhibits
a picture of the average mortality in England by this
disease. The years 1838, '39, and '40 were years of
PROPORTION OF SEVERE TO MILD CASES.
175
epidemic prevaleuce. It is probable that no epidemic
of similar length and intensity ever before visited this
country. It began in the metropolis in September,
1838, and reached its acme with us early in December,
1839. In the first week of that month, eighty-two per-
sons died of scarlet fever in London, being a daily
destruction of twelve lives. Nine hundred and seven-
teen persons perished in London by scarlatina during
the last quarter of 1839. In the whole year the deaths
were 2500, being four times as many as died of small
pox, and one-fifth more than the mortality by measles.
[In New York, the wbolo number of deaths ty scarlet fever from
1815 to 1828 inclusive, was only 97. while in the succeeding 21 years
(from 1839 U> 1S4D inclusive) G17D fell victims to iL In Pljiladelphia,
the number of deaths by it was comparatively smiiU from 1807 to 1831,
in which year 200 are recorded, and in the fallowing year 307, the
former sum enceeding by nearly fifty the whole morlality for the 24
preceding years. It began U> prevail extensively in Boston also to
1831, and has caused a targe number of deaths from that time to tho
present.]
The following are the observations of authors on the
proportion which severe cases bear to the mild — inflam-
matory, to the putrid. Dr. Willan states that in 17SG,
he saw 39 cases of mahgnant to 152 of the anginose
variety (one to four). Dr. Clark, of Newcastle, had 33
cases of malignant to 73 of angiuose (one to two);
and 23 out of 131 (or one in six) had dropsy superven-
ing, lie adds — " Considering the numbers that are
attacked in too mild a form to seek medical advice, the
proportion of malignant to mild cases should not be
rated higher than one in twenty."
With reference to tlie per centage of morlality. we
have sufficient materials for forming a good judgment.
We lay aside Sir Gilbert Blane's experience, as apply-
176
PER CIIITAGE OP aORTAUTT.
ing ody to picked cases. At Ackworth school, in
1803, the disease proved £sital at the rate of four per
cent Dr. Tweedie informs as that out of 644 cases
treated at the London Fever Hospital, in the twelve
years between 1822 and 1833, there died thirty-eight
(thirteen males and twenty-five females), which is
nearly six per cent The rate of mortality at that hos-
pital varies very greatly, far more than is observed in
small pox. In 1832, it was as low as one in forty ; in
1829, as high as one in six — an immense fluctnation,
extending fi*om two and a half to seventeen per cent
I am indebted to Mr. Ward, of Bodmin, for the fol-
lowing : —
TMe exhibiting the Number of Cases of Scarlet Fever occurring at
Bodmin between June 24 and December 24, 1842, with the Mor-
tality and Character of the Cases.
Cases with Eruption ....
Ciisos without Eruption . . .
Totil Cases . . .
Numbers.
Deaths.
Rate of Mortality.
324
108
2G
10
Eight per cent
Nine per cent.
432
3G
One in twelve.
Tliirty-nine of the cases followed by dropsy ; five, by convulsions, of
whom four died.
The average of these observations gives six per cent
as the medium rate of mortality by scarlet fever. What
a picture may be thence drawn of the actual extent of
scarlet fever in years of epidemic prevalence ! It shows
that in London, in 1839, there were 41,650 cases of
this disease ; while throughout England and Wales, in
1840, when 19,816 persons died, the total number of
seizures must have reached the almost incredible num-
ber of 330,266.
PER CE^TAGE OF MORTALITY.
There arc no statistical records to leach us (as in
stnall pox) the period of greatest danger ; death has
been said to take place in nine hours. I never saw
anything so rapid as this ; biit I have seen death occur
on the second day, and frequently ou the third. I
would call sixty hours from the breaking out of the
rash, the period of greatest danger Many, of course,
die at a much later period, — on the eighth or twelfth
day. Dropsy aud abdominal complications may pro-
tract the date of death to a month.
The proportion of fatal cases occurring at the several
periods of life (young, adidt, and aged) is well illus-
trated in the registrar general's tables. Out of 345
cases proving fatal in London during the months of
January and February, 3840, 3'26 were children (under
fifteen), and only nineteen were adults. Out of "2014
cases recorded by Mr. Farr in his fourth Report, '2419
were children, 182 adults, and 13 aged persons. The
violence of the disease falls therefore on children, as
compared witli grown persons, in the proportion of
seventeen to one in ihe first case — of twelve to one in
the second.
[AgM of '^014 persons who
died of BcarlBt fever
n New York duri
tlie elglit yeara from 1837 to
1844
inclusive, and of lfi14 who died
rs rr,.ra
1837 to 1845inc!i
sive :-
New York.
One yeiir and unJtr,
. 2S5
184
Il.'twe«n 1 and 2 ve
ra, .
. 483
3B3
■■ 2Btid 5'-
. 1214
919
" 5 nnJ 11) '
. 4G0
409
" 10 and 20 '
. 93
68
" 20 and 30 '
55
22
" 30 nnd 40 "
17
12
178 PER OENTAGE OF aORTALrrT.
New York.
PhiUddphia.
Brought over, .
. 2597
. 1967
Between 40 and 50 years, .
6 . .
5
" 50 and 60 " .
7
2
« 60 and 70 " .
1
Unknown,
4
Total .
. 2614
. 1974
New York.
Philadelphia.
30.12
40.69
76.75
75.49
97.39
97.77
2.60
2.22
Table exhibiting the per oentage of deaths by scarlet fever at diffsreni
ages to the whole mortality by that disease, in the cities of Glasgov,
New York, and Philadelphia : —
Glasgow.
Under 2 years, . . 35.40
•* 5 *• . . 70.15
" 20 ** . . 97.95
Above 20 years, • . 2.04
Tlus table shows a remarkable uniformity in the age at which death
took place by this disease in these diflferent places. {Proceed, of PhUoi.
Soc, of OloBgoWy extracted by Amer, Jour, Med. Set., Apr. 1845.)
It will be seen by the preceding tables, that but a fraction of the
mortality by scarlet fever occurs over 40 years of age, almost one half of
the deaths taking place between 2 and 5 years of age, although a few
are recorded between 50 and 60, and one in this city between 60 and
70 years. Sir Gilbert Blane saw but one case in a patient over 40
years of age, and Dr. Copland has seen but one between 50 and 60
years. Dr. C. Lees had one patient 70 years old with it, and Dr.
Chapman had one 80 years old. It is also comparatively rare in the
earliest months of life.
In some epidemics, the disease is almost confined to patients between
15 and 25 years of age.
Scarlet fever would seem to be about six times less fatal among blacks
in New York than among whites, the nuinber of deaths in proportion
to the population of the two races, during the eight years from 1837 to
1844 inclusive, being that of 1 to 70 of the whites, and of 1 to 450 of
the blacks. In the year 1837, there were only 3 deaths by this disease
among blacks to 570 among whites. Reference to the note on page
35 will show that the mortality by scarlet fever was also much less
among the blacks in Charleston (S.C.) than among the whites, though
the disparity is much less than in New York.]
Dr. Withering distinctly states, and certainly a gene-
DIAGNOSIS OF SCARLATINA PROM UBASLES.
ral iinpressioa prevails, that scarlaitoa invading adults
is, cteferis paribus, a severer disease, and occasions a
greater per centage of mortality, tlian %vlien it invades
infantile life. Whether this he the fact or not, I have
at present no means of jndging ; but for a long time it
lias been known that scarlet fever is peculiarly danger-
ous wlien it occurs at the puerperal period. The cir-
cumstances in which the system is then placed suffi-
ciently account for the fact: iho beat of ibe body — the
exertion — the consequent exhanstion; and possibly the
peculiar condition of the blood accompanying the puer-
peral state. AH these things naturally tend to augment
the virulence of fever, whether specific or non-specific,
originating at that period.
I shall not detain you wilh any remarks on prognosis.
After the exposition I gave of tbc character of the
symptoms in ibe anginose and malignant forms of scar-
latina, you cannot fail to perceive both the signs and
the causes of danger.
When treating of measles, I mentioned briefly the
chief points of diagnosis between it and scarlet fever, I
will now recur, somewhat more in detail, to this subject,
which, by ibe way, is very ably treated in Dr. Williams's
work on the morbid poisons.
1. Measles and scarlet fever differ in their incubative
periods ; scarlet fever Hes latent one week — measles,
two weeks,
2. Measles and scarlet fever differ in the periods of
their eruptive fever. Scarlet fever developes rasli in
twenty-four hours, measles in seventy-two hours, after
tlie setting in of fever.
3. The two diseases differ in the color and aspect of
the efflorescence. In scarlatina it is brigbl sc'arlet ; in
180 PATHOLOGY OF SCARLATINA.
measles, it is a dull raspberry red. In scarlatina, the
eruption is extensive and diffused, brightest on parts
covered. In measles, it is in patches, brightest on parts
exposed.
4. The diseases differ in the concomitant affection
of the mucous tissues In scarlatina, there is early and
often serious inflammation and sloughing of the throat
In measles, the mucous affection is chiefly in the nose,
eyes, and larynx. There is no disposition to cynanche
or its consequences.
5. The two diseases differ in their secondary actions.
Scarlet fever is accompanied and followed by phrenitis
and dropsy ; measles, by pneumonia.
6. The two diseases differ, lastly, in their tolerance of
remedies ; measles bears blood-letting well, scarlet fever
badly.
[In addition to the diagnostic marks mentioned by our author, majr
be mentioned :
1. Swelling of ih£ hands and sometimes of the feet, never present in
mejisles, and hence of some importance as an external mark.
2. Character of the desquamation — being in scarlatina in the form
of flakes of greater or less size, and especially on the hands, from which
the epidermis sometimes comes off like the fingers of a glove ; while in
measles it is fine and branny. This point of difference is sometimes of
importance on account of the sequelae of the two diseases.]
I come next to investigate the pathology of scarla-
tina ; to explain to you the laws which govern the
phenomena of the disease — its rise — its symptoms — its
varieties — its complications. The subject is one of great
extent and intricacy, but it is one also of much patholo-
gical interest, and of some practical importance.
The notion that scarlet fever was the result of a mor-
bid poison was one of very early growth. Morton
FATHOLOQT OF SCARLATINA.
181
expresses very clearly and pithily the opinions enter-
tained during the 17tli century on this subject: — " The ,
proximate cause of scarlatina," says he, "is a 2>oison
defiling the animal spirits, whose malignity does not
only overwhelm the spirits in its first attack, but by
agitating the mass of blood, breaks it down into an acrid
collnvies more en ergeiically than any other ferment."
Navier (a French author), who has given the history
of the epidemic of 1753, goes a step further, and attempts
to connect this poison with that which occasions the
distemper of horned cattle — a distemper which prevailed
in London in 1839, and which has lately devastated
Egypt. " In this bovine epizootic," says Navier, " the
convalescent beasts lose their hair, and their skin peels
off. When they die, the viscera are always found
more or less in a gangrenous state." He gives it as his
opinion that the contagion of scarlet fever originated
with cattle, and was by them communicated to man.
He traces also some connexion between these com-
plaints and small pox, 1 menliou these circumstances
because tiiey prove to yon how early liie attention of
men's minds was directed to the analogy between the
diseases of men and cattle, a doctrine uhich, investi-
gated by the genius of Jenner, led afterwards to such
brilliant results.
Scarlatina is peculiarly the disease of temperate
climates. It is comparatively rare in Bengal. Dr.
Jackson, formerly of Calcutta, now of Chatham, informs
me, that he cannot recall to mind having sceu any cases
in India deserving the name of scarlatina. I have
never met with any account of the disease as it occurs
in the black skin ; but perhaps this may be my owa
fault.
182 LAWS OF 8CARLATI1IAL MIASM.
[The lud afibrded by tint is lost in tho diagno«is of scarlet fever in
blacks, but the characteristic distribution is still presenred, and the [mrts
which are the seat of the eruption are marked by a deeper shade of the
color of the skin, whether that be of a deep black, or of some its modifi-
cations. Tlie precursory and accompanying symptoms, however, we
most to be depended upon for diagnosis in this race.]
America did not receive the contagion of scarlatina
till the year 1 735, as we learn from a curious paper by
CadwaUader Golden, Esq.* Its progress over that
^at continent was singularly slow, but attended with
great loss of life. ** Like most new diseases," says Mr.
Kearsley, describing the epidemic that began in I7469
*' it baffled every attempt to check its progress. Villages
were depopulated by it, and parents left to bewail the
loss of all their children."
[The first appearance of scarlet fever in New England was in May,
1736, at Kingston, an inland town about 50 miles eastward of Boston.
On the 20th of August of the same year it appeared in Boston, and of
about 4000 persons who had it, about 1 in 35 died. In the country
towns the mortality was much greater, from 1 in 6 to 1 in 3 dying of
it. In Kingston, where tho usual annual mortality was not above 9 or
10, it rose that year to 102. ITie disease as it prevailed in New
England in 1735 and '36, was described by Dr. William Doughu^, in a
work published in 1736, and reprinted in the New England Journal of
Medicine and Surgery^ vol. xiv. p. 1. For an analysis of his work, see
Historical Sketch of State of Medicine, Ac, by John B. Beck, M. D.,
Transac, Med, Soc, State New York, Feb., 1850.]
Scarlet fever affects the sexes in equal proportions,
and very remarkably. In 1838 it deslroyed, in London,
747 males, 777 females. In 1839, 1241 males, 1268
females. Throughout England and Wales, in 1840
(exclusive of die metropolis), 8927 males, 8935 fe-
males !
* Medical Obsenrations and Inquiries, toI. i. p. Sll.
LAWS OP BCAaLATINAL MUBH.
[Of 2iiU deaths by scnrlet fever in New York, (iurins; tlio eight
yearefrom 183T to 1844 inclusive, 1337 were ninlea and 12TT femnlea;
and of 1074 JeHtiis hy llie tiiime disease in Philiidelpliia, during the
nine yesra from 1837 to I8i5 inclusive, 1008 were males, wiJ 968
females.]
The infecting distance of the miasm has not heen
investigated; but It is found that when it invades a
school, no precautions avail anj-thing towards prevent-
ing the spread of tlie infection. This has often been
proved at ilie London Foundhng Hospital. At Ack-
worth, in 1803, the contagion hiigered in the school for
four months, in spite of every effort. With regard to
the susceptibility of this complaint. Dr. Bintis tells us,
that out of 216 scholars at Ackworth school, 184 were
affected. Dr. .Adams remarks that this is a larger pro-
portion than is commonly found susceptible in districts
or families. Like all other miasms, that of scarlet fever
is capable of attachment to fomitcs, especially clothes.
[The question is stili unsetlleU bolb la to the exact period at which a
jMtJenl with scarlet fever liegins U> ba ti fucus of cutitogion, and also
how loug he eontinuea to net as such by the secretion of the poison.
"With regard to the first point. Dr. Robert Williams {o» l^orbiil Poi-
wm) thought that the generatioa of the poison commences with the
fever, and before the appearance of the eruption. With regard to the
MOOnd, it WHS the opinion of l)r. Willan, that children convalescing fr>]ni
this disease, notwithstanding every attention to cleanliness and change
of apparel, are cnpnble of communicating it (especially to other children)
for two or three weeks after apparent recovery.
We have always been led to consider the end of the periwl of desqua-
nalion a» the time when the patient ceases to senerale the poison, and
to commuiiicale it directly by eirianntion tmm his own {lerson. All
com mu mention after tlint period we sliould be inclined to refer to
Ibmites, of the communication of the diseagc by which means at inter-
Tsla of even several months, and at considerable distances, numeroos
KDstences arc on record.]
No doubt exists that, in a very large proportion of
184 RBOURRENCE OF BOARLATIlfA.*
cases, scarlet fever is the produce of a specific miasm ;
but the qaestion may well arise, whether any combina-
tion of circumstances can developean eruption possessing
the characters of scarlatina. I am bound to tell yon
that I believe they can. I have seen scarlet eruption,
in no respect different from that of ordinary miasmatic
scarlatina, arising from exposure to cold and moisture.
A young man residing near St James's Street, some
years since went down to the Serpentine to bathe. He
walked in a hurry, plunged in when overheated, and
two days afterwards I saw him covered with scarlet
eruption. He had suffered in the same way once before.
I often see true scarlatinal eruption occurring in the
progress of the secondary fever of small pox, without
any grounds for believing that contagion had operated.
It seems as if secondary fever can develope this eruption
in the same way as it throws out erysipelas.
[We slioiild ourselves prefer the application of the term erytliematous
or roseolar, rather than " scarlatinal," to the efflorescence in the preceding
case, as well as to that sometimes occurrim; in the secondary fever of
small pox, produced as the former was by a sudden check of perspiration,
and belonging, as it does, to analogous forms of eruption produced by
connrnm causes of disease — restricting the use of the term scarlatinal to
that form of eruption constituting one of the characteristics of a febrile
exantliem, which originates in contagion, is governed by fixed laws,
pursues a definite course, is liable to certain complications and sequelae,
ike. We should fear lest the use of the ej)ithet scarlatinal in a generic
sense, to signify different kinds of redness, non-specific as well as specific,
however close the resemblance between them, would tend rather to add
to the confusion already too great, which hangs about the nomenclature
of cutaneous diseases.]
Thus much I thought it right to say before approach-
ing the vexata questio of secondary attacks of scarlet
fever. Observe the conflicting statements of authors on
Kecurrekce of scarlatina.
186
this licatl. Dr. V/ilhn (ctTtaiiily one ot" tbt; most Hcute
and careful observers of die disease) sajs, tliiit out of
2000 cases which be atteaded. he saw no ioslance of
recurrence. Dr. Carrie, of Liverpool, who devoted
much alteution to scarlatina, was compelled, by the
results of long experience, to " reuoiince the opinion he
had early imbibed, and to confess that the same indivi-
dual is liable to scarlatina once only," Sir Gilbert
Blane, on the other baud, met with one instance of
scarlet fever occurring thrice, and, as be says. " without
the least suspicion of ambiguity." Dr. Binns inclines
to the notion of occasional recurrence.
Exceptions do occur; ncvcribeless, the law of ex-
hausted susceptibility, as Dr. Williams calls it, is very
strongly marked iu tbis disease. I cannot doubt hut
that a large number of the alleged cases of recurrent
scarlet fever are cases of licbcnous or iirticarial eruption,
suddenly brought on by cold, or some deleterious article
of food — cases which have no decided iuculiative stage,
which run a premature cour.se, wholly distinct from the
steady march of a specific anginose fever. Medicine is
filled to overflowing wuh false facts of this kind, set
down without umch consideration, and with a scanty
knowledge of pathology.
[Dr. Tweedie says ibnt lie has cwrtainly met with several well aiilhen-
tuated iosUnces of a second attack of scarlet fever iu the mxn-i ponon.
{Cyel. Prac. Mtd^ Art. Scarlatina.)
One case of recucrence of ncirlol fuier came under the obaervaUoD of
H. Raf cr during IJie period whicli elH|«<>d between the 6rst &nd second
editioQs of his work on Diseases of the Skin. He had met with no in-
itanoe of it when the first edition was published.]
Scarlatina is one of the very few diseases to which
the foetus in utero is liable. On the 28lh April, 1839,
186 DIVERSITT OF ASPECT.
my youngest son was born, evidently saffering under
some form of fever. The throat was affected on the
following day, obviously from angina maligna. Erup-
tion was never developed. The child drooped, and
died on the first of May.
Attempts have been made to produce scarlet fever
artificially by inoculating with the blood, or with the
serum of miliary vesicles intermixed with the specifks
eruption. We are informed that scarlet fever, unmiti-
gated, was subsequently developed. No good could
have been anticipated from such a measure.
You see the great diversities in the aspect of scarlet
fever. Can any explanation of this phenomenon be
offered which is at all satisfactory t Is it attributable
to the weather, to diversities of individual habit, to di-
versities in the quality of the contagious miasm t Sta-
tistics teach us that season has nothing to do with it
The year 1839 was peculiarly fine, yet in that year
scarlet fever raged in London like a pestilence. I am
well aware that bad cases sometimes propagate mild
cases, and vice versa ; but I cannot shut my eyes to the
fact, that, on a large scale, you will find mild cases suc-
ceeding each other, and severe cases producing severe
cases. I am inclined, therefore, to attribute something
to the quality of the infective miasm ; but I candidly
acknowledge the obscurity in which this branch of
exanthematic pathology is involved, and hope, with
Huxham, it may hereafter be cleared up.
The management of scarlet fever, in all its varied
forms, now demands your best attention. Let us first
consider the objects which should be kept in view. 1.
It is your duty to moderate arterial excitement when it
HANAOEHENT OF SCARLATINA.
187
runs tiaugeroiisl)' high, and especially to lessen llie licat
of tlie surface, 2. You must support tlie tone of the
system, when oppressed or subdued by the malignity of
the poison. 3. You must obviate local congestions and
the organic complications which arise in the progress of
the fever. In ihese general propositions, all physicians
will probably agree; but the difficulty consists in prac-
tically carrying them out. What are the best means of
(iiltilliiig these indications 1 How far are the remedies
to he pushed ! These are the pinching questions. Our
chief reliance, in the management of scarlet fever, is
placed in the skilful use of one or more of the fidlowiug
classes of remedies : — 1. Emetics; 2. cold afrusiiin; 3.
blood-letting, general and topical; 4. purgatives; 5.
ionics, stimulants, and antiseptics. They will require
separate invesiigation.
We may begin, however, by getting rid of ihe mild
form of scarlatina, which, as Sydenham said, demands
very litde aid from the physician. The cases should be
watched, lest local congestions arise; but otherwise, a
gentle laxative powder, and abstinence from meat and
beer, are alone required. We may, in the same sum-
mary way, dispatch those cases which are at the other
extremity of the chain — the cases of angina maligna
gangrenosa, with undeveloped eruption, which, from
the very onset, are characterized by depression, or col-
lapse of the nervous system. Common sense here
dictates an early recourse to stimulatits — to wine, brandy,
cordial draughts containing aether, camphor julep, aro-
matic confection, and tincture of bark, in sncli quantities
and doses as the stomach will bear, and the age of the
patient justify. On this point there is no room for
doubt or cavil.
190 BLOOD-LETTING IN SCARLATINA.
duced. Sanctioned by my uncle, the late Dr. Gregory
of Edinburgli, this plan has been amply tried in all parts
of the world, but it has not realized the expectations of
its proposer.
The truth is, that the cold affusion is applicable only
to a small number of cases. It is adapted for young
people with high anginose inflammation and a burning
hot skin, without plethora, without depression of nervous
energy ; but it is inapplicable to the scarlatina of adults,
accompanied with coma, phrenitis, or marked debility.
It is wholly unfit for cases of cynanche maligna. It
answers its purpose very well for the first day or two,
but it is often impossible to continue its use. Lastly, it
seems to increase the disposition to dropsy. Dr. Currie
proposed to obviate some of these objections by substi-
tuting tepid sponging for the more formidable affusion^
but a palliative like this is little fitted to meet the exi-
gencies of severe cases. Affusion was practised by
stripping the patient and pouring over his naked body
four or five gallons of the coldest water, repeating this
process every two or three hours, until the fever was
permanently subdued.
I can recommend this practice to you, as being well
adaj)ted to the scarlet fever of young persons of san-
guine temperament, and tbe early stages of the disorder.
Cold or tepid sponging with vinegar and water proves
an useful auxiliary at all periods of the disease. It
refresbes the patient, relieves headache, and lessens
restlessness.
3. Blood-letting, general and topical. Some physi-
cians discourage all loss of blood in scarlatina, as being
foreign to the genius of the disease. Others strongly
advise it. Much will depend upon the character of the
GENERAL AND TOPICAL.
191
symptoms, the period of tlio disease, the couJilioii of
the paliciil ; t)Ut I wisli to impress upon you strongly,
that scarlet fever not only aduiils of blood-letiing, but
often imperatively reqnires il, and that on general bleed-
ing- alone the safety of the patient often depends. Let
me give you a few cases in illustration.
Miss Ramsay (ietatis 12), in 1832, had scarlet fever.
On the second day, slie becauie very sleepy. On the
third day, this sleepiness was fast treading on the con-
dition of coma. I had her liled in the jugnlar vein to
twelve ounces, and all went on well.
On Thursday, 22d June, 1837, my eldest son, then
six years old, was seized with rigors and vomiting. On
the following day. scarlet fever appeared in great in-
leosity. The boy is of sanguine temperament, and had
required venesection the preceding year for influenza.
On the uiglit of Sunday, the 25tli, the febrile symptoms
ran high ; all medicine was rejected hy the stomach.
The long continuance of the vomiting indicated the
extension of inllauimatory action to the mucous mem-
brane uf the stomach, and probably also to the dia-
phragm and neighboring structures. I bled him to six
ounces with decided benefit, and feel persuaded that
without the loss of blood, fever would soon have de-
stroyed him.
In 1840, Mrs, Sabine, of Hoxton, took scarlet fever
during her confiuement, and narrowly e-scaped. Secon-
dary fever ensued. Languor, failing appetite, and a
general sense of malaise, continued long. She had
been sent to Margate for change of air. On her return
I saw her. and had her immediately bled to twelve
otlDces, Her recovery then ■wont on progressively.
While I thus advocate the necessity of blood-letting
^mi
192 BLOOD-LETTING.
in certain cases, I freely acknowledge that it is inappli-
cable to others. You would not always do harm by
the attempt (for it is one thing in scarlet fever to open
a vein, and another to draw blood), but any such indis*
criminate use of the remedy would expose yon and the
profession of physic to just reproach. The successful
treatment of the disease by bleeding in one epidemic,
at one season, and in one district, does not authorize
the same procedure in another epidemic, a diflferent
season, or a diflferent locality. Dr. Willan tells us, that
in London, in 1785, the usual results of blood-letting
were, great depression and faintness, the pulse becom-
ing weak, frequent, and often irregular. Again, in the
epidemic of 1733, at Edinburgh, we find it stated that
but few died who were timely blooded. It was then
remarked, what I have often noticed, that vomiting in
this disease is only to be checked by venesection.
The blood drawn in scarlet fever scarcely ever pre-
sents a firm coagulum. In the majority of cases the
blood coagulates rapidly into a soft jelly, showing the
small power in the system, and rendering it probable
that the urgent symptoms in scarlet fever (such as deli-
rium and coma) depend more upon congested veins and
stagnation in the capillaries, than upon arterial action.
This pathological condition of the circulating system
was not unknown to the old authors, one of whom
remarked, that when the superficial vessels are dis-
tended, there cannot he the same amount of blood in
the interior as when the skin is cold. We may hence
learn why fainting so often follows venesection in scar-
latina, and why we scarcely ever bleed twice. Post-
mortem examinations confirm this doctrine. Dr. Wells
records the dissection of a young soldier who died of
BLOOD-LETTING.
scarlatina! coma, uoatteiided with any cousiderable
affection of the throat. No marks of inflaminalion, or
even of congestion, were discovered in the brain.*
Local hlood-letting is well adapted to many cases of
scarlet fever — to cases accompanied with great deter-
mination of blood to the throat — to cases attended with
headache, or threatening coma. I applied leeches to
the temples of Mr. Dry, of Tottenham-conn-road,
whose case was detailed in the last lecture. They
lowered the pulse until it began to flutter alarmingly,
but the progress of cerebral congestion was checked.
In the management of the several inflammatory sequels
of scarlatina (otitis, ophthalmia, and pneumonia),
leeches and cupping are quite indispensable.
Leeches generally bleed profusely in scarlatina, from
the excited slate of the cutaneous circulation. Four
leeches in scarlatina will often do as much as twelve in
typhus. It becomes occasionally necessary to slop the
bleeding, which lunar caustic will do effectually. This
tendency of leech-bites is always to be kept in view,
bat especially in the scarlet fever of young children.
The child's life might otherwise be sacrificed, and the
measure itself brought unfairly into disrepute.
[It mny safely be said, that genernl bleeding in scarlet fever b the
szoeption &nd oot the rule, at least in tbia country. That it may be
forv ia some caseH is doubtle^ trim, und ibat it may be ur^i^ntly
edled lor to relieve coDgestiitn of tlie bruin or of olbor interual organs,
(a oeeuional «!».«, is equally true — but it is no ]e«s true, that as tha
dbftMe luw prevailed of late yeare in this eity, it Las not been indicated,
ud baa rarely been u»ed, at least nith beneSt.
Leechea may more frequently do good, but even these must be u»ed
■ Tnnic lions of s Sooiely tor lbs ImproTem«ni of MedJeit and Cbirurgieal
Koowledga, toI, il. p. 33S.
194 PUROATIVB MBDIOIN£S.
with great caution in the primary disease. In some of the seqadtti b
certain cases, their good eflfect is more decided.]
4. Purgative Medicines. Dr. Withering, who was
so devoted to emetics, declared *'that the action of
purgatives was altogether repugnant to the curative
indications in this disease." On the other hand. Dr.
Hamilton, of Edinburgh, devoted one chapter of his
work on Purgative Medicines to the recommendation of
purgatives. Withering^s prejudices have entirely passed
away, and purgatives are now largely and most bene-
ficially used in every stage of scarlatina anginosa, firom
the first onset of fever to the close of the desquamation.
I know of no objection whatever to their use, and am
most confident of their great utility.
The forms of purgative medicine that I would
recommend to you are calomel and jalap — calomel and
rhubarb — senna and salts — jalap with cream of tartar —
senna with cream of tartar — castor oil, — and occasion-
ally, the combination of calomel, James's powder, and
extract of colocynth.
I have often pushed calomel to a great extent both
in adults and children, — not that I attach importance
to any specific effect from the mercury, for I never
saw it do good, except when it purged ; but because,
in the burning heat of scarlatina, no purgative will act,
unless aided by the relaxing qualities of calomel. No
secretion can otherwise be obtained from the vessels
of the liver and intestinal mucous surface ; and this, I
need not tell you, is the whole secret and theory of
purging. You must, of course, be cautious with your
drastic purgatives, when there is a tendency to syncope.
[PurgaUves are more sparingly used in this country, even in the
STIMULANTS AND CORDIALS,
196
pnow form of scarlBt fover, as h the ease with blood-letting, as
already remarked, than our author would seem to recommend, and
aoiuu jiractitioners abstain faim them entirely, using only mild Idxatires
or eccmata. There arc cases of the congestive farm, in «hich the
prompt effect of an active cathartic i« f-ivorahlc, both by removing
offending mBteriala from the bowels, and by ite revulsive effect ; but it
ii rare that the esbibition, much li-sa the repetition of the active catliar-
tics enumerated by our author, seems to be called for. At the same
time, fluitable means should be umd to keep the bowtU sufficientljr
open.
Tlie use of calomel in this disease originated witli Dr. William
Douglass in the severe epidemic in New England iu l73fi and 'S6,
of which ho published an account already referred to. page 182. Forao
analysis of his work, and account of the reasons which led him to the
use of that remedy, aee a valuable paper on the '* State of Medicine in
(lie American colonies from their lirsl settlement to the Revolution," by
John B. Beck, M.D., published in the TraMtacl. of l/ie Mtd. Soc. of
the StaU t^Neie York. Feb., 1850.
Dr. Jacob Ogd<m, of Long Island, also used calomel extensively in
tbis disease, and with success, about the year lT4f). (iVcui York Medi-
tal Repository, vol. v. p. 97, quoted by Dr. Beck in above-mentioned
[taper, and also in his Infant Thrrapeuties)
Calomel has been more or less used in the treatment of scarlet fever
uncc that time. Some practitioners continue lU use nt intervals during
the whole of the disease, while others give it only at thu commencement
«f the attack ag a purgative. For this purpose, and when tlie secretiom
of the stomach and small intestines are disordered, it is often of great
««rvice. In the formidable laryngeal complication of the disease, ita
exhibition in small doses at short intervalx, with appropriate local means,
should never be neglected.]
5. StimulRnts aud cordlRls are iiiiproppr (except in
rare cases) in the early stage, and wholly unfit for the
inflammatory type of scarlatina. When, either hy the
debility succeeding venesection, or the strong action of
purgative medicine, or the depressing iuf]ueuce of (he
poison, the pulse flags, the countenance turns pale, and
the skin cools down, camphor, sether, the citrate of
ammonia, and similar cordials, wllh wine, must be
196 LOCAL TREATMENT OF THE ANGINA.
given. The only stimulus that can be allowed at all
times is that of an acid. Direct, therefore, a drachm of
the diluted hydrochloric acid, with half an ounce of
syrup of orange peel and eight ounces of water; and
let the patient take an ounce and a half of such a mix-
ture frequently.
The occurrence of diarrhoea demands tlie employ-
ment of gentle aromatics and astringents, such as the
aromatic confection, chalk mixture, and laudanum.
Arrow root with port wine must be given at the same
time. In the truly sloughy and gangrenous forms of
anginose scarlatina, a variety of medicines supposed to
possess antiseptic properties have been extolled. In
the West Indies, in 1787, they found an infusion of
capsicum very serviceable. Dr. Peart recommends very
strongly the carbonate of ammonia, but Dr. Tweedie's
large experience docs not bear out the encomiums
which he lavishes on the remedy. One great objection
to its use is the difficulty of swallowing it — a difficulty,
indeed, which meets us in every stage of scarlatina, and
which authors are very little inclined to consider.
]jark was at one time highly extolled as an antiseptic
and tonic in scarlatina. It was even given when the
** heat of the surface was sharp." A broken texture and
putrid tendency of tluj blood were then considered valid
reasons for giving bark. The practice is now seldom
pursued, except as a last resource, when the throat is
sloughy, with a small pulse, cold skin, and great nervous
depression. Wine and brandy, however, are much
preferable under such circumstances.
You must not altogether neglect the local treatment
of the angina. Gargles of rose infusion wash away
the abundant and vitiated mucus of the throat, give to
LOCAL TREATMENT OF THE ANGINA.
197
it a clearer aspect, but do uo otiier good. When there
b a breach of surface, acids give great pain. You may
then use with advantage the decoction of bark with
mel rossc, or Sauvages' once famous gargle, lime-water
with houcy. As children cannot gargle, the nurse must
be instructed to clear the throat by means of a camel's
hair pencil dipped in a solution of currant jelly.
[Locai itifaua &ru ofl^n vnluiiblu auxilinriefl in the trealment of th«
aff«clioii ti( f.lie Ihro&t.
Ice has been used with great advnnlage in some Torina of the disease
when the thrunt is much inflamed, and is verjr gnitefui to tlie patient,
sod donbtless has an equalizing eSect on the ciiculation gcnerall}^, ae
well Bs a sedative influence on the local he«t and swelling.
Chloride of soda in solution is usetiil as a gai^lQ when there is
sloughing, diluted according to the age of tbe patient, and sweetened
with honey, about 3j or Sij of Labaraquo's solution to ij wHter.
When the tonsils and neighkiring parte are in a gangrenous stat^,
vith but little if any surrounding inflammation, a gargle of sulphate of
copper is useful, ten to thirty grains to Sj water, or a solution of sul-
phate of line— or an infusion of capsicum, to which common ssit is
often added nith advaritagi> — but in such cases, a solution of nitrat« of
•ilver, tweut}- to niidy grains to an ounce of water, ia probably the most
dSqent topical remedy, and should never be neglected, if other means
do not soon succeed. In such caaes, yeast often renders essential service
« a gargle.
Dr. Wnbwin (Pracl. ^f«^.) speaks very highly of the chloride of pot-
ash — 3ij to b» dissolved in Sij hydrochloric acid, previously diluted
witli Sij distilli^ waler — to be put into a stoppered bottle, and kept in
S dark room. Of this solution, 3 ij, with a pint of distilled waler, make
the chlorine mixture. Dose — a tablespuonful or two, according to th«
■ge uf the patient, frequently.
(Miers prefer finely jnilveriMd alum in these eases, either Applied by
niM» of n camel's hwr peucil, ur blown up the noBtrlls (aa recom-
mcbded by Veli><-'au) by means of a long tube, as two or three quills
y^nei together. The application of the strong hydrochloric acid, niived
wilb'honey, by means of a jiencil, has also been recommended in theso
Injection* through ih-i nostrils into the [tostL'rior fauces either of wm-
198 MANAGEMENr OF THE SEQUELiE.
plo warm water, or water medicated with chloride of soda (about 3j to
5j), either with o** without honey, or of a weak solution of nitrate of
silver, one or two grains to 5j water, will often be of service.
Emollient ])oulticos, or narcotic fomentations, afford the best external
applications for the tliroat.]
The inauagcment of the sequelae of scarlet fever
next claims your attention. The cellular iniSamniation
of the neck is to be treated by poultices in the first
instance. As soon as possible, free incisions must be
made through the skin, to allow of the escape of the
sloughs, and of that imperfect pus which is all that the
weakened state of the system pennits to be formed
The strength to be supported, meantime, with beef-tea
and wine.
In that state of general and vascular debility which
I have described as occasionally occurring as a sequence
of scarlet fever, the tongue being clean, and the heart
disposed to syncope, cordial draughts containing
compound spirit of ammonia with camphor julep
and tincture of lavender must be freely administered.
Nourishment, too, must be frequently given with port
wine.
The dropsy which succeeds scarlatina deserves all
your care and consideration. Dr. Wells was, I believe,
the first to throw off the pathological trammels which
connected this symptom with debility of the capillaries.
He saw^ in it an inflammatory allbction ; he noticed its
coincidence with a white tongue and a sharp pulse,
and he knew the benefit of an antij)lilogistic treatment
This doctrine is that now generally admitted. We
consider the dropsy succeeding scarlatina as depending
on arterial excitement, either general or local, which
must be subdued, by mild means if possible, but failing
HAKAQEUENT OF THE DKDP8¥.
199
them (or in the event of great urgenc)'', even iu the first
instance), by blood-letting.
Dropsy seldom occurs early in the secondary fever of
scarlatina, It is almost always preceded hy symptoms
which will warn you of its approach, when your eyes
are opened to the pathology of exanthematic sequelae.
In the larger proportion of cases, you will succeed in
relieving the dropsy effectuaHy. Plenck, however, a
celebrated physician of Vienna in the last century,
who wrote on eruptive fevers (1762), held that the
danger was even greater from the dropsy than the fever
itself.
I cannot doubt but that a large proportion of cases
of scarlatinal dropsy arise from the neglect of measures
which ought to have been adopted iu an earlier stage
of the disease. If a certain amount of hlood-leltiug, a
certain number of doses of calomel and jalap, a certain
amount of rest and abstinence had been indicated, but
neglected or withheld, then, when dropsy occurs, the
deficiency must be made up. The same things must
be done late, which ought to have been done early.
In all cases, it is your duty to watch carefully the
decline of scarlet fever. If the pulse, tongue, and secre-
tions be not satisfactory, exhibit daily, or on alternate
days, a purgative draught, containing infusion of senna,
cream of tartar, and tincture of jalap, so as to insure
two motions ; direct, at the same time, a diureiic julep,
containiug acetate of potash, tincture of digitalis, and
the spirit, setheris nitrici, or some equivalent promoter
of renal activity, in mint water. If these measures do
not meet the exigencies of the case, if the character of
die urine, and of the pulse and tongue, indicate increas-
ing or unabated disorder, take ten or twelve ounces of
MANAGEHBHT OF THE DBOPSY.
blood froui llie arm. Do not wait for the appearance
of dropsical swellings to adopt this proceeding, for by
sucli delay further mischief will ensue, Coagalable
lymph will be effused on some of the great serous sur-
faces, or in the interior of the heart. I need not say
bow immeasurably this would add to the severity of the
dropsy and the danger of the patient.
Tonics are not to be entirely ihrown aside in the
management of scarlatinal dropsy. You will meet with
cases that give countenance to the doctrine that the
exhalant vessels want tone, that blood is detained in
the cutaneous capillaries for want of sufiScient energy to
restore it back to the heart. Such cases will necessa-
rily carry with them other evidences of this condition
of the system, called by pathologists kucopklegmagia, or
white inflammation. You will find the countenance
sallow, the pulse feeble, the tongue clean (perhaps mor-
bidly red), and the urine, though scanty, yet pa!e.
Under such circumstances, you would be justified in
giving, and expecting benefit from, stimulants, in com-
bination witli diuretics. The infusion of cascarilla,
mixed with tincture of capsicum, compound spirits of
juniper, the spirit of nitric aether, a few drops of tinctore
of digitahs, and some syrup of ginger, will supply yon
with an old-fashioned, but not the less serviceable
combination.
The compound squill pill, with a due proportion of
pilula hydrargyri, may be given night and niornbg, so
as to insure the activity of the kidney.
Measures such as these will sufficiently relieve a very
large proportion of the cases of scarlatinal dropsy which
you will meet with, but some wiU prove rebellious to
all your care, probably from the serious injury done to
. tbe treatment of dropsy fulloivitiir senrlet
TREATMENT OP SCARLATINAL CONVULSIONS. 201
the lungs, liver, or heart, in the first days of the disor-
der. My earnest advice to you, therefore, is to try aod
prevent tJie secondary dropsy rather than to display
your skill by curing it when it has arisen.
[For lurtber remarks (
fuvtr, see Appendix I.]
Convulsions occurring during the secondary fever of
scarlatina demand the loss of blood cither from the arm
or by leeches, according to the age and strength of the
patient, with active purgatives containitig calomel, and
the application of cold spirituous lotions to the head
and precordial region.
[Dr. Marshall Hull ruhiles u coso of itcuto anasarca and convuUJons in
a boj, twelve years old, cured by venesection, fuUowed by leeches,
with purgatives, cold to the bead, pediluvia, dsc, and eays he oonsiders
that, in euch cnses, the remedy is blood-Utting, until relief and ueuritg
an oblavtcd. (Amer. Jour. Med. Sci., Feb., 1840, p. *50, quoted from
Londnn Laneei.)
At a meeting of the Royiil Med. Chir. Soc. (London) in Feb., 1847,
Dr. Rogers remarked [hat he had seen two cAies of scarlatinal convnl-
B10IW, wliieh dime on after the twenty-first day of th^ diBt^aae — both
patients having suffered from dropsy with albuminnria. In one oa«e,
he used dry cuj)ping over the loins ; in the other, at the nape of the
neck — both recovered.
Without entering further into the particulan of the trontm^Dt of
tcarlet fever, either generally or locally, we will add a few propositione
which we think worthy of remembrance, and the truth of which will
probably not be questioned :
1. It is a telf-limiUd disease, and nature is oflcn entirely competent
to conduct our patient safely through it.
2. It presents every variety as to tyjie and mode of attack, and every
degree as to severity, and hence we must prescribe for the svniptomB,
and not for tliu name of the disease.
3. Ataxic symptoms and local determinatjuns arc those which most
frequently require the interference of art.
4. The poison of the miasm is of a most depressing nature, and
^
202 OENRRAL PRINCIPLES OP TREATMRNT.
henoe great caution is required in the use of meant which tend to
exhaust the vital powers.
6. The iequila of the disease are often much more formidable than
the difleaae itself, and must always be carefully watched for and guarded
against^ depending, as thej often do, upon the management of the case
in itB earlier stages.
6. Tlie nature of the prevailing epidemic should always be carefully
studied, both in the management of our own cases at any particular
time, and in judging of the treatment of recorded cases ; for the history
of diflferent epidemics, both in this country and abroad, proves conclu-
sively that the most opposite means have been equally successful at
diftrent times, and in different places.
LECTURE IX.
ERYSIPELAS.
E^mology of erysipelas and 8L Anlhony's fire. Ancient opinions
cerTiing Ihe sources of eryaii)plaB. Graduftl olianges in Ihe viuws i
tained on tlio causes of eryaipuloa. Opinions of Dr. Wells. Cnntngiono- I
ncss of erysipelas, lis niin.smntic origin. Its rclnlioo lo piierpeni 1
perilonitia and lioxpital gnngrenc. Views of Dr. Rollo, Of liospital I
ralosni. Olber eouruoe of erysipelas. Connexion of erysipt'los with I
brosch of surface. Inoculation of er)'aipelas. Incubation. Plicnomena I
of eryaipelns. Of Ihe erysipelas phlegmonodes and gangrcnDsnn). 1
Ext«nuon of erysipelas from tlie akin to the brain, and other irilemil |
organs. Staliatica of erj'Bipelaa. TrealuenL Etlii'acy of blood -letliog,
pDrgutivOB, nnd stimulants. Local treatment of erysipelas.
Erysipelas, called also the rose, ignis sacer, and St^J
Anthony's fire, is an exanthema, and therefore properly 1
falls to be disctissed in this division of the course ; but 1
we shall find its pathology to be in many points differ- I
eat from that of the thrte diseases already treated of! 1
It is, ill fad, the link which connects the purely zymotic i
exautheiiiala with those diseases of the human body
which originate from internal causes, and are uncon-
nected with specific miasm. Erysipelas is a disease of |
which the pathological hearings, long as it has been i
known, are only now beginning to be well understood.
It is a disease which, from ils occasional severity, as
well as on account of its frequency, merits your best
attention.
Little need be said, regarding the literary liistory of 1
erysipelas. It was well known to the Greeks and f
Romans, and we retain the name which Hippocrates j
and the Greek pliysicians originally gave it. Two ;
204 BTTMOLOOT OP BRTSIPBLAS.
derivadons of the word erysipelas are proposed, both
supported by high classical authority; some derive it
from the two Greek words spt^po^, red, and csXXo^, livid
— ^livid redness. The German lexicographers sanction
this derivation. Almost all the English authorities
(including Donnegan) derive the word from cpuu, to draw
forth, and ctXa^, near ; expressive, it is said, of the ten-
dency of the disorder to spread or extend itself to
neighboring parts, in contradistinction to those forms
of inflammation called by the Greeks apostatic (a<o and
itfniiu) and metastatic, from their more fixed nature. I
give yon your choice of the two derivations, premising
that I prefer the first
The term St Anthon/s fire was first applied to this
disease in the dark ages of literature, when all the little
physic that was known was monopolized by monks and
ecclesiastics, who, in cases of difiiculty, naturally sought
aid in prayer and invocation. Diseases came thus to be
consigned to one or other of the many saints in the
Romish calendar. The intercession of St Nicasius
was implored in small pox. St Vitus's shrine was
sought by those who labored under chorea. Erysipelas
had for its patron St Anthony. The circumstances
which led to this selection are not unknown. In 1087,
a pestilential erysipelas, or sacred fire, ravaged the inte-
rior of France, and especially the district of Dauphine.
Now it so happened, that two years previous to this
epidemic, the bones and reUcs of St Anthony had been
brought from Constantinople by the pious care of
Joselin, a nobleman of that country, and deposited in
the church of a Benedictine priory, in the neighborhood
of Vienne. Numbers of pilgrims flocked tliither, and
many miraculous cures were there performed. This
ANCIENT OPINIOna OF EKT8IPELA8.
205
success fixed St. Anthony in the perpetual patronage
of erysipelas.
We may gather something from the simple fact ihal
erjsipelas was known to and well described by Hippo-
crates. It shows us that physicians who could so dis-
tinguish erysipelas would not have failed to describe
with equal accuracy, and to name with equal judgment,
small pox, measles, and scarlet fever, had those diseases
existed in tlieir days. Their not doing so is proof
positive that such diseases did not then exist. It shows,
farther, that there must be something very different in
the great pathological features of erysipelas from those
of the three greater exanthemata ; else how did it hap-
pen tlial erysipelas should have been known to them,
and not (he three others 1
It will conduce to a clearer understanding of erysipelas,
if, in treaiing of it, I reverse the order in which 1 have
hitlierto investigated the eruptive fevers. I shall here
first explain to you the pathology of erysipelas, I shall
attempt to show you In what respects it diSers from the
other exanthemata, under what circumstances it origin-
ates, and what explanation of its various sources has
been offered by ancient as well as by modern authors.
Having thus discussed the subject of erysipelas theoreti-
cally, we shall be better prepared for the iuvestigation
of its appearances, its progress, its terminations, its sta-
tistics, and, lastly, its methbd of treatment.
I must begin by informing yon, that by the term
erysipelas we mean an infiammatlon of the skin, and
very commonly, also, of tlie subjacent cellular texture ;
often preceded, and almost invariably accompanied, by
fever. Such a disorder originates from various causes.
Its course and duration are alike variable. So far from
206 CAUSES OF ERYSIPELAS.
the constitutional susceptibility (as in the case of the
three greater exanthemata) being exhausted by one
attack of erysipelas, the disposition to the disease seems
often, as life advances, to augment with each successive
seizure.
I shall have occasion to notice great diversities of
opinion among authors upon almost every topic which
tlie pathology of erysipelas involves. Nosologists differ
as to its true situation, whether among the exanthemata
or the phlegmasiac. There are strange contradictions
in the statements of authors regarding the mode of its
propagation, and still wider differences of opinion in
respect of the best method of treating the disease.
With regard to nosology, we have outlived that idle
display of learning which made it an object of impor-
tance to what class or order any particular disease was
to be assigned. We consider it here as an exanthema,
following in this respect the footsteps of Dr. Cullcn ;
but 1 beg you clearly to understand, that very good
reasons might be advanced why it should be transferred
to the phlegmasisc. The matter, however, is not wortli
wasting time about.
With respect to the causes of erysipelas, however,
and the manner in which it spreads, the diversities of
opinion are of infinitely more importance ; and these
must now be carefully hivestigated.
In ancient times, by Hippocrates, and the followers
of the Hippocratic or humoral patholog}-, erysipelas was
held to be a disease originating from some intestine
commotion of the humors, which threw off, or elimi-
nated, the peccant matter by means of the skin. ' This
doctrine continued, with very slight change of j)hrase-
ology, to be generally received by pathologists until a
OPINION or DR. WELLS.
comparatively recent period. Dr. Ciiilen says, '■ I con-
sider the erysipelas to depend on a mailer generated
within the body, and which, analogous to the other
cases of e.\aiithema, is, in consequence o(" fever, thrown
out upon the surface of the body," He admits a spe-
cies of erysipelas (or rather, erytiiema) arising from an
external cause, capable of throwing off contagious ema-
nations, but he makes no meQtion of any morbid poison
or miasm primarily giving rise to iL His words are —
" This disease is not commonly contagious, but as it
may arise from an acrid matter externally applied, so It
is possible that the disease may sometimes he commu-
nicated from one person to another."
The modern notions of the nature, and sources, and
pathological relations of erysipelas, have made con-
siderable advances since the days of Cullen (now more
than half a century ago), I know no author who has
laid them down fully, but Dr. Williams, in his valuable
work "On the Morbid Poisons,"
The first inroad upon the old notions concerning
erysipelas was made by Dr. Wells, formerly physician of
tliis hospital, who, in 1798, published some statements
showing the contagiousness of erysipelas. These facts,
and the opinion founded on them, were long neglected ;
but of late years they have been forced upon the atten-
tion of pathologists, Iiy the undeniable evidence of the
frequent spreading of erysipelas in hospitals, and the
difficulty of explaining that circumstance on any oiher
principle than that of the generation of erysipelas by a
morbid poison, or miasm.
I propose, first, to state to you the facts which prove
erysipelas to be an epidemic malady, and which, satis-
factorily to my mind, show that its most important
208 MIASMATIC ORIGIN OF ERYSIPELAS.
source is miasmatic. I shall then tell you on what
grounds we further maintain that this miasm, when
formed, is capable of propagating itself by contagious
emanations. Lastly, it will be my duty to explain to
you iiow erysipelas originates occasionally from causes
not of a specific nature, some of which are internal,
others external to the human frame.
Sauvages, in his " Nosologia Metliodica," pubUshed
soon after his death (which took place in 1767), admits
an erysipelas contagiosum, but on what turns out to be
most doubtful authority, for the epidemic referred to by
him in support of that opinion (that of Toulouse, in
1715) was scarlatina, not erysipelas : in fact, we cannot
detect any trace of the doctrine of iniasmatic erysipelas
prior to the year 1760. In the summer of that year, a
person laboring under eri/sijte/as of the face was brought
into this very hospital, where he died. Another patient,
having a diflerent disease, w^as put into the same bed
before it was duly purified. This patient was shortly
after seized with erysipelas of the face. Several other
persons in the hospital were then attacked, among whom
was an upper nurse, or sister, and she died. A rumor
hence arose that the plague had got into the hospital ;
and so widely did this opinion spread, that an adver-
tisement was inserted in the newspapers of the day,
contradicting the rumor. This, you will observe, is an
instance of erysipelas brought into a hospital, and there
propagating itself. I am not able to tell you who first
noticed the fact that erysipelas will comvience in a
hospital, without any suspicion of importation. Dr.
Baillie informs us that during the years 1795 and 1796,
erysipelas < f the face was much more frequent at St.
MIASUATIC ORIGIN OF ERYSIPELAS. 209
George's Hospital tban he had ever before knowD it to
be. Many persons, he says, were attacked by tliis dis-
ease after they came to the hospital: and as the cases
in a particular ward were more numerous than in any
other, Dr. Baillie was led tp suspect that the disorder
was contagions. He is silent, however, on the subject
of origin ; and we are unable to say whether this erysi-
pelas was originally bred in the hospital, or imported,
and afterwards propagated by contagion.
M. C'almiei, writing in 1828, says, " there are years
when in the hospitals for the insane in Paris, erysipelas
is almost indefinitely multiplied; so that it is necessary
to suspend all treatment by counter-irritants (setons,
moxas, and blisters), because tliey are almost certainly
followed by erysipelas. Even the opening of a vein, or
the appUcation of leeches, is followed by a like result.
We may be quite sure that these cases must have origin-
ated witliin the hospital, for it would be unreasonable
to suppose that an insane patient actually suffering
under erysipelas would be admitted.
M. Vclpcau, writing in 1831, describes the epidemic
prevalence of erysipelas m the Hopital de la Piti6,
where he notices, that both in the medical and surgical
wards the application of leeches, a trivial operation, or
even an accidental puncture, brought on this inflamma-
tion with all its consequences. Blache and Chomel
also mention the epidemic prevalence of erysipelas, and
instance the autumn of 1818, a year of excessive heat
and long drought. Of all the Paris hospitals, the Hotel
Dien is that which has suffered most frequently and
most severely by this terrible scourge of hospital esta-
blishments.
There is not. I believe, a single hospital in London,
Jbik
J
210 OOmiEXIOlf OF ERTBIPELA0
m
which has not, at times, been afflicted in like manner.
At St George's I have several times seen erysipelas so
prevalent that operations were postponed for fear of the
patient being subsequently attacked by it
A connexion of more than twenty years with the
Small Pox Hospital has given me abundant opportuni-
ties, not only of confirming the truth of these positions^
but of showing that we may carry our views much
further. I feel persuaded, ^r^, that erysipelas may
commence in an hospital without the suspicion of im-
portation. 2. That being so generated, from bed to
bed, it may spread by contagion. 3. That the miasm
generating erysipelas is identical with that which in
lying-in hospitab generates puerperal peritonitis, which
in foundling hospitals and workhouse nurseries gives rise
to pudendal gangrene and umbilical ulceration — ^which
in army hospitals generates hospital gangrene — which
in hospitals differently circnmstanced is found to occa-
sion a malignant form of cynanche, both mucous and
cellular, with otitis, glossitis, an asthenic form of laryn-
gitis, and sometimes the most aggravated type of typhus
gravior.
The origin of scurvy in crowded and ill regulated
ships is obviously a branch of the same general doctrine.
A destructive miasm is there generated which is far
more injurious to the human frame than the use of sah
provisions. Whatever be the exact nature (or essence)
of the miasm which thus generates erysipelas, peritoni-
tis, gangrenous ulceration, or scorbutic blotches, it is
something depressing to the vital power.
The dependence of erysipelas on a miasm sid generis
is no new doctrine. It has been stated over and over
again, by individual writers, but it has never, I think,
WITH OCHLETIO HUSH.
311
been urged by sjsteraaric authors with the importance
which it merits; nor has the doctrine been received aa
one of the avowed axioms of pathology. Dr. RoHo, in
a treatise entided " A Short Account of a Morbid Poison
acting OH Sores," and published very early in this cen-
tury, distinctly announces the principle, and illustrates
the intimate connexion between erysipelas and hospital
gangrene,
[We would remind our readers ibat our autbor has given the name
of ochUtie miiisni (from ox^'Ei " crowd) to the peculiar miasm generated
ia hospitals, crowded apartments, &c., &c., and the generic title of
OcHLBsis, to tbe several forms of inti'mal and external disease thenoe
ansing, (See Medical Timet (London), Mar. 31, 1849.)]
The circumstances which lead to the development
of ochletic miasm have never been investigated with alt
the accuracy which is desirable, and of which the sub-
ject is certainly susceptible. The first in importance is
andoubtcdiy overcrowding of the wards of an hospital
When the French academicians (I think it was early
in the French Revolution) were laboring diligently to
reform (he abuses in the Hotel Dieu, some of them were
at the pains to calculate in how many hours, supposing
the ward to have been hermetically sealed, all the patients
ID it must necessarily have died, presuming that each
adnit requires for his support a gallon of air per minute.
The time was wonderfully short,
2. But it is not numbers alone which are to be con-
sidered. A ward might safely hold fifty cases oi sitnple
fracture, which would not with safety contain twenty
cases of compound fracture. Something, therefore,
depends on the nature of the disorder. AH disorders
which tlirow out diseased secretions are more apt to
taint and vitiate the air, than those where no such
I
212 ocHLETic miasm:
secreting process goes fonvard. It is on this account
that the wards of the Small Pox Hospital are so pecu-
liarly liable to generate ochletic miasm.
3. Another element of great importance in determin-
ing the sources of ochletic miasm is the degree of
attention bestowed on cleanliness. If the bed linen,
mattresses, palliasses, sheets, and blankets, be frequently
changed, the floors well cleaned, and the walls fre-
quently whitewashed ; if the nurses be careful to carry
away all foul secretions, and to purify the patient's body
by abundance of soap and water ; in short, if the inter-
nal regulations of the hospital be good, miasm would, I
suppose, be rarely engendered, even though the ward
were crowded.
In the summer of 1844, 1 saw at the Vache in Buck-
inghamshire, a nursery of 500 young pheasants brought
up by hens. The attendant informed me that the great
secret of securing the health of the young brood is to
change the sleeping ground daily. If the locality of
the encaiuped aviary was not thus changed, a disease
speedily developed itself which was extensively fatal.
4. A fourth elouiont must enter into the calculation,
and that is, a good supply of fresh air. This by some
is considered all in all ; but it is not so, and all the ven-
tilation in the world, conducted on the most scientific
principles, and superintended by Dr. Reid himself, would
fail in preventing ochletic miasm, if feather beds and
bolsters, soaked in unhealthy discharges, are permitted
to remain in the ward.
5. Dr. liollo has advanced a step further in the
analysis of the sources of ochletic miasm, and maintains
that the disposition to erysipelas and its correlative dis-
eases (puerperal peritonitis and hospital gangrene)
OPINIONS RESPECTINQ IT.
213
depends partly on a peculiar but hitherto uudctected
conditioQ of the atmosphere. He is led to this opinion
l)j observing tlmt erysipelas sonietiuies shows itself in
the airiest, least crowded, and best regtdated hospitals.
Without stopping to inquire how much is due to this
circumstance, we are fully warranted in saying that the
state of the atmosphere must not be lost sight of in such
an investigation. We know, on the authority of JJr.
Lind, that in Batavia aud other localities notorious for
malaria, hospital gangrene and erysipelas, and every
sort of associated disorder, prevail with intensity at cer-
tain seasons.
Assuming it as proved, that erysipelas is liable, from
one or more of the five causes now detailed (viz. accu-
mulation of persons, character of the discharges, want of
cleanliness, want of ventilation, constitution of the atmo-
sphere), to spread epidemically, it is still to be shown
that this disease throws off contagious emanations,
which can, per se, independent of any such inOuences,
propagate the ]ike complaint.
Ur. Weils has met this question very fairly by detail-
ing a variety of cases where erysipelas spread by conta-
gion in private homes, and under circumstances calcu-
lated to exclude all agency save that of simple contagion.
I will state to you a few of these cases ; first, because
the doctrine of contagion in erysipelas is distrusted on
the continent, aud by many, too, in this country ; and
secondly, because it is important either to establish or
to negative the statement.
On the Sth of August, 1796, Dr. Wells attended, in
Vine street, Clerkenwell, an elderly man, named Skel-
ton, with erysipelas of the face, who died. A few days
after his decease, his wife took it, and died also.
214 OTHER SOURCES
Shortly after that, Skelton's nephew, a yonog man, who
had visited his uncle daring his ilhiess, took erysipelasi
and sarvived only a few days. On the 19th February,
Dr. Wells was called to attend Mrs. Dyke, the landlady
of the house in which Skelton and his wife had died,
and she also was found to be laboring under erysipelas.
She had attended them in their sickness ; and after their
death, furniture from their room had been removed to
her apartment
Dr. Fitcaim (a most acute physician) attended, in
February, 1797, a lady with child-bed fever, who had
erysipelatous inflammation in her skin. Her new-bom
babe had erysipelas of the pudendum, and both mother
and child died after a few days' illness. Eight days
after the death of the child, the lady's mother and a
servant maid, both of whom had attended the child in
its illness, were attacked with erysipelas faciei^ from
which both recovered.
Many similar cases are recorded. It is not meant
to insinuate that such are common. In by far the
larger proportion of cases where erysipelas invades pri-
vate families, no such result follows, — no member of
the family, no nurse sickens, but the possibility of such
an occurrence is to my mind satisfactorily proved.
[Similar instances of the spread of er}'8ipela8 in private bouses have
occurred under my own observation, and doubtless also to others ; but
the question may properly be asked, whether the small proportion of
cases in which such communication takes place, does not afford fair
ground for the supposition that some other caiuse, as, for instance, epi-
demic influence, or vitiated excretions from the patient first att-icked in
a small apartment, in conjunction with still other causes, may not have
been the occasion of such propagation in these cases, instead of contagion,
a term, the use of which ought perhaps to be restricted to specific commu-
nicable diseases.]
OF ERYSIPELAS.
emains, before I bring this branch of the subject to
a conclusion, that I iaforni you nhat are the circum-
stances, independent of contagion and miasm, which are
believed by pathologists to induce erysipelas. Here
another wide field of inquiry opens before us,
I told you that the miasms of small pox, measles, and
scarlet fever, operate on the humau body without pre-
disposing causes. A child in the most perfect health is
even more susceptible of these diseases than one out of
health. That is not tlie law with erysipelas. It has
long been kuown that certain conditions of the body
favor very much the development of erysipelas.
1. Weakness of the body, whether the result of ener-
vating employments, of prior ailment, or of bad food.
contributes to bring the frame under the dominion of
erysipelas. Hence it is that erysipelas is so frequent a
consequence of typhus fever, of small pox, and of all
febrile diseases which seriously reduce the vis vitEc,
2. Erysipelas is a frequent complaint in mihtary hos-
pitals. It is met with in soldiers of full habit of body,
as well as in those of intemperate tiabits of life. It has
therefore for its predisposing causes plethora and an
inflammatory diathesis. Medical men who have only
seen erysipelas in the wards of a London hospital, have
little idea of the phenomena which it presents, and of
the treatment which is required, when it invades the
plethoric soldier in the prime of life, eating abundantly
of animal food, drinking to excess of bad wine, and
exposed at night, without exercise, to the chilling damps
of an unwholesome atmosphere. Some of the most
formidable cases of erysipelas initiate in these circum-
stances,
3. The third source of erysipelas, independent of spe-
216 SOURCES OF BRTSIPELAS.
cific miasm, is original delicacy of stracture and consd-
totion. Women, formed of more delicate materials^
and often endowed with less of constitutional power
than men, are thereby rendered more liable to erysipelas.
Some women, of weakly habit, and yery delicate texture
of skin, hardly pass a year without an attack. This
delicacy of skin is hereditary, being transmitted, like the
lineaments of the fiice or the color of the hair, from
mother to daughter. Hence it is that erysipelas, like
gout and gravel, is hereditary in certain families. In
persons thus predisposed, erysipelas may be brought out
by cold, by heat, by any violent exertion, by strong
emotion of mind, by a deranged state of the liver and
digestive oi^ns, by atmospheric changes, especially the
setting in of the winter season.
[Of 373 cases of this disease which occurred at the hospital of
Stuttgart from 1828 to 1838, 117 were males and 256 females. Frank
gives the proportion of females to males as high as 4 to 1, and Phillips,
of London, in the proportion of 3 to 2.
In 630 cases distributed by the Bureau central, to the various hospi-
tals of Paris during the years 1830 and 1831, there were 326 females*
In 43 cases observed by Louis, 25 were women, as were also 13 out of
20 patients with it received into Chomers clinical wards at La Charity
Hospital.]
4. The last of the common causes of erysipelas is
breach of surface. In the very worst wards of an hospi-
tal, in the most unfavorable weather, in a habit of body
originally most prone to erysipelas, it often happens that
the disease is not developed until the surface of the body
be abraded or wounded. AH sorts of wounds, whether
made by leeches, lancets, the knife of the surgeon, the
sword of the enemy, or the forceps of the dentist, all
sores and ulcers, are at times followed by erysipelas.
You may naturally inquire, why ? The reason proba-
INOCULATION OF ERYSIPELAS.
217
biy is, that erjsipelas is the product of a morbid poison,
and we know that all morbid poisons are more easily
received by a wounded surface than by a whole skin.
This doctrine applies to small pox, cow pox, measles,
aud hydrophobia. The disease is, in fact, thus intro-
duced by a kind of iuoculation. All breaches of sur-
face, then, favor the development of erysipelas. It is
tftere, where the action begins, and from which, as from
a centre, it is diffused over more or less of the superfi-
cies. Let me further remind you that erysipelas may
be excited artificially, by a burn, a scald, a mustard
poultice, ammonia, or cantharides. The iuflammatioo
excited by a blister is erysipelatous.
Dr. Willan was of opinion that erysipelas could be
propagated by inoculation. He tells us that the fluid
secretion of the vesicles will occasion a red, painful,
and diffuse inflammation of the skin, in all respects like
that of true erysipelas. These experiments ought never
to have been made, and do not appear to have ever
been repeated. The facts, therefore, are open to doubt.
I have heard of a case where vaccine matter taken from
the arm of a child laboring under erysipelas com-
municated both diseases. But it did not fall under my
own notice, and possibly may have been misrepre-
sented.
From this sketch of the pathology of erysipelas you
will see how intricate the sabject is, and how widely it
behoves you to extend your views, if you would fully
inform yourselves of its sources.
The latent or incubative period of the erysipelatous
miasm is very short, certainly not exceeding one week.
It is capable, like other miasms, of attaching itself to
fomites, aud, so far as I have observed, is more difficultly
218 PHENOMENA OF EftTSIPfLAB.
banished from such fomites than any other known con-
tagion.
pn an epidemic which prevailed at Petenburgh (Virginia), during
the muter and spring of 1844-45, according to the observations of Dr.
Harrison, in Sussex county, the period of incubation in 14 cases was, in
every case, seven days. (Peebles on Epidemic Erysipelas, Amer, Jomr*
Med. ScLy Jan. 1846.)]
Erysipelas sometimes begins without any yery per-
ceptible marks of fever. In general, however, when
this happens, the succeeding disorder proves very mild,
and some nosologists have refused to apply the term
** erysipelas" to it They would fain restrict that desig-
nation to cases of a more noble character, such as are
preceded by fever, and accompanied in their progress
by well marked constitutional disturbance. To the
milder forms of rose-rash they appropriate the term ery-
thema. This nosological refinement is wholly inappli-
cable in practice. You will find that in nature a gra-
dation can be traced from the mildest form of local
erythema without fever to the most aggravated case of
constitutional, epidemic, and perhaps fatal erysipelas.
No precise point can be fixed upon as the boundary of
erythema and erysipelas.
Keeping this principle in view, I will tell you what
are the kind of symptoms present when a person is
breeding afebris erysipelatosa, whether within the walls
of an hospital or in a private house — whether succeed-
ing a wound, or arising from some obscure internal
cause — whether ultimately to develop itself on the face,
or on the extremities. The patient has a rigor^ fol-
lowed by heat of skin. His tongue becomes white ; he
feels languid and incapable of the exertion, mental or
bodily, which previously was easy to him. Very often
PHEN01IE^A OF ERYSIPELAS. 219
there is sickness at stomach, and vomiting. I know no
symptom more common than this. You will remember
how it accompanies the onset of small pox. I have
seen the same, equatly severe and long continued, during
the incuhadve period of erysipelas. Other symptoms
are also present, such as thirst, headache, disturbed
dreams, or perhaps complete sleeplessness, confusion of
thought — but I know nothing which can be called
cltaracferistk of approaching erysipelas, as contradistin-
guished from any other kind of eruptive ailment. The
circumstances in which the patient is placed contribute
materially to guide you to a right conclusion as to the
nature of the malady which is breeding. Thus, when
such symptoms occur, at the Small Pox Hos])ital, ^«^
denly, to a man recovering from small pox, we know
tbat erysipelas is going to show itself, and we are on
the waich for it. So, in hke manner, at the Fever
Hosphal, though there, it has happened tUat small pox
has followed, and not erysipelas. The pulse is pecu-
liarly quick and sharp during the onset of this disease.
[M. Grisolle mentions «s a premonitory symptom occurring In two
tliirds uf llie cases of erysipela.<i, n painful engorgement of ibc lymphatic
glHuds wliii'li receive the vessels coming from the part about to be
attacked, although the skin prcseola ss yet no appreciable clmnge in any
rttpoct. This engorgement of the glands precedes the development of
tbe erysipelas 1, 3, or 3 days, and sometimes even precedes the redness
7, 6, or 9 days. M. Chomel has particularly directed attention to the
Mine symptom. {Traitf tie Pallwl. Interne.)
It ought U) bo borne in mind, however, that, in quite a number of
cates, tlie disease, even in a severe form, may come on without premoni-
tory symptoms, the local affection bein^ the first manifralAtion of it,
especially in Becondary cases, as in typhus fever.]
Mr. Amott is of opinion that an inflammatory state
of the fauces accompanies in every case the initiatory
220 PHENOMENA OF ERYSIPELAS.
fever of idiopathic erysipelas. I iiave noticed die same
circumstance when the disorder has originated from
ochietic miasm. The intensity of the initiatory fever
of erysipelas is sometimes excessive. Some years ago,
a patient at the Small Pox Hospital died during the
incubation of a fever, which I had every reason to
believe was erysipelatous.
[In tlie epidemic of er}'si])ebi9 in Petersburgh, previously referred to,
Dr. Peebles says that the aft'eetion of the throat was the " only symptom
invariably present, — in the mildest forms of the disease, the chief symp-
tom coniphiined of; in the severe and malignant form, one of the most
formidable complications." He says, a diagnostic mark of the throat
affliction wjis, the uvula sintfularhj relaxed and elongated, and alwayB
hai'int/ ifnitj)ended from its ejctrcnuty a j^lUcle of viscid limpid niuctiSy
somefimcK resting on the tongue, which could be with difficulty removed
by tho patient or by a sponge. (Awer. Jour. Med. Sei., Jan. 1846.)
Dr. .1. A. AIlt»n, in his account of an epidemic of this disease which
prevail, d in MitMlobury (Vermont), in the winter of 1841-42, says that
the throat was uniformly t'ouiul inrtaniod. {Boston Med. and Surg.
Jouni., ISJi.)]
After a period, varying from twenty-four to sixty
hours, a nHJuoss appears oitlior on tho face or on the
leg, or sometimes (though much more rarely) on the
trunk. The redness is soon succeeded by swelling,
and a sense of heat in the part. The redness and
swelling extend. When the eruption attacks the head,
the side of the nose is g(Mi(»rally the part first allected,
hut sometimes the temj)le or ear. The swelling soon
reaches the eyelids, which assume a peculiarly puffy or
cedematous aspect, and often the eyes are for a thne
closed. Should the disorder prove severe, the face may
swell to such an extent as to present a truly hideous
spectacle, all trace of the natural features and expression
of countenance being entirelv gone. The extent of
PHENOMENA Of ERT8IPELAS.
221
surface occupied by redness is extremely varied. I
hare seen erysipelas erase when one side ouly of the
face had become affected. I btive seen it extend from
the scalp to the neck, from the neck to the breast, and
there suddenly stop. At other times, it descends to the
extremities, and ceases not until every portion of the
sVn has been successively attacked. Such cases, how-
ever, are very rare, for in general before that can take
place, some internal organ has become affected, the
coQStitution has given vi'ay, and the patient been carried
off, either by coma, vomiting, or diarrhcBa.
[Erj?aipelaa sometimes attacks the scaip without extjinding to ihe
facv, but diU form of the dise.ise is so rare, that M. Cbomel hns not
i«eii more thuti three or four cases of it, A cose is recorded by M.
Grisolle {Brit, and For. Med. Hev., April, 1848, p. 547, talieti from
L'Union MfdicaU, No. 14), in which the earliest Bjiuploms were a
stiShesB of the neck and enlargement of the cervieal glands, the latter
being a very common, though not a constant precursor of the disease.
The ayinptoms of this furm aro often very obscure. Pain and i^emft
of the scalp are, however, usually present, and redness may be seen on
close examination, Vesicles never form on that part, but numerous
small sbtMMsseB sometimes appnr at the close of the disease. Delirium
ia one of the most unfavorable symptoms, but is only sympathetic, and
not owing to inllHmmation of the brain or its membranes, as proved by
the autojwe-s made by MM, Chomel, Louis, and GrisoUe.]
The redness of erysipelas is easily distinguished. It
fades under the finger. It is bounded by a distinct
ma^n. The skin occupied by it is soft and inelastic.
It is accompanied by a sense of heat, or scalding.
There is no throbbing complained of, nor any sharp
lancinating pain, as in phlegmon.
[Tliis dinlinctly marked, slightly elevat<-d margin is characteristic of
erjsipehis, and is always produced at the limit of its extension every
litnu there i« a tendency of the disease to extend itself. Chomel
remarks that, by means of this conterminous Bwelliog, the periods of
222 ERYSIPELAS GANGRENOSUM.
shifting may be rcix>guised, and by its absence, the period of definite
limitation ; and that this double character is of importance, esj>ocially
when we wish to determine the value of remedies said to check the
progress of the erratic form.]
Very mild cases of erysipelas sometimes subside with-
out any further appearances than those now described ;
but in all cases of even ordinary intensity, the cuticle
becomes (in a period varying from twelve to thirty-six
hours) elevated into small vesicles, blebs, or blisters —
precisely like those which form after the application of
a plaster of cantharides, or which we see after a burn or
scald. These blebs or vesicles contain a thin ichor or
serum, sometimes perfectly transparent, sometimes yel-
lowish, sometimes livid, and occasionally mixed with
blood. They soon burst and discharge their contents,
while the subjacent surface of the corion becomes of ti
reddish brown, or perhaps livid color, according to the
degree of constitutional power present. The cuticle
over the whole extent of the erysipelatous surface is
killed, and dcstjuamates, as in scarlatina, in the course
of the succeeding fortnight.
1 have told you that the cutis vera may assume a livid
aspect. I may add, that at times erysipelas exhibits
still more aggravated and even appalling appearances.
Pure gangrene supervenes, the constitution sympathizes,
and the patient dies in the course of a week (generally
about the third or fourth day), with symptoms of
oppressed brain (coma or convulsion) — or with von)it-
ing and diarrhoea — or with oppressed breathing and
excessive restlessness. In these cases, prior to the gan-
grene, the skin appears hot, tense, and acutely painful
The pulse is rapid, almost beyond counting, and the
expression of countenance betrays the utmost anxiety.
ERYSIPELAS OANGRENOaUH.
Nowhere is ibis frightful fcirin of erysipelas gmigrefu)-
sum more frequently witnessed than in badly- ventilated,
over-crowded, and ill-regulated foundling hospitals and
workhouse nurseries. The erysipelas neoDatoruin, and
the erysipelas pudendorum vicerans, have been described
by Dr. Gartbshore, by Dr. Underwood, by Dr. Pcrcivai
of Manchester, and Mr. Kinder Wood of Oldham.
Fortunately, we have not many opportunities of seeing
such things in this country, Imt on the continent, where
foundling hospitals are in fashion, the disease, in all its
malignity, is still occasionally witnessed. It artacks
children from the period of birth to the second monlh,
or even later, and chiefly aflects the umbilicus, geuilals,
and groins.
On dissection of lliose who have died of this disease,
Dr. Garthshore was unable to detect any lesion of the
internal viscera, nor was the cellular membrane aflfectcd.
The skin was the only organ diseased. Death was the
result of the morbid condition of the fluids, engendered
by a malignant miasm.
Isolated cases of erysipelas gangrenosum may occa-
Monally be seen, iu all our hospitals, affecting adults. In
former limes it raged epidemically. Wc read that
during the middle ages, the gangrenous erysipelas fre-
quently ravaged France, where the disorder was called
the plague of fire (ignis sacer).
Such are the phenomena of what may be called
tuperjicifd erysipelas, or what some authors have called
erysipelas phlyctienodes. It is not often, however, that
the skin alone receives the whole force of the febrile
commotion. We must inquire therefore, nest, what
happens, during the course of erysipelatous fever, to the
Tteighhoriiig textures; and what other organs suffer.
224
EKYSIPELAB PilLGQHONODES.
lu almost all severe cases of er^'sipelas, wlietlier
affecting the face or extremities, the suhjaceut cellular
Diembraiie participates in the disease. luSammation
spreads to it, and, from the peculiar texture and dis-
position of this tbtsue, leads to the effusion cither c^
serum or pus. When serum alone is effused, patholo-
gists call the disease erysipelas adematodes. When
purulent matter collects, ehher in small abscesses, or, as
more commonly happens, when it is diffused through
the cells of the cellular membrane, we call tlie disease
erysipelas phlegmonodes. You will understand that all
these are only modiiicatioDs of the same disorder,
attributable to tbe varymg intensity of the inSamma-
tory action, or some peculiar malignity of the exciting
cause.
Tn the progress of erysipelas no organ is more hkely
to suffer than the brain. I'athologbts are in the habit
of saying, that a metastasis has taken place to the
brain, but it is more properly extension of disease than
change of locahtv. The external parts continue to he
red, swollen, and blistered. Phrenitis, whh delirium of
a fierce kind, is sometimes witnessed. At other limes,
coma and stertorous breathing supervene, and the
patient dies apoplectic on the seventh or eighth day of
tbe disease, sometimes even later. Dissection seldom
displays anything more than turgescence of the cere-
bral vessels. These cases are singularly untractable.
Instances of recovery have occurred, but the greater
proportion of cases of erysipelas (especially of the
face) comphcated with phrenitis, or coma, prove fatal,
and that very rapidly.
[Tbe recorameiiJuliun of iviuo and other stimuliinta in the treatment
of Llie ilelirium of erysipcliia shoWG tliat our author fullj recoguisee what
ERTBIPBLAS OF THE BRAIN.
225
we believe to be an important practical principle, tbat there is a furm of
mental diiturbanca in tliis disease entirely different from tljat depeuJing
upon phreaitia, described by bim, and cbaracterized by a hot skin,
■trong pulse, injected eyes, Ac^ and connected, indeed, with a pathological
state directly opposite in ita nature ; though no allusion to such a form
is made under this head.]
Occasionally, the stomach is the organ which suffers
during the progress of erysipelas. I attended, many
years ago, a gentleman of feeble frame, who, after a
severe attack of initiatory fever, threw out erysipelas.
The stomach, irritable at first, iiever recovered its tone.
Vomiting continiled, and so exhausted the patient that
he died in one week fi"om the seizure. In pome
mstances, erysipelas, especially when it occupies any
large portion of the surface, seems to affect the heart
sympathetically. There is frequent syncope, with an
exceedingly feeble pulse. Death takes place here by
exhaustion, unless the system can be supported in the
meantime by wine and brandy. Children attacked by
erysipelas often pi-rish by supervening mucous enteritis.
[Mr. Robert Adams stales {Dublin Hoipital Reports, toI. W.) two
cases of erysipelas of the head and face, one traumatic and one idio-
pathic, nhicb terminated fatally by metasiaus to the serous membrane
of the heart ; and also alludes to two other cases of a similar nature
■een by others, and a specimen of the morbid appearances presented by
the dissection of another similar case, preserved by Mr. Cusack in the
muieum in Park street, {Amer. Jour. Med. Set., vol. i. p. 433. )J
These intimations of the several sources of danger and
of death in erysipelas will preclude the necessity of any
formal inquiry concerning prognosis. I will merely
observe that erysipelas of the face is, cteteris paribus,
more dangerous than erysipelas of the extremities.
Nevertheless, gangrene is rarely observed as a con-
sequence of erysipelas faciei. This termination is more
15
226 STATISTICS OF ERYSIPELAS.
frequent in the erysipelas of parts at a distance from
the heart (the scrotum and extremities). Erysipelas
faciei most commonly proves fatal by supervening
affection of the brain.
[Colles says (Lectures on Theory and Pract, Surgery), " delirium or
coma coming on before the local inflammation, docs not indicate dan-
ger ; but this is not the case when the eruption, accompanied by slight
constitutional symptoms, has already continued for two or three days.*^
Erysipelas is most to be dreaded in weakly habits,
and constitutions exhausted by previous illness. Ery-
sipelas from miasm and contagion is more dangerous
than erysipelas from internal causes. The extremes of
life suffer from it more than the middle periods.
[For an account of a form of erysipelas which has prevailed at differ^
ont periods within a few years past in various parts of this country,
under tho name of " Black Tongue," see Appendix K.]
With reference to statistics, I have not much to tell
you that can be relied on. When the inquiries now in
progress in the several London hospitals, under the
guidance of the Statistical Society, are fairly carried
out, and an average of years taken, much will be
elicited on this subject that is curious and edifying.
At present, all is guess-work. It has been conjectured
by Dr. WilUanis that the rate of mortality varies from
one in three to one in fifteen (thirty-three per cent,
down to six or seven per cent). With respect to the
actual numbers perishing by erysipelas, we learn from
the registrar general's reports, that in the metropolis,
during the five years, 1838, 1839, 1840, 1841, 1842, the
deaths by erysipelas have been respectively as follows :
—405, 301, 311, 251, 235. Throughout England and
Wales, the deaths by erysipelas were, in 1838, 1203 ;
BTATISTIOB OF ERYSIPELAS.
227
in 1839, 1140; in 1840, 1217. The steadioess of
these numbers will attract your attention, so different
from the fluctuations of the true exanthemata. You
will notice at the same time that erysipelas is compara-
tiveiy more prevalent and more fatal in the metropolis
than in the provinces. The general mortality of the
one, compared with the other, is as four to one, but in
the case of erysipelas, it is as eight to one. Such a
result might have reasonably been anticipated from a
knowledge of the character and constitution of the
parties admitted into the hospitals and parochial infir-
maries of London, and also from considering the com-
parative purity of the air in town and country hospitals.
Females unquestionably exhibit more cases than
males in point of number, as already noticed ; but this
is compensated by the greater intensity of erysipelas in
males (from drink, mental exchemeut, tStc), so that( in
feet, as many males die of this disease as females. In
1838, there died (throughout the country) 605 males,
698 femalejs. In 1839, 550 males, 590 females. In
1840, 450 males, 456 females. In the metropolis, the
proportioa of male deaths exceeds slightly those oC
females.
[Of 420 ileallia by erysij^laa in New York from 1837 to 1844 inclu-
live, SOO were mnlea and 220 females. Great inequality prevailed
during individual years of tfaia series, sometimes in favor of one sex, and
■ometimeo in favor of the other. Of 264 deatlis by this disease in
Fhilndelphia, during the period from 1837 to 1846 inclusive, the num-
ber of Uiose of the two ee.xes was predsely equal ; but, as in New York,
there was great inequality of tbe two sexes in individual years of the
series.]
In like manner, all ages seem to suffer in nearly the
same degree. There died of erysipelas in London
daring the two years 1840-41, 562 persons, of whom
228
TRBATMBNT OF XRniPXLAa
172 were under fifteen years of age» 265 were adohs
in the prime of life, and 123 were aged above mitj, A.
more minute investigation, however, establbhes that
the aged are its chief victims. If we compare the
number of deaths with the numbers living at each
respective period of life, we shall find that erysipelas is
most fatal in advanced life, less so in eariy life, and
least so in middle life. The proportions are expressed
by the figures 55, 15, and 11.
[Ag6B of 420 persons who died of Erysipelas in New York, during
the eight years from 188f to 1844 inclusive, and of 254 who died of
the same disease in Philadelphia, daring the nine yean from 1887 to
1845 indutiye : —
New Yozk.
FfaiUdelpUB.
One year and under, .
183 .. . 94
Between 1 and 2 years,
24
. 11
** 2 and 5 "
29 .
. 13
" 5 and 10 " . .
8 .
6
" 10 and 20 "
. 22 .
. 9
" 20 and 30 "
. 48 .
» 13
" 30 and 40 "
. 63
. 23
" 40 and 50 "
. 32 .
. 24
" 60 and 60 "
. 22 .
. 19
" 60 and 70 "
. 18
. 14
" 70 and 80 "
. 13 .
. 16
80 and 90 " . .
5
. 11
" 90 and 100 "
. 2
1
Unknown ....
. 1
.
420
254]
We come now to the thorny subject of treatment
Erysipelas is obviously a highly inflammatory complaint
It displays most strikingly all the phenomena of inflam-
mation — pain, heat, redness, swelling. Nevertheless,
physicians for more than a century past have been
divided as to the proper mode of treating this inflamma-
BLOOD-LETTINO AND PURGATIVES.
tiou. Some contend for bleeding, purgatives, and the
usual anliphlogistic measures. Others still more forcibly
urge the adoption of bark, wine, and a system essen-
tially tonic. The great authorities are ranged pret^
equally on both sides. Cullen, Lawrence, Dupuytren,
are opposed by Drs. Wells, Willan, and Fordyce.
Some who recommend wine object to bark, and at all
events deny to bark that specific power over erysipelas
which Dr. Wells and Dr. Powell claim for it.
Out of this mass of conflicting opinion it is difficult
to extract any decided rule of practice. Facts are
opposed to facts. Statistical inquiries, carefully con-
ducted so as to guide our judgment, are wanting. In
this emergency I must tell you what I liave noticed
-myself, and what I believe you will find to be the safest
course to pursue.
We have seen that erysipelas arises from a great
variety of causes, and may display itself under circum-
stances the most opposite. It may happen to the ple-
thoric soldier and the exhausted inmate of a workhouse.
It may invade a young man in the prime of hfe, and a
female of hysterical habit and feeble powers. It may
arise from a depressing miasm, and it may follow a
debauch of wine. Common sense dictates that any
disease so occurring must be met by corresponding dif-
ference of treatment
As an army surgeon, yoa will often find it necessary
to bleed largely in erysipelas. If the pulse be full, the
tongue deeply loaded, and the urine of the color of
brandy, nothiug but full bleeding from the arm will
meet the exigencies of the case. I remember, some
years ago, being catlvJ to attend a young man in erysi-
pelas, aged about twenty-one, the apprentice of a
232 LOCAL TREATMENT.
TMicn the disease affects the face and head, it is important to keep
the patient in an inclined posture in bed, so that the head may be
elevated ; and also to keep it uncovered, to prevent accumulation of
heat
Particular care should also be taken to keep the part elevated when
either extremity is affected.]
If pliysiciaDs have differed on the canstitutional
treatment of erysipelas, they have not agreed better
with regard to local treatment. Some advise warm
applications, some cold ones. Some recommend watery,
some^ spirituous fomentations. Some banish all fluid
applications, and place their sole reliance on dry hair
powder. A few would counsel us to cover the affected
surface with mercurial ointment. Others have great
confidence in lotions containing lunar caustic ; and a
few, in their admiration of this remedy, pretend to con-
trol the advance of erysipelas by surrounding the affected
part with a ring touched by the lunar caustic, and say-
iiiji; to the inflammation — " Hitherto shalt thou come,
and no farther." Here and there a practitioner, some-
what more energetic in his notions, applies a blister to
the very centre of the inflamed surface.
I shall not occupy your time by niinuto criticism on
these several modes of practice. All of them have, at
times, proved useful — that is to say, patients have done
well under them all. In truth, it would be as absurd to
limit the local, as it would be to confine the constitu-
tional treatment to any precise detail. The feelings of
the patient may often be consulted advantageously, and
that plan adopted which best moderates the sensation
of heat and fulness which is so distressing to him.
You nmst not expect much decided benefit from any
kind of local treatment in a disease of constitutional
origin.
LOCAL TREATMENT.
You are not to neglect any means, however ;
rently trifling, which conlribiite to the ease and tempo-
rary comfort of the patient, but you are not to exagge-
rate the importance of external treatment, or to imagine
you iiave made a great discovery, when you find a
patient prospering better under a decoction of poppies
than under a cold spirit lotion.
In mild cases, the surface may be covered with hair ■
powder. In severe cases, the affected parts may be
painted with a lotion composed of a drachm of lunar
caustic dissolved in eight drachms of distilled water,
with eight drops of diluted nitric acid added.
I have left to the last the great bone of contention,
touching the propriety of local bleeding in erysipelas.
This question admits of being viewed in a great variety
of aspects. Mr. Lawrence and Mr. C. Hutchinson
contended for the honor of this improvement in the
treatment of erysipelas. I will state to yon, in a few [
words, my own opinion on the subject. In erysipelas,
there is undoubtedly great congestion of the superficial
Tessels, and, therefore, d. priori, great benefit might be
anticipated from the detraction of surface blood. Under
careful management, and with due regard to the powers
of the system, scarijicalions in erysipelas may be prac-
tised with great benefit upon the extranities. I have
my doubts as to the propriety of employing them on
the face. I enter my protest, however, most strongly '
against those deep incisions through the entire tliick-
ness of the inflamed and swollen chorion which some
sui^eons have recommended. If the object be to"
obtain a large quantity of blood, that object would be
gained more safely, and as effectually, by veneseriion.
It is difficult, in aU cases, and impossible in some, to
^^
control or limit the loss of blood proceeding from 1
gaping lips of a deeply incised erysipelatous surface ;
and I need scarcely tell you tbat exbaustion from the
excessive loss of blood in such a disease as erysipelas is
a very serious evil. Many cases of erysipelas have
undoubtedly been benefited by die detraction of surface
blood, but many thousands of equally severe cases ha^
done well without it
[Altliough we fully agree with our author in the amull
confidoEw to be placed in local romediea in an affection s
connected with constitutional causes, as is the case wilh erysipelas, a!
have indeed oureelves seen but little effect from them in arresting i
progrera of the disease, no havo thought that a notice of thoee whii
have been recommended by high authority, and are more or
common use, might not be unacceptable — tlie more especially a
of them are at least palliatives, and often serve to soothe tlie local ii
(ion, and thus contribute materially to the comfort of the patient
Mercurial ointment has had many warm advocates as a topical ap[
cation in erysipelas.
Lisfrinc thought that lard itself is a good local application ii
affection, and that it may be eubstjtuted for mercurial ointment.
Bays that it should be renewed every two hours, and ^veo ever
hour, if the parts are hot and the weather warm.
M. Jobert recommends ointment of nitrate of silver, which he n
three degrees of strength, according to the intensity of the disease, 4
and 12 parts to 30 parts of lard, to be applied freely. lie also a;
compresses, wet with tiuct. camphor in the simple form. M. Jot
says, however, that local remedies have no effect in arresting the p
grcss of the disease on the skin ; but that ointment of nitrate of s:
may be applied to ahortoa its duratjon on the part affected, and [
vent the inflammation from extending to deep-seated parts.
M. Trousseau has lately used locally, from the first day, and dui
the whole duration of the disease, lint dipped in a solution of c
in ether, and aj>plicd five or six times daily. This may be used in
ofiufanla. {Buliel. 0£nir.de Tk£r., Feb^ 1848.)
M. Chomel has never found blisters, nitrate of wlver, or mere
ointment, either limit or arrest the progress of the affection,
that the contradictory reports of the effects of certun topical applic
LOCAL TREATKENT.
235
maj pcrliaps be traced to the difference in cause in difieront caaca,
whether exwroal or internal, a dialjiiction of practical impnrtftnce.
Hr. LUtOD recommenda aconite (tinct. of root), both externally and
internallj, and Dr. Fleming has used it witli marked benefit io seferal
cases.
M. Mojon has found a solution of tartar emetic, applied continuously
hy tnt-'ans of compresses, very efficacious as a topical antiphlogistic It
may be usod tepid, but is better cold. {AnnaUa de Ther., Jan., 1846.)
Crea»ote baa alao tieen used and highly extolled, but is probably
equaUy inefficacious with tfae articles above enumerated.
Baw cotton has been used both in this country and elsenhere, and,
as is said, with benefit as a topical remedy in this afiectioQ. Tba
anBl<^ between erysipelas and the first stage of a burn first led to tbi«
use of it.
M. Velpeau speaks highly of sulphate of iron as a topical remedy of
dedded value. lie usea it both in the form of a wash and of an oint-
ment — the former in the proportion of S j lo a pint of wal«r — the part to
be kept wet with it ; the latter in the proportiou of about 3ij to Jj, to
be applied every second or third hour,
A mixture of equal part& of spir. mindereri and tepid water is also
reoommended.
The following cold lotion mentioned by our author in his Theory
and Practice of Physic, has been found very gratefiit to patients, and
liM been extensively used in the New York Hospital : — 9 Liq. ammon.
aoel. Siij; spir. vin. !j; aqu. fontan. Sxij. M. C lot.
Dry powders Komotimes beat and irrilafe the skin, and their use is
forbidden by some; while, on the other hand, they are favorite applica-
tions with others. M. Briquet has used collodion with success as an
external application, especially in E. ambvloM. The affected part must
ha covered with it dmly. (ffoi. rfr* ffdpit^ Oct. 1, 1860.)
A decoction of cantharides in spirits of turpentine was introduced into
practice some years since by Dr. Harlshome of Philadelphia, as a
topical application in erysipelas, in those of a relaxed habit, and in the
typhoid form of the disease, and has been employed losome extent. It
U prepared by boiUng one ounce of cantharides in four ounces of spirits
of turpentine, in some glass vessel (as n Florence flask), in a sand-bath.
This is to be diluted with ohve oil, and hnen cloths wet with it to be
kept applied to the affected parts.
Difft-rent modes of local depletion in erysipelas have been recom-
mended by surgeons of distinction, each claiming for his owu on advan-
LOCAL TREATMENT.
Ktege ovc-r tliat praetiaed ty otbers. Some adviso extensive
1. otben, abort iocUions ; olhore again, punctures witli the point of « I
J-lincet; while some prefer to take blood by leeches. We have lued I
B iocisioDB nilh marked benefit in eryeipelsis nfiecling the limbs, esp^J
lidally when there is great teosiDD — this is at onoe relieved, at iLe et
vtime iLnt tlie part is freely depleted. Neither bidhU indsioos nor pi
i atcoiTiplifih either of these objecte, nor do leeches effect il 09 1
I fffomptly. M. Chomel forbids the application of leeches near llw •!
I'HSected part, for fear of extending the inflaminalion.
Both punctures and incisions should be followed by warm foments I
ions or emoJlieDt poulticeii, and should be repeated if tlie tension is not ' i
k relieved. Neither of these modes of depletion should be used except I
I in tie florid, raised form of erysipelas, witL disleusion of the cellular 1
Vonnbrane. Tincture uf iodine and nitrate of silver are thougkl beUtt J
I idapled to the atonic form, ciiaracterized by a dusky line.]
LECTURE X.
mSTORY, PHENOMENA, AND PRACTICE OF
VACCINATION.
Earliest notices of cow pos. Devotion of Jenner to this subject. An-
nouncement of the diacovury of vaccioBtion. Its rapid adoption over tfao
whole world. Insusceptibility of cow pox in nertwn persona. Plieno-
mena of vaccination. Progress of the vesicle. Confititutionol symptoms
kccompsnying. AnoDLilios and varieties. Vitlue of the cicatris ns a teat
of vaccine inflnence. Modified how pox. Bryce's test Concurrence of
amall pox and cow pox. Surgery of vaccination. Selection of efficient
lympti. Mode of operating. Preservation of vaccine lymph.
The act of 1840, commonly called tlie Vaccination Ex-
tension Act, — though not nominally, yet in its practical
working, is an act for enforcing the practice of vacci-
nalion on the whole population of these kingdoms; for
with the penalties of that act staring ns in the face, our
only choice hcs between accepting vaccination, or
exposure lo the casual small pox. The latter alternative
has coupled with it the passage tlirough life in a state of
cvnstant and uiiserahle suspense, the disorder perhaps
seizing upon the individual at last under circumstances
the most distressing — possibly, after having married, and
become the father of a family, all of whom are depend-
ent upon tiiin for support. No parent in his senses
could seriously hesitate when such an alternative is set
before him. The whole population of England and
Wales, therefore, are virtually by this act cojnpi-Med to
submit to vaccination, whether they like it or not.
Formerly the case was diOercnt. Inoculation was
allowable, and if people adopted vaccination, it was
BARLIEST NOTICES OF OOW POX.
their own act and deed, for which no one could 1
blamed. Now the government of the country int«
poses, and takes the responsibility on Us own shouldei
The measure was a strong one, but it had been adopt€
in foreign countries, and found to answer. It rendei
more tlian ever necessary, that everything connect
with vaccination should be carefully studied by you — ia
history, pathology, phenomena, and practice. Tha
points will occupy our attention during the present lei
ture. I shall, on a subsequent occasion, speak to yea
concerning the practical results of vaccination, and i
Statistical details by which we have, after an experienci
of forty-five years, arrived at a knowledge of its ra
efficacy.
The earliest notice I have ever seen of cow pox is H
be found in a weekly paper published at Gottingen, 3
1769, where we leara that such a complaint was i
uncommon in the neighhorliood of that town, and l
those who caugltt it from the cows flattered themselw
ihey were secure from the infection of small pox.
notion of the same kind had long prevailed in Gloucsi
tershiro — a great dairy county, as you know, — and haj
often been forced upon the attention of the provincul
surgeons. But no one thought seriously of this i
tradition, or dreamt of applying it to the general benefil
of mankind, until Jenner arose. Dr. Jenner was bon
at Berkeley, in Gloucestershire, on the 17ih May, 174i
He displayed an early taste for natural history, and wa<
thrown from infancy among dairies and dairy maidi
There he heard of the cow pox, and appears, almost '
from die first, to have foreseen tlie uses to which it
might be turned.
In the year J770, being then twenly-one years of
Md
DEVOTION OP iBNKBR- TO THE SUBJECT.
age, Jenner came to London, to prosecute his medical
stndies under the eye of John Hunter. To that
enlightened man he repeatedly mentioned the popular
rumors prevalent in Gloucestershire concerning cow
pox ; but he does not seem to have received much
encouragemeut to prosecute the inquiry. In 1775,
being then engaged iu practice at Berkeley, he devoted
more attention to the subject He often talked the
matter over with his professional friends and neighbors.
Among them was Mr. Fewster, of Thombury, who
had, in his early days, been associated with Sutton, tlie
great inocnlator. This circumstance naturally inspired
him with a warm interest in everything connected with
small pox, but he never would beUeve in the prophylac-
tic power of cow pock. Other professional friends, in
like manner, dissuaded Jenner from wasting his time on
what they thought a barren study, " We have all
heard of these stories," they would say ; " but the real
caasc of the anomaly is some peculiarity of habit in the
person who escapes, not any efficacy in the disorder
received from the cow."
These and such like arguments would have effectually
damped the ardor of most men ; bnt though discouraged,
Jenner was not to be driven from his favorite pursuit.
No opportunity was neglected by him which seemed
likely to throw additional light on the subject. Cow
pox appeared to be the object for which he mainly lived.
He searched out all conceivable sources of failure. He
learned to discriminate the various forms of eruption to
which the teats of the cow are subject at different
periods of the year, and was led to the belief tliat one
only was possessed of specific or antivariolous powers.
This he called true cow pox. The others he termed
240
ANNODHCEHENT OF THE
spuriotts cow pox. By degrees he convinced himsel
that all tlic anomalies supposed by his professional
brethren to be insurmountable obstacles to the succei
I of his pursuit, were explicable on scientific principle!
and that cow pox was, what the nninstructcd bclicvei
I it to be, a true. Cull, and efficient preservative against t
small pox.
It would seem that about the year 17S0 he first coaj
ceived the magnificent project of perpetuating and pre
pagating this disease by inoculation, and thus extending
its benefits to the whole world. In 1788, he visit«
' London, and carried with him a drawing of the casaa]
I cow pox as it appears on the hands of the milliera.1
' This he showed to Sir Everard Home and other greatT
men of that day, but the physicians of London saw in il
only a curious and barren fact. Dr. Adams, physiciaaj
of the Small Pox Hospital, noticed the cow pock in I
" Treatise on the Morbid Foi^ous," published in 1795. J
It is a very curious circumstance that so far hack i
1782, when Dr. Archer was physician of the Small Pom
Hospital, Catharine Wilkins, from Cricklade, in Wilfrf
shire, who had had the cow pox casually during earln
f life, was tested with variolous matter at the Small Fox]
I Hospital, and found to be unsusceptible.
It was not until the year 1796 that Jenner began I
I esprrimcnt with cow po-: ahhough he had been talkitij
and inquiring about it for at least thirty years. Tb
decisive experiment was made on the 17th May, 179^
on a boy, named Edward Phipps, eight years of agi
He was tested with small pox on the 1st of July of tl
year, and found to be unsusceptible.
Jenner now prepared for publication, and sent hiJ]
paper, carefully and very philosophically drawn up, to
DISCOVERY OF VACCINATION.
241
the Royal Society, wishing that the discovery sliould
come forth to the world under its high auspii-es ; hut
that learned hody declined to receive the paper, lest it
should injure Jenner's fame, already established hy some
observations on the cuckoo ! Jenner, nowise discon-
certed, published the paper himself in June, 17!)S.
The work was drawn up witli singular skill. An
air of philosophical calmness pervaded it, which was
highly attractive. It was not the hasty productJoa of a
young man au\ions to push himself into early notoriety,
but the mature opinion of a physician whose life had
been devoted to a deep and careftd consideration of his
subject, and who staked his professional reputation on
the success of the measures which he recommended.
It is not to be wondered at, that a volume, published
under such circumstances, mole pnrvum, malerid gravem,
should have riveted the attention not of physicians
alone, hut of the whole civilized world.
It redounds to the honor of St. Thomas's Hospital,
that its medical officers were the first persons in England
to put Jenners discovery to the test. Mr. Cline vac-
cinated a hoy here, in the last week of July, 179S, wirh
dried lymph, which had been kept three months on a
quill. The hoy had diseased liip, and Mr. Cline, pro-
posing to convert the vaccine pock into a pea issue,
inserted the matter on the outside of tlie hip. Dr.
Lister, formerly physician of the Small Pox Hospital,
watched the progress of the case. The boy was inocu-
lated almost immediately afterwards, with small pox
matter, in three places, but the slight inflammation that
arose subsided on the fourth day. The experiment
therefore was perfectly successful.
On the aOth January, 1799, cow pock was found in
242 HISTORY OF VACCINATIOIV.
Mr. Harrison's dairy, in Gray's Inn Lane, from which
source, Dr. Woodville, my predecessor at the Small Pox
Hospital, commenced a series of vaccinations. That
same stock of lymph remained in use up to the year
1836.
To pursue the triumphant career of vaccination would
be gratifying to me, but it would not conduce to your
improvement. Suffice it to say, that the new practice
was received with enthusiasm, not only in this country,
but over the whole of Europe. It reached India in
1802, and penetrated with equal rapidity into the wilds
of America ; for foreign nations vied with us in efforts
to extend the beneficial practice to the farthest regions
of the globe.
[Vaccination was first practised in tliis country by Dr. "Waterhouse, at
Boston, in July, 1800, with matter received from Dr. Jenner himself,
lie used it first upon four of his own children, who, consequently, were
the first vaccinated |)ersons in the United States.
Dr. Miller, of this city, received vaccina matter from Dr. Pearson, of
Lond<jn, the same year, but it failed to produce the g(;nuinc disi-a^e ; as
did also another supply of matter sent on from Boston. [Thacher's
Amer. Med. Bior/raphtj.)
The credit of its fii-st successful performance in this city is, therefore,
due to Dr. Valentine Seaman, who obtained matter tirst from the arm
of a domestic vaccinated in Boston bv Dr. Waterhouse, who reached
this city on the 22d of May, 1801, just at tlie proper time for the matter
to be used. With tliis, his first supply, he vaccinated ei^hte<'n persons,
when, in consequence of being prevented by severe illness from pursuing
the subject, the infection was lost. In the course of the following win-
ter, however, he obt^iined a fresh supply, and by the 22d of DccembiT,
1802, thirty-five others had undergone the disease, making the whole
nunilM.T fifty-three, without his having obtain«-d a single coH»jK.»rator.
(Medical Beposi tort/, vol. v. p. 23(5 ; also, Discourse upon Vaccination,
by Valentino Seaman, M.D., 1810.)]
A few detached notices will complete my sketch of
the history of cow pox. In 1807, Parliament voted to
INSUSCEPTIBILITY OF COW POX.
243
Dr. Jonner a sum, amounliDg, in all, to X30,000, as a
reward for his discovery, and the generous devotion of
his time and talents to the pubhc welfare. In 1808,
the National Vaccine Estabhshment was formed, and
the support of government given to this measure, though
not in a very efficient form.
In 1823, Dr. Jenner died at Berkeley, the scene of
his early labors, full of years and honors.
In 1840, a Bill passed the legislature for the exten-
sion of the practice of vaccination throughout England,
Wales, and Ireland. The machinery of this act was
placed under the supervision of the poor-law commis-
sioners. Payment lo medical practitioners is directed to
be made, at a stipulated sum (averaging one shilling
and sixpence) for each successful case ; such expenses
to be defrayed out of the poor rate. A still later act
confirms these provisions, with a few unimportant addi-
tions. This act is working well, and the practice of
vaccination is now rapidly extending over the provinces.
Id the metropolis, owing lo the number of well-con-
ducted vaccine iustitutions, it had always prospered.
Having thus brought down the history of vaccination
to the latest period, my next object is to make yoa
famihar with the several appearances which it presents,
regular and irregular; but before doing so, I must inform
yOQ that occasionally we meet wilh persons who. from
some peculiarity of habit, are wholly insensible to the
vaccine poison, in whatever intensity and by whatever
mode it is applied. They receive it as they would so
mach cold water. The proportion of mankind who
exhibit this singular idiosyncrasy is very small. 1 may
have seen thirty or forty such cases in the course of my
life. It would be very interesting to determine whether
244 PHENOMENA OF VACCINATION.
this constitutional inaptitude to cow pox denotes a like
inaptitude to receive and develop the variolous poison.
In the few cases which I have seen, where inoculation
was subsequently tried, the insusceptibility was proved
to extend to both poisons, but 1 have read of instances
of an opposite kind. It is at all times very difficult to
arrive at the truth, on a question of this nature ; and
DOW that inoculation is forbidden, we may despair of
ever arriving at any certainty concerning it
The insusceptibility to the vaccine poison is, in some
cases, obviously dependent on constitutional weakness,
displayed in the slowness of dentition, the imperfect
ossification of the head, and the emaciated aspect of
bodv. 1 here exists here an atonv of the absorbent
system. If vaccine lyuiph is inserted into the arm,
either no vesicles arise, or they arc small, and imper-
fectly developed. In such cases, the indisposition to
receive cow pox is only temporary. In the former
cases, where idiosyncrasy is the cause of the phenome-
non, the inaptitude continues through life.
I now proceed to describe to you the phenomena of
vaccination.
The regular course of cow pox is as follows: — On
the third day from tiic insertion of the virus, the wound
will be perceived red and elevated. By aid of the
microscope, the efflorescence surrounding the inflamed
point will be distinctly jierceived even on the second
day. On the fifth day, the cuticle is elevated into a
pearl-colored vesicle, containing a thin and perfectly
transj)arent fluid in minute quantity. The shape of the
vesicle is circular or oval, according to the mode of
making the incision. On the eighth day, the vesicle b
PROGSBSS OF THE VE8I0LB.
in its greatest perfi!ction, its margin is turgid and sensi-
bly elevated above the surrounding skin In color the
vesicle may he yellowish or pearly. The qnantily of
fluid which it contains will he found to vary much.
When closely examined, the vesicle will exhibit a celtu-
lated structure. The cells are ten or twelve in number,
by the floor and parietes of which the specific matter of
the disease is secreted. The vesicle possesses the um-
bihcated form belonging to variola.
On the evening of the eighth day (counting from the
day on which the incision was made), an inflammatory
circle, or areola, commences at the base of the vesicle.
The skin becomes tense, red, and painful, for a consi-
derable extent around. The figure of the areola is per-
fectly circular. In some cases the subjacent cellular
membrane participates in the inflammatory action, and
occasionally the glands of the axilla swell. The areola
continues to advance during the ninth and tenth days.
On the eleventh day it begins to fade, leaving, in its
decline, two or three concentric circles of a bluish
dnge.
The vesicle, by this time, has ehher burst spontane-
oasly, or been opened by the lancet of the surgeon. Its
contents now become opaque. The vesicle itself begins
to dry up, and a scab forms, of a circular shape, and a
brown or mahogany color. Bv degrees, this hardens
and blackens, and at length, between the eigliteenth
and twenty-first day, drops off, leaving behind it a cica-
trix of a form and size proportioned to the prior inBam-
malion. A perfect vaccine scar should be of small size,
circular, and marked wiih radiations and indentations.
These show the character of the primary inflamniatlon,
and attest that it had not proceeded beyond the desira-
d
246 CONSTITUTIONAL SYMPTOMS.
ble degree of intensity. Many of the most perfect scars
disappear entirely as life advances.
Until the eighth day, the constitution seldom sympa-
thizes. At that period, however, it is usual to find the
infant somewhat restless and uneasy. The bow^els are
disordered. The skin is hot, and the night's rest is
disturbed. These evidences of constitutional sympathy
continue for two or three days. There is, however,
much variety observable here. Some children suffer
slightly in their general health throughout the whole
course of vaccination. Others exhibit scarce any indi-
cation of fever, although the areola be extensive, and
the formation of lymph abundant.
[Iq occasional, though rare cases, there is a general eruption of Tacdne
vesicles over more or less of the ^hole body, resembling in some patients
those of varicella, and in others those of the genuine cow pock, and
sometimes a mixture of the two. Two cases occurred among those
vaccinated in Franco in 1840, in which there was a general eruption of
pustul(5S over tlie whole body, the fluid from which produced regular
vaccinia. We have met wiih an instance of this general vesicular erup-
tion over the body res(;inbling vaccinia, but did not test the fluid con-
tained in the vesicl(?s. M. Aubry has also j)ublished a case of this kind.
(Archives de M^d.^ Paris, Sej»t. 1841.)
In Some instances, vaccine vesicles appear at other than the points of
insertion of the viru>, and sometimes on parts where no abnxsion existed
which could have been in<x;ulated with it. We have seen a single
vesicle on the finiier of the arm vaccinated in an infant, and in another
infant, one on the chin ; and in one case, the vaccine vesicles so numerous
about the neck of an infant as to form, as it were, a band of them
encircling the part, nearly an inch in breadth. This infant had suffered
from an erythematous affection of that part, which had produced some
excoriation of the surface. A second instance of the same kind came to
our knowledije afVir the vesieles had entirelv healed. In another case,
a child eighteen months old, vaccinated a fortnight before, had well
characterized vaccine vesicles on the external labia, and also on the
perineum, and about the anus. The vo>icles bore some resemblance to
certain forms of venereal eruption appearing about those parts in
CONariTUTIONAL BTMPTOHB.
247
«faildreii, and the case was carefully examiDed with reference to thii
A very remarkable case haa been recently reported by Dr. R, 0. Clark
^Lond. Med. Oaz,, Nov, 8, 1850), of "a genuine cow-pox vesicle rising
•t (mother part Lbnn the point of insertion." A healthy looking child,
nine months old, was vaocinat«d on the 28th of August, three JQcisiona
being made over the deltoid muscle of the left arm. On the 30th, thera
seemed a slight disposition to the formation of vesicles ; but all rednen
diaappeared during the next day, and there were no other signs of iti
faaving taken effect on that part. On the evening of the 2d of Septem-
ber, the mother noticed a small red pimple about the middle of the fora-
arin, which Dr. C. recognised the next day as presenting all the charac-
ters of H cow pox vesicle uf aboat the third day afler vaccination, and
which ran regularly through idl the stagea of such a veaele. He after-
wards vaccinated the child at two different times with great care, with
fresh mutter, but without any effect, so that the character of the vesicle
may be considered as fully established. He referred the matter to Dr.
Gregory for his opinion, who told him, that "if the single vesicle were
feond Jide cow pox, the case was a very curcous one indeed, undoubt-
edly the Grst of the kind that ever happened." Dr. G. recommended
the tmt of re-vaccination, after some laxatives to the child, and himself
«ent Dr. C matter for the purpose, which was used without effect Dr.
G. stated that, although he hud before seen constitutional vesicles, be bad
never seen them without tmeqaivoeal primary vesicle at the same time.]
It is not uucommon to find the cbiltl's body covered,
generally or partially, with a papulous eruption, of a
lichenous character, from die ninth to the twelfth day,
or even later. It is seldom seen in adult vaccination,
bnt is frequent in children full of blood, iu whom
numerous vesicles had been raised, which discharge
freely. Vaccine lichen, as this eruption is properly
called, often occasions great anxiety in the mind of
the parent, from a suspicion that small pox is coming
out. I have seen it in such intensity as to be fol-
lowed by minute vesicles ; but this latter appearance
b very rare. It is an accidental occurrence, chieflj
attributable to the peculiar delicacy of the child's skin.
248 ANOMALIES AND VARIETIES OF COW POX.
and fulness of its habit. Like the constitutional irrita-
tive fever, it indicates that the disease has taken effect
on the system, but it is not deemed essential to the suc-
cess uf the process.
[Tn some cases, patches of roseola appear in the neigliboiliood of the
place of insertion of the mntter, and extend more or less along the arm,
gradually disjippearing as the areola fades. At other times, an er}*the-
matoiis or raseolar redness covers the palms of the hands and soles of
the feet alwiit the eighth to the tenth day, disappearing at the end of
twenty -four or forty-eight hours, and requiring nothing but that its true
character shall be recognised, so sis to give tlie necessary explanation to
fipiends. Wo may add, that the lichen described by our author as
accompanying certain ca«^es of vaccinia, may attend upon spurious as well
as genuine vaccination, and hence cannot be regarded as any certain test
of the efficacy of the operation.]
The irregularities and anomalies of cow pox are
various, and require to be specially described. The
most singular variety of cmv pox is the petechial, or
that, where from some peculiarity of habit, the vaccine
poison (levolopes the hyemorrhagic diathesis. Of this I
have only met with one instance, recorded in the Med.
Chir. Trans, (vol. xxv.j).253). Petechijc, haemorrhages,
and an ecchvmosed areola, were the characteristic
featiu'es of this remarkable case. The child recovered,
all luemorrhagic apj)carances having declined on the
sixteenth dav of vaccination.
./
[A nntice of this case may be found in the AfeJ. Chir. Rev., Jan.,
184:?. p. -JO.]
The most common irregularity is that wherein the
vesicle, at a very early period of its course, becomes
prematurely red and itchy, whereby the infant is
tempted to rub or scratch it. To this rubbing the sub-
sequent ai)pearances arc usually attributed, but most
unjustly, for the same consequences follow, though the
child's hands arc mufiled. In this irregular form of
VALUE OF TUE CICATRIX.
vaccination, a small acuniinaled or conoidal puslvle will
be perceived ou ihe sixth or seventh day, surrounded by
a slight areola, of irregular shape. The contained fluid,
instead of being a clear and transparent lymph, is
opaque, and of a light straw color. The succeeding
scab is small, and drops off prematurely.
In some cases, the specific inflammation, or areola,
proves very violent, extending from the shoulder to the
elbow, and sometimes running into genuine erysipelas.
The vesicle, instead of drying into a hard scab, is con-
verted into an ulcer, discharging profusely, and leaving
behind it a large scar, of the size of a common wafer, io
which neither rays nor depressions can he traced. Much
temporary inconvenience, but no permanent ill conse-
quence results. The poison has taken full effect upon
the causlilution upon the eighth day. All that happens
afterwards is iintnaterial in respect to the security of the
child. These facts will enable you to decide on the
degree of importance to be attached to the cicatrix as
an evidence of the perfection or imperfection of the
original vaccine process. In every country, this is the
test chiefly trusted to, for in the course of twenty or
thirty years all memory of the actual appearances is
iisuallv lost, and it is rare that any written record of
ihcni is preserved. A perfect cicatrix, that is, small,
circular, radiated, indented, and persistent through Ufe,
is doubtless satisfactory proof that the individual pos-
sessing it has passed through the regular cow pox, and
has obtained from it all the protection which vaccina-
tion is capable of affording ; but an imperfect cicatrix
is no proof that such influence never had been felt, or
that having been felt, it has subsided. Irregular cica-
trices are coinpatihlc with full constitutional effect.
250 ANOMALIES AND VARIETIES OF COW POX.
because, as I have told you, they often depend upon
irregularities commencing incidentally after the tenth
day, when the specific influence has been completed.
Even the total absence of cicatrix is not decisive
against the present or prior existence of vaccine energy
m the system ; for in many cases, the specific inflam-
mation is moderate, and the resulting scar wears out in
the progress of life, as other scars do, which are not the
products of a specific poison. Perfect security is com-
patible with a small and scarcely distinguishable cica-
trix, with a large watery cicatrix, and with no cicatrix
at all, at least none perceptible five years after the
operation.
[The committee appointed bj the Provinc. Med. and Surg. Associa-
tion, in their report in July, 1830, say that, by itself, the cicatrix ought
never to be absolutely trusted. They add, " we are inclined to believe
that, though tlie presence uf a ]>erf<.'ct cicatrix is not a sure sign of pro-
tection, it^ absence must be held to speak strongly against the existence
of vaccine influence."
Abundant evidence might be adduced, if necessary, derived from
extensive observation in the Prussian, AVirtomberg, and l^avarian
armies, as well as on a smaller scale in other places, to show that no
dependence can be placed upon the vaccine scar as an evidence of pro-
tection from an attack of variola. Indeed, it may be considered as an
established point, that such is the case.]
Another variety of cow pox exhibits, about the sixth
or seventh day, the vesicle partially inflamed and scaly.
A species of psoriasis has taken the place of areola.
Whether these and similar anomalies are to be held as
depriving the cow pock altogether of its specific anti-
variolous property, is a question not }\?t decided.
Jenner contended, that under such circumstances, no
reliance could be placed on it in after Ufe; while on the
otlier hand, Bousquet, a high authority, maintains tliat
ANOMALIES AND VARIETIES OF COW FOX.
in such cases, constitutional influence is by no means
impaired. It is doubtful how far confidence can be
placed in so defective a process as this.
Cow pox is occasionally retarded in its normal pro-
gress. That this should happen in consequence of the
prior occupation of the system by measles or scarlatina,
yon can readily understand. So likewise is it easy to see
why this maybe the result of an accidental bowel com-
plaint. But sometimes the cow pock vesicle, without
any such cognisable cause, is retarded for three, four,
or more days. Retardation of the vesicle does not ,
in any degree take from the ullimate security of the
child.
[Dr. Jenner enrly obsen-eJ that the presence of certain forms of I
cutaneous disease, more especially the squainoiis and tlio veaicular,
modified tbe progress of llie vaccine vesicle, and stated tliat vaccination
performed on a skin occupied bj' any of these diseases " produceE every
grwdatjon, from that slight deviation from perfection vrliich ia quite
immaterial, up to that point which affords no security at all."
The committee of the Provincial Medical and Surgical Aasoeiatioii |
any, " Wherever there is the slightest diaturliance of vaccination mani-
fested by a pre-existing cutaneous disease, the vaccination ought to be
<listrusted, and repeated as soon as the ekin has been brought to t
healthy stat«," — {Traniae. Frov. Med. and Surp. Aisoe., rol. viii '
p. 3].) I
Mr. Slerry gives a case {Land. Med. Gtu:.,Apri\ 9, 1847) of Iha '
infiuenoe of lepra on vaccination, and says that he did not remember aa
instance of succes>>ful and perfect vaccinatioa in a patient tlie subject of
cutaneous disease.
Dr. Bjron alao reports a cnse of interruption of vaccination by cuta-
neous disease, and others might be quoted. i
It is not, however, uniformly the case that the progress of the vaccine
veeiele is Jnipeded by the previous existence of cutaneous disease.]
Small pox and cow pox are sometimes seen running -
their course simultaneously without mutual interference.
At other times the cow pox is retarded. Occasionally
L
252 ANOMALIES AND VARIETIES
they mutually restrain and modify each other's action.
Much depends on the time which has elapsed from
the application of each germ respectively. As a gene-
ral rule, it may further be stated, that extraneous fever,
however excited, restrains the growth and modifies the
normal progress of the vaccine vesicle. It never
reaches perfection, unless the system be in a sound
state. If, therefore, the variolous germ be received into
the body quietly, and eliminate itself with little consti-
tutional disturbance, vaccination may advance pari
passu with the small pox, and complete its series of
changes undisturbed.
The following case strikingly illustrates this principle,
and exemplifies at the same time the incubative period
of small pox, and the law of exanthematic suspension :
— William Bavin, fetatis 27, coachman, from 15 Cur-
zon street, visited his brother on Friday, February 3,
1813, whom he found laboring under small pox. He
took the j)rccauti()n of being vaccinated on Monday,
Fcbniary G ; began to feel poorly Saturday, February
11 : obliged to leave off work, February 13. Eruption
of small pox appeared on Wednesday, February 15,
being the thirteen th day from exi)0sure to contagion.
Scarcely any fever was present. The small pox proved
distinct and mild, and ran a perfectly normal course.
The vaccine vesicles were retarded, so tbat both dis-
orders maturated togetiier. On Monday, February 20
(the sixth day of variolous eruption, and the fourteenth
of cow pox), the small pox pustules were well acumi-
nated, and six vaccine vesicles were to be seen, full and
finely developed.
[The practical question of most interest connected witli the reciprocal
influence of vaccinia and variola upon each other is, as to the latest
OF MODIFIED SMALL POX.
253
afTurds protection after exposure to
this puiut tltere Beeius to be sume
perioO of time at whicli vi
li)c coiitiigiott of variola;
diBcrepaacy of opinion.
M. Legendre gives as his couclusioDs, from a comparison of GfLy-six
obBen'atiuiis, derived from different Kiurces, that u')jile vai^cinatiun per-
(bnned during the incubation of small pox, raodilita tlie cl>uruDl«r of
that disease, the vaccine disease ilaelf ia usually modified in a degree
directly pro|iortioBed to the shortness of the iritervsl between llie per-
iormancB of the vaccination and the appearance of tlie small pox. The
■Teoia is not so nell marked, and there ii no subcutaneous swell-
ing. When vaccination is performed after tlie ap|iearaucf of variola,
the vaccine vesicle sometimes ruus ila course, but does not modify ibe
variola.
Dr. Tardieu relates ft case {Jrckivtt ff^nA-, de Mid, 1815) of ft
young man vaccinated after the pustules of variola had appeared. The
pustulea reached the period of def^uamation by the sixth lo the eighth
day, and tliere was no fuver nor awelling of the face and extremities.
At the tenth day of eruption, the vaccine points had undergone no
<^ange, but six days afterwards tht) jiatient atjited that for five daya
put the vaccination scemtd lo have taken, and four vaccine ]iustules
(the matter had been inserted in twelve or fifteen places in eai'h arm)
were then seen on the right arm, almost entirely dried up. It would
Mem from this as though vaccination is of s«rtice in those not vacd-
sated, not only during the primary fever, but even at the commcucement
of ihn variolous eruption.
Dr. L. V. Bill (of Derry, N. II.) states that he has minutes of cases
in vhich there was no evidence of vaccination liaving laken efil-'ct until
after exposure for seven, nine, ten, and eleven days, to small pox in its
meet malignant form, when the succeeding vartoluid was of the mildest
diaracter. In these cases, hotrever, the patienta had been placed on a
precautionary treatment and diet, and were usually vaccinated daily,
onttl it was evident that the vaccine matter had talien. (Notice of his
paper on Small Vox, Varioloid, and Vaccination — Aiiier. Juar. Mtd.
Sei., May, 1830.)]
Another vatiety of anomalnns, or what is called
modified cow pox, presents ilsclf when the vaccine
vims is reinserted ou the fourth, fifili, or sixth day from
the primary vaccination. The result is, that the vesi-
cles of ihe secondary vaccination form rajiidly, and are
254 brtce's test.
hurried forward in their course, so as to overtake the
first crop, when the whole maturate and scab together.
The secondary vesicles are thus necessarily much
smaller than the primary. Mr. Bryce, in 1802, inge-
niously proposed to avail himself of this law, with the
view of ascertaining whether the svstem was under the
full influence of vaccination. The plan, though it
never received the sanction of Dr. Jenner, has never-
theless enjoyed great popularity, and is everywhere
known by the name of Bnjce's test. He recommends
that the second application of the virus should take
place on the evening of the fifth or morning of the sixth
day, so that the new vesicles may have fi'om thirty-six
to forty-eight hours to grow, before constitutional or
irritative fever is set up. Of late years, this procedure
has fallen comparatively into disuse. In cases where
the primary vaccination proves unsatisfactory, it is now
more usual to recommend a repetition of the operation
at the interval of one, two, or three years, according to
the extent of the apparent imperfection. I believe this
to be a great improvement on the plan of Mr. Bryce.
Wiien re- vaccination is practised at distant periods
from the primary insertion of the virus, the arm very
generally presents the appearances of modified cow pox
— that is, the vesicles advance with abnormal rapidity.
Areola forms around them on the fourth or fifth day.
Tiie resulting scabs arc small, and fall off in a few days.
Much itching accompanies the process. In some
cases, the renewed insertion of the virus occasions
considerable local uneasiness, with more or le>s con-
stitutional sympathy. I have seen re-vaccination in
irritable habits occasion irregular and extensive areola,
painful swelling of the absorbent glands, headache,
SURGERY OF VACCINATION.
general weakness and lassitude, and a stroug dlsposltioa
lo recurring erythema of llie arm.
The surgery of vaccination, simple as it may appear
to you, has nevertheless been a fruitful theme of con-
troversy. Differences of opinion have existed with
respect to the selection of lymph, the mode of making
the incisions, and the number of incisions necessary to
insure a full effect. Each of these points merits your
attention.
I. One of the earliest and most important disputes
which chequered the career of vaccination (inasmuch
as it led to the secession of Jenner, in 1807, from the
original Jennerian Institution) had reference to the
mode of taking the lymph. Dr. Walker adopted the
plan of detaching the epidermis from the vesicle, and
vaccinating with the lymph (or lluld) which exuded
from (he abraded floor of the vesicle.* Jenner objected
strongly to this, and employed only the superficial
lymph. Dr. Walker persevered in his plan ; and it is
but fair to confess that his vaccinations have stood the
test of time fully as well as those conducted according
to the Jennerian method.
The proper time at which lymph may be taken so as
to obtain it in the most efficient state for propagating
the disease, has also been a subject of discussion. Some
have objected to the employment of very early lymph,
others have scruples in taking lymph after the first
appearance of areola, and all parties have concurred in
condemning the use of lymph taken on or after the
tenth day. The facts bearing on this question are as
Vsccxu llouid
nm iho Select Coiiimiiiee of the llonce of Commoti* on ihe
lUSS." Page J14.
I
256 SELECTION OF EFFICIENT LYMfll.
follows. The younger the lynipli is, the greater is its
intensity. The lymph of a fifih-day vesicle, when it
can he ohtaincd, never fails. It is, however, equally
powerful up to the eighth day, at wMiich time it is also
most abundant. After the formation of areola, the
true specific matter of cow pox becomes mixed with
variable proportions of serum, the result of common
inflammation, and diluted lymph is always less effica-
cious than the concentrated virus. Nevertheless, very
pure lymph, if not too long humanized, will often prove
effective when taken from the arm on the ninth, and
even sometimes on the tenth day. After the tenth day,
the lymph becomes mucilaginous, and scarcely fluid, in
which state it is not at all to be depended on. Out of
a dozen incisions made with such viscid lymph, not
more than one will prove effective. The scabs of cow
pox, ground to powder, and moistened with lukewarm
water to the consistence of mucilage, will sometimes
rc[)r()dnco the disease in all its purity, a sati.>factory
proof that the alteration which the lymj)h undergoes in
its progress to maturity is not of a sjiecific kind, liable
to inflneiice the rrsult of the subsocjuont vaccination,
but simply dilution. ExpcrimcMits with diluted lymph
were formerlv made bv Dr. Adams, at the Small Pox
Hospital, and have sincte b(»en repeated in France by
M l>ous(jU(*t, and it is ascertained that effective vacci-
nation may be thus |)roduced.
Cow |)()x matter differs in its character and qualities,
according to the source from which it has been obtained.
Healthy and well Ivd children afford a lymph much
superior to that which is obtained from weakly and ill
fed children, whose blood is thin and poor. Lymph
being a product of blood, it is obvious that the purer the
SELECTION OP EFFICIENT LYMPH. 257
blood, (he purer will be the lymph derived from it.
But, further, experience teaches that the vesicles, even
of apparently healthy children, are not equally fitted to
reproduce the disease in purity. Some contain an
acrimonious lymph which occasions irritable vesicles in
all children, healtliy and unhealthy, vaccinated from it.
Such vesicles are with difficulty distinguished, even by
a practised eye. A good vesicle, too, may be drained
so much that the exuding lymph possesses little or no
intensity. Infantile lymph is more to be depended
upon than the lymph obtained from aduhs. The mat-
ter of primary vaccinations is more energetic tlian that
of secondary vaccinations. These statements may
serve as a guide to you in the selection of lymph where-
with to vaccinate.
[U is much to be fcnreii that sufficient attention has not heretofore
been, and U not now always paid to the selection of good lymph, Ab
well remarked by the committee of the Provinc. Med. and Surg. Associa-
liao, " if a deviation commences, it may be perpetuated, and atTord a
gradually decrcnaing protection ;" they add, " there is do doubt that
lymph of this kiud bos been often used."
The import«nce of the following rules laid down by that coraroitt«e,
renders them worthy of transfer to our p^es : —
" 1, The progress of the vesicle must bo noted at suitable periods, to
learn tLat it passes through its stages regularly.
" 2. Lymph should be taken from the fiflh to the eighth day, and be-
fore the formation of tbe areola, a rule of Jenner, and which should
always be observed.
" 3. Lymph should never be taken from a vesicle which deviates in
the least degree from the perfect standard, nor from a patient luboting
under any cutaneous disease.
"4, One or more vesicles should always be left to run their courae
withotit being in any way disturbed. This ought always to be insisted
npon.
" 3. Whenever there is the slightest diiturbnnce of vaccination taani-
fetted by a pre-existing cutaneous disease, vaccination ought to be dis-
258 MODE OF OPERATION.
trusted, and repeated as soon as the skin has been brought to a healthj
stote."
Dr. Waterhouse, in a letter to Dr. Mitchell, dated Cambridge, Sept
20, 1801, says: "Yesterday I received a letter from Dr. Jenner, one
paragraph of which I must transcribe, because it contains the golden rvle
(^ vaccination^ viz. "I don't care what BriUsh laws the Americans dis-
card, so that they stick to this — never to take the virus from a vaccine
pustule for the purpose of inoculation^ after the efflorescence is formed
around it, I wish this efflorescence to be considered as a sacred bound-
ary, over which the lancet should never pass." {Med. Repository^ N. Y.,
Tol. V. p. 236.)]
2. The second subject for oar consideration is the
mode of making tlie incisions, so as to ensure the best
and most certain results. Failure in the operation is
always harassing to the friends, and is often made the
pretext for delays dangerous to the child. Some sur-
geons use a sharp, others prefer a blunt lancet Some
consider it necessary to make the wound very superfi-
cial, others go deeper, and arc careless whether much
or little blood follows the iiiciiiion. A few operators
scarify the skiu in numerous places, in preference to
nraking incisions. I know very well that, provided the
lympU be good, it matters little in what way the virus
be applied, but the most uniforuily successful mode is
the following. Let the lancet be exceedingly sharp.
It should penetrate the corion to a consideral)le depth.
The notion that the subsequent effusion of blood will
wash out the virus, and thus di^feat our intention, is
quite imaginary and groundless. Provided that a genu-
ine lymph of due intensity has once come in contact
with the abs()rl)ing surface of the cutis vera, the rest is
immaterial. The vessels of the part have received the
specific stimulus, and nothing can prevent the advance
of the disorder but some constitutional cause. In
NOMBBR OF inciSIONS.
making the incision, the skin should be held perfectly
tense between the forc6nger and thumb of the left hand.
The lancet should be held in a slanting position, and
the incision made from above downwards.
3. The number of incisions which it is requisite to
make, in order to produce a full constitutional effect,
has been always a disputed point. At an early period
of vaccination, one vesicle was held to be sufficient
Then three, four, or six, were recommended. In Ger-
many, great importance is attached to the raising of
numerous vesicles, it being a received doctrine in that
coantry, that unless some decided constitutional effect
be produced, little reliance can be placed on the process
as a security in after life. Common sense dictates that
the greater the number of vesicles, the greater will be
the local inflanmiation, the greater the probabiUty of
constitutional sympathy, and on this theory the greater
chance of ultimate security. Some of the German
inoculators have been in the habit of raising from
twenty to thirty vesicles in each subject. In forming a
just judgment on this matter, the nature and quality of
the lymph must always be taken into account, Lymph
recently derived from the cow possesses so much inten-
sity, and fixes itself with so much more of a poisonous
character upon the skin of the arm than lymph long
humanized or habituated to the human constitution, that
a single incision made with it is equivalent to six or
eight made with lymph of minor energy.
I would recommend that whh lymph of ordinary
intensity ftve vesicles should be raised, and that these
should be at such distances from each other as not to
become confluent in their advance to maturation.
[With regard to the Dumber of places of insertion of tba virus, tii«
I
260 QUALITY OF THE VACCINE LYMPH.
oommittce of the Provinc. Med. and Surg. Association saj in their
report, ^ the insertion of the virus in three, or, at the most, four places,
we believe to be quite sufficient This,'* they add, *^ nvill allow one or
two of the vesicles to be opened for the abstraction of Ijniph, and the
others to proceed in their regular and undisturbed course.*^
Dr. Heim thinks that twelve punctures are sufficient for vaccination
of the young as well as for re-vaccination. He says that " too many
punctures have been followed by severe local inflammation and gangrene,
dangerous irritative fever, convulsions, and even death itself.** Among
the Wirtemberg physicians, when only a single vesicle comes to perfec-
tion, it is a very general practice to re-vaccinate. In this country, one
vesicle is usually considered sufficient by practitioners, and even this is
not always left undisturbed.
"With this latter fact in view, it is a question of interest, and worthy
of investigation, whether varioloid is of more frequent occurrence in this
country than in those places where the virus is inserted in so many
points at once. It is believed that only one vesicle was aimed at by
Jenner, when ^he practice was first introduced.]
Vaccine lymph should always be used in a fluid state,
and direct from the arm, wherever practicable, for it is
a very delicate secretion, and very slight changes in it
arc capable of materially altering its quahties. Lymph
which has been retained fluid for four or five davs, is
very apt to occasion that irritable vesicle which I de-
scribed to you as the most frequent of all the anomalous
appearances. Dr. GiiUiver has lately been occupied in
attempts to discover, by means of the microscope, what
is the exact change which vaccine lymph undergoes by
keeping, and which gives to it this noxious quality.
His observations have not hitherto yielded any decisive
results, but enough has appeared to warrant further and
more extended inquiries.
When lymph fresh from the arm cannot be obtained,
other means must be had recourse to. Vaccine vims
may be preserved fluid and effective for two or three
days in small bottles, with projecting ground stoppers,
PRESERVATION OF THE TAOOINB LYMPH.
2S1
fitted to retain the matter. It may be preserved for a
like time in small capillary tubes having a central bulb.
This is the mode usually adopted in France for the
transmission of vaccine lymph lo the provinces, and
which proves very effectual; but if you attempt in tliis
manner to transmit lymph to the East or West Indies,
you fail utterly.
Ivory points, carefully armed from vesicles possessing
the true characters, are very effective. They should
be used as soon as possible, for in the lapse of time the
thin pellicle of dried lymph is liable to be rubbed off.
With care, however, they will retain their activity in a
cold climate for several weeks or even months, and
they are found to be the most certaiu mode of sending
lymph to oar colonies. Some practitioners prefer
glasses to points, but they are less certain. The em-
ployment of scabs for the propagation of cow pox was
first recommended by Mr. Bryce, of Edinburgh, in
1802. It is a very excellent mode of transmitting vac-
cine matter to distant countries, but some nicety is
required lu operating with scabs, which experience alone
can teach.
pifr. Cheyne recommends the me of glycerine to pre-terve vaccine
Ijrmpb. He ilipa tbe sharp end of s probe in glycerine, and luuchea wilt
it the lymph he wishes to preserve. He says its «ctivily neems to be
rather increaBed than diminished by this process, and that he always
succeeds in developing the vuccine disease in its roost complete form,
even when lyciph kept in this wivy for two mouths has beta used.
{Jifedieal Timti, March, I860, p. 227.)]
LECTURE XL
PATHOLOGY AND RESULTS OF VACCINATION.
Theory of the identity of small pox and cow pox. Arguments in sappoit
of that theory. Inoculation of the cow with variolous matter. Variolo-
yaccine and retro-vaccine lymph. Objections to the theory. E2quine ori-
gin of cow pox. Doctrine of antagonism. Results of vaccination. Early
views of Jenner concerning the permanency of vaccine influence. Notice
of the variolous epidemics which have prevailed since the introduction of
vaccination. Statistics of small pox as it occurs after vaccination. Nnm^
ber of coses. Ages of those attacked. Per centage of mortality. Actual
amount of vaccine security. Suggestions for increasing it Recurrence
to the cow for lymph. Re-vaccination. Inefiicacy of these measures.
Among the niany subjects of curiosity which the theory
of vaccination opens, the chief interest now attaches to
the doctrine that small pox and cow pox are diseases of
the same nature — not simply analogous diseases (which
all must be ready to admit), but identical diseases.
When a child is vaccinated, therefore, he has, according
to the supporters of this, the homophysic theory, received
small pox a first time. If the child happens to take
tlie ordinary casual small pox in after life, he is, accord-
ing to the same theory, undergoing a second or recurrent
attack of small pox. It is here assumed that cow pox
and small pox are identical affections possessing a com-
mon origin, and it is therefore argued that they must
necessarily be governed, in their ultimate effects, by the
same laws. It is a matter of considerable moment to
determine on what grounds this opinion has been taken
up, and to what objections it is fairly open.
Dr. Jenner through Hfe adhered steadily to the notion
which he had early imbibed, that cow pox and small
IDENTITY OP SMALL POX AND COW POX.
263
pox were only modifications of each other. So strongly
was this persuasiou impressed upon him, that in lua
original essay he called cow pox variola vaccina. Bat
he went even further. He entertained the idea, that
cow pox was the original or parental form, which time
and nnfavorahle circumstances had converted into the
malignant variety of small pox. Jenner believed, there-
fore, that in giving to man cow pox, he was in reality
giving to him smalt, pox in its primitive and mildest
form. Some of the followers of Jenner have adopted
this fanciful notion.
Diseases that mutually produce each other are clearly
referrible to a common origin. Thus swine pox and
small pox are the same diseases ; but cow pox and small
pox are differently circumstanced. In man, no com-
bination of circumstances, however unfavorable, has
ever converted cow pox into small pox ; and no caro has
ever succeeded in converting the small pox into the
cow pox, although Dr. Adams, at one period of his life,
flattered himself he had made approaches to that desira-
ble consummation.
But Dr. Baron and others have attempted to prove
the identity of the two disorders, by reference to the
history of epizootic maladies, and the frequent con-
currence of a lues bovilja, or distemper in cattle, with
variolous epidemics. Epizootics have often attracted
public attention. In 1746 an act was passed to suppress,
by strong preventive measures, the distemper among
homed cattle. The fine for non-compliance was ten
pounds. In 1757, another more stringent act fur the
same purpose was passed, the penally being raised to
fifty pounds. In 1769, a severe and fatal distemper of
this kind ravaged England, and was considered of suffi-
i
864
ARODBIBNTS IK SUPPORT OF IDENTITT.
cient importance to form part of the speech with wh
King George the Third opened the parliament, Janua]
9th, 1770. He recommends "this very important s
ject to the immediate consideration of parHameiti
Dr. Baron, in his " Life of Jeuner," (chapter 7,) iabi
diligently to prove that this bovine disorder is a)Hed'|
many of its features to small pox. " A beast," it is s
"having once had tliis sickness, naturally or hy inoi
lation, never has it a second time,"
A second argument brought forward to prove I
common origin of small pox and cow pox, is dedaa
from the alleged fact, that matter taken from the cow~
laboring under the malignant epizootic has produced
in man, by inoculation, small pox. The experiments
performed in India, in 1833, by Messrs. Furnel and
£rown, which appear to hear out this assertion, are
open to many sources of fallacy.
It has further been argued, in support of the same
theory, that we can, by making cows breathe an atmo-
sphere impregnated with (he matter of human small pox,
infect them with a pustular disorder attended wiih fever,
the pustules so developed in the cow assuming the cha-
racteristic appearances of cow pox, and being filled with
a lymph exactly resembling that of the vaccine vesicle.
These facts would he very decisive if they could he
relied on, but no one in this country or iu India has yet
been able to verify them.
The pathologists who support the doctrine of identity
have lately abandoned these views, and maintain that
the principle is fully made out by the experiment of in-
oculating the cow with variolous matter. Such an
attempt was first made by Gassner. in 1807. and it was
announced that the resulting vesicle yielded a lymph,
IKOCUIATION OP THE COW.
which, transplanted into the human body, produced
cow pox. The subsequent experiments of Coleman,
Sacco, Dr. Naylor, and of others made under my own
eye at the Small Fox Hospital in 1828, threw a
doubt over these statements, and they were generally
discredited.
In 1839, Mr, Ceely, of Aylesbury, decided the ques-
tion, by showing, in a perfectly satisfactory manner,
that by operating upon the mucous surfaces instead of
the more insensible corion, the cow can be made with
fecilily to receive the variolous poison, which tlie con-
stitutlou of that animal converts into vaccine. These
important experiments were instituted under the super-
vision of the Provincial Medical and Surgical Associa-
tion, in whose Transactions (vols. viii. and ix.) they
are detailed at great length. Into the details of these
experiments it is unnecessary to enter. No doubt can
be entertained concerning tlieir correctness, which
indeed the labors of some contincutal physicians, engaged
nearly at the same lime in the same pursuit, have abun-
dantly corroborated. The lymph thus obtained has
been called the variolo-vaccine, to distinguish it from
that which is obtained from the idiopathic affection
of the animal.
[Vt. J. C. Martyn, residing at the lime in tie town of Attleborough
(UHsa,), claims as original the discovery that the cow cnn be variolated
from small pox virus. On the 2 J of October, 1 835, bu inserted small
pox mutter in one of the tcflis of b cow, making fourteen or fifteen
punctures, one of which took, and was followed bj a regular pustule on
the eighth and ninth dap. The matter from this, taken on the tenth
day, he inserted in tlie arm of a boy, ten years old. This was followed
by a regular vaccine vesicle, from which he vaccinated others, auouriling
Id the whole to twenty-three. Ilia experiments cost him his practice,
and he was obliged to remove to another state. The late Dr. John D.
XuW, of Boston, gave him credit for these experimenls.
EQUINE DRIGIK OF OOW POX.
morbid secretion, is often observed to arise from con-
tagion — that is, to originate in the application of the
diseased secretion, thus idiopathicallj developed, to tlie
teats of healthy cows, differently circumstanced, by the
hands of tlie milker. I have already told you, that
vaccine lymph from the arm of a child will, in hke
manner, excite vaccine vesicles when applied to the
teats, or the mucous surfaces of the cow, even though
twenty years had elapsed since that lymph had been
humanized or assimilated to the human constitution,
3. A like morbid product, possessed of like proper-
ties, may be developed in the teats of the cow, by tfae
application to them of matter taken from the diseased
heels of the horse. Dr. Jeuner was so deeply impressed
with the importance of this principle in vaccine patho-
logy, that he put it prominenily forward in his very first
paper, and even contended at that lime, that the cow
pox never appeared in cows, except %vhen they had,
directly, or indirecily. access to horses. Dr. Jenner
believed that this affection of the heel of the horse was
that commonly called by farriers the grease. Attempts
have been made of late years to throw discredit on this
supposed origin of vaccinia. Some have doubled the
facts altogether. Others, as Dr. Baron and Mr. Ceely,
aver, that the affection is not the pure grease, but a
disorder allied to it, Tiic name of the disease is a point
of little importance. The experiments of Dr. Loy, Dr.
Sacco, and many others, have satisfactorily shown not
only that vaccine vesicles may be produced in the cow
hy matter originally supplied by the horse, hut that the
secretions from the horse's heel may be applied directly
to ihe arm of the child, and will produce these vesicles
in all respects identical with those of the true vaccine.
VABIOLOUB OBIQIN OP COW POX.
Dr. Baron himself acknowledges that "in his views on
the cunnexioQ of vaccine with equine disease, once
considered as a wild speculation. Dr. Jenner proceeded
with his usual caution and discretion."
as been ascertftinod to be a pculiar
>nlj' the beeU, but the timbs and body
[This diaease in the hor
vesicular disorder, affecting ;
of that animal.]
4. To these three modes, so long known, of exciting
vaccinia in the cow, the labors of Mr. Ceely liave now
added a fourth. He has proved that the matter of
human small pox will excite the vessels of the cow's
teat or vaginal membrane to the production of a fluid or
humor, identical in all its properties with that which
arises from febrile disturbance in the cow's system, from
contagion, and from the matter of grease, or some alUed
disorder of the horse.
To conclude, however, from these experiments, that
cow pox is small pox in a modified form, it should be
shown, 1st, that the febrile disturbance of the cow is of
the nature of variola; and 2d, that the affection of the
horse's heel is also variolous. Dr. Baron and Mr. Ceel),
sensible of this, have attempted to prove both these
points, but, in my opinion, have signally failed in each
instance. The variolous character of the equine affec-
tion appears to be entirely gratuitous, and I have else-
where given my reasons for thinking that the lues
bovilla is more nearly allied to scarlatina than to variola.
In truth, it is neither the one nor the other, but an
affection siii generis.
I would rather deduce from these experiments and
observations, the conclusion at which Mr. Greaser, 'of
271
natB AQAIttflT IDBNTtTT.
Bath, arrived, in January, 1801* — viz. "that a morbid
poison applied to different animals produces, not a simi-
lar and specific disease, but the disease to which the
animal, from constitution and stmclure, is predisposed."
Equine matter, long humanized vaccine lymph, varioloas
matter — each, when applied to the vessels of the cow,
developes vaccinia. The constitution of the cow con-
verts tlie variolous and (he equine miasm into the vaccine
miasm, in the same way as the vaccine fluid is secreted
under several forms of feverish excitemeuL
Other facts might be mentioned which militate agRiost
(he theory of identity. If, for instance, a child is
inoculated for smalt pox some days after exposure to
casual infection, the diseases, locally and constitutionally
excited, coalesce, and unite in producing one etTecl on
the body. But if a child be vaccinaled some days after
exposure to variolous infection, the two dbeases do not
coalesce or hybridize. Each preserves its separate and
specific character. In October, 1800, this actually hap-
pened at the Small Fox Hospital. A child, wlio had
been exposed to the infection of small pox, was vacci-
nated. Both diseases advanced. A lancet charged
with lymph from the vaccine vesicle produced cow pox.
Another lancet charged with matter from a variolous
pustulc,_/ormp</ within the vaccine areola, communicated
small pox.f If the diseases were truly identical, and of
the Srime intimate nature, it is incredible that tliis dis-
crepancy of residt should have been observed.
• ■■ CwaKt's Evidence of tho Ul.liiy of Vaccine Inoculation. Dslh. 1801.-
Pago 10,
t-See case of llip co-exiswnce of vsrioU and vat
Title, in Med. and Pliya. Jeunial, ISOl j toI. v. p. E
111, leconled bj Dr. Wood-
DOCTIUNK OP ANTAOOHIBH.
On all these grounds I demiir to the theory of
identity, and bold that smalt pox aud cow pox are
antagonist affections — that cow pox, instead of being,
as Dr. Baron maintains, of a variolous, is, in fact, of aa
anti-vario/ous nature — that it alters and modifies the
human constitution so as to render some individuals
wholly, others partially, aud for a time, unsusceplihle of
small pox. Cow pox and small pox may be viewed as
opposing powers, striving to gain the mastery of the
human frame, and each, under different circumstances,
and at different times, proving successful. I'he con-
clusion to which M. Bousquet (Traife de la Vaccine,
page xvi.) has come appears to me to be the just
one. " La vaccine," says this acute writer, " et la
variole ne sont pas la meme chose. Mais si elles dif-
f<lrent dans leur origiue, daus leur principc, elles se
rapplecnt mcrvcilleusement dans leiirs effects. II vty a
pas entre elles identity dc nature, niais il y a reciprocity
d'action." To my mind, nothing can be more satisfac-
tory than such a conclusion. ^
I have gone into this detail, because the doctrine of
identity is now very generally received throughout this
country, and I cannot but think it has been hastily
adopted. The difiiculties into which such a dociriuo
leads us will be made very mauii'est %vhen we have
investigated tlie facts regarding post-vaccine small
pox.
[Variola nnd vaccine are con*idcred by some as merely anolo^us,
uid by oliiera ns identical in llieir cbarocter; wlule otLers, again, ci^n-
cide willi our uulLor in txilieving tliem tu he antuiruiiislic, and olhura
regard ibcm as retiprocnl in tlieir action, or suUilitutea liir each oilier.
The fact stated by the Comm. of the Provinc Med. and Surf;. Assoc,
and proved by statietics, that re-vaccination sncceads ur otlmrwisQ on
perwiM who have had smnll pox or cow pnx, ahuoftt cxnclly in the same
k
272 RESULTS OF YACCINATIOlf.
ratio, establishes, as the committee remark, a most remarkable analogy
between these diseases.
The committee of tlie French Academy on Vaccination for 1843 (M.
Gastel reporter) say, that if they are not identical in their nature, there
is at least a great analogy between them, and give reasons for this
opinion.
Since the decisive experiments of Mr. Cecly, whose successful inocula-
tion of the cow with small pox matter is now so well known, the
advocates of the identity of the two diseases have been very much
strengthened in their opinion, and are doubtless in the majority.
Dr. Alex. Knox considers the question as settled, and remarks that
the *' identity supplies a powerful argument in favor of vaccination ; bo
much so,'' he adds, ^ that a conviction of the non-identity of the two
diseases would go far to shake, in toto^ our belief in the real efficacy of
vaccination." (Lond, Jour, Afed., Nov., 1 850.)
At the same time, it would seem yet to be an open question, but not
one of sufficiently practical importance to call for more space than has
been already devoted to it]
When we were engaged in tracing the early history
of vaccination, you must have been struck with the
extraordinary contrast between the absolute scepticism
concerning the prophylactic virtue of cow pox which
p^vailed before the publication of Jcnner*s first essay,
and the unlimited confidence reposed in it, within two
years afterwards, in all parts of the world. A cahii and
dispassionate examination of .Tenner's first essay, is cal-
culated to awaken some surprise at this sudden conver-
sion of men's minds. The equine origin of cow pox
which the work begins by pronmlgating, was mere
theory, which time has since greatly modified. The
identity of small pox and cow pox, also put promi-
nently forward, was at that time a doctrine unsupported
by any direct experiments. The cases of successful
result which the work recorded were few in number
(twenty-three in all — viz. sixteen of the casual, and
seven of the inoculated disease), and the doctrine of
)
EARLY VIEWS OF JENNEE. 273
permanent security was deduced from casual causes
alone. It is singular tliat in tliis first essay no mention
is made of any instances in which tlie cow pox failed
to afford protection in after life, though, as I stated to
you, such occurrences had frequently been pressed upon
Jenner's attention. It was not until the year 1800,
and in his third publication, that any allusioo to
them is to be found. It ran in these words — " Some
there are who suppose that the security from the small
pox obtained through the cow pox will be of a tempo-
rary nature only. This supposition is refuted, not only
by analogy with tlic habits of diseases of a similar
nature, but by incoatrovertible facts, which appear ia
great numbers against it."* In his uriginal essay, Dr.
Jenner does not propose the abandonment of inocula-
tion, nor does be allude to the possible e.\ternunation of
small pox by tlie general adoption of vaccination, hut
he suggests the probabiUty of its usefulness to four
classes of persons: — 1. to those who from family pre-
disposition may be presumed liable to take small pox
severely ; 2. to those constitutionally predisposed
to scrofula ; 3. to those who from peculiarity of habit
resist small pox inoculation iu after life ; 4. to those
who may labor under some chronic ailment in wiiich
counter-irritation is desirable, I have shown you that
it was an individual belonging to this fourth class, who
was selected by Mr. Cline at this hospital, as the sub-
ject of the first experiment in London.
It was not long before Jenner threw off that reserve
with respect to the powers of cow pox manifested iu his
first publication. He confidently stated that the security
• •• CbatiDuation of Facu and Obaeivjinoiis, hy Dr. Jeaner. 1800,"
L
274
VARIOLOUS EPIDEMICS.
afforded by cow pox was as complete and as permanent
as that afforded by once undergoing tbe disease ; and
in May, 1801, within three years from the first an-
nouncement of his discovery, he writes thus ; — " It is
now too manifest to admit of controversy, that the anni-
hilation of small pox, the most drcadfnl scourge of the
hnman species, must be the final result of this practice."
The popular voice went fully with Dr. Jenner in these
pleasing, but illusory anticipations. After ten years of
almost uninterrupted prosperity, however, the course
of vaccination began to be slightly clouded. In the
year 1809, Mr. Brown, of Musselburgh, published an
inquiry into the anti-variolous power of vaccination, in
which he broached ^e opinion, that its virtue dimi-
nished as the distance from the period of vaccination
increased. His statements, however, were vague, and
made no impression upon the public mind.
In the year 1818-19, an epidemic small pox per-
vaded Scotland, the first that had occurred in these
countries since the great epidemic of 1796. During
this epidemic, many vaccinated persons passed through
a mild form of small pox. About this period the term
modified small pox was introduced, and generally
adopted. Dr. Monro, of Edinburgh, and Dr. Thomson,
detailed the chief events of these epidemics, and though
much discussion arose, the general confidence in vacci-
nation was in no degree shaken. In 1824, small pox,
after being in abeyance fourteen years, prevailed epi-
demically in Sweden, and attacked a considerable
number of vaccinated persons. The total mortality
amounted to 560, of whom 103 had undergone vacci-
nation, 69 bearing good marks, and 34 less perfect
evidences of the vaccine process. Of the 560 deaths,
Variolous epidemics.
275
391 were infants aud childreo (below the age of 15)
— lOy were adults. In 1825, this epidemic visited
London, a great increase in the deaths by small pox
appeared in the bills of mortality, and many persons
vaccinated in early Hfe took the disease. In 1826-27,
France suffered from an extension of the same epidemic,
which fell with great severity on the population of
Marseilles. Many vaccinated persons went through the
modified disease. In 1829, the same epidemic invaded
the north of Italy, and was particularly severe at Turin.
In the same year, the governments of Germany, who
always encouraged and even enforced vaccination, see-
ing the steady advance of the disease towards them,
took alarm; and then began that practice of re-vacci-
nation which has formed so striking a feature in the
medical history of the German states for the last twelve
years, It commenced in the royal armies of Wirtem-
berg. Then succeeded the re-vaccination of the Prus-
sian, Danish, and Baden armies.
In 1835, the government of Wirtemberg, satisfied
with the results of the military trials, extended the
plan, aud ordered the re- vaccination of the entire civil
population of the kingdom. In the meantime, however,
small pox had made considerable ravages in the country.
We le^firn from Dr, Heim's elaborate work, that in the
five years from 1831 to 1836, there were attacked by
small pox in Wirtemberg J677 persons, of whom 198
died. 1055 had been vaccinated, 75 of whom perished
— 622 had never been vaccinated, and of them 123
died. The population of Wirtemberg is estimated at
rather more than a million and a half of souls
(1,587,438).
276
VARIOLOUS EPIDEMICS.
Ceylon was the British colony where tlic govemiiieni
earliest interfered and most energetically encouraged
the practice of vaccination. Salaried vaccinators were
scattered over the whole island. So successful were
their labors, that up to the beginning of 1819, it bad
often been said that tlie experiment of exterminating
small pox had been made and successfully carried out
in Ceylon. In July, 1819, however, a severe epidemic
small pox broke out there. In 1830, a second epidemic
overspread the island — in 1833, a third, and in 1836 a
fourth. In these four epidemics, 12,657 persons were
attacked, of whom 4090 died, being at the rate of
thirty-three per cent, or one out of every three, — prov-
ing that small pox had lost nothing of its malignity
during its period of quiescence.
It is true that the largest proportion of the persons
so attacked had never been vaccinated, hut in each of
the epidemics a certain number of vaccinated persons
took small pox. The proportion of the vaccinated to
the unprotected varied. In the third epidemic, out of
a total of 460 attacked, 341 represented themselves as
vaccinated.
Denmark has undergone several visitations of epi-
demic small pox ; yet in no country in Europe has
more attention been paid to the practice of vaccinarion,
both as respects the numbers submitted to the process,
and the purity of the lymph employed.
The first was in 1824, the second in 1826, die third
in 1829. Copenhagen suffered also in the years 1833
and 1835.
England experienced the second epidemic visitation
of this century in the year 183S, and again many vac-
^
STATISTICS OF SHALL POZ.
cinated persons (or persons believing themselves to
have been vaccinated, and trusting to it as their
security) suffered attacks of the prevaihng malady.
This epidemic commenced in the summer of 1837,
and did not finally terminate til! Deceuiher, 1839. The
total deaths throughout England and Whales during
that period (two years and a half) by small pox,
amounted to 30,819, or an average of 12,200 deaths
per aanuni. Calculating that the rate of mortality ruled
aboat twenty or twenty-five per cent, it follows that in
those thirty months there occurred in England and Wales
not fewer than one hundred and fifty-four thousand
cases of small pox. In 1844-45, another severe epi-
demic invaded London, commencing April 21, 1844,
and terminating May 25, 1845. Nearly at the same
period, small pox appeared as an epidemic at Calcutta.
After this imperfect sketch of the reappearance of
small pox both in Europe and Asia, since the lull which
succeeded the first introduction of vaccination, I shall
proceed to state to you the results which statistical
researches have given, as to the relative numbers and
ages of the vaccinated who have been attacked by
small pox, and the ratio at which small pox succeeding
to vaccination has proved fatal in this and other
countries.
I shall begin by stating the results of the experience
at the Small Pox Hospital, and shall then contrast them
with the recorded experience of other countries and
other establishments.
The following table was preseutcd hy me to a com-
mittee of the House of Conunons which sat, in 1832,
to consider the expediency of continuing the Vaccine
Board.
278
STATISTICS OF SMALL POX
JPo. L—TahU exhibiting the Admiaioiu and Jkathiot the Small Pw
Moepital in the Seven Teanfram 1826 to 1882 indunwe.
TUBS.
•
ToUl Number tretted
at the Hospital.
Nomben haring the
QauAl Pox at variable
periods after Vac-
ciDation.
DmAm.
D-lk.
1826
168 •
52
63
4
1827
305
85
105
1
1828
202
67
71
8
1829
828
103
109
7
1830
259
76
84
7
1831
193
53
66
6
1882
Total . .
830
98
121
12
1785
534
619
40
With this we may compare the results of the sac*
ceeding seven years at the Small Fox Hospital, which
will be seen in the fpllowing table : —
No, 2. — Table exhibiting the Admissions and Deaths at the Small Pox
Hospital in the Seven Years from 1833 to 1839 inclusive.
TEARS.
Total Number treated
at the Hospital.
Numbers having the
Small Pox at variable
periods after Vac-
cination.
Adniiaiions.
DmUm.
AdnuMitiaa.
Defttha.
1833
242
50
89
4
1834
105
23
63
3
1835
401
89
144
7
1886
329
84
128
10
1837
251
46
95
1
1838
712
188
298
31
1839
Total . .
155
27
83
4
2255
507
900 j 60
i
Also the results of the next four years at the same
hospital : —
AFTER VACCINATION, 279
No. 3. — Table eihibiting the admisiioag and dealfia at the Smull Pox
Social in the levm years from 1840 to 1846 inclusine.
ToUlnumbafalpeu
ledinthaHo>plul.
NdidbM hiving
;,TX":™i
Toul
■>f
Aan.H«d.
Dl"l.
Admllied
1840
a27
11
316
95
120
8
..
1841
337
15
342
74
151
10
"
1642
155
14
141
34
62
4
"
1843
160
11
149
27
09
1844
647
4
S43
151
312
24
»
1845
384
16
368
79
217
13
"
1846
152
5
147
29
80
5
"
7 years.
2182
76
2106
489
1011
64
«i
From the preceding tables it appears that the num-
bers admitted after vaccination, had increased in the
second septennial period from 34 to 40 per cent of the
total admissions, and in tlie third septennial period to 49
per cent., the rale of mortality remaining the same.
The sum total of the three septennial periods affords
ihe following gross results : —
Total itdroissions into the Small Pox Hospital during 21
y^ara.
6222
Total deaths in the same period, . . . .
Total ca^s of bidhU pox after TaccioalJoD id 21 yean, .
2530
Total deaths among the cases of small pox after vaccina-
tion in 21 years,
164
General rat« of mortality,
25 per cent
Rate of mortality after vaccination, ....
7 per cent.
Among the most interesting documents which I have
obtained, bearing upon the subjects now under consider-
ation, are the following, which exhibit the amount and
280
STATISTICS OF SMALL POX
character of the cases of variola succeeding vaccination I
which occurred in the British army, on home and for-
i eign service, during the five years from 1834 to 1838 1
I JDclusive, I must premise that the strength of the army >4
[during that period (including men, women, and chil- *
n), was very uniform, averaging about 105,000.
I The regulations of the army require, and the careftd'J
I BOperintendence of the medical oflicers ensures, that!
■ every individual of that force (not having previouslya^
I nndergone small pox) had been f^ef/iWy vaccmateAll
I There is here, therefore, no room for dispute as to th&j
I reality of the alleged prior vaccination — a difficultj
f which meets us in almost every other case.
' A. TabU ahowing IhM total nutnbtT of caacM of Small Pox aftrr V
tiim, with 1A« mortality, tvkifh occurred in the Brittsh Army, on Ai
aniiforfiirn ifrviee, during l/it_^tf yean from 1834 to 1638 inclusivt, '
dislinffulshing the yeur» : —
TUU.
H«u.8.^>-.
Ponlp. Bwvk«.
Totil
i2X
Rat. or
noruUlr
permL
^^X„.
D«...
mlBlDDI.
DeiUii.
1834
1833
1836
1837
1898
42
63
106
163
23r
3
3
7
26
27
23
50
10
200
137
3
8
1
21
24
65
113
118
S03
368
6
11
8
46
61
0-2
9-7
6-9
12-6
13-8
Total
605
65
420
57
1025
122
11-9
Avertige strength of the army od home service, .
" u (1 foreign Bervicc,
B. TahU exkiinting the oomparativt sevfrily of tmall j)ox, as it ocrurred
in the Brilish Amii/, among the vaccinated, on home and foreign
AFTER TACCINATION.
tereice, during the Jive year* from 1834 to 1838 inclusive, with the
mortality.
"■•ri."'"
Home ButIm.
Funlpi B«Tl».
T.)l.l. [
RlluiilHII.
D»)h..
DlllllOIU.
D«lbi.
^..
D«.*..
Distinct, . .
Confluent, . .
Modified, . .
139
208
258
4
00
1
107
9S
154
4
61
2
300
307
412
8
111
3
Totol, . . .
805
C5
420
57
1025 i 122 1
The next table shows the niodifying effects of vacci-
natiou whenever the variolous miasm spreads epidemi-
cally in a population extensively vaccinated. Such is
the population of Copenhagen.
Table exhibiting the Amount and Mortality by Small Pox in the veil
vaccinated population of Copenhaijtn, from 1B24 to 1835.
1st Epidemic
2d ditto
8d ditto
4th ditto
6th ditto
Period occupied hj uch
Epidemic.
.^..
Si.
After
Viccinslion.
A,ss;..
ES
J«n.22.I824 toFeb.38, 1825
SepL 1825 to Aiigt 1820
March 1828 to July 1830
Augt. 1832 to Dec 1834
Ubj 15 to Dec. 31, 1836. .
Total .
412
1123
502
1045
1197
40
39
28
45
100
257
438
457
898
1043
3
2
4
10
47
3839
■258
3093
66
These statements and tables are amply sufiGcient to
sho%v how large a proportion of those who, in Europe,
at the present time, contract small pox, have undergone
vaccination in early life. They cannot be perused
without the conviction, that some material error had
crept into the views orighially entertained regarding
the power and capabiUties of tlie vaccine inoculation.
282
AGES OF PERSONS ATTACKED
If small pox can invade so large a proportion of a well
vaccinated population, as tlie last table exhibits, it is
obvious, that all idea of banishing that disease from the
earth is vain and illusory. It is equally manifest, thai
any attempt to institute a parallel between cases of
small pox after vaccination, and cases of secondary or
recurrent small pox, nuist fail. The most credulous on
this point may search far and wide, before he finds in
the records of the last century any counterpart to the
facts which these five Danish epidemics display.
The interval between the primary vaccination and
the attack of small pox fluctuated in inost of the pre-
ceding instances between seven and thirty years. By
far the larger proportion of the cases consisted of adults
in the vigor of Ufe. The following table exhibits the
ages of those who were admitted into the Small Pox
Hospital, having small pox after vaccination, during the
epidemic of 1838.
Agtt of ihoae admtltid into the Smalt Pox Hotjntal, m 1838, kavit^
Small Pox after Vaeeijiatum.
.....
D-U..
Under Shears of aga
From 5 to S inclusive
" 10 to 14 .
" 16 to 19 .
" 20 to 24 .
" 25 to 30 .
" 31 to 36 .
Above 35 years of 1^
G
25
90
106
55
13
4
6
16
8
1
Total .
2B8
31
From this it will be seen that between the ages of
twenty and twenty-five, the disposition in tbe vaccinated
to take small pox is at its maxim am.
283
^ We may compare these results with those derived
from the experience of Continental physicians. The
writiugs of Dr. Heini, of Ludwigsburg, and Dr. Mohl,
of Copenhagen, furnish us with tlic required details.
Table exhihilhg Ike rtlallv
after Vacctnatioi
AffPS of Periona allarked by Small Pox
in Wirtctnbcrg and Denmark.
.....
''^^^■
rsiS:
Between 1 ond 5 years, inclusive, .
6 and 10 .
" 11 and 16 .
" 16 and 20 .
21 and 25 .
» 26 and 30 .
» 31 and 35 .
Total
40*
68
186
273
230
172
75
u
102
173
187
156
]g
2
1055
653
' These tables correspond so closely with each other,
and with the experience of the Small Pox Hospital
already given, that you may rest assured they indicate
some law of the animal economy. In each instance,
you perceive, llie maximum of cases occurs at the
period which immediately follows puberty. It is there-
fore rendered more than probable that some modifica-
tion of the system takes place at that eventful epoch of
human life which lessens the protective power that
vaccination had previously exerted, I have already
made you acquainted with the fact, that in very early
times an impression prevailed that the protective power
of cow pox did- deteriorate in the course of time, and
that Jcnner was very unwilling to give credit to it. It
is a matter of general notoriety that small pox is very
seldom taken by vaccinated children who are under
284
PROTECTIVE POWER OP COW POX.
the age of eight years. In the course of a long expe-
rience at the Small Fox Hospital, I have never seen
F more than three or four instances of such an occur-
I rence. The protective power of cow pox may there-
I fore, for aJI practical purposes, be considered z.s cmnplete
I for that period ; but we are compelled to confess that
later in life it diminishes in a certain proportion <rf j
cases. What the exact proportion is, never has beail
ascertained, and, for very obvious reasoDS, never can boj
■ known or even guessed at.
But though this be impossible, there seems no reascH
t why we should not attempt to ascertain the laws whid
[ affect and limit that power of resistance to the varicHa
I lous vims which cow pox displays in so many instance!
1 and so remarkably in infantile Hfe. I have mentionet
' pnberty as a disturbing cause. I have no doubt that!
I others exist, of equal, perhaps of superior efficacy.J
I Among them may be mentioned change of cUmatt
which appears to have a very marked influence, suffi*-!
cieut to induce ns to recommend tlie re-vacci nation c
I all young people going to or returning from India,
severe fever, in hke manner, may so alter and modify!
tlie general mass of fluids as to open a door to the
reception of the variolous effluvium. Importance should
he attached also to die epidemic constitution of the
season. It is certain that persons who under common
circumstances have, through tlie agency of the cow
pox, resisted the variolous miasm, succumb to it undi
epidemic visitation. To pursue those speculadotH
would lead us out of our course. I -recommend them, '
however, to your future study, from a firm conviction
I that a knowledge of the laws which limit the powers
RATE OF HORTALITT.
285
of COW pox will improve pathology far more llian a
blind adherence to the doctrine of its unvarying pro-
phylactic virtue.
The preceding tables, while they certainly counte- '
nance the notion of diminished vaccine energy through
the medium of those changes which time effects in the
frame, prove at the same time, most incontestably, that
a portion of virtue still clings about the system sufficient ,
to preserve life, though not to exhaust susceptibility. .|
To determine with accuracy the average ratio of mor-
tahty which obtains when small pox invades those who
have been well vaccmated, is a point which the statisti-
cal records of the last twenty years teach us with
considerable precision. You will remember that small
pox in former times (and among the unprotected in
recent times) proved fatal at the rate of twenty-five, or
from thai to thirty-three per cent, (one out of four, or
one out of three).
Table shoieinff the Rate of Mortality by Small Poi afltr Vamnatitm
at different periodi and in different parts of the world.
LOCALtrr.
SamlttoC
Dewhi.
fmtttnl.
S'°«"^<'J^^a^j;'*''} 1820 to 1832
Ditto .... 1833 to 1839
Ditto .... 1840 to 1B46
Total at ditto 1B26 to 1S46
British Army . . 1834 to 1838
Copenhngen . . . 1824 to 1835
Wirlemberg. . . 1831 to 1836
Vienna .... 1834
Ceyton, Epidemic of 1830
Ditto .... 1833 to 1884
Total . . .
819
900
ion
40
64
1
7
H
7
12
2
7
8
13
7
2630
1025
30D3
1055
200
2S0
341
1C4
122
66
75
16
34
23
8504
600
6
The previous table, compiled from various sources,
will show how great is the diminutiou in the ordinary
rate of mortality by small pox when vaccination has
preceded. It will be seen that the average rate is
ttien six per cent., the maximum being thirteen and
the minimum two.
The result of these statistical investigations may be
stated to you in a few words. Small pox in the un-
vacciuated is five times more fatal than it is to those
who have previously undergone vaccination. The fol-
lowing table, carefully drawn up from the records of the
Small Pox Hospital for the year 1841, shows you how
this is effected. It is an analysis of the several cases
admitted in that year, having small pox after vaccina-
tion. It will be seen that nearly two thirds of the
cases (or GO per cent.) received the disease in a modi-
fied form. The remainder (-10 per cent.) received it
in a normal form, but in variable degrees of intensity,
the mortality among them following the ordinary law.
Analgm of 151 case* of Small Pox tucceedinp Vacctnatioti, which
oecvmd at the Small Fox Hospital m 1841.
Normal .
Abnormal, or
modified
56
Ad-
Dnllu.
25
19
12
18
IS
68
8
1
1
Distinct, regular . .
Coijfluent modified .
Semi -confluent modified
Varicelloid, or disUnct
modified ....
Total . .
\
151
10
Deducting the two deaths among the milder cases,
which were the results of superadded disease, there
FREQUENT RENEWAL OF LYMPH.
287
remain eight deaths. Now supposing that these 151
persons had never heen vaccinated, the mortality would
have been at least five times eight, or forty, and might,
under unfavorable circumstances, have reached fifty.
Such appears to be the actual amount of the protection
which vaccination affords, and with it, such as it is, we
must, I believe, rest satisfied. My firm persuasion is,
that no additional precautions on the part of vaccina-
tors, and no alteration in the kind of lymph employed,
will have the slightest effect on the general results.
But the world are not so easily persuaded to rest upou
their oars, They have been taught to believe that
vaccination was an almost certain preventive of small
pox, and they are loath to see it shorn of its original
splendor. A restlessness and dissatisfaction, indeed, in
regard to tlie amount of vaccine protection, have been
perceptible throughout Europe for many years, and
two expedients have been largely practised, with the
view of increasing the security of the vaccinated. One
of these is the employment of lymph recently derived
from the cow ; the other is re- vaccination. A few
observations on each of lliese topics will conclude my
account of cow pox.
[For remarks on the mortalily of small pox after vawination, see
Appendix L.]
An impression that vaccine virus decaj-s in power,
in proportion to the number of times that it makes the
circuit of the human body, has long prevailed. In all
parts of the Continent, and recently in England also, it
has led to the frequent trials of lymph fresh from the
cow. Jenner did not object to occasional renewals of
the stock of lymph, but it does not appear that he ever
acknowledged deterioration of the virus by use as a
288
FREQUENT RENEWAL OF LYUPH.
common occurreuce, or as a source of failure. In
1829, the invasion of epidemic small pox induced the
Sardinian govemmeiil to try a variety of new stocks of
[yniph. We are informed by Dr. Griva, chief of the
vaccine establisbment at Turin, that no perceptible
difference was to be traced between tlie aspect and
progress of the old and of the new lymph. lu Wir-
temberg, between 1S31 and 1836, forty new varieties
of lymph were tried, but without any obvious advan-
tages. In other parts of Germany, the same trials were
made. In France, a new variety of lymph, obtained
from the dairies of Passy, near Paris, was brought into
use by M. Bousquet in 1836, and it certainly proved
much more energetic in its primary effects than thai
which had previously been employed. About the same
period, we changed our stock of lymph at the Small
pox Hospital, and with decided advantage. There are
occasions, therefore, when I should be disposed to
recommend the measure, but it is not lightly to be
resorted to. Helm calculates that three fourths of the
inoculations made with lymph direct from the cow fail
altogether of effect. When they do take effect, it often
happens that severe local inflammation is excited, pro-
ducing irritable sores and glandular sweUings. Nor are
we at ail sure that the ultimate effect, the security of
the patient in after life, wilt be sensibly augmented.
[Some (liffereace of opiiiion seems to exist as to Lhe necessity of
resorting to tho cow for supplies of fresh lymph. The Committee of
the Proiincial Med. Htid Surg. AssociatioD conclude that it does not
necessarily become deteriorated, though it may huve passed through a
great Dumber of subjects, and have been used for a great number of
M. Fiard, however, infers from the reault of hi« experimentB with tin
vncdne mttUer of 1830 and 1844, that it baa decreased in efficacy, and
RE-TACCINATION.
289
hence concludes, that it should be procured fresh from the cow every
fire or six years. (VAbfU/e M6i., Nov., 1844, p. 26i.)
M. Castel Bays (Report of Comuiittee on Vaccinalion of FrcDch
Academy for 1843), thnt nbstever may be the opiaion of practidoaers
on this controverted qucstiou, it in an act of prudence to permit no
opportunity to escape of renewing tlie vaccine virus.
Mr.Steinbrennersays(7Vairf <fe^ ForctRe, Paris, 1846) tliat "vHccine
virus does undergo a positive deterioration by transmission througb suo-
oesuve individuals, and that il is tJierefore desirobla to obtain fresli lymph
from the cow frequently, nliidi may be done by taking il annually,"
The Committee of the French Academy which reported in 1845,
also recommended, as a prudential measure, the frequent rvnewsl of
vaccine lymph, and resorting to the cow for this purpose.]
And now as touching re-vaccination. It is believed
bj many that vaccine protection may be renewed, as
we renew the lease of a house, every seven, fourteen,
and twenty-one years. By the physicians of Germany,
re-vaccination has been held up as a measure scarcely
less Important in its efTects, nor less widely applicable,
than primary vaccination, Tn France, on the other
hand, the repetition of the vaccine process has been
disparaged. A commission, expressly nominated to
investigate the matter, comprising some of the most
talented men in Paris, reported against re- vaccination.
The question is not easily decided for want of data,
which, in the very nature of things, can never be sup-
plied so as to insure a satisfactory result. Happily,
there is no occasion to press the cause to judgment
The operation, except in a few rare instances, is pro-
ductive only of slight and temporary inconvenience,
and may safely be reconmicnded.
If the resulting vesicles prove good, and the course
of the disorder normal, you have good grounds for
congratulating the patient upon the success of your
measure. In the larger number of instances, however.
290 RE-VACCINATION.
this will not happen. The vesicles will be small, the
areola irregular, and the benefit scarcely appreciable.
In a few cases, the process of re-vaccination occa-
sions considerable local distress, and some amount of
constitutional disturbance. I have seen extensive ery-
thema of the arm follow re-vaccination. DeUcate
young women of scrofulous habit of body are liable to
sufier in this way. It is the chief drawback to the
general adoption of re-vaccination in adult life.
The imperfect aid afforded by re-vaccination suggests
the question whether, in adult inoculation (between
the ages of twelve and twenty), we might not find a
better mode of testing and improving the security of
tlie vaccinated. Small pox, taken casually after vacci-
nation, proves fatal, as we have seen, at the rate of
seven per cent. Inoculated small pox proved fatal, in
former times, at the rate of only one fifth per cent, or
one iu five hundred. As regards the extension of small
pox from the practice of inoculation, no real danger
need be apprehended. The experience of ten years in
England has amply demonstrated that the difinsion of
small pox is wholly independent of such artificial j)ro-
pagation. Small pox has been as general in England
since inoculation was abolished as it was previously.
But it is as yet little known, that small pox may be
received into and pass through the system without pro-
ducing either fever or eruption. I inoculated three of
my own children at the respective ages of twelve,
thirteen, and fourteen, after successful vaccination in
infancy, and the result was as follows : — In two, local
affection without any fever or eruption. In the third
case, local affection without fever, but with papular
eruption on the seventli day, not advancing to vesicles.
RE-VACCINATION. 291
I firmly believe that these children are now, and will
remain through life, unsusceptible of smaU pox. The
advantages derivable from such a course of procedure
are these : — If the child's constitution be under the full
vaccine influence, no effect will follow. If the vaccine
influence be subsiding or altogether lost, then the small
pox will be taken at the period of Ufe (puberty) most
favorable for safety, instead of being received (as too
often happens under the present system) under circum-
stances the most unfavorable, — for instance, by mothers
at the period of parturition, by young women on the
eve of marriage, or by young men at a distance from
their friends. The state of the law in England pro-
hibits the practice here ; but I hope it will be tried in
other countries, where the judgments of medical men
are less fettered.
[For remarks on Re-vaccination, see Appendix M.]
294 HISTORY OF VARICELLA.
occurs in medical history until the year 1767, when Dr.
Heberben, in the first volume of the Transactions, pub-
lished by the Royal College of Physicians in London,
entered fully into the tlieory and diagnosis of varicella.
He adopted the notion, hitlierto unavowed by any
medical author, that variola and varicella are different
diseases. He brings forward very strong arguments in
(avor of this doctrine. His paper is long, and appa-
rently drawn up with great care and attention. But
Hoberden falls into many errors, and was obviously
ignorant of some essential facts bearing upon the patho-
logy of varicella. He merits our applause, however,
for having first distinguished varicella as the offspring
of a specific poison. The strange thing is that, with
this impression so strong on his mind, he should still
have calleil the disease variola pusilltB. It had been
named varicella three years before, by Vogel, in Ger-
main. The term varieella does not occur in Sauvages'
" Nosv^loi^v," published in ITl^S. His synonyms are
" wattT poek, petite verole volaute. verolette, variolae
lvmphutiou\ varii^he volatiea\" We mav be sure from
this that the term varieella did not come into general
use until after 1 770.
lleberdeu's memoir on chieken pox was long con-
siilered as the standard work on the disease. The
prineipal authors on a arieella in the present century are.
Frank, of Vienna, who wrote on it in ISOo. under the
title iM* reninhiirus Variolodes V» sieulosus : Willan, in
ISi'o. who has a ehaprer devoted to varicella in his
wvM-k on •• Vaeelue Inoeulation ;" Pr. Helm, of Kerlin.
lSOi>. a notiee ol* whose work is to he found in Cross's
" Aeeouut of the Variolous Epidemic of Xonvieh:"
Pr. Mohl. of Copenhagen ^1:^17', whose treatise is
DETAIL or ITS STHPTOHS.
295
entitled " Dc Varioloidibus et Varicellis ;" and lastly,
Dr. Thomson, of Edinburgh, who wrote on it in 1820,
and revived the exploded doctrine of its identity with
small pox.
And now I must give you a brief descriplion of this
disease, the true, vesicular, lymphatic varicella — the
hastard, flying, lymphatic, crystalline, or imperfect
variola of some authors. The defiuitiou of varicella is
as follows : — " A slight disorder, the offspring of a spe-
cific miasm, which, without initiatory fever, throws out
an eruption of vesicles, sometimes distinct, sometimes
confluent, which maturate in three days, and desiccate
into granular scabs, which speedily fall off Little or
ao fever accompanies the maturative stage, and no
secondary fever follows. The disorder chiefly prevails
among children, and occurs but once in life."
Varicella has a very short incubation, not exceeding,
as I believe, four days, certainly less than a week. Dr.
Heberden, in his Commentaries, mentions the case of
a lady whose two boys had varicella. On the eighth
or ninth day from the maturity of the vesicles, the
mother sickened for tlie same malady. He then
inquires whether this is the usual period of incubation.
This incubative period is always, so far as I have seen,
siknt, and so say Heberden, Plenck, and Bryce ; but
Dr. Willan, who is entitled to attention, says there are
often present, for one, two, or tliree days prior to the
eruption of varicella, languor, somnolency, a furred
tongue, a hot skin, a quick pulse, with some sore throat
and rheumatic pains. I cannot reconcile these state-
ments of Willan with the results of my own expe-
rience.
[In an epidemic of variccllii hi the Hospital Neclter (Puris) id
S96 PS0GRE8S OF THE ERUPTION
1643—14, accurately described by M. Deli>ecli, ha fixed tbe tnculxi
period at twelve dnp.]
The first thing I ever observe in varicella is the
eruptiou of vesicles, of the size of a split pea, being
simple elevations of tbe cuticle, or minute blisters, pre-
senting the appearance of the skin having been exposed
to a shower of boiling water. The parts chiefly occu-
pied by the eruption are the back and scalp. Tbe face
is not so universally the seat of eruption, as happens in
small pox. Nevertheless, at times, ibe face is exten-
sively occupied. The vesicles vary in shape. Dr.
Willan, who loved minuteness, wishes to distinguish
three kinds — the lenticular, conoidal, and globaie. I
cannot see these distinctions myself, and therefore I
will not attempt to teach them to you. The vesicles
are surrounded by a superficial and narrow areola.
They appear in successive crops for two or three days.
Wliile the new vesicles are forming, the old ones shrivel
and dry up.
[Careful exainination will show that the vesicles in varicella do pn-
Bcut tlieie three varieties of furin pointed out by Dr. Willan, and
admitted by later writei's ; but they may all be found in the Mine
indiridiiol at the same time, and therefore the difltinction is of no impor-
tAnce in a jtraclical point of view.
The vesiclea are sonK^iaines preceded by small, pale, roee-colored
spole, with little or no elevatiou, the color of which disapjiearG under
pressure of the finger, vliich are soon followed by elevations of the
epidermis. Tlie occurrence of auch spots has been denied by some,
but they have been pointed out by Ilatl^, and were psrticnUrly noticed
by M. Trousseau during an epidemic of varicella at the Ilospital Necker
(Fans), in 1843 and 1844.
Souietiincs, also, the vesicles enlarge to such an extent as (o resem-
ble true bullse of pemphigus. We have known the bulhe reach tlia
size of half a dollar, and even of a dollar ; and in one cas«. the excoria-
tioua left by several bullie wliicli had been rubbed, extended for 6vo
VARICELLA 00NTKA8TED WITH VARIOLA.
297
or sijc inches on the upper part of the back, iu an infant eij^ht montlis
and a hair old.]
On puiicturitig the vesicles, a clear Ij'mph, scarcely at
all mucilaginous, escapes, and the cuticle falls to the
level of the surrounding skin. There is no tumor, no
varus. If the vesicle remain unbroken for twenty-four
hours, the contained fluid becomes slightly opacjue.
They are very itchy, and when rubbed, a degree of
superficial inflammation may succeed, sufficient to con-
vert the lymph into an imperfect pus. The scabs of
varicella are very small, and as the lymph wants a
mucilaginous quality, they are granular. The desicca-
tion is very rapid, and in sl\ days the complaint com-
pletes the whole circle of its phases.
I once saw varicelloid vesicles occupying the throat.
The case was more severe than the common type of
varicella, and was accompanied by a light febricula.
Generally speaking, no constitutional symptoms of any
importance are present. The tongue is clean, and the
pulse unaffected. The aspect of countenance betrays
neither languor nor feverishness. The appetite is good,
and the sleep undisturbed. The complaint often shows
itself in schools, and mns through all the young mem-
bers of a family. It is manifestly both contagious and
epidemic.
Now, can tliis be a form of variola ? Observe the
marked difibrences between the two disorders. Vari-
cella has not the incubative period of variola. It has
not the character of variolous eruption. Children take
it almost exclusively, I do not say that adults never
take it. 1 have seen a few adult females attacked by it,
but it is a rare occurrence. This is not like variola.
But far and above all, it is taken indiscriminately by
298 VARICELLA CONTRASTED' WITH VARIOLA.
•
those who have and those who have not been vacci-
nated. Its course is not in the sHghtest degree ahered
by previously undergoing vaccination. It is now nearly
always taken after vaccination. Whether it was taken
equally after inoculation of small pox I cannot tell you
from my own experience, but I have the authority of
Sir Henry Halford for saying that it was ; and there
are few physicians now besides himself who can be
appealed to on such a point These general conside-
rations are of themselves sufficient to decide the ques-
tion of non-identity.
But if we examine the subject still more closely, we
find that the organization of the varicelloid vesicle dif-
fers from that of the variolous. I acknowledge to have
seen vesicles on the face, of a true varicelloid origin,
which in aspect and arrangement closely resembled
those of genuine small pox, but in the greater number
of cases, especially when the vesicles of the trunk and
extremities are examined, there is no uml)ilication, no
central depression, no division into cells, no slough.
There are simply partial elevations of cuticle, of irregu-
lar and undetermined arrangement. Here we see no
groupings into threes and fives, no crescentic or circular
figures formed. Everything in varicella is hurried for-
ward—the incubation, the eruption, the desiccation.
These things seem so clear, that you may naturally
be tempted to ask — how did the notion of identity ever
originate \ A reply to this question will lead us still
further into the consideration of diagnosis and general
pathology. There is a disease which resembles vari-
cella in its mildness, which really does arise from the
variolous poison ; and physicians, in former times, look-
ing only to the general, and neglecting the minute
DIAQNOSia OP VARICELLA AND VARIOLA.
299
anatomical characters of the erupdou, have thought
proper to confouod the two diseases. By way of dis-
tinction, we will call the one varicella vera ; the other,
variola varicelloides. I do not say that mistakes can
always be avoided. During the year 1842, a child
was admitted into the Small Pox Hospital, baviug
the incubative symptoms of variola, and the local
symptoms of varicella. 1 remain doubtful about this
case. Nothing but iuoculation with small pox could
clear up the difficulty. In most cases, however, the
diagnosis is clear enough. Let me enumerate the chief
features of each complaint.
la the true lymphatic varicella, there is no premoni-
tory fever. In the variola varicelloides, there are at
least forty-eight hours of preceding febrile disturbance.
In the varicella vera, there are no hard van or tuber-
cles. In the varicelloid form of variola, tuberculous
elevations of the skin are distinctly perceptible. In the
vesicles of the one, there are no central depressions ; iii
the other, central depressions can always be traced,
either by the naked eye or by the microscope. In the
true varicella, the crusts are granular, and quickly fall
ofl! In the variola varicelloides, the lymph being muci-
laginous, the crusts arc firm, adherent, and drop off, en
vimsc, at the end of six or eight days. Authors have
described pits as having succeeded true varicellons
eruption, but the occurrence is very rare. I have
never seen any case where the inflammation ran so
high as to admit of such a result.
Hitherto I have not touched upon a question which
you might naturally suppose would at once settle the
dispute — I mean, the question of inoculation. Can
varicella be communicated in ibis manner t The
300 INOCULATION OF VARICELLA.
question is more easily put than answered. Dr. He-
berden blinks it He does not say he ever saw inocu-
lation performed with the lymph of varicella, or rather
serum (for it is nothing else), but he says that mistakes
have been made in such inoculations, implying that the
disease is propagable in tliat mode.
Dr. Willau entertained the belief that varicella was
so communicable ; but his experiments are few, and, to
my mind, very unsatisfactory. I need not state them
to you, because, since his time, Mr Bryce, of Edin-
burgh, by more extended and careful observations, has
set the question at rest He states* that he has inocu-
lated with the fluid of varicella vera, at all periods of
the disease, and at all seasons of the year, children who
had never undergone either small pox or cow pox, and
yet that he had never been successful in producing
from it either variola or varicella. Since the date of
IJrycc's experiments (1816) I know of none on the
inoculation of varicella.
[In the epidemic of varicelhi at the Hospital Nocker in 1 843-44,
already referred to, M. Delpecli was unable to propagate the disease bj
inoculation.]
What, then, are the arguments which can be brought
forward in support of the doctrine of identity ? There
must be some, seeing that up to the date 1767, certainly
for lUOO years since the disorder was known, physicians
adopted that notion, which has even been revived in our
own times.
Dr. Thomson's great argiinients are these : — 1. Vari-
cella prevails when variola prevails, and never without.
Hence, says he, we may deduce the probability that
» s
ce " Thomson on Varioloid Diseases," page 74.
NOK-IDENTITY OF VARICELLA AND VARIOLA. 301
one contagion is operating, not two. The answer to
tliis argument is, that the facts are incorrectly stated.
Varicella frequently prevails without variola. Dr.
Mdbl has shown this most satisfactorily from the expe-
rience of the Copenhageu epidemics. From i809 to
1823, chicken pox was annually observed at Copenha-
gen witliout accompanying variola. Since 1823, both
diseases have prevailed epidemically, but the physicians
could always trace their sources, and this convinced
them that the generating miasms were distinct.
Besides, the doctrine goes for nothing, if it can be
shown, as has been shown over and over again, that
some children take varicella after cow pock, and olhers
cow pock after varicella, while some have cow pock
and varicella going through their phases at the same
time. I have published the details of a case of this
kind which occurred to me in 1837.*
Dr. Thomson's next argument is, that be had never
witnessed chicken pox in those who had undergone
small pox. I cannot imdertake to meet this objection,
because I see so few children who have undergone
variola ; and chicken pox is a disease of infantile life.
I strongly suspect, however, that here also the facts are
imperfectly known. All I can assure you is, that at
the Small Pox Hospital no difficulties in diagnosis are
acknowledged, save in a few rare cases.
It cannot be doubted for one moment, after reading
the details of this conlroversy in the works of Dr.
Thomson and elsewhere, that a very large proportion
of the cases of alleged secondary or recurrent small pox
are really cases of genuine lympiiatic varicella mistaken
• See " London Medical GbmiU," toL ii. p. G33.
302 HERPES.
for small pox. Several of even the most recent writers
on cutaneous diseases adopt Dr. Thomson's views, and
apply the term varicella to those milder forms of variola
called the modified and mitigated small pox. These
writers distinctly avow their belief that all forms of
varicella without exception are of variolous origin, and
each susceptible of propagation by inoculatioa With
such views, it cannot be a matter of surprise to any one
that the question of recurrent small pox should still be
so keenly agitated.
The treatment of varicella demands no comment A
little manna and magnesia, with abstinence from animal
food for a few days, comprise all that is essential.
HERPES.
This disorder may be thus defined: —
" An exantheiiia originating from obscure internal
causes, and not propagating itself by contagion ; cha-
racterized by partial clusters of phlyctcnae or vesicles,
which are surrounded by areola ; preceded and accom-
panied by fever, passing througli a regular course of
increase, maturation, and decline, and terminating within
a fortnight by small scabs."
Such a disorder was well known to the ancient Greek
and Roman physicians. The term herpes is derived
from the Greek g^^w, to creep. The phlyctenae which
characterize it derive their name from the Greek
(pXvxraiva, a bUstcr ; or (pXiw, to bubble up. The best
modern authors on herpes are. Dr. Willan, Dr. Bate-
man, and Dr. A. T. Thomson, whose essay you will
find in the " Cyclopaedia of Practical Medicine."
Nosologists have delighted to form species of herpes.
Five or six have been so enumerated. I shall be com-
SPECIES OF HERPES.
303
pelled lo instruct yoii in tlieir names, but you will bear
in mind tliat there is nothing palbologically important
in these subdivisions. They display merely the inge-
nuity of the nosologist. The leading variety of herpes
is that called zosler (from the Greek ^ue-rnp, a belt, or
^wvjfjinj, to girdle). By the vulgar in this country the
disease is familiarly called the shingles — a corruption
from the Latin cingulujii, a girdle. These deuomiua-
tions it receives from the peculiar seat of the herpetic
disorder, the waist, or rather, a circular line around the
belly, commencing at the navel. I know of no other
disorder which specially affects this portion of the
human body. All oiher cutaneous affections appear
on the face, the arms, the lower extremities, ihe scalp,
the back, the chest. Herpes zoster alone fixes on the
belly.
1. The eruption of herpes is preceded for several
days, sometimes for a week, by symptoms of general
constitutional disturbance, occasionally aggravated into
fever. Languor, low spirits, a succession of bad nights,
a failing appetite, and weakness of the limbs, betoken
some lurking disorder. Rigors and flushes, with a
white tongue, are sometimes superadded, but the febrile
symptoms, so far as my observations extend, never
attain any considerable height.
At length the eruption shows itself, and very fre-
quenUy the precise spot will be indicated by a previous
sensation of heat and itching, sometimes amounting to
actual pain. I have seen some cases with so little pre-
ceding constitutional disturbance, that the patient has
been startled by finding the abdomen occupied by
eruption. Inflammation first shows itself by the side of
the navel, followed by the rapid formation of vesicles in
L
304 CHARACTERS AND VARIETIES
clusters. These spread round the belly, generally (but
not invariably) from right to left ; and a vulgar preju-
dice teaches, that if they extend entirely round the body,
the patient dies. This may be said very safely, for such
an event is scarcely ever witnessed. The eruption
seldom extends more than half round the body. A
perpendicular position of the clusters is very rare.
Rayer tells us, he once saw this arrangement on the
thigh, but on the trunk of the body it is unknown.
Herpetic vesicles are about the size of a pea. The
areola surrounding them, which forms very early, is
often considerable. They attain their maximum ot
development in three, or at furthest, in four days. The
contained fluid is at first perfectly limpid, but before
desiccation, becomes opaque or semipunilent Dark-
colored scabs succeed, which harden and fall off in the
course of a week or ten days, during which time the
skin cicatrizes. A certain amount of feverishness
accompanies the maturation of the herpetic vesicles.
Some relief to tlie constitutional depression is afforded
by the development of eruption.
[Tho vesicles of herpes vary in size from that of the head of a large
pin to that of a pea, and sometimes reach a size much larger, by the
union of two or more at their edges.
The eruption sometimes commences on one side or the other of the
median line i)Osteriorly, and sometimes there and at the median hne ante-
riorly at the same time, the groups of vesicles then extending gradually
from each point of origin until they meet.]
2. Having thus made you acquainted with the fea-
tures of the chief form of herpes, I will briefly allude to
the other varieties of this affection. Clusters of her-
petic vesicles running the same course with that now
described sometimes appear on the chest, and extend
OF H£RPETia ERUPTION.
305
across the slioulder, in the usual direction of a sword
belt. They may also show themselves on the extremi-
ties. The course of the disease in such situations is in
every respect ihe same as that of the regular shingles.
Dr. Willan has distinguished this form of herpes by the
spec)6e term pk/i/ctanodes.
3. In some cases die vesicles which appear on ihe
arms, shoulders, neck, temples, and groin, assume an
oval, or sometimes a decidedly circular shape. These
are called herpetic ringworms. Sometimes there shall
be one such, sometimes many. To this variety of
herpes the term circinntys is applied. This form of
herpes is seldom accompanied hy any cognisable con-
stitutional disturbance. The vesicles are very small,
and they include a portion of unaffected skiu. The
complaint, if so it uiay be called, runs its course in
eight or ten days, but successive crops of vesicular rings
may procrastinate recovery. Though called a ringworm,
you will remember that this affection is not contagious,
like the true ringworm of the scalp (porrigo scutulata).
4. The term herpes iris has been appropriated to
those forms of herpetic vesicles which forui on the hack
of the hand, and arc characterized by the phenomenon
of concentric circles of vesicles of different colors, yel-
low, brown, dark red, and light red, corresponding to
tlie period of inflammation in each successive crop.
Their form is generally oval. The iritic form of herpes
may display itself on other parts, but always where the
skin is near the bone.
5. The fifth variety of herpes is the herpes labialis.
Here the seat of eruption is the upper lip. It is a fre-
quent attendant on common catarrh, but sometimes also
appears as an idiopathic affection originating from cold
L
306 SOURCES OF HERPES.
and fatigue, and is then preceded for a day or two, by
languor, lassitude, nausea, perhaps vomiting, and head-
ache. I have seen it extend round the whole mouth,
accompanied by such tumefaction that speaking and
swallowing were exceedingly painful. The variety of
herpes termed praeputialis belongs to surgery.
The sources of herpetic fever and eruption are now to
be considered. This complaint invariably has its origin
in irregularity of one or more of the non-naturals, which
you will recollect to be, air, aliment, the secretions —
sleep and watching, exercise, and mental anxiety. Any
irregularities in these will, in certain constitutions, give
rise to an attack of herpes. Let me give you a few
illustrative examples.
A gentleman, accustomed, in his native county
(Yorkshire), to great regularity of life, came up to Lon-
don to engage in parliamentary matters. He sat till
late at iii{;ht in the heated gallery of the House of
Coiiiinoiis. He had his meals most irregularly, some-
times dining in the forenoon, sometimes not till nine
o'clock at night. His sleep was broken, and his mind
harassed. After about a fortnight of this system, lie
became languid and oppressed. Herpes zoster, fully
developed, came to his relief, and in little more than a
week he was restored to his ordinary condition of health.
A young lady (Mademoiselle Missonicr) came over
from France to England some years ago. She had a
very bad passage. The hatches were closed. The air
in the cabin was stifling. Heat, anxiety, change of air,
change of diet, change in her habits of Hfe, conspired
to disarrange the young lady's whole system. Herpes
labialis in great severity succeeded, on the disappear-
ance of which her health speedily returned.
CAUSES OF HERPES.
'In January, 1824, Mr. Simpson, one of my earliest
papils, passed tbrough a severe form of low fever. At
the end of the tiiird week, herpes labialls appeared, and
coniiniied so long, and proceeded to such an extent,
that for many days he could not speak Dor protrude
his tongue, and hardly could he swallow enough to
support life. His aspect was hideous. The saliva was
so offensive that it could not he swallowed for more
than a fortnight. It yielded at Icugtii, and subsided
much quicker than could have been expected — in about
six days. No medicine appeared to exert the smallest
influence over it.
We ujay enumerate the following, as some of the
most usual sources of herpetic affections : — 1. Confine-
ment to a hot and crowded room (defect of air) ; 2.
sudden changes in the mode of life (irregularities of
aUinent) ; 3. in infantile life, dentition ; 4. at all ages,
prior disease of a catarrhal, bilious, or typhoid kind.
With reference to causes, I would add that in its
most perfect development, herpes occurs chiefly among
adults. Children often display clusters of herpetic
vesicles on the hand, arm, or below the ear, but seldom
in any notable intensity. Herpes occurs more fre-
quently in warm than in cold seasons. It attacks
chiefly those of fine and delicate organization of skirt
It is therefore more common in women than men. A
disposition to herpes is hereditary ia some families. In
the London Medical Gazette (vol. ii. p. 632) will be
found a brief notice by me of a family named Swin-
burne. The grandfather, nncle, and nephew, had each
experienced an attack of herpes zoster. The boy had
it at the early age of nine. It was strongly marked,
affectiag the thorax, and extending from left to right
308 MILIARIA :
The treatment of herpes is very simple. In children,
during the process of dentition, an eruption of herpetic
vesicles is critical and salutary. So is the herpes labialis
vvhich succeeds catarrh. Hence we may estimate the
value of blisters in several forms of infantile feverish-
ness, of catarrhal and gastric fever. It is often impos-
sible to repress herpes, and if it were possible, it would
be highly injudicious.
Herpes zoster is to be treated by gentle laxative
draughts, containing senna, magnesia, and its sulphate.
Whenever herpes or any other febrile eruption is
attended with much itching of the surface, magnesia is
a useful remedy, for this itching indicates acidity acting
on the denuded coats of an irritable stomach. A mix-
ture of magnesia, mucilage, and the liq. opii sedativi,
allays the uneasy feeling. You may direct, at the same
time, a camphorated Saturnine lotion, which cools the
part. Cold cream is a convenient means of allaying
irritation. The black wash may be employed to the
herpetic vesicles so often observed in infantile life.
MILIARIA.
The history of medicine presents few chapters so
discreditable to physicians as that which is devoted to
miliaria. It would certainly be to our credit to pass it
over sub silentio^ but it is right that you should know
something about it, and about the controversies to which
it has given rise.
Some obscure allusions to miliary eruptions may be
traced in the writings of Hippocrates, but the term does
not occur there, nor, in fact, is it anywhere to be met
with until the middle of the seventeenth century, the
period which I have aheady mentioned to you as
ITS EARLY HISTORY.
309
famous for the perfection to which medical art had
brought the healing, or alexipharmic mode of treating
fever. About that period, some German writers de-
scribed certain epidemic fecers having miliary eruption
for their distinguishing character. These epidemics
happened in 164:8, at Lubec ; in 3652, at Leipsic.
In 1710, Sir David Hamilton, physician to Queen
Anne, published a regular treatise on miliary fever, the
English translation of whicli extends to 256 pages, and
makes a goodly octavo volume. Later in the eighteenth
century, it attracted the attention of Dr. Fordyce, in
London, and of physicians in various parts of the
continent, among whom may be mentioned, Allioni,
Fantoni, Walthier, and Gastellier. 8auvages, in his
"Methodical Nosology" (1768), devotes eleven quarto
pages 10 miliaria, and only eight to variola! In 1760,
De Haen, then practising physic with great success at
Vienna, attacked the miliary doctors, and being himself
rather fond of controversy, continued his attacks upon
them with increasing severity for many years.
De Haen labors to prove, and certainly to my mind
succeeded iu proving most satisfactorily, that there is no
, form of fever which has miliary eruption for its specific
or distinguishing feature. "Miliary eruptions," he says,
" are, like petcchisp, accidental occurrences in the pro-
gress of fevers, which may be encouraged by certain
modes of treatment, and diminished or entirely pre-
vented by others." He shows up the inaccurate obser-
vations and the loose reasoning of physicians concerning
miliaria during the preceding hundred years, without
the smallest mercy.
Notwithstanding these cutting criticisms of De Haen,
authors continued to write about specific mihary fevers
I
310 PHENOMENA OF MILIARY ERUPTION.
for many years afterwards. Pujol described with great
minuteness an epidemic miliary fever which prevailed in
Languedoc in 1782. Since the present century set in,
however, miliary fever has been at a discount. I know
of nothing written on it in this country, but Rayer has
detailed the particulars of an epidemic miliary fever
which pervaded the department of the Oise (Normandy
and Picardy) in 1821. The disease is duly noticed in
all our systematic works. You will see it ably described
in Dr. Craigie's work "On the Practice of Physic,"
and in the " Cyclopaedia of Practical Medicine," by Dr.
Tweedie.
It is greatly to the honor of Sydenham, that he never
fell into the fashionable theory of miliary fever. He
was aware of the occasional appearance of miliary vesi-
cles, and of their causes, and he alludes to them espe-
cially in his sketch of the fevers of 1685 and following
years ; but it requires a careful study of his works to
detect even this incidental mention of them.
I now proceed to describe briefly (for I need not do
more) the phenomena of mihary eruption.
The first appearance of miharia is preceded by fever,
with redness and roughness of the skin, especially on
parts covered by the bed-clothes — the chest, belly, and
thighs. After a time, the skin thus affected exhibits
innumerable minute confluent vesicles of the size of
millet seeds (whence the name, iiiiliuni), of a pearly-
white color. Now and then small blebs, of a size
superior to the common miliary vesicles, are seen inter-
mingled with them. The duration of the eruption is
uncertain, being, in point of fact, determined by the
treatment pursued. Authors generally allowed a week
for the continuance of the eruption, and state that it
APPEARANCES OF MILIARY ERUPTION.
thea terminated by thin crusts, with general desquaina-
tioD of the cuticle.
The symptoms which by the authors of tlie seven-
teenth century were considered as the initiatory signs of
miliaria were, sighing, oppression of the pr^cordia, rest-
lessness, jianting of the breath, jactitation, cramps, sub-
suhus teiidinum, and a sense of fulness and faintness.
"I knew," says Sir David Hamilton (describing the
case of Mr. Bullock, August 8, 1700)— "I knew, by
the oppression of the breathing, and the languor and
faintness of the spirits, that this would end in a miliary
fever." It is scarcely needful to apprise you, that these
symptoms indicated congestion of blood about the lungs
and great vessels. The miliary eruption is accompanied
by a pulse always rapid, and generally small. Some-
times, however, we read of a hard, irregular, and inter-
mitting pulse, co-existing with a crop of miliary vesicles.
The tongue is often clean and moist. Much thirst is
usually present.
Mihary eruptions (termed by the old authors suda-
mina) are always associated with a moist state of the
surface, and the odor of the sweat is singularly rank,
offensive, aud acid. This is tlie clue to the theory of
mihary eruption. It never appears under a cool treat-
ment, or with a cool condition of surface ; but it may
appear in any fever where the surface is either naturally
very hot, with a strong and full action of the heart and
arteries ; or where such a condition of surface is
brought on artificially, either by sweating drinks, or by
sdmulating medicines, or by superabundant bedclothes,
or the excessive heat of the weather, or the great exer-
tions of the patient To give you some examples : —
1. Miliary eruptions have always been observed in
312
APPEARANCES OF MILIARY ERUPTION.
the l^ing-in room. To this three things contribute:
the exertions of the woman, the closeness of the cham-
ber, and llie caudle whh which the officious nurse siip-
phes tlie object of her care. Tlie febris pucrperarura
miharls is described by Hoffman, and all the writers of
that day (17(J0). It is still occasionally seen under the
same circumstances.
2. Miliary vesicles occur occasionally in the early
stages of ail fevers whose natural tendency is to dcve-
lope eruption. They are obsened, therefore, and have
been already noticed, as accompaaying the outbreak of
small pox, measles, and scarlatina, and that witliout the
additional aid of beating or forcing medicines.
3. Miliary vesicles appear in the progress of all
fevers treated by sweating remedies. You will remem-
ber that it was In 1640, when this method of managing
fevers had attaiued its acme of absurdity, thai miliaria
first attracted the special attention of physicians. The
most complete and universal eruption of miliaria which
I ever saw was in the case of a young man, aged
eighteen, laboring under acute rheumatism. His first
medical attendant had enveloped his body in folds of
flannel from head to foot, giving him very much the
appearance of a mummy. When I took charge of the
patient and unrolled this living mummy, the most
superb crop of miliary vesicles was displayed which I
bad ever seen, or ever expect to see again. The effect
of such local treatment, and of tlie guiacum, camphor,
and Dover's powder, which formed so prominent a part
in the old treatment of rheumaiic fever, is not only lo
drive the blood to the surface, but to gorge the large
vessels of the lungs. Hence the dyspnoea. Now, if
the blood is detained in the lungs and the cutaneous
CAUSE AND TREATMENT.
capillaries, it cannot be in tbe heart. The supply of
blood to the heart, therefore, is iuiperfect, and hence
the fainting which made Sir David Hamilton know
that his patient was going to have miliary fever. Cool
the skin, and the tendency to faiiitness goes ofF, because
the blood is then driven towards the heart. Upon this
principle you treat a young woman who has fainted at
church, wlien the congregation and the gas-hgbts are
aUke numerous.
When miliary eruptions occurred in the progress of
typhus fever, it was generally remarked tliat they ap-
peared about the tenth day of the fever, and declined
about the eighteenth. All authors agreed that no criti-
cal days were perceptible. Sometimes fresh crops of
vesicles would appear and protract recovery.
Attempts have been made to propagate nnliaria by
inoculation, but, as you might anticipate, without eflecL
Miharia, then, is cbieily an artificial exanthema. I
will not say but that fevers may exist which have
a greater tendency than others to develope miliary
vesicles, but the idea of a purely miliary fever is now
abandoned.
The cure of tbe complaint need not detain us long.
Tbe cause is, superabundant warmth and too violent
action of tbe heart and arteries. When, therefore, you
chance to meet this disorder, banish from your thoughts
whatever you may have read as to the danger of sup-
pressed eruption, and have no scniples about repressing
it Throw off superfluous bedclothes, admit cool air
into the apartment, refresh the skin by tepid abhition,
provide the patient with cool, subacid drink, exhibit a
mild laxative, and withdraw all stimulants. You will
not then long be troubled with miliary eruptions.
314 PEMPHIGUS AND POMPHOLYX.
PEMPHIGUS AND POMPHOLYX.
These terms designate such forms of cutaneous dis-
ease as are characterized by the appearance of large
vesicles, blebs, or bullae. Three varieties of bullous
disease have been described, viz. — the acute pemphi-
gus, the chronic pemphigus, or pompholyx, and the
infantile, or gangrenous pemphigus. None of these are
common, but the most frequent is the chronic variety,
which I may begin by noticing.
1. Chronic pemphigus, called also pompholyx, exhibits
a succession of blebs on different parts of the body, with
very little surrounding inflammation. No fever is pre-
sent, and in many cases the evidences of constitutional
sympathy are few and obscure. It is chiefly met with
in the aged, and in those whose constitutions have been
brought below par by debilitating causes, such as low
diet, fatigue, anxiety, intemperance, residence in damp
situations, diseased liver, or some other form of visceral
disorganization. It is always symptomatic of a weak-
ened, and very often of a broken down constitution. I
saw a remarkable instance of the complaint many years
ago in a woman seventy years of ago. Her face, arms,
thighs, and buttocks were occupied by numerous blebs,
of the size of walnuts. Their usual aspect was trans-
parent, but some were livid, and these, when broken,
displayed a dark subjacent corion. She died in the
course of a few months, deriving very little benefit from
the plans of treatment which I had adopted. It
appeared to me to be pathologically allied to erysipelas;
to be, in fact, an erysipelas erraticum, solitary blebs
taking the place of the usual diffused inflammation
with phlycteUcE or blisters.
PEMPHIGUS GANGRENOSUS.
315
The treatment of chrooic pompholyx is neither well
established nor very satisfactory I have seen blood
drawn from the arm without either benefit or aggrava-
tion of the symptoms. A warm bath is a good pallia-
tive. Dr. Batcman praises bark, cordials, and diuretics.
Sarsaparilla would naturally suggest itself as an appro-
priate alterative and tonic.
2. Dr. Bateman did not acknowledge the existence
of any form of fever sufficiently marked to merit the
title of acute pemphigus, but the old authors describe a
fehris bullosa, and a few modern pathologists have done
the same thing. The acute pemphigus is described as
throwing out its peculiar eruption after a varying num-
ber of days of fever. The abdomen and lower extre-
mities are the usual localities. The subjacent corion,
when exposed, appears red and tender. The disorder
raay last a week, or be protracted to a month. It is
occasionally associated with gastro-enteric irritation and
an aphthous state of the mouth. It is scarcely con-
sistent with sound pathology to view this otherwise
than as an accidental complication of bultse with dysen-
tery or typhus. As such it ought to be treated,
3. The pemphigus gangrenosus of infajits has been
ably described by Dr. Whitley Stokes in the Dublin
Medical and Physical Essays. It is chiefly met with
in children under five years of age. It commences
withont fever. Numerous blebs and vesicles appear on
the skin, succeeded by sores, discharging a thin ichor.
Sloughy ulceration destroys the skin and neighboring
textures, and speedily exhausts the already weakened
child. The chief seals of the blebs and sores are the
ears, mouth and lips, hands and feet, the genitals, breast,
and belly. The disorder prevails more in winter than
I
316
in summer, and affects those especially who reside in
datup localities.
It is obviously a disease of the same nature as the
cancrum oris that succeeds measles. It is brieSy
I alluded to by Dr. Bateman under the title of Rupia
' esckarotiea. Its treatment must be conducted on the
principles applicable to gangrenous affections occurring
in exhausted habits.
Tills disorder is known in Ireland by the name of the
Hives, and it would appear from the population returns
that a large number of children in that country die
annually from such a disease.
I
sai
LECTURE Xin.
TUE NON-CONTAGIOUS EFFL0KE8CENCES.
lioliea. Il£ charecteri and chief varieties. Lichen ftbrilU of odalta.
IKagnosis of lictienoua nnd variolous crnplion. Lichen febrilia of chll-
dreti. VnrietieB of strophulus. Syphilitic lichen of adults. Lichen
trofMcus, or pridiiy heat Urticaria fpbrilis. Its chnnictera and cHuaea.
Roseoln. Its sevenil varietteB. Roseola exnnthemntica. Erythi'Dio. Its
relation to roseola and erysipelas. Notice of llic xcveral vnrieliea of
erythema. Character, coarse, and treatment of the erythema nodosum.
PaUiologienl connexion of fever, efflorescence, and Hpecilic cxaiithem.
Conclusion.
We come now to llie consideration of tliose forms of
febrile eruption wliicli are not associated witli actual
inflammation of the corion, and conseqaently exhibit
no traces of fluid efi'usion. We call them the siniple
efflorescences, and they have for their coniniou patholo-
gical feature a more than average supply of blood to
the cutaneous vessels. They are four in number : —
lichen, urticaria, roseola, erythema.
The term \i,^-^<, was introduced into medical litera-
ture by Hippocrates, who applied it to designate a
species of chronic tetter, the precise nature of which is
unknown. Since the adoption of Dr. Willau's system
of cutaneous nosologj-, lichen is appropriated to an
eruption (sometimes attended, sometimes unattended,
by fever) consisting of small elevated papulse, which do
not run into vesicle or pustule, but terminate by scurfy
desquamation. Such a disorder acknowledges various
I
S18 OBAKAOTBM AND ▼ARIBTIB8 OF LIOHBH.
causes, and occars under veiy opposite conditions of
the body. It is not contagions, is dependent on no
miasm, and may recur frequently to the same indi-
viduaL
Such is the definidon of lichenons eruption. Dr.
Willan has introduced into his work a great variety of
species of the genus Bchen — viz. the lichen simplex^
agrius^ circumscriptus^ pilaris, lividus^ urticatus, and tip-
|MC08. Every trifling alteration in the appearance of
the eruption has been magnified into importance, and
beat made the foundation of a species. I cannot see
the utility of these learned minutie. When the difier-
ences are such as indicate important distinctions in
pathology, or affect materially the treatment, they may,
and indeed ought to be adopted, but not otherwise.
]. The first kind of lichen that I shall describe to yon
b the lichen febrilis of adults.
This complaiut is cue of the most frequent sources of
difficuhv and error iu exanthematic diagnosis. A modi-
fication of febrile lichen, perhaps the disorder itself, is
called bv some ** rubeola sine catarrho.*' Lichen is fre-
queutiv mistaken for true measles, and almost as often
lor small pox. Not a vear passes over without our
Kc^iviu^ at the Small Pox Hospital, three or four
patieuts having this form of febrile eruption ; and, to
cwiliess the truth. I have myself, in former times, mis-
taken the compfaunt for small pox
Lichen tietwihs affects chiefly adults. Its familiar
diw^natMa u^ a smfi^. Its most usual cause is, sudden
«ipwtti^ lo coM when the body is perspiring proftisely.
Hmc^^ bv 6ur the most frequent subjects of it are cooks,
wW in their nsaal callings, are suddenly taken Irom
l^faf 1^ hi|p Christtnas fire to a cold scullery or a
damp coal cellar. But lichetiouy eruptions display
tlieuiselves wliere the same cause cannot he traced.
We are justified, therefore, in concluding that other
"vices of the non-naturals" (to use the language of our
professional forefathers) may occasion iichenous fever
— such as irregularities of exercise, sleep, and diet.
Modern pathologists concur in attributing a large pro-
porlion of such cases to disturbance iu the gastric and
hepatic functions, and there can be no doubt but that
the skin sympathizes largely iu the morbid affections
of the liver aud stomach. The old authors were fully
alive to the importance of this doctrine, and mentioned
the vitiu secretorum et excretorum as leading to lichen.
An eruption, truly Iichenous in its character, is frequently
associated with typhoid fever. It is perhaps the most
constant of all the evidences of secondary syphilis.
Febrile lichen has an incubative stage of twenty-four
hours only. This is the great secret by which to effect
the diagnosis of lichen from the greater exanthemata
(small pox and measles). There is here the same lan-
guor and lassitude, the same sickness, restlessness, debi-
lity, and loss of ajipetite, the same confusion of intellect,
and general diminution of secretion, which characterize
eruptive fever under other circumstances, Lichenoua
eruption usually appears over the whole surface of the
body at once. I have seen it in the course of twelve
hours as vivid on the lower as on the upper extremities.
This happened to me, to witness, on one occasion, in
consultation with Mr. Money on the case of a young
woman who had travelled up by railway from Birming-
ham. The confusion prior to her journey, and the heat
during and succeeding it, had, in common parlance,
healed her blood. The result was, a sudden and severe
320 DIAGNOSIS OF LICHENOUS ERUPTION.
burst of febrile lichen. A few days of rest restored the
system to its normal condition, but in the meantime
great alarm had been taken in the fashionable hotel at
the west end of the town in which she was lodged,
under the persuasion that confluent small pox had
broken out there.
The eruption of febrile lichen is sometimes nearly as
vivid as that of scarlatina, but generally it is of the
darker or venous color, characteristic of rubeola. Some-
times its color is so deep as to induce nosologists to
dignify the occurrence by the name of lichen lividus.
The eruption of lichen is decidedly j^apuli/orm. Ele-
vations of the skin in the form of pimples, close set, or
confluent, and very extensively difiused, can be per-
ceived. The eruption is accompanied by considerable
itching. Its usual course is as follows. On the second,
or at furthest, the third day, it fades. The associated
fever diuiiuishes. The patient expresses a desire to get
up, and in less than a week is again at her ordinary
employments ; I say, her employments, because the
disorder is so much more common in females than in
males.
The diagnosis is to be effected — 1. by inquiry into
the prior history of the patient ; 2. by the shortness of
the incubation ; 3. by the character of the eruption ; 4.
by a comparison of the quantity of eruption with the
intensity of the accompanying fever. The eruption,
from its amount, would perhaps suggest the idea of
small pox, but the fever necessary to develope so much
variolous eruption would not correspond with that
which would be present in a case of Hchenous eruption,
however full and confluent
Lichen febrilis is a disease of no danger. It arises
LICHEN FEBRILIS OF CHILDREN. 3S1
from causes not affecting any of the great organs essen-
tial to life. It therefore never appears in the tallies of
mortality. A few doses of opening medicine, low diet,
and some saline draughts, include all that 13 essential
with regard to treatment.
2. Lichen febrills of children. During the process of
teething, and again when under process of vaccination,
still more frequently when these two processes are
going on simultaneously, children are very liable to be
attacked with lichen. The complaint, as it occurs in
infantile life, is called strophulus Iiy most authors, bat
the character of the eruption is simply lichenous. some-
times with, sometimes wirhout, sympaihetic fever.
Strophulus — the red gum or infantile lichen — has been
split and subdivided by the cutaneous nosotogists into a
variety of species, the specific differences being some
accidental and unimportant shade of color, or unusual
mode of grouping of the papulie. It will be sufficient
to have merely enumerated them. They are — stro-
phulus interiinctus, albidus, confertus, volaticus, and
candidus. Many cases of strophuhis are compatible
with a good state of health, and really require no medi-
cal treatnienl wliatever.
When lichenous eruption arises in the infant from
the vaccine poison, it usually shows itself on or after
the eighth day. It is most common in the warm
months of the year, and in children nourished on a
good breast of milk, and full of blood. But peculiaritjr
of habit will suffice to develope it in some children
without such contingent circumstances. It frequently
occasions great uneasiness to the parent, who is
impressed with the belief that her infant has taken
small j)ox, or been vaccinated from an unhealthy child
322 cHEomc lichkii.
or cot with a fool lancet None of these nodons are
ibaoded in reason. Vaccine lichen may continne to
show itself for ten dajs. It then gradaallj sohsides,
especially with the aid of a little aperient medicine. A
powder cootaioiog ooe grain of calomel with five of
jalap and five of rhabarb, may be divided into foor
parts, of which ooe should be taken daily.
3. Licheo cfaronicns syphiliticus. The third variety
of lichen is that which attacks adults in a chronic form,
as the secondary offspring of the venereal poison. To
describe the appearances of venereal lichen is the doty
of the lecturer on surgery. I have no wish to poach
upon his manor, but as the diagnosis of exanthematic
affections may be materially aided by your knowledge
of lichen syphiliticus, I may tell you briefly the princi-
pal points in its history. This variety of lichen has its
chief seat between the shoulders, and it sometimes
extends over (he whole back. It is often accompanied
by, or alternates with, syphilitic iritis, or syphilitic
affection of the throat. It is rarely, if ever, associated
with fever. It is very chronic in its nature, often per-
sisting for three weeks or a month. I have known it
to continue for upwards of a month, especially where
no remedial measures are adopted for aiding the elimi-
nation of the poison. This kind of lichen is much
benefited by gentle doses of blue pill, and decoction of
sarsaparilla with hydriodatc of potassa.
['1'Ih- j'jij'ular form of sy|'liilitic cnijili.jn is also vt/ry fn'qucnth' seen
on the linihs, of which it iin)st commonly occiijties the external surfaces,
«nd is very rarily found on tlie cliest or <ni the abdomen.]
These are the three varieties of lichenous eruption
chiefly observed in this country. It remains that I
notice one other, exceedingly common in hot climates.
where it is known hy the name of the pr'tchly lient.
From nosologists it has received the appropriate name
of lichen tropicus.
All Europeans, on (heir first arrival in a tropical
climate, suifer more or less from this affection. It is
the direct effect of the burning rajs of a vertical sun
upon the tender and irritable white skin, unprotected
by a rete mucosum and its black pigment. Many con-
tinue to suffer iVom it in spite of acclimatization. We
can sometimes trace, even in this climate, during the
months of July and August, an approach to the lichen
tropicus. The character of the eruption is purely
lichenous — that is, papulae elevated, hut not advancing
to fluid effusion. The great peculiarity of lichen tropi-
cus is the intolerable pruritus or itching wliich accom-
panies it. All that we see of the itchiness of lichen in
this country gives hut a faint picture of the miseries
endured by the unhappy European suffering under
lichen tropicus in the East Indies, especially when the
cutaneous circulation is e.vcited by such exercise as
brings out perspiration, by drinking wine, or even
laking hot soup at dinner. The sensation is a horrid
compound of heal, tingling, itching, and pricking. The
cold bath rather aggravates than appeases the sufferings
of the patient, especially during the glow that succeeds
the immersion.
We have the liigh authority of Dr. James Johnson
for saying, that until the constitution liecomes assimi-
lated to the climate, the only thing that can he done is,
to use light ciothhig ; to he temperate both in eating
and drinking ; to avoid all exercise in the heat of the
day ; to keep the bowels gently open ; and to resist,
with stoical flrmness, the disposition to scratch.
J
334 VRTICABIA.
[An analogoiM form of eruption is very conitnon here daring Uie
CECes»iTe bent of our xnmrner months, nnd >a quiu mild, being attended
with but very Utile itching, and rarely leading those who have it to
•eek toi medical aid. It occurs chiefly on parts expoccd to the sun.]
URTICARIA.
The febrile nrticaria, nr nettlerasb, is an exanthema
usually of a very niilii or benignant kind, possessing the
following characlers ; —
It displays elevations of the onter surface of the
corion, of considerable extent, and usually of a circular
fonn, of a wbite color, to which the term wheals b
popularly applied. These eminences, or wheals, are
aometimes persistent, but more commonly they fade
during ihe day and return with the return of night.
They are always attended with troublesome itching,
and the alfecied parrs are hot. The accompanying
fever is sometimes severe. Sometimes little or no con-
stitutional affectiun is perceptible. It occurs to persons
of all ages, and acknowledges several sources, but has
DO origin from miasm.
Urticaria, like lichen, has been a favorite complaint
with uosologisis. Every minute deviation from the
ordinary character of the eruption has been tbe signal
for the creation of a fresh species. I know but of two
Kinds of urticaria, the acute and the chronic; but Dr.
Willan gives iis no less than six. The chief source of
the disease is to be found in some peculiar irritabiliiy
of the skin. Those who once suffer from it are liable
to it again and again. In such a condition of tbe sur-
fece, tnaiiy causes suffice to bring on an attack.
1. The simplest form of uriicaria is that which arises
from tbe local application of nettles. Uence tbe name
-'' CRTICARIA FEBRILla. 325
— urlica, a nettle. Some animals of the uiolluscous
kind have a like effect apon the skin.
2. The acute or febrile urticaria is a wpII marked
variety of exanthema, of which, in the course of my
life, I have seen several striking examples. The incuba-
tive stage is short, and presents no pecuhar characters.
This eruptive ailment is attended with const iiutional
excitement, or fever, much more intense than the
nature of the exanthem would lead you to expect
The heat o( skin is often as great as in scarlatina.
The pulse is active. Delirium and other evidences of
constitutional disturbance are souietimcs met with.
Dr. Elliotson first taught me tlie necessity of taking
blood from the arm in severe cases of febrile urticaria.
The blood will be found highly cupped and budy,
evidencing the inflammatory nature of the disorder. I
have followed the practice with great advantage, and
strongly counsel you to pursue the same line of treat-
ment. On several occasions I have tried to do without
it, and have failed. The itching and heat accompany-
ing febrile urticaria are great sources of discomfort
They admit of partial relief from the use of the decoc-
tion of bran, with a little spirit of rosemary. Purgalive
medicines are useful, but it is better to draw blood
moderately from the arm, than to attempt to subdue
any considerable amount of iaflammatory fever by pur-
gatives alone.
I know nothing of the immediate causes of the febrile
urticaria different from what I stated with reference to
the acute forms of herpes and hchen. Any notable
deviation from (he ordinary course of life may end in
an attack of acute urticaria. Severe exercise, exposure
to cold, a draught of cold water taken when tlie body
kb
SfM- 0AUBB9 OP NBRILB URTiqABU.
i%overbeate4 may prove an exciting cause* AH thff
more urgent cases of orticaria, therefore, occur in per^
sbns between the ages of fifteen and twenty-five, but
other periods of life are not exempt firom the malady* .
The vaccine poison, when developed in great aboiH'
dance in a plethoric child, has brought out urticaria^
with some fever. Certain articles of food will produce^
in particular habits, where the skin is irritable^ an
ephemeral feverishness, daring which an * urticarial
exanthem shall display itself. Almonds, or pnisrie
^ciA in any ^ape, has this effect on some ; lobsten^
shrimps^ and certain other kinds of shell-fish, on othenn
Cucumbers, vinegar, cayenne pepper, honey, mush-
rooms, and other vegetable substances not possessing
apy particular noxious principle, will have a like effect
on a third class of persons.
This latter kind of urticaria is very evanescent A
gentle emetic, followed by a mild laxative, su£Bces for
its cure.
3. A chronic form of urticaria has been observed, in
which the eruption appears and recedes alternately for
a great length of time, without fever or any perceptible
derangement of the general health. It probably arises
from some irregularity of diet, such as over-indulgence
in wine, or food of too stimulating a quality. According
to the permanence, extent, or firmness of the wheals,
tlie disorder is denominated urticaria evanida, perstans,
conferta, snbcutanea, or tuberosa.
In all these chronic forms of urticaria, warm baths,
restrictions on diet, with the use of magnesia, or other
simple laxative, are generally found adequate to effect
a cure.
VARIETIES Oi' ROSEOLOUS RASH.
ROSEOLA.
The term roseola is appropriated to a mild rash of.
a rose color, appearing in patches of Irregular shRpe,>
without any pimples or perce[itible elevation of the
corioD. This disorder is accompanied by a light
evanesceot febricula, and is not contagious.
Little need be said concerning a disorder which,!
except as it may lead to mistakes in diagnosis, wouldt
hardly be reckoned worthy of notice. On that ac-*
count, however, the circumstances under which ij'
appears deserve some attention.
1. A roseolous eruption occurs in the hot months of
le year, and occupies (as roseola generally does) ihrf
;e and upper parts of the body. It is called ihft
iseola sestiva, and if accompanied by any affection of
,e throat is probably a mild variety of scarlatina.
2. I have occasionally seen roseola in females of ple-f
thoric habit and irritable temperament. In them, a
little extra exercise, an additional glass of wine, nay,
sometimes emotion of mind, will throw out a roseoloutf
rash over the neck and bosom. Such women may bel
said to blush, not only with the checks, but with th«
whole upper part of the body.
4. A roseolous rash occurs often in children in coa<-'
nexion willi dentition (roseola lufantilis).
5. The most Important of all the varieties of roseolft-
is the roseola exanthemalica, or variolosa. It happetu
occasionally that after one, two, or three days of fever,
a roseolous rash is suddenly tbrown out over the face,
neck, arms, and back, in irregular patches. In some
cases, this eruption assumes the aspect of scarlatina.
On the second or third day from the appearance of this
LUIS ^^_
328 ROSBOLA bxanthbmatica;
rose-colored or scarlet rash, pimples display themselves
in the very midst of these patches. These gradually
advance, and in three days more show the depressed
centres of variola. The occurrence is very annoying
in practice. The physician first pronounces that his
patient has fever. Two days afterwards he changes
his note, and informs the friends that the patient,
besides fever, has the roseola, or rose-rash, an affair of
no cousequence. Two days after that, he announces to
the astonished listeners that the patient has small pox !
This once occurred to myself in consuhation with Mr.
Hammond, at Windsor. Three diseases in as many
days ! The unprofessional man considers this impos-
sible, and is perhaps disposed to question the sagacity
of his medical attendant, but in this he is wrong. He
is deceived, because he has neither studied the pheno-
mena of exanthematic nisus, nor reflected on the
manner in which exanthematic maladies slide into each
other.
Roseola exanthematica frequently accompanies the
incubative stage of post-vaccine small pox. It indicates
invariably the advent of a mild form of variola. It was
a frequent attendant on the inoculated sn)all pox, and
always hailed as a good omen by the professed inocu-
lators. The most perfect specimens of roseola which
can now be seen are those which attend the develop-
ment of cow pox in some children of irritable habit and
delicate skin.
The treatment of roseola offers no topic of sufficient
importance to arrest our attention. I have seen one
case where the urgency of febrile tumult demanded the
abstraction of ten ounces of blood from the arm.
VARIETIES OF ERYTHEMA.
' The last in the series of eruptive fevers is erythema,
which is so closely allied to roseola that it is only a
stretch of nosological refinement whicli lias separated
tbeni into distinct disorders. The term EpuS^^in, as used
everywhere by Hippocrates, simply denotes redness;
and it is tlierefore correctly applied to any disorder
having for its character simple efflorescence, not accom-
panied by swelling, and not advancing, under common
circumstances, to vesication, Bat this is the nosological
definition of roseola. Having so many terms, there-
fore, to express the same thing, we cannot wonder that
modern aulhors should have differed in their acceptation
of the term erythema. Some hold it to be merely the
mildest form and earliest stage of erysipelas ; others
restrict the term to such cases as exhibit redness of the
skin, in patches, with some concomitant consliditional
disorder, but neither originating in a contagious miasm,
nor terminating in flnid effusion. In this sense I shall
employ the term, but I shall not detain you long either
with the history or the pathology of the disease. Ery-
thematous eruption, indeed, offers little to interest 09,
though, as usual, nosologists have done their best to
turn lliat little to good account. Dr. Willau describes
six species, varieties, or rather, as we ought to say,
shades of erythema, to which he gives the names of
erythema fugax, iteve, marginatum, papulatnm, tuiiercu-
latum, and nodosum. Without attempting any formal
description of these several kinds of efflorescence, I may
state briefly all that it concerns you to know concerning
erythema, its aspects, sources, and most characteristic
variety.
330 VARIETIES OP ERVTHEHA.
Erythematous redness is sometimes obviously depend-
ent upon the presence of local irritation, such as pres-
snre, friction, distension, cold, heat, the bites of insects,
acrid and stimulating applications, wounds, and ulcers.
At other rimes, it originates idiopathically without any
obvious cause, and is then attributable to some deraoge-
mem of the hepatic, gastric, or nervous systems.
Tlie best illustration i can give you of local erythe-
matous redness is tiie areola of cow pox. It does not
commonly advance to vesicle. We are therefore hardly
justified in calling it erysipelatous redness. Yet to
show yon bow nearly allied are the two disorders
(erytiieiiia and erysipelas), I may state, that occasion-
ally the vaccine areola does merge in erysipelas, and by
so doing creates no small alarm in the mind of the
patient or parent It is not uncommon to see the
re-vaccination of adults followed by irregular erysipela-
tous areola.
Patches of erythematous redness appear at uncertain
times in the progress of various kinds of febrile disease,
especially of the low and typhoid character, and in
many chronic affections, especially those of gastric or
hepatic origin. Erythema is an almost constant atten-
dant on ihc aggravated cases of anasarca, where [be
skin is put upon the stretch. Under such circumstancea^
it appears in streaks of a dark red or purple hue. The
intertrigo or dialing to which both infants and aged
persons are liable, especially when very fat. Is of the
nature of erythema. Sinapisms, pitch plasters, turpett*
tine, and ainmoniacal embrocations, arc applied for th^'^
express purpose of exciting erythemalous rednesis
Leech-bites and blisters are often succeeded l>r Uk
extensive erythema of the neighboring intcgi
ERYTHEMA KODOSirM. 331
these varieties of erylhema are obvioaslj' sjmptomalic.
The only importaot qiiesrion for onr consideration is,
wlietber there exists any disease liaving erythematous
redness lor its chief character, siilhciently distinguished
from erysipelas and from roseola to be entitled to sepa-
rate examination T There is such a disease, and it is
called erythema nodosum. It is a mild exanihem, being
often preceded and accompanied by fever. It is distin-
guished from erysipelas, in tliat it does not nm into
vesications. It is distinguished from roseola by the
circumstance of its occupying tlie lower parts of the
body, to the exclusion of the upper.
Erythema nodosum is characterized by patches of
efflorescence occupying the skin lynig over the tibia.
The patches are oval in shape, the long diameter being
parallel to the tibia. They slowly rise into hard and
painful protuberances, and present very much of the
appearance of nodes. I have seen this disorder ushered
in by a kind of irregular or low fever, with foul tongue,
impaired appetite, and a faulty state of the secretions.
Languor and lassitude have been the predominant
symptoms, and the patient has often been surprised by
accidentally discovering the eruption. This complaint
is chiefly met with in young women between the ages
of fifteen and twenty-five. I once saw it in a delicate
lad, the apprentice of Mr, Courtney, formerly chemist
and druggist in the Regent-circus.
Erythema nodosum is a tedious disorder, often
extending to three or four weeks, during the whole of
frilicbifHliod-'' ' only urgent symptoms are languor
Uid d^lffl^ T ption suhsidcK as the constitution
impT0vc& ' lis, containing calomel and colo-
' infusion of senna with manna,
333
CONCLUmON.
are reqnired ia the first instaace. The acidulated
decoction of hark may afterwards promote the return of
■trength.
The same observalioas which I have made with
reference to the origin of herpes zoster, urticaria fehrilis,'
and lichen febrihs, apply equally to erytliema Dodosum.
These febrile efflorescences are all closely associated in
their pathological features ; they constitate the extreme
links of that chain which connects the specific exanthe-
mata with the febrile diseases of the human body, where
the skin is simply dry. In those fevers yon find increased
action of the cutaneous vessels, but it is neither of that
kind, nor is it in (hat intensity which ends in eruption.
Everything tends to show that there exists in nature
a great law binding together fever, simple efflorescence,
and specific exanthem, Thronghont the preceding
lectures, this principle has been frequently illustrated,
and as it is one of the most interesting which dermatic
patliology presents, so is it that which warns uie that
' here my labors terminate.
APPENDIX.
[ A.-— Page 6. ]
EXAHTHEMATIC MORTALITY.
Tables showing the number of deaths in the cities of New York, PbiKv
delphia, and Boston, by the four epidemic discoseH, Small Pox, Measles,
Scarlet Fever, and Hooping Cough, during different decenninl periods in the
different cities, from 1806 to 1846 inclusive: nnd also the average of the
mortality by these diseases to the whole mortality.
I. — New York. From 1806 to 1846 inclusive.
DISEASES.
Small Pox . . .
Measles. . . .
Scarlet Fever . .
ToUl Ezanthe- )
matic Mortality )
Hooping Cough .
Total Epidemic \
Morulity ]
Total Mortality .
1806-15.
1816-25.
1826-35.
183G-J5.
Number'
or !
Deathf.
1
percent.
Number
of
Deatht.
Percent.
Number
of
Dealh«
Percent.
Ntmber
ef
Deftths
Percent
4-45
148
22
664
521
32
1414
1005
1723
1680
1559
2880
615
595
1217
595
4142
11.55
6119
1194
1210
1 in 18
1812
1 in le
5297
1 in Hi
1
7313 1 in lU
21,867
or5i
percent
32,980
or 5^
Percent*
60354
or 8 J
Percent
«2^64!p;;,l
Average for the whole period, 1 in 12f (12-66), or 7^ per cent (7-89).
Population in 1810, 96,373. In 1820, 123,706. In 1830, 119,112. In
1840, 312,701.
136
▲FPEHDIX.
NEW YORK.'^Continued.
Small Pox . . .
Measles . * . . .
Scarlet Fever . .
Total Bxanthc- )
matic Mortality \
Hooping Cough .
1829
1830
1831
1832
1833
1834
1835
1836
16
91
188
176
22
246
224
39
258
89
290
221
25
38
179
233
212
418
351
82
174
173
443
S02
295
52
444
97
521
181
702
600
63
242
105
863
141
607
172
818
153
Total Epidemic )
Mortality )
347
511
663
347
1004
779
960
Total Mortality >
of New York S
4734
5198
5991
9975
5354
8590
6608
7503
183:
Small Pox ....
i Mcas'lov'*
Scarlet Fever . . .
Total Exanthcmatic )
Mortality \
Hooping Cough . .
\ Tr»tal Hpicicniii; }
! Mortality ^
' Total M'»rt:il.ty }
of New ^'oik S
16^(
238
579
981
63
1044
H182
1838
1839
91
79
257
68
133
158
427
219
359
113
C46
472
7.)33
7361
1840 1841
232
186
391
•229
113
366
809
73
708
67
e&2
775
78G8 8531
1842 1843
181
60
416
tll9
118
233
657
191
460 >
63
848
523
8175 7933
1844
51
2:25
18-15
1840
1H47
1848
1849
1850
■
Small Pox
Measlos
Scarlet Fover ....
4:l>5
130
03
141
17
114
5.3
275
14U>
1585
93
3:26
125
266
231
324
311
Total E.xanlhcmalic )
Mortality \
Hooping Cough . . .
296
164
024
89
272
214
470
80
755
213
717
112
866
180
Total Epidemic }
Mortality J
400
713
480
556
908
829
1046
Total Mortality )
of New York S
8127
9880 10.079
14,441
14.553
22.373
15,758
Population in 1805, 75,770. In 1810, 96,373. In 1815, 100,619. In
1820, 123,706. In 1S-J5, 166.086. In 1830,202,589. In 1835,270,089.
in 1810, 312,852. In 1845, 371,223. In 1850, 515,394.
• Incliidinpc 20 of vario'oi'.
I Including 41 of varioloid.
t Including 2 of varioloid.
▲PPBNDIX.
337
II.— PHILADELPfflA. From 1807 to 1846 inclosive.^
Small Poz . . .
Measles ....
Scarlet Fever . .
Toul Exanthe- )
matic Mortality ]
Hooping Cough .
Toul Epidemic >
Mortality ]
Toul Mortality )
of Philadelphia ]
1807
1808 1809
1810
1811
1812
1813
1814
32
1
145
73
2
101
1
3
33
2
2
117
20
2
1
1
9
7
33
17
220
11
105
96
37
32
139
54
2
24
9
29
7
23
50
231
201
69
193
36
38
30
1961
2145
1684
1897
2249
2017
2223
2041
Small Pox . . .
Measles ....
Scarlet Fever . .
Toul Exanthe- )
matic Mortality ]
Hooping Cough .
Toul Epidemic )
Morulity )
Total Mortality (
of PhiladelphU S
1815
1816
1817
1818
1819
1820
1821
1822
2
97
52
8
1
1
108
2
47
30
13
8
2
6
97
46
52
21
9
6
111
151
77
11
13
36
8
38
8
143
73
15
262
88
49
46
1943
2225
2107
2609
2979
3189
2961
3334
Small Pox . . .
Measles ....
Scarlet Fever . .
Total Exanthe- >
matic Morulity )
Hooping Cough .
Toul Epidemic i
Morulity ]
Toul Mortality )
of Philadelphia ]
1823
1824
1825
1826
1827
1828
1829
1830
160
156
8
325
102
8
6
38
8
3
101
4
100
9
1
107
58
81
53
9
86
7
40
324
79
435
42
52
40
108
43
110
51
165
57
143
37
133
35
403
477
92
151
161
222
180
168
4372
4284
3539
3845
3659
3971
4001
3948
22
838
PHILADELPHIA.— Con^tntied
Small Poz . . .
Measles ....
Scarlet Fever . .
Total Exanthe- >
matic Mortality )
Hooping Cough^, .
ToUl Epidemic >
Mortality \
ToUl Mortality )
of PhUadelphia {
1831
1832
1833
1834
1835
1836
1837
1838
14
23
200
37
118
307
156
1
61
195
7
83
101
248
305
86
4
240
79
49
205
42
123
134
237
67
462
58
218
53
285
48
654
106
330
94
333
40
299
27
304
520
271
333
760
424
373
326
4939
6425
4128
5073
5358
5022
4881
5118
1839
1840
1841
1842
1843
1844
1845
1846
Small Pox . . .
Meaalefl ....
Scarlet Fever . .
5
3
225
63
2
244
259
119
83
156
24
220
36
1
395
17
3
269
190
90
199
251
6
221
Total Exanthe- )
matic Mortality )
Hooping Cough .
233
191
309
4
461
6
400
197
432
16
289
101
479
33
478
104
Total Epidemic] >
Mortality j J
424
313
467
597
448
390
512
582
Total Mortality )
of Philadelphia \
4765
4593
5293
5558
5155
5187
5882
5944
Population in 1810, 96,664. In 1820, 119,326. In 1830, 167,811. In
1840, 205,580.
m.— BOSTON. #rom 181 Ito 1860 inclusive.
Small Pox . r :
Measles. . .T'.
Scarlet Fever . .
Total Exanthe- >
matic Mortality )
Hooping Cough .
Total Epidemic )
Mortality )
ToUl Mortality )
of Boston. S
1811
1812
1813
1814
1815
1816
1817
1818
2
1
1
4
21
G
3
1
1
1
3
14
1
5
25
2
9
9
1
19
2
1
17
1
6
27
18
20
3
894
633
750
695
830
873
875
925
839
BOSTON.— C>mKiiuedl
Small Poz . . .
Measles • • • •
Scarlet Fever . .
Total Ezanthe- >
matic Mortality )
Hooping Cough .
ToUl Epidemic )
Mortality ]
ToUl Morulity )
of Boston )
1819
1820
1821
1822
1823
1824
1825
1826
13
11
149
4
•
3
1
1
1
9
1
1
77
5
10
16
13
3
11
24
153
26
4
5
1
17
4
13
83
27
26
23
15
35
179
9
18
17
110
49
981
1014
1321
1088
1045
1208
1362
1167
Small Poz . . .
Measles ....
Scarlet Fever . .
Total Ezanthe- )
matic Mortality )
Hooping Cough .
Total Epidemic i
Mortality ]
ToUl Mortality )
of Boston \
1827
1828
1829
1830
1831
1832
1833
1834
3
8
2
3
78
4
1
13
5
4
2
85
2
70
200
2
90
4
1
39
11
6
5
40
82
11
19
16
91
26
272
22
92
28
44
38
17
45
93
35
117
294
120
82
939
1159
1156
1025
1353
1705
1374
1440
Small Pox . . .
Measles ....
Scarlet Fever . .
ToUl Ezanthe- >
matic Morulity >
Hooping Cough .
Total Epidemic >
Mortality )
Total Mortality >
of Boston S
1835
1836
1837
1838
1839
1840
1841
1843
7
188
73
6
31
31
13
23
50
3
20
106
60
3
222
115
1
76
57
87
89
43
33
373
268
44
68
17
86
19
129
28
385
34
192
70
233
37
338
33
312
85
105
157
319
262
370
361
1818
1643
1743
1799
1732
1841
1783
9960
BOSTON^Con/inuoi
Small Poi. . .
Heule.. . . .
Sculet Ferar . .
Total Exanibe- >
■nalic Mortality \
HoopiogCoogh ;
Total Epidemic [
Mortality J
TcUl MortalUr )
IS43
1644
IB45
1846
1847
184S
1^9
1850
55
43
150
3G
240
31
8
160
92
ISO
IDS
33
15
59
31
16
177
91
31)9
317
193
75
69
34e
54
276
S4
199
63
348
36
97
36
314
33
547
36
336
81
3oa
300
SGS
386
133
247
583
417
a0O8
30&4
3340
30SG
3853
3664
5079
3CC7
IV^PROVTOENCE (R. I.). From 1843 to 1849 inclnaTo.
im.ll Pox. . .
Maa»les. . . .
Scarlet Fever . .
Total Eiantho- >
matic Mortality \
Hooping Cough .
Totttl Epidemic 1
Mortality \
Total Mortality 1
of Providence \
1843
1843
1844
1845
IS46
1847
1848
1849
3
9
4
16
17
30
1
5
36
4
3
55
3
7
43
4
9
13
t
3
33
15
6
30
7
37
3
4S
9
61
3
S3
4
35
16
37
6
91
H7
40
51
64
56
41
43
556
6ie
633
714
806
884
870
1079
Populalion in 184Q, 31,753.
v.— LOWELL (Mass.). Prom 1839 to 1860 incluBive.
Small Poi
Menales
Scarlet Fever ....
MonaUty \
. Hooping Cough . . .
Total Epidemic )
Mortality \
Total Mortality of )
Lowell \
1639
1840
1841
1843
1843
1844
13
1
1
3
4
43
13
33
6
10
3
13
3
8
6
49
3
44
6
6
11
13
4
15
14
63
49
17
!7
340
436
466
473
363
363
▲FFEHDIX.
341
WWELL—CorUinued.
•
Small Pox
Measles '
Scarlet Fever ....
Total Exanthematic )
Mortality \
Hoopitig Cough . . .
Total Epidemic )
Mortality ]
Total Mortality of >
Lowell \
1846
1846
1847
1848
1849
1850
4
12
4
17
38
1
2
27
17
27
48
41
1
82
3
1
16
13
59
10
30
92
11
124
7
4
1
29
69
30
103
131
5
363
690
949
825
903
491
Population in 1840, 20,790. In 1844, 26,163. In 1846, 28,841. In 1860,
36,000 (nearly).
VL— BALTIMORE. From 1836 to 1849 inclusive.
Small Pox* ....
Measles
Scarlet Fever ....
Total Exanthematic >
Mortality J
Hooping Cough . . .
Total Epidemic Mor- >
tality )
Total Mortality of )
Baltimore S
1836
1837
1838
1839
1840
1841
1842
1
1
30
52
141
134
71
4
141
2
57
112
9
32
71
1
6
74
1
103
27
32
43
327
69
216
18
171
75
112
9
81
35
131
63
75
396
234
246
121
116
194
2192
2518
2476
2260
2045
2247
2477
Small Pox ....
Measles
Scarlet Fever . . .
Total Exanthematic \
Mortality ^
Hooping Cough . .
Total Epidemic Mor-
tality
Total Mortality of >
Baltimore \
1843
1844
1845
1846
1847
1848
1849
4
56
1
370
110
20
288
115
114
132
1
7
166
4
74
407
19
31
155
60
20
371
59
418
62
361
26
174
104
485
59
205
59
80
430
480
387
278
544
264
2333
2665
2896
2994
3414
3861
4165
Population in 1840, 102,513. In 1845, 121,161.
* Besides 7 cases of varioloid during the 14 years.
343
VIL*— CHARLESTON (S. C). From 1823 to 1849 inebuif^.
1822
1823
1824 1825
1826
1827
1828
Small Pox
Meaftles
Scarlet Ferar ....
ToUl EzaDthematic >
Mortality \
Hooping Cough . . .
Total Epidemic Mor- )
Ulity ]
Total MorUlity in }
Charleston \
26
46
15
1
7
52
3
29
5
7
5
72
4
8
69
"55
10
34
10
7
5
67
72
19
77
65
44
7
72
925
814
1059
840
764;
803
793
Small Pox
IVfeasles
Scarlet Fever ....
ToUl Exanthematic )
MorUlity ]
Hooping Coogh . . .
Total Epidemic Mor- )
Ulity I
Total Mortality in )
Charleston \
1829
1830
1831
1832
1833
1834
1835
16
7
16
9
27
42
1
11
23
5
1
14
7
23
7
52
15
54
9
23
5
8
1
8
21
16
30
67
63
23
13 1 9
37
762
763 733
560
542 692 664
Small Pox
Mea>*le8
Scarlet Fover ....
Total Exanthematic >
MorUlity \
Hooping Cough . . .
Total Epidemic Mor- )
tality \
Total Mortality in )
CharU':?ton S 1
1836
1^37
1838
1^39
' 1840
1841
1842
15
1
1 '
p.
i
9
8
56
51
2
9
1
6
30
15
16
25
16 '
12
1
64
9
51
11
25
45
9
41
28 '
73
51
11
32
54
1172
630 1
1209
836
1
605 j
594
560
• It is proper to remark, in connexion with the table exhibiting the mortality of
Charleston, that of the 452 deaths entered under the head of Scarlet Fever (of
which 289 were among blacks and 163 among whites), 245 are cla.^-sed as " sore
throat" (155 whiles and 90 blacks), and the remainder under the head of " scarlet
fever," in the abstract of deatlis for individual years, in the ** census" of that city
343
CHARLESTON.^ ConUnued.
Small Poz
Measles
Scarlet Fever ....
Total Ezanthematic >
MorUlity $
Hooping Cough . . •
Toul Epidemic Mor- )
taUty ]
Total Mortality in )
Charleston S
1843
1844
1845
1846
1847
1848
1849
50
1
30
9
54
16
1
20
11
1
5
5
6
81
63
31
16
6
21
7
11
18
11
2
6
3
81
84
22
28
29
13
9
697
553
570
607
548
614
798
Population in 1820, 24,780 (10,653 whites, 12,652 aUves, 1475 free
eolored). In 1830, 30,289 (12,828 whites, 15,354 slaves, 2107 free colored).
In 1840, 29,261 (13,030 whites, 14,673 slaves, 1558 free colored).
Vffl.— MASSACHUSETTS, exclusive of Suffolk County (in which Boston
is situated). From April 30, 1841 to April 30, 1848, inclusive.
Small Poz
Measles
Scarlet Fever ....
Toul Ezanthematic }
Mortality \
Hooping Cough . . .
Toul Epidemic Mor- )
Ulity \
Tot. Mort. Mass., ezcl. )
of SufibllK Co. S
1842
1843
1844
1845
1846
1847
1848
13
86
395
12
30
559
11
32
328
5
44
538
32
46
516
12
136
418
20
42
175
494
43
601
61
371
60
587
68
594
100
566
104
237
76
537
662
431
655
694
670
313
7538
8293
8250
8642
9211
10,816
11,001
published in 1849 ; while, in a general summary of the causes of death, in a sub-
sequent part of the same work, the word " sore throat" is not used, and the whole
number entered there under the head of scarlet fever corresponds exactly with
those in the ubles under the two separate heads of scarlet fever and sore throat.
In the same ubles, there is a separate head for " quinsy/' and another for " mem-
branous sore throat ;" hence, we felt authorized in considering those entered under
the head of " sore throat" in the tables as cases of scarlet fever.
844 AFFEirDDC.
[ C— Page 18. ]
The co-existence of two febrile exanthemata in the same individual has
now been observed in so many instances, and so many cases of it are ob
record, that its occurrence may be considered as beyond donbt We have
added a few to those mentioned by our author, to show still farther ob
what authority this settlement of the question rests, and to illustrate the
laws by which it is governed.
Dr. P. Tracy (of Norwich, Conn.) reports {Medical Repository, vol. iii. p.
105) a case in which measles and small pox occurred at the same time in
the same individual, and each pursued its regular course without mterfering
with the progress of the other.
In another case, he inoculated with a variolous matter a young man whd
had been exposed to measles a day or two previously. The variolous
disease was mild, and progressed regulariy, and on the tenth day the pre-
monitory symptoms of measles appeared, followed the next day by the
characteristic eruption, which parsed through its stages regularly to a
favorable termination. Neither of these patients had been previously
affected with measles, but communicated that disease to a considerable
number of patients in the hospital, who had not been otherwise exposed.
A case is also stated by Mr. Delagarde, in the 13th vol. of the Medico-
Chir, Transactionsj of the co-existence of measles and small pox, in which
the characteristic eruption of each appeared at the same time, and ran
through its course ref^ularly. A child inoculated with matter taken from
one of the pustules had tlie small pox.
Dr. VVitIierin<r, in his work on scarlet fever (p. 25), alludes to two chil-
dren (the only two instances he ever saw) who had scarlet fever and suiall
pox at the same time.
Dr. John Watson reports a case {Vmted States Medical and Surgical
Journal, Oct. 1835, p. 8i)) of tlie co-existence of measles and scarlet fever
in a boy eijrht or nine years old, examined hy himself and another physician,
and decided to be measles, in whom there appeared, two days after, the
characteristic eruption of scarlatina, with swollen throat, and red tongrue, so
far as it could be examined, and which proved fatal soon afterwards. He
subsecjuently attended two children in the same house with scarlet fever,
who had desquamation of the cuticle, iind anasarca of the legs.
Mr. (Jilder reports a cast' {Med. Chir. Transar., vol. xii. p. 106) of a
child, fourteen months old, vaccinated during the premonitory sUitre of
measles, in which each disease pnssed through its regular stages, without
interference with the other. The progress of the disc-ase was also perfect
in an infant vaccinated with matter taken from its arm.
Mr. Little, in a letter to Mr. Dumiing, relates an instance of casual
chicken pox passing through its regular stages, refrardless of the local
action of cow pox, and also alludes to a case of casual measles which came
under his observation, which progressed undisturbed by the cow pox.
846
{Comparalhv Stalemmt of FaeU ami OhMenationi relalive to tin Coa Pox.
London, 1800, p. 28, note.)
The two following cases are reportcHi by Robert Barnoa, M.B. ^London
Lancet, May, 1845), ns inatiLnces of inrection of the ByBtem at Ihe iunie time
by the poison of mmiW pox and of scarlatina. A girl, nine jreHre old, hud
a/lnptoDts of malaise, &i.c., with a red tongue, fiiuces injected, niid a rash.
Ill two days the rash di-tappenred, and papul» of varioloid appeared more
diatinclly, and ran through their regular course, the patient having vaccine
Bcnrs. At the end of three weeks, she liad anasarca. Twelve days after,
three Bisters had varioloid, and another girl in the house had irarlalrna.
One of the sisters oUo had sore throat. Hence the writer says, " It may be
fairly presumed, that the first patient served as (he common focus of con-
tagion from whence tiie two disenHes were propagated ; that she not only
labored under the two diseoseti conjointly, but tmnsmitted them separately
to other individaals."
It is proper to odd, (hat these coses of Mr. Barnes are regarded by Mr.
Uonon aa instauces of small pox preceded by variola. We have not
nnfi^uenlly seen variola tliua preceded, and have not heailaled to regard
as such eome cases which have been reported as those of the co-existence
of rarioln and scarlatina ; bnt, in the present instance, feel that the occur-
rence of anasarca at the end of three weeks, and the case of acarlatiiia in
the same house, furnish strong presumptive evidence b favor of the view
token by (he reporter of (hem.
Mr. Marson, surgeon to the Small Pox and Vaccination Hospital, London,
in a paper on the co-exislenee of different eruptive fevers, stales that he hoa
*een seven coses of the oo-existence of variola and scarlatina at that instita-
tioii during the l^t eleven years, and that three coses had occarred at the
London Fever Hospital within Ihe lost few years. He also alludes to
numerous other instance* of the co-existence of different eruptive fevers.
(Limd. Mrd. Oas., June 18, 1847; also Paper on Co-exinleiice of Small
Pox and Scarlatina, Jtteit. Chk. Tram., vol, ux. 1847.)
MM. Barthei and Rillict hove seen scarblina co-existing with measles
seven times, variolous eruption twelve tines, and erysipelas three times.
M. Levy, in his memoir on measles in the adult, also gives instuncea of
the co-exlt(ence of different febrile exiiiithemata. (_Mai. Chir. Rev^ Oct
1847.)
Dr, John Wal.ton also, in a paper read before Ihe New York Medical and •
Surgical Society, in M.iy, 1835, has collected othtr cases of such co-cxiat-
cnce, and also gives in detail some of those to which we have referred,
(r. Slates Med. and Surg. Jour., Oct 1835.)
The cases quolcd by our author (p. 135) fntm Dr. Russell at Aleppo, of
the simultaneous occurrence of measles and small pox in (he same per-
son, may be found in the Mai. Chir. Tram., vol, iL p, 90. Ojic was in «
female child, (wo years old, and tlie other iu a boy, three years old. In
both cases, each eruption pursued its regular course, and with a &vonible
J
Wemddaddiim fbiAar proof flirt tiM iMto onlhflBMfai do
tofeflier In flie mum inditidiudt and nrnflieir eoime tkoMtinmadjtlmk
Ibd fliitflM poiniii toowdl ertibtUbad to all tor onyw mrtondod
notfM of flio aal^joei
[ D^*Ptf0[« 9L ]
NvMroiu npoiti of iooltted oawi of Moonday nail poi^ ad of
«idonbtod oatfao nl fcJI yt are on neoid, and tow pnetiflonoffa, e^eeiaHy in
flitlea, paaa many yoaia wtthovt maeting one or more anoli oaaea. We tod;
tao^ fliat atatfati a a will aho w a fkeqaenej of audi reeonenee greater ttaa
flio fiewa of onr anflior, aa expreaiod in the teart, woold lead na to antk^
pato. The antject baa of late yeaia detired fteah intereat from the fuBTwiaa
of mortality by gniall pox after vaeeination,the aaanmed dimiiridring prote^
lion aibrded by wliieh baa ineUned eoaoie to propoae a fetnm to the old
BMfliod of inoenlation, on aoeoont of the aappoaed greater proteeflto power
of variola. We ahall leave theee topioa tor a aabaeqnent part of oar
appendrr, and confine oviaelvee in tUa plaee to the notioe of a fewi na tanee a
of aoeh recnirenee of more qieehd intereati and to aome atatfatfeab to diow
the comparative fteqneney of eeeond attaofca of mall pox.
Mr. E. O. Bpooner mentione a caae aa nnder bia care at the tSme of
writing, of a woman, aevenfy yeara of agOi who, alzty yeaia previooalyt had
been auceeaafally inoenlated tor email pox, and iHio boie ita peenUar Barim
botii on her arm and on her body, and waa then reoovering from a eeeond
attack of casual small pox. (Provinc. Med, and Sta^. Jour.^ July, 1850.)
Dr. John Watson, of this city, has reported a well marked case of a
eeeond attack of small pox in a child two years and ten months old.
(^United Slates Med, and Surg. Jour., Oct 1835.) This child we ourselves
aaw, and felt satisfied at the time, from the character of the eruption and
from the marks left by a former attack, that it was undergoing the disease
a second time.
M. Gilet reports a case {VAhetOe Med., Paris, Oct. 1844, p. 239) of the
confluent form in a woman eighty-seven years old, who had a scar of small
pox on her forehead from the disease in infancy.
Dr. Renaud gives a case (Revue Mtdicale, Feb. 1839) of a little girl,
twenty-eight months old, who had small pox in the distinct form in August,
1838, and died from an attack of it> in the confluent form, in October of the
same year. The grandmother on the maternal side had been twice affected
with small pox, and the mother, who was twenty-six years of age, and who
nursed the child, and had the disease in her infancy, took it again a short
time after, and died with it, in the confluent form, on the seventeenth day.
The frequency of its recurrence, as well as its fatality when it does recur,
varies with different epidemics.
In France, in 1840, of 14,470 persons attacked with epidemic small pox,
it occurred a second time in only twenty-four cases ; and of these, three
proved fhtal.
In an epidemic in Edinburgh, in 1818, in which 556 cases were seen by
APPBiniKe.
841
Dr. Thompson of Ihat city, forty-one previously Iwd small poi. Thirty
other CDBOs were reported to Dr. T., and of the whole Beveoty-one, three
died, or one in Iwenty-tliree. (Maunsell on Vaccination ; Dublin Med.
JottTn., vol. li. p. 396.) It will be recollected, however, that Dr. T. believed
in the identity of smnll pox and chiclcen poi, and would, almost of neoeseily,
■ee a larger share of seeond attaclis of variola than could fairly be adiDill«d
to bear upon the queslion of the comparulivo frequency of its reeurrence.
Dr. M6lil, of Copenhagen, records thirty-one fatal casea out of 1G3 of
•econdary smull pox.
Of 148 cnaea during the epidemic in Philadelphia in 1823-34, as reported
by Drs. Mitchell and Bell, eight were in Uioae who hod been previously
affected, and of these fonr died.
M. Serres stated to the Freiieh Academy of Sciences, in July, 1343 (Gai.
Mid.de Paris, Ja]y 9, 1B43), Ihat from an observation of between llOO and
1800 cases of small pox in private practice and in hospitals, he could say,
that eases of a second attack of Bmall pox are as numerous as of attacks of
small pox after vnccinulion.
In MarscilleB, in 1828, of 30,ODO persona who bad been vaccinated, 2000
were attacked wilh small pox, and 31 died. Of 2000 who liad previously
bad ttmall pox, twenty hnd it a second time, and four died.
Dr. Maeiiinlosh says, lliat he knew upwards of twelve well aathentkated
ioBtances of persona attacked a second lime with small pDX,and lluit all hia
cases of secondary small pox, with the exception of two, were remarkably
severe, whereas he rarely saw a severe case of sioall pox after vaccinatioo-
{Praelice of Medicine ; Phila, edit., 1844, p. 169.)
On the other hand, we doobt not that ttio comparative frequency of such
recurrence has been sometimes much overrated. The Commitlee of the
Provincial Medical and Surgical Association say, for instance, {Trani,Prot'
Med. t^ Surg. Assoc., vol. viil, p. 67,) that, occordbg to the most aDCilrate
calculation they can make, there cannot bo fewer llian 239 cases ttecwded
by aiity-lwo correspondents ; and that of these, twelve or thirteen proved
falsi. We feel conhdent tliat some allowance should be made fur errors in
diagnosis, and perhaps for the inflnence of the probable prevalence, to »
eonsiderable extent, of the views of Dr. Thompson, before alluded to, in
lavorof the identity of sniall pox and chicken pox, in weighing the authority
of the commanications lo that body, made as they were by practitioners scat-
tered throughout tlie country ; and, perhaps, the some remark may be sppli-
enbleloalleastaport of the writers referred to by Dr. Boron, the chairman of
that committee, who, in liis Life of Jenncr, (vol. 1, p. 266,) says, that more
than one hundred and thirty different writers may be named who luive
reported cnses of secondary or recurrent smull pox, many of these being
probably tlie same as those quoted by that commiltfe. Indeed, the very
low rate of mortality, according to their own ligDres, is strong presumptive
proof Bgainst the geiiuine nature of all the cases thus reported to that
!, the deatlia having been only m the proportion of 1 ia 19.
a
848
We feel bound, &lao, freely to acknowledge the authority due to the
opinion of our author, ho strongly pupressed in the text, in favor of (he in&e-
quency of such recurrence, foiind«'d,as it is, on careful obaorTnlion.forBolong
a. series of years, and under Buch favomble circumstaoces ; and lo record, in
addition, tlie striking fact stated by tiim in a letter recently received, that>
during tlie last forty-one years, but one single case of recurrent email pox
bos been repoKed to the Medical and Chirurgicnl Society of London, the
iant and only recorded case in their tranwutions beinv one by Dr. Batemao,
in 1310. One cuae, adds Dr. G., did occur in London, about twenty yean
ago, but was not reported.
While, therefore, we feci tliat facts will fully warrant the fear that aecond
Bltiicks of this cruel disease are not of such very mrc occurrence aa has been
supposed by some, we rauBl ndrnit, that sucli attacks ure evidently less fre-
quent than they Imve been Bsautui-'d lobe by others, and it is hoped that further
investigation may lead to a still more favorable aspect of it in ttua respecL
[K-Pcgt 93.3
The comrounication of small pox to the fcetus in Utero is not of so rare
occurrence as to render it necetsary to addnce cases in proof of it ; but we
inlrodnce a few to illustrate its more common phenomvaa, nnd to show th«
relation between it and the influence of vaccination and of vnrioln oii the put
of the mother, n rclulion by no means cunsiani, as the sequel will bhow.
In the Amer. Jour, of Med. Sci., five cases are repdrlcd of such coomn-
nication, in which the child was born with small pox, the mother rcauuning
entirely free from tiie disease.
The first was communicated by Dr. J. K. Milchell (vol. vii. p. 655.) In
this case, the child was bom healthy, bat exhibiled symptoms of the dl^ase
three days after birth, and nbe days after birth iho puaiules were in a stale
of complete maturity.
The second ease (vol. sL p. 499) was communicated to the French
Acodemy of Medicine in Jaly, 1833. by M. Deneux. The child was covered
at birth with confluent variolous paatulea, in the eleventli or twolfth day of
the eruption.
The third case (vol, iv., new aeries, Oct. 1843, p. 485) occurred lo Dr. C.
Guoli, in a child bom June 3, 1341, covered with pustules of variola. The
pustules appeared at iheir height on the second dny, and on the fiflh day
maturation began, bat the child died on the ninth day after birlh.
The fourth ease (vol. vi., new series, July, 1843, p. 210), reported and
exhibited lo Ihe French Academy of Medicme in 18-13, by M. Gerardin, was
that of a child born five days previously with a. full eruption of the diseue
is a state of suppuration.
The fifth case (reported in vol. v„ new scries, Jan. 1843, p. 349) occnmd
in our city in 1843, in the practice of Dr. B. F. Joslio. The child had 01 "
body at birth about 170 regularly formed pustules, apparently in the •!
at which they would be found in ordinary coses about eight or ten dayirf
▲FPSHDIX. 349
the attack. The child lived only a quarter of an hour. In this case, the
infection was received by the mother just thirty days previous to the birth
of the child. She was exposed but once to a single case, at the very com-
mencement of the eruption, and for a single day.
In the first case, the mother bore distinct marks at the time of the natural
small pox with which she was affected in childhood.
In the second case, the mother had been vaccinated, but had never had
the small pox ; and in the third case, the ; mother had been successfully
vaccinated when an infant No mention is made of the protection of the
mother in the fourth case.
In the fifth case, the mother had been vaccinated in early childhood, and
the operation was repeated on the day of exposure by Dr. Joslin himself,
but without effect
M. Depaul met with a case of transmission of variola from a mother to
her child, which had numerous pustules at birth, though the mother had
visited a person with the disease a short time before without taking it
(BuUeL de Thir,, Apr. 30, 1849.)
A ease also occurred in the Maternity Hospital in Paris, in which the
fkee, scalp, and different parts of the child's head were covered with the
pustules of small pox at birth, though the mother retained titc marks of
vaccination, and stated that she had never hod the small pox. She had hod
DO connexion with persons suffering under the disease, but only, about eight
or ten days before, had gone to see a patient at La Pitie, near where lay
another patient with the small pox. (London Lancet^ Feb. 18, 1843, p. 741.)
Dr. Mead has recorded an instance in wliich a woman was delivered of a
dead child at the full time, covered with variolous pustules. She had
formerly had the disease, and was attending her husband with it, when
delivery took place. (Medical Works, chap, iv., p. 253.)
Dr. Lebert exhibited to the Biological Society at Paris, a foetus about
four months old, whose body was covered with pustules of variola. The
mother had the disease slightly, and aborted during her convalescence.
(Bulletin de TJUrap., Apr. 30, 1849.)
Dr. King mentions a case (New York Jour. Med. and Surg., Apr. 1840,
p. 292) which occurred in Paris, of the birth of a living child at seven months
covered with an eruption of umbilicated pustules, the motlier having entirely
recovered, and presenting at the time of its birth no evidences of the erup-
tion, except the red spots succeeding the scabs ; the child having been bom
twenty-one days since she was first attacked, or seventeen days after the
appearance of the eruption.
Dr. Luther V. Bell gives an instance of a lady who hod small pox in the
eonfluent form at the seventh month of pregnancy, and escaped without
abortion ; but " at the expiration of her full term, was delivered of a healthy
ehild, whose abdomen and thighs were marked with decided small pox
pittings, and who was unsusceptible of the vaccine disease." (Notice of
Esnay oh Small Pox, Varioloid, and Vaccination, Amer. Jour. Med, Sci,
May, 1836.)
S60 APFUUiZ.
Van Swieten (quoted by Dr. Hoaack) mentioiis a similar ease of a child,
born at full time, with pita of small pox, the disease having been commnm-
eated by transmission through its mother, who had herself long before gone
through the disease.
In one of Dr. Jenner's eases, referred to by our author, the mother, who
had had small pox when a child, waa exposed to it ** a few days before
eonfinementf the child was indisposed on the fifth day after birth, and the
small pox appeared on the seventh day. There were but few pustules in
this case, and they maturated completely.
The cases of Dr. Jenner, originally published in the first volume of the
Med, Ckir, Tranuc cf London^ and also the one by Dr. Mead, to which he
alludes in that pi^r, may be found in the Amtr. Jour. Med. SeLf voL viiL
p. 225.
Cases of communication of the disease to the foetus in utero are also
given by Dr. D. Hosack, with numerous references to other cases by difiSBr-
ent authors. (Medical Essays, vol. iL p. Ill : also vol. iiL p. 470.)
On the other hand, as our author remarks, the child sometimes ese^ies
when the mother has the disease. A ease is related in the BnUelm €Untr.
de ThSrapeuHque (Feb. 1847, p. 143), in which a child bom of a mother
with small pox of the confluent form, and in an advanced period of desioefto
tion, showed no marics of the disease whatever.
It will be found on examination of the preceding and of other cases, that
this communiciition has occurred after vaccination of the mother in infancy,
and after her re-vaccination on the day of her exposure, and also after
variola, both naturally and by inoculation.
It also takes place when the mother is yet suffering from the disease, and
after she has passed through it years prenously, and when she herself
escapes entirely.
The fa^tus may be infected by absorption of the virus through the
mother without her experiencing any effect from it, or transmitted directly
by inoculation of the mother, and may be communicated any time from the
fourth month (and perhaps earlier) to the full time. The foetus may be
thrown off in three or four days after cessation of motion, or may be
retained for three or four weeks.
The child may be covered with eruption at birth, and this eruption may
present itself in different stages of its progress in different cases, even up to
the eleventh or twelfth day of the eruption, or may not appear until three
or four, or even seven days after birth. It may also be bom at full time
with pits left by the disease some weeks previously.
The child almost invariably falls a victim to the disease at once, or lingers
for only a few days ; but has been born healthy at the full time, with marks
of previous disease, and has survived, when the disease in a mild form has
appeared after birth.
Other meanB bcBides those mentjoned in the text hare been used for
preventing the pitting by the puetnles of email |k)x, cither by caoaing their
abortion in Uic forming stage, or drying them up after they hu\e maturated,
•nd upon autliority whicli would seem to render them worthy of some
As a general rule, the more recent the eruption, the more easily is it
arrected. One writer thinks that the puelDlea can be arrested even after
suppuration, and anotliec flxes the period at wbieh it can be done as lale as
the seventh day.
Mercury hai been used under different forms, both as a plaster and ax a
waah. M. Briquet employs (at the Hdpital de la Chariti.-, Paris) a mask
ooroposed of mereuriai ointment, and solidified by means uf the powder of
■Iftrch or of fecula, which is renewed once or twice a day. A thick layer
of it is spread with the finger over the forehead, check*, eyebrows, nose,
lips, eara, &c., which causes abortion of the pustules, and preventa the
■welling usually attendant upon the confluent form. (Bullelin Genir.de
Thirap. Med. et Chimrg., torn, juxii. p. 60, Jan. 1847.)
Prof. Bennett, of Edinburgli, also uses mercurial ointment thickened with
starch C^. Ungt. Hydrarg. Sj, Pulv. Amyli 3ij. m.), smeared over the fiice
Digfat and morning. (Monthly Jour. Med. Sci., Jan. 1850.)
A compound mereuriai plaster, known under the name of " plaster of
vigo," of the French Fharmacopcela, is a favorite application with some
FVench physicians.
If mercurial plaster is applied before the fifth day of the eruption, one of
two things happens, — either the papules disappear by resolution, or they are
changed into vesicles or into tubercles. The latter change is more rare,
according to Af. Briquet, and seldom takes place except on Iho face.
When the dressing is removed, small, hard excrescences, bsensible to the
touch, are seen, which gradually fade, and disappear at tlie end of ten or
twelve days, partly by resolution, and partly by desquamation, and without
leaving any trace. The mercurial plaster must be be kepton eight to twelve
days. (Repnrl by M. Briquet la French Aead. Med., Apr. 7, 1846, on a
eommjinication by M. Cliarcellay — Oar. Mid. de Parit, Avr. 11, 1846.)
Ptyaliam sometimes occurs from the application of mercnriol phiater, a
case of which is given in the Renie Midkale ; the result, however, proved
eventually favorable.
A solution of corrosive sublimate (one grain to J vij. of distillod water,
with 3j. of laudanum), applied by means of compresses kept wet with lE, !■
also said to prodnee very marked effects in causing the disappearance of
pustules, even afler they have fully matured.
Simple mercurial ointment is used much more fVcquenlly, both in this
country and in Europe, tlion either the plaster of vigo or the wash of the
bi-chloride, and is probably equally eScocJoua, It may be applied freely
362 AFFERBIX.
with a brash or earners hair pencil. Dr. Stewardson^of Philadelphia, speaks
very favorably of its effects. {Amer. Jour. Med. ScL, Jan. 1843.)
Baron Larrey communicated to the French Academy the use of gold leaf
for this purpose by the Egyptians and Arabs ; bat stated that he derired
nearly as favorable results from repeatedly anointing the face with almond
oil, an application which we have ourselves found grateful to the patient,
and, to a certain extent, protective against cicatrices.
M. Malapert recommends a solution of hydrate of potassa for this purpose,
which, he says, dries up the pustules without leaving any cicatrices or stains
on the skin, but does not mention the strength of which it is to be used.
{UAbeiUe Mid, Juin, 1847.)
Dr. Corrigan employs a coating of emplast plumbi, melted with oil of
almonds, and laid on with a cameFs hair pencil. (Dublin Quarterly Jour*
Med., Aug. 1846, p. 245.)
The exclusion of light is also thought to prevent pitting. See result of
experiments by M. Serres, mentioned in Amer. Jour. Med, ScL, Oct 18439
p. 469.
Dr. Crawford, of Montreal, and Dr. Samuel Jackson, of Philadelphia, have
succeeded in preventing pitting by the application of the tincture of iodine,
each without the knowledge of the other, the former having published the
first account of his trial of it (Med. Examiner, Phila., Dec. 1846.)
Sulphur ointment ( 3 iss. to 3 ij. to 5 j. lard), rubbed lightly, three times a
day, over the parts affected, has also been recommended as not inferior to
mercurial preparations in preventing the suppuration of the pustules and the
scars that usually follow them. (Gaz. Mtd. de PariSj Avr. 10, 1841, p.
232.)
Velpeau says that if the pustules are cauterized within the first two or
three days, and even somewhat later, no marks will be left ; and Dr. Morton,
of Philadelphia, says that he has confirmed the truth of this statement
Dr. Morton states that he has adopted with great success the plan of having
the face frequently wet with spirits of hartshorn, which, he says, keeps down
the inflammation, and prevents the pustules from becoming either large or
irritable. (Notes to Mackintosh's Pract. Med.)
M. Piorry recommends very highly the use of blisters for this purpose,
and claims for them several advantages over other means. (Med. Chir.
Rev., Jan. 1847 ; from Gaz. des HOpit.)
Mr. Ranking suggests the use of collodion for this purpose, and the
suggestion strikes us favorably ; but we have met no report of its applica-
tion in this way. (Braithwaite's Retrosp., No. 19, p. 208.)
A more extended notice of some of the means mentioned in this summary
may be found in the third number of the Journal last quoted, for January,
1841.)
[G.-Pagein.]
Others besides Sir Gilbrrt Blatie hnve drawn the same inference that he
djd tiom the bills of mortslity of London during the lost century reepMting
the increase of mortality by the practice of inocalatiou, an increaui which
our author attrihutes solely to epidemic prevnience ul' the disease : and thete
Hre alBo additional facts which would aeem 1« indicate thai ila effect hia
been equally posilivo during the present century.
Mr. Marshall says of small pox in London, " It was more general, and
more severe in ite charoclcr, and caused greater mortality after the introduc-
tion of inocuktion, until tlio time of the introduction of vaccinatioD."
(MoTlalily of Ihf MttTopdii frojn 1639 20 1S21, by John Marshall: iMndimr
1833.)
According to Uie "Report on the Protective Powers of Vaccination" by
DrB. Cundie, Hewson, and Afoore, of Philadelphia, vnriolous inoculation woa
prohibited in that city in 1811 ;, and for four succeeding years, not a death
from amall poi was reeorded. According to the same authority, for the
period of sixteen years terminating with 1801, the proportion of deaths by
small poK to the whole mortality was 73 in 1000. From I SOT to 1811, the
proportion was 40 to 1000, during which lime vaccination was practised j
and from 181 1 (when inoculation was abolished), tlie pruportioniil morlallty
has been reduced lo I8> 1000,; {Medical Examiner, Phihi., Jan. 1847,
^39.)
Reference to the tables in the Appendix (B) will Bhojf that small pox
has prevailed epidemically several times since 1811.
Mr. Wylde says that "the superiority of vaccination over inotnlation ia
ahown by the fact that umall pox mortality is highest in tho^e provinces
in which inoculation is moat practised, and vaccination leasL" {Dr. Wat*
Rrport—Bril. and For. Mtd. Rev., Oct, 1845, p. 581.)
Dr. Baron saya (Life nf" Jenncr, vol. L p. 260) " tlic practice of iaocnlation,
the greatest improvement ever introduced in the treatment of small poi,
atlhough beneficial to ihe person inoculated, has been detrimental to man-
kind in general. It has kept up a constant sonrce of noxious infection,
which has more than counterbalanced ihe advantages of individual swurily."
Sir Gilbert Blane says that ttie diifueion of snuill pox by inoculation was
more Btrongly exempliRed in the country than in London ; Kince there ore
many places where small pox was not known for twenty, thirty, and even
forty years, in which at present scarcely au ndnlt can be found who has not
had it In this case, however, wo musl make due allowance for epidemio
influence, which has doubtless contributed very much to its more general
<Uffb^n.
Besides, we cannot think that there would have been such nnanimity in
diffcrtnt counlrics in abolishing the practice, and, as in Great Britain, uitb
the altachment of a heavy penalty to ila exercise, hod not the evidence in
bvor of such a measure been of the most decided character.
We learn tioD) Dr. Baron {Life r^Jenner, vol. I p. 334) that the practic*
854 AFFEIDZX.
was prohibited in Paris, by royal authority, in 1763, in consequenee of its
being foand, on investigation by the police, that the infection was multiplied
and diffused by its means. Also, that in Spain, where the practice was
scarcely ever admitted, small pox has caused less mortality in proportion to
the population than in any other country in Europe. Dr. R also states
(p. 235) that in 1768, the Empress Catharine of Russia submitted herself
and her son Paul to inoculation, and that this spread the practice among the
Russian nobility; and the disease prevailed so extenmvely, that Sir A.
Crichton, subsequently the imperial physician, has stated that, previously to
the adoption of vaccination, every seventh child bom in Russia died annually
of small pox.
There seems also to be some discrepancy of opinion respecting the rate
of mortality after inoculation. Our author states it to be, with ordinaij
precautions, one in five hundred. Though we perhaps might have hoped
that improvement in the mode of conducting the operation, both in the
preparatory and accompanying treatment, the selection of the proper season
of the year, &c., might have led eventually to a diminii>hed rate of mortality,
still we fear it rarely descended to so low a figure.
Dr. Jurin concluded, from an examination of the London bills of mor*
tality for forty-two years, that of those who had been inoculated, one in fifty
died.
According to Mr. Shattuck (Viitd Statistics cf Boston — Amer. Jour. Med.
Set., Apr. 1841), the deaths among those who were inoculated in that city
between the yea'^ 1721 aiul 1792, amounting to nearly 23,000, varied from
five in a ihous^md up to tliirty in a thousand, the smallest mortality thus
reaching one in two hundred of those inoculated. During the same series
of years, the deaths by natunil small pox ranged from the proportion of 95
in 1000 to that of 34 1 in lOOO of those attaoki^.
In addition to this, we must not overlook the permanent disfigurinff of
many, the danger of loss of eyesight, and also the liability to be followed
by diflorent chronic disea«»es.
However great, therefore, may be our indebtedness to inoculation for the
amount of life saved bv it to mankind, and we freely acknowledcfc it to have
been great, we cannot but feel that the practice can never be relieved from
tlie objection of multiplying foci of contagion ; and, while we concede that
its continued employment would doubtless have led to great improvement
in the mode of conducting it, and to still more decided benefits from it, with
probably diminished risk of communicating it beyond the individual operated
upon, we cannot be too grateful for the substitution of another protective
power, apparently equally eflicacious in its results, and almost entirely free
from the charge of the least danger in itself, either to the individual or to
those about him. Not that we love inoculation less, but that we love
vaccination more.
At the same time we fully agree with our author that there are circum-
stances which would warrant its adoption in special cases, and with proper
restrictions, and that those mentioned by him come under this head ; and we
I
I
could even add to tlie list. It h not denied tbot iDocnlation mny be per-
fectly aafc, ao fur us the individuul on whom it is performed U coacemedi
juid that it may bo a valuable test of his proteution from casual variola ; bat
the fact that, tiowcvur mild in itself, it may communicute tlte moat umlignant
Ibrni of the disease to anotlier, la one whieh lenders it a dnngerous agent,
the nse of whioh, independently of other reaaona, ahould be restricted nitliin
narrow limits — and, indeed, prohibited altogether from the risk unavoidably
attemlttot upon iU general employment
[ H.—Page ni. ]
The difTeTeal views which have been entertained respecting the pathology
of the dropsy follomng scarlet fever show that the subject, allliough it has
received much attention, still requires further investigation.
Some ehor^ it upon the akin, whoae funclions aa an emunctory ore aaid
to b« impaired, according to some, by the simple action of cold, and aecord-
ing to others, by the specific poison of the disease ; while another ascribes
it to a sub-infiamnjation of tlic cellular texture originating in the eruption.
Others again attrihule it to general debility of the ayatem.
Dr. Qolding Bird thinks that the seqaelce of acarlatiiui ore " almost oil
loferrible to the retention of the nitrogeniied elements of urine in tike
blood," to which he attributes the tendency to the setting up of eerona
inflammalion, especially of the pericardium, pleura, and arachnoid.
Ila connexion with an albumiuous statu of the urin«, at leoat in s great
nuqority of cases, has led many later pathologists to place tlie seat of it in
the kidney ; but even among those who have token this view of its origin,
there is discrepancy of opinion as to the exact port of tlie organ ufleuled.
Dr. George Jolinson regards it as dependent upon an inflammution of the
kidney, very umilar to that stute of the skin which results in desquamation
of the cuticle. lie calls it "actUe daiiuamalive nephrilu," He eaya that
this desquamative ataio of the secreting cells may exist some time before
eridenou of congestion of the kidneys appears. When tilts desquamation is
the tubuti urioiferi may become choked with epitiivlium, and
may thns be produced, and this may be followed by infUinma-
tion. {Med. Ckir. Tratu., vol. xxz. 1S47.] Dr. West takes tlio same
view of the notivu character of the inflammation.
Dr. Sohilnlein is of the opinion that the exfotiation of the urinary epithe-
linm is the prodlBposing cause of aoariatinal dropsy, and says that tha
patient {a not Hnfe ao long as any of Ihia deposit ia found in the nrine.
Dr. James Miller conaiderv the dropsy as " a port of the disease, or merely
an evidence of another, but less obvious expression of the acarlatinal poison
in the human body," and aays that " it is no casual complication or sequel
utaing from undue exposure alone." He contends that the poison has a
primary influence on the kidney, and affects it according to definite lawa,
•hewing itself then, as a geaerol rule, on the fourteenth and lwenty4int
dajSi— «id tays that this ordinary period of the Mcanence of tenal aym^
356 AFFEKDIX.
toms ** IB probably in accordance with the normal action of the ecarlatinil
poison Btill active on the kidney." The eruptive action is sometimes
wanting, and to this form Dr. M. gives the name of " renal scarlatina^ or
scarlatina of the kidney s.^^
Dr. Bchrend describes two forms : — the first dependent upon congestion
and inflammation of the kidneys (Hydrops nephriticus) ; the second upon
debility, or impoverished state of the blood (/f. antcmicus). In the first
form, he thinks that the dropsy is partly a direct result of the impediment to
the eliminative process of the skin, and of the efforts of nature to restore
this, and partly a consequence of the impediment to the excretion of urine
by the kidneys. To the latter cause he attributes the effusions into the
serous cavities ; while the dropsy of the cellular tissue seems to be a sequel
of the renewed attempt at elimination by the skin. For a sumouuy of his
opinions and his conclusions, see Ranking' s Abstract^ No. 10, p. 28.
Some support of the opinion which refers it to impaired function of the
skin itself, at least occasionally, would seem to be afforded by an epidemk
of scarlet fever in Berlin, in 1840, where, in a great majority of cases, the
urine was not albuminous.
On the other hand, the deposits of epithelial cells and ** fibrinous casts**
of the tubuli uriniferi found at times in the urine, would seem to fiivor the
opinion of infiammation of the kidney as the primary form of the disease.
This hypencmia or inflammation of the kidneys is doubtless the cause of
the albuminous urine, which may disappear as that condition of the organ is
removed ; or it may become acute nephritis, with effusion of fibrin or pus;
or may piiss into the confirmed albuminous nephritis of Rayer (Brighfs
disease).
Hence, in fatal cases of scarlatinal dropsy, we find after death evidences
either of simple congestion, or of inflammation in different stages of progress
in ditferent cases, from the earliest to the most advanced stage, and even
abscesses in the kidney, and in protracted cases, tlie well known lesions of
Briglit's disease, instances of all which clianges arc on record.
Dr. R. B. Todd considers the conditions of dropsy after scarlet fever to be
— 1st, a j)arlicular state of the $kin ; lid, a particular state of the kidney ;
and 3d, a particular state of the bjiml ; and says that he does n(»t think you
get the dropsy fully developed without the concurrence of all three con-
ditions ; that if one of them is absent, you niny have a threatening of the
dropsy, but the full result does not follow. {I^md. Med. (;«:., Feb. 1849.)
Mr. J. W. Trii)e acknowk'dg«^s three varieties of scarlatinal dropsy : — 1.
That in which the urine is not alljuminous. 2. That in which it is albumi-
nous, with subacute nephritis. 3. That in which the urine is .albuminous,
with acute nephritis ; or dropsy from debility, dropsy from renal derange-
ment, and from disftrganizati(»n. (M(dirnl Tiriics^ Oct. 21, 1848.)
Chanm-s occur durinir this, as wt-ll as during' many other acute diseases,
which give rise to dropsy, especially in protracted crises, as is seen in
phthisis, in convalescence from fever, malarial diseases, &c., when there is
no reason to suppose that there is any affection of the kidney. But when
APFESDIX. 357
dropsy supervenes early, and particularly if it comes on suddenly, and
iq>pear8 in the face first, and the patient shows no decided evidences of
debility, there wUl be good reason to look to the kidneys as the cause.
[ L^Page 201. ]
The treatment of the dropsy following scarlet fever may be described
under the two heads of prevenlive and curative^ the former, as our author
remarks, always of course to be aimed at
Among preventive measures may be mentioned careful protection of
patient from atmospheric changes, a regular diet, a free state of the bowels,
and especially the frequent use of the tepid bath. The symptoms men-
tioned in the text as precursory of effusion, must be carefully watched, and
also the first indications of its appearance, which may generally be earliest
detected in a puffy state of the eyelids, and an oedematous condition of the
faiteguments of the cheeks, particularly about the lower part of the face.
The treatment of the effusion, when it has once supervened, must depend
upon the length of time since it appeared, its extent, its manner of appear-
ance, whether slowly and gradually or rapidly, the constitution of the
patient, the previous treatment, his condition at the time, and the nature of
the prevailing epidemic. A careful attention to these several points, and
especially to the condition of the patient at the time, will often enable us to
decide upon the proper plan of treatment in a given cose, and will also
reconcile the apparently contradictory statements of those who recommend
on the one hand an antiphlogistic course, and of those who, on the other
hand, insist upon the necessity of tonics, each plan being proper under
eertain circumstances.
The leading indications of treatment of this form of dropsy may be stated
to be — 1, to relieve the congestion of the kidneys ; 2, to remove the accu-
mulated fluid ; 3, to promote the action of the skin ; 4, if necessary, to
•upport the tone of the system.
The principal means to fulfil these indications are :
1. Cupping, leeching, poultices, and fomentations;
2. Ilydragogue, cathartics, and mild diuretics ;
3. Diaphoretics, tepid bath, warm diluent drinks.
4. Tonics of different kinds.
In the early stage, and when there is a decidedly inflammatory state of
the system, with a hot and dry skin, &c., and the patient is of a strong
constitution, and the urine is highly charged with albumen, and the more
BO if it contains blood, depletion from the lumbar region by means of cups
or leeches, followed by emollient poultices, may be called for; Jind in
patients over six or eight years of age, it may even be necessary to take
blood from the arm under such circumstances — but, as a general rule, the
abstraction of blood, either locally or generally, may safely be dispensed
with, and the application of poultices and fomentations be trusted. In this
■tate of things, diuretics must be avoided, and the internal means restricted
358 AFPBHmx.
to catliartics, diaphoretics, and emollient drinks. This coarse will be tlie
more called for, if the effusion has taken place suddenly.
In other cases, when the constitutional disturbance is slight, and the
effusion has taken place gradually, and the patient is not enfeebled, hydnu
gogue cathartics, with mild diuretics, and light diet, as mentioned by our
author, will be all that is required. Among such cathartics, the combination
of jalap and bi-tartrate of potassa is probably one of the best Elateriom is
also valuable, when more prompt action is necessary, and the effufflon
requires more immediate removal, and may be given in doses of i to i of a
grain, every three or four hours. Castor oil may also be used, if these are
tardy in their action. We have derived very decided benefit from the use
of the apocynum cannabinum (Indian hemp) in cases of abundant effusion,
when there was little or no febrile action, and have seen it act freely, both
as a purgative and diuretic.
In still milder cases, the iodide of potassium presents us with a good
alterative and diuretic, and may be given alone, or in combination with some
bitter infusion ; and when the system is much debilitated, and especially in
those of strumous diathesis, iron constitutes a very valuable addition to our
therapeutic means, and may be given in the form of iodide, citrate, or, as
highly recommended by some, muriated tincture. In these cases, the diet
should be generous and full, but carefully adapted to the state of the diges-
tive organs, and the bowels kept in an open state.
The acetate of lead lias been recommended bv some, after the active
symptoms have subsided, when the kidneys are in a stale of passive conges-
tion, and a kind of serous lurniorrhage is taking place.
I)iaj)li(»r<''iics are also used with advantage, and may be combined with
diun-tii's, a.s the syru]) of ipecac, with acetate of ammonia, and sweet spirits
of nitre.
To any and all these means, the tepid bath will be found a valuable
auxiliary, and may be given every second or third evening, of the tempera-
ture of I'li^ t(» 91^ Fahr., and the child kept in it from twenty to thirty
minutes.
The cure is taeilitated by keeping the patient in bed, and also by directing
the constant use of llannel next to the skin.
[ K.— iVgf 226. ]
We have thought that our readers would be interested by a >hort abstract
of some of tiie leading l\'ature& of erysipelas in an epidemic form, as it has
presentid itM*lf in dillerent plaees in our country, remote from each other,
during the past eight or nine years, and has been deseribed by dilTerent
writers under the ditlerent names of "K])idemic Krysij>elas," ''Erysipelatous
Fever," as well as under the j>opular name of " Black Tongue," a name
which one form of it has received in some parts of the Uni<ui.
The earli«'st account of erysijH'las in the form of an epidemic, within the
period alluded to, which we have met, is that given by Drs. C. Hall and G.
369
J, Dexter (Anur. Jour. Med. Sci., Jao. 1844) who dewribe it under the
mune of ■■ eiyeipelulous fever" at it occurred in tliu nortlieru section of
Vermont and New Hampshire, in the years IS'U—IS. In Ibis ejndenuo,
there was great nniformity in the mode of nttuck for two or three moalhi
from its first appearance. Afler premonitory ■ymptoms of pyrexia, with
nore or leas soro tbroat, enlarged loadls, and eub-maxjllary glands, difficult
degliititioD, and aometimes pAinfui respiration, attended with Issaitude, pain
in the back and Umba, fro()uent and depreHsed pulse, cold and clammy honOB
and feet, &c., &c., and generally at the end of twenty-four hours, there wae ft
chill, sometimes a severe rigor, followed by general reaction, with frequent
ud bounding pnlae; and in some inaUncos, the skm was bnlhcd with a
copious acrid perapiratioo. In other eases, the attack came on when the
patient was in apparent health, without an; premonitory symptoma, with n
sense of coldness, soon followed by severe chills. These were succeeded
by pain in the head, stomach, abdomen, back, and joints, or some or all of
these at the same time, followed in the course of twenty-fonr or tMrIy-«ix
hours by the soro tlirout. The utysipeUtoDS affection of the skin usmatly
appeared about the third or tourtli day ; and when it did appear, was not
conflned lu any particular location. It
side of the neck or fact', prcsciiling an i
rod spot.
In this epidemic, there wa« n marked c
pnerpeml peritonitis, and striking cases ai
was commnnicatcd to parturient females by physicians In attendance o
oases of erysipelas. The puerperal disease proved very fatal.
In one county in Vermont, of thirty cases of puerperal peritonitis which
ooonrred, only one recovered ; and in Balh (N. H.), containing a population
of 1500 or 1600, twenty mothers died from puerperal perituiiilia, and ahont
forty with erynpelas.
Diaphoretics, anodynea, hot fomcnlatioiia, and counter-irrilants, were
fonnd the most useful means of trealmenL In some casus with great beat,
ftill, bounding, and frequent pnlse, pain in the head, back, and limbs, and
•xtreme thirst, prompt and efficient bleeding was the only remedy to be
depended upon ; but it waa ncceBsary to employ it early. Different opinions
were enterloined respecting venesection by practitioners in the same neigh-
borhood in this epidemic, but the general impression was against it, except
in the class of cases just referred to.
In the stage of collapse, quinino was given with much success, wilfa
diSiiaible stimuli ; and when low muttering delirium supervened, opium, with
tartrate of antimony, had a very excellent effect.
The same form of erysipelas, with afll'ction of the throat, ooenrred in
Middlebury (Vermont) in tlie winter of 1841 and 1843, and has bc<en
described under the name of "eindemic erysipelatous fever" by Dr. J. A.
Allen in the Bo^on Med. and Surg. Jour., vol. Ttxix. 1844. The throat was
niuformly found inflamed, and the tonsils swollen, sometimes to such an
extent in ■ few hours that deglutition could only be performed with
usually first observed o
:utely sensible and circumscribed
between the disease and
which this latter disease
360 AFFEnnx.
extreme difficulty. The tongae became so much enlarged in some cases as
to fill the mouth, and prevent the passage of anything to the stomach. Bat
this was rather a rare occurrence. In the course of a day or two, the
disorder of the throat and mouth became mitigated, or entirely gone ; and in
proportion as the local affection diminished, the face, scalp, or side of the
neck became swollen, painful, hot, and vesicated, presenting the unequivocal
characteristics of erysipelas. The local disease in some cases attacked the
brain, in others the lungs, in other cases the abdominal viscera, and occa-
sionally the soles of the feet, ankles, or palms of the hands.
The number of cases in Middlebury was estimated at about tax hundred
and fifty, with a population of about 3,200. A few cases occurred in
November and December, 1841 ; but by far the largest number occurred in
the next two months. Thirty-four deaths were caused by it between the
first of January and the latter part of May, 1842. Puerperal peritonitis
assumed an erysipelatous character, and added to the mortality, both in this
epidemic, and in an epidemic of erysipelas in the same town in 1825-6;
five cases occurring in the former, and all fatal, and seventeen in the latter,
of which only two survived.
In 1826, there were not less than sixty cases of parturition in Burlington,
and in 1842, not less than twenty. ^ Hence,'' adds Dr. A., ** at each time of
the prevalence of the epidemic erysipelas^ one fourth of the obstetric cases had
the child-bed fever.*" In the winter of 1841-42, at Crown Point (N. Y.),
two physicians had over sixty cases of delivery, and of these, fifteen or
sixteen had puerperal fever, and died.
Venesection was found of the greatest value in this epidemic, when there
was great vascular action, or congestion of any vital organ ; but was prac-
tiseii in only a minority of the cases. Diaphoretics, witii external warmth,
were found useful, and among the mo^t valuable means for acting on the
skin, wjLs pulvis antimonialis. Dr. A. derived no particular benefit from tlie
use of calomel as an alterative.
The same fever also prevailed extensively at Moriah (S. Y.), a town
about twenty miles from Middlebury, in 1842, at the time it was most rife
at this latter place, and it was estimated that nearly a thousand cases
occurred there. It also prevailed in the neighboring towns in the winter of
184*2- 13. From what Dr. A. observed, he dt'duc«d the conc]usi(m that
" w7j' 72 it haa oiicc cxpcjuhd ilself in a place, lilhiirf, or vt'ij^hhorhHnl, it will
not rcrur (la^nin in the sarn^ placf for a i^frirs of ijrnrs ;" also, '* that those
individuals irho hive had it at one cpiJemic jMriod are. exnnpt from its influ-
ence' at its nej't occnrrrnc.^^
Dr. GcorLTc Sutton, of Aurora, Indiana, publi>hed (We<tfrn LanctL Nov.
1843) nn account nf tlie disease as it appeared in Ripley and Dearborn
counties of that State, in 184'2-43, under the name of '•Epidemic Erysipelas,
known by the popuhir name of ' Bhick Tongue.'" The epiileniic assumed
different chnrncters, one of which was an erysipelas, connected with
cyniUK'iie tonsillaris, or swelling of some of the lymphatic glands. Another
was a typhoid pneumonia, sometimes connected with swelling of the axillary
am
givids. Ho Bays the premonitory symptomB in each disease were alike,
tad the chnroclcr of the fever the same ; and that one form of disease often
changed into the other, and the two forms frequently attacked different
mombera of the same family at the siime time. The uttaek Viaa always
uahered in by a cliill, lasting in some caaes four or five hoar?, nAur premo-
nitory symptoms for two or three days. *■ This was followed hy a high
fever, swelling of the tonsils, submiuillary, parotid, and lymphatic glands of
the neck ; noumlgic pains, darting over the side of the neek and hend,
fi^quentiy following the temporal artery ; the tongue, covered at first with
a thick, brown coat, soon became swollen, and often very dark in the centre i
dcglotitjoa fVeqnently very difficult ; pulse generally very full, though eaaily
oompresBcd ; skin at first hot and dry, becoming moist, and continuing so
after venesection. Sometimes the mild form had only the appearance of
Cjmonche tonsillaris. But in the more malignant form, when the throat was
affected, after the above symploms had contitiued for two or three days,
and Homelimes from the very commencement, the pharynx becatno of a
dork purple color ; this color generally spread over the palate, tongue, and
sides of the cheeks, the tongue becoming very much swollen, assuming a _
blockish brown color; deglutition in many eases was almost impoe.'<ihte.
In most of these cases, an eryBipelas would commence at the angle of tiia
mouth or nose, and spread over the face and heed, with all the symptoma
peculiar to that diseaso." "In nearly every case," he says, "the throat
became loelt, iphik the erytipelas was tprtading over the ikin." TTib diaeaae
seemed sometimes to commence in the frontal sinnses end antrum. There
would then be a discharge of large quantities of water from the nose, and the
foce would swell so inuch as to close the eyelids. These symptoms gradu-
ally continued until an cry^pelasmodeitsappearBnce, or there was a copious
discharge of bloody mucua from the nose. In a case of this kind seen by
Dr. Sutton, the neck woa unormonsly swollen from the left ear down to the
atemnm, without any redncas of the skin, and but little inflammation of the
pharynx; this swelling rapidly Buhsided, and was Toliowed by a profound
coma that terminated in death. " In a number of caxei, the inguinal
glands were the seat of the disease, becoming very much Inflamed, and
an erysipelas first making its appearance there, and spreading over the
abdomen."
The treatment of the epidemic at the commencement of the attack wia
strictly antiphlogistic, bearing in mind the tendency it had to asEume a
typhoid character. Blood was drawn from a large oriticc, with the patient
in (lie upright position, until a decided impression was made un the system,
and this was generally produced by taking a few ounces In pneumonia.
When the tliroat was attacked, emetics, followed by mercurial calharlica,
nausennls, blisters, liniments, and sinapisma to the throat, pediluvin, acidu-
lated and pepper gargles, scarifying the lonaila, and when the throat was
olecniled, the application of a solution of nitrate of silver, was (he course
generally adopti-d. and in a lai^e number of cases, the bleeding, the emetic,
and the mercurial cathartic cut ahort the disease at once. Great eantion
■
362 APFEIIDIX.
was required in giving mercury, care being exercised to avoid its spedfie
effect
When the erysipelas appeared on the skin, alterative doses of calomel
and ipecac, (carefully avoiding ptyalism), followed by saline cathartics and
antimonial diaphoretics, were used in the robust ; and wine whey, carbonate
of ammonia, Dover's powder with calomel, followed by gentle laxatives,
when the disease assumed a typhoid character. As a local application to
the erysipelas, a solution of the sulphate of copper, and also of the sulphate
of iron, appeared to produce good effects ; and when the skin was not
blistered, the spirits of turpentine answered very well.
The fatality of the disease varied very much in different places, in some
townships being very great. In several places it was accompanied by
puerperal fever, which was also very fatal.
Dr. Sutton was unable to give any statistics of its mortality, but says
that it was generally considered by the oldest inhabitants to have been the
most fatal epidemic within their memory that has visited our country, not
even excepting the cholera. (Quoted in Amer. edit of Nunneley on Erysu
^felas ; and also in Amer. Jour, Med, ScL, Jan. 1844, p. 247.)
^ In an account of "epidemic erysipelas" at Michigan City (Indiana), in
1843-44, given by Dr. Meeker (Illinois Med. and Surg. Jour,., June, 1844,
quoted by Amer, Jour, Med. Sci., July, 1844, p. 273), of sixty cases, one
half were fatal. In this epidemic, the skin alone was affected in some
cases, with the mucous membrane of tlie fauces ; and in other cases, the
internal orj^ans became intiamcd, withont its making its appearance upon
the surface at all. It attacked nearly all puerperal females, not more than
one in ten e.sca[)inpr. The rate of niurtility in tliese cases is not stated.
In an cpiclcmic which occurred in Petersburjxh (Virir.), during the winter
and si)rinjL,^ of 1814-15, described by Dr. Peebles under the name of
"epidemic erysipelas'' (Amer. Jour. Med. Sci, Jan. 184())? to which we
have alren<]y alluded in the body of the work, "the disease presented three
distinct varieties, or «^n-ades of violence. First, simple erysipelatous fever
characterized by the peculiar throat atVection, accompanied by enlargement
and tenderness of the t,dands of the neck, and stiffness of the cervical
muscles. Secondly, to these symptoms, usually coming on with a chill of
greater or less violence, there was after the third or fourth day superadded
the external erysi|)elatou8 inflammation, generally on the face and s<'alp.
Thirdlv, the disease assuniiufr totally different features, much increased in
severity and danger, was tirst manifested in the form of severe inflammatory
action located in some important internal organ, wiiich symptom was only
ultimately relieved by the apj)earance of the cutaneous inflammation." The
internal disease was always located in the mucous membranes, and was
liable to seize that in the lungs, including the larynx, and the miimte
bronchial ramiflcations, that of the stomach and bowels, and of the bladder
and urethra.
Dr. Peebles states that it was invariably the case in his practice in this
epidemic, as was also true in that described by Dr. Allen, that the symptoms
or the interns] afibetion were relieved or were speedily removed by the
appearance of inflammHtion on tlje surface, which iDvariiibly toolt place id
■U Ihe moat severe and malignant cases of the diseasB.
Dr. Daniel Dmlie ilIso gives a general acuount of a form of eryupclas
known under the name of " Black Tongue" whkih prevailed b MiaViMip^
and Missoari in 1841, founded entirely on verbal aecounta of fixe disease
derived from diflerent practitioaers in those stateo with whom he held
persona] comniunicatJOD. He says that it ofiecta both wliilea and blaoha,
the latter perliaps more frequently and fatally than the furmvr, and occurs
in both winter and summer. In some cases, the local, and in otlsers, Ibe
conslitulionol symptoms appeared Itrst, but the fever has always preceded
the cattincouB inflamniation. In some oasea, the stomach instead of the
throat was the seat of the disease. As the eryHipelsa appeared, the angina
generally erased. In some eaaos, the tongue was so swollen and inSamed
u to make glossitis tbe prominent part of the disease. Dr. Dralce conndeiB
the diaenao to be a compound of erysipebs and scarlatina, Ihoogh be does
not reg^ such a conclusion as eatitblished. The brain, lungs, and aloraaeh
and liowels, were sevemlly the subject of the disease in diflerent ensus.
The Uncet was employed with advanUge in the early stage of the
diBease, especially when the brain, or lungs, or any of the abdominal viacem
were attacked. Csthartics were generally employed, but not in large
quanliliuH, and eopioui putting waa not on the whole beneficial. When
exhaustion came on, as was the case in many instances after the first few
days, diffusible stimulants, with tonics and nutrients, were required, and
were found useful, especially in extensive suppuraUon, and with a tendency
to gangrene. Vaiioua local applications were used by different practitiouera,
and all with an equally equivocal beneGL {Watem Jour, of Med. and
rSur^.,Oct. 1844; quoted in BtiHtlm of Mtdkal iScience, Nov, 1S44.)
The some disease, as it o<%urred in Warrenlon (Miss.), in March, IS44, is
deacribed under the same name by Dr. W. R. Puekett of that place, and
presented tlie some general characteristics as the form which prevailed
elsewhere, presenting similarly great diverwty in mode of invasion as well
aa in its points of atlacli. (iV«tf> Orleaiu Mfd. Jour. ; quoted also in Buil,
Mtd. Sci., Nov. 1844.)
This disease also prevailed in Delaware county, Pennsylvania, during the
spring And early part of summer of 1841, in a severe form, and Is described
under the name of " epidemic orynpelaa," by Dr. Jesse Voang. It generally
came on with the usual symptoms of catarrh. The ciyMpetatous indamma-
tion appeared on the surface at the end of three or four, and frequently
seven and eight days aAer the commencement of Ihe constitnlional symp-
toms, but without any regularity in this respect. When it came out in
patches for a short time, and then receded, wiilch it was very apt to do, the
patients rarely recovered, no Iroitment having any effect in such cases.
When tlio efHorescencc came out and remained on the sorCice, the patient
generally recovered at thu end of from one week to three or four. Tbe
864 AFFBHDIX.
efflorescence appeared often on the head and face, but frequently on the
extremities, or some part of the body.
The plan of treatment found most efficacious connsted of emetics of
ipecac, and ant. tart combined ; afterwards cathartics of calomel, followed
by jalap or some other purgative, in a few hours ; and after free evacuations,
mild diluent drinks of different herb teas. The lancet was freely used in
the earliest cases, but with unfavorable effect ; and all agreed, after more
familiarity with the disease, that ^ venesection was a dangerous, or at least
a very uncertain, expedient"
When the disease did not receive early attention, the patient sank from
day to day, until great prostration ensued, and sometimes the erysipelatous
surface was attacked with gangrene, with extensive sloughing. In such
cases, tonics, with powerful stimulants, were required.
The writer states that " quite an unusual number of deaths occurred,**
but most of them in the early port of tlie epidemic, but gives no statistics.
(Medical Examiner, Phila., Sept 7, 1844 ; quoted by Amer. Jour. Med.
ScL, Oct 1844, p. 646.)
Dr. Lovelace describes the ** black tongue" as it appeared in Vicksburg
(Miss.), when it was first observed in March, 1844. He and his partner
saw forty-two cases, of which six terminated fatally. Blood-letting did
not answer in that epidemic. (New Orleans Med, and Surg. Jour., Sept
1846, p. 190.)
Dr. A. M. Keller gives cases (Western Jour. Med. and Surg., Oct. 1845)
of " erysipelatous laryngitis" or " black tongue," occurring in Courtland,
Alabama.
Dr. S. Glisson also, in a letter to the editor of the New York Journal of
Medicine, dated Livinijfston, Michigan, June 20, 1847, speaks of a form of
"malignant erysipelas, commonly called Black Tongue," which, he says,
had been lately observed in the neighborhood of that place. He says " the
black appearance of the tongue has not been noticed more than once, p«^r-
haps, out of ten cases;" but that it looked more as if it had been boiled.
There was also very great tumefaction of the face and scalp, and also of
the fauces, palate, tt)nguc, &.c. He says the disease proved fatiil in many
cases, but gives no statistics.
The treatment which appeared most successful was the sthnulating and
diaphoretic. The anti|)hh)gistic made but little imprfssion, and the patient
soon frll into a typhoid state, which rendered stimulants necessary. {\ew
York Jffiir. MfiL, .luly, 1847, p. Ii27.)
Dr. II. \. Bennelt lias given a description (\cio York Jour. Med., Mav,
1848) (if an ''epidemic erysipelatt)us fever," as it occurred in Bethel, Fair-
field county (Conn.), from the middle of \ov. 1837 to the middle of March,
1818. Tht* disease resemlded very strongly, as Dr. IV remarks, in its
general sym[)toms, local IcNions, and the mort.ility attending it, the charac-
ters which it has presented in other portions of the country. Great
uniformity existed in the premonitory symptoms. A very constant, and Dr.
865
B. thinks, a nnlform se&tof infliiiDmatio[i,waa the throat, presenting diBbrtsnt
nppeariDcea in different individuals. " In all es«es without exception, there
was more or less tenderness and Bwclling or L'itlier the Buli-rooxilbuy,
parotid, or lympliatic glands of the nerk, as well as of the tonails ; and the
uvula was almost as universally elongated." The erysipelatous efflorescence
occurred in one sixth of the cases.
The ages of the patients, in fifty-nine cnaes of wliich a liblo is giTctii
varied from eight to seventy-Gve yeors, and llie duralion of ihe diBeaae from
three days to aa many months, including the milder cases of angina
extreme, and the cases of pectoral abscess on the other.
In this epidemie, the scroaH membranes were a frequent seat of tbft-
disease, especially the pleura and peritoneum.
Dr. B. inclines to the opinion of the conto^ons nature of Qie
with certain restrictions, but thinks tiint the evidence of fomitic contagioil|.
with reference to the puerperal cases is very neogre.
In the treatment of the onginose cases of the disease, t>r. B. commeneed
wtlh an emetic of tartarized antimony, taken with a strong decoction of
enpaloriam. This was followed by a blister to the neck, and Bometimea a
strong solution of nitrate of silver directly lo the inflamed mucous surfaces.
In more nmh'gnant cases, he depended mainly upon hark, with serpentine
snd mild laxatives during the fir^t sUges, and the more powerful sllmulanta
afterwords. He abandoned all external remedies except cooling lotions,
I
[ U—Page 287. ]
That the ground taken by the earliest vaccinators, and among them the
Immortal Jonner himself, that vaccination is a perfect protection of the
fljstem through life against variola cannot now be majntniiied to the letter,
is almost universally acknowledged. The extent of the protection nfibrdod
by this precious gift to man, the causes which interfere with its entire
protective power, and the means necessary to n-move the obstacles in the
way ofsneh protection, are not so well agreed upon. It must be conceded
that cases of a modified form of variola ore occurring, and apparently with
somewhat increasing frequency, in ibosu supposed lo be protected by the
process of vaccination ; but it is consoling to notice, tlint even witli this
increased A«quency of attack, there is a mildness which divests it of very
much of its dread, and a mortality which, compared with that in the
unprotected, is slight — and there is much reason In believe lliat the fatality
does not increase in proportion to tlie frequency of attacks, and that tlie
rate will be foand not to reach that of seven per cent, aa furnielied by the
Btatistics of the London Small Pox Hospital.
We have collected statistics bearing on this point IVoni different and
distant sources, which would serve to prove that, st least under certain
circumstances, and, perhaps, we may with propriety any, as a geuurnl rule,
this ift tlie case.
At the same time wo would premise, that bstnncea are recorded where
866 AFFBHDBL
the mortAlity has reached a higher ratio ; bnt they are so few in number,
that their very rarity affords fair ground for the question whether some
peculiar circumstances may not have operated in the case.
The replies received by the Committee of the Prov. Med. and Surg.
Association would seem to place the matter in a different light The only
two statements at all conflicting with the general favorable tenor of these
replies was that of one gentleman, who stated that of nearly one hundred
cases attended by him the previous year, one half were after vaccination ;
and of another, who reports that of eighty cases of small pox, sixty or
sixty-one had been vaccinated. In the latter instance, it is stated that tho
majority of the vaccinations had been performed by a superannuated excise
officer, and the only fatal case that occurred had been vaccinated by this
man, and by him pronounced safe.
This Committee say ^ the total number of deaths reported by all the
gentlemen who have answered our questions, throughout nearly the whole of
England, amount to very little above thirty. They say also, that they have
the testimony of those who have been engaged in the practice of vaccination
from its commencement down to the time of their report (1839), who have
never met with an instance of this kind. One gentleman who began in 1802,
and had vaccinated from six to seven thousand, had not met with more
than ten or twelve failures, and not one death. Another who commenced in
1806, under the immediate inspection of Dr. Jenner himself, and who con-
tinued to practise it up to 1838, never saw a death from small pox after
vaccination. Dr. Henry Jenner, the nephew of the distinguished Dr. J.,
met with the same result. Another who had vaccinated extensively and
gratuitously tor twenty-four years, had not seen twenty cases of modified
small pox, and not a death after vaccination.
Mr. Ceely, of Aylesbury, reported that there were twenty-eight deaths by
small pox last year in that place (1838), but not one occurred after vacci-
nation.
Another practitioner of vaccination for thirty-two years stited that,
thout,Hi small pox had prevailed the previous winter (1838) to a great
extent, and was vtry fatal, he had not seen in proportion more cases of that
disease after vaccination than of small pox after small pox.
One physician, who be^jfan to vaccinate in 1798, stated that "very few"
cases of small pox had followed vaccination in his experience, and that in
most of the instances of the khid whieh he had heard of, the vaccination
had either been interrupted in its progress, or performed by a non-medical
person. He f^ives one melancholy instiince in which a family had been
" cut " by an itinerant quack, most of whom afterwards caught tlie small
pox and died. He adds, that he had never seen a fatal case of small pox
after vaccination, but liaJ seen five cases of small pox after small pox.
Two physicians, father and son, could altogether enumerate about twenty-
four persons in whom small pox had followed vaccination during the whole
of their professional lives, and of these, they themselves only saw nine.
Another, who had been settled in practice thirty-one years, had had two
eases or Btnall pox nfter vHceinntion, both very niitd and modified ; and tind
had tliree cusea of aecontkry nnall [iok, two after inoculation, OQC of wbkh
proved ta\a\,
At tlio Roynl Military Asylum (England). 1406 children were adtoitted
from 18in to 1837, and all were vftecinaied, whether prtvioualy vucciiialed or
not : and among these, one Ciuc of small pox or varioloid eruption happened
in 1826, During a pan of thia time, amallpoi had been Tery prevalent and
fiiUl among Iho poor.
Of onu hundred and fourteen coaea after reputed v«ccina Won in 1837,
niHnlJoned by Sir. Dodd, tho Secretary of the Committee, only two were
btaL He nevifr saw a cnae of amail pox in n patient lie had vaccinated,
after a practice of ten yearB,
According to tlie report of the National Establiahment, eighty-three
Ihouaand fix hundred and forty-aix persona were vaccinated from IBM to
1S33, and among these, only two dciitha by small pox occnrrvd, and one «f
liie«e of a very doubtful nature.
In tho Roynl Military Asylum at Chelsea, from August. 1803, to Augnit,
1833, those reported lo hare had sronll pox before udmieaion were 3982
(1887 boys, 645 girls); the nnmber reported to have been vaccinaled before
admission was 30GO (3459 boys, G62 girls). Those who liad small pox
after re|iuted small pox were -26 (Ifi boys and 11 girU). The casea of
■moll |Kix after reputed vaccination were 2-1; 19 boys and S girls. The
whole nnmbur vofcinated at tho asylum aubsequently to admission waa
636; 46a boys and 108 giris. Of the whole, only two boys nnd one girl
oangfat the small pox. Five deatiis occurred ; four boya and one giri. Of
the«e five children, Ihrce hnd the disease after reputed small pox, nnd two
had neitlier been vaccinated nor bod undei^one the amall pox before. In
tbia instance, it will be aeen that not a single deaUi occurred after TBccioa-
tion, while three out of the five fotal cases were after amall poi.
Dr, Labntl, who, from the commencement, paid very great attention to
the character of faccination, and watched it witli care, atalea that, from his
obaervstion, "the reputed failures have almost invariably originated either
from want of skill or inattention of pmctitionera, from inoculation having
been performed by unprofesdonal persona, or the extreme inattention of
perents and others in not showing children at the several stages of the
■ffection." He adds that, during an extentive practioe of tliirty-six yean
■nd upwards, be has not witnessed a nngle cose of death ft'om small pox
after regular vaccination, and not more than Icn caaes in which tinuill pOX
occorred in persons who previously had cow pox.
In one of the largest institutions of Dublin (none not mentioned), tha
average number of whose inmairji was between 3000 and 3000, np to Hie
latter port of Horch, 1839, thirty-eight cases of small pox hod occurred, nnd
but a single caae of that disease afl«r vaccinaliDn. and that in n child said
to have been vaccinated two years before in Liverpool, but on whose arm
there was no trace of cow pox.
The Committee of the Prov. Med. and Surg. Assoclal. conclude their
J
368 APPENDIX.
remarks on the continued protective power of cow pox by saying, ** we hold
it to be proved beyond all doubt, that the same laws which govern human
small pox apply, * mutatis mutandis^ to cow small poxP They deny that
the cow small pox, duly and efficiently communicated to man, loses its
inj9uence by time. They remark tliat in the midst of such conflicting
evidence, there is no other way than to recur to first principles, and inquire
whether the lymph has been pure, and the development of the aflfection
regular and complete, and the state of the patient such as to present no
impediment to the regular course of the affection. A patient should never
be considered safe, nor has vaccination been duly performed, unless all
these things have been attended to, and it is doubtless to the neglect of
sucli attention that many failures are to be attributed. They add, *^aU cases
cf reputed vacciruiiioTi, unless they have passed under review of a competent
judge^ who has untnessed the different stages of the affection, should be
considered as ho vaccination at all."
Mr. Thomas Hunt, of London, says, ^in a large medical practice in
Hertfordshire, embracing the majority of the population of thirty square
miles, only one case of small pox occurred in seven years — from 1812 to
1819, and that not after vaccination. At that time, medical men only
vaccinated." "Dr. Walker, who vaccinated with his own hands half a
million of human beings, and pronounced them all secure for life, after
being engaged in vaccinating for thirty years, saw but two cases of small
pox after vaccination, and these, he says, were two lives saved ; for they
only out of two hiTge families were vaccinated, and the rest all perished
with the disease." (On Protective Power of Vjxccination — Prov. Med. and
Surg. Jour., Sept 18, 1850.)
^fr. Xewnliuni s^iys, '* instances of perfect security after vaccination may
be multiplied indetlnitely : the instances of failure arc few in comparison with
the numhers vaccinated : and the cases of death from really modified small
pox, by j)revious elVective vaccination, are, u{)on the i^'ross scale, inappre-
ciably few." (Prov. Mid. and Siinr. Jour., ^Uiy 1, 1850.)
We have thus far confined ourselves to statistics furnished by English
practitioners, for the purpose of a more fair compari.Non with those furnished
by our author — but have reason to believe that those furnished by conti-
nental practitioners, as well an those of our country, will atlbrd a corres-
pondini: low state of mortality after vaccination.
From a table })repnred by ^I. Villeueuve, Reporter of a Commission
appointed by the Academy of Medicine at Paris, it appears that of 8G5 cases
of confirmed small \)ox, in persons who had been at some previous j)eriod
succosl'ully vaccinated, there were only ei^dit tlmt proved fatal — about 1
in '15 or -KJ. (Anirr. Jaur. Mrd. Sci., July, 1841.)
]\I. 13ous(pKt has collected the statistics of thirty-one epidemics in different
part^ of France, from 18J() to 1811 inclusive, which he has presented in a
tabular form, and from these we learn, that of G.OTl persons atUicked with
variola after vaccination, only sixty-three died, or about one per cent.;
while during the same series of years, of thirty-four cases of secondary
▲FPENDIX. 369
small pox, five proved fatal. (Nauveau TrailS de la Vaccine, Paris, 1848.)
It mast be remembered that these results occurred during epidemic preva-
lence, a condition necessary for the proper settlement of the question. The
same author has also collected, with great industry, extended statistics
on this subject from other countries, presenting evidence of the same
general character, to which we must refer our reader, without transferring
them to our pages.
Dr. Luther V. Bell, of Derry (N. H.), states, as the result of his own
experience, that no instance of death, when vaccination was performed prior
to exposure, had occurred in more than two hundred cases of variolous
disease attended by him, and a very large number of other cases he had
witnessed. {Amer. Jour, Med ScLy May, 1836.)
According to the Report of Drs. Mitchell and Bell, who had charge of
the Small Pox H6spital in Philadelphia, forty-seven cases occurred there in
1823-24, in persons who had been previously afiected by vaccination, and
not one proved fatal. Eight cases occurred in persons previously affected
with small pox, of whom four died. (Quoted by Dr. Chapman — Eruptive
FeterSi p. 91.)
A committee of the Philadelphia Medical Society, appointed to collect
facts upon the subject of small pox, say, ^ We may, without the least want
of candor, come to the conclusion, that only one death from small pox after
vaccination has occurred in Philadelphia during the year 1827, amoii<r eighty
thousand vaccinated persons, and during the prevalence of a most malignant
and mortal small pox ; while several individuals have lost their lives by
small pox, after they had already gone once through the disease." (Quoted
by Dr. Morton — Notes on MackintosKs Practice of Medicine^ 4th Amer.
Edit., p. 174.)
We might multiply statements from still other soun*es of the same
general character with tho«e already quoted, but will not enter into furtlier
detail, as we feel that sufficient has been brought forward to console us
with the belief that the rate of mortality by small pox after Viiccination, at
least in countries at large, falls short of that shown by the statistics of the
Small Pox Hospital of London to be true with regard to that iiiHiiiution —
and we cannot but hope that the high rate of seven per cent, may be con-
fined to limited sections of country, and perhaps to hospitals nlont', and thus
depend upon circumstances more or less local in their chanicier.
As these sheets were on the eve of going to press, we rect ived from Dr.
Gregory the following table, giving the statistics of the London Small Pox
Hospital for the ten years from 1841 to 1850 inclusive, which, as will bo
seen, fully sustain the rate of mortality by small pox after vaccination in
that institution, as already stated by him.
24
^^K» APTEKinX. ^^^^^^^^H
^^H|Wa exhiUting the totd vamhft of personH having amall pox, admitled
^^H intu llio Small Pox Ho^pjtnl of London, in Xha yean ttom 1841 to 1860, .
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We feel that the propriety, if not the daty, of re-vaccinatioii is now m
generaltf acknowled^ as perhaps to render it mineeegsary for na to
adduce evidence in fiivor of the practice. But an the views of some on the
■object may not be so fully established, and as others may feel interested in
an examination of the evidence by vhieh it ia aupported, we have conduded
to devote a short apace to it
Some of the earliest, and at the same time moat conclUMve testimony in
its favor, is famished by its reaulta in the Wirtemberg, Hanoverian, Bav*-
riiin, and eapedaliy in the PmsBian armies. Our limits will not permit Dl
even to give a anmmary of the figures on which the results are founded,
't the Age of fiftfcn yoHTs.
vaccinated, but rot showing
distinguish such csces trom th*
■ Nearly iha whole of these 1753 cases w
t Many of the poreom alleging to hati
cicatrices, were doobllen duly vaccinated, but tc
othera was impossible.
t N. B. The peiBons professing to have had small pox it some former period,
■ometimes announced themseWeB to have been iaaculated. sometimei to have bad
the casaal amall pox, tmt in no one inalince was there any corroborating evidence
of the truth of the sutemepl. Thesa came, therefore, are included ia the third
eoiamn of " Ptrmat UnprolteUd."
APPENDIX. 871
and we can only transfer to our pages some of their most striking featores
and items.
Re-vaccination was first ^ commenced systematically in the Prussian
armies in the year 1833, after having been practised in the Wirtemberg
army and among smaller bodies of men for several years previously, and
recommended by several leading practitioners, and has been continued in
that and in several other armies, and also among large bodies of civilians,
from that time to the present. The following are among the results :
In Wirtemberg, but one case of variola occurred in five years among
14,384 re- vaccinated soldiers, and three only among 26,864 re-vaccinated
civilians.
Not a single case of small pox occurred among those who had been
re-vaccinated in the Prussian army in 1836, 1837, or 1839. But three
deaths by this disease occurred in all the military hospitals of Prussia in
1841, and of these, one was in a person not vaccinated on entering the
army, because it had been done shortly before ; a second in a recruit who
had not been re- vaccinated ; and the third in an officer, who had been
re-vaccinated some years before, but without success.
In 1834, two deaths are recorded of those who had been re- vaccinated
with effect in the Prussian army, and one in 1843. In 1849, but one case
was fatal, and this was in a recruit, vaccinated when a child, and who had
not yet been re-vaccinated.
During an epidemic of small pox in Copenhagen in 1828 to 1830, and
also a very severe one in 1832, and another in 1835, not a single instance
of variolous or varioloid disease was obsen^ed among any who had been
re-vaccinated.
In the Danish army, of those who were successfully re-vaccinated in
1838, not one was attacked with small pox.
In an epidemic of variola at Heidclburgh in 1843 and 1844, described by
Dr. Hoefle, of all those attacked, not a single one had been previously
re-vaccinated, while the vaccinations most successfully made did not protect
from the most severe varioloid those older than ten years.
M. Lombard stated, during a late discussion at the Belgian Academy of
Medicine, that in the dreadful epidemic of variola which has just desolated
Liege, none of those who underwent re-vaccination took the disease.
{Brit and For. Med. Chir. Rer., Jan. 1851.)
Steinbrenner, as the result of extensive investigation of the subject, says,
** re-vaccination is the indispensable complement of the first vaccination, not
that it is always necessary, as some pretend who admit the loss of its pro-
tective power by time, but because it is necessary in very many cases, and
because there is no other means of distinguishing such urgent cases from
those in which re-vaccination is unnecessary." (Traitt sur la Vaccineyp.
684.) He derives his arguments in favor of re-vaccination from its effects
in the different European armies to which we have already alluded, as well
as when performed by various individuals on a smaller scale, of which he
presents a long array, and says that, in the absence of every other argument,
these results are atrongty in its favor, beconw it ia impDunble that the pro-
cess shuulil be BO often succesaral unless the saccess depended vpon k
[««dl»poulioD which exposed the bdividrnds to taiiota. He also demotk
otrnt^Mi the necessity of general re-vnctiiiBti«D by conudemliotis derived
iVoiu tliu loo great frequency of raecinntions whieli fire not alt protective, or
only iiD|K<rf(jet1y h«.
H. Bouaquot sajs, sfler giving a long list of inilJUKes of protection by
K-Tsccinntion without a failure, even in the midst of e^croics, a 1
whicb. he say*, be oonld easily extend, " there has not been an epidea
Whkh bus not proved, st tbe some time, tbo vinnea both of Tsecinatioii and
of re-voccination." (iVout«au Tnnli de la Vaccine — Piiri:<i. IS48, p. 506-)
He also nays (p. fiO 1 ), " tbe success of rc-voecination is at the same time
cdect and the proof of the wants of the syBtem" — "when it sncceeds, it
only proves that the protecliTO power of vacnnalion is dioiioi^ed, but it
■ntapliei a nmedy for tbis diminution,"
The following are the conclnaions on this subject of the Committee o
Vaccination, of the French Academy, as contained in tlieir report to that
body, in Febniary, 1846- —
1. Snuill pox ranily attncka those who have b«en vaecinoted before the
•g« of t«l or twelve, from which age, sntil thirty or thir^-fire, they a:
^Uible to Muall pox.
ia the only known method of distingiu«fatDg those
nt remfun protected, from tlioBe thai du Dot.
t. The stweeaa of re-vMeiiuitioD is not » certain pioot that the penon n
whom K succeeds was Iwble to contract small poz ; it merely eetablidiM •
tolerably strong presumption that be was more or less liable to take it.
4. In ordinary perioda, re -vaccination ahonld be practiaed after foarteen
years, but sooner daring an epidemic.
Among the eoDclnaions of a report on the subjeet of vaecinatioD, lately
made by a Committee to the Belgian Academy of Medicine, are the
following : —
■* As the immunity conferred by vaccination is not indefinitely abaidnte,
re-VBceinalion, at least for a great numlier of individnalt, is lalienaUj
indicated.
" Experience bas proved that a recent re-vaocination preserves from variolft
and varioloid, and that, practised on a sufficient scsle, conjointly with v^xA-
nation, it constitnlee a snre means of arresting the progresa of this maladj
when it appears epidemically.
" It succeeds best in proportion as it is most required, that is, the taore
remote the period dnce the individual has bad varioia, or has been vacei-
nated.
"During the prevaleoca of an epidemic cJ variola or varioloid, it is
pmdent to re-vaccinate all those whose first vaccination dates ten yean
bock, and all those whose filat vaccinatJOD givea rise to any donbL" (Brit.
and for. Med. Cfiir. Rev.,Jan. 1851— from Gat. Mid.)
Tommaiiid was led by liia obeervations of it* resnlU during an epidemie
a
I
Amtma. 373
of varioU in Italy, to recomroond it to his fell ow-country men, and we might
add iJie DumeB of many higlily diatingniahed of our proiesAion on both
tides of the Atlantic, who concur fully in the imporUnce of the practice,
and some who even think it eriminai to neglect it.
We cannot but feel, therefore, in view of these faets, that the testimony
in &var of re- vaccination is too strong to admit of its neglect. If no other
argument could be adduced, the fact that it immediately arreits the course
of epidemics when they appear, and that its fajthfnl performance has almost
entirely banished small pox from somo armies in which it had formerly
coratnitled great tavagos, would aeem conclusive in its fevor.
It may perhaps be said that tlie results in the European armies to which
we have referred speak against the manner in whicli primary vaccination
was performed in these cases, and con bnrdlj, with justice, be advanced in
proof of what would have occurred, bod the process been perfect in every
respvct. But allowing this to be true, they may still be adduced as a
warning of the danger to which our own population is at least partially
exposed ; for it cannot but be true, that the process has been not no&e-
quently performed among ue in sacb a way as to diminit^h, if not entirely
destroy, its protective power. Hence, we need re- vaccinal ion as a lest of
security, and as the only one within our reacL And when we con!<ider tbe
almost perfect prolculion, thus far at least, afforded by ro-vaccinalion, and
how trifling is the operation, we con surely hardly entertain for a moment
the idea of resorting to variolous inocuhilion, either as a test, or fur addi-
tional security against the failures of vaccination — an operation which is at
least oc«a^unally fatal, which subjects those on whom it h> performed to
Bome of the serious results which follow in the train of variola itself, and
which cannot be practised without multiplying centres of contagion, and
thns aiding the rovagea of the very enemy it ia intended to combaL
It ia proper, however, to alate, that the value of this practice is doubted
by some, and even ila propriety questioned.
Occasional instances of an aitaek of varioloid after re-vacclnation doubtless
do occur ; but lliey are so rare as to be thought worthy of record when a
aingle one occurs. Bousquet gives a case in an infant M. Newnham also
gives a case, after re-voccl nation by himself. (iVoii. Med. and Svrg. Jnun,
Hay I, IBtiO.) Ue considers the practice as a test of the efficacy of Ihe
first vaccination, and not a renewal of its bifloencc, which, he contends,
con never take place. The occurrence of n regnlnr vaccine veu<.'1e after
re-voccination he regards as a proof tliat the individual had not jtrerioasly
been successfully vaccinated.
It is true, as our author remarks, that a lulenied commission, nppoiuted
for the purpose in Paris, reported against the practice of re-vaccination ; bat
it is equully true that another commission (the one whose conclusions we
have quoted), appointed for the same purpose, at a later date, reported in
its favor.
As to the ago at which its prxtice should be advised, that of about ten
or twelve years is the one most generally recommended, advice founded a
tlw time at wbich cosai of variuloid have t>i?«n found b
rtng — Ihe proporiioii of coses uoileT ten years of age betng very smiilL
SteinbreiiDer fiie« apou the period of tweire to fitt«ea yeara of «ge
W the uiie moat proper for re>vweiuation, and uys iLat, if performed at
that time, it will protect for Ufa froin variola.
BouiwjuM aayi llmt there it dsug^ of variola from tho afe of t«n or
twelve to tliSrty or thirty-fire year*, and that the time for r
Mtmoicnccs from the age of teu ur twelve years, Uiat its value ii
flfteen ypar^ and la never grvalur than between twenty and thirty. In
limes of epuJCBile prevalence, it should be pmetised earlier.
In gencrul tennt, il may be aaid, that the prevalence of variola, Uie
Bxpu«iire of lu Individual at purliculnr limes, nod anxiety felt on the subject
I M any time, may each afford n renson for performing an operation «o tiifiing
^ Id ita itsture, and attended tuunlly with ho little ineonveuienee, that it bnd
belt«r be aubtnlltcd to more than once nnneceamrily, than neglected when
it might hnvD preaeni'd from nn attack of a loathsome diseaae, and perhaps
even saved life itself.
We need hardly add, that even grenter care should be talien with the
Mcond and Bnbseqnent voecinuttona than with the lirat, as we hnve n<
e l«st of ila sncceM as in that case. It should therefore be a mle Of ^
IpiBclice to repent the re-vaccination, if not auocessful the Brst time, onftl
ircn to rcpe.it it several lime*, in such a case ; ns a failure to produc
diaeose might happen from some imperfection in the
oeenn in the primary vnocimilion.
EXPLANATION OF THE PLATES.
PLATE I.
The casual ano pox on the teaU and udder of a black and white milch cow»
The disease is at its acm6 ; and tbo skin being fair, a slight areola is visible
aroond some of the vesicles, many of which have a bluish central tint. It exhibits
papulae, vesicles with central crusts, unacuminated and acuminated vesicles;
imperfectly developed and also broken vesicles, both solitary and interfluent.
The vesicles on the extremities of the teats are nearly of the color of the skin on
which they are placed — a circumstance of itself sufficient to distinguish them from
spurious or sub-epidermic vesicles.
TLATE n.
Casual vaccine vesicles on the thumb and finger of a boy who commenced
milking on the 9th of October. On the 19th, he observed on his finger a red
pimple of the size of a pin's head, and the next day, one on the thumb, very small.
The engraving representfl the vesicles as they appeared on the 23d, four days after
the first was observed, and three days after the second.
On the finger, the vesicle was small and flat, with a slightly depressed centre,
contaioing a minute crust. On the tliumb, the vesicle was also flat and broad, but
visibly depressed towards the centre, where there appeared a transverse linear-
shaped crust, corresponding, doubtless, with a fissure in the fold of the cuticle.
PI^VTE ni.
Casual vaccine vesicles on the hand and thumb on the eighth day afler the
pimples were first observed (ninth day of papulation).
On the side of the thumb was a flat vesicle, raised on a hard, red, tumid base.
The vesicle was of a dirty white hue, with a slight central discoloration rather
than depression, and a pale red areola extended around the vesicle, and beyond
the last joint of tho thumb.
ncnrj
UTIOH Of TBB Fl^ns.
On Aa bMk of A* laai Ihare was ■ snUler voBvIe. of * difleienl color tnd
iweilsppiag at the outer mugia, and drpresBed in llie
d biii ui)tioo» b&n. The YMwle wm of ■ light ficab
K 4aik btuwD ; and a moderole light rose-colored areoU,
iBMunded and raued the vbole.
•nmmm
PLATE IV.
>fHUUiMMnatoIll.,on lb«rallowing da; (iMith daj of papulation)
irfriM aoMidKiUir «>Dlsrged. and the areola much iscreafcd. There
dvibb t^MfcodoD of the Ihmnb and the back of lbs band ; ind the
.MMi%H^U^Mam«d, could be traced bf the ejeinio lbs uilln.
INDEX
Pa«e
AcOLlMATIZATIONj 82
Affusion, cold, 189
Adams, Dr., . . . 73,84,111,256
AlexipharmicB, 37
Animal origin of Miasms, . 17, 181
Al hasbet, 115
Anthony, St., 204
Ackworth School, . . . . 176,183
Areola, 55
Amott, Mr., 2l9
America invaded by Small Pox, . 43
" " Scarlet Fever, 162
Avicenna, 43, 116
Archer, Dr. 240
Angina Maligna, 161
Baron, Dr., . . . . 17,24,41,268
Baillie, Dr., 137, 208
Binns, Dr., . . . ' 183
Black Tongue, 358
Blane, Sir Gilbert, 112
Blankets, red, 94
Bleeding in Small Pox, .... 98
" Measlea, 142
" Scarlatina, .... 190
" Erysipelas, . . . .229
" Urticaria, 325
Bousquet, M., 54,256
Bruce, Mr., 42
Bryce, Mr., 261
Bryce's Test, 254
Bubo, pestilential, 59
Burns, Mr., 117
Calmiel, M., 209
Ceely, Mr., 17,266
Cancrum oris, 131, 144
Cicatrix, Vaccine, value of, . . . 249
Chlorine gan, 84
Chicken Pox, 292
Cholera, Asiatic, 23
Chomel, M., 209
Colden, Cadwallader, .... 182
CUne, Mr., 241
PaM
Complication, secondary, ... SO
Condamine, De la, . . . 24, 47, 88
Contagious origin, 25
" of Erysipelas, . 213
Contagion, 26
Concurrence of Cow Pox and Small
Pox, 251
Cow Pox, Petechial, 12
Conhtantine Africanus, . . . .115
Confluent Small Pox, .... 59
" Superficial, .... 60
Cotugno, 53, 67
Creaser, Mr., 269
Cullen, Dr., 148, 207
Currie, Dr., 154,185,189
Culmination of Epidemics, ... 84
Debility, Exanthematic, .... 37
" Scarlatinal, 167
De la Garde, Mr., 133
Delirium Ferox of Variola, ... 61
Desquamation of the Cuticle, . .165
Diagnosis of Small Pox, . . 68,89
Measles, .... 134
Scarlet Fever, . . .179
Lichen, 69
Diemerbroeck, . . . 29,32,44,116
Dropsy, Scarlatinal, . . . 167, 198
pathology of, ..." 355
treatment of, 357
4(
it
U
tt
t€
Emetics in scarlatina, 188
Enteritis, mucosa, 166
Epiphora, 120
Epidemic Mortality, 7
Ditfusion, 31
Influence, theory of, . . 32
Succession, 34
Visitation, 84
Tables of, 333
Epizootic, Bovine, .... 181, 263
Erysipelas, 106,203
of the scalp, .... 221
Gangrenosum, . . . 223
«(
«
tt
n
«
«
u
Guotilto,
Gibreluir, hier of, 33
Guththore. Dr. 933
GUodeni, !»
G]o99il», 59
Greu« of hinea, 36^
GolliTer. Dr. 260
. l-tO
■■ oeUelic 310
M«d, Dr., . . .• . 34,88,91,105
MeuJes. 68, 114
lofdc
. 141
Hamiltun, Sir David, .
Dr.
Harsutb, Dr. 31
Hmi, febnle
" Zo'jtei. '.'.'.'.'.'.'.
Hollind, Df
^ HoImoo. Mr, OK of,
Home, Dr
Huuiaral paltfotogr, . . . . .
HuDter. John, 54,
Haxlum, Dr
Hydrolhoiai, lilent,
Ideolitr. eianthomatio
Modified Varioli,
Cow Pox, ... .254
Morbid poisoD 36
Mili.H» 308
Monugue, Lady M. W., . . 46, 4S
Maw. Dr. 294
Marbilli 115
.180
3Vi Mucous [DembraiiB, aflectiod of.
. 18, IBl
. 334
43,304
Nelllerssh, . . .
Non-nilunlj', .' .'
Norwich Epidemic,
OchUiic mium SIO
Opiates, 39
Opblhalmit, raboolouF, .... 128
" BcarUlinal, .... 158
. 117 Fempbigut aod Pampholyl,
INDEX.
379
PngB
Pemphigus, chronic fonn of» . .314
" acute form of, . . .315
" gangronosus, . . . .315
Peritonitis puerperarum, . . . .210
Petechial small pox, 62
Peart, Dr., 196
Pitcaim, Dr., 214
Phlyctidium, 54
Plenck, Dr., 199
Pleurisy, variolous, 65
Phrenitis erysipelatosa, .... 224
Pneumonia, rubeolous, .... 126
Points, vaccine, 261
Procopius, 42
Predisposition to small pox, ... 81
" erysipelas, . . .215
Prognosis in small pox, .... 95
Pyrexia, 11
Quarantine, 30
Raucodo, 120
Recurrence of small pox, . . 88, 346
** of measles, . . . .137
" of scarlatina, . . . .184
Re-vaccination, .... 289, 370
Rhazes, 43, 88, 115
Rollo, Dr., 211
RoseoU, • 327
" exanthematica, . . . .327
Rose rash, 328
Rubeola, 114
** sine catarrbo, .... 121
" maligna, 129
Sacco, Dr., 268
Sauvages, Dr., 208
Schwenke, Dr., Ill
Secondary fever of small pox, . . 59
** " measles, . . . 126
" " scariatina, . .184
Scabs, vaccine, 261
Small Pox, 41
'* miscarriage in, ... 63
" diagnosis of, . . 68, 295
" age of deaths by, . . 71
" Hospital, founded, . . 47
*< to prevent pitting in, . 351
Seasoning, ....*... 81
Shingles, 303
Sibbald. Sir Robert, 147
Scarlet fever, 146
" ages of deaths by, . 177
'' aflecting the foetus, . 185
Seymour, Mr., case of, . . . .158
Sweating system, 44
Stewart, Dr. L., 62
Squibb, Mr. 164
Susceptibility, exanthematic, . . 22
Speranza, Professor, 138
Strophulus, 321
Suspension, law of, 18
Sydenham, . .45,101,116,144,147
Symmetry of disease, 16
Statistics of small pox, . . 70,277
" measles, . . . 133, 140
" scarlet fever, . . . .174
" erysipelas, .... 226
Sutton, Robert, 47,110
Surface, breach of, 21 G
Syphilis, 69
Surfeit, 318
Thompson, Dr., 17,295
Tongue, strawberry, 155
Trophilus, saying of, 40
Tweedie, Dr., 196
Types of fever, n
Urticaria, 324
Vaccination, 237
" theory of, .... 262
" mortality by small pox
after, . . . 285,365
Van Swieten 56
Varicella, 292
Vicarious mortality, 6
Vitus, St., 204
Variola, 41
" modificata, 56
" coufluens, 56
" pelcchialis, 62
Variola; vaccina, 263
Velpeau, M 209
Walker, Dr., 255
Wachsel, Mr., 138
Webster, Dr., 137
Watkinson, Dr., Ill
Williams, Dr., . . . .13, 139. 226
Ward, Mr., 176
Wells, Dr., .... 192, 198, 207
Willan, Dr., 41,114,217
Withering, Dr., 116,148
Woodville, Dr, .... 23, 242, 270
Zymosis, 29
Zymotic diseases, 29
K
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L106 Gregory, Cuorg*.
Q82 Lectures on the erup-
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