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The Pennsylvania Hospital Reports. Volume Two, for 1869. To be continued annually. Price to Sub- scribers paying in advance, 84.00. Price to Non-Subscribers, 85.00. Copies of Volume One can still be furnished to Subscribers or others. LECTURES ON CLINICAL MEDICINE, DELIVERED AT THE HOTEL-DIEU, PARIS. BY A. TROUSSEAU, Late Professor of Clinical Medicine in the Faculty of Medicine, Paris ; Physician to the Hotei-Dieu ; Member of the Imperial Academy of Medicine ; Commander of the Legion of Honor ; Grand Officer of the Order of the Lion and the Sun of Persia; Ex-repre- sentative of the People in the National Assembly; Ac. Ac. <£c. FROM THE OF l868, Being the Third Revised and Enlarged Edition ; BY JOHN ROSE CORMACK, M.D. Edin., F.R.S.E., Fellow of the Royal College of Physicians of Edinburgh ; formerly Lecturer on Forensic Medicine in the Medical School of Edinburgh, and formerly Physician to the Royal Infirmary and Fever Hospitals of Edinburgh; Corresponding Member of the Academy of Surgery of Madrid, dec. But in w'hat manner has the human mind progressed from the beginning of time ? I ask you, if it has not always proceeded to verify an hy- pothesis after the fashion of the daring navigator who, with prow to the wrest, trusts to unknown seas his genius, his glory, and the lives of himself and his adventurous comrades ? What ideas germinated in the head of Galileo before he discovered the movement of the pen- dulum ! and do you believe that he required to see a thousand candelabra oscillating under the dome of Pisa to enable him to create that splendid hypothesis which soon became part of the domain of science ? Toricelli formed an hypothesis; he put mer- cury and water into tubes, and thus he discovered a law ! Lavoisier weighed the peroxide of mercury, and thus was modern chemistry discovered! In one fact, the w'hole science was revealed to him. How? many millions had seen the steam raise the lid of a tea-kettle! Watt saw it once. The fact wras fecundated, and the man of genius who invented the steam-engine at once made himself and his country illustrious. The proposition of Gaubius, adopted by one of the most eminent practitioners of our day, is true, provided its application be re- stricted to the incredible vagaries of minds unguided by a single fact. It is obvious that, if we proceed, without either premises or induction, to create a system which, sooner or later, we shall be WHAT IS CLINICAL MEDICINE? 39 asked to submit to the test of experiment, we do what is useless and absurd; but the proposition of Gaubius ceases to be true, and it especially ceases to be scientific, if we possess any facts, however few in number they may be, and however insufficient as materials for systematisation, to guide our first steps amid the darkness. These facts bear a certain analogy to the thread of Theseus and the blind man's staff; and though, assuredly, if we have no other aid, we are walking in darkness and running towards the unknown, we are, nevertheless, not withont a guide; and even if we find the road shut up, we shall have well merited the gratitude of our suc- cessors for showing them that the way was not open, and so sparing them laborious research in a wrong direction. But the oftener we accomplish something better than this, we put up sign-posts in unknown defiles. I maintain, then, that it is better to walk in darkness than to stand still, if by darkness you mean primary facts and mental pro- cesses which precede secondary facts. Why should God have given us minds unceasingly yearning towards progress and always devouring the future ? Why has he given us intellects ever active, eager to compare, to form conclusions, to abstract, and to systematise, were it not that the intellectual faculties might be constantly at work with the primitive materials called facts ? And are not the products of this mental work, ideas, inductions, hypotheses, and systems, to be tested by the numerical method and statistics ? I hear you ask me :—Why begin with induction and systematisa- tion, if you have ultimately to come to a matter of accountancy with facts and of facts ? It is very easy for you to say to me :— Shut the eyes of your understanding; here is an object which pre- sents itself with colour, form, weight, and density; state its modalities, but I prohibit you from forming a concrete. Is it possible for me to refuse an attribute to the subject, to disjoin violently what my mind has strongly united and combined ? Can I see, hear, and feel, without judging—judge without forming con- clusions—form conclusions without systematising ? What is it you wish ? Shall I make a repertorium of ideas ? Shall I bridle my understanding, and wait for the signal to start on my intellectual race ? You say, “ Off ! ” But, I ask, how am I to equip myself for the course? bo you suppose that the rust of inactivity can be rubbed off at your word of command? You wish the pupil to see only crude facts, and to stifle his intellect: and when, by means INTRODUCTION. of this dismal labour, his mind has been to some extent mutilated, you will ask him to show mental vigour, and will dare to hope for his manifesting prolific thought. We must allow the luxuriant intellect of youth to grow up in freedom. We must take care not to stop the flow of that generous sap which seeks to spread forth only in blossom and branches; so long as the vital juice is drawn from a soil fertile in clinical observa- tion you need not fear that the growth will stretch too far. The members of the Faculty whose duty it is to guide pupils in their practical studies will moderate their impetuous ardour. They also have some accounts to settle with hypotheses; but they have attained an age which has whitened their hair and ripened their ex- perience, and, having become accomplished practitioners, they place at your service, for your instruction, their disappointments, their knowledge, and as much of that which constitutes individuality in their art as it is possible to transmit. What I have said regarding philosophical methods is only appli- cable to the science, and in no degree to the art of medicine. In point of fact, methods belong to the sciences; in the arts they neither have, nor ought to have, any existence. Method and art re- ciprocally exclude each other. Every science touches art at some points—every art has its scientific side; the worst man of science is he who is never an artist, and the worst artist is he who is never a man of science. In early times, medicine was an art, which took its place at the side of poetry and painting; to-day, they try to make a science of it, placing it beside mathematics, astronomy, and physics. In my opinion, a science deals with concrete elements or calcu- lable abstracts; it implies the possibility of formulae, and excludes individuality: an art creates manifestations without having calcu- lated their connection with causes, thus implying the impossibility of formulae and proclaiming the idea of individuality. A Newton would be the most stupid of mathematicians if he only occupied himself with the calculus; a painter is a painter, and nothing more than a painter. Scientific results are, we may say, stereotyped; results are not scientific unless they are identical—that is the criterion. Artistic results are essentially various and variable, and the more individuality there is in the artist the more is he an artist. In the sciences there are no schools; in the arts there are as many schools as there are great masters. WHAT IS CLINICAL MEDICINE ? 41 In accordance with the definition which I have given of science, provided the inferences which I have drawn from that definition be correct, I shall be allowed to regard medicine as an art; and those, even, who most ardently desire to see it raised to the rank of a science will doubtless admit with me that, up to the present time, it is very little deserving of the honour which they wish to confer on it. It would, no doubt, be very desirable to see all physicians, in a given malady, calculating the causes, the issue, and the treatment, with mathematical precision; it would be beautiful to see all persons entrusted with the sanitary regulations of communities making up annually an exact balance-sheet of their practice, and proudly sub- mitting their inflexible results to the inflexible examination of a court of medical accountants. Unfortunately, such a consummation can never be; we shall always be called upon to lament the deplorable uncertainty of medicine/ precisely for this reason, that if science necessarily has principles, art (which even ignores itself, which often goes forward to its object through darkness) can at best only have processes very difficult of transmission. In medicine, do not con- found art and science. All cannot become artists; but persons of the most ordinary intelligence can make acquisitions in science; it does not, however, gentlemen, follow that science is useless, or, in the present day, an unnecessary part of the education of the greatest men of art. We are, therefore, entitled to exact from you evidence of the possession of scientific because it is something which can be acquired, and which by industry is acquired by all, in greater or less proportion; but we will never exact more than scientific knowledge, for the rest is a natural gift. Take care not to fancy that you are physicians as soon as you have mastered scientific facts; they only afford to your understandings an opportunity of bringing forth fruit, and of elevating you to the high position of a man of art. I still recollect the concluding years of my medical studentship. Like many others, I went to a celebrated amphitheatre to study operative medicine; like many others, I was led away by the exacti- tude of the methods which directed the knife and the lithotome in so invariable a manner; like many others, I made a hobby of the most laborious surgical operations; and when we were drawn by curiosity and the desire for instruction to the Hotel Dieu or the Charite hospitals, where the masters of the surgical art were about to put in practice the precepts which we knew so well, we often, 42 INTRODUCTION. with sly satisfaction, detected that the knife was going astray between the rough surfaces of a refractory articulation, or was not held at a sufficient angle to avoid a vessel with certainty; and then we were not far from thinking that our right places were not on the benches among the students. What did it matter, though the operator was the best surgeon who ever amputated at the shoulder-joint, or whether operative medicine was an occupation more difficult than that of the carver! Assuredly, if we could collect and reanimate the ashes of Ambrose Pare, if we could here evoke the most illus- trious surgeon of modern times, J. L. Petit, I much fear that these two great men would be found less brilliant operators than many young students proud of possessing so easy a talent! Gentlemen, most of you know more chemistry than Paracelsus, many of you more than Scheele and Priestley, some of you even more than our Lavoisier. You know chemistry, but still you are not chemists; and among those who now hear me, do you believe that there are many whom posterity will deem worthy of being placed beside the men whose glorious names I have just mentioned? Thus it is, gentlemen, that there is a great difference between the man of science who reaps, and the man of art who produces. Do not, therefore, fancy yourselves physicians because you have acquired the habit of applying to the diagnosis of diseases the ingenious proceedings by which science has become enriched since the begin- ning of this century. The admirable diagnostic methods—ausculta- tion and percussion—given by Laennec to the public for the general good, and.of which no one is allowed to be ignorant, are in our hands what the telescope and the magnifying-glass are in the hands of the astronomer and the naturalist—instruments intermediary between external objects and the mind; but a magnifying-glass will no more make a Tournefort or a Galileo, than a stethoscope will make a Sydenham or a Torti. And moreover, gentlemen, it is undeniable that the increased means of investigation possessed in the present day, by multiplying elementary facts, or at all events by rendering them more exact, does not fit the mind for producing more prolific, more practical, or more reliable manifestations of art. How, then, does it happen that the mind becomes indolent in proportion to the increase of scientific notions, satisfied to receive and profit by, but caring little to elabo- rate or originate them ? Scientific processes assist art less than is supposed. Chemistry teaches you how to form colours ; it has told WHAT IS CLINICAL MEDICINE? 43 you wherefore, and when, they do not blend; it has taught you to fix them upon a canvass less liable to change and better prepared. An illustrious man of science has given you a knowledge of the modifica- tions which shades of colour produce upon each other; in a word, he has made a science of the harmony of colours. And yet, the blood still circulates under the pallet of Rubens, textile fabrics still shine resplendent upon the canvass of Yan Dyck, and the Madonnas of Raphael retain all the divinity and sweetness of their beauty. Why, then, with so many ways of study, with so much valuable scientific knowledge at command, have our painters remained so far behind the less scientific masters who constitute the glory of the art ? Why, then, do not we, so rich in preparatory knowledge, so rich in means of diagnosis, produce such men as Baillie, Sydenham, Torti, and Stoll ? It certainly is not because nature has been more chary of her gifts to us; each century brings forth the same class of minds, and ages the most abjectly barbaric have probably given birtli to men of as vigorous intellects as those which produced Pericles, Augustus, Leo X, and Louis XIY. How often in our intercourse with the young men who crowd our benches do we meet with intel- lects of the highest class, who only require a fitting opportunity and a favorable direction to produce fruit! But some of you who have shown exceptionally great talents, when you have acquired, by long study, perhaps, but without difficulty, a knowledge of the preparatory sciences (to which unfortunately so large a place is accorded in the medical curriculum), when in a few months you have equalled, or, it may be, surpassed your masters in the easy art of applying the senses and the various obtainable instruments to local diagnosis, be- coming elated by a conquest which has cost you so little, and strength- ened in the good opinion of yourselves by persons who look on medicine as consisting only of the common stock of knowledge, accustom your minds to no efforts of production, and sink down into a sort of moral inertia; while, on the other hand, we see that our predecessors, less rich than we are in available knowledge, ceaselessly laboured to originate : poor they were, but they turned to account the tiny stock of information which chance or experience had given them; they exercised their intellectual powers as constantly as wrestlers exercise their muscles, and the result was power, which sometimes showed itself in singular aberrations, but likewise also in views full of greatness and fertility. The very poverty of means increased the intellectual efforts, and the results were immense; and you, sur- 44 INTRODUCTION. rounded by a profusion of means, spoiled, enervated, cloyed with the abundance presented to you, know only how to receive and gorge, while your lazy intellects are smothered with obesity, and are sterile. For mercy’s sake, gentlemen, let us have a little less science, and a little more art! But I said that a man is born the artist, and that he becomes the savant; I said that scientific knowledge is easy: well! already I hear persons who either understand me amiss, or think they ought to do so, accuse me of encouraging young men in apathy and fatalism. If, say they, we are born artists, we are likewise born physicians; let us quietly wait for the natural inspirations of art. I do not allow any one so to misinterpret my words. A man is born an artist in this sense—that if nature has refused you artistic aptitude, do what you like, you will never be savants ; but, with the most happy aptitudes, you will be nothing without hard work. Hard work is a powerful source of inspiration; contemplation of the masterpieces of art constitutes the education of the artist, and a painter, endowed with the loftiest intelligence, who would not go to pass some years of his life in that atmosphere of genius which is breathed on the other side of the Alps, will never be more than an incomplete man, shut up in his own straitened individuality, whereas with study, with example, he will at once profit by the laborious inventions of artists of past ages now belonging to and easily ob- tained from science, he will correct the flights of his impetuous imagination, which will be constantly brought back to the beautiful by the contemplation of the beautiful; he will instinctively, involun- tarily purify his taste, and all his originality, henceforth properly directed, will throw itself in full force with the greatest ease into the lofty regions of art, and bring forth those wonderful productions which the artist bequeaths to the admiration of future generations. God made Lavoisier, but our immortal chemist would not have been more than a happy farmer of taxes if he had not, amid the fumes of the furnace, and by frequenting the society of the scientific men of his day, educated that intellect which wras destined to give birth to the most prolific of chemical discoveries. Do you suppose that Pare, J. L. Petit, Sabatier, and Dupuytren— do you suppose that Baillou, Pernel, Laennec, and Corvisart—do you suppose that Lavoisier, Pourcroy, Berthollet, and Dumas—do you suppose that they, and many others whose names are in the WHAT IS CLINICAL MEDICINE? 45 mouth of every one of you, could by the powerful gifts which nature bestowed on them have become princes of their art unless they had cultivated their natural powers at an early stage of their career, unless they had in early life greedily devoured the treasures of science which were spread out around them as they are spread out around you—unless, though wearied by, they had never been satiated with labour, and had believed that they had no right to reserve for their own use the riches which they had acquired, the discoveries by which they made themselves illustrious, and had been jealous to see their country, already foremost in literary renown, become fore- most also in scientific glory ? May this, gentlemen, be your noble heritage. But to secure it toilsome exertions are required. Whilst you are young, and while you make your first essay in arms, let your fields be the hospitals and the clinics; when your knowledge has increased, let the hospitals and clinics still be your fields; and let the hospitals and clinics continue to be your fields of industry after you have acquired all the scientific knowledge which we exact from you at the probationary examinations. By pursuing this plan, you will attain expertness in the practice of your art, knowing what science teaches, and having the power within yourselves of originating; then, also, will you begin that priesthood which will honour you, and to which you will do honour; then, too, will commence the life of sacrifice, in which your days and nights will be the patrimony of your patients. You must resign yourselves to sow in devotion that which you must often reap in ingratitude; you must renounce the sweet pleasures of the family, and that repose so grateful after the fatigue of laborious occupations; you must know how to confront loathsomeness, mortifications of spirit, and dangers; you must not retreat before the menaces of death, for death achieved amid the perils of your profession will cause your names to be pronounced with respect. MEDICAL CLINIC OF THE H&TEL-DIEU OF PARIS. LECTURE I. SMALL-POX. Gentlemen,—Since the great discovery of Jenner, small-pox seems to have occupied a much less important place in medicine. It was even hoped in the early days of vaccination that a means had been found to destroy the worst scourge which ever decimated the human race; but ere twenty-five or thirty years had passed away, in spite of the practice of vaccination, epidemics of small-pox reappeared, and did not always spare the vaccinated. In giving the history of cow-pox, I propose to tell how it has lost some of its original properties, to study the plan by which it may, perhaps, be possible to restore to the vaccine virus that which it has lost, and likewise to state the methods by which vaccination may henceforth be made as efficacious as possible. Cases of small-pox are at present so common that a week does not pass without our seeing patients afflicted with this disease in our wards; whereas, thirty years ago, in the same wards, they were exceedingly rare, and only met with in persons who had not been vaccinated. Is not one entitled to ask, whether this change does not depend upon the medical constitution through which we have been passing for a certain number of years, and which might have been otherwise more troublesome had it not been rendered milder by cow-pox ? Although epidemics of small-pox do not spare even those who have been vaccinated, it must be owned that they spare most of them; again, in most of the vaccinated, the disease has generally been modified in its form and symptoms, so that vaccina- tion, though it has not in our day its original efficacy, still retains a degree of efficacy which cannot be disputed. 48 SMALL-POX Nevertheless, although antecedent vaccination generally modifies the disease, small-pox is a terrible calamity when it scourges even vaccinated communities, but it is the most severe of all epidemic diseases when it attacks the unvaccinated. Perhaps some of you have read the account of the epidemic of small-pox which ravaged the aboriginal Indian tribes of Canada some years ago; nearly twenty-two thousand persons were attacked, and in from five to six months almost the entire population was carried off by this frightful fever. At the close of last century, in proportion as the navigators penetrated into the isles of the Pacific Ocean, small-pox, which the men of the old continent brought with them, burst forth with fury among the inhabitants of the newly discovered world, and the mor- tality assumed a frightful magnitude. It appears, then, that the study of small-pox is a matter of great importance, and this importance wall probably increase more and more in consequence of the neglect of the practice of re-vaccination, which, though as commendable as it ever uras, is rejected by many physicians, and is not universally accepted by the public. Por fifty years, the study of small-pox had come to be looked on as of secondary importance in medical education. It has now become necessary to return to it and insist upon it; I also propose, there- fore, to sketch the principal features of the disease. Though I have acquired a sad experience in small-pox, I have learned almost nothing regarding it which has not been much better observed and described before me. I shall, therefore, take Sydenham as my guide. Some of you have in your hands extracts from his writings, which I have arranged in the form of aphorisms in a pamphlet of a few pages, containing the most important statements made on this subject by the English Hippocrates. I now propose to paraphrase this little book, and to add to it some critical remarks; I will some- times appeal from the waitings of Sydenham to the clinical studies which w7e pursue together in the hospital, and, without changing much of what that illustrious man has said, I hope to teach you everything which it is essential to know regarding this exanthe- matous pyrexia. Small-pox differs from scarlatina in this respect, that it always shows itself to the eye. During the first few days, during the period of invasion, one may not have suspected it, but as soon as the eruption appears there is no longer any scope for hesitation. Its manifestations are unmistakably characteristic, and it ought DISTINCT SMALL-POX. 49 not to be possible to confound variola even with varicella, an essen- tially different disease, though the two are sometimes confounded with each other. Small-pox is subject to modification in respect of the eruption, and the course which the disease runs. This modification, or new phase, is the consequence of antecedent small-pox or cow-pox. It is an error, as I shall afterwards explain, to apply the term varioloid to modified small-pox. Under all circumstances, whether modified or unmodified, small-pox appears under two principal forms, viz., the distinct and confluent; and whichever form it assumes, the symp- toms are either normal or abnormal. It is not a matter of indifference to establish the varieties of the disease, and it is quite essential to recognise its two principal forms; for distinct small-pox is generally free from danger, while confluent small-pox is one of the most terrible of diseases, almost always proving fatal to those whom it attacks. The course and termination of the two are so different, and the phenomena which characterise them so decisively distinctive, that it is of the utmost importance, following Sydenham's example, to describe and study each separately. Distinct Small-pox.—Constipation.—Convulsions.—Rachialgia.— Paraplegia of Small-pox.—Duration of the Period of Invasion. —Eruption considered with reference to its position on the Face, Trunk, and Limbs.—Orchitis of Small-pox.—Desiccation. In every case of small-pox, the clinical observer can recognise a period of incubation, and four other periods, viz., those of invasion, eruption, maturation (or suppuration), and desiccation. The period of incubation has a duration the extent of which has been established by observation in cases of ordinary contagion, and demonstrated by experiment for more than half a century in Europe, by the inoculation of natural small-pox. Attentive observers, then, have satisfied themselves in a precise manner as to the number of days which elapse between inoculation and the manifestation of the disease; they have ascertained that, except in extraordinary and exceptional cases, the period of incubation extends to between eight and eleven days. The period of invasion, in distinct small-pox, is characterised by a violent rigor, or sometimes by many rigors, interrupted by accessions 50 DISTINCT SMALL-POX. of burning beat; and these phenomena are always more decided in this disease than in any of the other exanthematous pyrexioe. The skin continues relaxed up to the eighth day, and, in the adult, sweating is an essential symptom; in children it is otherwise. The perspiration, which appears with the first access of fever, is checked by nothing, and continues, even when the patients are lightly covered, up to the period of maturation; it then goes on, even when the fever has subsided, and after the completion of the eruptive process: it seems to constitute a favorable crisis on the part of the skin, coming in aid, as a sort of emunctory discharge, to the great cutaneous eruptive manifestation. I must here remark, that in confluent small-pox this tendency to diaphoresis is generally absent. In distinct small-pox, the period of invasion is also characterised by vomiting, or a desire to vomit; this symptom is very seldom absent. A more important symptom, still more rarely wanting in adults, is constipation:—it persists during the entire course of the disease, or at least the bowels are relieved with difficulty. It must be mentioned, however, that in some epidemics diarrhoea has been observed in adults.1 Diarrhoea in children, on the other hand, is the rule and not the exception. Besides this complication, there are others met with in children, to which it is still more important to call attention. In the first place, there is a tendency to sleep; and still more frequently, even in those who have cut their teeth, convulsions occur. They more frequently occur in children in the earliest stage of small-pox than at the corresponding epoch in cases of measles or scarlatina. So well aware was Sydenham of the frequency of this symptom, that when lie met with convulsions in a child whose dentition was completed, he at once suspected that he had to do with a case of in- cipient small-pox; he did not consider convulsions ushering in an attack of small-pox as at all a serious complication. This proposi- tion, however, if applied generally, requires to be stated in a less 1 Diarrhoea in the adult.—“In quadam constitutione epidemica variolas observavit Carolus Richa, quae cum alvi fluxu incipiebant, et eundem ad fincm usque comitem habebant, bouo cum eventu, sive id a saburra primarum compli- cata eveniret, sive a materiae variolosse portione, quae hac via excerneretur. Consil.epid. Taurin., anno 1720, § xv.)—Yogelius, etiam, diarrhoeam salutarem ab initio ad undecimum usque diem vidit, lethalem vero earn quae postea supcrvenerit.”—Note of Borsieri, p. 150. DISTINCT SMALL-POX. absolute form :—if a child, for example, lias one or two convulsive seizures shortly before the appearance of the eruption, it is not in great danger, but there is more risk when the convulsions occur early and recur frequently, Tor my own part, however—but my experience of small-pox in children has been small—I should say that the occurrence of convulsions is a troublesome complication rather than a favorable symptom. It must be borne in mind, too, that (as Borsieri has remarked) convulsions may constitute a mis- leading as well as a serious symptom, inasmuch as they sometimes carry off the patients before the appearance of the eruption. Simultaneously with the shivering and sweating, the burning fever and the vomiting, another important symptom supervenes —this is pain in the lumbar region (rachialgia)—it is hardly ever absent, and in no other pyrexia, excepting yellow fever, is it so severe. It is not, as has been supposed, a muscular pain, but is dependent upon an affection of the spinal marrow. Here is the proof. In a great many cases (and last year within a few days I could have shown you two examples) the lumbar pain is accom- panied by paraplegia. "Without your putting any leading questions, the patients themselves mention this paralysis: they complain of painful numbness in, and inability to move, the lower extremities. When you inquire whether the upper extremities are similarly affected, you discover that their motor power is in no degree im- paired. The paralysis sometimes affects the bladder, as is evidenced by retention of urine, or at least by great dysuria. The paralytic symptoms are generally of short duration, but in some cases they continue till the ninth or tenth day; generally, they cease spontaneously when the eruption appears. There are, how- ever, some cases in which the paralysis persists not only during the whole course of the disease, but likewise constitutes one of the com- plications of convalescence. When the lumbar pains are not very acute, the patient only ex- periences lassitude and dull pains (like those of rheumatism) in all the limbs, with occasionally pain, increased by pressure, at the pit of the stomach. “Doloris sensus hi joartibus quce scrobiculo cordis subjacent, si manujrremantur” says Sydenham. To 'sum up:—the period of invasion is characterised by rigors, ardent fever, and constant sweating, by nausea and constipation, by disturbance of the nervous system, such as convulsions in children; by general, but particularly by lumbar pains, with which are frc* DISTINCT SMALL-POX. quently associated paralysis of tlie inferior extremities, and occa- sionally paralysis of the bladder. I must, nevertheless, remark that in some exceedingly rare cases mentioned by old authors, small-pox proved so mild that the erup- tion made its appearance without having been preceded by any febrile disturbance; the outbreak of the pustules was either the sole manifestation of the disease, or, if there was any fever, it was so slight as to have passed unnoticed. In such cases, as Borsieri has remarked, there is no appreciable period of invasion. In distinct small-pox the period of invasion is usually three com- plete days; rarely three days and a half; still more rarely four days; and almost never only two days. This duration is so generally the rule, that when one sees, after the inoculation of natural small- pox, the fever of invasion set in with a certain amount of vehe- mence, and three times twenty-four hours elapse before the eruption is developed, it may be prognosticated with certainty that the attack will not be severe. The fact is, that the longer the eruption is in appearing, the less serious will the disease prove ; and the less delay there is in its appearance, the more dangerous will the disease prove. When the eruption appears at the end of the second day, it is certain to be confluent; if on the third, it is almost always con- fluent. If, on the other hand, the eruption does not appear till the fourth day, still more, if it be delayed till the fifth or sixth (as in a case observed by Yiolante), or till the fourteenth (as in a young girl whose case is recorded by Haen), it is necessarily distinct. Sydenham, nevertheless, informs us that in some exceptional cases, in consequence of great organic lesions, oh atrocius aliquod symptoma, the eruption may be retarded till the sixth or seventh day both in distinct and confluent cases. But under such circum- stances, there exist, in addition to the ordinary symptoms of the period of invasion, others depending upon the profound disturbance of the economy and the danger which lies concealed in the affection of an internal organ. In support of the observation of Sydenham, let us recall the circumstances of a case which we had in 1863 in the St. Bernard Ward, bed 27. The patient was a woman of 30, in whom the eruption did not appear till the fifth day; at the com- mencement of her attack of small-pox, she had had all the symptoms of sporadic cholera, such as vomiting, purging, cramps, general coldness, blanching of the mucous membranes, dry cold tongue, in- jection of the conjunctiva, and a dull appearance of the cornea. The DISTINCT SMALL-POX. 53 choleraic symptoms ceased on the fourth day, and on the fifth the eruption of small-pox appeared. At the commencement of the second period, that is, as soon as the eruption appears, the fever subsides, and the other symptoms cease, except, as has already been stated, the tendency to perspire, which continues till the maturation of the pustules. Recollect that I am now speaking exclusively of distinct small-pox; in the confluent form the symptoms in question do not cease with the appearance of the eruption. I ought here to remark that modern scientific precision has con- firmed the observation of the old clinical observers. The thermo- metrical researches of Wunderlich and his scientific emulators show that when the eruption appears, and when the pulse is found to diminish in frequency, the other phenomena characteristic of fever disappear; there is simultaneously a notable fall in the general temperature, which gradually returns to its normal standard, which, as you know, is 37 degrees in the axilla. Here are the leading facts in relation to the progressive change of temperature in the distinct form:—At the commencement of the disease the temperature rises very quickly, and remains as high for a considerable time as from 40° 5" to 410 5", that is to say, that the temperature of the body rises from three to four and a half degrees above the temperature in health, which is an enormous increase. Trom the time of the appearance of the eruption the fall of temperature is so rapid that in about thirty-six hours it has gone down to below thirty-eight, or, in other words, has become normal. This diminution, though gradual, is not continuous, for while there is a fall of one degree in the morning, there is a rise of half a degree in the evening. It appears, however, that from the time of the disease becoming external, so to speak, the central temperature falls, and there is a complete remission in the general symptoms. The Germans apply the term defervescence to the return of the body to its natural temperature. We shall afterwards attend to the thermometrical phenomena which are seen when every pustule has become a centre of suppura- tion. I now return to the description of the eruption. The Eruption.—The eruption first shows itself on the face and neck ; but, according to Swieten and Borsieri, it appears also at the same time upon the scalp, a fact which can be most easily verified in persons wrho are bald; it then comes out a little upon the upper 54 DISTINCT SMALL-POX. part of the chest; soon afterwards it takes possession of the arms and hands, and later of the trank, that is, of the lower part of the chest and of the abdomen, in which latter situation the pustules are very few in number, and sometimes altogether wanting; last of all, the eruption invades the legs. The successive order in the appearance of the pustules is not so regular as authors describe it to be. If the eruption appears to commence on the face, it is because it is best seen there. When I have uncovered patients, I have seldom found pustules on the face without finding them in quite as advanced a state on the trank, and limbs. Trom the commencement, also, of the eruptive period, the patients complain of pain in the throat, which depends upon the existence of pustules on the mucous membrane of the pharynx and mouth. In very rare cases, some of which have been described by authors and some of which I have seen, the only symptoms characteristic of the disease were a few pustules on the pharynx and pendulous veil of the palate. The skin, to which one naturally ought first to look, is, at the commencement, studded with spots resembling exceedingly fine pricks made with a needle, and still more with papulae, such as are met with in persons affected by lichen or prurigo; these small specks, which are red, slightly pointed, and hardly above the surface of the skin, are disseminated over the face, neck, and upper part of the chest. Next day, they are more prominent, and from the sixth day of the disease, which is the third of the eruption, the vesicular papules begin to contain a milk-like fluid; next day they increase very perceptibly, their elevation is great, and the fluid which they contain becomes a little more opaque. On the eighth day they have become much larger still, and their opacity is also more decided. After the eighth day, it is very important to consider small-pox in relation to the eruption as seen on the different parts of the body, because it takes very different forms, according to the parts affected. On examining the face, neck, trunk, and upper part of the limbs, we perceive a sort of gradation, which enables us, however, to recognise the eruption as essentially the same in these various situations: nevertheless, on comparing the papules on the hands with those on the face, the differences between the appearances of the two strike one as being considerable. DISTINCT SMALL-POX. 55 On the face, as I have already said, the eruption, on the first day it is visible, presents the appearance of small, red, slightly acuminated papules, which next day become more elevated, and on the third day (which is the sixth of the disease) are filled with an opaque, but as yet non-purulent fluid. They go on increasing in size: they generally vary in size, and do not all resemble one another : some are small and some are large, but none attain a magnitude equal to that seen on other parts of the body; and, whatever be their size, they all pass through the same stages. On the seventh day of the disease, they still further augment in volume; and upon the circumference of the base of each papule a redness begins to be perceptible. On the eighth day, this coloration becomes bright, and the more bright and rosy it is, so much the more may the disease be regarded as normal. The eruption now consists of small abscesses — of pustules: the pustules become painful, and swelling begins. This is the starting-point of the third period—the period of maturation and suppuration. The swelling attains its maximum on the following day, that is, on the ninth day of the disease; it decreases on the tenth, and by the eleventh day has disappeared. The tumefaction, which is always great in proportion to the abundance of the eruption, is apparently, but not really greater, in the distinct than in the confluent form; it is specially conspicuous in certain situations, particularly upon the eyelids, which swell out in a remarkable manner, from the laxity of their cellular tissue. When even there are only three or four pustules upon the eyelids, they become so swollen, that Sydenham compared them to puffed out bladders—vesicant ivfatam non male refert; and on the ninth and tenth days they prevent the patient from opening his eyes. It sometimes happens, as in a case which we saw in the clinical wards, that pustules occur on the ocular conjunctiva. The swelling is sometimes quite as conspicuous in other regions as on the eyelids. Aan Swieten, for example, saw a single pustule on the prepuce of a child produce a phimosis, which occasioned difficulty in passing the urine. And here, gentlemen, let me recall the fact to your recollection, that the cellular tissue of the prepuce is of exactly the same nature as that of the eyelids. In confluent small-pox, to which we shall afterwards return, the swelling of the face being more general, the tumefaction of the eyelids has the 56 DISTINCT SMALL-POX. appearance of being less than it really is, and less than in that form of the disease which we are now studying. At the beginning of the period of maturation, the progress of the pustules on the face is special. Up to the eighth day, they are velvety and soft to the touch—leves ad tactum, to use Sydenham’s expression; but after that day, upon passing the hand over the nose and cheeks, they are felt to be rough—asper lores, ad tactum rudiores ; and this roughness depends upon a slight oozing from the surface of the pustule of a yellowish matter like thick honey. This exuda- tion only takes place from the pustules on the face, wdiere they dry up immediately, the desiccation being complete on the eleventh day. The pustules on the trunk and extremities have a more regular form, and present more similarity to each other; while those on the face are not navel-shaped, those on the body begin to flatten on the eighth day, and sometimes to exhibit in their centres a small greyish depression called the umbilication. It must not, however, be supposed that the formation of this umbilication is a necessary occurrence. Upon the arm of patients affected with true small-pox, I lately circumscribed a certain number of pustules, and it wras found that in only two or three of them did umbilication occur. Do not suppose, then, that the undergoing this change of form is a special character of the small-pox pustule; you will find this very same umbilication occurring in the simple pustules of ecthyma, particularly in the ecthyma produced by friction with tartar emetic. And let me here remark, as a circumstance noteworthy in connection with this point, though not otherwise of any importance, that some physicians of the last century regarded it as an inauspicious sign when pustules were observed, which, though somewhat prominent, were not acuminated, but, on the contrary, bore a small central depression—in apice faveolam impressam gerunt. About the eleventh day, the pustules are filled with a purulent fluid: from that time may be noticed upon the upper part of the limbs, and particularly on the knees and elbows, a drying up of some of the smallest, but without any exudation similar to that seen to proceed from face pustules: between the fourteenth and seven- teenth days, as a general rule, desiccation is completed. On the hands, the appearances presented are different from those hitherto described. From the eighth to the eleventh day, the pus- tules resemble those on the body, if it be not that the inflammation of the base commences later; but towards the close of the ninth DISTINCT SMALL-POX. day, the hands continue to he a little painful; on the tenth they swell, and, concurrently with the tumefaction of the hands, cederna- tous swelling of the fore-arm is observed, which extends to the elbow, and is very painful. This condition is seldom of equal intensity on both sides, a fact which I am unable to explain. Per- haps it may depend upon the crop of pustules being a little more decided on one side than on the other, or upon the patient resting more on one side, and the swelling being greatest where the impedi- ment to the venous circulation is greatest. If the eruption has been, I do not say confluent, but somewhat abundant, the patient is unable to close his hands from the tumefaction of the skin. The existence of this oedemato-phlegmonous swelling is shown in a very simple manner. It is sufficient to press more or less gently upon the skin between the pustules to leave the mark of the finger; this swelling and pain, which never set in before the eleventh, continue till the fourteenth day. Similar phenomena occur in the feet, as in the hands, when the eruption is copious upon them. While the pustules have generally acquired their greatest size upon the trunk about the eleventh day of the disease, they continue to increase in volume till about the fourteenth day upon the hands, feet, fore-arms, and lower part of the legs; the oedemato-phlegmonous swelling by which they are surrounded then goes down, leaving them without umbilication, and presenting the exact appearance of beautiful, perfectly round drops of virgin wax. They are, in fact, thickish phlyctaense filled with pus. Generally speaking, the pustules of the trunk and limbs burst, instead of desiccating—disrujptione abitum sibi parant; the pus which they contain escapes, and soils the sheets and body-linen of the patient. The rupture takes place in three or four days; but on the hands, feet, fore-arms, and lower part of the legs, they remain unbroken until the eighteenth, nineteenth, twentieth, or even twenty-second day, an example of which latter occurrence I had an opportunity of showing you. Sydenham, then, was mistaken when he wrote that their duration is not more than one or two days longer than that of the pustules on the body—diei unius aut alterius mora Mas vincunt. I have, however, gentlemen, pointed out to you at the bed of the patient, that if the pustules on the back of the hand and on the fore-arm present the characteristics with which I have just made you acquainted as occurring on the dorsal aspect of the fingers and toes, they cornify and desiccate without suppuration, 58 DISTINCT SMALL-POX. exactly like the pustules of modified small-pox, or like those of the knees and elbows of the unmodified disease. Before leaving this subject I must remark that it is in the most vascular parts of the skin that the eruption is most copious; and, as was pointed out long ago by observers, the situations in which the pustules are most numerous are the face, the extremities, the circumference of small wounds (such, for example, as those made by the cautery), or the vicinity of blisters. Let me recall to your recollection, as a case in point, the patient who occupied bed iNo. 9 of St. Agnes’s Ward, a lad in -whom the eruption was very abundant on the posterior aspect of the fore-arms; he was a cook, and in that capacity constantly had these parts exposed to the heat of kitchen- stoves. At the commencement of the period of maturation or suppuration, there is a new manifestation, viz., the fever of maturation. The serious symptoms present at the beginning of the disease had so entirely disappeared with the coming out of the eruption, that the patient had regained his cheerfulness and appetite; but they return on the eighth day, and constitute the fever of maturation. Here, again, investigation with the aid of the thermometer gives valuable information. We have seen that on the fourth day of the disease, at the date of the appearance of the eruption, and also whilst it continues, there is a fall in the temperature of the body and a truce to the fever, the entire morbid effort being concentrated, so to speak, in the skin, but the temperature does not remain for more than a day or two, or for three days at the most, at the normal standard of 370; it rises a little during the period of sup- puration, but does not become so high as it was during the initial fever. In severe cases, however, the fever which attends suppura- tion is more intense, and the temperature may even rise as high as it was before the eruption appeared. To be more precise:—in slight cases, within three days, the temperature rises to about 380,5, while in the more severe cases it may rapidly ascend to 40°’6, and even to 410,2. This great elevation of temperature, however, is most fre- quently observed in the confluent form of the disease, of which I shall immediately have to speak to you. In the mean time, to sum up what has now been stated, I may say that the central temperature rises anew about the seventh or eighth day of the disease. The fever of maturation lasts for three days; on and after the eleventh day of the disease the patient is free from it, provided the DISTINCT SMALL-TOX. 59 case is of the distinct form. The temperature becomes again the exact index of the progress of the fever; thus, after having risen to at least 380>7 in the fever of maturation, it falls progressively in three days to the normal standard. If the fever continue longer, it depends 011 complications, which, as I have already said, are rare in the distinct form of the disease. Orchitis, and ovaritis, its analogue in the female, next claim our attention as phenomena which sometimes occur concurrently with the appearance of the eruption. M. Beraud, an hospital surgeon, has in recent years treated the subject in a very complete manner.1 We must not restrict the terms orchitis and ovaritis to inflammation of the parenchyma of the testicle or ovary, but extend it to inflam- mation of the tunica vaginalis, and the folds of peritoneum which surround the ovaries. The inflammation of the serous membrane is the result of the small-pox eruption affecting them as it does the skin, although of course the appearances presented in the two situa- tions have very different characters, just as herpes on a mucous surface is very different from herpes on the skin. Small-pox mani- fests itself upon other serous membranes than those now named. Long ago, Yan Swieten and Hoffmann had called attention to variolous meningitis; Fernel, Werlhoff, and ATolante have men- tioned variolous affections of the lungs and intestines twenty-seven years ago; Pedzholdt published the observations he made on variolous meningitis and peritonitis, in the epidemic which prevailed at Leipsic during the winter of 1833 and 1833. Yariolous orchitis is detected by the patient complaining of pain when the slightest pressure is made on the scrotum, or wrhen he moves; forthwith, swelling of the parts is perceived, and subsequently fluctuation; the pain is less acute when the inflammation occupies the parenchyma of the organ. The symptoms of ovaritis are not so well marked, and are less known. The facts recorded by Beraud have been regarded as exceptional. Till he wrote, neither my attention nor the attention of any one had been specially fixed upon this subject; but his work had scarcely been published when, within a week, I showed you two cases of variolous orchitis in my wards. Since that time, we have had very many similar cases, not because they are more common now than in Sydenham’s time, but because we now look out for the affection, 1 Beraud ;—Archives Generales de Medecine, Mars et Mai, 18.^9. DISTIN CT SM ALL- P 0X. and have learned how to detect its presence. In the same category we must include diphtheritic paralysis and rheumatismal disease of the heart, affections which, though not more common, have recently been better observed. From all I have now said, gentlemen, respecting the rise and fall of the temperature of the body in small-pox, it follows that the thermal line drawn for this disease is a material and striking repre- sentation of the singular course of the fever. Indeed, there is nothing more characteristic than the curve in the line which indi- cates the rise and fall of temperature in small-pox. There is, first of all, the rapid rise at the beginning of the attack, then the con- tinuance of the high temperature for two or three days, that is, during the initial fever; secondly, there is a gradual diminution in heat during the two days which correspond to the period of eruption; thirdly, a fresh rise of temperature (more moderate than is seen at the beginning), corresponding to the fever of suppuration; while, fourthly and lastly, the diagram indicates a return to the normal temperature, marking the period of desiccation to have been reached. Period of Desiccation.—Let us now study this fourth period, and consider how cicatrisation is accomplished. Upon the face and body, crusts are formed, which fall off; upon the hands, the abraded epidermis leaves in its place a small red surface, exactly like that left by the pustule of ecthyma. Upon the fall of the crusts—which takes place from the face-pustules about the fif- teenth, eighteenth, or twentieth day, and a little later from the body-pustules—there remains in their stead, not a depression, but a projection of a violet-red hue, deep in shade as in the skin of indi- viduals who have been exposed to cold. On this projection a small scale of epidermis forms, which separates in a few days, and is succeeded by a thinner scale, which in turn gives place to another thinner still, and thus, in succession, epidermic scales form and fall during a period of from ten to thirty days. By degrees the projection dimi- nishes ; after from four to six weeks there is seen in its place a slight depression; in four, five, or six months, the redness of the skin has disappeared, leaving only the small whitish puckered cicatrix familiar to all of you. It must, however, be recollected that when the disease has been of the distinct form, and when the pustules on the face have not been very large, the red marks generally disappear without leaving more than a slight and transitory unevenness of DISTINCT SMALL-POX. 61 surface; but there are other cases in which, notwithstanding the absolutely “ distinct ” character of the pustules, deep cicatrices are left. Such is the normal course of the distinct form of small-pox; it is not a fatal disease. Distinct small-pox, however, though apparently strictly normal, may sometimes, though very rarely, terminate in a manner totally un- looked for, as so often happens in scarlatina. Recall to your recol- lection a young woman of twenty-one who lay in bed No. 7 of St. Bernard’s Ward. She had passed through a remarkably mild attack of distinct small-pox. The sister of the ward had left her at eight o’clock in the evening in a perfectly satisfactory state. Soon after- wards she was seized with cerebral symptoms, and difficulty in breath- ing ; in an hour she was dead. It is a curious, anomalous fact, that when distinct small-pox does prove fatal, death occurs earlier than in the confluent. Sydenham observed, and so have I in many cases, that when death occurs in distinct small-pox, it happens about the eighth or ninth day, but not till the eleventh or thirteenth in the confluent. The illustrious physician whom I have just named, Sydenham, and after him Van Swieten and Borsieri, observed anomalous and malignant epidemics of distinct small-pox. They were characterised in the prodromous period by the severity of the pain in the head and back, great prostration of strength, anxiety, agitation, stupor, and sometimes by delirium. The want of appetite, amounting to disgust for every kind of food, was very marked. Sometimes there was delirium and sleeplessness; at other times, profound coma, twitcli- ings of the tendons, a tendency to syncope, and very often, irre- gular, quick, and laborious breathing—the latter, an indication of great danger. The fever was at times very high, and at other times the pulse was small, feeble, and irregular; there was not much heat of skin; the perspiration was very copious. The eruption came out well on the third or fourth day, but there was more than one crop: on the fifth or sixth day fresh pimples appeared; all the pustules did not attain the same size, some remaining pale and indolent, while in cases where the eruption was mild, pressure on a level with the pustules occasioned acute pain. The fever and other disturbances of the system continued, in place of subsiding on the appearance of the eruption, as in ordinary cases. Inordinate per- spiration stopped suddenly, and could not be recalled in any degree by treatment. Micturition was frequent, but scanty, and sometimes 62 CONFLUENT SMALL-POX. there was suppression of urine, a symptom which Sydenham regarded as of most unfavorable augury at that stage of the disease, as well as in the decline of the distinct form. Occasionally, copious diarrrhcea set in. At last, the patient sunk, as I have already said, on the eighth or ninth day, under the nervous and comatose symptoms of which I have spoken. From the facts now stated, it appears that when the eruption does not come well out by the fifth, sixth, or seventh, day—when the pustules are irregularly developed; when the perspiration ceases, and cannot be restored; and, lastly, when delirium, profound coma, and twitchings of the tendons continue or supervene, the worst pos- sible prognosis must be formed. The fatal issue is impending and very near. Delirium, however, must not be confounded with acute mania, of which we had a case in a woman, who, during the progress of modified small-pox, presented no disturbance of the nervous system, except attacks of mania without fever. At the beginning of the fever of maturation, on the sixth or seventh day of the disease, it is not unusual, even in distinct small-pox, to meet with delirium, lasting for one or two days; it is most frequently observed at night ; sometimes it is rather violent. At one time I used to be much alarmed by the occurrence of delirium; but at present it is a symp- tom which gives me no anxiety. It subsides without the interven- tion of art, and modifies neither the general character nor the prognosis in distinct small-pox. Here 'I must, however, make certain reservations. I do not fear delirium if the pulse maintain its volume and do not become rapid, if sweating continues; but if the skin is dry and cold—if the pulse lose its proper strength and become small, sharp, or irregular, the delirium has a very different meaning, and is a certain sign of approaching death. Confluent Small-pox.—Diarrhoea (chiefly in children) at the commencement of the illness.—Salivation.—Sioelling of the Face. —Swelling of the Hands and Nervous comjilications.—Boils.— Abscesses.—Purulent Infection. — Albuminuria. — Anasarca.— Treatment. When the fever of invasion is exceedingly intense—when the initial shivering has been greatly prolonged, the pain in the loins CONFLUENT SMALL-POX. acute, the paralysis of the lower extremities and bladder very decided, the vomiting continuous—when sometimes, even in adults, the cerebral disturbance has been great—and, finally, when the per- spiration has not been abundant—when such circumstances arise— it may be concluded that the case is to be confluent. But there is another sign, independent of the symptoms now enumerated, by which we may confidently predict the same result, when the disease is normal; and that is, the appearance of the eruption at the end of the second day, or not later than during the third day. In normal distinct small-pox, as I have already said, the eruption is generally delayed till the fourth, or even till the fifth day. These remarks, however, are only applicable to the normal course of the two forms of the disease, for in some bad cases, malo semper omine, as Syden- ham and Borsieri observe, the eruption does not come out till the fifth, sixth, or seventh day, or even later. Diarrhoea is very often observed in confluent small-pox- from the commencement of the illness,, both in adults and children, but par- ticularly in the latter; whereas, in distinct small-pox, as I have already mentioned, constipation is the rule, at least in adults. This diarrhoea, which is most common in children, continues not only to the fourth and fifth day of the disease—the second and third of the eruption—but even to the ninth and tenth; and in young subjects it tabes the place of salivation, which in adults is a leading feature of the confluent form. While in the distinct form, on the appearance of the eruption, the fever ceases, or at least diminishes to such an extent that the patient is free from discomfort and seems restored to health, it does not at all abate in the confluent form, when the erup- tion comes out; on the contrary, it goes on, and even increases, up to the eighth day, and, indeed, sometimes up to even the thirteenth day. Here you no longer find the period of initial fever from the first to the fourth day, and the period of maturation fever from the eighth to the tenth day. The fever is continuous from the begin- ning of the illness to the end of the second week, or often to a later date. There is a reduction of heat for not more than twenty-four hours, to the extent of one degree. During the suppuration of the pustules, the temperature may rise to, or even exceed, forty-one degrees. The confluent is still further characterised by three great phe- nomena not seen in the distinct form. I have already alluded to salivation. I now add great tumefaction of the face and swelling of CONFLUENT SMALL-POX. the hands and feet. The two last-mentioned symptoms do not exist in distinct small-pox, or at least if they are present when the erup- tion is rather abundant on the extremities, it is in an insignificant degree as compared with what is met with in the confluent form. Salivation is almost never seen in distinct small-pox. Let us now attend to the characteristic features of the eruption in confluent small-pox. On the first day of the eruption—the end of the second or begin- ning of the third day of the disease—a redness appears on the face, which, unless it be closely examined, has a diffuse aspect. This redness is so great on the following day, that it is often impossible to know whether the eruption be that of small-pox or measles. This is a point on which Sydenham lays great stress, remarking, in refer- ence to external appearances, that the eruption of confluent small- pox coming out, nunc erysipelatis ritu, nunc morbillorum, it is very difficult for those who have not had great experience in the two diseases to avoid confounding them, unless attention be paid to the general phenomena of the case; though with this precaution it is impossible to mistake the one for the other. It is not till the third day of the disease that notable projections are visible on the countenance. The diffuse patches of redness, which at an earlier stage might have been mistaken for measles, have now become papules, some of which already contain a little milky fluid. On the face the papules have hardly any space between them, so that when the hand is drawn across the forehead or cheek of the patient, the inequalities on the surface of the skin can scarcely be detected. The papules, besides being smaller than in distinct small- pox, have a less determinate form, running more or less into each other. However, towards the fifth day—the seventh day of the disease—their projection from the surface is more appreciable, and the swelling of the face, although far from having attained its maxi- mum, is universal. The epidermis is elevated by a slight secretion of a milky appearance, and on the following day patches are to be seen similar to those produced by the application of a blister. This kind of vesication is sometimes so general, that the face looks as if it were covered with a mask of whitish-grey paper, of an opaline lustre, \\Yq papier Joseph or parchment: “ PergamenyE speciem visa horrendam (cutis facei) exldbetas Morton said in his ‘ Pyretologia/ This is the pathognomonic symptom of confluent small-pox; it is never met with in the distinct form of the disease, except in a very CONFLUENT SMALL-POX. 65 limited degree, when the pustules, being coherent, form a few isolated patches. The swelling of the face increases up to about the end of the ninth day, when it has attained its maximum ; it remains stationary on the tenth, and ought to begin to decrease on the eleventh day. The head and face, particularly at the angles of the jaws and around the ears, are much swollen—as much and more than in erysipelas; the eyelids, though less swollen than in distinct small-pox, participate in the general tumefaction of the face, and for four, five, or six days the patients remain without opening their eyes. The eruption does not spare even the globe of the eye ; it involves the conjunctiva and cornea, and so gives rise to more or less severe ophthalmia, leading to perforations and purulent discharges, which may ultimately involve complete loss of vision. I shall now resume consideration of the character of the eruption, and particularly the subject of the universal uplifting of the epider- mis, caused by the confluence of the pustules. This sometimes proceeds to such an extent that the surface of the skin presents the appearance of one large phlyctsena. About the eleventh day (and not on the eighth, as in distinct small-pox) the phlyctsena becomes yellow, begins to be wrinkled, and exhales a horrible stench, which is never present in the distinct form of the disease. From the second, sometimes from the first day of the eruption, salivation sets in. At first, the secretion consists of a fluid resem- bling clear saliva, slightly viscous, but the viscidity of which in- creases on the succeeding days, while at the same time the amount of fluid secreted goes on increasing till the sixth or seventh day of the eruption (eighth or ninth of the disease), when it is so enormous in quantity, that a patient will give off from one to two litres.1 The inconvenience arising irom this discharge is very great, and prevents the patient from sleeping. When he does fall asleep, with his head resting on the pillow, a constant flow of saliva inundates the bed, and, awaking, is followed by great discomfort; finally, he is tor- mented by a burning, inextinguishable thirst. The salivation is coincident with the appearance of pustules on the inside of the mouth, veil of the palate, and pharynx. I say salivation is coin- cident with, not that it is dependent on, the presence of pustules on the mucous membrane of the mouth. The salivary excretion may 1 A litre is rather more than a British Imperial quart.—Tkanslatoe. 66 CONFLUENT SMALL-FOX. be connected up to a certain point with extension of the inflamma- tory excitement to the glands; but it is no less true that excessive salivation in confluent small-pox is a phenomenon in some degree independent of this excitement, and dependent, perhaps, upon the essential nature of the disease. In proof of the accuracy of this statement, it is important to call attention to the fact that salivation does not take place in distinct small-pox, even when there are nume- rous pustules on the buccal mucous membrane. We had an example of this in a young man, who, in July, 1857, lay in bed No. 11 bis, St. Agnes’ Ward. He had distinct small-pox, with an abun- dant eruption on the inside of the mouth, and yet there was no salivation. On the third day of the eruption, evidence is afforded of the existence of the pustules, which become confluent, and cause inflam- mation of the entire mucous membrane of the mouth and pharynx. The swelling is greatest on the sixth day of the eruption, when also, as I formerly stated, the salivation is most abundant; it continues till at least the ninth or tenth day, the salivation likewise going on, and lasting one or two days after the swelling has somewhat sub- sided. There is, therefore, another cause for the salivation, as was well illustrated by the case of a young girl, who occupied bed No. 7 of St. Bernard’s Ward. Every day she filled three or four spittoons. She stated that the act of spitting excited violent pain in the throat, which prevented her from swallowing the saliva. She was equally unable to swallow beverages, which she rejected after rinsing the mouth with them. I would not, however, maintain, gentlemen, that in this case salivation resulted solely from dysphagia, for in scarla- tina, for example, in which there generally is very violent sore throat, salivation is not observed. Salivation, therefore, is a complex phenomenon, for which, although a certain number of causes may be assigned, it is not easy to give to each its proper share. The patient coughs; his voice assumes a certain degree of hoarse- ness. These symptoms are explained by the affection of the larynx, to which organ the inflammation is propagated from the mouth and back of the throat, and which is also often invaded by the eruption. The laryngeal affections are not without gravity, for it sometimes happens that, in consequence of them, patients are suddenly carried off by fits of suffocation. You may have seen three cases of this kind in this hospital. Three small-pox patients, at the eighth day of the disease, which had run a perfectly normal course, were sud- CONFLUENT SMALL-POX. 67 denly seized with a fit of suffocation which carried them off in a few seconds, before there was time for any one to come to their assist- ance. In one of them there was found, on examination after death, indications of inflammation of the larynx, and variolous pustules below the glottis. The salivation has generally reached its maximum about the ninth or tenth day of the disease, and on the following day; consequently, on the eleventh day of the disease, or occasionally a little later, it begins to decrease, and at the same time the swelling of the face diminishes. At this stage appears a symptom, not less momentous than the salivation and swelling of the face; it is swelling of the hands and feet. This is an essential part of an attack of confluent small-pox ; it succeeds the salivation, and still more the swelling of the face. When it fails to appear the patient almost invariably dies. Since I began practice I have only seen three patients recover from con- fluent small-pox, without having swelling of the hands and feet, after the subsidence of the salivation and tumefaction of the face. Of the three individuals to whom I now refer, one was in our wards two years ago; another was our patient during the current year, and some of you may have seen him, and may recollect that he w as very ill indeed; for more than four months he suffered from large abscesses, and numerous very painful boils on the limbs and other parts of the body. The third was a young man who occupied bed No. 12 of St. Agnes’ Wrard, in August, 1861. He reached the thirteenth day of an attack of confluent small-pox without having had any tumefaction of the extremities. The general symptoms wTere so grave that wre were despairing of his recovery. Under these circumstances I resolved to subject him several times a day to ablutions with cold water, giving him, at the same time, the sul- phuric lemonade recommended by Sydenham. To our great joy, he wras somewhat better next day, and in four days convalescence was established, although there wyas no swelling of the hands or feet. Is not the red oedema of the hands and feet seen in confluent small-pox simply a consequence of a natural determination to these parts, in itself salutary, and proportionate to the number of pus- tules which are proceeding to normal inflammatory evolution If it be so, we can understand wrhy cold affusions, by acting energeti- cally upon the whole system, may re-establish the functions of the skin, and bring the disease back to its normal course. 68 CONFLUENT SMALL-POX. The tumefaction of the extremities sets in at the end of the ninth day with rather acute pain, which on the eleventh or twelfth becomes very violent. The swelling and pain then cease. It is a symptom similar to the swelling of the face, and, like it, depends on the ma- turation of the pustules. As in distinct so in confluent small-pox, the face-pustules attain their full development sooner than those on the body; and they are smaller than in the distinct form of the disease. The pustules mature more quickly on the trunk than on the extremities; concurrently with the inflammation which arises around the pustules (commencing about the tenth day, and attain- ing its maximum on the eleventh or twelfth), it is not surprising that the extremities should swell, and that the swelling of the face should cease. But the great question to be determined with refer- ence to the swelling of the hands and feet is :—What is the value of this symptom? Sydenham, Morton, Van Swiefen, and Borsieri attached immense importance to it, and in relation to prognosis I wish again to insist on its great value, and to repeat that swelling of the hands and feet is a necessary phenomenon in confluent small-pox, that patients almost invariably succumb when it is absent, unless there be a great critical discharge by the kidneys or bowels. When there is absence of the swelling of the hands and feet diarrhoea is as beneficial as it is to be dreaded in opposite circumstances. This opinion was held even by Sydenham and Morton, who, as a general rule, considered purging a formidable complication. Swelling of the extremities, which is the rule in confluent small- pox, is an exceptional occurrence in the distinct form of the disease, and is only met with in it when the pustules are numerous on the hands and feet. In a young woman, whom we had as a patient in the Hotel Dieu, in January, 1861, with normal distinct small-pox, although she bore three true vaccination marks, there occurred tume- faction of the hands and feet at the end of the ninth day, when, how- ever, the face and neck were still very swollen. The swelling of the hands and feet continued to the thirteenth day. At the beginning of confluent small-pox, as I have already said, nervous symptoms appear pretty frequently, such as tremors and sometimes slight delirium. When this delirium is met with, it gene- rally occurs as a transient phenomenon just as the eruption is coming out, and returns about the third day of the eruption (fifth of the disease), and continues to the end of the attack, or at least to the thirteenth or fourteenth day of the disease. When it is violent— CONFLUENT SMALL-POX. 69 when it assumes the form of typhic delirium—when it is accom- panied by coma vigil, picking the bed-clothes, and twitching of the tendons, its prognostic significance is exceedingly grave. The same may be said of diarrhoea. It generally shows itself in the early days of the disease, and ceases about the fifth day from the date of the invasion, that is to say, about the second or third of the eruption; but w'hen it continues, and is violent about the eighth, ninth, and tenth days, the prognosis is unfavorable, except in the exceptional conditions formerly mentioned; in ordinary cases patients who have violent diarrhoea at or after the eighth day almost always die. This, however, was not the opinion of Hoffmann, who, so far from dreading diarrhoea, even when violent, in confluent small-pox, looked upon it as beneficial; but the opposite opinion, which I hold, is that of Sydenham, Morton, and Borsieri. When the eruption has reached its thirteenth or fourteenth day, just when the swelling, which has for two or three days left the face, appears in the extremities, the patient exhales, as I have already said, an insupportable fetor. If you raise the bedclothes you are shocked with the disgusting smell which comes from the putrefac- tion of the pus exuded by the pustules. This putrefaction has, perhaps, something to do with the serious complications which occa- sionally supervene at this period. There may be absorption of the putrescent fluids and miasms, poisoning the blood, and producing in that way the grave symptoms which arise. I dare not, however, assert positively that facts are in exact harmony with this theory, which has Borsieri as a supporter. With a view of preventing the dreaded purulent infection, some practitioners, as you are aware, are in the habit of opening the pustules as soon as possible, and bathing the skin very frequently with chlorinated lotions. This practice, at least to the extent of opening the pustules, was followed by the Arabian physicians Avicenna and Rhazes. Ambrose Pare also adopted it. It may be very beneficial; but its performance must,in my opinion, be often exceedingly difficult. The baths have likewise great utility, as have all measures winch conduce to cleanliness—a maxim strongly put by Yan Swieten, wflien he recommended that the patients should have their linen changed frequently. It must be clearly understood, however, that such proceedings demand great precautions, and that in our hospital practice it is sometimes very difficult to carry out the very useful precepts now noticed. As the disease advances, as the patient enters the third week, the 70 CONFLUENT SMALL-POX. delirium, which had continued up to the thirteenth or fourteenth day, ceases; the fever, however, continues, and generally goes on till the twentieth, twenty-first, or twenty-second day, which is accounted for by the persistence of the violent inflammation of the skin, still almost entirely covered with pustules more or less deeply ulcerated. Then, however, the crusts formed upon the ulcerated surfaces present the appearance of ecthyma crusts; they become detached, leaving the dermis more or less scooped out. New crusts, thinner than their predecessors, then form; they also fall off, and are succeeded by others thinner still; and so on during two, three, or four weeks, crusts succeed each other on the small ulcerations which ultimately cicatrize, leaving the scars more or less rugged, which seam the faces of persons who have gone through confluent small-pox. After the fourth week of the disease it often happens that the fall of the crusts is followed by a true furuncular diathesis. Patients may have, on the surface of the body, as many as twenty, thirty, or even a hundred boils, causing excruciating pain, and succeeding each other so as to maintain the crop for from two to six months. The tendency to suppuration, consecutive to confluent small-pox, not only shows itself in an outbreak of boils, but also by the forma- tion of abscesses more or less deep seated. Too often these abscesses prove very dangerous complications. We see our convalescent patients suddenly seized with rigors and the most intense fever; they complain of pain in the deep-seated muscles; and the fluctua- tion detected on examining the parts gives clear evidence of the existence of a more or less considerable collection of pus to which it will be necessary to afford an exit. The abscesses, like the boils, go on in succession for from two to six months, unless the patient unfortunately succumbs previously, as is generally the case, ex- hausted by the protracted suppuration. .Almost always these abscesses occur in the limbs. Sometimes they are situated around the anus, and give rise to detachment of the rectum from the sur- rounding cellular tissue, necessitating, at a later date, the operation for fistula. In some still rarer cases the abscess may be more deeply seated, and cause dreadful complications. On the 7th February, 1861, we performed the autopsy of a lad who died after an attack of confluent small-pox, whom you saw when he occupied bed No. 21 of St. Agnes'’ Ward. During convalescence he had numerous boils and subcutaneous abscesses, some of which opened spontaneously, and others of which were opened by us. He CONFLUENT SMALL-POX. 71 nevertheless complained of acute pain in swallowing, which I attri- buted to the persistence of an inflammatory condition of the pharynx and curtain of the palate, which existed when the small-pox was running its course. About the end of January, when an epidemic of influenza wras prevailing, he was seized with acute bronchitis, and we soon afterwards detected slight pleurisy at the back of the left side of the chest. The inflammation of the chest seemed to have moderated, when, on the 5th of .February, I found him unable to breathe in the horizontal position, with difficult, wheezing inspiration, and very laborious expiration; the symptoms of oedema of the glottis were unmistakeably evident; I was under the impression that there was necrosis of a portion of the larynx, and erysipelato-phlegmonous inflammation of the aryteno-epiglottidean folds. I ordered a solution of tannin to be applied to the back of the pharynx by means of the apparatus of Mathieu, and at the same time directed that everything should be in readiness for tracheotomy. At four in the afternoon the symptoms had become so formidable that the sister of the ward summoned the chaplain before she sent for the interne on duty; when the latter arrived, the patient was dead. You will recollect that, on examination after death, we found cedematous inflammation of the aryteno-epiglottidean folds, and an abscess, as large as a pigeon’s egg, between the oesophagus and back of the larynx; this abscess, limited in front by the denuded cricoid cartilage, spread under the cellular tissue within the larynx, and bulged out con- siderably into the larynx above the vocal cords. It is not usual for oedema of the glottis to occur in this manner in cases of small-pox. It appears, as I have already said, between the ninth and twelfth day of the disease, w'hen the eruption is very confluent on the mucous membrane of the throat and larynx; the tumefaction of the aryteno-epiglottidean ligaments comes on as does that of the eyelids and hands; and you have seen a young man die in our wards, in a few hours, suffocated by this form of variolous oedema of the glottis. But, gentlemen, you can remember a young woman in St. Bernard's Ward, in i860, who, about the twelfth day of an attack of small-pox, was seized with dyspnoea, hoarseness, and wheezing inspiration, and who, nevertheless, was completely and quickly cured by injecting a saturated solution of tannin into the back part of the throat. We have lately had an opportunity of observing a case of distinct small-pox in a child of twenty months, which is full of clinical instruc- 72 CONFLUENT SMALL-POX. tion. This patient, on the third day of the eruption, was seized with dyspnoea, which seemed to be chiefly dependent on oedematous laryn- gitis. Tracheotomy was performed : at the moment of opening the windpipe, two false membranes were thrown out through the wound. The child died a few hours after the operation. An autopsy showed that the small-pox had been complicated by a pseudo-membranous inflammation extending to the larger bronchial tubes; on the right side there were isolated masses of purulent pneumonia, and on the same side a small quantity of purulent effusion. This is an exceed- ingly rare complication, but still it is well to notice it to you. I take this opportunity of remarking that all inflammatory action has a great tendency to become purulent in cases of small-pox, and that we see this in the inflammatory affections of the cellular tissue and parenchyma of organs. But, in addition to this tendency, the result of a special diathesis which belongs to small-pox, another com- plication may arise, viz., metastatic abscesses presenting analogous general symptoms to similar collections of pus occurrring after ampu- tations and in puerperal women. This manifestation of metastatic abscesses begins particularly between the ninth and fourteenth day of the disease, that is to say, when the skin is covered with a sheet of pus. Possibly there exists at this time capillary phlebitis, as the starting-point of the purulent infection, a view maintained by Kibes, and which Legallois has endeavoured to establish in his essay on purulent infection. The existence of capillary phlebitis in small- pox has not been demonstrated, but the hypothesis of its presence becomes very truth-like when we recollect that we sometimes meet with erysipelas of the arms and legs in confluent small-pox; in these cases the lymphatic vessels or veins may participate in the purulent inflammation of the skin, and become the cause of infection. It is only in exceptional cases that distinct small-pox is fatal; but we have said enough to show that it is far otherwise with the confluent form of the disease. The history of epidemics proves this : in some epidemics, the half; in others, four fifths; and in others, less fatal, we find that one third die of those attacked. It is therefore the most deadly of all pestilences; the mortality is much in excess of that from yellow fever or cholera. The terrible feature of small-pox is, that it not only kills in the acute stage, but even after it seems to have left the patient, and when all danger appears to be past. It proves fatal by the deep-seated suppurations of which we have spoken—suppurations which invade the cellular tissue of the limbs, 73 and likewise become developed in the serous cavities, more frequently in the pleurae than in the peritoneum; it proves fatal by peri- pneumonia, which rapidly proceeds to 'suppuration, and that so late as the second or third month from the beginning of the eruptive fever. We are then right in saying, and repeating, that small-pox is the most formidable of epidemic diseases; for while other diseases strike down their victims, they rarely do so during convalescence. CONFLUENT SMALL-l’OX. In small-pox, when death occurs during the course of the disease itself, it occurs at a period which it is necessary to indicate, inas- much as it is of the highest importance to know when to expect the fatal issue, so that we may be able to foresee and predict it. In confluent small-pox the patient very seldom dies before the eleventh day, and, in general, the most fatal epochs are the twelfth, thirteenth, and fourteenth days. However alarming the symptoms may be, even when death seems imminent on the seventh or eighth, we may hope that life will be prolonged at least to the eleventh or twelfth day. Sometimes, nevertheless, the disease terminates fatally within the first five or six days, but this is only when it has assumed an anomalous form, and is of an exceptionally malignant type. Quite suddenly, and without apparent cause, the strength fails, unusual symptoms, not in accordance with the ordinary course of the disease, show themselves; there is a formidable increase in the nervous symptoms—in the delirium, coma, prostration, anxiety—and also in the dyspnoea, although there is no appreciable thoracic lesion. A rapidly fatal issue is particularly apt to take place in those frightful cases of haemorrhagic small-pox, of which we had some in the hospital, and of which I shall immediately speak. Anasarca, which supervenes in the last period of scarlatina, and occasionally, though rarely, at the end of an attack of measles, also occurs in confluent small-pox; it is rarer than in scarlatina, and more frequent than in measles. Albuminuria is almost as common in confluent small-pox as in scarlet fever. There is this difference, however, that in scarlatina the albuminuria appears during the decline, and in confluent small- pox during the acute period of the disease. Extensive observations made by Dr. Abeille1 have shown that, in confluent small-pox, as in scarlatina, albuminuria is met with in about one third of the cases. Developed at the beginning of the attack, the renal affection may 1 Abeille :—Traite des maladies a urines albumineuses et sucr^es. 74 CONFLUENT SMALL-POX. continue to the end of it, so as then to present a kind of analogy with scarlatinous albuminuria. Although albuminuria does not show itself nearly so often during convalescence from small-pox as in the decline of scarlatina, the occurrence is sufficiently frequent to be remembered as a possible complication. The same remark applies to hematuria, an affection which often precedes and announces the existence of scarlatinous albuminuria. It is rarer in confluent small- pox than in scarlatina; and when it does occur, it is at the com- mencement of the disease, and not during the period of its decline. Independently of the cases in which the hematuria is connected with Bright's disease of more or less transient character [affection Briglitique plus ou moins passagere de reins], there are others in which passing blood by the urethra constitutes an epiphenomenon of the most serious import. Such is it when coincident with nasal, buccal, bronchial, and subcutaneous haemorrhages, as in the terrible forms of the malady described by the ancients as variola nigra, or black small-pox. Many of you, gentlemen, ought still to recollect two cases of this kind which we saw, in i860, in the wards of our colleagues, Drs. Legroux and Pelletan. The two patients to whom I refer had bleeding from the nose, mouth, eyes, anus, urethra—in point of fact, from all the emunctories—accompanied by a general subcu- taneous eruption of frightful intensity, of a violet-red colour, like the lees of wine, so that the individuals looked as if they had been soaked in vats full of the residuum of pressed grapes. You recollect that some of the pustules were stained reddish-black by the blood with which they were filled, and you were, no doubt, particularly struck by the small number of the pustules, although the date of their appearance, within forty-eight hours of the pyrexial invasion, left no room to doubt that the disease was confluent small-pox. Some years earlier, in 1854, we had analogous examples in our wards. But in them—to which I shall return when I speak of measly and scarlatinous eruptions in modified small-pox—in them the haemorrhagic complications were essentially milder, and had not the disastrous consequences seen in the other two cases, the small- pox having been modified by antecedent vaccination. The two unfortunate patients of i860 were seized with delirium, restlessness, and high fever, and sunk rapidly from the beginning of the attack. In young children small-pox presents important peculiarities in its onset, course, and issue. 75 CONFLUENT SMALL-POX. In them the period of incubation is the same as in the adult, viz., from nine to eleven days. The initiatory symptoms often pass un- observed, because the little patient cannot tell what he feels; still, the experienced clinical observer will always be on the outlook for the eruption of small-pox, when he meets with quick pulse, vomiting, diarrhcea, restlessness, convulsions or coma, in an unvaccinated child, whose previous morbid condition was inadequate to explain the appearance of these symptoms. Two or three days after these epiphenomena a variolous eruption, distinct or confluent, is observed. It appears on the surface of the skin, in successive outbreaks; in some places it may be distinct, while it is confluent in parts where there is a previously existing cause of irritation, as on the hips and other parts irritated by the contact of the urine and the swaddling bands. The development of the pustules in children differs in no respect from their development in adults; but the younger the patient is, the more reason is there, to fear that the course of the disease will be anomalous. Thus, it is not uncommon in infants of one, two, or three months to see the eruption fade on the first day of the appearance of the papules; under such circumstances, the surface of the body is very pale, and the papules have an opalescent aspect. At other times, and particularly about the second, third, or fourth day of the eruption, it has a haemorrhagic appearance, the herald of a speedy and fatal issue; the patients remain drowrsy, with small, thready, irregular pulse, and they die without a struggle. It sometimes happens that, immediately after the first outbreak of the eruption, they take the breast eagerly; their skin continues hot, their pulse somewhat frequent, but regular, and they support wrell the fever of maturation. Infants above a year old may recover, but under that age almost invariably die. On the fourteenth or fifteenth day, just when we are believing that the case is progressing favor- ably, death takes place, either without a struggle, or after one or two fits of convulsions. These remarks show how very reserved we ought to be in our prognosis of small-pox in childhood, even when to all appearance the case seems to be going on well, Small-pox, confluent or dis- tinct, is almost always fatal in children under two years of age; they may be carried off without having had any of the complications looked upon as so inauspicious in adults. When death occurs during the first few days, it seems to be caused by variolous toxfemia; when it occurs later, say about the third week, it is CONFLUENT SMALL-POX. apparently the result of the long struggle having exhausted the vital power of the patient. Need I recall to your recollection that, in distinct small-pox in children, diarrhoea is not a serious complication, that, on the contrary, it seems, like perspiration in the adult, to be a favorable symptom; that in them, in the confluent form of the disease, it takes the place of salivation, and ceases spontaneously on the appearance of tumefaction in the hands and feet? Young children, when they do not succumb, often have, like adults, nume- rous abscesses on the surface of the body. As it is, for obvious reasons, in the wards of an hospital, that there is the most danger of contracting small-pox, the physician in charge ought at once, on the admission of children, to inquire whether they have been vaccinated; and if they have not, his first care ought to be to have the operation performed, unless there are circumstances which constitute a positive contra-indication. The treatment of true small-pox, distinct and confluent, has now to be considered. Necessarily, I shall be brief on this subject, for there is rarely room for energetic medical interference in the eruptive fevers. These diseases run a natural course, which is inevitable and definite; this remark is strictly true in respect of measles and scarlatina, but its correctness is even more strikingly manifest in small-pox, the different periods of which are distinctly determined, mathematically limited, so to speak, according to the form of the disease being distinct or confluent. Distinct small-pox is generally a mild malady, and may generally be left to itself. We may rest satisfied with prescribing cooling beverages, and slightly acidulated diet-drinks, such as lemonade, orangeade, and currant-water. Confluent small-pox, unfortunately, does not call for any very different treatment. In recent times, the advantages resulting from the employment of certain medicines have been vaunted, but the facts upon which such opinions rest are far from being conclusive. My practice is, excepting when there are complications involving special indications, to confine myself to prescribing diet-drinks acidulated with sulphuric acid, as recommended by Sydenham and Van Swieten under the name of antiseptics. When there is much cerebral disturbance, baths and the cold affusion do real service, though less than in scarlatina. Baths and lotions, not exactly cold, but of a moderate temperature, demand a 77 CONFLUENT SMALL-TOX. very important place in the hygienical treatment of small-pox. We have already seen that some practitioners bathe their patients fre- quently with a view of preventing the purulent infection likely to result from the formation and stagnation of variolous pus on the sur- face of the body. It is an equally useful measure to change the linen frequently; and without going the length of Van Swieten, who inculcates exposing it to the vapour of aromatic substances, to get rid of the lye and the soapy smell, one cannot be too careful as to the way of carrying out in practice the frequent change of linen. The risk of exposing small-pox patients to cold air has been exag- gerated. Sydenham combated the erroneous opinion that persons suffering from eruptive fevers ought to be kept in rooms at a high temperature; there is nothing so dangerous as this vulgar prejudice, which caused patients to be smothered under a load of bedding, and to be placed in chambers having every chink stopped up, and the airing of which was hardly ventured upon. Cold is less dan- gerous than excessive heat. For this reason, Sydenham prohibited the too much covering of small-pox patients, and in distinct small- pox, in warm summer weather, he did not confine them to bed. Cullen and Stoll went still further, and directed that they should be exposed to moderately cool air. Diarrhoea in confluent small-pox is a terrible complication, when it continues till the eighth, ninth, or tenth day; it requires to be kept in check by small doses of opium, but constipation must be equally guarded against. This was the opinion of Sydenham, Freind, Lobb, Huxham, and many others. Morton himself, who so much dreaded intestinal flux, recommended, nevertheless, the employment of lavements, and even of purgatives, when the patients were without stools, and the reaction excessive; he advised similar means to be resorted to when it was desirable to excite a salutary crisis, in consequence of salivation ceasing, without the swelling of the extremities taking place. In small-pox, as in typhoid fever, it is not judicious to place our patients on too low diet: they ought to have meat broth; and light soups, made with or without meat, should be given frequently and in small quantities throughout the twenty-four hours. 78 MODIFIED SMALL-POX. Modified Small-pox—does not differ from true Small-pox in its essence.—It differs from Varicella or Chicken-pox.—It was well known lefore our times.—In the period of invasion it is Identical 'with Small-pox.—Scarlatinfform and Petechial Eruptions at the commencement.—Black Small-pox.—Particular Modes of Desic- cation.—Is Seldom a Dangerous Disease. Gentlemen:—Let ns now attend to the subject of modified SMALL-POX. In recent times a proper custom has arisen of designating by the terms rheumatoid pains and diphtheroid exudations, the pains and exudations which resemble rheumatic pains and diphtheritic exuda- tions, the object of using these new names being to point out that there is only an analogy in the manifestations, and not an identity in the nature of the maladies; thus, the pains which belong to syphilis may be called rheumatoid, and we may designate as diph- theroid the pultaceous exudations which proceed from certain inflammatory affections of the mucous membranes of the mouth and genital organs, not in any way dependent upon the general disease named diphtheria. If it was right to introduce this phraseology, it would be wrong to continue to apply the term “ variolo'ide•” to modified small-pox, as it would leave room for supposing that the natural and modified diseases are essentially different from each other. Henceforth, therefore, we shall substitute for the word “ variolo'ide” the expression “ variole modifte” Modified small-pox has been observed long ago. Such of you as would wish to read the histories of anomalous epidemics of small- pox by Sydenham, the ‘ Commentaries' of Yan Swieten, and the Institutes of Borsieri, will be soon convinced that long before the discovery of vaccination persons had been observed to be affected with a form of small-pox presenting all the characteristics of the modified small-pox of the present day. The modified disease showed itself in those who had had small-pox previously, whether com- municated by accidental contagion, by intentional inoculation, or by intra-uterine communication; this has been demonstrated beyond the possibility of doubt in our day, and was perfectly well known to the ancients. One cannot too often peruse and reperuse the in- teresting passage in the ‘ Commentaries5 of Yan Swieten on Boer- haave's (Aphorisms/ in which, when discussing the subject of 79 second attacks of small-pox, the illustrious physician of Vienna describes several kinds of modified or bastard small-pox, although he has confounded under the name of variola spuria chicken-pox and small-pox, which are essentially different from one another. Modified small-pox is simply small-pox modified either by antece- dent small-pox, or by antecedent vaccination. Varicella or chicken- pox is, on the contrary, a special and specific malady, having no relationship whatever with small-pox. It is easy to demonstrate the truth of both statements. When we come to study varicella we shall see that it never engenders small-pox, just as small-pox never engenders varicella. Again, vaccination has no preventive influence against varicella. With respect to modified small-pox, we see that it is very different. If a patient suffering from natural small-pox, distinct or confluent, enter a ward where there are individuals who have been vaccinated, but who no longer enjoy the vaccinal immunity in a sufficient manner, these individuals may take the disease; but it will present features different from those of natural small-pox; they will, in fact, have modified small-pox. Again, if a patient affected with modified small-pox, in its simplest and mildest form, be placed in contact with one who has neither had small-pox nor been vaccinated, the latter may contract the disease; and if so, it will not be the modified form, but natural small-pox, distinct or confluent; he, in his turn, may communicate the variolous contagion to a third person, in whom the case will assume the natural or modi- fied form, just as he has or has not been vaccinated—that is, just as he may be in the condition of the first or second patient. Such cases as I now refer to, you have seen; they are quite sufficient to demonstrate, rigorously and incontestably, the absolute identity of the modified and the natural small-pox. This identity may also be demonstrated in another and more direct manner. An imperious necessity has several times obliged me to practise inoculation, both in this hospital and in my wards for children at the Necker hospital. Having no vaccine lymph, and small-pox being prevalent in the wards, I hoped by inoculation to impart a milder form of the disease than that which the persons I inoculated might contract from the patients who had small-pox. You can un- derstand that, under such circumstances, I only inoculated with virus taken from a case of modified small-pox, in which the charac- ters of the distinct form of the disease were as well marked as I could possibly find them. Now, in spite of that precaution, I MODIFIED SMALL-POX. 80 MODIFIED SMALL-POX. always communicated natural small-pox, of the distinct form, it is true, but still unmistakeable, natural small-pox. So legitimate was the disease I imparted, that if some days after recovery I introduced the vaccine matter into one arm, and the variolous matter into the other, neither declared themselves. The individual had lost his aptitude for contracting the disease, which, like the other eruptive fevers, does not attack the same person a second time, save in exceptional cases. Small-pox, natural and modified, are, therefore, identical, because they reproduce natural small-pox. During the first quarter of this century the existence of modified small-pox was almost disputed. However, at the London Small- pox Hospital persons were from time to time received who said they had been vaccinated; and Jenner himself avows having seen some such cases; but as there was a desire at that time to make out that vaccination could never fail, it was alleged that vaccinated persons who took small-pox had been badly vaccinated, and their attacks were looked upon as natural small-pox. At last evidence became irresistible, when about the year 1832 epidemics of small- pox were seen to strike vaccinated populations, when three years later they reached Paris, where in recent years they have continued to prevail. The influence which the variolous matter exerts on the economy, and the modifications which it imprints on the organism, being necessarily subordinate to the predisposition acquired by the or- ganism under the variolous influence, or (which is the same thing) under the influence of antecedent vaccination, it necessarily follows that a second variolous inoculation will produce on the economy various effects proportionate to the degree of immunity previously conferred upon it, and which it still possesses more or less com- pletely. Also, although modified small-pox is in its essence identical with natural small-pox, it is far from being identical in its lorms. In place of having, like natural small-pox, fixed and precise features, it even presents essential differences from itself, and has no settled character. So correct is this statement, that the only way to describe modified small-pox is to speak of each of its numerous varieties as I now propose to do. There is one period in which modified is always identical in symp- toms with natural small-pox; that is, the period of invasion. How- ever much attention you may bestow upon initiatory phenomena of the disease, it will be as impossible for you as it was for me to MODIFIED SMALL-POX. 81 establish a difference between symptoms of each during that period. Rigors followed by heat, anxiety, headache, pain in the epigastric region, nausea, retching, vomiting, pain in the back, feebleness, paralysis of the inferior extremities and bladder—such is the train of prodromic symptoms which alike supervene in modified and natural small-pox. In both the symptoms are mild, if the case— be it natural or modified small-pox—is going to take the distinct form; and in both they are more or less violent, if it is going to take the confluent form. The eruption comes out on the same days and in the same manner; that is to say, on the fourth day in the distinct, and on the second or third in the confluent. Here, thermometric investigation furnishes valuable information; thus, for example, the temperature, which had risen as high as 40 or 41 degrees, suddenly falls to about 37 degrees on the appearance of the eruption. This rapid decrease of heat takes place continuously, and not slowly, as in distinct small-pox. The rapid subsidence of heat may enable us to diagnose modified small-pox, wrhen, from the apparent gravity of the symptoms, we might have supposed that the case was one of natural small-pox. Let me add that, in modified small-pox, we begin, as pustules appear, to discover some of the characters of anomalous small-pox described by Sydenham, such as a premature appearance of the eruption in the distinct, and a re- tardation of it in the confluent form. Delirium, as we have seen, may supervene in confluent small-pox during the period of invasion, and continue to the end, the patients dying about the twelfth day. In modified small-pox, cerebral com- plications are observed more frequently than in natural small-pox; but there is this capital difference, that they have not an unfavour- able prognostic signification in the former. Last year, among others with modified small-pox, we had some in our wards who were a prey to violent delirium, which, after continuing, not only on the morrow of the eruption, but also for the two or three following days, ceased abruptly on the seventh or eighth day of the disease, when the patients became convalescent. It is more common to meet with anomalous cutaneous eruptions, according to the prevailing epidemic constitution, in modified than in unmodified small-pox; they appear the day before or simulta- neously, with the pustular eruption. Sometimes they so much simu- late, as to be mistaken for, the eruption of measles, even when they are looked at closely; still more do they sometimes resemble the 82 MODIFIED SMALL-POX. exanthem of scarlatina. The spots are small, of a more or less deep red colour, sometimes blackish, nearly always running into each other, so as to form large patches, haemorrhagic looking, to which the English have given the name of rash} This is in a slight degree that of which I spoke of to you as black haemorrhagic small- pox, recalling to your recollection the terrible examples we had in the -wards of our colleagues, MM. Legroux and Pelletan. These haemorrhagic scarlatiniform eruptions, which in natural small-pox constitute an alarming symptom, do not lead to an unfavorable pro- gnosis in modified small-pox. They generally show themselves in the groin, on the thighs, and on the lower part of the abdomen. They do not disappear on pressure with the finger, or at least there remains a greenish-yellow mark, which quickly acquires the reddish hue, of a more or less violet shade, momentarily effaced by the pressure of the finger. This rash is sometimes more uniformly dif- fused ; the condition of the patient is then apparently more serious; and I recollect that, in 1854, we had in our wards three remarkable cases of modified small-pox, accompanied by haemorrhagic scarlatini- form and measly eruptions, which presented very alarming symptoms at the beginning of the attack. In two of these cases, to which allusion has already been made, the patients were young women between twenty and twenty-three years of age, who came into the hospital complaining of violent pains in the loins, nausea, vomiting, and rigors; the pains in the loins were accompanied by extreme debility in the inferior extremities and partial paraplegia. On the third day in one case, and on the fourth in the other, we saw an eruption of small red livid spots, varying in size from a pin’s head to a lentil; they did not disappear on pressure. In one of these young women, the eruption was limited to the groins and axillae; in the other, although it was more confluent in these situations, it likewise covered the upper part and base of the neck; it showed itself on the legs, wdiere it was of a deep shade, and was even disseminated over the entire surface of the body, which pre- sented an appearance of small dots, of a bright rosy hue, which became effaced on being pressed by the finger. This eruption was 1 The author is evidently not aware that English physicians, as well as the general public, use the term rash when speaking of any exanthematous eruption, and that the word, except with the assistance of one or more other words, does not indicate a special exanthem, nor a particular form of exanthem.—Teaks* latok. MODIFIED SMALL-POX. 83 more copious on the following day; but on that day, which was the sixth from the beginning of the disease, the characteristic eruption of small-pox came out. The haemorrhagic discolorations enlarged still more on the second day from the appearance of the pustules, and during the night the patient had slight bleeding from the nose. She had at that time persistent fever, much delirium, and great rest- lessness, both of which continued till the eleventh day of the disease. At that date, the greater part of the variolous pustules aborted, and the rest desiccated; while simultaneously the general symptoms ceased without any treatment. Thus, in this case, there was not only scarlatiniform eruption, but likewise a true nasal haemorrhage; and between the twelfth and thirteenth day of the disease the sub- cutaneous sanguineous stains left characteristic traces, some reddish and others yellowish. An additional cause of great anxiety was the continuance of the fever, delirium, and extreme restlessness up to the eleventh day. The nervous phenomena, however, ceased in an abrupt manner, and the patient recovered. In another young woman, and in a young man whom we had under observation about the same time, the general symptoms and haemorrhagic eruptions were nearly as strongly marked as in the first mentioned of the two young women; and the issue was equally favorable. We had to do with persons who had been vaccinated, for we found true charac- teristic vaccinal cicatrices; and we had to do with modified small- pox. Under such circumstances, even when the symptoms have an alarming aspect, the case generally terminates favorably. I haye hitherto spoken of cases of modified small-pox, in which scarlatini- form eruption remained after the appearance of variolous pustules ; there are others in which it disappears rapidly, and may escape observation. It is a remarkable fact, and one to which attention was long ago directed, that variolous pustules are either not de- veloped, or are only developed very sparingly in parts where the scarlatiniform eruption exists. I have, gentlemen, been speaking to you of the scarlatiniform, and not of the scarlatinous eruption; and I have much insisted on the name scarlatiniform, which I have given to it. I wish still more to insist on this name, for I confess that I am at a loss to un- derstand how grave men, hospital physicians, occupying an eminent position in our art, can constantly say and print that small-pox was complicated with scarlatina in cases similar to those which I have just brought under your notice. This deplorable mistake is made MODIFIED SMALL-POX. by the anatomical school of pathology, which, determining the nature of a disease by one of its manifestations on the exterior of the body, does not take into account the constituent elements of the disease, the aggregate of which represents the morbid unity of which we ought to form a conception. The cases now under consideration have no more to do with scarlatina than with dotliienteritis—no more than pneumonia, small-pox, or scarlatina have to do with typhoid fever, when typhoid symptoms appear in the course of an attack of any one of them. Sometimes, though rarely, the eruption is measly. In July, 1862, we received into the clinical wards a young woman in the third day of an attack of small-pox. She had been vaccinated. The symp- toms of the initiatory period had been rather severe; but there was nothing abnormal in the aspect of the case. At the visit-hour the patient had already some characteristic pustules; at the same time we found an eruption resembling measles on the hands, posterior aspect of the fore-arms, on the elbows, knees, and anterior surface of the thighs. It was displayed in irregular patches, separated by oddly-shaped intervals of white. The exanthem was morbilliform, and not scarlatiniform. But some of the red patches on the fore- arms and thighs presented a very particular character. In the centre was a small red papule, around which there was an areola of about a centimeter in diameter. The singularity of the appearance consisted in the injection of the dermis not proceeding outwards from the central papule, and diminishing in intensity as it got nearer the healthy skin; so far from this being the case, the discoloration was sharply defined by a narrow, bright-red band, between which and the centre, the hue was notably less deep in colour. The characteristic eruption of modified small-pox comes out like that of the natural disease. It begins on the face, forthwith gains the trunk and limbs, and finishes with the hands in from thirty-six to forty- eight hours from the commencement of its appearance. It is at first identical with the natural variolous eruption. Like it, it is formed of small red spots, which become acuminated, and then flatten towards the third day. But generally from the third or fourth day of the eruption—the seventh or eighth of the malady—they undergo a remarkable modification, which is never seen in natural small-pox, whether distinct or confluent. In place of showing a tendency to increase up to the eighth day—in place of becoming surrounded by an inflammatory areola, and beginning on the nose and chin to be MODIFIED SMALL POX. 85 covered with small, yellowish rough crusts, they dry up without ex- hibiting the inflammatory areola; and they leave in their place small hard, corneous projections, which fall by a sort of desquamation between the tenth and fifteenth days. Such is modified small-pox in its elementary form, and as it is known to the English by the name of “ horn-pox." In some cases, however, the pustules continue for from three to six days, or longer. If you examine three patients with modified small-pox at present in St. Agnes's Ward—one in bed No. 8, another in bed No. n bis, and the third in bed No. 17—you will see in the first that the pustules became horny on the eighth day of the eruption; in the second, they assumed that appearance on the ninth; and in the third, they did not dry up till the twelfth, thir- teenth, and even fourteenth day. These three cases are examples of the varieties of the disease, which they show you is in reaiity abortive small-pox, and that is only developed on account of the morbific germ having been thrown upon a congenial soil. It appears, in fact, that there are certain diseases, among which small- pox is conspicuous, which, like the seeds of plants when sown in different soils, germinate and grow up in different manners; in soil suited to their nature, they spring up invested with all their natural characteristics, they blossom, shed their seed, and, in a word, attain to perfection; in a poorer soil they grow with more difficulty, scarcely blossom, and ripen badly; in a still poorer soil they germinate, but almost immediately die. The seeds of diseases, like the seeds of plants, are liable to degenerate. The quality of the germ, the recep- tive power of the soil, whether it be the earth or the human body to which the germ is committed, are not always the same. Under certain circumstances, the organism undergoes a constitutional change in virtue of which it is more or less fitted for the reception and germination of the morbific seed; whooping-cough, for example, impresses the economy in so special a manner that the same person will not take that disease twice, and the same is true in respect of scarlatina and small-pox. This is most conspicuously true in respect of the latter, though the explanation of the fact is as inex- plicable in the one as in the others. As already said, small-pox and vaccination place the organism in that special condition in which it is incapable of again contracting small-pox. This resistance, how- ever, to the morbific conception is not absolute. Second attacks of small-pox and attacks of small-pox in vaccinated persons do occur, 86 MODIFIED SMALL-POX. but in such cases the morbid germ does not grow up with its natural characteristics. The effects, as I before said, are proportionate to the degree of immunity which has been conferred, and this degree of immunity appears most frequently to depend on the longer or shorter interval which has elapsed between the second attack of small-pox and the antecedent small-pox or vaccination. If the vac- cination is of recent date, the nature of the small-pox will be more radically modified, milder, for example, than if twenty-nine or thirty years had elapsed. Side by side with cases of benignant modified small-pox, you will see others which for ten or twelve days follow the exact course of natural small-pox; the swelling of the face and eye- lids takes place, the pustules on the limbs are surrounded by an inflammatory areola, and pain is complained of in the regions which they occupy; then this swelling subsides more rapidly than in natural small-pox; the pustules on the hands, in place of attaining their maximum of development on the fourteenth, are filled with pus on the eleventh or twelfth, when they wither, instead of waiting till the eighteenth or up to the twenty-second day, as happens in distinct natural small-pox. The disease, in a word, in some individuals, after seeking to exhibit itself in its usual character, suddenly changes its manifestations, and terminates in a rather abrupt manner, while in others it altogether fails to develope itself. In some persons the organism seems so refractory to the action of variolous matter, or, to continue the comparison which we formerly employed, the soil is so ill prepared to receive the morbific germ, that although there has been neither antecedent small-pox nor vac- cination, the small-pox, when it is contracted, is modified. Dr. Birmin lately mentioned to me the following case which he had just met with in his practice:—A patient had been vaccinated by him, and the vaccination did not take effect. Some time afterwards, when he was thinking of repeating the operation, he was called to see the patient, whom he found suffering from distinct small-pox, which ran a course exactly like that of modified small-pox. Does not this case offer a certain analogy to that of the young woman who now lies in bed No. 18 of St. Bernard’s Ward ? She took small-pox a few'days after her child, who has just died of that disease in its confluent form. This young woman was never vaccinated, and she never had small-pox, so she said; and she bore no traces either of vaccination or small-pox. On and after the tenth day, however, the case followed the usual course of the modified disease. The period of invasion MODIFIED SMALL-POX. 87 was characterised by general discomfort, great lassitude and muscular pains, nausea, and epigastric pain; of the usual symptoms, rachialgia alone was absent. There are still two circumstances which remain to be noticed. In distinct, natural small-pox, there is a cessation of the fever upon the appearance of the eruption, but we see it return on the eighth day, when the pustules on the face are beginning to maturate, to continue during the ninth and tenth day, finally to cease on the eleventh. In modified small-pox, even when maturation begins on the eighth day, which is very unusual, there is hardly any febrile excitement, and it does not last for more than twenty-four hours; the tempera- ture in the axilla is likewise at that time hardly raised. In con- fluent natural small-pox, at the coming out of the eruption, salivation appears, and is the great phenomenon of that form of the disease; then on the fifth day there is swelling of the face, which goes on increasing till the ninth, when it has attained its maximum, at which it remains on the tenth, and on the eleventh it diminishes simul- taneously with the appearance of tumefaction of the extremities. In modified small-pox, even when very confluent, salivation almost never occurs, swelling of the face is rare, and when it does appear there is no swelling of the hands and feet. Modified small-pox generally has a favorable issue, but it is not invariably a mild disease. Five years ago, I lost a relation by confluent modified small-pox. Delirium supervened at the beginning of the attack, and continued to the last; death took place on the thir- teenth day, swelling of the face having previously shown itself. This person had been vaccinated, and bore evident marks of vaccinia; yet he died with the symptoms of confluent small-pox in a very slightly modified form. The immunity afforded by vaccination is nearly or wholly lost by some individuals after the lapse of a certain number of years; but even in such persons confluent small-pox, which is the only form of the disease fatal to those who have been vaccinated, does not present its normal characters. Cases of a second attack of small-pox—a rare occurrence, I repeat —have been recorded by highly trustworthy authors. Diemerbroeck even mentions having seen individuals take the disease three times in three months; and Borsieri, referring to these cases, quotes others, and among them one celebrated in history, that of Louis XV., who died of confluent small-pox at the age of 74, although MODIFIED SMALL-POX. he had had the disease when fourteen years old. I have had in my wards a medical student who., though he bore the marks of two attacks of small-pox, took it a third time, and that too in a rather severe form. LECTURE II. VARIOLOUS INOCULATION. Advantages of Inoculation. — Experiments on Clavelisation}— Dangers of Inoculation and Means of diminishing them.— Methods of Inoculating.—The Mother-Dock and its Satellites.—• General Symptoms. Gentlemen :—Nations dismayed, and physicians intensely occupied with the terrible ravages of small-pox, were in search of some pos- sible means of protection from, or at least of some means of mode- rating, the scourge. Remedies alleged to be rational, and empirical nostrums seemed equally in vogue; but all prophylactic measures had alike proved failures, when, in 1721, a woman, Lady Mary Wortley Montague, announced to England that she had witnessed a practice at Constantinople, which afforded perpetual protection from the disease to all who availed themselves of it. This practice of variolous inoculation, derived from China and Persia, countries in which from time immemorial it had been in common use, as well as in Georgia, Circassia, and Greece, consisted in giving small-pox to persons in health. It was already known by ex- periment, that the prophylaxis of the pestilence was in the pesti- lence itself; it was known that those who had been once attacked, however mild the symptoms might have been, were henceforth in a condition to traverse small-pox epidemics with impunity, and to expose themselves without risk to the contagion of the disease; it was known that second attacks were exceedingly rare, and altogether exceptional; but it was also known, on the one hand, that small- pox could not be communicated at pleasure by simple contact; and ' Clavelisation is a term derived from clavelee, the French name for ovine variola, popularly known in England as “ tag-sore,” or “rot,” or small-pox f sheep.—Translator. 90 VARIOLOUS INOCULATION. on the other hand, that even if it could be communicated in that way, there existed no method of moderating the attacks by subject- ing the individual to the contagion of a mild case. Inoculation seemed to offer every desired advantage; while it conferred an almost absolute immunity for the future, it wras attended by no danger. Never, it was said, has small-pox proved serious when communicated by inoculation; the disease has always assumed the distinct form, has probably left no trace of its passage, or, at all events, there have been none of those horrible cicatrices to deplore, which so often remain after attacks produced by contagion. The wonderful statements of Lady M. W. Montague, who, when residing at Constantinople in 1717, had not shrunk from having inoculation practised upon her own son, a boy of six years of age, the new example which she gave, when, on her return to London, she proceeded to have her daughter also submitted to the same treat- ment, the successful results proclaimed by her, and of which she offered proofs, enlisted the sympathy of a great number of right- minded persons, both among physicians and in general society. Experiments were speedily set on foot in England, where inocula- tion was soon adopted, and was ere long generally employed. The new practice (which had many opponents as well as adherents) was carried to America in the same year that it was introduced into England, and three years later it became known in Germany, where some of the children of the first families of Prussia were inoculated. The practice of inoculation did not obtain a footing in England, America, and Germany, without opposition; but opposition showed itself in Erance in an inveterate manner. It was absolutely pro- hibited when first proposed in 1723; and it was not till 1756, thirty- three years later, that any one ventured to try it. Although, in Erance, the movement in its favour originated in high places—for those first inoculated were the children of the Duke of Orleans—it was far from being general. Such of you as have a curiosity to know the different phases through which the question of variolous vaccination has passed in our own and foreign countries, ought to read its history as written by Sprengel.1 The controversy ended in variolation being accepted and generally practised till it was de- throned by vaccination; and perhaps you still knoAV of individuals who were inoculated at the beginning of this century, when, in 1 Sprengeg :—Histoire de la Medecine; traduiie de l’allemand, par A. J. Jourdan, tome vi. VARIOLOUS INOCULATION. 91 its turn, the discovery of Jenner was meeting with numerous adversaries. At that epoch, although very advantageously replaced by vaccina- tion, variolous inoculation, which at first had excited so much opposition, had rallied resolute partisans, particularly in England, where, as I have just told you, it was first introduced on its arrival from the East. It was employed in England down to 1841, and to eradicate the practice it was found necessary to pass a stringent Act of Parliament. It has nowr been everywhere entirely superseded by vaccination. Circumstances occur, however, in which, for reasons which I will explain to you, one is still obliged to have recourse to inoculation, notwithstanding the palpable inconveniences which it presents. I have found myself placed in such circumstances; and as it is my duty always to give you an account of my proceedings at the bed of the patient, I have something to say to you on the subject of variolous inoculation. As I stated when speaking of modified small-pox, I have repeatedly practised variolation. I did so for the first time long ago at the Aecker Hospital, and more recently here, under your observation. But neither at the Necker Hospital nor at the Hotel Dieu have I ever resorted to it, except when vaccine matter was not obtainable, and when a prevailing epi- demic of small-pox placed in imminent danger the lives of the young children in our wards. In practising variolation, I have always been anxious—and this is of the highest importance—to place myself as much as I could in the position of the inoculators of former times. Without ham- pering myself with the precautions which they considered necessary —without preparing, as they supposed, the subjects for the opera- tion by their plan (precautionary measures which they themselves soon abandoned, having found them to be useless), I proceeded with a view to communicate the disease in as mild a form as possible. I wras struck with a fact which belongs to veterinary medicine. The tag-sore of sheep is a malady identical in its general features with small-pox in the human subject, and the analogy between the two diseases is sufficiently great to enable us to derive from the study of the one practical lessons for the study of the other. Since last century clavelisation has been practised by the most enlightened veterinary surgeons and farmers, whenever the disease has begun to prevail, with a view to prevent the ravages of an epi- zootia. In Bessarabia, where inoculation is still universally practised, 92 VARIOLOUS INOCULATION. an agriculturist conceived the following plan for obtaining the mildest possible form of ovine variola; he selected a hundred sheep, placed them in a separate park, and then inoculated them. In nine or ten days the disease declared itself among the animals. The inoculator then took virus from one in which the symptoms were mildest, and with it inoculated a hundred other sheep. He repeated the same proceedings with a third series of a hundred sheep, select- ing, as before, the animal in which the symptoms were mildest. The following results were obtained. A considerable number of the first series died, the virus not having lost any of its energy. The disease, however, was less fatal than if it had been produced by ordinary contagion. The sheep of the second series had the eruption in the distinct form, and none of them died. For the third series the distinct character was still more decided than in the secoud, and in some cases the only eruptive manifestation was the development of a pustule at the point of inoculation. It was then supposed that this last result could be always obtained. The experimenter had obtained, in point of fact, a preservative virus, which conferred complete immunity, and pro- duced an eruption limited to the mother pustule. Inoculation of aggravated tag-sore, performed on sheep so preserved, afforded abso- lute proof of the immunity which they, had acquired, because it produced no manifestation. These facts made a great impression upon mo, and I asked myself whether the same results would be obtained in human as in ovine variola—whether, by successive series of inoculations in the human subject, an equally great modification of the disease could be produced as had been produced in the sheep, by which the eruption had been limited to a single pustule in the spot where the inocula- tion had been made. I tried the experiment at the Necker Hospital in conjunction with Dr. Delpech, then my interne, now my colleague as physician to the hospitals and agrege of our Faculty. We ob- tained the desired result in some children, to the extent that the mother pustule, the master pimple (le maitre bouton), the pustule of inoculation was alone developed, and that around it there were little pustules, its satellites. If we could be sure of always attaining equally fortunate results, inoculation ought to be the rule, for then it would be attended by no risk, and its consequences would be purely beneficial. The inoculation would be equally without danger to the person inoculated, and to those with whom he came in VARIOLOUS INOCULATION. 93 contact. This localised variola, without general eruption or serious symptoms, would perhaps be no more contagious than a cow-pock. Unfortunately, matters did not turn out so propitiously. In some cases, I attained the complete success of having only the pustule of inoculation; but in others, in which the very same virus had been employed, there were general eruptions, and, worse still, communication of small-pox to noil-inoculated persons. In one case, regarding which I shall have to speak in connection with the subject of regeneration of vaccine virus, the small-pox resumed all its original violence, after having passed through a succession of individuals in a series of inoculations. This result is opposed to those recorded by the inoculators, who made out that the variolous virus becomes pro- gressively milder as the succession of transplantations proceeds. The inconveniences of inoculation are, on the one hand, the risk of giving dangerous small-pox to an individual, and on the other the dangerous possibility of thus establishing a focus of contagion. It must be admitted that these inconveniences are serious, and they are precisely the inconveniences which, after affording arguments to the adversaries of inoculation, caused it to be abandoned after the dis- covery of vaccination; they are also inconveniences of such a character as to compel me to discontinue my experiments, and to reserve inoculation for the exceptional circumstances to which I have already alluded, and of which I shall again speak. It became my duty to renounce inoculation, from the fear that even by inoculating with virus derived from the mildest case, I might cause the death of persons who had neither been vaccinated nor inoculated, through their taking the disease in an aggravated form from the individual to whom I had given it. I should have acted otherwise, if it had been possible to isolate the persons inoculated. During an epidemic of small-pox, if I could not obtain vaccine virus, I should not hesitate again to try and to recommend a trial of inoculation, for I should not then feel the responsibility of propagating a disease which was already everywhere. There is a small number of persons so constituted as not to take small-pox, though exposed a thousand times to its contagion, and there are also those to whom it cannot be given by inoculation; but it is more usual to find others who, though more or less insusceptible to the virus, manifest the disease very slowly after inoculation. To take again the example from comparative medicine which I have already mentioned, it happens that when the tag-sore breaks 94 VARIOLOUS INOCULATION. out in a flock of five hundred sheep, it does not attack all the indi- viduals at once, but in succession, so that it rarely occurs that the epizootia has terminated in less than from three to five months. The explanation of this is that some of the sheep, in virtue of a special susceptibility, have at once taken the contagion, while others have required several repetitions of contact with it for the produc- tion of the same result. The same is observed in small-pox. When, in former times, small-pox prevailed as an epidemic, attacking the entire population of a locality, hospital, barrack, or prison, it was observed that it shownd itself at successive intervals on different sections, although every one had been equally exposed at first to the contagion. In fact, for the production of the disease, there must not only be its cause or morbific germ, but there must also be an economy, a soil, prepared to receive it: a special aptitude of the organism is wanted, without which there can be no conception of the contagion. Inoculation, by forcibly introducing the virus into the economy, without waiting for this aptitude to be developed, finds the subject in that state of unreadiness—the soil is not suffi- ciently prepared, and consequently the germ does not grow with the vigour which under other circumstances it vrnuld have manifested. Moreover, the inoculation can select the germ, that is to say, take the virus in the conditions which are most favorable. By employing matter from a distinct case which has been modified by antecedent vaccination, wre attain the greatest probability of communicating a very mild variola, just as the Bessarabian agriculturist acquired by experiment the powrer of imparting to his sheep a very slight attack of tag-sore. Lastly, inoculation practised during an epidemic is a preservative against aggravated attacks, protects individuals from contagion, the consequences of which it is impossible to estimate, while, within certain limits, we can estimate the severity of attacks induced by inoculation. It is an exceptional occurrence for inoculation with virus taken from distinct small-pox to develope the disease in its confluent form. When inoculation was first introduced into Europe, it was more common for it to cause confluent small-pox than after- wards, when vaccinators took the precaution to select their virus under the conditions which I have indicated; and by reading what our predecessors have written on this subject, I have become con- vinced that inoculation was day by day diminishing in danger, and might have become almost as harmless as vaccination. VARIOLOUS INOCULATION. 95 Inoculation was formerly accomplished by inserting a thread impregnated with variolous matter in a small incision in the skin, the arm being the part generally selected for the operation. Kirk- patrick, in his f Treatise on Inoculation/ said that it was sufficient to rub the wound with a bit of linen soaked in variolous matter. He also stated that threads impregnated with the virus, if shut up in well closed boxes, preserved their power for several months. To prove the great length of time variolous virus preserves its power, Dr. Sunderland, of Barmen, alleges that blankets saturated with the pus of small-pox preserved their contagious properties for more than two years, producing after that interval characteristic pustules on the udders of cows. The blankets referred to were used in his experiments upon the regeneration of cow-pox by communicating small-pox to cows. It was necessary, however, to cover up carefully these blankets with paper, and to keep them in a little cask in a shady, cool place, where the temperature never rose to more than io° of Reaumur above zero. It is recorded that the Chinese kept the crusts of variolous pustules in porcelain vessels well stopped with wax. They inoculated by introducing into the nostrils tents of charpie covered with the dried matter. At the end of last century, inoculators performed the operation in a manner that was simpler, quicker, and surer than those I have just described; it consisted in raising the epidermis by means of a lancet, so as to introduce the matter with which the lancet was charged. A prick is sufficient. The symptoms which ensue are the following : First of all, there are local phenomena; thus, on the second day after inoculation, there is visible, in the place where the puncture has been made, a small red pimple similar to that which results from vaccination. About the fifth day this pimple has become an acuminated vesicle; it sometimes exhibits in its centre the mark of the puncture, which has a sunken appearance, like an umbilication. On the seventh day the vesicle has become a pustule, and is sur- rounded by a slightly red areola, which becomes flattened, and assumes a bluish tint. Next day the inflammatory areola increases, and on the ninth and tenth days it increases still more. The pustule, however, continues to grow larger, becomes more depressed in the centre, and assumes more and more the bluish tint; its edges have an uneven, puckered appearance; there now arise upon the inflam- matory areola a variable number of small pustules, ten, fifteen, or twenty true satellites of the mother-pustule, which at first contain a 96 VARIOLOUS INOCULATION. limpid serosity, and afterwards some watery pus. At the same time the lymphatic glands in the axilla begin to be turgid; this turgidity has attained its maximum on the ninth day, after which it decreases, and about the fourteenth or fifteenth day it disappears. Generally speaking, in thirteen or fourteen times twenty-four hours, the pustule of inoculation has dried up, but there is sometimes formed below it a deep slough, which separates in from twenty to thirty days, leaving a more or less misshapen cicatrix. In general, however, there is no slough, and the crust falls, being succeeded by another, which in its turn also separates; and after a succession of crusts, there is at last a cicatrix larger than that which is left after vaccination. The mother pustule, which is sometimes found when the disease has been communicated by contagion in the ordinary way, the “ master pimple,” to use the German expression, presents exactly the same characters as the pustule of inoculation. You have seen an example of this in a man who occupied bed No. 11 ter in St. Agnes' ward. He was seized when in our wards in June, 1857, with a varioloid affection. Besides tolerably distinct pustules de- veloped on the skin, there was observed, on a level with the naso- labial line, a pustule larger than the others, with a diameter almost equal to that of a twenty-centime silver piece; it was deeply hollowed out—cutirn satis prof unde exederat, as Yan Swieten said of this kind of pock, which he called the master pokken. A very red areola, as large as a franc piece, surrounded it, and was covered with small vesico-pustular satellites. The patient affirmed that the great pimple had appeared at least twelve days before those on the other parts of the body. On the ninth or tenth day after the operation, the constitutional symptoms make their appearance. The patient has headache, pains in the loins, vomiting, and, in a word, all the primary symptoms of small-pox. About the eleventh, twelfth, or thirteenth day, the specific eruption is seen, which in general is but slightly confluent, and follows the course of normal or sometimes that of modified small-pox. You have had an opportunity of observing the local and general symptoms of inoculated small-pox in an infant, upon whom I deemed it right to practise inoculation at a time when the nurses of our wards were being carried off by an epidemic, and when we had no vaccine virus. This infant, aged twenty-four days, suckled by its mother, was inoculated by means of a puncture on the right arm, VARIOLOUS INOCULATION. 97 with variolous matter taken from a pustule at the eleventh day of the disease, in a case of modified distinct small-pox. An unsuccess- ful attempt to inoculate this infant had been previously made with matter from an exceedingly distinct varioloid case. The result of the second operation was to produce on the fourth day a small um- bilicated pustule, which, following a regular course, left, on the twenty-first day after its first appearance, a very deep slough. On the eleventh day after inoculation, the seventh from the appearance of the mother-pustule, the infant had the disease in its distinct form, and without any serious constitutional symptoms. The pustules dried up on the seventh day from the setting in of the primary symptoms, such as vomiting and diarrhoea, which began on the ninth day from inoculation. The little patient recovered rapidly, and thenceforth he was safe from small-pox, and even unsusceptible to vaccination. Indeed, on the eighteenth day, we tried in vain to affect him with the vaccine virus, and twenty-five days later we inoculated him with matter from a case of confluent small-pox, which did not even produce the pustule of inoculation. Notwith- standing the complete success of this experiment—a success such as I had formerly obtained elsewhere—I felt that it was my duty to discontinue inoculation, as we had obtained a supply of vaccine virus, and the epidemic of small-pox seemed as if it were on the wane. LECTURE III. COW-POX. Grease of Horses.—Cow-pox in the Cow.—Cow-pox in the Human Subject.—Cow-pox and Horse-pox are Analogous to, but not Identical with, Small-pox: Practical Importance of this Dis- tinction.—Regeneration of Cow-pox. Gentlemen :—Soon after the middle of last century, when the prac- tice of inoculation had become general in England, a belief prevailed in certain counties that persons who contracted cow-pox from cows were permanently protected from small-pox, whether exposed to its contagion, or inoculated with its virus. Jenner, the inoculator of the district in which he resided, was not unacquainted with this popular tradition. At first he did not believe in it; but he soon became convinced of its truth, having ascertained, upon reliable evidence, that several persons who had twenty-five, thirty, and fifty years previously contracted cow-pox in the dairies of the country had, from the date of that occurrence, escaped small-pox. He was thus led to inquire into the conditions under which cow-pox became developed in the human subject, and to entertain the idea of inocu- lating with it. His experiments led to results identical with those produced by direct contagion, for the persons to whom he communi- cated cow-pox remained as insusceptible to variolous influence as those who had had natural small-pox. Ear be it from me to argue that Jenner was not the discoverer of vaccination; for even though he should not be accepted as the first who communicated cow-pox to man by inoculation, there would be nothing to subtract from his glory, since it appears probable that he did not know of the experiments which Benjamin Jesty made in his family. Although there may be involved in this history a question of priority, Jenner had the incontestable merit of having contended COW-POX. 99 against all the obstacles put in the way of the practice of vaccination, and of having communicated to contemporary physicians the belief which he had deduced from the observation and rigorous interpreta- tion of facts. Respect, however, for historical verity makes it incumbent upon me to lay before you various documents lately translated in the Gazette Medicale de Lyon, from the Lancet, of London, and which seem to prove that Benjamin Jesty, a Gloucestershire farmer, was the first to inoculate with cow-pox, he having, in 1774, per- formed the operation upon his wife and two sons, for the purpose of protecting them from small-pox. The same periodical publishes a note from Mr. John Webb, showing that small-pox may be communicated from man to the cow, and that persons contracting the disease modified by this trans- mission are proof against variolous contagion. Allow me to trans- late to you John Webb's narrative, a letter from Mr. Alfred Haviland, surgeon, regarding Benjamin Jesty's discovery of cow- pox, and also an extract, on the same subject, from the records of the Vaccine Institution. First, then, I will now read to you the narrative of John Webb, which was found among his manuscripts after his death, and is dated in the year 1799. This document was communicated to the Lancet by his grandson, Thomas Watts, and is to the following effect:— “Some time in the month of May, 1792, having twenty-four children collected together at a house in Doynton for the purpose of being inoculated, and a Betty Bowman, then aged 80, accidentally coming in, she was asked by another woman present whether she had ever had the small-pox; to which Betty replied in the negative, asserting, with a considerable degree of confidence, that she was certain she never should, having in her younger days caught the cow-pox from a cow that was infected by a man in the small-pox. Such an opinion naturally induced me to desire of her a more par- ticular account of the circumstance, when I was informed that, when she was twenty-three or twenty-four years old, she lived in the service of a farmer, on whose estate, at a distance from the farm- house, or any other habitation, there was a small cottage, together with some cowsheds, that the cottage was let to a man (probably one of his labourers) who dying in the small-pox some time betwixt Michaelmas and Christmas, the bed and bed-mat on which he had lain were thrown out into the sheds j that a cow belonging to their 100 COW-POX. dairy being, as she termed, very chilly, frequently went into the cow-shed, and had been observed to lie down on or near the bed and mat; that shortly after the same cow was seized with the cow- pox, and the whole dairy, consisting of nine cows, sickened one after the other, till at length the milk was so bad that it could not be used, and of course the cows were suffered to go dry, till which time she constantly assisted in milking them; that soon after she was seized with rigors and pains in her limbs, had a tumour form in the right leg and axilla, and that three pustules appeared on the hand near the thumb, from which there was a discharge for some time (she believed about nine days) ; that, as before mentioned, she neither prior nor subsequent to that period had the small-pox, though she had frequently visited persons ill in it, and once, in par- ticular, lay on a bed on which a person had died in that disease, the bed-clothes only being changed. She likewise observed that two or three persons who had had the small-pox were frequently among the cows, but received no infection. She likewise informed me that she knew a Mary Hathaway, who milked infected cows at one time, and was not infected by them, but that at another time she wras; that she likewise never had the small-pox prior or subsequent to that period, though she resided several years in Bristol.” 1 As a sequel to the narrative now quoted, the Lancet gives the following statement, by Mr. Alfred Haviland, Surgeon to the In- firmary of Bridgewater. It refers to Mr. Benjamin Jesty, “the proto-martyr of vaccination” : — “ At the Rose and Crown Inn, Nether-Stowey, county of Somer- set, my attention was drawn, on the 31st of May last, to a photo- graph taken from a larger portrait of a good specimen of the fine old English yeoman, dressed in knee breeches, extensive double- breasted waistcoat, and no small amount of broad-cloth. He was represented sitting in an easy chair, under the shelter of some wide- spreading tree, with his stick and broad-brimmed hat in his left hand, his ample frame was surmounted by a remarkably good head, with a countenance which at once betokened firmness and superior intelligence.” “ I have been thus particular in describing the portrait, for I am not quite certain whether the photograph was taken from a drawing, an engraving, or an oil-painting; if, however, the source was an 1 La.ncet:—13 September, 1862, p. 291. London. COW-POX. 101 engraving, in all probability there are some copies still extant, which the curious in such matters may think worth collecting. On the back of this photograph is a copy of the epitaph on our subject, as follows :—f Sacred to the memory of Benjamin Jesty, who departed this life on the 16th April, 1816, aged 79 years. He was born at Yetminster, in this county, and was an upright, honest man, par- ticularly noticed for having been the first person {Jcnown) who intro- duced cow-pox by inoculation ; and who, from his great strength of mind, made an experiment from the cow on his wife and two sons, in the year 1774/ (Prom the tomb in the churchyard at Yetminster, Dorset.) “ I am informed by his relative, Mrs. William May (ne'e Jesty), that when the fact became known that he had vaccinated his wife and sons, his friends and neighbours, who had hitherto looked up to him with respect on account of his superior intelligence and honorable character, began to regard him as an inhuman brute, who could dare to practise experiments on his family, the sequel of which would be, as they thought, their metamorphosis into horned beasts. Consequently, the worthy farmer was hooted at, reviled, and pelted whenever he attended the markets in his neighbourhood. He re- mained, however, undaunted, and never failed from this cause to attend to his duties; and the secret of this bold conduct may be traced in his determined chin and nose and firm lips. After living to see another enriched and immortalised for carrying out the same principles for which he had been stoned thirty years before, he died of apoplexy, like Jenner, in 1816. Jesty's experiment on his family was performed in 1774; and Jenner’s on the 14th of May, 1796, just twenly-tioo years later.” 1 Dr. H. P. Davis, of London, having received from one of Ben- jamin Jesty’s grandsons a copy of the following document, indited and signed by the medical officers of the Original Vaccine-Pock Institution, sent it to the Lancet. “Mr. Benjamin Jesty, farmer, of Downshay, in the Isle of Pur- beck, having agreeably to an invitation from the medical establish- ment of the Original Vaccine-Pock Institution, Broad Street, Golden Square, visited London in August, 1805, to communicate certain facts relating to the cow-pox inoculation, we think it a matter of 1 Lancet :—13 September, 1862. London. cow-rox. justice to himself, and beneficial to the public, to attest that, among other facts, he has afforded decisive evidence of his having vaccinated his wife and two sons—Robert and Benjamin—in the year 1774, who were thereby rendered unsusceptible of the small-pox, as appears from the exposure of all the parties to that disease frequently during the course of thirty-one years; and from the inoculation of the two sons for the small-pox fifteen years ago. That he was led to under- take this novel practice in 1774, to counteract the small-pox at that time prevalent where he then resided, from knowing the common opinion of the county ever since he was a boy, now about sixty years ago, that persons who had gone through the cow-pox naturally —that is, by taking it from cows, were unsusceptible of small-pox; by himself being incapable of taking the small-pox; by having gone through the cow-pox many years before; from having personally known many individuals who, after the cow-pox, could not have the small-pox excited; from believing that the cow-pox was an affection free from danger; and from his opinion that by the cow-pox inocu- lation he should avoid engrafting various diseases of the human constitution, such as the evil, madness, lues, and many other bad humours, as he called them.” “The remarkably vigorous health of Mr. Jesty, his wife and two sons, now thirty-one years subsequent to the cow-pock, and his own healthy appearance at the time (seventy years of age), afford a singular proof of the harmlessness of that affection. But the public must with particular interest hear that during their late visit to town Mr. Robert Jesty very willingly submitted publicly to in- oculation for the small-pox in the most vigorous manner, and that Mr. Jesty also was subjected to the trial of inoculation for the cow- pock after the most efficacious mode, without either of them being infected.” “ The circumstances on which Mr. Jesty purposely instituted the vaccine-pock inoculation in his own family, viz., without any prece- dent, but merely from reasoning upon the nature of the affliction among cows, and from knowing its effects in the casual way among men, his exemption from the prevailing popular prejudices, and his disregard of the clamorous reproaches of his neighbours—in our opinion well entitle him to the respect of the public for his superior strength of mind. But further, his conduct in again furnishing such decisive proofs of the permanent anti-variolous efficacy of the cow-pock, on the present discontented state of many families, by COW-POX. 103 submitting to inoculation, justly clams at least the gratitude of the country.” “ As a testimony of our personal regard, and to commemorate so extraordinary a fact as that of preventing small-pox by inoculation for the cow-pock thirty-one years ago, at our request, a three- quarter-length picture of Mr. Jesty is painted by that excellent artist Mr. Sharp, to be preserved at the original Vaccine-Pock In- stitution.” “ G. Pearson, L. Nikol, Thos. Nelson, Physicians. “— Wheats, F. Forster, Consulting Surgeons. “ J. C. Carpue, J. Doralt, Surgeons. “ F. Eiyers, E. A. Brande, P. De Bruge, Visiting Apothecaries. “ J. Heaviside, T. Payne, Treasurers.”1 Gentlemen, however long you may think these details, you will, in consideration of the interest which they present, pardon me for having laid them before you. I repeat, however, that if Jenner was not the first to inoculate with cow-pox, his was no less the honour of having established the practice of vaccination. Jenner, in his first publication, which appeared in 1798, while he avoided affirming in too absolute a manner that cow-pox was a com- plete preservation against small-pox, showed anxiety to make known the nature of his discovery. Experiments, repeated first by Pearson, were afterwards undertaken on a great scale by Woodville, Physician to the London Inoculation Hospital, and ere long the testimony of these physicians, along with that of very many others, was given in favour of Jenner’s discovery. Vaccination, in spite of the opposi- tion it encountered, in spite of the violent and unjust attacks to which it was subjected, in spite of the most obstinate resistance and the most absurd prejudices with which it had to contend even in England, soon came to be generally employed. The favorable re- ception which it immediately received in Hanover extended to the rest of Germany, and, almost simultaneously, to France, where the Duke of Rochefoucault-Liancourt, who during his residence in Great Britain had seen its success, forcibly called the attention of government and the public to this important subject. 1 Lancet:—25 October, 1862, p. 461. London. The documents in the text are reprinted from the Lancet; and are not translations from the French.—Translator. 104 COW-POX. Cow-pox, that singular malady derived by man from the cow, and then transmitted with wonderful facility from person to person, had ceased to be thought of in relation to its source, and had, so to speak, become forgotten. In the years immediately subsequent to the discovery of vaccination, picote1 is so seldom mentioned by authors, that one may be led to believe that cases of it were then rare, that it occurred seldom, at long intervals only, and in privileged places. In England it had nearly ceased to be a topic of discussion, when, in 1812, attention was called to several cases in the neigh- bourhood of Berlin. In 1816, it was met with several times in the Duchy of Brunswick. At a later period, however, the occurrence of small-pox in persons who had been vaccinated having suggested the idea that the vaccine virus had degenerated, it was deemed necessary to go back to the fountain-head, or, in other words, to search for cow-pox in the cow. The investigation began in Germany, where, at the commencement of the inquiry, it was established that the picote of cows was by no means so rare as might be inferred from the long silence which had existed regarding it. In Holstein, irre- spective of isolated cases, it had prevailed as an epizootia five times in eleven years. The attention of Government having been awakened, orders were issued in 1826, 1829, 1830, and 1831, to search for vaccine matter in the cow. Prizes were offered to the proprietors of cows affected with the disease, aud from that time cases multiplied in Wiirtemberg and the Duchy of Baden. In 1836 a commission was appointed by the Academy of Medicine of Paris, to examine into a case at Passy, near Paris. A lady of the name of Eleury, residing at Passy, having stated to Dr. Perdreau, of Chaillot, that her cow, affected with picote, had communicated the affection to her hand, MM. Bousquet, Emery, and Gerardin, were commissioned to study the case; and the result was that they ob- tained characteristic cow-pox by inoculating the arm of a child with matter taken from Madame Eleury's hand.2 When these inquiries were going on in Europe, Dr. Macpherson, 1 The word picote in the text evidently refers to the vaccine disease in the cow, but in some districts of Trance, picote is the current name of small-pox in the human subject; and wherever Trench is spoken, a man marked with small- pox is said to be picote.—Translator. 2 Sur le Cow-pox a Passy pres Paris, le 22 Mars, 1836.— Memoires de VAcademie de Medecine, t. v, p. 600. COW-POX. 105 in 1833, published his experiments on vaccination, and announced that he had seen in the neighbourhood of Calcutta, in India, an epi- zootia of tag-sore. He found that this affection could not only be communicated by inoculation from cow to cow, but also from the cow to man, and afterwards from man to man. Observers were struck with the remarkable fact that transmission took place more readily when the virus was humanised, or, in other words, when it had been transmitted from man to man. The action was more powerful than that produced by inoculating the human subject direct from the cow. Dr. Steinbrenner has recorded a remarkable example of this peculiarity, which I shall now quote exactly from his Treatise on Vaccination. “ On the 18th May, 1845, a proprietor informed me that one of his cows had an eruption on the udder and teats. Upon examining the cow, and comparing what I saw with the descriptions of authors, I became nearly certain that I had at last found picote ; and although the eruption was too far advanced to justify the hope of obtaining very efficacious virus, I lost no time in collecting a considerable quantity on four plates of glass. About an hour afterwards I inocu- lated, by sixteen punctures, two unvaccinated children. Only one of the sixteen punctures produced a vaccinal pustule; but it was a very beautiful and large one, which passed through the different stages in the most perfectly, regular manner. On the eighth day, two children were vaccinated from this pustule, the virus beiug transferred direct from arm to arm; and this time the sixteen inocu- latory punctures produced sixteen beautiful vaccinal pustules. Since that occurrence I have only vaccinated with lymph derived from that source, and have obtained precisely similar results. I sent supplies of lymph taken from my first cases to the Academy of Medicine of Paris, through M. Bousquet; to the Medical Society of Strasburg ; and to many brother physicians, particularly to the cantonal phy- sician of Saar-Union; and to Drs. Podere, Kuntz, Clausing, &c. Everywhere it produced a very beautiful vaccine pock, yielding lymph, which was at once substituted for that formerly in use. Similar results have been more recently obtained by physicians and veterinary practitioners in the department of Eure-et-Loir, by whom cow-pox in the cow was also found. Similar results are 1 Steikbbenner :—Trait6 de la Vaccine, p. 534. 106 COW-POX. observed in the vaccinations—particularly in the revaccinations— now taking place in our hospitals, with vaccinal lymph derived from the heifers of Dr. Lanoix. That lymph gives rise to vaccinal pus- tules much less frequently than that taken from the arm of a child. With reference to this point, I would remark, that the lymph obtained from the heifers of Dr. Lanoix is not primitive lymph, and therefore is not more active than that taken from the human subject; and, moreover, it is the virus of cow-pox modified and weakened by a considerable series of successive generations. It appears to me that it has lost much of its power in passing succes- sively from heifer to heifer. Whatever theory we adopt, the fact remains, that vaccine lymph taken direct from the heifers referred to is less active than that which has been taken from man—than that which has been humanised. I must not allow this opportunity to escape without explaining to you the characteristics of cow-pox in the cow; as it is of the greatest importance for physicians, especially for those practising in country places, where the supply of vaccine lymph may fail, to be able to recognise the affection. The eruption consists in pustules on the udder and teats of the affected animal, having a great resemblance to those which we lately saw on the face of a small-pox patient who lay in bed No. u ter of St. Agnes’s Ward, whose case I have already brought under your notice, as presenting a remarkable example of the inoculation-pustule. The cow-pox pustules are at first pimples, varying in size from that of a lentil to that of a common round bean. They become more and more elevated; on the second or third day from their first appearance, they acquire a pustular character, are filled with a colourless lymph, and are depressed in the centre. Toward their centre, these pustules are of a bluish-white, livid colour, and towards their periphery, where an areola has already formed, they are reddish or yellowish white ; they then resemble the pustules produced by variolous inoculation. In other cases, they are of a silvery hue, of a pale red, a reddish yellow, or a clear yellow. This difference in the colour of the pustules is dependent upon their degree of development, and also, to a certain extent, upon the natural tint of the udder. On the following days they become larger, and often attain the size of a half-franc piece; and in these rare cases they are also more numerous, the udder and teats sometimes pre- senting from eight to twenty pustules, which reach their maximum development on the ninth or tenth day; at this period also, the COW-POX. 107 areola which, since the formation of the pustule, has formed a narrow ring, becomes more extended, but in cows with brown or black udders the areola is scarcely visible. Hardness, swelling, increased heat of skin, and sometimes very great tenderness, are then percep- tible. There is at the same time an exacerbation of the general symptoms, such as distaste for food, restlessness, and fever. The milk both deteriorates in quality and diminishes in quantity, and its secretion is altogether arrested when the eruption is very abundant, and accompanied by an excess of reaction. Immediately after the ninth day, crusts form in the centre of the pustules, while at their periphery the lymph grows thicker and thicker, till at last it becomes converted into a cheesy pus. The crusts, if not previously torn off, fall between the eighteenth and twenty-fourth day, leaving in their place ulcerations, which in some cases eat so deeply into the tissues as to detach the teats. In other cases, inflammatory swellings and abscesses of the mamma supervene, which continue for three or four months. As I have broached the history of cow-pox, allow me, gentlemen, to say a few words upon questions connected with that subject. First of all: What is the origin of cow-pox ? Considering the immunity from small-pox which cow-pox confers on the human race, it has been asked whether cow-pox is not in point of fact human small-pox modified by transmission to the cow, just as cow-pox is modified by transmission from the cow to man ? It has also been asked whether cow-pox is not a distinct disease, peculiar to the animals in which it is observed ? And, finally, it has been asked, whether it does not originate in a disease peculiar to other kinds of animals, and which is not small-pox ? Jenner, adopting the opinion generally received in his own country, regarded cow-pox as originating in a disease peculiar to horses termed grease in England and eaux aux jambes in France. The illustrious discoverer of vaccination had remarked a fact, well-known also to the farmers and peasantry, that cow-pox was met with only in the dairies where the cows were attended to and fed by men who likewise had charge of horses. 'Whenever grease was observed in stables, cow-pox soon showed itself in the cow-houses, whither it was brought by the men-servants of the farm who came to milk the cows with hands soiled by pus from horses affected with grease. In dairies, where women only were employed, as in Ireland, cow-pox wras very rare. Although the proposition of Jenner cannot be 108 COW-POX. accepted as absolute, experiments have proved that there is an analogy between, if not an identity in, the two maladies. It is one thing, however, to admit that grease may be transmitted from the horse to the cow, and then produce true cow-pox, and another to maintain that the only source of cow-pox in cows is grease in horses. A recent case has once more demonstrated the identity of the two diseases. Early in March, 1856, Dr. Pichot of La Loupe, a phy- sician of the department of Eure-et-Loir, was consulted profes- sionally by a farrier's assistant; this individual had on the back of both hands pustules which were opaline, confluent, of about a centimeter in diameter, and depressed in the centre, where a small linear crust was visible. They had exactly the appearance of vaccinal pustules of the eighth or ninth day. The man, wdio had never been vaccinated, affirmed that he had not been in contact with a diseased cow, but he recollected that twenty-four days previously he had shod a horse affected with grease. The horse in question belonged to a farmer. The veterinary practitioner at La Loupe, a distinguished pupil of the schools of Alfort and Toulouse, verified the disease, which still existed when he examined the horse. Dr. Pichot imme- diately collected, between glass plates, fluid from the pustules, and sent some of it to Dr. Maunoury of Chartres. Without waiting to hear the result of Dr. Maunoury’s experi- ments, Dr. Pichot tried to vaccinate his patient. The operation produced no characteristic effect, although the lymph used was taken from the arm of a child, from which at the same time two other children wTere vaccinated, in both of whom the true vaccinal pock appeared. These were visible on the sixth day from the operation, in the situation of the six punctures made on the maids arm, only two small rounded pustules, which were partially covered with a crust, and bore no resemblance to the pustules on the arms of the children. An attempt was made to inoculate another child with liquid from these two pustules; but on the eighth day no result whatever had taken place. On that day, the same child was vacci- nated with ordinary vaccine lymph, and in seven days he exhibited four superb vaccine pocks, from which three other children were successfully vaccinated. Dr. Maunoury inoculated a child with the matter sent to him by Dr. Pichot, making five punctures, viz., three on the right and two on the left arm. The result was the appearance, on the eighth day, on the right arm, of one beautiful clear pock, as large as a lentil, COW-POX. 109 filled with yellowish serosity, and surrounded by a reddish circle of about a centimeter in diameter. Dr. Maunoury vaccinated several subjects from this pustule. Three children were inoculated with pus taken from it, and all three were found to be perfectly vaccinated. A fifth child wTas vaccinated with lymph taken from one of the three, and the lymph in this its third generation w?as proved to be efficacious ; it wras found to be equally efficacious in a fourth and fifth generation. It is evident, therefore, that it wras true vaccine matter which wras communicated to the first patient by the horse affected with grease which he had shod. In this history, accord- ingly, wre find a confirmation of Jenner’s opinion. Jenner, however, notwithstanding the soundness of his theory, was never able to produce more than a simple inflammation in those whom he inoculated with matter taken from horses affected with grease; but then it must be remembered, that he always used pus from the old ulcerations, and never the clear lymph of the recent pock. After his time, the same facts, confirmed at a later period by Drs. Pichot and Maunoury, were irrefragably established by experi- mentalists. In 1801, Dr. Loy published an account of his experi- ments on the origin of cow-pox, in which he mentioned that he had inoculated men as well as cows with matter taken from horses affected with grease. Dr. Loy having observed on the hands of two persons, a farrier and a butcher residing in Yorkshire, a pus- tular eruption much resembling cow-pox and accompanied with great constitutional disturbance, inquired into the circumstances and found that one of these individuals, for some time previously, had had charge of horses suffering from grease. He took lymph from this person and with it inoculated his brother and another child; in both cases this inoculation produced pustules exactly similar to those of true cow-pox, both in respect of their appearance and the course they ran. With the same lymph with which he inoculated the two children, he inoculated a cow, producing thereby a very beautiful cow-pock, which was accompanied by all the accessory phenomena. From that pock he inoculated a child in whom, in due course, a beautiful cow-pock appeared; this child was ascertained to be proof against small-pox, for on the sixth day after the vaccinal inoculation, variolous inoculation was performed without causing any subsequent result. It will be seen that the observations of Dr. Loy bear a great analogy to those made at a later date by Drs. Pichot and Maunoury. 110 COW-i’OX. But, at first, Dr. Loy failed in his attempts to inoculate cows with matter taken from horses affected with grease. He repeated his experiments several times without success, using matter taken from other horses; he was also at first equally unsuccessful in his attempts to inoculate man from the horse. At last, he succeeded in finding a horse in which the grease had existed for only fifteen days ; the cases from which till then he had obtained his matter were of older standing. With matter derived from this recent case, he in- oculated five cows, and in all of them cow-pox was the result. From these cows he obtained lymph with which he produced cow-pox in children, whom he subsequently found to be proof against variolous inoculation.1 Sacco, of Naples, who had at first unsuccessfully inoculated twenty-seven cows and eight children with lymph taken from grease in horses, observed pustules on the hands of persons who had charge of horses affected with the disease; with fluid from these pustules, he inoculated nine children and one cow; in two of the children he produced normal cow-pox, a result exactly similar to that formerly noticed as having been obtained by the physicians of the department of Eure-et-Loir. Finally, in 1805, Viborg, a Danish veterinary practitioner, inocu- lated the udders of cows with grease-matter, taken from horses, and after several failures obtained the desired result, viz., a characteristic, well-developed eruption of cow-pox on the fifth and sixth days after inoculation. Other observers, among whom may be mentioned Professor Ritter, of Kiel, have reported cases of cow-pox following inoculation with grease-matter, and yielding a perfectly efficacious vaccine lymph. To these statements I may add facts observed in the spring of i860, by MM. Sarrans, of Rieumes, and Lafosse, of Toulouse. During an epizootia among horses, a man was attacked with swelling of the hamstrings, whence issued a sanious discharge. M. Lafosse charged a lancet with this exudation, and then therewith inoculated in succession two young cows; in both, pustules appeared, presenting all the characters of cow-pox. With matter taken from these pustules he reproduced vaccine lymph, with all its characteristics and properties. 1 Steinbrenxer :—op. cit., p. 608; and Loy’s Account of Some Experi- ments on the Origin of Cow-pox. 8vo. Whitby, 1801. COW-POX. Hitherto I have spoken of grease [eaux aux jamles\, employing a term in common use; but, in point of fact, observers have not yet made out the exact nature of the disease of the horse, which, when transmitted to the cow by inoculation, gives rise to cow-pox. In a discussion at the Academy of Medicine,1 and afterwards at the Biological Society in 1861, Mr. H. Bouley pointed out at great length that veterinaries were much divided in opinion as to the exact nature of the disease which goes by the name of eaux aux jambes. M. Leblanc, who went to Toulouse to study the disease in the mare which had supplied M. Lafosse with new vaccine lymph, proved that this mare had not the disease called eaux aux jambes, but all the veterinaries who observed the epizootia at Bieumes were agreed that it presented all the characters of an epidemic eruptive fever. It is not within my province to give a name to a disease of horses which has already received a name from veterinary physicians. Can we, looking at it as an eruptive fever, compare it with the tag-sore [clavelee] of sheep ? Can there exist in the horse an eruptive fever, which, when communicated to man by direct or indirect inoculation, yields a virus which either is vaccine virus or is analogous to it in its properties P These are questions which we may at present ask, but it will only be in the future that they can be answered. Alongside of the experiments conclusively in favour of the trans- mission of the disease from horses to the cow and human species, others of an opposite tendency are cited. In Prance, attempts, made at Alfort and Eambouillet, to inoculate cows with cow-pox, by using grease-matter, were not till recently attended with success, but then inoculation of children with matter from the horse-disease was not tried. In explanation of these negative results, it has been urged that possibly the cows which resisted the inoculation by grease-matter from horses had had cow-pox at some former period; and also that the malady is not inoculable at all its stages, and that it cannot be communicated by punctures made anywhere. Finally, as was alleged by Dr. Loy, there are evidently several different diseases which have been confounded together under the name of grease, only one of which is the true disease capable of being trans- mitted to the cow, and transformed in the cow into cow-pox, and 1 Bulletin de l’Academie de Medecine; 1861-62, t. xxvii, p. 854—880. 112 in the human subject into vaccina. The researches of M. H. Bouley have corroborated this opinion of Dr. Loy. Jenner does not seem to have been acquainted in an exact manner with the disease of horses which, when transmitted to cows, produced cow- pox; he gave it the vague name of “ sore-heels,” which means disease of the heels. To the “ sore-heels ” of Jenner, the “javart” of Sacco, the “ affection furonculeuse ” of Her twig,” the “ maladie pustuleuse ” of M. Lafosse—of all of which it has been said, and of some of which it has been demonstrated, that they pro- duce cow-pox by inoculation—to these affections M. H. Bouley has just added aphthous stomatitis. M. Depaul, however, has shown that what was supposed to be merely an aphthous affection of the mouth was a general pustular eruption very analogous to small-pox. In other words, it was horse-pox, the malady which gives cow-pox to cows. But the distinctive characters of horse-pox have not as yet been accurately determined, and it is still a disease without an historian. There are numerous examples in human pathology of inoculable diseases not inoculable at all their stages, and also of diseases which can be set up more easily by introducing the virus at one part of the body than at another. "We know that syphilis can be easily introduced into the system by making a puncture, and inoculating with pus taken from a chancre; and we also know that generally syphilis cannot be inoculated by using matter from a pustule or muculent scab of ecthyma syphilitica. Some physicians, wrongly, however, deny that it is ever possible to effect this last-mentioned kind of inoculation. It is now beyond dispute, that in certain exceptional circumstances syphilis can be inoculated from secondary forms of the disease. When wTe return to this question in treating of syphilis in new-born children, we shall see that the disease is transmitted from infant to nurse only under very special con- ditions. These conditions chiefly consist in frequent and long-continued contact of the syphilitic virus of the affected parts of the infant with the absorbing surface in the nurse. They are most favorable when the infant sucks with power and energy, and when the nipple is in a state of continuous and increasing erection from the time that it is touched by the lips of the infant. The excitation of the nipple imparts to it an anatomical and physiological state, in virtue of which the skin covering it, in obedience to the laws of endosmosis, opens a COW-POX COW-POX. 113 door for the absorption of the contagium, so that there is required neither denuded surface, excoriation, nor fissure of the nipple, the more usual way by which syphilis enters the system of the nurse from that of the nursling. If, then, we compare what takes place in respect of the transmission of syphilis and grease in their more advanced forms, we can understand the unsuccessful attempts which have been made to inoculate the latter, and can explain the negative experiments made at Alfort and Rambouillet, as wTell as other negative experiments, by supposing that the virus was taken at a period when it had lost its energy through the too great length of time which had elapsed since the primary development of the disease. Is it possible otherwise to explain the positive results obtained by learned and conscientious observers, such as Loy, Sacco, Yiborg, Ritter, Berndt, Pichot, and Manoury ? Prom this brief statement of facts, I conclude with Steinbrenner, whose opinion is also that of Woodville, Coleman, Yiborg, Sacco and others, that cow-pox may originate in grease: but here I must repeat a proposition I have already carefully established, that this is not equivalent to saying that cow-pox has an exclusive origin in inoculation or in contact with the disease of horses : indeed, cow-pox generally arises quite independently of grease. Although grease is undoubtedly transmissible from horse to cow and from horse to man, it loses much of its likeness to itself by transmission : and cow-pox in the cow has not a greater resemblance to grease than vaccinia (or humanised cow-pox) has to cow-pox in the cow. These modifications in the form of affections, which are essentially and fundamentally identical, depend on the nature of the organisms in which they are developed; and similar modifications are not rare in comparative pathology. Por example, malignant carbuncle [sang de rate], a disease pecu- liar to the ovine species, becomes quarter-evil [charbon] in horned cattle, and malignant pustule [pustule maligne] in man. This typhic, strange, general disease, frequently destroys a great number of wool-clad animals in certain countries of Europe, particu- larly in the departments of Prance which constitute the old provinces of Beauce, Berry, and Brie. It can be transmitted to sheep, by inoculating them with the blood of an infected sheep. If a little blood, taken from the spleen immediately after the animal has been killed and before putrefaction has begun, be introduced by inoculation into the car, groin, or inguinal region of another sheep, 114 COW-POX. there is no indication of any effect having been produced, till from twenty-six to thirty-six hours have elapsed: the animal then, all at once, loses appetite, shows typhic symptoms and, within an hour or two, dies. On dissection, lesions similar to those found in the sheep from which the blood used for the inoculation was taken, are observed. On inoculating with blood taken from the second sheep, a third in a district far away from that of the other two, the malady is communicated; and it can in succession be similarly transmitted to individuals of the same species, the disease always remaining the same, and identical in its symptoms. If, however, you inoculate an ox or a cow with blood from the spleen of an infected sheep, you no longer produce the ovine malignant carbuncle [sang de rate\, but a kind of charbon which, though at first only a local affection, will soon become a general disease attended by grave symptoms, quickly proving fatal, unless it be eradicated in its original site by energetic cauterization. Again :—A shepherd, when skinning a sheep which had died from sang de rate, was inoculated with the disease, either by his excoriated hands haying been soiled with the animal's blood, or by his hands, perhaps quite free from excoriations, having remained too long in contact with its hide. After a certain time, a disease of special cha- racter was developed in this man: which, although sang de rate is from the onset a general malady, was at first exclusively local: it was the affection called malignant pustule. This malignant pustule, which is really a small vesicle, occasions tingling in the skin for a day or two, soon followed by a feeling of numbness extending along the arm, if the pustule is situated on the hand or fore-arm: soon after this, there appears in the centre of the little vesicle a gangrenous speck, which resists the point of the bistoury, while at the same time general disturbance of the system supervenes and the patients sink under ataxo-adynamic symptoms, lasting sometimes for five or six days. Malignant pustule is at first so purely a local affection that its constitutional development may be prevented and the patients saved by the treatment now generally followed in Beauce, which consists in vigorous cauterization, effected more particularly by applying corrosive sublimate to the parts previously deeply scari- fied. The physicians of the department of Eure-et-Loir, as well as those of Perclie and Berry, are well acquainted with this treatment, and when called in to a case promptly, that is to say sufficiently early to cut short the progress of the disease, they have little anxiety COW-POX. 115 about the issue. I am myself in a position to form an opinion on this question. In 1856, one of my country servants contracted the disease when handling three sheep which had died of the sang de rate. One Sunday, just as I came home, this man showed me his hand, on which I saw a very characteristic malignant pustule: the begin- ning of the malady dated back to the previous Wednesday: there was already some feverishness and general constitutional disturb- ance. I scarified the affected part and introduced corrosive sublimate into the wound: in forty-eight hours the cure was ascertained: on the following Sunday, I found my patient in perfect health, excepting that he had a painful scab on his hand. When we see a disease undergo such remarkable mutations by transmission from an animal of one species to an animal of another species; when we see different organisms respond in so different a manner to the same morbific cause, it ought not to be looked on as astonishing that grease should also change its form when transmitted to the human subject or the cow ; nor need it any more be considered wonderful that there is so little resemblance between cow-pox in the cow and vaccinia, although the nature of both is the same. We can in the same way understand how the further question may be asked —whether cow-pox is anything else than human small-pox modi- fied by development in the organism of the cow, so as to lose its original qualities, and be re-transmissible to man with its behaviour wholly changed. Let us pause a moment to consider what has been done to elucidate this question so full of interest. Many attempts liad been made to produce cow-pox in cows by inoculating them with virus of small-pox from the human subject, but without causing anything like cow-pox, although the experi- ments were made in various ways, and upon animals of different ages, till 1807, when Dr. Gassner of Gunzburg announced, that he had obtained the desired result. He inoculated eleven cows with small-pox virus, and obtained true cow-pox from them, with the matter of which he inoculated children in whom real vaccinia was thereby produced. These results were called in question ; but in 1839 Dr. Thiele of Kasan, having repeated the experiments of Gassner, stated that after having tried ineffectually to inoculate the cow both with vaccine lymph and small-pox matter from man, he at last succeeded with the latter, cow-pox pustules being produced in the cow : with matter taken from these pustules, he obtained normal vaccinia in children. These experiments date back to 1836', 116 COW-POX. from which time Dr. Thiele continued to vaccinate with the same lymph; and when he wrote, it had passed through seventy-five generations, and had demonstrated its efficacy in more than 3000 persons. More recently, to put this efficacy to the test, he inocu- lated with small-pox twenty-one of those he had vaccinated, and without causing small-pox in any of them. The cows upon which Dr. Thiele made his experiments were between four and six years old, newly calved, and were, as often as he could find them, cows with white teats. He confined them to their shed, keeping the temperature there at 150 Beaumur : their food was not in any way altered; and they continued to be milked. The place selected was shaved immediately before inoculating; and the place selected was the posterior surface of the udder, so that the cow was unable to lick it. Punctures were there made, a little deeper than is usual in vaccinating the human subject, and were covered with a linen cloth soaked in the matter. The matter was taken from small-pox pustules, nacreous, and bead-like, before they had lost their trans- parency, and containing very clear lymph: that he might proceed with still greater certainty, Dr. Thiele kept the lymph for ten or twelve days between glass plates before using it. On the third day after inoculation, a protuberance was formed under the skin; on the fifth, a pock like the vaccinal pock was visible, which, between the seventh and ninth, contained a limpid lymph and presented a central depression. Between the ninth and eleventh day, this pock began to desiccate and to form a crust which, when it fell off, left a small smooth cicatrix. Dr. Thiele generally obtained one or two pocks from about three or six inoculated punctures. In 1840, Dr. Bitter of Munich announced that he also had inoculated cows with small-pox. He stated that during ten years he had experimented on more than fifty cows without the least success, but that at last, having adopted Dr. Thiele’s plan, he obtained his results. He produced cow-pox in the cow, whence he derived matter which gave children a perfectly normal vaccinia. Concurrently with the publication of the result of Dr. Thiele’s experiments, Dr. Ceely of Aylesbury met with similar success. I shall not relate the details of his experiments, which you will find in extenso in Dr. Steinbrenner’s remarkable work. Dr. Sunderland of Barmen also tried to get cow-pox by inocu- lating the cow with small-pox, but he proceeded in a different manner from Drs. Thiele and Bitter. Dr. Sunderland, in llvfe- COW-POX. 117 land’s Journal for 1830, has described the plan which he adopted, which consisted in covering cows with a woollen blanket taken from the bedding of a man who had died in the suppurative stage of a severe case of small-pox. The blanket was immediately taken from the dead man’s bed, rolled up in a sheet, and carried to a shed where there were young cows: it was carefully fixed successively on the backs of the animals, and allowed to remain on each for twenty- four hours. Not only did each of the cows wear the blanket for twenty-four hours, but it was after that fixed along their manger, so that they could not avoid breathing the miasmata which it exhaled. After some days the cows ceased eating, drank a great deal, and had fever : about the fourth or fifth day, pustules appeared upon the udder and other soft parts. These pustules followed the usual course of cow-pox, and between their fourth and eighth day they yielded lymph which served for vaccination. This marvellous discovery could not fail to command attention : eagerness was shown to repeat Dr. Sunderland’s experiments. The results which he announced had been nowhere obtained, neither in Denmark where, in 1833, the Government requested physicians to investigate the subject, nor at Berlin, Weimar, Dresden, nor Cal- cutta. In Trance, the success was no greater. M. Miquel of Amboise made several fruitless attempts to inoculate the coav with a view to produce cow-pox from the virus of small-pox. Our learned brother of Touraine, however, experimented under apparently the most favourable conditions. Those who have visited the banks of the Loire between Blois and Angers must have seen dwellings excavated in the rocky slopes wherein herds of peasants live crowded together, and only separated from their cattle by slight partitions. Well! M. Miquel had occasion to see an epidemic of confluent small-pox prevailing amid that population. It being winter, the cows were shut up in their sheds day and night, so that they actually lived among the sick people. Still, under these circum- stances M. Miquel was unable to find small-pox among the cows : he wrapped them up in the blankets of the sick people, but was not able in a single cow to detect the most minute cow-pock. The plan of Dr. Sunderland, then, only yielded satisfactory results when put in force by himself, unless we take into account circumstances mentioned in the narrative of John Webb which I quoted from the London Lancet, and which certainlv corroborate the experiments of the physician of Barmen. 118 COW-POX. M. Depaul has recently supported the proposition that small-pox and cow-pox are identical, and that cow-pox is human small-pox transmitted to, and modified by the cow, or in other words, that it is nothing more than mitigated small-pox. An epidemic of small- pox would in his opinion be sufficient to explain, on the principle of contagion, the development of that disease in horses, and the inocu- lation of the cow with horse-pox would in all probability give rise to a modified form of small-pox—that is to cow-pox. He says :— “ Cow-pox when transmitted to man will reproduce itself with its characteristics,” that is, with its vaccinal characteristics; and finally, that “tag-sore [clavelee] is nothing more than small-pox in the sheep, and is probably the same as small-pox in the horse,” whence, he adds, “ it follows that the true secret for mitigating small-pox in the human race consists in causing the disease to pass through another species of animal and in then communicating it to man by inoculation.”1 T have quoted the opinions of my learned colleague in his own words—opinions which he supported by experiments which seemed, for the moment, to prove that his views were right. In point of fact, small-pox can be transmitted by inoculation to oxen and horses: the inoculation originates in them a pustular affection analogous to cow-pox, but only analogous, for the disease imparted to them is really small-pox. This question ought to be considered as definitely settled by the experiments of a commission appointed by the Society of the Medical Sciences at Lyons. As we have here to do with a doctrine in which theory is intimately associated with practice, and regarding which the holding of unsound conclusions may lead to and, as you shall see, has led to irreparable mischiefs, I ask you to allow me to read to you some of the salient passages of the report made by M. Chauveau in the name of the Lyons Commission. The learned reporter has first shown that small-pox can be per- fectly well communicated to the bovine species by inoculation, to which species it stands in the same relation as vaccinia to man; that is to say, that when an ox is inoculated with small-pox it is thereby made proof against cow-pox, just as a vaccinated man is proof against small-pox. But a much more important practical point is, that “ small-pox in its passage through the system of a cow is not transformed into vaccinia: it remains small-pox, and returns to the 1 Depaul :—Bulletin de l’Academie de Medeciue, 1863-64, t. xxviii. COW-POX. 119 original state of small-pox when re-introduced into the human species.3’ The experiments of the Lyons Commission upon soli- peds gave results similar to those obtained from bovine rumi- nants. There is only a difference in form. Thus in the cow, the eruption of small-pox consists of pimples so minute as to escape notice unless one is on the outlook for them. Cow-pox, on the other hand, engenders an eruption of the vaccinal type with its large and very characteristic pocks. In the horse, also, the inoculation of small-pox engenders a papular eruption in which there is neither secretion nor crust; and although this eruption is much more for- midable than that produced in the cow, it need never be confounded with horse-pox eruption, so remarkable for the abundance of the secretion and the thickness of the crusts. Hence it follows, that small- pox and cow-pox, or horse-pox, are different diseases, and that when we vaccinate after the method of Thiele and Ceely we in reality inoculate small-pox. This kind of inoculation of small-pox may possibly be free from danger, the disease being—according to hypothesis—modified in its passage through the cow or horse. Some even believe in a mixed virus, to which the epithet vaccino-variolic has been given. Expe- riment, however, utterly demolishes this theory. Here, again, we are indebted to M. Chauveau for demonstrative evidence. The facts are as follow :—A girl of two and a half years of age was inocu- lated with the so-called vaccino-variolic virus—that is to say, with matter taken from pustules in a cow which had been inoculated with small-pox. This child had, on each arm, three magnificent primitive pustules, and at a later period, a disseminated eruption of about fifteen pimples. The pustules on the arm furnished virus with which two very healthy children were inoculated. “ On the tenth day, both took simultaneously very severe general small-pox: the eruption was as confluent as it wTas possible to be, the fever was very intense, and there were convulsions and vomiting. One of these two children died from the severity of the attack.” But this is not all: another child was inoculated with, the vaccino-variolic virus taken direct from the cow : on the eleventh day, there was a well- marked local eruption, and three days later confluent small-pox, which for several days placed the life of the child in imminent jeo- pardy. Einally, in this case there were indelible variolic cicatrices. Here, inoculation only disfigured the child: but I have now to mention another case in wrhich it was a homicidal act. The virus 120 COW-POX. was taken from the horse: the inoculated child had an anoma- lous form of small-pox, from which it died. Influenced by highly commendable prudential motives, M. Chauveau does not give more circumstantial details of this case, but the details which he furnishes are quite sufficient. By the evidence now adduced, I hold that the question is defini- tively settled. Both in Trance and foreign countries, however, suc- cessful and unsuccessful experiments may be quoted. Bretonneau in his experiments, which he repeated several times, never obtained any result when he operated on heifers, to which he gave the preference from not wishing to dry up the milk of nursing cows. But other experimentalists were more fortunate. Drs. Haussmann of Stutt- gard, Numann, Billing, professor of the veterinary school of Stock- holm, Magliari of Naples, Heim of Meschede; Drs. Zybel, Nicolai, and Leutin; MM. With, professor at the veterinary school of Copenhagen, Prinz of Dresden, &c.; lastly, Dr. Bousquet, Member of the Academy of Medicine, who has paid much attention to the subject of cow-pox,1 Dr. Steinbrenner, MM. Boutet, Maunoury of Chartres, have produced true cow-pox by vaccinating cows with the human vaccine lymph with which they were vaccinating infants. When confronted with these contradictory facts, we are obliged to ask :—What is the explanation of the successes and failures ? The solution of the problem is not devoid of difficulty. Must we, to explain the diversity of results, invoke assistance from the question of morbid susceptibility—opportunite morbide ? Let us take an ex- ample. I assume that some particular disease—say influenza—is prevailing. One individual, living in the midst of the epidemic, is seized with influenza under influence of the slightest cause, while another escapes who is living close to the first, and exposed to the same morbific causes, as well as to others more powerful. During the whole of the course of the epidemic, this individual may be exposed with impunity, and then, at some future time, take influenza without any appreciable cause. There are times when an individual is proof against morbific influences, in virtue of I know not what, in virtue of a special condition, of a peculiar state of the organism; but whenever this special state ceases, the same organism is easily affected by the smallest of the influences which it formerly resisted. 1 Bousquet:—Nouveau Traite de la Vaccine et des Eruptions Vario- euses. Paris, 1848. COW-POX. 121 Is it to special states of the organism we ought to look for the ex- planation of the different results which have followed vaccination of the cow ? Or ought we to call in question the virus employed in the experiments ? Shall we say with Steinbrenner, that the total absence of results observed at a certain period after the early days of the Jennerian discovery, in which successful were in excess of unsuc- cessful cases, depended on the lymph having in its descent become much weakened in power ? The observations of Fiard and those of Boutet and Manoury seem to give support to that view : the inocu- lations of cows which they made with matter of old descent never succeeded, but when they used the matter regenerated in their expo - riments, they obtained a pock from which they were enabled advan- tageously to vaccinate children. With Steinbrenner we further ask whether vaccinal matter in its first generation in the cow produces more than local results, and whether, after successive generations in animals, it does not gradually acquire the properties of cow-pox such as they were found by Jenner ? Transmission of Cow-pox from Man to Man.—Circumstances favourable to Successful Vaccination,—The Lymph ought to be taken between the Fifth and Seventh Lays.—Selection of Subjects from whom the Lymph ought to be taken.—Health of Fersons who are to be Vaccinated.—Transmission of Syphilis in Vac- cination.— Vaccinal Eruptions. Whatever explanation, gentlemen, may be given of the facts which I have now laid before you, it is very remarkable that cow- pox when first introduced had a much greater activity than it manifests in the present day. Jenner foresaw this degeneration: he foresaw it, because he suspected that the virus would lose its power in successive transmissions, and also because he reckoned on the shortcomings of vaccinators. The first proposition is to a cer- tain extent established by what I have already told you of the enfeebling of cow-pox in the bovine species itself, which took place by transmission from heifer to. heifer. What I am about to say of the manner in which vaccination is too often performed will prove the second proposition. Forgetful of the rules laid down by Jenner, vaccinators in place of taking lymph before the eighth day, and by preference on the fifth, waited till the eighth day : that was the general practice, but some physicians did not scruple to use 122 COW-POX. lymph taken even as late as the ninth day. Moreover, no attention was paid as to whether the individual to be vaccinated was or was not in a favourable state for the development of cow-pox. This state of fitness, however, is a consideration of the highest importance, and the frequency with which it has Uen neglected is the reason why we have to deplore many disappointments in the present day. Let us, then, study the conditions necessary for the reproduction of a vaccine lymph, which will retain its anti-variolous power to the greatest possible extent, and be transmissible from age to age. Jenner pointed out these conditions: Dr. Truchetet has re-stated them in his inaugural thesis, basing his conclusions upon experi- ments which he made in my clinical wards.1 Some of these condi- tions pertain to the virus, others to the subject into whose system it is introduced. If the virus has degenerated, it is, as Steinbrenner says, because the lymph employed has been taken indiscriminately from any individual provided the pocks were normal, no inquiry being made as to the beauty of the pock, its progressive develop- ment, or its age. Upon reflection, however, it is evident, that, as the laws of biology are equally applicable to the life of animals and plants, physicians ought always to act in this matter upon prin- ciples similar to those which influence the selection of seed by agri- culturists, who know that by sowing their fields with the finest grain, they will in return reap from them grain of the finest quality. And, without leaving the domain of pathological biology, it is a well-known fact that after a certain period in the development of the pustule, the variolous virus is inert. In 1784, Earle an English physician, communicated his observations on this subject to Jenner, stating that when he had inoculated with matter from too advanced small-pox pustules no effect was produced. The selection of vaccinal lymph is, therefore, a matter of great importance. Its activity is far from being the same at all its ages. Twenty-four or thirty hours after introduction, it is powerless; in from forty-eight to seventy-two hours, it has begun to develope power; and on the fourth, fifth and sixth days, it possesses its maximum energy; on the seventh, day, it has decreased in power, and after from the eleventh to the fourteenth, it is absolutely powerless. 1 Truchetet :—Quelques Recherches sur la Yaccine. [Theses de Paris, 1855-] COW-POX. 123 Jenner, who at first employed lymph taken on the eighth day, then believed that that was the most favourable time, but he after- wards discovered that on and after the fifth day, the pock contained a lymph perfectly inoculable and of great energy : he said that this energy diminishes from the time that the inflammatory areola begins to appear: and not only did he abstain from employing lymph taken after the eighth day, when he could do otherwise, but he preferred to obtain it on the fifth. This was likewise the opinion of Delaroque, the Trench translator of the English physician's work; it is the opinion of a certain number of the most notable prac- titioners ; it is Dr. Bousquet's opinion; and it is also mine. These opinions, gentlemen, have been beautifully expressed in verse by one of our most illustrious poets. Casimir Delavigne, in his poem on Vaccination, says :— Puisez le germe lieureux dans sa fraicheur premiere, Quand le soleil cinq fois a fourni sa carriere. [Draw forth the auspicious germ in its first freshness, when the sun has Jive times completed his course.] Casimir Delavigne, in the poem from which I quote, gives with singular felicity and elegant precision the symptoms of cow-pox which he had observed along with Dr. Pariset, Secretary of the Academy of Medicine. If then you wish to have vaccine lymph possessed of all its power, and of the greatest possible amount of efficiency as a protection from small-pox, you must take it at a sufficiently early stage of the pock: you must take it between the fifth and seventh days in- clusive. Matter taken at that period produces a large pock, which becomes surrounded by a large and more lasting areola of inflamma- tion : in a word, a cow-pock is obtained more vigorous than if the virus used had been taken at a more advanced stage. During an epidemic of small-pox, if you can procure no better vaccinal matter, you may vaccinate with lymph taken from a forty- eight hours' old pimple : its activity will be less than if .taken some days later, but greater than at the eighth day. When eight-day lymph is used, evolution proceeds more slowly, the papule not ap- pearing till the third day, whereas when use is made of lymph taken between the fifth and seventh days inclusive, the papule is visible on the second day. In the former case, the areola appears on the seventh or eighth day, and in the latter, on the fifth or sixth. The one begins to dry up on the eleventh or twelfth, and the other on 124 COW-POX. the twelfth or thirteenth. Finally, while the period for maturation is from eight to nine times forty-eight hours for eight-day lymph, it is prolonged to eleven or twelve nycthemera when the lymph used has been taken between the fifth and seventh days. The choice of the subjects from whom the supply of vaccine lymph is derived, and the health of the persons to be vaccinated are also matters of importance; for if the conditions favourable to the perfect development of a germ are inherent in the germ itself, so likewise are they in the soil wherein it germinates and grows. In respect of the selection of persons from whom to take vaccine lymph, it has been shown that they ought to be in good health and of vigorous constitution, as the pock is much better developed in them than in sickly drooping persons. But, gentlemen, there is a point to which I desire to call your special attention to-day; it is—never to vaccinate with lymph taken from one under the influence of the syphilitic diathesis. The trans- mission of the great-pox by vaccination is a fact which now seems to have been demonstrated. Since the beginning of this century, and particularly in later years, cases of this kind have been re- corded both in France and in foreign countries; to them I can add one which you have seen in the clinical wards, and which I shall now briefly recall to your recollection. The patient, a young woman of eighteen years of age, came into the Hotel-Dieu for a uterine affection. As we had at the time some cases of small-pox, I recommended that she should have herself vaccinated. The lymph was taken from a child apparently in perfect health, and from the same lymph four infants in the nursery-ward were also vaccinated. Cow-pox was regularly developed in the chil- dren, and during their residence in hospital nothing anomalous was noticed, but unfortunately when they left, we lost sight of them. The young woman had false cow-pox : on the day after vaccination, the punctures became salient; they were surrounded by an inflamed areola, and accompanied by great itching of the skin; in four or five days, no trace of puncture remained. The patient then left us, but it was agreed that she should return once a fortnight to follow out the treatment of the uterine affection. On her first return, twenty- three days after vaccination, she drew attention to the punctures on both arms : two of those on the left arm seemed to have taken: I observed that the pustules were ecthyma. At her next visit, a fort- night later, the pustules of ecthyma were observed to have become COW-POX. 125 transformed into scabs of rupia indurated at the base : in the axilla, we found some of the lymphatic glands in a state of indolent tur- gescence; finally, an eruption of roseola clearly showed that the woman was under the influence of syphilitic poisoning, and that the starting- point of the poison was incontestably the vaccination pustules. Gentlemen, you know how many questions have been recently raised in relation to cases of this kind: the subject is one of grave importance and its discussion is not yet closed. If some physicians still doubt the possibility of syphilis being communicated in vacci- nation, the majority are open to the logic of facts, and remain on the alert. But among those who constitute this majority, what diversity of opinion exists! Some hold that syphilis is transmissible and inoculable through the medium of the vaccine virus, others, absolving the vaccine virus from all blame, hold that the syphilitic virus passes with the blood which has accidentally been drawn in taking the lymph from the pock. I shall not stop to discuss the two classes of facts by which these views are respectively supported, as my own experience is insufficient to solve the difficulty. The fact which I wish to impress upon you is this—that syphilis has in numerous cases been transmitted in vacci- nation. I cannot better bring my remarks on this subject to a close, than by quoting some of the conclusions in relation to it which have been arrived at by Dr. Yiennois of Lyons.1 I agree with Yiennois that one ought never to use vaccine lymph taken from a suspected subject, and that in respect of infants one ought not to take it unless the infant has passed four or five months, the age at which hereditary syphilis usually shows itself by visible signs : for infantile syphilis, even before it appears on the exterior parts of the body, is transmissible. But I cannot in any degree adopt the conclusions of this author when he adds :—“ if special circumstances make it necessary to take vaccination lymph from a syphilitic patient, great care must be observed so as to draw the pure lymph without the slightest admixture of blood or syphilitic humour.” I cannot in any circumstances whatever sanction vaccine matter being taken from a syphilitic subject. It is more a matter of hypothesis than of demonstration, that it is only by the blood that syphilis is transmitted in this class of cases. Besides, it is 1 Viennois:—Archives Generates de Medecine, Juin, Juillet, et Sep- tcmbrc, Paris, i860. 126 COW-POW. rather difficult to understand how that which is contained in the serum of the blood, that is the syphilitic virus, should not also be contained in the serosity of the vaccinal pock. Finally, it is so difficult to draw off the vaccine lymph free from “ the slightest ad- mixture of blood or syphilitic humour,” that the recommendation of the required precaution amounts, so far as I am concerned, to a prohibition. My opinion on this point admits of no modification. Abstain always from taking lymph from a syphilitic subject. In the discussion which took place in 1864 and 1865 in the Academy of Medicine, upon the transmission of syphilis in vaccina- tion, MM. Depaul and Bouvier demonstrated the relative frequency of cases of transmission, and showed that vaccination carried out with lympn derived from a syphilitic child may sometimes assume the character of a real social calamity. Thus in 1856, at Lupara in the Neapolitan territory, Dr. Marone vaccinated in the beginning of November a certain number of children with lymph in tubes which came from Campo-Basso : it was slightly coloured with blood though as clear and transparent as usual. The first child vaccinated with this lymph was Philomene Listori, aged eight months, and from her the others were vaccinated, of whom, besides Philomene Listori, twenty-two, being nearly the entire number vaccinated, took syphilis. These children were born of healthy parents, and all had from their birth to the date of vaccination, been free from venereal symptoms. In most of them, vaccination took effect on the first trial, but in some the operation required to be repeated. The vaccinal pock was followed by characteristic venereal ulcerations, accompanied by swelling of the axillary glands. Then, a little sooner in some, and a little later in others, but in the majority about the middle of January, 1857, there appeared eruptions of roseola, im- petigo, syphilitic papules and even pemphigus: these eruptions were soon succeeded by mucinous scabs on the lips, the interior of the month, on the parts around the anus, on the vulva and on the scrotum, with consecutive enlargement of the posterior cervical and inguinal glands, loss of flesh and a disturbance of the general health proportionate to the severity of the case. The mothers, most of whom suckled their infants, contracted syphilis from them. A series of venereal symptoms, at first local, and which Dr. Marone has well described, manifested themselves in these unfortunates. Some of them communicated the disease to their husbands. Prom fathers and mothers, it extended to other members of the family, to 127 children under puberty of both sexes, and sometimes to entire families. Almost all the women who became pregnant miscarried, bringing forth syphilitic infants, or dead foetuses presenting in some cases traces of syphilis. Most of the patients were cured by specific treatment: there was, however, a great tendency to relapses; and in some cases, two years and a half had elapsed before the disease was eradicated. Some of the infants died, and several of the adults were in jeopardy. Dr. Marone had taken lymph from the first series he vaccinated for the purpose of vaccinating others. Eleven of this second series contracted syphilis like the first, and communicated it to their mothers, who gave it to eleven nurslings who had not been vaccinated. Some of the women gave the disease to their husbands, and all the young girls were also affected through their contact with the nurses and children. It appears, therefore, that at Lupara thirty- four children were inoculated with syphilis in being vaccinated; and that a greater number of individuals of different ages were directly or indirectly contaminated by these children. At Rivalta, there were eighty victims. COW-POX. The details now laid before you are given by M. Bouvier. I have now to add, on the authority of M. Depaul, the history of forty infants contaminated with syphilis out of forty-six vaccinated in 1821. According to the report of M. Cerioli, there were thus from four original cases 155 children directly infected with syphilis by vaccination, and there were others secondarily infected through them, bringing up to 300 the total number of syphilitic contamina- tions. I cannot, therefore, too earnestly recommend you to examine with the greatest possible minuteness the subject from which you take the lymph for your vaccinations, and to abstain from taking it not only from syphilitic persons, but likewise from all who present the slightest ground for your suspecting that they have venereal contamination. With respect to those whom it is wished to vaccinate, we have to bear in mind age, constitution, certain antecedent diseases, and also the diseases which supervene during the progress of cow-pox. Vac- cination succeeds better in childhood than in adult age : it must not, however, be supposed that the younger the infant the greater is the fitness. At the age of some months, vaccination does much better than in the new-born infant. The cow-pock will be much finer in an individual of good health and sound constitution than in one who is weak and drooping. In the latter, the vaccinal pimple is 128 COW-POX. softer and less prominent, its areola is smaller, of a dull-red colour, and desiccates at an earlier date. M. Truchetet, finding by experi- ment that lymph taken from persons of unsound health became very feeble in its third generation, abandoned the use of it after two transmissions. Acute antecedent diseases have no effect on vaccination, provided the child has recovered its health. Small-pox and cow-pox, how- ever, are exceptions to this law : it may be superfluous to say so, after what I have several times repeated, to the effect that there is an antagonism between the two diseases, and that they reciprocally confer immunity from one another. Nevertheless, cases have been cited, and I have also seen cases, in which vaccination took effect in persons wdio had had small-pox previously; but such cases are very rare, and when they are looked into, it is generally found that the cow-pox was of a feeble, spurious kind: regular cow-pox after small-pox is exceedingly uncommon. Examples of antecedent vaccina- tion not preventing a subsequent vaccination from producing cow-- pox have been occasionally noticed from the date of Jenner's discovery downwards: indeed two cases of this class are recorded by Jenner himself, in which vaccinated persons went through normal cox-pox a second and even a third time, but at long inter- vals. Such cases, however, are at least quite as exceptional as the occurrence of cow-pox in persons who have previously had small-pox. Is tliere anything surprising in these returns of the disease ? Was it not known that small-pox might attack the same person more than once? Why then, may not its congener cow-pox likewise offer sometimes an exception to the general rule ? Such exceptions were, moreover, much more uncommon formerly than now that the vaccine lymph in general use has undoubtedly become degenerated. But before pronouncing any opinion on the number and value of these second attacks, it is important among other things to ascertain whether the persons in whom vaccination has taken effect more than once have ever had previously the legitimate cow-pock, in what condition it was developed, in what manner vaccination was per- formed, and what was the date of the first vaccination; it is particu- larly important to ascertain positively that the second vaccinal eruption is not that which is called false cow-pox, which may some- times be mistaken for the true, and to which I shall return, as it is indispensable to be acquainted with the differential diagnosis of the two affections. COW-POX. 129 It has been also asked, gentlemen, whether cow-pox, an affection ■which so radically modifies the economy, and is in the opinion of some observers only a form of small-pox, does not sometimes declare its presence by a general eruption : indeed, there is room for surprise that such is not ordinarily its mode of manifestation. I have often recalled to your attention a case which I saw in the Keeker Hospital, and I am not the only vaccinator who has observed cases of this kind. I vaccinated a strong young child, making eight punctures. Eleven days afterwards, to my great astonishment, I saw on the face, trunk and limbs twenty-seven pocks having exactly the appearance of cow-pox. I confess that at first I believed in a general eruption, like that which follow's variolous inoculation, but on a closer examination I abandoned that idea, or at least I enter- tained great doubts as to its correctness. Before vaccination, the child had sudamina all over the body. It was summer. He scratched the vaccinal pimples which were excoriated, and thus he carried the virus on his nails to parts denuded of epidermis, and so produced on these parts vaccinal pocks. Inoculation of cow-pox in a recently vaccinated child takes place readily, but the time comes when attempts at this kind of secondary vaccination prove abortive. You have often seen the experiments which I have made in the wards in relation to this point. I vaccinate: in four days I make a new puncture with a lancet charged from one of the incipient pustules; I continue to do this daily; and you have seen that up to the ninth and sometimes till the tenth day—but not later than that—there is a cow-pock developed at each new puncture. The secondary pocks, however, do not attain to the size of the primary pock, and it is observed that the secondary pocks earliest in date are the best developed, and that in succession, as the date of the puncture from which they proceed becomes more distant from that of the original vaccination, they lose the normal appearance, those of the ninth and tenth days aborting soon after being slightly inflamed; w'hilst after the tenth day, the prick produces no more effect than if the lancet were charged with the pus of an ordinary boil. Our little patient of the Keeker Hospital must, therefore, have secondarily vaccinated himself, at latest, seven or eight days after the primary vaccination. The general pustular eruption of which I have just spoken, and the occurrence of which is altogether exceptional, must- not be con- 130 COW-POX. founded with a secondary eruption very common in small-pox, and of which physicians give different explanations. On the seventh, or at latest on the eighth day after vaccination, fever is lighted up, analogous to the fever of maturation in small-pox. It is generally, and I think correctly believed that this fever is symptomatic of the very acute inflammation going on around each pock, and of the swelling of the axillary lymphatic glands. Another interpretation is, that it is simply the general fever of invasion dependent on the disturbance of the system caused by the reception of the vaccine virus, just as the fever of the eighth and ninth day after variolous inoculation is nothing more than the invasion-fever of the small- pox then becoming developed in the system, and not at all a symptom of the inflammation manifested around the pustule of inoculation. Looking at it from this point of view, we are obliged to hold that the vaccinal fever is not the necessary consequence of the general cutaneous eruption, differing in this respect from the eruptive fever in small-pox and measles. But as the secondary vaccinal eruption occurs very often, and as in summer as many children have it as escape it, the question may be asked, whether the initiatory vaccinal fever may not, up to a certain point, be analogous to scarlatinous fever, which, as I shall have to tell you on some future occasion, is not always followed by the specific exanthem. Finally, without going in search of explanations more or less hypothetical, we may consider the eruption frequently seen about the tenth or eleventh day after vaccination to be nothing more than that exanthem so common in children having suppuration going on in some part, and at the same time, fever and copious sweating. In point of fact, gentlemen, the secondary vaccinal eruption differs in no respect from that which I have called sudoral eruption, regarding which it is my intention to speak in an early lecture. It is a measly or scarlatinifonn exanthem, almost always very transitory, sometimes, however, taking the more severe form of acute eczema, or impetiginous eczema, and constituting the first link in the very long chain of suppurations of the skin and mucous membranes which have caused a sort of reprobation of vaccination still existing among prejudiced and ignorant people. Let us now return, gentlemen, to other conditions which modify cow-pox. Chronic diseases, by reducing the vital power of the economy and weakening the constitution, necessarily produce a condition un- COW-POX. 131 favourable to the development of cow-pox. Infants with hereditary syphilis readily take the cow-pox, whether the syphilis be still latent, or whether it has showed itself by unmistakable visible signs. AY ithout entering into too much detail, I would, in proof of this assertion, remark that you have often seen in my wards the normal development of cow-pox in infants who at a later period showed symptoms of hereditary syphilis, as well as in other infants who were admitted to be treated for syphilitic psoriasis, rupia, and other venereal affections. Syphilis, then, does not constitute an obstacle to the development of cow-pox. It is not so with the eruptive fevers. Dor example, when measles or scarlatina supervene during an attack of syphilis, the progress of the latter is arrested, and is not resumed till the exanthematous disease has run its course. As small-pox and cow-pox mutually exclude one another, it seems rational to believe that the two diseases cannot co-exist. Again, it has been demonstrated that the incompatibility of the two is not declared till the fifth, sixth, or seventh day of normal cow-pox. If the system is under the influence of the variolous poison during a few days immediately succeeding vaccination, the small-pox and the cow-pox both germinate and become simultaneously developed without in any way influencing one another. The experiments of Woodville leave no room for doubting this, and M. Bousquet states that Professor Leroux has seen a vaccinal pock implanted, as it were, in the centre of a variolous pock. “ He separately inoculated the two viruses : vaccination produced cow-pox with all its advan- tages, and variolation produced small-pox with all its dangers.” I have seen the two diseases develope themselves simultaneously. I am well aware, and I ought to tell you, that statements have been published in contradiction to the cases I now refer to as having seen. Thus, a physician of Dunkirk, Dr. Zandyck, concluded from experi- ments which he made during an epidemic of small-pox, that persons vaccinated during the incubation of small-pox always had modified small-pox with its symptoms and characteristics. Similar results were obtained in experiments made by MM. Bayer, Herard, and Tardieu. The latter has even recorded a case in which he saw success attend vaccination performed at the beginning of a variolous eruption. Although this case is unique, Dr. Zandyck does not the less decidedly give his opinion that vaccination ought to be prac- tised under these circumstances, inasmuch as the dangers never originate in the cow-pox, but in the small-pox simple or complicated: 132 COW-POX most assuredly he is right. Dr. Zandyck is of opinion that the affec- tion—cow-pox or small-pox—which is first in possession, influences, but is not influenced by the other.1 I have, however, told you that the experiments of Woodville and Bousquet, as well as my own, demonstrated that cow-pox and small-pox become simultaneously developed, without exerting any influence on one another: and my observations have been confirmed by the paper of M. Marc d’Espine, published in the Archives Generates de Medecine for June and July, 1859. You have recently had under your observation a new proof of the correctness of this opinion. A mother and her infant of two months old simultaneously took small-pox in our wards. The mother, though never vaccinated, had the distinct form of the disease, which ran a course like that of modified small-pox; but the infant had a confluent eruption, and died on the eleventh day. This infant had nevertheless been vaccinated on the second or third day of small- pox incubation: the vaccination ran a perfectly normal course, there being, however, only one pock from six punctures. On the eighth day, a period at which there was no ground for supposing that the child was breeding small-pox, two new punctures were made below the pock, when two other pocks developed themselves in a regular manner. It was not till the third day of the variolous eruption that all the vaccinal pocks appeared modified in their mode of evolution: they were then the seat of haemorrhage which ex- tended to the surrounding cellular tissue, and the sub-vaccinal ecchymosis became very hard. You have seen that in this case the patient derived no benefit from the cow-pox, which did not prevent death from confluent small-pox. It is but fair, however, to remark that this child was only two months old, and that the termination of small-pox, as well as of erysipelas, is almost always fatal at that early age. As a set-off to this unfortunate history, I must mention a case which several of you had an opportunity of seeing in 1861, and which tends to support the opinion of MM. Zandyck, Bayer, Herard, and Tardieu. The patient was a male infant of eleven months, whom I had vaccinated during the incubation of small-pox. The progress of the cow-pox was retarded up to the eighth day; that 1 Zandyck :—Essai sur l’Epidemie de Variole et de Variolo'ide qui a regne a Dunkerke en 1848, et 1849. Paris, 1857. COW-POX. 133 is to say, the pimples did not show themselves till the fifth day, and the pustular development proceeded exceedingly slowly. On the eighth day, the child was seized with fever, vomiting and diarrhoea, which continued for two days, and on the following day the vario- lous eruption appeared. It pursued its normal course till the fifth day, when the pustules became dry and crusted. The small-pox had then been modified by the cow-pox, which, on the very day of the appearance of the small-pox eruption, showed itself in beautiful pocks which followed a regular course. To sum up what I have said on this subject:—If you wish to propagate efficient cow-pox, you must select your virus under cir- cumstances as favourable as possible for securing its activity, you must take it from children who are healthy and of sound consti- tution, you must choose pocks which are large, beautiful, in full bloom [bien fleuries\ if I may be allowed the expression, and which are from five to seven days old. However we may explain it, gentlemen, taking into account all the conditions and circumstances to which I have directed your attention, it cannot, in the first place, be denied that it is much more common nowadays than at the commencement of the century, to meet with anomalous cow-pox, which bears the same relation to cow- pox as modified small-pox bears to small-pox : and in the second place, all vaccinators have seen—as I have seen—a very considerable number of persons with cow-pox who had been previously vacci- nated. The normality of the first vaccination had been proved by insusceptibility to re-vaccination lasting for a number of years, by immunity from epidemics of small-pox, and also by the length of time which elapsed before successful re-vaccination was possible. By vaccinating from arm to arm, there is certainly the least risk of failure; but as we cannot always have recourse to the pock itself, we are frequently compelled to use preserved lymph. I do not pro- pose to enumerate the different plans of preservation which have been devised. You are acquainted with the method of placing the lymph between two perfectly smootli plates of glass of about two or three square centimeters : the dried lymph between the glass plates, (which are closely applied the one upon the other,) may be kept in this way protected from air and light, provided the plates are, as is usual, enveloped in tin-foil. The method which I prefer consists in shutting up the lymph in capillary tubes—not in phial-tubes, which are most objectionable, as it is impossible to fill them with the 134 COW-POX. virus, which consequently is left in contact with air, and so does not keep. The tubes which I recommend are in the strictest sense capillary : as you have often seen them employed, you know that the proceeding is simplicity itself. When you wish to fill them, you open a vaccinal pock by making very slight scarifications in the elevated epidermis : forthwith, an exudation of minute drops of sero- sity is seen : this lymph is collected by moving over the surface of the pock the extremity of the tube, which ought to be held almost horizontally : the liquid is drawn into the tube by capillary attrac- tion. The proceeding is continued till the tube is nearly full, when it is closed by holding in the flame of a candle, first, the end by which the lymph entered, and then the other. When you wish to use the lymph, you break off both extremities of the tube, place one of them between the lips and blow through the tube, placing the other extremity upon the thumb-nail or the blade of a lancet: a small drop is then deposited. I need not describe the operation of vaccination. You all know how to perform it, and you likewise know the place wdiich ought to be generally selected. There are just two matters of detail to which I wish to refer: the one is the number of punctures which ought to be made, and the other, the circumstances under wdiich it is expe- dient to select another than the usual place for operating. How many punctures ought to be made ? This is not an unim- portant question. Although the production of a single pock is generally sufficient to confer immunity from small-pox, the labours of Eichborn have demonstrated that it is not always sufficient. Dr. Mar son, ail English physician, has lately conclusively confirmed this opinion of the German pathologist. He has shown, from excellently handled statistical data, that of the vaccinated persons who take small-pox, those have it in the mildest and most modified form who bear more than one vaccinal cicatrix. Here is a summary of Dr. Marsoffs observations as given by my friend Dr. Lasegue. Of 768 small-pox patients with one cicatrix, 550 had the disease in a modi- fied form, and 3 died, giving a mortality of per 1000. Of 608 with tvro cicatrices, 486 had modified small-pox, and 1 died, giving a mortality of r6 per 1000. Of 187 wdth three cicatrices, 156 had modified small-pox. Einally, of 203 individuals presenting four or more vaccinal cicatrices, 182 had modified small-pox and none of them died. These figures speak with emphasis, and taken along with others less decisive, though valuable, demonstrate that COW-POX. 135 the number of punctures made in vaccinating is a matter of impor- tance. There is a prejudice against which I wish to put you on your guard; viz. prohibiting the washing or bathing of the infant on the day of vaccination, and for some days afterwards. The uselessness of these precautions was shown by experiments made in 1863 by Dr. Peter, then my chef de clinique, now my colleague in the hospi- tals and Professor agrege of the Eaculty. Acting on my recommen- dation, Dr. Peter, after vaccinating a child by means of three punc- tures on each arm, immediately washed the right arm with a copious splash of water, at the same time rubbing it vigorously. The vaccinal eruption not only appeared on the right arm of all the infants thus treated, but, by a strange chance, the pustules were most numerous and most beautiful on the washed arm. This expe- riment was repeated on more than sixty infants, and as the results were always similar, it is evident that we ought to give no coun- tenance to the puerile prohibition of ablution for some days after vaccination. Besides, how can one believe in the absorption of the virus being hindered by bathing or washing, when the experiments made in 1862 by Dr. Martin demonstrated that it was not prevented by cauterization. This young physician, who was an interne at Saint Lazarus Hospital when he made the experiments, applied potassa fusa [caustique de Vienne'] to the punctures of vaccination some minutes after he made them, and the deep cauterization thus produced did not prevent absorption of the virus, although it pre- vented vaccinal pocks from appearing : it was found that the subject so treated acquired immunity, and that subsequent attempts to pro- duce cow-pox were ineffectual.1 The consideration of the rule to be followed in selecting the punctures, and the modifications which may be required in that rule, lead me to speak of vaccination as a means of curing vascular nsevus maternus. This method of treating erectile tumours has been practised in England by Hodgson, Earle and Gumming, and is mentioned by numerous Erench practitioners, some of whom have also employed it, particularly Baudelocque, Itayer, Velpeau, Bous- quet, Paul Guersant, Pigeaux, Lafargue of St. Emilion, Costilhes, Laboulbene, Marjolin, Blache, &c. It offers the double advantage of conferring vaccinal immunity and of getting rid of an affection 1 Petek:—Des Maladies Virulentes Comparees, 1863, p. 17. 136 COW-POX. which, at a later period, by assuming increased development, might become at least a serious infirmity, though not exactly a disease. Legendre has published a note on this eminently practical subject in the Archives Generates cle Medecine for May, 1856. Our lamented colleague, in publishing a case which had come under his observation, has formulated some practical rules. He says that before vaccinating an infant, inquiry ought to be made as to whether it has nsevus, for it is obvious that if this method of cure is to be employed, it must be had recourse to uninterfered with by antece- dent vaccination. When the existence of an erectile tumour is ascertained, it ought forthwith to be treated by vaccination. This rule extends even to those which are likely to disappear sponta- neously, as the proceeding involves no risk, and as it often happens that simple vascular stains on the skin hardly causing the slightest elevation and resembling flea-bites in appearance ultimately become bulky tumours. As vaccination cures nsevi by the inflammatory process set up in connection with the development of the pock, it follows, that in proportion to the size of the erectile tumour ought the vaccinal punctures to be more or less numerous. For the same reason, it is important that all the pocks should be freely developed, and to secure this, the vaccination should be made from arm to arm on the fifth or sixth day of the pock, so that virus employed may be at its maximum of activity. The punctures ought to be so made as only to involve the superficial lymphatic network of the skin, and the lancet must be newly charged for each puncture. To avoid bleed- ing, of which there is risk when the tumour is very vascular, it may be well to substitute for the lancet a needle, or an exceedingly fine- pointed instrument, such as several practitioners have had made for this particular operation. Some have recommended that the vac- cinal punctures be made around and not in the erectile tumour. By adopting that plan, there is obtained a series of pocks which, being partly on the sound skin and partly on the nsevus, circumscribe and invade the latter, determining an inflammation which accomplishes a complete cure. 'When the vaccinal crusts fall off, the place of the tumour is found to be occupied by a smooth cicatrix which is either perfectly white or still dotted with a few red points: these red points are isolated, not elevated, in size not larger than a small pin's point, and their increase in volume is rendered impossible by their being situated on cicatrix-tissue. This method of treatment is COW-POX. 137 applicable when the nmvi are situated on the trunk and limbs, but not when they are on the face, as in the latter situation the cicatrix will be very extensive, and may even be larger than the nsevus. Modified Cow-pox.—Regeneration of Lymph.—Re-vaccination.— Vaccination at the Bar of Public Opinion. I said that I should return to the subject of false cow-pox, an affection which it is necessary to be able to recognise, so that it may not be mistaken for true cow-pox. It has been thus described by M. Bousquet:— “ True cow-pox hardly begins to show itself at the end of the third day, but the false is much earlier, and may be seen from the first to the second day after introduction of the virus, a circumstance which from the first constitutes a distinction between the two affec- tions. But this precocity is not by itself sufficient to establish a differential diagnosis. Talse cow-pox is sometimes so rapid in its course as only to appear that it may disappear: at other times it shows itself in the form of a small pimple, more appreciable by the eye than by the sense of touch. This pimple goes on increasing in size till the fourth or fifth day, leaving the physician uncertain as to its future progress; but on the sixth or seventh day, in place of becoming developed, its progress is arrested, it grows pale, and dries up: at other times, it advances farther, always preserving in its rapid development, a conical and globular shape which I look upon as an unerring a sign of false cow-pox as the flattening and central depression of the pock are signs specifically characteristic of the true.” “ The false pock is sometimes red and sometimes yellowish. It never assumes the brilliant silvery lustre which distinguishes the prophylactic cow-pock. Though not exactly irregular in shape, it has an ill-defined margin. Some time between the fourth and seventh day—for the false cow-pock has nothing fixed or normal in its course—it becomes yellow, suppurates, and dries up.” To this description it may be added, that false cow-pox is often accompanied, as local symptoms, by inflammatory induration of the subjacent cellular tissue, disagreeable itching in the affected parts, swelling and pain in the axillary glands; and as general symptoms, bv restlessness, headache, and sometimes by fever. 138 COW-POX. There is another kind of false, or, to speak more correctly, of aborted, cox-pox. It is met with when the pustules of true cow-pox have their development arrested or impeded by excoriations caused by the scratching of the infant, by the pressure of too tight clothes, or by the irritation of unnecessary handling. Under such circumstances, the suppuration begins at once: the pustule becomes yellow, swells, and its virulent lymph disappears. The term false cow-pox which I have employed is not quite a correct term. Gentlemen, neither false cow-pox nor false small- pox has any existence. When the economy is in no state of apti- tude for receiving or developing the virus of small-pox or cow-pox, the puncture made in vaccinating produces no more effect than if the lancet had been charged with pus from a common boil; when there is some partial aptitude, the result is abortive cow-pox at the end of some days; when there is a state of still greater aptitude, the pock, quicker in its evolution than in the normal order of events, closely resembles that of regular cow-pox; but it passes away more rapidly. In a wrord, we have modified cow-pox, just as we have modified small-pox. I have described the manner of propagating that legitimate cow- pox, which will confer immunity from small-pox, and have pointed out the manner of preventing degeneration of the virus. But is it possible to regenerate virus which has lost its original energy? It certainly would not be difficult to do so, if one could always go back to the original source—provided we could always obtain cowr- pox from the cow. Unfortunately, that is impossible. The question then is :—Can we, in the circumstances in which we are placed, by any means accomplish that object so much to be de- sired, the regeneration of vaccine lymph ? Cannot we, by taking lymph of the best quality and propagating it through a succession of the most favourable subjects, do the same for it which horti- culturists do for plants, when, from seeds of the most common- place kinds, they obtain, after a succession of generations, the most beautiful varieties, by always sowing chosen seed in chosen soil? The observations which I made, along with M. Delpech, on the inoculation of small-pox, give credibility to this supposition. A gijl of 17, whom I had vaccinated in her infancy, was admitted into my wards at the Necker Hospital, with mild modified small-pox. With variolous matter taken from this young girl, I inoculated a child, COW-POX. 139 making only one puncture : the pustule of inoculation became developed, without any other eruption being produced. A second child was inoculated with matter from the first: in this case, besides the development of the inoculation-pustule, there was a secondary variolous eruption in the distinct form. A third child was inoculated with matter from the second: in this case, the eruption was more abundant. Last of all, in the fifth generation, the variolous eruption was confluent: the small-pox had become regenerated. Why has not a similar plan been pursued with vaccine lymph ? Experiments were instituted under my observation by M. Truchetet in the wards now under my charge. We employed lymph taken on the sixth day, that is to say weak lymph which did not become papular till the third or fourth day, nor pustular till the sixth, nor surrounded by an areola till the seventh, nor desiccated till the tenth; nor did the crusts fall till about the fifteenth day. We inoculated a healthy child : we took matter on the fourth or fifth day from this child, and successively transmitted it to other children in the best possible state of health. After a certain number of generations, the lymph appeared to us to have become more energetic, to manifest its effects more quickly, and to take a longer time to complete its evolution, than the lymph with which we commenced the series of inoculations. Not wishing to put too much reliance in our own impressions, a child was sent to the mairie of the eleventh arondissement to be vaccinated. On the eighth day, lymph was taken from this child, and with it the left arm of a healthy child was vaccinated, while, at the same time, the right arm was vaccinated with lymph taken from a subject in our wards. Several other children were vaccinated in the same manner, and our impression was that our “ regenerated ” lymph was more energetic than the lymph used in the town. As the results of these experiments challenge a positive admis- sion of the doctrine that vaccine lymph can be regenerated, they ought to be repeated and generalised. Unfortunately, it cannot be denied, that the lymph in common use has become degenerated; and this, as I have pointed out, is perhaps exclusively due to the unfavourable circumstances under "which the practice of vaccination is carried out. As in the present day, vaccination gives in many cases only temporary immunity in place of the absolute immunity which it seems to have imparted at the beginning of the century, 140 cow-rox. it is incumbent on ns to revert to re-vaccination, a practice which has been long ago lauded. Immediately after the promulgation of Jenner’s discovery, as I have already had occasion to remark, doubts arose in England re- garding the value of vaccination: even then, many physicians had proclaimed the necessity of re-vaccination after the lapse of a certain time. In France, at a later period, Drs. Berland, Boulu, Caillot, and Genouil stated their belief that the prophylactic power of vaccina- tion was limited to ten, twelve, fourteen, fifteen, seventeen, eighteen, twenty, and twenty-five years. In 1825, M. Paul Dubois under- took the refutation of these statements, and rejected re-vaccination as a useless practice, although he admitted the apparently conclusive character of the facts on w’hich it rested. In 1838, this important question wTas submitted to formal discussion in the Academy of Medicine, where re-vaccination encountered numerous adversaries, but where it also had most eminent defenders, such as Chomel and Bouillaud. The Academy adopted the conclusions of the commission appointed to report on the subject, which conclusions were adverse to the practice of re-vaccination. This decision, supposed to have been a definitive settlement of the question, wras warmly defended by M. Dezeimeris, in his journal, the Experience. He based his arguments upon numerous facts observed in France, and on rigorous statistics collected in Northern Germany. On the other side, Drs. Fiard and Hardy protested against the decision of the Academy— Dr. Fiard in a letter addressed to that scientific body, and Dr. Hardy in a paper published in the Experience, in which he showed the agreement of the documentary evidence from England with that supplied by Denmark, Sweden, and Germany, and adduced by Dezeimeris. Notwithstanding the diversity of opinion now noticed, re-vacci- nations on a great scale were performed in the northern countries of Europe, particularly in Germany. Since 1823, every soldier, on admission into the Prussian army, has been immediately re-vacci- nated. The practice, thus adopted in foreign countries, was in the first instance condemned in France, notwithstanding the vigorous manner in which some defended it, and although followed by nume- rous physicians of the highest repute, including Favart, Bayer, ltobert and many others : it wras afterwards mildly recommended, and has at last been accepted as a proper proceeding. Be-vaccina- tion is now the rule in public practice, and it has been made obli- COW-POX. gatory in the French army. Epidemics of small-pox have only made it too clear, that when small-pox prevailed in a population, persons who had been long previously vaccinated were struck, and that the disease wTas most severe in those in whom the date of vaccination was most remote. The history of epidemics ought to tell us what is the influence of re-vaccination upon the progress of small-pox, and I cannot give you a better example of the information which they afford than by laying before you the abstract of the excellent wrork on this subject by Dr. Gintrac, published in the Gazette ties ILopitaux of nth July, 1857 “ In a parish containing a population of about 2,600 souls, a young wmman who had been vaccinated was attacked, towards the end of October, 1853, with small-pox contracted during a long residence with a relation suffering from that disease. During the whole of her illness this young wmman was attended by her mother, wdio also took the disease, although she was fifty-seven years of age, and had been vaccinated. Both recovered : but, early in January, at the begin- ning of the mother's convalescence, the disease was becoming epi- demic. It invaded families, attacking each member in succession or simultaneously. In January, the number of persons seized exceeded 180, and by the 10th of February it had reached nearly 260. From day to day, the number rapidly increased. Men and women, vaccinated and unvaccinated persons, those who had had and those who had not had small-pox, yielded in almost equal pro- portions to the epidemic influence." No opportunity could have been more favourable for studying the influence of vaccination upon the course and severity of small-pox. Dr. Gintrac, recapitulating the facts which he saw, has drawm the following conclusions:— “ There were no cases of small-pox in vaccinated subjects under twrnlve years of age. The greater the age of those attacked, or in other words, the longer the interval since vaccination, the greater wras the severity of the disease. Some families strikingly exempli- fied the remarkable relation which existed between the more or less advanced age of the patient, and the greater or less severity of the attack. In a family of eight, father, mother and six children, the parents had confluent small-pox; three sons, aged twenty-six, twenty-three, and twenty-twro respectively, had the disease less severely; two sons, aged eighteen and fifteen, had modified small- 142 COW-POX. pox; and tile other son, aged twelve, though constantly exposed to the contagion in the same room with the others, had no eruption at all. In another family consisting of seven persons occupying the same lodging, five were struck down by the epidemic, of whom three had been vaccinated between twenty and thirty-five years, and two from fourteen to fifteen years previously. In all of them, there was a great similarity in the prodromic symptoms and eruption, but when the disease attained the suppurative stage, those who had been most recently vaccinated recovered in a few days, and the others suffered severely and had prolonged suppuration.” “ It was ascertained that in general, the disease was decidedly modi- fied, and essentially milder, in those who had been vaccinated: in them the duration of the attack was less than half of the usual duration. There were only prodromic aud initiatory symptoms ; when the period of suppuration was reached, desiccation took place, and the disease seemed from loss of power to be unable to proceed any farther. There were no fatal cases among the patients who had been vaccinated. Ten deaths occurred among the unvaccinated. The ages of those wdio died were one, two, twenty-one, twenty- three, twenty-seven, twenty-nine, thirty-one, fifty-two, fifty-five, and fifty-seven. In all of these cases, death took place during the suppurative period.” “ In February, 1854, when the epidemic was daily striking down many individuals, the question of vaccination and re-vaccination Avas keenly discussed. It having been at last decided that both should be practised, they were immediately resorted to. In less than ten days, 180 vaccinations and 713 re-vaccinations were per- formed. The result surpassed the most sanguine hopes.” “In 180 persons vaccinated for the first time, 171 had true prophylactic pocks, which furnished lymph for vaccination; and in the nine remaining persons, there was no result.” “ The possibility of vaccination taking effect twice in the same person is no longer doubted : it is nevertheless necessary to inquire what modification the vaccinal fermentation undergoes in persons previously vaccinated, and what is the course of the pocks in a second vaccination. Here are the results of 713 re-vaccinations. In 303 individuals, the success was complete: the pocks were de- veloped about the fourth day and were full on the seventh : on the eighth day, they in due course became surrounded by an erysipe- latous areola, then desiccated, and formed crusts which fell off on the COW-POX. 143 twentieth day. The pocks were umbilicated, and presented indis- putably all the characters of the legitimate vaccinal eruption. In eighty-five of the re-vaccinated, the pocks were modified: they appeared on the third day after the punctures, became filled between the fifth and seventh days with a plastic lymph, became surrounded by a reddish areola, and sometimes even caused en- largement of the axillary glands. The non-umbilicated pocks presented neither the swelling nor hardness which belong to cow- pox, and when the crusts fell no perceptible cicatrix was left. In 119 cases, the introduction of the vaccine virus produced, within twenty-four hours, an acuminated pimple which rapidly disappeared. In 206 cases, no visible effect was produced on the skin. The persons who had been vaccinated and re-vaccinated, successfully or unsuccessfully, almost all escaped small-pox. There -were five ex- ceptions, but in these cases, vaccination only preceded the eruption of small-pox by a few days.” “ The following are some of the conclusions drawn from the observations made during the epidemic.” “ Small-pox did not attack indiscriminately and by chance: it generally seized the old and respected the young. If this epidemic has shown that cow-pox is not absolutely preservative, a fact estab- lished by the daily occurrence of sporadic cases, it has at least established that cow-pox exerts a salutary influence upon the issue of an attack of small-pox by shortening its duration and lessening its danger.” “ Re-vaccination applied generally to a population during the full tide of an epidemic has at once arrested its ravages and destroyed its power of development: it has proved itself to be undeniably pro- phylactic, and it even seems to have imparted a certain degree of immunity to persons in whom the disease was already incubating. Finally, re-vaccinations performed in the midst of an epidemic have been found to be free from all bad consequences, notwithstanding the fears of evil which were entertained by some physicians.” The results of Dr. Gintrac's experiments agree in a remarkable manner with those obtained on a large scale in Germany, Denmark, and Sweden, of wjhich you will find an account in the essay of Dezeimeris in volume second for 1838, of the Experience. The statistical summaries of the German authors, applicable to the four years, from 1834 to 1837 inclusive, prove that the occurrence of cases of small-pox became more and more unusual, just in pro- COW-POX. portion as rc-revaccination became more and more practised. I cannot place before you all tbe tables which have been drawn up in illustration of this subject, and must confine myself to the following brief abstract, which will give you a fair idea of the facts. In 1834 there were 619 cases of small-pox: in 1835, there were 259 cases : in 1836, there were only thirty; and although in 1837 the number was 94, that was very much under 619. Other statistical summaries also corroborate that which was de- monstrated by Dr. Gintrac's observations, to the effect, that the immunity derived from vaccination had become weak and tempo- rary, and also that more than twenty-five years ago, the utility of re-revaccination was great. From the summaries referred to, it appears that of 44,000 persons who were revaccinated, 20,000 had the legitimate cow-pock, a result which superabundantly showed that nearly half of those operated on had lost their vaccinal immunity. Nine thousand had had abortive cow-pox. It was only in fifteen thousand that vaccination produced no other effect than a slight redness, lasting from twenty-four to thirty-six hours, round the place where the punctures had been made. Similar conclusions were arrived at by Dr. Marc d’Espine of Geneva. You will find his papers in the Archives Generates de Medecine for June and July, 1859. Another question has now to be solved :—"What is the duration of vaccinal immunity ? Or otherwise expressed :—At what age, and how often, ought individuals to be re-vaccinated ? So long ago as 1804, Dr. Godson raised doubts as to the preser- vative power of vaccination, and alleged that it did not confer im- munity for more than three years: but on the other side of the question, Jenner then showed that the duration of the preservative povrer was much longer, by adducing cases in which he had ineffec- tually attempted to inoculate with small-pox persons who had had cow-pox, in one case, twenty-three, in another twenty-seven, and in a third fifty years previously. However, in the early days of vacci- nation, the immunity which it gave seemed so protracted as to lead to the belief that it might continue during the whole of life, but afterwards, wdien it became admitted that the immunity wTas not perpetual, endeavours were made to ascertain its limits. I have already said that in France, Drs. Caillot, Boulu, Berland, and Genouil had each fixed these limits, the first at ten or twelve years, the second at fourteen or fifteen, the third at seventeen or eighteen, COW-POX. 145 and the last-mentioned physician at from twenty to twenty-five years. But it is impossible to name any absolutely precise period. Eor example, I re-vaccinated three of my daughter's children: in the eldest, aged seven years, and in the second, aged five and a half, I saw normal cow-pox reproduced three years after their first vaccination, while in the third, who was under four years, there was no result when I vaccinated her the second time. Dr. Marc d'Espine, holding very much the same opinion as Dr. Caillot, says that the first re-vaccination ought to be performed between the ages of ten and fifteen. He says that inasmuch as the generalisation of vaccination has advanced the age of the maximum frequency of small-pox from infancy to adolescence and maturity, so will the generalisation of re-vaccination carry it on twelve or fifteen years farther, bringing the maximum to a period of life beyond the age of thirty. Arguing in this wray, he suggests the necessity of a second re-vaccination at thirty, and even a third re-vaccination about the age of forty. Eesting my convictions upon the facts which I have now cited, I generally recommend vaccination to be repeated as nearly as possible once every five years. If this practice is unnecessary, it is at all events free from objection. "We ought certainly to endeavour to multiply the chances of immunity from small-pox — and even from modified small-pox, which, though generally a mild disease, is in exceptional cases attended with danger, a fact I was careful to point out when giving you its history. The principles which apply to the re-vaccination of persons under thirty-five are equally applicable to those who have passed that age. Dr. Yleminckx, who recommended re-vaccination after thirty-five, was met with the objection, that when that period of life was attained the aptitude to contract small-pox had become less, it being alleged that the successful re-vaccination of persons of fifty and sixty did not in the least degree tend to show the existence of such an aptitude. Maintaining the great principle hitherto generally admitted, that successful re-vaccination is proof of the return of aptitude to take small-pox, Dr. Yleminckx threw out the idea, that if the individuals referred to have either become insusceptible or less susceptible to variolous contagion in the ordinary way, they might perhaps contract the disease, if inoculated with the matter of small-pox: he then, defending his practice of re-vaccination, replied to objectors by 146 COW-POX. reminding them that cases of small-pox were still too common in this very class of persons. The practical conclusion to be drawn from all the facts is that we ought to prescribe re-vaccination and a repetition of re-vaccination according to circumstances, but particularly if an epidemic of small- pox is prevailing; and that we ought to promote the general adop- tion of re-vaccination with as much zeal as we bestow on propa- gating the practice of vaccination, because re-vaccination undoubtedly augments the chance of resisting variolous contagion, and renders the disease milder in those who are not proof against it. Gentlemen, the opposition, the unjust and vehement attacks which the immortal discovery of Jenner encountered when first announced to the world, have been renewed in our day. Within the last few years, some physicians, a very small number it is true, following the path opened up to them by a mathematician, a stranger to our art, have desired to put vaccination once more on its trial. These vaccinophobists—for that is the absurd name which they have taken—returning to the ideas of IUiazes, who regarded small-pox as a natural and useful depuration of the blood, exhuming the theories and ideas of the celebrated Hoffmann, of Willis, of Yiolante, and of Hahn (which perhaps, nevertheless, they did not understand), have asserted that small-pox was a necessary disease. They say that it is as old as the human race; that it exists as a germ in the economy; that every one has within his body a special pro- clivity, in virtue of which he must sooner or later be affected; and finally, that the prevention of the manifestation of the variolous germ is a proceeding similar to the practice of those who would wish to prevent the manifestation of the herpetic or gouty principle. They go much farther, for they add that cow-pox, by setting itself up in opposition to the external manifestations of small-pox, has originated new diseases more terrible than that which it was wished to destroy, and that in point of fact vaccination has raised the death-rate in Europe. Such, gentlemen, are the conclusions at which statisticians have arrived after long and toilsome exertions! But are they unaware that the statistical weapon has two edges ? Do they not know that from the same elements, from the same facts, one may lead, or be led to opposite conclusions ? Do they not know that a statisti- cian can make statistics say whatever he wishes them to say ? If asked to prove this statement, I shall bring forward as a case in COW-POX. 147 point this very attempt to make out a charge against vaccination. On the one side, the vaccinophobists have used statistics to maintain their accusation, and the defence has equally derived its arguments from the same source. This is explained by the former having been dominated by a deplorable preconceived idea, and by the others having examined the figures in a spirit of enlightened and judicious criticism. If it be a fact that there has been an increase in the rate of mor- tality in Europe, it would certainly be interesting to study the causes of the increase, but such inquiries would here be out of place, for, as I hope to prove, vaccination is in any case blameless. Be the conjecture true or false, it belongs to that vast question, the displacement of mortality, which involves as an accredited hypothesis the general principle which leads to the conclusion, that humanity pays the debt of death in accordance with an inevitable and inexor- able law. If small-pox played the essential part which some wish to assign to it, if it were a natural depuration of the blood, if it were almost an indispensable condition in the economy of the human body, it must have existed from all time. Although Hahn has laboriously disinterred notices of this disease from among the historical remains of Grecian Medicine, one must hold by the opinion held by Werlhof, and reproduced by Yan Swieten. Small-pox was unknown in the times of Hippocrates, Galen, and JBtius: these illustrious observers make no mention of it. If it existed in their times, they must have described it, for they could not have disregarded a disease present- ing such precise characters. If we admit that small-pox is as old as the world, we must also admit that the germ remained quiescent for many centuries, till an opportunity occurred for manifesting itself. It would be necessary to assume, in respect of the whole human race from the creation, that which Ehazes and the partisans of his theory assume regarding each individual, viz. that the morbific germ of small-pox remains concealed in the body, for a longer or shorter period, in a home of its own, which Hoffmann localised in certain parts of the spinal marrow, which Willis and after him Yiolante placed in the supra- renal capsules—cajosulis atrabilariis, sive renibus succenturiatis dictis—whence sooner or later, he said, it made its irruption. Need I say, that this doctrine is neither in accord with fact nor reason ! Small-pox, then, inasmuch as it has always existed, is not a neces-= 148 COW-POX. sary malady. Nor is it a constitutional malady, for in constitutional diseases there must be a diathesis. Now, what do we mean by diathesis ? Diathesis is a special state, a particular proclivity in the economy which is either hereditary or acquired, but which is essentially and invariably chronic: it is transmittible from father to son, and, in virtue of this hereditary power, is reproduced with identically the same fundamental character : in form, it is liable to modifications and varieties, but its morbid manifestations are in general strongly marked with a good deal of distinctiveness. Gout and rheumatism, for example, are diasthetic maladies. When gout is quiescent during the interval between its attacks, the individual seems to enjoy perfect health; but when an attack comes on, the diathesis manifests itself, sometimes, by inflammation of joints, by peculiar secretions in particular parts, such as the joints, the skin (especially that of the hands), the soles of the feet— at other times, by neuralgic affections, asthma, gravel, or dyspeptic symptoms. In whatever way these manifestations appear, we can generally recognise in them an expression of the gouty diathesis. It is the same with rheumatism : the diathesis which constitutes that disease will make itself known in a great variety of forms, and by very different special lesions of the heart, fibrous tissues, nervous system, &c. These numerous forms of disease are all parts of one disease, which, by attention, we can diagnose. The same may also be said of scrofula. But the essential parts of these diatheses are on the one hand chronicity, and on the other, a tendency to returns and repetitions, not only in the same individual, but also in his direct and collateral descendants. Thus, a manifestation of the strumous or tubercular diathesis in any one organ leads us to fear strumous manifestations in other organs. An attack of gout or rheumatism in an individual makes us expect a succeeding attack ; and a suc- cession of such attacks leads us to apprehend that the disease will reappear in his children, for experience has taught us that gout, rheumatism, tubercle and scrofula descend from generation to gene- ration. Is it so with small-pox ? Is it so with other contagious diseases ? Small-pox is an essentially acute disease, which runs its course in a determinate space of time, leaving no trace of its passage except cicatrices on the skin. Will any one venture to say that it is hereditary ? The cases of intra-uterine small-pox which occur are accounted for by contagion. But are the children of parents who COW-POX. 149 have had small-pox at some former period necessarily variolous, as children of tuberculous and gouty parents are born predisposed to tubercle and gout. There are, however, some points of resemblance between contagious and diasthetic diseases, and indeed some have called the former the acute diatheses. Like diasthetic diseases, they involve a special disposition of the economy, but they differ from them essentially in being acute, and in not being transmittible by descent: they are caused only by the operation of a special morbific principle; and thus in a certain way they are transmittible from a sick person to another individual: but they differ from diasthetic diseases in being propagated by the transmission of a contagium. From the very fact that small-pox has not always existed, it is evident that it must have become spontaneously developed in its first subject: it has originated, therefore, under the influence of causes which have escaped observation. If, moreover, it should one day disappear from pathology, as has disappeared leprosy, a disease so common in former times, or if it should cease to present the characters by which it is now recognised, it is reasonable to suppose that it can again originate without contagion, under the influence of causes similar to those whence it first sprung. This mode of development has hitherto, however, eluded observation, and no one can adduce a single well-established case of spontaneous small-pox. It was originally brought into Europe by contagion, and to this day is propagated by contagion. It is difficult to demonstrate the influence of contagion in great centres of popula- tion, where people are so commingled and so confusedly brought into contact with each other, but in small places it is more appre- ciable. If an epidemic of small-pox break out in a village where no case of the disease has been seen for twenty, twenty-five, or thirty years, it can generally be ascertained that it has been im- ported by some one who has come from a place where it was pre- vailing. Among other examples of this, read the cases published by Dr. Gintrac, whom I mentioned in connection with the subject of re-vaccination: read also the work of Dr. Marc d’Espine, wherein you will see how some epidemics can be followed up to their source. It is not necessary that the person who conveys the contagion should have had the disease. All writers on the subject testify that the variolous contagium possesses an inconceivable power of repro- 150 COW-POX. duction. The minutest drop of variolous matter, or the effluvia from a living or dead patient, are sufficient to transmit the disease. Moreover, the morbific germ, like certain volatile substances which, for a longer or shorter period, cling to the vases in which they have been shut up, or to the rooms in which they have been placed, has an action vast beyond all appreciable limitation, a divisibility which is infinite : the most imperceptible atom is sometimes sufficient to engender the disease, just as the minutest spark of fire suffices to kindle a conflagration when it falls amid combustible materials. Small-pox is propagated by contagion, whether the contagium be communicated by inoculation or by absorption from air carrying variolous effluvia. It is then neither a diasthetic, nor an essentially constitutional disease, and still less is it a disease necessary to the human economy, inasmuch as it has not always existed. And, Gentlemen, it is not the only new disease. Was not Asiatic cholera a new disease in Trance when it broke out among us in 1832? I admit that it had been known in India long before that, but even in India where it seems to have had its origin, the date of its appearance is not very remote, as the first well-authenticated epidemic observed, occurred in that country about the middle of last century. It is hardly eight years ago, since yellow-fever was un- known to more than four fifths of the globe, and to two thirds of the transatlantic hemisphere. Till then, it had so completely spared South America, notwithstanding the numerous lines of communica- tion established between north and south, that no case had been seen in the Brazils, Bahia, Ternambouc, Buenos-Ayres and Monte Yideo. But after that time, having passed the line, it cruelly ravaged these countries, and began to reach the shores of the Pacific ocean: it is only two years since it appeared at Lima, where it has been neither very fatal nor very severe; and till now it has not been seen in California. Unfortunately, there is every reason to believe, that it will continue its progress, and that proceeding beyond its present limits, it will invade countries hitherto preserved from its ravages. Besides the new diseases—small-pox, cholera, and yellow-fever— there are others which have been erroneously supposed to be new, some from the former means of diagnosis having been defective, and others from neglect of the histories left by our predecessors. The detractors of vaccination point to these diseases, miscalled new, when they argue that vaccination, by preventing the external mani- COW-POX. 151 festations of small-pox, has caused the development of diseases more terrible than small-pox itself. It has been said and written, that through the absence of small-pox, the blood is no longer depurated and the economy no longer put into a condition to resist morbid actions; hence, it has been said, proceed the uterine affections, the diphtheria, and particularly the typhoid fever so common in our day, and by the two latter of which communities are decimated. But there were good reasons for uterine affections having been imperfectly known. The speculum which has rendered so great services to uterine diagnosis was not in common use till Recamier generalised its employment in the beginning of the present century, though it had been invented in the days of Paulus iEgineta, and Rhazes, and modified subsequently by Ambrose Pare, Scultet, and Garengeot. Ejfty years ago, the vaginal examination of the uterus by the finger was unheard of, except in cases of pregnancy: up to that time women would have revolted at the very idea of such examinations, and no physician would have dared to propose them. Now, it is no longer so, and even our English neighbours have freely accepted the speculum and the toucher. Nowadays, we are likewise better acquainted than formerly with uterine pathology. Never- theless, though then but imperfectly understood, uterine diseases existed in the days of our predecessors, as their writings testify. The pathological anatomy of these affections had engaged the atten- tion of physicians, as you can see by reading the cases recorded by Morgagni, who quotes a certain number from the works of preceding authors.1 Although the acquaintance with uterine affections was imperfect in early times, it was considerably diffused even among the general public, as is evident from the very significant manner in which they are alluded to in the epigrams of the ancient poets. Diphtheria has also been proclaimed as a new conquest of human infirmity. In verity, a doleful conquest! It has been said that this terrible disease was unknown in former ages, and did not begin to show itself till after the practice of vaccination had become com- mon. Need I discuss such a proposition as this ? Any one possessed of even a very slight acquaintance with the history of medicine is aware that sore throat with plastic exudation [angine couenneuse], the most common form of diphtheria, was long ago observed and 1 Morgagni :—De Sedibus et Causis Morborum: 45, 46 et 47. 152 COW-POX. described, and that authors of the most remote antiquity mention it. Iretseus called it the Syrian and the Egyptian disease, which shows that when he wrote, it was common in Syria and Egypt. Without going so far back into antiquity, but at the same time going back to the sixteenth century, an epoch remote from our own, it may be stated that Spanish physicians of that period described frightful epidemics of angina and croup which ravaged the Iberian peninsula and Italy. The name which they gave to this affection of the trachea was morbus strangulatorms, and they have also preserved the names by which it is commonly known—garotitto and male in canna. Pinally, to come nearer our own times, was not gangrenous sore throat described a hundred years ago, in France, Sweden, Ger- many and America, under the names of diphtheritic angina and croup? Vaccination, therefore, cannot have the discredit of origi- nating a disease which had an existence prior to vaccination. Indeed, if we were to reason after the manner of the vaccinophobists we might rather say that vaccination arrested the development of diph- theria, because by a singular chance never were diphtheritic angina and croup less prevalent than at the beginning of the present century, the very time at which cow-pox began to be propagated by vaccination. The argument upon which the depredators of vaccination chiefly rest is drawn from their allegation that typhoid fever is a more com- mon disease now than prior to the Jennerian discovery. In reply, it is only necessary to refer to some pages of the aphorisms of Stoll; for in the short chapter which he devotes to putrid fever [febris putrida], it is impossible not to recognise our own typhoid fever, portrayed in its most striking characters and with all its symptoms. Is there any difference between it and the ataxo- adynamic fever of Pinel? Do not the works of Prost, published in 1802, show us this fever, attacking subjects of twenty and thirty years of age, who, be it remembered, had never been vacci- nated, and in whose bodies were found on examination after death the very intestinal lesions now regarded as essentially characteristic of dothienteritis ? Similar anatomical proofs are also supplied by the treatise of Petit and Serres. These physicians observed the affection, which they described in 1814, in individuals above fifteen years of age and who consequently could not have been vaccinated. Typhoid fever, then, so inappropriately appealed to, has no connection whatever with cow-pox : it existed Jong before Jenner> though under different COW-POX. 153 names, such for example as sgnochus putris, febris putrida, la fievre adynamique, la fievre nerveuse, la fievre maligne, &c. The physicians whose opinions I am now calling in question— because they have made some noise lately—see in typhoid fever a repressed small-pox, the eruption being, as they say, on the mucous surface of the intestine, in place of on the skin: they repeat the statement of Lecat, comprised in the name of gangrenous mesenteric small-pox, which he gave to an epidemic disease prevalent at Rouen in 1763. I am quite willing to admit that typhoid fever bears a resemblance to small-pox, to this extent, that its symptoms are those of an eruptive fever, and that it has a pimply eruption for its specific anatomical characteristic: but that is not the sense in •which I understand that the attempt is made to establish the re- lationship of typhoid fever and small-pox. The physicians who call typhoid fever a kind of small-pox do not say that typhoid fever and small-pox are analogous, but that they are identical. They lose sight of the fact that the intestinal lesions of typhoid fever bear no resemblance to the pustules of small-pox. If it be said that the dissimilarity of the lesions is explained by the difference of their seats, I reply, that upon comparing in the most unprejudiced manner possible dothienteritic eruption with variolous eruption on the mucous membrane of the mouth and pharynx, I could not dis- cover any similarity between them. Finally, if typhoid fever and small-pox are the same disease, persons who have had one could not take the other : and this is a point in respect of which facts utterly contradict the theory of the vaccinophobists. You have very re- cently seen in our wards convalescent small-pox patients seized with typhoid fever, and others during convalescence from severe attacks of typhoid fever take small-pox. To those who object to vaccination, on the ground that since its introduction there has been an increase in the mortality from typhoid fever, I would remark, that as the infantile population (thanks to vaccination) is no longer decimated by epidemics of small-pox, the representatives of the children who used to die in childhood, grow up, to run the risk of all the diseases incident to adolescence and manhood, a circumstance which would explain why typhoid fever may perhaps be more frequent now than formerly. Should the day ever come when we shall have the good fortune to discover such prophylactics for measles and scarlatina as cow-pox is for small-pox> there will perhaps be people who in their turn will COW-POX. try to show that measles and scarlatina are necessary maladies, the prevention of which occasions the development of new diseases. Such individuals would not be more mistaken than those whose theories regarding cow-pox we have now been refuting,. If these gentlemen were logical in their reasoning, they would hold that the more severe small-pox is, and the more copious the eruption, so much the more complete will be the depuration of the organism, and so much the better protected will the economy be from the diseases from which small-pox exempts:—consequently, that the confluent is the most desirable form of the disease ! It appears, then, that no charge can be substantiated against cow-pox, that the verdict must be in favour of it as a prophylactic against small-pox, and that the discovery of Jenner must remain unchallenged as one of the greatest benefits conferred by medicine on humanity. The only reproach which can be adduced is that the prophylactic power of vaccination has in our day too often become unreliable, and is gradually diminishing. On that account, adopting in principle the opinion of Gregory, I would prefer variolation to vaccination; but nevertheless, it is to the latter we must have recourse, for reasons which I laid before you when discussing the inoculation of small-pox. LECTURE IY. CHICKEN-POX. Chicken-pox, or Varicella, essentially differentfrom Modified Small- pox.— Unlike Small-pox it does not protect from Variolous Contagion.—Small-pox does not protect from Chicken-pox.— Course and Characteristics of the Eruption. Gentlemen :—If I concur with the general opinion of physicians in believing that small-pox and modified small-pox are identical, I am not at one with them as to the nature of chicken-pox, or flying small-pox [petite verole volante] as it is still very commonly desig- nated. You will read in books, you will hear it said and repeated, that varicella is only a modification of variola; that chicken-pox and modified small-pox are identically the same disease ‘ and that both are merely different forms of small-pox. You already know my opinion on this subject: with many others I hold that chicken-pox and modified small-pox are as much strangers to one another as small-pox is a stranger to measles; that they resemble one another as little as measles resembles scarlatina; and that they are as different as possible from each other in their symptoms, forms, and essential nature. And I will venture to affirm, that physicians who maintain an opposite opinion have never taken the trouble to examine chicken- pox; for if they had, they must have become convinced of their error. Chicken-pox looked at from a general point of view, as an abstrac- tion deduced only from its anatomical characters, presents such sharply marked differences from modified small-pox that it is diffi- cult to understand how the two diseases should have been confounded. Then, on the other hand, we learn from the history of epidemics that chicken-pox can exist in an epidemic form by itself, whereas modified small-pox never prevails without being accompanied by normal small-pox. Again, the two diseases differ in respect of the 156 CHICKEN-POX. age of the person for whom they have a predilection. Small-pox before the discovery of vaccination and prior to the practice of variolous inoculation, while it chiefly attacked children, likewise attacked adults, whereas chicken-pox was then as now almost limited to young subjects, not attacking adults, who had escaped it in their youth. As inoculation in England, Germany and Erance dates from last century, as vaccination was not in common use till the beginning of the present, cases of modified small-pox were very rare in those days: but at that time chicken-pox was perfectly known and described. Except in exceedingly rare exceptional cases, small-pox does not attack a child vaccinated two or three years pre- viously. You may with impunity inoculate such a child. But if you bring him into contact with another child who has chicken-pox, he easily takes it. From this fact alone, it is evident that chicken- pox is not small-pox. Again, if a person who has just had chicken- pox is brought into contact with a centre of variolous contagion, he ought not to contract small-pox if the chicken-pox of which the marks are still visible were the remains of modified small-pox; but nevertheless we have learned from experience that such an individual may quite well contract small-pox. The two exanthematous diseases may even go on simultaneously. Dr. Delpech, in a paper published in 1845, narrates the case of a child who had had at the same time small-pox and chicken-pox. A person will never contract small-pox from being exposed to the contagion of chicken-pox. Will there be a similar immunity if you inoculate an individual with virus taken from the mildest possible case of modified small-pox ? Again, small-pox presents itself under very variable forms, but chicken-pox is always the same in form and symptoms : in no case does an antecedent attack of small-pox exer- cise the slightest influence upon it. Moreover, while second attacks of small-pox occur only as exceptional cases, second attacks of chicken-pox are far from being so uncommon. Do not all these considerations clearly prove that verolette—for this also is a name of chicken-pox—differs essentially from small-pox ? The differences between the two diseases come out still more strongly when we examine them more minutely, comparing chicken- pox with modified and with natural small-pox. In distinct small-pox, as I have reiterated on several occasions, the fever of invasion lasts for three days, and the eruption appears on the third: in modified small-pox, distinct or confluent, the period of invasion has the same CHICKEN-POX. 157 duration as in the natural form of the disease. The course of chicken-pox is quite different. To-day, a child is seized with head- ache, feelings of general discomfort, and all the symptoms which accompany the onset of any fever; but on the very same day, before twenty-four hours have passed, there are visible on some part of the body—it may be on the face, back, abdomen, or legs—small slightly acuminated rosy spots resembling the rosy lenticular spots of putrid fever. During the first twenty-four hours, from ten to fifteen such spots may be seen. The fever, nevertheless, continues. On the following day, from one hundred to one hundred and fifty spots may be counted: those of the previous evening have by this time elevated the epidermis, the elevations being generally in the form of blobs, which are sometimes rounded in the most perfect manner and contain a serosity transparent like rock-water, and without any surrounding inflammatory areola. This description is quite inapplicable to the natural variolous eruption : it is also inap- plicable to the manner in which the eruption of modified small-pox appears in respect of situation, development, and form. The erup- tion of modified small-pox—unlike that of chicken-pox—bears no resemblance to a phlyctsena, a blob of pemphigus, or to certain forms of herpes. These palpable anatomical characters are in them- selves sufficient to establish categorically the differences which so clearly distinguish the two affections from each other. Next morning, there is almost no fever, and it is observed that a new crop of from one hundred to one hundred and fifty spots have appeared during the night. In the evening of this day, fever again sets in, and continues till next day, when the spots of the previous evening have become blobs, and newT spots appear (without indi- cating a preference for any particular locality), in the situations where the eruption had already come out. Successive crops of eruption, and new onsets of fever, sometimes violent, occurring during the night and ceasing during the day, are repeated for four or five nycthemera. The fever, therefore, has no resemblance to the variolous fever, which is continuous, and usually during a single paroxysm brings out the eruption however generally distributed it may be over the body. After four or five attacks of fever, the eruption of chicken-pox is complete, and there is no more fever. The rosy elevations, which after from seven to ten hours were transformed into blobs, perfectly round, shining, and distended with lactescent serosity, in from 158 CHICKEN-POX. twenty-four to thirty-six hours more increase in size., and become irregular in shape like some of the pustules of ecthyma; their serosity acquires an opaline appearance; and an inflammatory areola surrounds them. They remain in this state for about three days. Towards the third day, the serosity is replaced by pus : the pustule bursts: it is large, irregular, and painful. Thus, whilst from eight to nine days are required for the evolution of the variolous pustule, three nycthemera are enough for the blob of chicken-pox. Farther, the variolous pustules are largest on the hands, but it is on the back and trunk that the varicellous pustules attain the greatest size. On the seventh day, the pustules of chicken-pox are dry, and in their place are to be seen blackish crusts like those which succeed the pustules of ecthyma, or red spots such as are presented by im- perfectly healed blisters, according as they have proceeded more or less freely to suppuration, or have broken the skin like a blistering plaster of cantharides or ammonia. In chicken-pox, the eruption is in the form of blobs: in small- pox it is in the form of pustules. This important difference irre- spective of other distinctive characteristics drawn from the general symptoms is quite sufficient to establish the non-identity of the two diseases. The following case, for which I am indebted to M. Dumontpallier, furnishes me with additional evidence of the essential nature of the difference between small-pox and chicken-pox :— “On Tuesday 4th March 1862/'’ writes M. Dumontpallier, “I was called in to the family de E—. The eldest of the daughters, between thirteen and fourteen years of age, had been only slightly unwell from the previous evening, but nevertheless, at my first visit on the 4th March, I observed a vesicular eruption on the face, arms, legs and trunk. There existed slight lassitude, with some feeling of debility and pains in the limbs, a very little aching in the loins, no nausea, and hardly any fever. This young girl had beautiful vaccinal cicatrices. I diagnosed the case to be one of modified small-pox. The patient was soon restored to health; but she will retain one or two pock-marks on the face.” “ On Saturday, 8th March, I vaccinated Miss de E—*s two sisters, aged respectively ten and twelve, and also Mrs. de E— and her brother a young man of twenty-three. A vaccinal pock was deve- loped on the arm of Mrs. de E—, but in the two girls and the young man, the vaccination did not take effect. Matters remained CHICKEN-POX. 159 in this state till Monday 17 th March, that is till thirteen days after the onset of the fever in the eldest of the three sisters, and nine days after the vaccination of the family, when I was sent for to see the two youngest sisters. I was told that both had had some feel- ings of discomfort on the previous day : during the day they had taken a walk, but in the evening had begged to be allowed to go early to bed. Next day, the 17th, a very beautiful eruption of papules, which soon became slightly vesicular, appeared on the face, limbs and back. On the following day, the blobs were filled with lactescent serosity, and soon dried up into the form of crusts. There was no severity in any of the general symptoms, and by the third day the appetite had returned/’ “ I called in Professor Trousseau in consultation, who had no hesitation in saying that it was a case of chicken-pox. He came to this conclusion from the short duration of the period of inva- sion, the vesicular form of the eruption, the rapidity of the desicca- tion, and the small amount of constitutional disturbance. It is evident, from the facts just stated, in the first place, that the Misses de R— were proof against the contagion of small-pox, for they were still under the protecting influence of a first vaccination; and in the second place, that small-pox and chicken-pox are diseases distinct from each other in their nature and in their germ, as the Misses de R— took chicken-pox, though proof against small-pox/” Chicken-pox sometimes presents phenomena which are never met with in small-pox. Thus, in an epidemic of chicken-pox which pre- vailed in the Necker Hospital, the fever ceased when the malady began; and during from fifteen to forty days pemphigoid blobs appeared on different parts of the body, leaving, on the surfaces which they had occupied, ulcerations exactly like those of pem- phigus, which ulcerations continued for six weeks or two months. No such occurrences are ever observed in small-pox. To sum up :—Epidemic conditions, general symptoms, tlie manner in which the eruption appears and its form, all combine to establish the essentially different nature of chicken-pox and small-pox. Again, chicken-pox is never a fatal disease. No physician has ever seen a patient die of chicken-pox, though of course there may be a fatal issue from some complication independent of the exanthematous fever. This cannot be said of small-pox nor of modified small-pox. Finally, the incubation of small-pox extends over nine, ten, or eleven days, as has been demonstrated in the practice of inoculation* CHICKEN-POX. whereas the incubation of chicken-pox is a period of from fifteen to twenty-seven days. Chicken-pox is not inoculable, or at all events my attempts to inoculate it have been failures: but when a child suffering from it, returns to its family, we may prognosticate, from the teaching of experience, that within from fifteen to twenty-seven days other children in the house will have taken the disease. LECTURE Y. SCARLATINA. Variety in the Characters of Epidemics.—Contagion.—Incubation. — Complications at the Beginning of an Attach.—Characters of the Eruption.—Desquamation. Gentlemen :—It is now nearly six months since we have been frequently receiving cases of scarlatina into our wards. In town, it seems to be prevalent as a somewhat severe epidemic. You have here at present, an opportunity of judging for yourselves of the strange forms which this disease is apt to assume. I am unwilling to allow the opportunity to pass without bringing it under your notice, as it is a malady rather imperfectly known by hospital students. Scarlatina is more variable in its forms and symptoms than any other of the contagious exanthematous fevers; and its dangers are also more difficult to foresee. Small-pox, whether distinct or con- fluent, mild or malignant, is always small-pox : its leading characters can always be recognised—always, except with a very few exceptions, chiefly observed by our predecessors—its external anatomical lesions being peculiar to itself, whether it be in its natural form, or modified, as it so often is, by vaccination or a previous attack of small-pox. Scarlatina, on the contrary, may exist without showing itself on the skin; and when this is the case, the disease is not the less serious on that account. Measles always preserves pretty exactly its charac- teristic features: its diagnosis is usually, almost always, easy: its complications are generally foreseen, and occur at a certain stage, even on a particular day which the physician can predict. Scarla- tina, as we shall see, presents complications which for the most part cannot be foreseen, and of which the most experienced practitioner can know nothing before-hand, even when they are imminent. SCARLATINA Scarlatina is sometimes so very mild, that Sydenham, one of the greatest medical observers of past times, said of it:—“ Hoc morbi nomen (vix enim altius assurgit)Sydenham gives us in his writings only the results of his personal experience, and as he had never seen severe scarlatina, he spoke of the disease with a sort of contempt which he was far from having for measles or small-pox. In our own day, some of the authors to 'whom wre ought always to refer state, that for a long series of years the epidemics of scarlatina which came under their observation were so far from being serious that they were without fatal cases. Graves mentions that from t 800 to 1804 scarlatina ravaged Ireland and was very fatal; while from 1804 to 1831, the physicians who had found it so terrible in 1800, 1801, 1802, 1803, and 1804, saw scarcely any fatal cases, so wonderfully mild had been the disease. But in 1831, an epidemic of malignant scarlatina broke out in Dublin and its vicinity: in 1834, it covered Ireland with mourning more extensive than that which was caused some years later by typhus, or than that which had been produced two years previously by the outbreak of Asiatic cholera.1 At the commencement of my medical studies, when attending the clinic of Bretonneau, my illustrious master taught his class that scarlatina, which he had formerly heard spoken of as a very danger- ous malady, was then a mild affection. He told us that from 1799 to 1822 he did not recollect having seen a single fatal case; and yet he had long practised in the country before he became first physician to the hospital at Tours. The numerous cases which he met with both in his hospital and private practice seemed at that time to have satisfied him that scarlatina was the mildest of all the exanthemata. But in 1824, an epidemic broke out in Tours and its environs: in less than two months Bretonneau learned that several patients had died with such frightful rapidity that—being opposed to the doc- trines of Broussais then in repute—he blamed the treatment adopted by his colleagues, who bled most resolutely with a view to subdue the sore throat and the so-called inflammatory fever which attends the beginning of the attack. Bye-and-bye, coming personally to close quarters with the disease, he found that he could not always successfully contend against it, and he saw it carry off many of his own patients. The result was that Bretonneau who had formerly 1 Gjjaves : Lefons de Clinique Medicale. Traduit par Jaccoud, 2ue edition, T. i. Paris, 1863. SCARLATINA. 163 looked upon scarlet fever as a slight malady now learned to regard it as equally mortal with plague, typhus, and cholera. Thus you see that during a quarter of a century, scarlatina appeared as an epidemic without showing any severity: then all at once it became changed in its manifestations, and cruelly smote all whom it touched. It is not usual for measles or small-pox to mani- fest themselves in this way. Yery severe epidemics of measles and small-pox do, no doubt, sometimes occur, but as epidemics they never show such extremes of mildness and severity as scarlatina. Scarlatina is a disease which is more influenced than measles or small-pox by a dominating epidemic constitution, and hence it arises that an epidemic of scarlatina is sometimes very mild and at other times very severe. You may have observed, gentlemen, with what care I have inter- rogated our patients with a view to ascertain the circumstances under which they contracted scarlatina. Causes which generally favour the appearance of other diseases have very little to do with the evolution of the exanthematous pyrexise, and in respect of their causation, contagion ought to be the point most particularly inquired into. We shall afterwards have to return to the consideration of the evolution of contagion-germs. I should fear that I was doing injustice to this great question were I only to skim its surface: I should, through my own fault, be unable to make myself understood by you. You have seen how much importance I attach to ascer- taining the day of first contact, direct or indirect, with a contaminated person or place. You have seen that proof of this contact was sometimes clear, and that at other times it was quite unattainable, and also that there were cases in which communication between the patients and persons with scarlatinous infection had been such as to make it impossible to determine the duration of the period of incubation. Nothing is more difficult than to state the exact time at which contagion has been contracted in an exanthematous fever, when the virus has not been directly introduced by inoculation; and con- sequently, nothing has been more variable than the manner in which this question has been solved. According to some the incubation of scarlatina varies in duration from three to five days, according to others it lasts for eight days, and some believe that it may be prolonged to fifteen, twenty, or even thirty days. In fact the figures given have been hypothetical. There exists an unwillingness to SCARLAT1XA. admit the fact that it is impossible to determine the duration of the period of incubation, just because it is impossible to fix the date of its commencement. Small-pox is the only fever in respect of which this date is determinable with precision, being the only one directly inoculable. In consequence of variolous inoculation having during half a century been practised on a large scale throughout Europe, the time which elapses between the moment at which the virus is placed under the skin, and that at which the malady declares itself, has been determined with precision. The rigorous determination of the length of the period of incubation in small-pox is dependent, therefore, upon its inoculability, a property which does not belong to any other exanthematous fever. Erom the non-inoculability of the other exanthemata, it has been necessary to assume as the beginning of the period of incubation, the moment at which the patient was first in contact with an infected person. But inoculation and contact are not the same thing. Here is a case in point! Five hundred sheep are collected together in the same park, or in the same fold: one of them takes the tag-sore, an eruptive disease of sheep, analogous to small-pox in the human species. Fifteen or twenty days later, seven or eight other sheep are seized, and on each succeeding day several more fall sick. It is sometimes four months before the entire five hundred have taken the disease. Now, these animals contracted the contagion at very different periods, although they were all shut up in the same place, breathed the same impure air, were together in crowded contact, and soiled by the discharge from the sores of the affected. Is there any reason to suppose that the period of incubation was longer in some of these sheep than in others ? None: because if all the sheep had been inoculated simultaneously, the manifestation of the disease would have occurred in all without exception on exactly the same day. Inoculation and contact, then, are two very different things : by inoculation, the virus is introduced almost of necessity into the system: but by mediate or intermediate contact, the absorption of the virus, its conception, if I may be allowed to use that expression, is not always secured— that only takes place when the economy is in a certain state of aptitude:—the way must be open so to speak. 'When absorption has once taken place, whether after inoculation or contact, it is pro- bable that the evolution of the disease occurs within a determinate time, which, within a few days or hours, is the same in all cases. Very well! Till we can inoculate scarlatina by the scarlatinous SCATtL ATINxV. 165 virus, we shall be as unable to determine the duration of its period of incubation as we are to determine the duration of the incubation of the tag-sore contagion in the different sheep constituting the flock of five hundred. In a family consisting of ten individuals, five weeks will sometimes elapse before scarlatina has attacked all the members, the case being quite similar to that of the flock of sheep. This neither arises from certain individuals having been free from contact for a certain time, nor from the period of incubation having lasted longer in some than in others, but from the difference in the respective aptitudes of the different subjects to receive the contagium. This is what we see take place with syphilis. 'When the syphilitic virus is scientifically inoculated, it determines, after the lapse of a certain number of days, the evolution of a specific vesicle, and the number of days is almost exactly the same in every case; but when several men have connection with the same infected woman, some will take the pox immediately, while others, after having been exposed on seve- ral successive days to the contagion, will not contract the disease till the last day, or perhaps not at all. This is explained by the fact, that those who at once contracted the disease from the first contact were in a physiological and pathological state suitable for the absorp- tion of the virus, while the others were not in that condition of aptitude. To sum up:—The duration of the period of incubation in scarlatina, that is to say, the time which elapses between the exact moment at which the morbid poison is absorbed and the exact moment at which appear the first manifestations of the disease, cannot be rigorously determined in the present state of our knowledge. The same state- ment holds good in respect of measles. Under very exceptional circumstances, howrever, it is possible to attain considerable exactitude as to the duration of the period of incubation in scarlatina. In the beginning of the year 1859, I saw a very curious case which occurred in the practice of my friend Dr. McCarthy, who did me the honour of calling me in in consultation. A London merchant had taken one of his daughters to the Eaux Bonnes in the Pyrenees, and had passed the winter with her at Pau. On his way back to England, he stopped at Paris, where he wished to remain some days. His eldest daughter was keeping house for him in London. Impatient to embrace her father and sister, she started for Paris. When crossing the Channel, she was seized with fever and sore throat, and seven or eight days later arrived at Paris, 166 SCARLATINA. in the middle of a very serious attack of scarlatina. She alighted at the hotel, almost at the very moment when her father and sister arrived from Pau. The two sisters remained together in the same room, and in twenty-four hours the sister who had come from Pau showed the first symptoms of a mild attack of scarlatina. In London, the dis- ease was then epidemic; but there were no cases at Pau. This curious history proves that in scarlet fever the duration of the period of incubation is sometimes not more than twenty-four hours. I am, however, very far from believing that that is its ordinary dura- tion. Although the period of incubation is limited with precision in small-pox, there is probably no similar exactitude of limitation in the other exanthematous fevers. The period of invasion in scarlet fever is quite as much without exact limits as the period of incubation. Recall to your recollection what takes place in small-pox. In normal small-pox, when the eruption appears within forty-eight hours of the first manifestation of symptoms, it may be affirmed that the case will be confluent, for, as a general rule, it is towards the end of the second day, or at the commencement of the third, that the pustules begin to come out in that form of the disease; and when the eruption does not appear till the fourth day, the diagnosis is—distinct small-pox. In cases of confluent small-pox, it is very unusual for the eruption to be retarded till the fourth day, and it is as unusual in distinct small- pox for it to appear on the second. Observe, that I am at present only speaking to you of normal small-pox. I was on a former occasion careful to point out that in the modified disease the symptoms are different. In scarlatina, events do not proceed as in small-pox. In some cases, the eruption comes out during the first four or five hours of the fever, while in other cases there is no fever at the beginning of the disease, a fact mentioned by Ileister and other old authors, and which in later times has been repeated by various writers. Barthez and Rilliet state that in eighty-seven cases observed, the eruption was the first symptom of the malady in four cases : in the majority of the eighty-four cases, the fever of invasion lasted twenty-four hours, and rarely continued longer. It is still more unusual, except in complicated cases, for the eruption to be delayed beyond the second day, and very much more unusual for it to be retarded till after the third day. Some physicians believe that they have seen cases in which the eruption did not appear till during the SCARLATINA. 167 third day. I do not absolutely deny the possibility of such an occurrence, but I say emphatically that the occurrence is one of extreme rarity. My opinion is, that in the class of cases referred to, the eruption is often not recorded because, though present, it has escaped observation, owing to its not having been looked for in the proper place. As a general rule, wTe first seek on the face for the eruption in exanthematous fevers, because, in point of fact, it first showrs itself there in measles and small-pox; but in scarlatina, the eruption does not come out first on the face. It generally appears first on the trunk, fore-arms, lowrer part of abdomen, and bend of the thighs, and may exist in these localities from twenty-four to thirty-six hours before it is visible on the face or neck. Under such circumstances one might suppose that the eruption was only beginning to appear, w'hen in reality it had been out for some time: but it is easy to avoid this mistake, if we are aw7are of the fact I have now mentioned. There are, however, complicated cases of scarlatina, as of small- pox, in which the period of invasion is prolonged greatly beyond its ordinary term. It sometimes happens in seriously complicated cases of scarlatina that the exanthem does not show itself till as late even as the eighth day; as I know7 from the following case. Six years ago, I wTas summoned by my honourable colleague Dr. Sarrazin to see a child of six or seven years of age supposed to have cerebral fever. He w7as complaining of headache, and had vomiting. We observed squinting, slowness of pulse, stupor, and somnolence. Prom these symptoms wTe believed that the patient w7as suffering from inflammation of the brain and its membranes. I saw the child again on the fifth, sixth, and seventh days without changing my diagnosis, and continued to give a very unfavourable prognosis. On the eighth day, there appeared a well-marked scarlatinous eruption, accompanied by the usual sore throat: from that time, the cerebral symptoms entirely ceased. I have not seen another case like this in the whole course of my medical experience, but I know that similar cases have been observed by others. They are excep- tional and very rare. As a general rule, I repeat, the period of invasion is very short in scarlatina. The symptom which generally characterises it is fever with or without previous rigors: in the last patients you have seen in the wards, these rigors were absent. The ]pulse is quicker than in the other exanthematous fevers. This is an important fact; for in 168 SCARLATINA. studying the disease in its component parts, in speaking of scarla- tina without eruption, we find that we often form our diagnosis solely from this extreme frequency of pulse, which is very rarely met with in other affections liable to be confounded with scarlatina. Diarrhoea and vomiting often accompany the fever of invasion. The sore-throat almost always shows itself simultaneously with the fever: this is the symptom to which the patient first calls the attention of the physician, and it therefore takes a very important place in the diagnosis. The tongue has no characteristic appearance on the first day : it is febrile, that is to say coated with a some- what slimy fur, and scarcely red at the point and edges. On the veil of the palate, however, there is already perceptible a rather bright redness, and sometimes a dotted appearance. This redness is very distinct upon the tonsils, which are slightly swollen. When the type of the disease is malignant, the symptoms assume a totally different form. There is a frequency of pulse still greater than in simple cases; and sometimes in adults from the first day of the fever, even before there is any appearance of eruption, the pulse is 130, 140, 150, or even 160. Disturbance of the nervous system at the same time supervenes, in the form of great restlessness, convulsions, invincible insomnia, and delirium, or at least a mut- tering delirium when the patient is left alone. Such symptoms are very unusual in simple sore throat or pvrexise other than scarlatina. Prom its ' first day, nay even from its first hours, malignant scar- latina makes itself known in all its malignity, and this malignity may be so intense as to carry off the patients within the first twenty- four hours. I was summoned by my friend Dr. Bigelow, to see a young Ame- rican lady at a boarding-school near Paris. Prom morning, she had been in a state of frightful delirium : she had incessant vomiting, intense fever, a pulse too frequent to be counted, and an extreme dryness of skin. On seeing the patient, I was led by these symp- toms to pronounce the illness to be scarlatina; and although there was nothing else to demonstrate its existence, my diagnosis was confirmed by the presence of the characteristic scarlatinous eruption in another young girl in the same boarding-school where the disease was at that time epidemic. Our patient died before the close of the day. In 1824, the commencement of that disastrous epidemic which desolated Tours—and of which I have already spoken—I saw, SCARLATINA. along with Bretonneau, a young woman die in eleven hours with symptoms of the most terrible description—delirium, excessive agitation, and an extraordinary acceleration of pulse. There was nothing else to indicate the nature of the disease, except that we wrere then in the middle of an epidemic of scarlatina, and that several members of this young lady's family had taken the disease. Under similar circumstances, during an epidemic of scarlatina, particularly when the disease has already attacked persons in imme- diate communication with your patient, be very guarded in your diagnosis, if the case present cerebral symptoms. Be specially guarded, if such symptoms declare themselves at the beginning of the illness, as they then almost always announce that the malady is malignant scarlatina, w'hich with very few exceptions proves rapidly fatal. I must insist upon this point, as inattention to it will cause most serious errors of diagnosis, and give rise to mistakes in pro- gnosis exceedingly injurious to the reputation of the physician. People forgive us more easily for allowing our patients to die, than for having made a mistake as to the issue of an illness. The very great importance of these precepts has been emphatically proclaimed by Hippocrates in his first chapter on prognosis.1 He says :— “ To my mind he is the best physician who knows before hand what is going to happen. By penetrating into, clearly describing the present and the future of the maladies of his patients, and explain- ing symptoms which they omit to state, he will gain their confidence. Convinced of his superior intelligence, they will unhesitatingly place themselves under his direction. It is impossible to restore every patient to health, but the prediction of the succession of symp- toms will be even more highly appreciated. It is of importance to recognise the nature of similar affections, to know the extent to which they exceed the constitutional power, and likewise to discern where there is any supernatural element in the disease; for that is a point which affects the prognosis. It is in this way that the physi- cian will obtain the merited mead of admiration, and practise his profession with ability. Knowing the cases which are curable, he will be the better able to guard his patients from danger, by indicat- ing the precautions to be taken against each untoward contingency: and by foreseeing and predicting fatal and favourable issues, he will escape blame.” 1 Hippocrate :—CEuvres Completes. Trad. Littre. Paris, 1840, T. ii, p. in. 170 SCARLATINA. Such are the considerations which ought always to be present to your minds, and the full import of which you already under- stand. But to return to our subject: when, during an epidemic of scarla- tina, you meet with the formidable symptoms of which I have now spoken, give your opinions with reservations for the cases may per- haps terminate rapidly in death. Similar fatal symptoms almost never show themselves thus unexpectedly in measles or small-pox. The temperature rises to a higher point in scarlatina than in any other eruptive fever. The skin of the patient communicates to the hand a sensation of the sharpest and most pungent heat. The ther- mometer placed in the axilla sometimes rises to forty-two or forty- two and a half degrees, which is the highest temperature ever observed in disease. The fever continues moderate, and the heat inconsiderable during the prodromous stage, but about twenty-four hours prior to the eruption, the temperature rises suddenly to a high point, at which it remains during the development of the exanthem. The maximum of the eruptive process corresponds exactly with the maximum of temperature: this is the reverse of what occurs in small-pox, in which there is a diminution of temperature proportionate to the evolution of the exanthem. In scarlatina, the abatement of heat, in place of being rapid as in small-pox, is gradual, steady, without exacerbations, and is not completed till from four to eight days have elapsed. I have endeavoured to point out to you at the bed of the patient, the characters of the eruption, but I fear that I have not succeeded, notwithstanding the careful manner in which I have proceeded. Upon consulting certain books, one might suppose that it was im- possible for a physician to have any scope for hesitation in the dif- ferential diagnosis of eruptive fevers. Measles is an eruption of small, isolated, irregular spots, with blank intervals between them. Small-pox is recognised by its small acuminated papules, which on the second day become vesicular; on the third, pustular; and about the eighth, umbilicated and surrounded by an inflammatory areola. These features are so well marked, that they cannot be mistaken. As to scarlatina, we are told that its characteristics are still more precise: it is a diffused scarlet redness of the skin occurring in patches. This is all very simple, but the description is far from an accurate account of what is seen in all cases. Indeed, I have shown you cases of measles in which the eruption was diffuse and SCARLATINA. 171 uniform, without intervals of unaffected skin. Such cases are cer- tainly exceptional; but still there are such cases. On the other hand, we meet with cases of scarlatina, both distinct and confluent, with the eruption in some places in patches, or in numerous small, red, rounded points, perfectly isolated from each other, and devoid of that winy raspberry hue generally attributed to it: though dif- fering in appearance from measles, it may be mistaken for that erup- tion. The eruptions most commonly mistaken for scarlatina are those to which I have already called your attention, as pretty fre- quently occurring at the beginning of attacks of small-pox, particu- larly of modified small-pox, and to which the epithets scarlatiniform and morbilliform have been applied. •Scarlatina is distinguished, at the first appearance of the eruption, from other eruptive fevers, by the redness of the skin being often accompanied by the millet-seed rash, which is almost invariably met with when the scarlatinous rash is confluent in ever so small a degree. The miliary eruption shows itself on the sides of the neck, on the chest, and on the lower part of the abdomen : it can be detected without being seen, by passing the hand over these parts from the little inequalities communicating the sensation of what is called goose-skin. When the inequalities are examined by the eye, a multitude of small vesicles are seen, which, at the end of thirty- six or forty-eight hours, are filled with a lactescent fluid. The scarlatinous eruption itself is not really constituted by one uniform blush as in erysipelas, but by an infinite series of small red elevations of the skin resembling the vesicles of a very closely placed eczema. The elevations can be recognised by the touch, and the correctness of their description now given can be verified by using the magnifying glass. It will also be seen that the small elevations rest upon a rosy basement. The intensity of the redness of the skin is greatest on the neck, chest, abdomen, and internal aspect of the arms and thighs. When strong pressure with the finger is made on the parts occupied by the eruption, or when a pencil is drawn over the skin, as if to mark a line, the redness gives place momenta- rily to a white line across the red; on the removal of the pressure, the redness rapidly reappears. This fact did not escape the notice of our predecessors, and you will find it clearly stated by Borsieri. The eruption comes out everywhere pretty nearly at the same time, but is generally visible on the neck and chest before it shows itself on the face, The character which it presents on the face and trunk 172 SCARLATINA. is similar; it is streaky, with a bright red in some places alongside of white streaks: on the face, which is swollen, the skin seems as if it bore the marks of a smart slap with the fingers of the open hand : there is swelling of the hands and face, as well as of the face. The swelling, which shows itself with the eruption, also increases along with it, and is therefore most conspicuous about the second or third day. The tumefied condition of the hands is very obvious to the sight, impedes the movement of the fingers, and prevents the patient from closing the hand. The swelling keeps pace with the eruption, and generally disappears at the same time from the face and extremities. The swelling I am now speaking of must be very carefully distinguished from scarlatinous rheumatism, which I shall have forthwith to bring under your notice. When we look at the patient's throat, we find that it is of a bright red colour, and that the veil of the palate and tonsils are swollen ; the latter very often present small whitish concretions, the earliest manifestation of the membranous sore-throat of scarlatina. The aspect of the tongue, already described, is so essentially specific, that it is in itself sufficient to enable one to recognise the existence of scarlatina. Nothing like it is ever met with in measles or small-pox. It is as specific in scarlatina as are pustules on the mucous membrane of the mouth in small-pox. On the first day, there is only a slimy fur, more or less thick, more or less white, and which if the patient has vomited has a yellow or green colour: at the point and edges, there is only a slight redness. On the second day, the redness increases in intensity and in extent: and this change continues to proceed on the third day. About the fourth or fifth day, the saburral coating has almost or altogether disappeared: the whole tongue is then scarlet and swollen, and the papillae rise above the level of its surface in such a way as to give it a strawberry- like aspect. This appearance is produced by the tongue being denuded of its epithelium: we can sometimes see this desquamation in progress, and can even accelerate it by gentle rubbing with a bit of linen cloth. This is a constant phenomenon in scarlatina, except when there is an absence of fever; and nothing like it is met with in measles or small-pox, even when in the latter there is stomatitis. About the seventh or eighth day, the tongue, whilst it retains its red colour, becomes smoother: about the eighth or ninth day, the restoration of the epithelium commences very perceptibly, being at first exceedingly thin, then of the thickness of onion-peel and about SCARLATINA. 173 the twelfth day, it has nearly regained its normal thickness, but the mucous membrane still remains redder than natural. In studying the relation which the severity of the disease bears to the intensity of the eruption, it becomes obvious that some authors have in respect of this subject fallen into a capital error liable to lead astray those practitioners who are not familiar with scarlatina. These authors say that when the eruption is full-blown, bright, and well come out, (to use the common phrase) the patient is in less danger of serious complications. The opposite of this position is the truth. In scarlatina, as in small-pox, the more intense the erup- tion, in the same ratio, the more severe is the disease. In non- confluent scarlatina, the danger is usually less than in confluent, just as the danger is less in distinct than in confluent small-pox. In both of these exanthematous fevers, in proportion to the intensity of the eruption is the severity of the symptoms and the peril to the patient: this proposition is established by what has been seen in the course of epidemics, and you have an opportunity of verifying it for yourselves by the observation of patients in the wards. The proposition, however, is not absolute. In scarlatina, as in small- pox, if the eruption is checked by some serious antagonistic deter- mination, by profuse haemorrhage, by great disturbance of the nervous system, it comes out badly and incompletely. Scarlatina, as I said in beginning my lecture, is not always like itself; it is identical in its essence, but very dissimilar in the forms which it assumes. In some cases, after ten or twelve hours of fever, an insignificant eruption appears on the neck and trunk, and in two or three days the slight febrile excitement by which it was accom- panied disappears, the patient having scarcely experienced any discomfort. Desquamation proceeds by small stripes or patches, and sometimes in a manner hardly perceptible : in five or six days more the patient is restored to perfect health. If he avoid exposure to cold and other acts of imprudence, the whole affair is at an end. The malady has been of so simple a character, that it might have run its course unnoticed. Between the very mild and the very severe, the two forms, which I have had principally in my eye vrhen sketching the leading features of the disease, all intermediate forms are met with; and there is besides, that terrible scourge, malignant scarlatina, than which no pestilential disease is more formidable. Desquamation in scarlatina is not very well understood by the 174 SCARLATINA. majority of physicians. This morning I showed you two women, in one of whom, though at the seventy-second day, it is still going on : in the other, at the thirty-fifth, it is in full activity. The red colour of the skin generally disappears with greater or less rapidity before desquamation commences, but it begins sometimes in various parts of the body while the eruption is still visible. It begins on the neck and chest between the sixth and ninth days: it then proceeds on the limbs, then on the hands (first on the back and then on the palms), and last of all on the soles of the feet. On the w'hole body, desquamation presents special characters, but they are more distinctly marked on the hands and feet than elsewhere. On the trunk, the scales are tolerably large, often, it is true, not being more than two or three millimeters in breadth, but at other times measuring from one to two centimeters. On the arms and legs, where the epidermis is a little thicker, the desquamative plates have sometimes a size of four or five centimeters, and they can be stripped off in broad bands, as is the case after erysipelas and inflammation of the areolar tissue. Scarlatinous desquamation never assumes the furfuraceous form, as in the desquamation which follows measles. In measles, the bran- like scales are so small that unless you look at them very closely, you cannot see them, and it even often happens that this white, dry epidermic dust, resembling flour in appearance, is only observa- ble upon brushing the skin of the patient with the sleeve of the coat. In scarlatina, the desquamation of the hands and feet has too signi- ficant an appearance to be mistaken. The epidermis peels off in irregular flakes, variable in size, and sometimes very large like pieces of a glove. From the feet, where the process goes on most slowly, the detached flakes are still thicker than those which come off the hands, and in some cases the nails, which as you know are prolon- gations of the epidermis, fall from the toes. This is a rare occur- rence, but it has been observed, and one example of it is recorded by Graves. In concluding my remarks on the subject of desquamation, let me add that ’Wunderlich has observed a considerable elevation of temperature during the process. This is not what we should expect, and is the reverse of w’hat we meet with in small-pox. To me, it seems to prove, that the fever is far from being ended when the more palpable symptoms of the disease have ceased; and as the morbific action is not completely exhausted, one can to a certain extent understand the development of those formidable complications SCARLATINA. 175 which insidiously supervene during this period, and of which I shall have much to say bye-and-bye. Cerebral and Nervous Complications.—Sore Throat, Complicated xoith Diphtheria.—Buboes.—Rheumatism. The most striking as well as the most alarming phenomena in scarlatina are the nervous symptoms which are liable to occur. Their intensity is a peculiar feature in this disease, and in most cases they suffice to establish the diagnosis between it and the other exanthematous fevers. We hardly ever meet with serious cerebral disturbance in the beginning of an attack of measles or small-pox, with the exception of epileptoid convulsions, which are not very unusual at the onset of both of these diseases, particularly in chil- dren ; but as ultimately, when the eruption appears, there is not even a possibility of any confusion except between measles and scar- latina, the intensity of the nervous symptoms in the latter constitutes the capital circumstance which determines the differential diagnosis. In scarlatina, nervous symptoms set in from the very first: during the first day there is delirium. I am now speaking of what takes place in the severe forms of scarlatina, for in the mild forms, we only meet with disturbance of the nervous system in exceptional cases. In very severe scarlatina, delirium seldom fails to occur, and in the worst cases, it is as formidable as in typhoid fever of the most aggravated type: it declares itself simultaneously with the appear- ance of the exanthem, and often continues up to the period of desquamation, or, to speak more correctly, till the subsidence of the fever. There are other forms of nervous disturbance met with in scar- latina besides these which are indicated by the terms carphologia, jactitation, coma, and coma vigil. In a word, we meet with every form of typhic nervous disturbance. And in children, we also meet with epileptoid convulsions during the first two or three days of the disease, but less frequently than at the beginning of attacks of measles and small-pox, when, as I have already remarked, they are not uncommon. But convulsions in scarlatina have a much more serious import; for whilst they are considered by some authors, (among whom is Sydenham, from whom in this I dissent), when 176 SCARLATINA. occurring in small-pox as a favourable omen, and are generally looked on as having only a moderately unfavourable influence on the prognosis in the onset of measles, they always indicate con- siderable danger when they occur during the first or second day of scarlatina. They indicate still greater danger when they occur in the third stage of the disease, in connection with general oedema. I shall afterwards have to explain what they then imply, and to point out that they are almost iuvariably followed by a fatal issue. Even in adults there are examples of epileptiform phenomena. They occur about the second or third day of the disease, and principally in indi- viduals subject to true epileptic seizures. These convulsions recur, they are followed by coma, and death may close the scene within twenty-four hours from their first manifestation. Dyspnoea is another nervous complication which is important, and of sinister presage. The difficulty of breathing of which I speak is quite unconnected with any appreciable lesion of the lungs, and in this respect, as well as in the sadness of its meaning, resembles the same symptom so often met with in many septic diseases, in puer- peral typhus, in camp typhus, and in cholera. You saw a terrible example of this kind of dyspnoea in a recently delivered woman who was carried off by scarlatina with fearful rapidity, and the history of whose case I shall recall to your recollection, when we come to con- sider the subject of treatment. Besides the nervous symptoms dependent upon disturbance of the cerebral and spinal systems, there are others originating in the ganglionic system which I must now mention; and among which probably is the alarming dyspnoea I have just been speaking of. Every one is acquainted with Claude Bernard’s remarkable inquiries into the functions of the great sympathetic nerve: all know that when this nerve is divided, the parts to which its branches are dis- tributed are not paralysed, but on the contrary manifest increased functional action in augmented calorification and secretion. The scientific professor of the College of Trance has shown that on cutting on one side the branches of the sympathetic which are dis- tributed to the ear and face of the rabbit, the temperature of these parts rises to four or five degrees centigrade above the normal tem- perature, and above that of the corresponding parts of the opposite side where no section has been made. He has shown that by de- stroying the thoracic ganglia and the ganglia of the solar plexus, effects of increased vascularity are produced similar to those seen in SCARLATINA. 177 the experiments just mentioned, and causing violent inflammation: he has also shown that the secretions are greatly influenced by the ganglionic system. Applying to pathology the results of the phy- siological experiments, we come to the conclusion that when there is abnormal increase of temperature in an animal, there is more dis- turbance of the sympathetic than of the cerebro-spinal system. Now, there certainly is no disease attended by so great a general elevation of temperature as scarlatina. When the centigrade ther- mometer is placed in the axilla, or is introduced into the rectum of scarlatinous patients, it marks forty or forty-one degrees. Dr. Currie has even noted 1130 Fahrenheit, which is equivalent to forty-four and a half degrees centigrade. This increase of temperature can only be explained by a great disturbance and a very impaired power in the ganglionic system, a condition at the same time indi- cated by disorder in functions under the influence of the great sympathetic, as manifested in incessant bilious vomiting in the beginning of the disease, lasting sometimes for four, five or six days, and in intractable profuse diarrhoea which I have often seen. It is essential to bear in mind that these morbid symptoms are not of an inflammatory character. If, under the influence of the notion that the dry burning skin is a proof of the presence of in- flammation, we treat the vomiting and diarrhoea by antiphlogistics, we pursue the most pitiable and perilous course we could adopt. Of all the eruptive fevers, scarlatina is that which least demands the employment of antiphlogistics, a mode of treatment, which is also rarely beneficial in small-pox or measles. There remains another complication to be noticed, viz. hemor- rhage from the mucous surfaces, and into the sub-cutaneous cellular tissue. When there is from the beginning of the attack a haemor- rhagic tendency, death is invariably the issue; while hsematuria when observed, as it frequently is, in the course of the disease, and in conjunction with anasarca, is a much less evil omen. You have seen several patients restored to perfect health after having passed bloody urine for more than a fortnight. WTe shall afterwards return to this subject. The sore throat of scarlatina is the next topic which presents itself. It is very difficult to understand well and describe well this affection. It seems, in general, sufficiently easy to point out its simple and its serious forms; but in respect of the latter there is one 178 SCARLATINA. form, which in its turn we shall have to study, in which this facility does not exist—a form in which diphtheria probably intervenes as a complication, to contradict the anticipations of physicians, and to impart to the sore throat a character of the most alarming severity. I have already established that the sore throat is an essential part of scarlatina. It is very rarely absent, even in the mildest cases, just as it is very unusual for measles, however mild, to be unattended by pain in the larynx. Sore throat is also met with in small-pox, for three or four pustules on the pharynx are quite enough to produce it; but there is a very marked difference between variolous and scarlatinous sore throat. In scarlatina, from the first day of the attack, as I have already said, the veil of the palate has a red hue, analogous to, but deeper than, that of the skin : the tonsils are swollen, and of a purple colour. The fever continues its course, and after from two to four days, there often appear 011 one and sometimes on both tonsils small whitish concretions, generally of a milky whiteness, unless the patient has vomited, when they may be stained by the ejecta from the stomach. In minutely examining them, and raising them up with the handle of a spoon, we find that they differ from diphtheritic false membranes. The latter are generally yellowish white, adherent to the tonsils, and when seized with the forceps generally peel off in strips : the concretions are pultaceous, less adherent to the tonsil which they cover, devoid of the character of false membrane, and much more resemble the secretions which form on the surface of ill- conditioned ulcers. In point of fact, they are nothing more than a compound of epidermis and sebaceous matter produced by the tonsil, and not at all a pseudo-membranous secretion. Dr. Peter, indeed, has shown that the characteristic feature of pultaceous sore throat is an exaggerated production of epithelium, which by desquamating rapidly gives rise to the fibrinous-looking deposits. It is an affection, therefore, which has no relation to diphtheria.1 As the progress of the affection advances, its intensity may become so formidable as to embarrass both respiration and deglutition, but especially the latter. The drinks which the patient takes are returned by the nose, and the voice becomes nasal. The cervical glands, particularly those at the angle of the jaw, are swollen. 1 Peter (Michel):—Article “Angines” in the Dictionnaire Encjclope- dique des Sciences Medicales, T. iv, p. 707. SCARLATINA. 179 Without any medical intervention, or under very slight treatment, this kind of sore throat begins to abate in severity as the disappear- ance of the cutaneous scarlet eruption commences. The tonsils throw off the concretions, which leave behind them a red and some- times excoriated surface; and the affection is cured. The throat and tongue, however, remain susceptible, and this increased sensi- bility is more persistent in the former than in the latter. This condition ultimately ceases after a sort of desquamation analogous to that which we see take place on the tongue. Such is the common, and simplest, form of the sore throat of scarlatina. I have already told you that there are other more serious forms; and one of them, to which I have already referred, is according to my experience almost invariably fatal. To that form of sore throat I must in a very special manner direct your attention. Some indi- viduals have scarlatina in a medium degree of severity: there is a little dilirium at night, and scarcely any other nervous symptoms: the pulse is rapid: the pain in the throat is moderate. On the eighth or ninth day of the attack, recovery seems a certainty: the fever has subsided, the eruption has disappeared, and the family has ceased to be anxious. In this propitious state of the case, swelling suddenly appears at the angles of the jaws, which not only takes possession of that situation, but extends to the neck and sometimes to part of the face: a sanious fetid fluid flows profusely from the nasal fossse: the tonsils become very large : the breath exhales an intolerable smell: the pulse becomes small and suddenly regains its rapidity : the delirium reappears, and other nervous symptoms occur. Then, the delirium continuing, coma supervenes: at the same time, the skin becomes cold, the pulse acquires a more and more miserable character, and after three or four days of this state, the patient dies, sometimes sinking slowly, and at other times being carried off suddenly as if in a faint. How are we to explain what has taken place ? Has diphtheria supervened to complicate the scarlatina, and divert it from its proper course ? The symptoms bear so strong a resemblance to the terrible forms of that frightful disease which carry off both adults and children before the affection has extended to the larynx, the false membranes still remaining localised in the nasal fossse, ears, and throat—the symptoms so much resemble the rapidly fatal forms of diphtheria, that one is induced to believe that the case is no longer one of scarlatina, but that the other dreadful scourge has 180 SCARLATINA. come to destroy the patient. I am the more disposed to adopt this view, as under certain circumstances the larynx is invaded. Graves cites cases of persons dying of croup at the end of an attack of scarlatina, and also of persons recovering from the exanthematous fever after having discharged false membranes of tubular shape, moulded in the trachea. In mentioning these cases, Graves calls me to account for having mistaken this form of scarlatinous sore throat: and in proof of my having committed a mistake, he quotes my expression—“ Scarlatina does not like the larynx.” Daring my period of service at the Children's Hospital, I so often found such an extraordinary identity between the sore throat of malignant scar- latina and the sore throat of malignant diphtheria, that I became shaken in my opinion. At present, I cannot prevent myself from believing, though I dare not affirm it as a fact, that the symptoms now under consideration depend upon a complication with a for- midable form of diphtheria occurring at the close of the attack of scarlatina. The patients certainly sink with all the symptoms of diphtheritic poisoning, such as a lowering of the general temperature, a small pulse, a fetor of the breath exhaling from mouth and nose, and a general paleness of the skin, a combination of symptoms not met with in any other serious disease. We can suppose, then, that in persons placed under certain conditions, as for example in a centre of epidemic diphtheritic influence, such as is, one may say, always dominant in hospitals for children, the scarlatinous sore throat may become the starting-point of a diphtheritic attack, exactly in the same way that a small excoriation behind the ear, an ulceration of the vulva, or any other solution of continuity existing in persons in the midst of erysipelatous epidemic influences, may become the starting-point of erysipelatous manifestations. A circumstance which tends to support me in looking at the facts from this point of view is this—that I can only recollect one case of recovery from sore throat supervening suddenly at the ninth or tenth day of an attack of scarlet fever. The patient who made this recovery was the daughter of my honourable friend Dr. Caffe. Now, in true scarlati- nous sore throat, even of a serious character, beginning with the exanthematous fever, and reaching its maximum intensity on or between the fifth and eighth days of the disease, recovery is the rule, and generally takes place without the assistance of art. When we come to consider the treatment of scarlatina, I will speak of the treatment of scarlatinous sore throat: in the mean time, SCARLATINA. 181 I will only remark that membranous scarlatinous sore throat runs a very different course from diphtheritic sore throat. Observe, I am not now alluding to the malignant scarlatinous sore throat, to which I directed your attention, but to the simple form of the affection, which, as I have already said, is almost always accompanied by pul- taceous concretions. The diphtheritic affection has a tendency to spread to the nose and larynx, but the scarlatinous sore throat generally remains confined to the pharynx, and notwithstanding Dr. Graves's condemnation of the proposition, I still maintain, that scarlatina has no liking for the larynx. True scarlatinous sore throat, then, is pharyngeal, differing in this respect from the sore throat of measles, which is laryngeal, and from that of small-pox, which is both pharyngeal and laryngeal. The voice of scarlatinous patients, when affected, is snuffling, but its tone is sonorous: the voice does not undergo the modifications to which it is subjected in the other form of sore throat, when traversing the throat, nose, and mouth. In measles, it often happens, that the tone of the voice, very much altered during its formation in the larynx, undergoes no farther change in traversing the back part of the throat. In describing the eruption, I noted that the swelling by which it is accompanied impedes the movements of the fingers and toes; but a congested state of the integuments is not the sole cause of the complaints which the patients make of this description of embarrass- ment : it may also be dependent upon rheumatism, another com- plication of the acute stage of scarlet fever. Scarlatinous rheuma- tism is, at least in adults, a very common epiphenomenon, and we have at present two patients suffering from it. The nature of the affection is often mistaken from the absence of the general symptoms of ordinary rheumatism, and from the rheumatic manifestation being confined, in the majority of cases, to three or four joints, particularly to those of the hand and -wrist. The patients complain of very little else, and unless attention is directed to this particular condition, its existence may remain unnoticed. By minute inter- rogation, by carefully examining and applying a certain degree of pressure to the joints, articular pains are found to be present in perhaps a third of the cases. It is important to know this; for acute affections of the joints, general arthritis, pericarditis, and en- docarditis frequently occur during the course of the disease. Graves has called attention to these complications. I have observed them. Thev seem to be of the nature of rheumatism. St. Vitus's dance is 182 SCARLATINA. sometimes, in children, a consequence of scarlatinous rheumatism, I shall return to that subject. Engorgements of the glands, true scarlatinous luloes occur some- times towards the close of an attack of scarlatina, about the decline of the eruption. They are met writh in different situations, but chiefly in the neck. All pestilential diseases are accompanied by buboes. Eor example, dothienteritis has its mesenteric buboes : for, as you are aware, about the ninth or tenth day of that disease, the mesenteric glands may become so enormously large as to equal in size the egg of a pigeon. Scarlatina which is likewise a pestilential disease has also its buboes. The cervical region is their principal seat, and their evolution is contingent upon the lesions of the throat. Erom the very beginning of the disease, swelling of the glands is observable in both sides of the neck and at the angles of the jaw. Sometimes the cervical glands suddenly become the seat of inflammation, about the tenth or twelfth day, independent of the effects of the severe form of sore throat of which I have spoken. The skin becomes red and tense, and in four, five, or six days, there is formed an abscess of greater or less size, from which, if opened, pus issues. The cellular tissue surrounding the glands is in some cases sphacelated. I recollect a lad of fourteen years of age, in whom the gangrenous condition was so extensive that the muscles of the neck were dissected, as occurs in diffuse phlegmonous inflam- mations, showing the carotids pulsating at the bottom of a horrible wound. The patient recovered, but a hideous deformity remained as a consequence of the gangrenous destruction of tissue. A similar case is described by Graves. Analogous lesions may occur in parts of the body where there are no glands, or at least where they do not seem to have been the starting-point of the mischief. In the lad whose case I have just detailed, besides the great abscess in the neck, a diffuse phlegmon appeared in the leg, on the tenth day of the attack of scarlatina: it caused considerable shortening of the tendon, and left such an amount of permanent lameness as was sufficient to exempt him from military service, when he was drawn in the conscription six or seven years afterwards. Scarlatina may cause, not only glandular engorgements, acute buboes, and diffuse phlegmonous inflammation of the cellular tissue during the active period of the disease, but likewise chronic en- gorgement of the glands. In children untainted with scrofula, we 183 SCARLATINA. meet with chronic glandular engorgements dating from the beginning of the attack of scarlatina, and continuing two, three, or four months after recovery. In persons of strumous diathesis these en- gorgements become king’s evil [ecrouelles~\, and in them the inflam- mation of the glands often terminates in scrofulous ulceration. Complications occurring during the Decline of the Disease.— Anasarca.—Hcematuria.—Albuminuria.—Convulsions.—(Edema of the Glottis. — Pleurisy. — Pericarditis. — Endocarditis. — Rheumatism.—Scarlatina Without Eruption.—Anasarca Without Eruption.—Treatment. We have still to study, on the one hand, the complications which supervene during the period of the decline of scarlet fever; and on the other, to consider the disease in its rudimentary forms, by which term I am far from meaning its simple forms, but the forms which it assumes when its usual characteristics are absent, when it is, as in many cases, so disfigured that we cannot recognise it except by the exercise of an exceedingly minute attention. This is undoubtedly the most important part of the history of scarlatina—less important, however, from a nosological than from a practical point of view. The complications of the period of decline may be divided into two groups; first, the immediate ; and second, the mediate, or those which occur much later than the immediate. In the decline of the disease, we may still meet with nervous complications. An individual recovers from scarlatina: he is con- valescent, and you have ceased to be anxious about him, when fits of vomiting suddenly occur, like those which ushered in the original seizure : the vomiting is accompanied by delirium, alarming restless- ness, and great frequency of pulse, the patient ere long dying comatose or in convulsions. Nevertheless, there is an absence of anasarca, albuminuria, limmaturia, and of everything which could lead one to anticipate the symptoms just enumerated. Complica- tions of this kind are met with in adults as well as in children. Occurring during the wane of the disease, they have a much more unfavourable meaning than when they appear in the first stage, though they are then of very serious import. I cannot, therefore, too often repeat, that we ought not to look upon patients as reco- vered from scarlatina till long after the cessation of the last of the morbid phenomena. There is no other disease which so greatly 184 SCARLATINA. foils the physician, and so completely throws him out in his calcu- lations. The fever is at an end, and there is nothing wrong to be seen except some symptoms which in appearance are very slight. You state that recovery has taken place; but nevertheless the malady may remain unconquered, and may carry off the patient with great rapidity at a time when there no longer seemed anything to fear. Anasarca is one of the immediate phenomena of the wane of the disease which ought most particularly to engage our attention. It is met with in cases of medium severity, rather than in those of the most serious forms of scarlatina. It not only occurs in conva- lescent patients who have been exposed to cold, who have committed some imprudence, such as an error in diet, but even in those who have been constantly surrounded with every possible care, and watched with unremitting solicitude. MM. Barthez and Billiet have noted that this symptom was present in one fifth of their cases. It never appears till fifteen or twenty days after the erup- tion, and I have seen it supervene a month after the eruption was entirely gone. Anasarca generally sets in suddenly. It invades the face, and every part of the body. It sometimes happens that a child whom, at our evening visit, we left lean and wretched looking, appears quite plump on the morrow, in consequence of turgescence caused by infiltration of the subcutaneous cellular tissue. This turgescence sometimes attains its maximum in twenty-four hours: it is generally universal, and much greater in degree than when the anasarca is dependent on organic affections of the heart, or on Bright’s disease. But there are cases in which it shows very little, and is limited to the face and extremities. The anasarca is asso- ciated with a remarkable paleness of the skin, and is almost always preceded or accompanied by hsematuria. Hcematuria is in point of fact a rather common occurrence in scarlatina, although it frequently escapes observation. If the blood passed is pure, or only slightly altered by admixture with the acids of the urine, which has then a black colour, the sanguineous cha- racter of the urine is recognised and pointed out by the persons in attendance on the patient; hut it is not observed when, from the quantity of blood being less, the urine is rose coloured. The tint of bloody urine may he as greenish as whey, which has a tint essentially different from urine in Bright’s disease, ns well as from every other description of urine. During the first few days, the hmmaturia may be so great as to enable one to see blood at the SCARLATINA. 185 bottom of the urinal, and on pouring the urine into a test-tube, there will be perceived a precipitate of blood-globules occupying one or two centimeters. The liquid resembles a strong solution of rhatany. As the affection progresses, the urine assumes the colour indicated by this comparison, but the presence of blood can still be ascertained by finding altered blood-globules adhering to the sides of the test-tube, as well as by an enormous quantity of albumen being contained in the urine. When the urine is heated, and treated writh nitric acid, we do not obtain a white albumen as in Bright’s disease, but an albumen which is either of a brownish hue, or slightly stained in colour like that which wre meet with in acute albuminuria. Albuminuria—this acute albuminuria, generally transient, and in the majority of cases disappearing at the end of a fortnight or three weeks, sometimes even more rapidly, may pass into a chronic state, and become real Bright’s disease. The acute symptoms have dis- appeared, and the economy seems to have returned to its normal state; but notwithstanding, on examining the urine from time to time, we find that it always contains albumen. When it is per- sistent in the urine for a month or six weeks, the symptom is very unfavourable. It shows that the kidney has begun to be infiltrated with fibro-plastic deposit, and that, sooner or later, the patient will sink under the progress of the new7 complication. Anasarca, like the transient albuminuria which it accompanies, and to wrhich it is related, is generally, but particularly by children, quickly got rid of with the aid of simple hygienical measures. But it sometimes happens that in spite of every care, this complication, particularly when it has come on very rapidly, carries off patients by producing effects variable in their nature, and which it behoves us to understand. When anasarcous scarlatinous patients complain of sudden and violent headache, accompanied by disordered vision, convulsions are to be dreaded. It is necessary that you bear in mind this fact, both that you may inform the families of your patients of what may happen, and that you may use means to prevent the convulsions, which is sometimes possible. The measures occasionally employed with success consist in keeping the head in an elevated position, placing the patient so that his legs hang over the bed, and purging him somewhat briskly. But in the majority of cases, do what you will, the convulsions supervene, and often prove at once fatal. In 186 SCARLATINA. other cases, they recur at intervals of an hour and a half, of an hour, of half an hour, and then they become almost continuous, one fit beginning before the previous one is quite terminated, till at last the patient dies in a state of coma. It sometimes happens that the anasarca gets possession of deep- seated parts. I have seen it seize the veil of the palate, the uvula, the epiglottis, and the aryteno-epiglottidean ligaments. In the child in whom we witnessed these lesions, symptoms of oedema of the glottis immediately set in; and it was only by an energetic caute- rization of the upper part of the larynx that life was saved. My colleague, Professor Eichet, mentioned to me his having been called to a child affected with this description of consecutive oedema of the glottis, in whom he was obliged to have recourse to tracheotomy to prevent impending death. Por persons to be carried off in scarla- tinous anarsaca by this affection of the respiratory passage is not uncommon: suffocation takes place all the more readily, that the throat having been previously in an inflamed condition, an extension takes place of the inflammation to the aryteno-epiglottidean liga- ments, where it becomes the head-quarters of an cedematous turges- cence; and also the more readily, that tumefaction of the pharynx complicates the swelling of the upper orifice of the larynx. I have now to speak of some other affections which occur in the wane of scarlatina; which, though they begin to be better known than formerly, are still much less familiar to practitioners than the complications I have already described. I allude to malignant pleurisy, pericarditis, and rheumatism. The latter I have already referred to. In treating of eruptive fevers, it is usual to say that there is a peculiar tendency to thoracic affections in measles: the statement is correct, for measles attack the bronchial tubes first, and in preference to all other parts: it there declares its presence before anything can be seen on the skin, just as scarlatina makes its exist- ence known by the sore throat prior to the appearance of the cuta- neous eruption. The first symptom of morbillous fever is pulmonary catarrh, and hence it is easy to understand how this affection when more than ordinarily severe should pretty frequently give rise to inflammation of the lungs. Thus it happens that when the fever continues on the seventh or eighth day of an attack of measles, it is almost a certainty that the patient has either acute catarrh, pneu- monia, or perhaps pleurisy. But authors are unanimous in stating that scarlatina has no tendency to attack the thoracic organs. In SCARLATINA. 187 truth, these organs are not assailed during the acute period of the disease; but they enjoy no such immunity when it is on the wane. It is not uncommon after scarlatina, both in those vTho are, and in those who are not affected with anasarca, to meet with the sudden occurrence of chest symptoms; but it is not, as in measles, the lungs which suffer, but the serous membranes—the pleurae and the pericardium. Pleurisy occurring as a complication of scarlatina is generally of a bad kind, not only in respect of the rapidity with which effusion takes place, but also in respect of the quality of the effused fluid. About the eighth or tenth day of the pleurisy, the effusion is often of a purulent character, as in puerperal pleurisy. This production of pus depends upon the fact, which we cannot explain, that there exists a condition of general contamination, in virtue of which scar- latinous inflammations have an extreme tendency to suppuration. At the Children’s Hospital, I had occasion to perform paracentesis of the chest in a scarlatinous child who, so early as the twelfth day, had pus in the pleura. In another little patient, I performed the same operation at the twelfth day of the pleurisy, and withdrew seven hundred and fifty grammes of perfectly formed pus.1 This child had become anasarcous without having had the eruption, but there could be no doubt as to the nature of the disease, as scarla- tina was prevailing in the household. I shall have to say more regarding this case immediately. In scarlatinous pericarditis, the tendency to suppuration is not so strong as in scarlatinous pleurisy. Scarlatinous pericarditis is also less frequent, and comes on more gradually. The relation which exists between inflammation of the pericardium and scarlatina was pointed out by Graves, and has been established in a very remarkable manner, especially by Dr. Thore, jun. He has shown that in a certain number of patients convalescent from scarlatina, some died from acute hydro-pericarditis, and others recovered after having had the same affection.2 1 Perfectly formed pus weighing 750 Prench grammes, may be estimated as measuring rather less than 1J British imperial pints.—Farther particulars of this case will be found at p. 191.—Translator. 2 Thore, fils :—De l’Hydropericardite Aigue Consecutive a. la Scarlatine, et de son Traitement. Archives Gene rales de Medecine, fev. 1856, 5me serie, T. xii, p. 174- 188 SCARLATINA. Articular rheumatism, as I have already said, is an exceedingly common complication of scarlatina. We have seen it in the acute stage of the disease, and have met with it in adults in a proportion of cases greater than that in which it is generally believed to occur. We have also encountered it during the wane of the disease. The same occurrence was pointed out by Graves.1 “ In a great number of cases/-’ he writes, “ I have met with articular rheumatism as a sequel of scarlatina."” Similar statements have been made by other reliable observers, among whom may be mentioned Drs. Pidoux, Murray and Yalleix. The coincidence of rheumatism with scarla- tina was nevertheless a generally forgotten fact, and consequently for several years past I have been constantly insisting upon it in my lectures. It is a singular eccentricity of scarlatinous rheumatism that it rarely assumes a formidable character : it is more localised, but less liable to return than ordinary rheumatism; when it has once left a joint, it seldom comes back to it: generally, it goes away quickly and spontaneously, without requiring any treatment. The manifestation of the rheumatic diathesis in scarlatina gives, however, up to a certain point, an explanation of the development of pleurisy and pericarditis : it assists us in understanding wThy these affections are as frequent as they are, and why it happens that endo- carditis occurs as you yourselves have seen and as authors have stated. Generally speaking, in the first instance, scarlatinous rheumatism attacks the joints, and then the serous membranes of the heart and the pleurae, but sometimes, like pure rheumatism, it seizes the thoracic organs at the first brunt, without touching the articu- lations. Sometimes also, it takes the terrible and pitilessly fatal suppurative form. In point of fact, it is as a sequel of scarlatina and puerperal fever that we see suppurative rheumatism. Por the first few days, the affection appears to be mild, then the articulations become painful, intense fever sets in, delirium supervenes, ataxo- adynamic phenomena appear, and death closes the scene. On dis- section; pus is found in the articular cavities and in the sheaths of the tendons. Such are the complications of the wane of scarlatina which belong to the group we named immediate ; the mediate complications'come on at a much later period, and are linked with—are sequelae of— those of the first group. 1 Graves :—Lepons de Clinique Medicale. 189 St. / 7tils’s clance is the most important of the mediate sequelae of scarlatina. In children, you will see this affection following very dose upon the exanthematous fever, showing itself in three months, two months, or even in six weeks. The remarkable researches of Dr. Germain See have thrown light upon the relations which exist between rheumatism and chorea.1 His researches and later observa- tions, including my own, justify us in stating, that it is unusual for children to escape St. Yitus’s dance, who have had attacks of acute articular rheumatism; and to this statement may be added, as a sort of corollary to it, though requiring to be received less absolutely, that a child who has had St. Yitus’s dance generally has rheumatism sooner or later. In chorea consecutive to scarlatina, the bel- lows-sound indicates the existence of cardiac lesions, the result of pre-existing endocarditis. And sometimes, the rubbing peri- cardiac sound, the last characteristic manifestation of scarlatinous rheumatism, points out to us that it is by the rheumatism that the convulsive neurosis is linked with the attack of scarlatina, and con- stitutes one of its mediate sequelse. SCARLATINA. You have often seen suppuration supervene in different parts of the body after exanthematous diseases : you have especially seen the boils, the superficial and deep abscesses which indefinitely prolong the convalescence of confluent small-pox, and endanger the life of the patient. You recollect a case which we recently lost, in St. Agnes’s ward, from exhaustion caused by these colliquative suppurations. After scarlatina, some of the mucous membranes, particularly those of the nose and ear, remain for months or even for years affected with chronic eczema. Some of you may very recently, and not without surprise, have seen me make a retrospective diagnosis of scarlatina from having before me eczematous coryza. The patient to whom I refer was a wroman who came into hospital for a condi- tion of general discomfort, characterised by excessive debility and absence of fever. She was affected with eczematous nasal catarrh. I observed that she also had on the elbows excoriations covered with crusts of comparatively recent date. I attributed the excoria- tions to violent rubbing, the rubbing to delirium, and the delirium to a fever. I further concluded that the fever was probably scar- 1 Gekmain See Memoires de l’Academie de Medecine. Paris, 1850, T. xv, p. 373. 190 SCARLATINA. latina, as that fever frequently produces delirium, and brings coryza in its train. In reply to my interrogations, the woman said that a month previously she had had scarlatina, which had been accom- panied by delirium, and followed by general debility. My diagnosis was not the result of inspiration, but was a logical deduction from an association of ideas and a bringing together of phenomena. The lesion of the mucous membrane sometimes extends to the deeper parts, caries and necrosis of the bone taking place. Other conse- quences may also result, such as lachrymal fistula, perforation of the tympanum and loss of the small bones of the ear, caries of the petrous portion of the temporal bone leading to incurable deafness, facial paralysis, and, unfortunately in not a few cases, to inflamma- tion of the meninges, and abscesses of the brain at points con- tiguous to the affected bone. These terrible occurrences sometimes follow measles, but not so frequently as they succeed scarlatina. We have now come to that part of our subject which is the most difficult, and which is likewise, from a practical point of view, the most important. I refer to disguised scarlatina, to which I have given the name of defaced scarlatina [scarlatinefruste\. You know what an antiquary means by a defaced inscription; it is an inscription the greater part of which is obliterated, and of which there may remain only a line, a letter, or a point. Diseases, too, are defaced; or in other words they present nothing for the physi- cian to read but a single word of the symptomatological phrase, and with this one word he has to reconstruct the entire phrase, just as the archaeologist or the numismatist has to restore the effaced in- scription by filling up the blanks in the remaining letters. De- ciphering is a department with which the physician and the antiquary have to become acquainted by the use of very similar means : the antiquary must begin by learning to read what is written on well-preserved medals and unmutilated stones; and at the beginning of his studies, the student of medicine requires to recognise in a disease the aggregate of its characteristic symptoms, but by-and-bye, as the skilled antiquary deciphers a lost inscription by a remaining word or letter, so the student becomes a skilled physician, and will divine the whole nature of a disease from a single sign. Of all diseases, gentlemen, scarlatina is that which is most frequently defaced [fmste\. A case in point will be more useful than an elaborate description. In 1829, a friend wrote to inform me that scarlatina was prevalent 191 SCARLATINA. in a little village near Mennecy in the department of Seine-et-Oise, and that it was most severe in the communes of Villeroy Castle. I was particularly pleased to go to study this epidemic, as in consequence of the castle being perfectly isolated from the village, I could easily follow all the movements of the disease. I saw members of the same family who after having had sore throat without eruption, were afterwards proof against scarlatina, though surrounded by cases of various degrees of severity. Their sore throat had been of a very aggravated form, and accompanied by ardent fever: the redness of the pharynx was very characteristic, and the consecutive stripping of the tongue left no room for doubt as to the nature of the affec- tion. I saw other patients who had the original disease apparently very slightly, as they had only drooped a little for eight or ten days, but who nevertheless afterwards became swollen, and passed blood with the urine. At that date, we were not acquainted with albumi- nuria. I was struck by the facts I have now stated; and I came to the conclusion that the persons who had only had eruption and consecutive anasarca, those who had only had anasarca, and those who had only had sore throat had all had scarlatina, the affections seen in all of them being manifestations of that disease. At Meaux, in 1854, along with my accomplished friend Dr. Blache, I observed similar occurrences. A young girl fourteen years of age took violent scarlatina, characterised by atheromatous sore throat, intense fever and the specific eruption. Some days later, her sister, living in the same house, was seized with similar symptoms: almost at the same time, a lady’s-maid sickened: two or three days afterwards, a valet, who had remained the whole day in the apartment with the invalids, became affected with violent sore throat accompanied by a deposit of pulpy matter on the tonsils, a red and subsequently peeled tongue, burning fever, but no eruption. It was evident to me that the family physician, Dr. Saint-Amand, was right in believing that all had had scarlatina: that the valet, being in the midst of the epidemic influence, had taken the fever like the other members of the family, but in a different form: in him, the inscription “ scarlatina” was defaced, whereas in the other cases, it was complete. Another member of this household, a boy of six years of age, all at once, and without having had a moment’s previous illness, became swollen. Dr. Blache and I were then called in in consultation. AVe considered the case to be one of scarlatinous anasarca coming on at the first brunt of the attack of scarlatina. 192 SCARLATINA. The anasarca was considerable, and accompanied by hmmaturia. The father and mother, persons very watchful over the health of their son, assured us that on the morning of the very day on which the boy became ill, he had taken his breakfast as usual: and the master of the boarding-school where he attended stated that he had played in his customary manner. In this case then, there was neither fever nor eruption, and scarlatina was detected solely by the individual symptom for which we were called in. Eight days later the boy had a double pleurisy : death was supposed to be impending, when Dr. Blache and I were again called in. We detected effusion in both pleurae: four days later, we found that one side of the chest was restored to its natural state, and that the other was enormously distended. We proposed, and forthwith performed, paracentesis, withdrawing 750 grammes of pus. For two or three months Dr. Saint-Amand injected iodinous solutions into the pleurae. Although the lung was perforated during the treatment, the child recovered, and at present enjoys most excellent health. I have not met with another similar case. But as regards examples of defaced scarlatina, you will find them scattered in the works of authors. Graves has in particular mentioned several, some of which I will now quote from his clinical lectures. E— was taken home from a school, where scarlatina was pre- vailing : he complained of pain in the throat on swallowing, slight headache, and nausea. Next day, the tonsils were swollen, and there was increased difficulty in swallowing: the pulse was sharp, and the skin was hot, but there was no trace of eruption. These symptoms, without increasing in severity, continued for three days, and then disappeared. Before this boy had completely recovered, his father and two sisters took scarlatina. In the two sisters, the eruption appeared, and terminated in desquamation. In the father, there were only a few small red points on the skin, and no subse- quent desquamation occurred. O— likewise came home from school with scarlatina. During his attack his two sisters and brother took the disease. I11 the three it showed itself in the form of an eruption of small spots on the skin. At the same time, and in the same house, a valet and a lady's-maid were seized with very violent sore throat and high fever, which continued for some days : in neither case was there any eruption. These cases of Dr. Graves are identical with others, which I have 193 SCARLATINA. met with. In the following very curious narrative relating to a physician's family, we see scarlatina showing itself only by anasarca at the onset of the illness, just as occurred in the lad whose case I described to you a few minutes ago. The facts were communicated to Dr. Graves by an eminent practitioner of Dublin. Some years ago, scarlatina broke out in this practitioner's family. It attacked all his children with the exception of one young lady, vrho had no symptoms whatever of the disease, although she waited on her sisters during their illnesses. All was going on well, and the family wras sent to the country for change of air : the sister who had not been ill vrent with the others. In the country, to the great surprise of all, this young lady wTas suddenly seized with that special form of anasarca observed in those who have had scarlatina. Her father, v7ho attended her during her illness, wras exceedingly struck with the occurrence : he observed the case with very special attention, and came to the conclusion that it was one of latent scarlatina. Dr. Graves, in speaking of these cases, remarks that they are very interesting in a pathological point of view, as tending to prove that diseases originating in contagion very often do not exhibit their ordi- nary series of characteristic symptoms. The quotations now made from the Irish author show that similar phenomena occur under the Dublin and under the Parisian sky. You will assuredly meet with these cases of defaced scarlatina; and you will do well to accustom yourselves to recognise them. Graves maintains that they can only be cases of scarlatina, because the disease being essentially contagious, it is impossible for the persons who have only had sore throat or anasarca to be in the midst of their scarlatina-stricken families, and yet be the only ones who have been exempt from attack. In December, i860, I saw with my friend Dr. Leon Gros, a young man of fifteen whose case furnishes us with a new example of defaced scarlatina—a case in which the diagnosis would have been impossible without assistance from accessory circumstances. This youth came home from college with a little fever and an insignificant sore throat. The illness was so slight that Dr. Gros did nothing; and after twro days of trifling indisposition the patient was quite well. A few days afterwards, his younger sister took scarlatina; and during her convalescence, the brother was seized with hsema- turia which continued more than a month. I never entertained the 194 least doubt that this young man had communicated scarlatina to his sister, and that his hsematuria was the sequel of his slight febrile attack. Dr. Gros did not feel quite sure as to the accuracy of this view. The young man did not contract scarlatina after his sister, and must have had it before her, if he can be said to have had it at all. In this case, albuminuria continued for nearly a year; and it required the most assiduous and skilful treatment on the part of Dr. Gros to prevent the patient becoming a victim to an exanthe- matous fever which had begun so mildly as to make its very existence a matter of doubt. SCARLATINA. Eruptive diseases have a fatal tendency in this sense, that they have determinate characteristics against which we cannot prevail. This remark is equally applicable to diseases in which the eruption shows itself on the skin, and to those in which it comes out on the mucous surface of the intestine, as in dothienteritis or putrid fever, which is an eruptive affection of the alimentary canal. In treating these diseases, the physician must not lose sight of the great prac- tical fact that it is impossible to stop the progress of a putrid fever, and equally impossible to cut short an attack of small-pox or measles. It is possible by injudicious treatment, at great peril to the patient, to retard, and in some degree to modify the appearance of the eruption, but the evolution of an exanthematous fever cannot be prevented. Treatment ought therefore to be restricted to the alleviation of the symptoms and complications which arise during its course. The physician ought in this class of diseases more than in any other, to be the servant and interpreter of nature—minuter naturae et inter pres—for, to continue the quotation,—quidquid meditetur etfaciat, si naturae non op temper at, naturae non imperat: he ought to remain passive when things take their regular course. If no untoward symptoms occur, there is nothing for him to do but to fold his arms, for at the end of a few days the malady will have safely run through all its stages. Even when eruptive fevers assume some threatening symptoms, our interference, it must be confessed, proves of very little use. The auspicious circumstances in which the interference of art proves beneficial occur more frequently in scarlatina, than in measles, small-pox, or putrid fever. I now propose to point out to you the good which the physician can do in scarlatina. It is of the utmost importance that he have always present in his mind the fact, that this disease differs much SCARLATINA. 195 from itself both in symptoms and severity : he must always re- member that it is sometimes exceedingly mild, and at other times as terribly malignant as typhus or plague: in a word, he must bear in mind the type of the prevailing epidemic. It behoves him not to set down to the account of successful treatment results entirely attributable to the mild character of the epidemic, and equally to avoid throwing the blame of unfortunate issues upon the treatment, when they are really dependent upon the inherent malignity of the cases. Epidemics of scarlatina may be of a formidable type in respect of an entire population, or in respect of a single family. The malignity may, so to speak, remain confined to one small circum- scribed centre, within which nearly all who are attacked will have the disease in a malignant form. As a case in point, I may refer to a melancholy statement lately made public in an English newspaper, to the effect that a clergyman of the city of York lost, by scarlatina, in one week, his six or seven children. It seems as if the scarlatinous poison with which such unfortu- nates are infected has a special energy, and that the constitutions of every one of them is specially disposed to receive it. Whether the malignity is dependent upon the nature of the disease itself, upon the constitution of the epidemic, as Sydenham and others allege, or whether upon the idiosyncrasies of individuals, as Stoll believes, there is no uncertainty as to the great fact, that wrhen scarlatina breaks out with fury in a family, killing the first person attacked, there is cause to fear that it will carry off other victims; and that, on the other hand, when its first assault upon a family is moderate, when the first cases are mild, there is reason to hope that all the subsequent cases will likewise be mild. It wras necessary to say what I have now said before entering upon the subject of treatment, so that you might be put on your guard against yourselves. I cannot too often repeat that the best treatment will fail when the type of the disease is essentially bad, and that when it is mild, recovery will be the rule, even when inappropriate or injurious measures have been employed. There is a general agreement among all epidemiologists that injury is done by pursuing such antiphlogistic measures as local or general bleeding, too active purging, and very low diet. Most authors who have seen, studied, and recorded several successive epidemics point out the danger of this kind of treatment in severe 196 cases of scarlatina, even when acute inflammatory affections have supervened, such as phlegmon of the tonsils, lymphatic glands, or cellular tissue. Bleedings and the application of leeches generally produce a bad effect, probably because they are employed to combat the symptoms of a septic disease, a malady of a bad character— mail moris—for antiphlogistic measures almost always prove disas- trous in malignant diseases. Epidemiologists, however, while they condemn antiphlogistic treatment on account of the evil which they have seen it produce, inculcate that although energetic purgatives are injurious, mild purgatives, such as mercurials and the neutral salts, are of real service, when given in moderate doses. My own experience has demonstrated to me the truth of that doctrine. If the alimentary canal is loaded, and signs of faulty chylification exist, it is advan- tageous to open the bowels by administering a purgative suited to the age and strength of the patient. I cannot participate in Sydenham's dread of diarrhoea,"so long as it remains moderate and is dependent upon a loaded condition of the alimentary passage. I have already said that in scarlatina, particularly in the acute stage, patients are frequently carried off by nervous affections. These affections may have their starting-point in the centres of organic life, in which case they are characterised by an extraordinary eleva- tion in the temperature of the body, by vomiting and intractable diarrhoea; or they may originate in the centres of animal life, when the phenomena are delirium, coma vigil, jerking of the tendons, and convulsions. I have already insisted on the fact that vomiting and intractable diarrhoea at the onset of scarlatina are very unfavor- able symptoms, and that it is difficult to control them by medicines. It is in vain that we administer opiates and poisonous solinaceous drugs. The vomiting and diarrhoea are sometimes moderated by the use of tepid baths, and by administering ice, effervescing draughts, and small doses of calomel. They are generally aggra- vated by bloodletting. Cold affusions have been proved by experience to produce beneficial effects in these affections dependent on disturbance of the nervous system, particularly on those originating in the centres of animal life; but nevertheless, it is with trembling that the practitioner employs them. Currie was the first to formulate rules for their use. He employed cold affusions with a certain measure of success in a large number of very bad cases of scarlatina. Emboldened by SCARLATINA. SCARLATINA. 197 fortunate results, lie became still more urgent in bis recommendation of this method of treatment, and laid it down as a general rule of practice that it ought to be adopted in scarlatina when there were formidable nervous symptoms, such as delirium, convulsions, diar- rhoea, excessive vomiting, and great heat of skin. The patient being placed, naked, in an empty bath, has thrown over his body three or four pails of water at a temperature of from 20 to 25 degrees of the centigrade thermometer. The continuance of the affusion is from a quarter of a minute to one minute, which latter is the maximum duration. The patient is immediately after- wards put back to bed, without being dried, but being wrapped up in blankets and properly covered. Eeaction is generally established within fifteen or twenty minutes. The affusion is repeated once or twice in twenty-four hours, according to the severity of the symptoms. This treatment ought at once to be resorted to, when the nervous phenomena assume such intensity as to threaten imminent danger, and they ought to be repeated at proper intervals till the symptoms have so far abated as to relieve the physician from serious anxiety. This practice must be carried out in watchfulness. It is above everything essential not to require the support of public opinion to justify your instituting a method of treatment which has the appear- ance of being so audacious. You must be actuated by a profound sense of duty to venture to oppose the popular prejudice—a most disastrous prejudice—which insists upon patients with eruptive fevers being kept on hot drinks, and wrapt up in a more abundant supply of blankets than they were accustomed to when in health. I say that there is no popular prejudice more disastrous, for there is none which so often occasions the death of patients. Nevertheless, the mighty voice of Sydenham, who though dead two hundred years still speaks, and the authority of the most mature modern physicians, ceaselessly oppose it without avail. Hence the difficulties which the young physician has to encounter, -when he feels that it is his duty to have recourse to cold affusions in scarlatina. These diffi- culties are all the greater, that it is in cases which threaten to prove fatal that the treatment is indicated. When you adopt it, you know that the disease only presents you with one chance of reco- very against two of death : and you can foretell the reflections of the family in the event of your efforts not being crowned with success! I have long been in the habit of employing cold affusions. I used 198 them, however, in my private before administering them in my public practice, because I never venture for the first time upon a new mode of practice upon my hospital patients, I declare to you that I have never resorted to the employment of cold affusions with- out obtaining beneficial results. I am far from pretending that all my patients so treated have recovered: like my colleagues, I have lost the greater number, but even those who died experienced a tem- porary relief from suffering, and the affusion, so fjp from proving injurious to them, always moderated the symptoms, and also seemed always to retard the fatal termination. The adoption of this prac- tice subjected my popularity as a practitioner to great risks, and my resorting to it, from a profound conviction that it was right, has often been badly recompensed. But still, I have always firmly con- tinued in the line traced out for me by duty, and now I do not hold to it with less determination, that I am less afraid than formerly of incurring responsibility. I perfectly appreciate your alarms: not because I suppose you doubt the goodness of a mode of treat- ment which perhaps you would not dare to resort to, but because I imagine that whilst consulting, in the first instance, the interests of your clients, you will naturally desire to protect your professional reputation, so liable to be blasted at the beginning of your career. However, remember that when the voice of duty commands, when your conscience tells you that the cold affusion ought to be admi- nistered, you must not flinch from having recourse to this method of treatment because it is opposed to the prejudices of the public. But in place of fighting face to face with prejudice, in place of taking the bull by the horns—pardon me the phrase—evade the difficulty, by adopting such manipulations as will lead the patient, and still more those in attendance, to believe that the affusions are warm and not cold. I have already repeatedly said that scarlatina, especially when its form is malignant, is of all diseases that in which the temperature of the body rises to the highest point. Yery often it rises to forty-one degrees, which is three degrees above the normal standard. Yery well, then: in place of giving your patients cold affusions, give them mere lotions of water at twenty-five degrees—that is, of water fifteen degrees under the temperature of the skin in scarlatina, and therefore, relatively to it, cold. Let the patient be placed on a folding-bed:—and then, let the entire body, first the anterior and then the posterior surface, be rapidly wetted with sponges soaked in SCARLATINA. SCARLATINA. 199 this water at twenty-five degrees ; and when this has been done, let him be rolled up in blankets and put back into his own bed, follow- ing the same rules as after the cold affusion. Though these tepid lotions are less efficacious than the cold affusions, they are produc- tive of real benefit. Consequent upon their employment, the following effects are observed. The skin previously characterised by extreme aridity and stinging heat, in half an hour becomes cooler and moist. The diminution in the rapidity of the pulse is a still more remarkable phenomenon: from between 160 and 180 in chil- dren, it falls to 140 or 130; and from 140 or 150 in adults, to 120 or 115 :—there being consequently a fall ranging between 30 and 40 beats. Simultaneously with these amelioriations, the severity of the cerebral symptoms diminishes, and there is a proportionate de- crease in the profuse diarrhoea and excessive vomiting, symptoms dependent upon disturbance of the ganglionic nervous system. You thus obtain—for a very limited time I admit—a remarkable sedative effect from the tepid bathing. The benefits, I say, are not long continued, for sometimes in two or three hours the symptoms have returned. It is necessary, in point of fact, to renew the lotions or the cold affusions two, three, or four times in the twenty-four hours, and sometimes to continue to employ them for five or six consecutive days. I saw very lately, along with my excellent friend Dr. Baret, a lad of thirteen suffering from very severe scarlatina. From the third day of the attack, the nervous symptoms assumed so formidable a character that Dr. Baret contemplated the employment of cold lotions: I also believed them to be indispensable. The relations were terrified, but, with that resignation so becoming in intelligent persons who feel their absolute incompetence to judge medical ques- tions, they allowed the proposal to be carried out. Each bathing was followed by considerable amendment; and at the end of four days, when the lad was out of danger, they loudly proclaimed that he owed his life to the cold applications. Relatives are much reconciled to the use of the cold affusions and cold lotions by the circumstance, that the skin, pale before, almost always becomes much redder after they have been employed—there is more eruption seen. This method of treatment so far from effacing the eruption, increases it. This is so palpable that it is noticed by the relatives of the patient who will, so long as danger lasts, often be the first to solicit the renewed application of cold water, so evi- 200 SCARLATINA. dent to them is the amendment which has resulted from the treat- ment, and so struck are they by the material fact of a brighter red having been imparted to the eruption. It is nevertheless true that if the amendment noticed is not perfected by recovery, if death come, in the inevitable march of events, they too often forget the encouragement they gave to your proceedings. Some of you, gentlemen, recollect a case which I am now going to relate in detail. On the ioth of May, 1857, a stout, fine girl of twenty came into Professor Eostan’s wards with scarlatina in an exceedingly severe form : she had been ill for two days. My honorable colleague had the goodness to show me this patient, and to propose that she should be received into my wards. She had violent delirium and excessive restlessness; her pulse was 144 in the minute; there was great heat of skin, and scarlatinous sore throat of aggravated character. The restlessness and delirium were serious and threatening symptoms. Professor Eostan wished to have my opinion as to the treatment to be adopted : he inclined towards bloodletting; and I proposed cold affusions. The patient was received into my wards. On her admission, I had her put into an empty bath: to accomplish this, it was necessary to have the assistance of four persons, so great was her violence. I then, some- what slowly, poured over her body two ewrers, each containing about two litres of water at a temperature of about 150 centigrade [590 P.]. I at the same time watered the face and limbs: after this treatment, without being dried, she was wrapped up in a blanket and put back in her bed. Her violence was by this time sensibly calmed, the pulse had fallen ten beats, and there was less of a burning character in the heat of skin. I advised my chef de clinique, Dr. Blondeau, to see her again towards evening, and repeat the affusion, if, as I hoped, the first application had produced a change for the better. In the evening, the affusion was repeated as in the morning, the patient offering less resistance. Soon after the evening affusion, the heat of skin subsided greatly; and the pulse fell to 120 : in the morning, as already stated, the pulse was 144. The delirium ceased; she passed a quiet night; and at the visit next morning, answered my questions intelligently. The disease had resumed its normal course, disentangled from all complications. Although this patient had slight albuminuria for eight days, she left the hospital quite recovered from her attack, and in perfect health, at the beginning of July. Desquamation wras not completed till 201 SCARLATINA. near the end of June, forty-five days after the onset of the attack of scarlatina. There are two cardinal points in this case, gentlemen, to which I wish to call your attention: the first embraces the diminution of the febrile heat, the lessening of the rapidity of pulse, the cessation of delirium and restlessness; and the second is the increase of the eruption. The cold affusion, so far from driving in the eruption, brings it out more vividly. The young woman whose case I have just detailed was at the end of the third day of the attack wdien I saw her, and the eruption, therefore, was at its maximum of in- tensity : nevertheless, it became more vivid after the application of the cold water. With respect to the diminution in the frequency of the pulse, the lowering of the temperature, and the cessation of delirium—ataxic symptoms which as a rule increase in severity up to the sixth or seventh day of the disease—they did not merely remain stationary, which would have been a relative benefit, but they became more moderate, and ultimately ceased. A few days later, on the 33rd May, 1857, another opportunity was afforded in my wards for employing the same treatment; but the case was of so complicated a nature that we could not hope for similar success. The patient was a woman of 24 years of age, who ten days previously had given birth to a healthy infant, and four days after her confinement was attacked by scarlatina. There were no symptoms specially dependent on recent delivery—no signs of peritonitis or phlebitis—but the patient was not the less in a puer- peral condition when the exanthematous fever declared itself with great violence. When admitted into our wards, she was suffering from great excitement and delirium. The skin was very hot, and covered with a vivid red eruption; the tongue was dry and black; there was considerable oppression at the chest, and the pulse was 136. Without being deterred by her puerperal state, and the lochial discharge which was flowing in a normal manner, my chef de clinique, Dr. Blondeau, who saw her in the evening, had her sub- jected to the cold affusion: I approved of the treatment, which I would myself have ordered. Immediately after the affusion— during which she had a fainting fit—this unfortunate woman felt much better : the delirium subsided as if by enchantment; there was relief from the violent pains, chiefly in the loins, of which she had been complaining; and she expressed herself as grateful for this rapid relief. A few hours later, however, there was a return of the 202 SCARLATINA. nervous symptoms. She passed a very bad night, and at my visit next morning, the delirium, excitement, and oppression at the chest were extreme. The pulse which had in the evening, after the affusion, fallen from 136 to 130, had returned to its former fre- quency. The eruption continued at least as vivid as before the employment of the cold affusion. I administered a second affusion : the delirium ceased at once, and the excitement became less. The patient again experienced a feeling of improvement, similar to that which she had felt after the treatment on the previous evening, and the recollection of that feeling always present to her mind, caused her during her lucid moments to ask for the cold water. Those of you, gentlemen, who were present at the visit can testify to the beneficial effects which resulted from the treatment; the pulse again fell from 136 to 122, but the great oppression at the chest con- tinued, and could not be in any way explained by the state of the thoracic organs, auscultation presenting nothing particular. This symptom gave us serious anxiety as to the issue of the disease which was in so formidable a manner complicating the puerperal condition. I seize this opportunity of telling you how very perilous scarlatina is when associated with the puerperal state : the patients either succumb under aggravated nervous symptoms which leave no lesions appre- ciable on dissection, or from inflammations of the serous membranes —the pleurae, pericardium, or peritoneum—passing rapidly into suppuration. In 1828, Drs. Ramon, Leblanc and I were sent by M. de Mar- tignac, then Minister of the Interior, to study the epidemics and epizootise prevalent in old Sologne, that part of France which lies between the rivers Cher and Loire, extending from Blois to Gien. We saw occurring simultaneously with severe cases of scarlatina, numerous cases of membranous sore throat. Scarlatina was par- ticularly severe at Cour-Cheverny, a commune situated four miles south of Blois: and it had proved so specially fatal to puerperal women, that even the very poorest were leaving the place and going to Blois to be confined. The district physician informed us that he had lost nine cases. Now, as you know, puerperal epidemics are very rare in country places. Generally speaking, pregnant women are proof against epidemic influences, but in thirty-six cases, forty- eight hours after delivery, the scarlatinous eruption showed itself, and in a few days the patients were dead. The puerperal state, therefore, is a very serious complication of SCARLATINA. 203 scarlatina. This was seen in our patient in number 19. The disease called puerperal fever was prevailing in Paris. The Maternity Hospital had in consequence been recently closed, and I had cases of this formidable malady in my wards in the Hotel-Dieu. New- born infants were carried off by erysipelas of bad type, a manifesta- tion of puerperal fever in young subjects, and which proves fatal to them without leaving any appreciable lesions in internal organs. Our patient you see was in the most unfavorable circumstances. Oppression at the chest, when unconnected with any material affection of the respiratory passages, is an exceedingly serious symptom in a great number of septic diseases, particularly in puerperal fever, typhoid fever, and cholera, indicating a profound disturbance of in- nervation. This kind of dyspnoea, unconnected with any appreciable lesion of the lungs, pleura:, heart, pericardium, or great vessels, is one of the most unfavorable symptoms which can occur. The symptoms referable to the nervous system became more formidable, and our patient died during the day. On opening the body, our attention was chiefly directed to the lungs, heart, and membranous coverings of the encephalon. I was the more desirous to discover whether there was any lesion in these latter organs, as in the girl who was the subject of our first case, the nervous symptoms were referred to the meninges. The autopsy, which was carefully made, revealed nothing. The encephalon, attentively examined, presented no trace of lesion; and in the lungs, there was nothing found except slight congestion, such as we find in persons who have died a violent death. The heart, pericardium, and large vessels were in a perfectly healthy state. The results of the microscopic examination did not surprise me, for I had often examined the bodies of persons carried off under similar circum- stances, and had never met with any appreciable alterations in the encephalon, which, however, is not equivalent to saying that it is never the seat of any organic changes. These morbid changes are met with in connection with certain symptoms referable to the nervous system, but essentially different from the symptoms pre- sented by the patient whose organs are now under our consideration, and which organs had no trace in them of the symptoms which had occurred during life. We, therefore, had to do in this case with the delirium to which our predecessors gave the name of delirium sine materia—cerebral disturbance without appreciable lesion of the brain. We all form a SCARLATINA. strange conception of the nature of delirium. When it occurs in the course of an acute affection, we at once explain it by invoking cerebral hypersemia, and our theory, which has in it something of the leaven of the old physiology, is based on a belief in the irritation of the organ of the function which is disordered. Such was the language used in 1820, 1824, and 1825 : and at the present day, these ideas exist in a modified form. There is, it appears, therefore, a desire to attribute functional disturbance to a state of congestion leading to inflammation. The simplicity of the theory certainly makes it attractive. A man is delirious, he coughs, he vomits bile : nothing is easier than to say that he has cerebral, pulmonary, or hepatic hypersemia. But at the autopsy, the aspect of the case is changed, when the examination of organs frequently demonstrates that an erroneous opinion had been formed. The supposed hy- persemia does not in any way reveal its past existence: reasoning, moreover, shows a connection between the phenomena during life and appearances after death appreciable to the senses. Is not anaemia—the condition exactly the opposite of hypersemia —accompanied by similar symptoms ? Do not the animals whose throats are cut in the slaughter-houses die in convulsions from loss of blood? What are these convulsions, if they be not a sort of delirious action of the muscles ? Why may not anaemia produce in the same way a delirious action of the intellect ? A woman, in con- sequence of profuse metrorrhagia, is attacked with great functional disturbance of the cerebro-spinal centres : in such a case, it is clear that hypersemia cannot be assigned as the cause of the nervous symptoms. In such cases, we have an absolute demonstration of the fact, that anaemia can produce convulsions, coma, and delirium. We have, therefore, no right to assert, as one is too often tempted to do, that these symptoms depend on congestion of the nervous system. There is no doubt evidence to show that they sometimes depend on that state, and on meningitis; but meningitis is far from being a condition essential to their production. In septic diseases, the conditions are very different, for then we have to do with real cases of poisoning. Whether the blood under- goes a great change under the influence of the toxic principle, or whether it is only the medium by which the poison is carried to the centres of nervous power, there to originate disordered action, still, the same thing which happens in septic diseases also occurs when we administer drugs having an action on the nervous system, such as SCARLATINA. 205 belladonna, henbane, mandrake, thorn-apple, and hemlock, sub- stances which cause delirium varying in character according to the individual substance given. The delirium caused by opium is different from that caused by members of the family solinacece, and they again do not produce the same kind of delirium as is deter- mined by the umbelliferce. The differences in the character of the nervous symptoms resulting from the administration of different drugs are so distinctive, that a physician acquainted with their re- spective modes of action will, from the form in which the convul- sions or delirium show themselves, be able to recognise the particular substance which has produced them. The septic poisons of scarla- tina, measles, small-pox, malignant pustule, dothienteritis, or puer- peral fever have also their special action on the nervous system. Why, therefore, should we be surprised to see these poison-diseases accompanied by delirium ? To explain this, is it necessary to have recourse to hypersemia, seeing that it is not taken into account in considering cases of poisoning with vegetable substances ? In both classes of cases, the symptoms arise independently of hypersemia; and our inability to discover their cause is no reason why we should be forced to admit the existence of an unknown action which we cannot explain. Moreover, delirium and other nervous symptoms may occur irrespective altogether of any toxic or septic cause : they may be produced by mere tickling, using the word [yellication] in the acceptation of the Latin verb vellicare. Cases are mentioned in which persons have caused women to die by tickling the soles of their feet. The unfortunate victims became exhausted and fell into a state of violent delirium, accompanied by extraordinary nervous phenomena. Tickling may by itself, then, produce delirium, or an exaggerated state of innervation caused by forced excitement of the nervous system, similar, for example, to a condition almost physiological, that which exists in the act of copulation. This tickling [yellication]—to continue the use of the word—this unnatural excitement of the sensibility, due perhaps to reflex action, is equally liable to occur in the nervous apparatus of organic life, and in that which regulates relative life. It is thus that we can explain certain formidable symptoms in children, such as delirium, convulsions, paralysis, and loss of vision, caused by the presence of intestinal worms, even when the worms occasion no decided pain in the abdominal viscera. In these cases, cerebral hypermmia plays no part; and even in other cases where the brain is directly 206 SCARLATINA. implicated, congestion has no share in the production of the nervous phenomena to which I am now calling your attention. In the in- sane, in individuals who during many years have had frequent attacks of delirium, we occasionally find on dissection lesions indicative of chronic inflammation having existed, but most frequently we meet with no traces of hypersemia. Still less will hypersemia explain that sort of delirium, or transient disturbance of the intellectual powers, to which men of the greatest abilities and best regulated minds are sometimes subject. Let us now return to the treatment of scarlatina by cold affu- sions. You must quite understand that I do not employ them indiscriminately in all ordinary cases of the disease, as is the practice of the extreme partisans of the treatment: I only use them to subdue serious nervous complications—formidable ataxic symptoms. We may also beneficially combat ataxic symptoms by internal remedies. In their first rank stand ammonia, and its preparations carbonate of ammonia and spirit of Mindererus, the latter being a mixture of acetate of ammonia with some empyreumatic products. Both preparations in doses of from two to four grammes, and the solution of ammonia in doses of from ten to twenty drops, may prove very useful. I may say the same of musk, which is pre- scribed in doses of twenty, thirty and forty centigrammes, and of which as much as a gramme may be given in twenty-four hours. Some prudence is required in the management of these remedies: they constitute an accessory means of treatment in the cases in which we use the cold affusions; and when for any reason the affu- sions are not employed, ammonia and musk are our principal thera- peutic agents. Scarlatinous sore throat accompanied by fibrinous exudation does not involve absolute danger, unless the exudation is excessive. Under observation of the followers of any clinical practice, I have allowed patients labouring under this affection to remain without treatment; and this abstinence from interference was very con- spicuous in the case of a lad who occupied bed No. 17 in St. Agnes’s ward. In his case, the fibrinous exudations and the pappy patches on the tonsils disappeared spontaneously within four or five days. Though this kind of sore throat undergoes spontaneous cure in simple scarlatina, the throat affection is generally intractable in the malignant form of the disease. I have tried cauterization with SCARLATINA. 207 nitrate of silver and with hydrochloric acid; I have tried borax washes ; I have prescribed chlorate of potash in gargles and potions; and I declare that they have all frequently failed to produce any beneficial results in the sore throat of malignant scarlatina. The least untrustworthy of these therapeutic agents is hydrochloric acid, which when applied twice a day has appeared to have some efficacy. This caustic requires to be employed with prudence and precaution. In children struggling to resist the application, there is a risk of burning the tongue, injuring the teeth, and touching the internal surface of the mouth, thereby almost always aggravating the evil without properly effecting the cauterization. But by holding the child in a convenient position, and separating the jaws by means of a tongue-depressor, it is possible exactly to touch the affected parts with a hair-pencil soaked in the acid. Good results are sometimes obtained by cauterizations effected in this manner twice in twenty- four hours for five or six days. Insufflation of alum and tannin, practised alternately, are also very useful. When this bad form of the affection of the throat is met with after the acute stage of the attack, coming on suddenly about the ninth or tenth day with copious discharge from the nose, deafness and acute pain in the ears, horrible foetor of the breath, great frequency of the pulse, and depression of the vital power, I look upon it as a diphtheritic complication of the eruptive fever. I have found that all means directed against it prove ineffectual. Styptic nasal injections of solutions of sulphate of copper, sulphate of zinc, nitrate of silver, of decoction of rhatany, and of tannin, as well as energetic cauterizations of the throat, have all failed: whatever was done, the patients almost invariably died. In these cases, the general treatment is the most important: we must chiefly rely on diffusible stimulants, sulphate of quinine, infusion of coffee, and especially on a system of tonic alimentation: but it too often happens that these measures prove of no avail. We must now consider the treatment of scarlatinous anasarca and its complications. As I have already remarked, anasarca occurs perhaps less frequently after severe cases than during, or at the decline of, mild attacks. It is sometimes a very formidable, and at other times, not at all a serious complication. When the anasarca is slight, hygienical measures, rest in bed, tepid drinks, and moderate diet are all that is required; and even in slight anasarca associated 208 SCARLATINA. with some hoematuria, the symptoms may be easily subdued by acid drinks, lemonade, decoction of uva ursi sweetened with spirit of turpentine, small doses of fox-glove, and mild laxatives. But when the anasarca increases very rapidly, it is necessary to have recourse to other means for the prevention of the troublesome symptoms which then threaten. As the treatment required in the two forms of the affection is different, you require to keep both present to the mind. When the anasarca is accompanied by a real febrile reaction characterised by heat of skin, quickness of pulse, oppressed breathing, thirst and dry tongue, antiphlogistic treatment is necessary, and you may with great benefit bleed from the arm once or even twice : the relief afforded by the bloodletting is shown by a diminution of the phenomena of reaction. By following up the abstraction of blood by the administration of calomel in minute doses—a specially ex- cellent antiphlogistic measure—you deprive the anasarca of its acute character, while at the same time, by the purgative action of the medicine, you lessen the oedema. This result may now be accelerated by giving diuretics, although before the institution of the anti- phlogistic treatment they had been of no use. Should the oedema be of a cold character, unaccompanied by fever, you must abstain from bloodletting, and promptly administer those purgatives which cause the intestinal mucous membrane to pour forth serosity in such abundance as to bring about the cessation of the anasarca, and you will also, with the same object, stimulate the urinary secretion by diuretics. If the relaxation, the loss of tone in the tissues, should be very great, it will be advantageous to combine the employment of tonics, particularly quinine, with the treatment now recommended, or to give large doses of the iodide of potassium, a remedy much lauded in such cases by Graves. The acute form of anasarca is often preceded or accompanied by heematuria, or at least by the passing of some of the constituents of the blood with the urine. All pathologists are agreed in attributing this passing of blood or of its elements to hypereemia of the kidneys, often inflammatory in character, as is evident from its attendant febrile reaction. Measures of general depletion, such as I have recommended in the acute form of the anasarca, have a very beneficial influence on this kind of renal congestion. I concur with the unanimous opinion of clinical teachers that diuretics do harm by increasing the renal hypermmia, and consequently augmenting the quantity of blood passed with the urine. Benefit is often derived SCARLATINA. 209 from the use of haemostatics, such as sulphuric acid or alcoliolised sulphuric acid [eau de Rabel]—the latter in doses of two, three, or four grammes a day, in a tisane sweetened with syrop of rhatany. Among the complications of scarlatina, anasarca is that which is most frequently brought on by exposure to cold. It is necessary, therefore, to protect patients as much as possible from this influence, particularly at the epochs of the disease at which, according to statistical data, the swelling is most liable to occur; that is to say, during the second and third week, and, in a very special manner, immediately before the fourteenth and twenty-first day. The pre- cautions to be taken will be more or less rigorous according to the season of the year. There is no similarity, but on the contrary curious differences between small-pox, measles, and scarlatina, in their relation to the injurious influence of cold. Sydenham thought that small-pox patients ought to get up every day, even when the eruption was at its height: and nothing happened to show that patients treated in this way were disposed at any period of the malady to contract intercurrent affections through chills. Patients suffering from measles are neither so little affected by exposure to cold as variolous patients, nor so susceptible to it as scarlatinous patients. Upon some persons suffering from measles, cold seems to produce no impression, whilst it increases in others the bronchitis, the inse- parable companion of the eruption : this affection may extend to the minutest bronchial ramifications, and to the pulmonary tissue, giving rise to capillary bronchitis or a special form of pneumonia, the two most serious complications of measles. The pulmonary complication sometimes supervenes during a slight attack of anasarca. The susceptibility to cold is at its maximum in scarla- tinous patients. Hence it is necessary to take the greatest possible precautions to protect the patients from exposure to chills. But in saying this, I do not mean to imply, that it is ever right, at any stage of the disease, to shut up the patient in a suffocating atmo- sphere, to load him with blankets, and excite him with hot drinks. A moderate temperature, no more blankets than he is accustomed to in health, and the use of tepid beverages, acidulated and slightly cooling, are the most appropriate measures. It is necessary, however, to confine scarlatinous convalescents to their rooms for a long time, to save them from the risk of exposure to sudden transitions of temperature, currents of cold air, and damp; for from such causes 210 SCARLATINA. arise anasarca, hsematuria, effusion into the pleurae and pericardium, or still worse into the ventricles of the brain. Extensive anasarca, coming on rapidly, is often accompanied by convulsions which sometimes prove fatal in their first attack. Brisk purgatives are useful in these cases by stimulating the intestine to discharge a part of the serosity effused into the cellular tissue. The patient should be placed on the edge of the bed with the legs hanging over it, and ought to have the head propped up by pillows. By these means an impending attack of convulsions may be warded off. But sometimes, from the convulsions occurring without the slightest premonitory signs, no preventive means can be attempted. The patient complains of intense headache, imperfect vision in one or both eyes, ringing in the ears, and very obvious deafness. In these cases scarifications of the inferior extremities may be useful, by producing disengorgement. This object, however, is more success- fully attained by applying very large blisters to the legs—not to the thighs. In seven or eight hours, phlyctsenm -are formed: by open- ing them, an exit is afforded to a stream of serosity, by which dis- charge the patient is wonderfully relieved, and enabled to tide over the most perilous crisis of his anasarca. When convulsions occur during the disease, give musk in com- bination with small doses of belladonna. To children between eight and ten years of age, give the musk in doses of from twenty- five to forty centigrammes, and the belladonna in doses not exceed- ing one centigramme, in the form of a draught. At the same time that you employ these medicines, you ought also to practise com- pression of the carotids, a means which I have extolled for twenty years, and which has rendered very great services to me and other physicians. The compression requires to be performed with care and according to rule. If one side is more affected than the other by epileptiform convulsion, it is on the opposite side that the com- pression ought to be most specially applied. If the convulsion predominates on the right side, you compress the left carotid; and if it predominate on the left side, yon compress the right carotid. If both sides are equally convulsed, you compress each carotid alternately. Of course I am speaking of the common carotids. The compression must be effected in such a way as to interfere as little as possible with the respiration of the child. The compression of these vessels is much easier than you might suppose. You place yourself in such a position as will enable you to compress the right SCARLATINA. 211 earotid with the left hand, and the left carotid with the right hand. You keep apart the bellies of the sterno-cleido-mastoid muscle; and then, at the same time that you isolate the wind-pipe, using the back of the distal phalanx, you feel the pulsations of the artery, which is very mobile. You then seize the artery with the cushioned extremities of the fingers, push it a little backwards, and press it against the vertebral column. You immediately find that the vessel is compressed, by observing that there is an absence of pulsation in the corresponding temporal artery, and perhaps also by seeing a sudden paleness take the place of the previous red colour of the child’s face. Sometimes, also, you have the satisfaction to find that no sooner is the compression established than the eclampsia entirely ceases. You maintain the pressure for fifteen to twenty minutes, first on one artery and then on the other. It is useful to have the co-operation of an assistant in this irksome operation. Mothers, who through affectionate anxiety for their children become so intel- ligent, may take your place for a time. You may thus, by exer- cising the necessary patience, in a few hours, in a certain number of cases, put a stop to the convulsions which accompany scarlatinous anasarca. Serous effusion into the pleurse and pericardium, formidable com- plications which occur in the last stage of scarlatina, about the same period as anasarca, ought to be treated by a succession of large flying blisters. If the hydrothorax or pericardiac effusion be con- siderable, tapping will be useful. When the pleural effusion is very great, paracentesis is sometimes a necessity after a few days. But it often happens, as I have already observed to you, that at the first tapping, even when the effusion is not of older date than ten, fifteen, or twenty days, you may find the serosity lactescent, and even con- taining formed pus : you have then to do with veritable empyema, a formidable complication which is often curable in young subjects by tapping and frequent iodinous injections; but which, notwithstand- ing the use of these means, rarely terminates favourably in adults. LECTURE VI. MEASLES; AND IN PARTICULAR ITS UNFAVOURABLE SYMPTOMS AND COMPLICATIONS. Normal Measles.—Period of Invasion is longer than in any other Eruptive Fever.—Complications of the Period of Invasion.— Convulsions at the Beginning of the Attach.—False Croup.— Suffocative Catarrh.—Epistaxis.—Otitis.—Diarrhoea.—Compli- cations of the Eruptive Stage, and of the Last Stage. Gentlemen :—In speaking of measles, I shall not go into the subject with that circumstantial detail with which I have treated scarlatina. There is no eruptive disease which assumes such strange forms, and furnishes materials for so much pathological discussion as scarlatina: measles has not the same claims on our attention. I shall, therefore, only trace rapidly the symptoms of measles in its normal form, and specially enlarge upon the unfavourable symptoms and complications which may accompany or follow an attack of that disease. These unfavourable symptoms and complications are un- fortunately too little known to young physicians, as I have often had occasion to point out to you. You are aware, gentlemen, that it is not for me in a course of clinical lectures to give you a complete history of measles: that duty belongs to the professor of medical pathology. But I wish to make you acquainted with the complica- tions of this exanthematous pyrexia, explaining to you their mode of evolution by analysing and discussing cases selected for that pur- pose in the wards. I must, however, in a summary manner, recall to your recollection the ordinary phenomena of the different stages of measles, which, when they become exaggerated, constitute what we call the complications. Yrom the very beginning of the attack, in the simplest forms of the disease, symptoms present themselves in the mucous membranes of the eye and respiratory passages, which are perfectly well known MEASLES. 213 to those who have once observed them. They consist in lachrymation, injection of the eyes, and slight intolerance of light; in coryza, cha- racterised by a flow of acrid tenacious mucus, frequent sneezing, and often accompanied by profuse epistaxis; and in a severe cough, at times a little hoarse, and at other times very violent and very harassing. The mucous membranes of the eyes, nose, larynx, and bronchial tubes are affected, therefore, from the earliest days of an attack of measles. From the very first day, as in scarlatina, they show the presence of the eruption; and before there is any exanthem on the skin, you see the disease inscribed on the pharynx, tonsils, and veil of the palate. In this stage—the stage of invasion—the fever has not the same character as in small-pox, in which disease, from the very outset of the first febrile symptoms up to the appearance of the eruption, the fever is continuous, always lasting at least till the day on which the pustules come out. In measles, the febrile symptoms follow an entirely different course, which sometimes singularly misleads physi- cians. Sometimes the fever continues up to the period of eruption : at other times, it only lasts one or two days, abating very much and sometimes ceasing entirely on the third day, leaving the patient, whether adult or child, with only a slight feeling of discomfort; it reappears, however, with great intensity on the day the eruption comes out. It begins with slight rigors, recurring from three to six times in the twenty-four hours, which, as they are followed by hot fits and sweating, simulate the paroxysms of the remittent and intermittent fevers, which have a tendency to become continued, and are rather common in the beginning of attacks of dothienteritis. In the absence of lachrymation, coryza, epistaxis, and cough, one is very often embarrassed as to the diagnosis, and does not recognise the existence of measles at the beginning of the attack, unless guided by other circumstances than those which belong to the disease itself, such as some of the family having measles, or its being at the time prevalent as an epidemic. The duration of the period of invasion is, therefore, a material circumstance in relation to the diagnosis. The period of invasion is longer in measles than in any other eruptive fever. In scarlatina on the other hand, it is shorter than in any other eruptive fever, its duration sometimes not exceeding a few hours or a few minutes. Next comes confluent small-pox, the invasion-stage of which continues three days, the pustules appearing 214 MEASLES. very regularly at tlie end of the third or beginning of the fourth day. The cutaneous exanthem of measles does not appear till the fourth or fifth day, and sometimes, even in perfectly uncomplicated cases, not till the sixth, seventh, or eighth day. We have just had an example of this in the workman of twenty-eight years of age who occupied bed No. 18, St. Agnes’s ward. In his case I completely mistook the nature of the disease, as the eruption of measles did not appear till the seventh day : notwithstanding the delay in the eruption, the case was free from any complication. In rare and exceptional cases of scarlatina and small-pox, when serious complications supervene at the beginning of the attack, the appear- ance of the eruption is retarded: in measles the general rule is that the duration of the period of invasion is four or five days irrespective of all complications. During the period of invasion, at the very time when the fever seems to be subsiding, it suddenly acquires a considerable renewal of its intensity. The lachrymation, coryza, and cough, after having been for a very brief space of time in abeyance, return with extreme severity; and simultaneously with this exacerbation of symptoms, very profuse diarrhoea supervenes in the majority of cases. This phenomenon—the simultaneous advent of eruption and diarrhoea— belongs essentially to measles, a fact which has not been sufficiently pointed out by authors. The occurrence, though not invariable, is common enough to demand special notice. A child will have from four to fifteen stools in the twenty-four hours. In some cases the diarrhoea is not only serous, but likewise glairy and bloody, caused by an inflammatory affection of the colon which continues for a day or two. If the diarrhoea continue for more than twenty-four hours, it may, in very young children, become a source of danger, and ought, therefore, to be checked as quickly as possible. The eruption first appears on the face, next day (the fifth or sixth of the attack) it invades the trunk, and on the following day the limbs, after which it is general. I perceive, gentlemen, that I am causing you to take up an erroneous impression. I already hear some of you reminding me that I have several times shown you in our nursery wards infants in whom at the second day of the fever of measles small efflorescences were visible, in situations where the skin wras hot and covered with perspiration. On the next day, or the day after the next, there was scarcely a trace of these efflores- cences to be found : and on the regular day of the eruption becoming MEASLES. 215 due, it appeared with its precise characters well marked. I must here repeat what I have already said to you beside the cradles of our little patients, regarding the limits of the law of evolution in the exanthem of measles. But in many cases analogous to those which I have just brought before you, the efflorescences mentioned were nothing more than sudorific exanthemata, an eruption not to be confounded with the specific exanthem of measles. So long as the eruption of measles remains bright and blooming [yive etfieurie] the fever continues very intense. This is also the case in scarlatina ; but the opposite is the rule in distinct small-pox, in which the fever at once subsides when the pustules appear, to be rekindled, however, on the eighth day of the disease, the com- mencement of the period of maturation. In measles, then, the fever goes on for two or three days after the appearance of the eruption : it then subsides because the eruption subsides: should it not then subside, there is reason to fear the occurrence of com- plications. To increased lachrymation, coryza, and cough, there are generally added a little deafness, sometimes acute pain in the ears, in conse- quence of the Eustachian tubes being affected like the other passages lined by mucous membrane. The eruption in its simplest form, particularly when examined on the chest and abdomen rather than on the face, presents a crop of small, red, velvety elevations, having neither the roughness to the touch nor the wrinkled aspect so often met with in the eruption of scarlatina. They have a certain similarity to the elevations of urticaria: both the dermis and epidermis are raised up, and the elevations are even more appreciable by touch than sight. The ele- vations are generally of unequal shape, and somewhat variable in size, being about as large as a grain of rice or corn, and so placed as to circumscribe portions of skin free from the eruption. The elevations are at first separate and disappear under pressure made by the finger, to reappear when that pressure is removed : they afterwards become grouped together in irregular patches unequally cut up into little crescents. When the eruption is very confluent, the redness is diffuse and uniform, sometimes rendering the diagnosis difficult. Occasionally, particularly in summer, when patients have been too much clothed and perspire profusely, vesicles appear: they are accumulated, gene- rally contain a puriform fluid, have an inflamed base j and they are 216 MEASLES. much larger than the vesicles which are noted as occurring in scar- latina : in measles a vesicular eruption is exceptional, but in scar- latina it is the rule. The morbillous patches are sometimes so elevated above the cu- taneous surface as to have almost a papular character. When this character predominates in the eruption, the case is said to be one of pimply measles [rougeole boutonneuse\. It frequently happens that when the eruption has been very violent, patches of a violet-red colour are seen, particularly on the extremities : they are evidently ecchymotic, for they do not disappear under the pressure of the finger like the exanthematic patches. These spots of purpura remain for seven, eight, or ten days after the disappearance of the morbillous eruption, leaving behind them greenish-yellow stains. This form of measles is more severe than the other, inasmuch as the eruption is more violent; because it is a general rule in eruptive fevers—in sinall-pox, scarlatina, and measles—that the gravity of the attack is proportionate to the in- tensity of the eruption. It is most frequently met with during the predominance of certain medical constitutions of the atmosphere, and it may then become one of the most seriously complicated kinds of measles. Generally speaking, during the periods of invasion and eruption, on auscultating the chest, we hear sibilant rales, which on the day of eruption very often become sub-crepitant, and which, sometimes general throughout the whole extent of both lungs, are accompanied by a degree of oppression in breathing: we have sub-crepitant rales, which indicate that the morbillous catarrh already occupies the minute bronchial tubes. This catarrh may be serious from the first, and may go on increasing in severity up to the eighth or ninth day of the disease, then culminating in an affection of intense severity. The sub-crepitant rales usually heard at the time the eruption is coming out need occasion no alarm, even though they are very fine, provided the other symptoms are not serious: as in general they either disappear or diminish about the seventh or eighth day, when coarse mucous rales are again heard, then sibilant rales, and finally the sounds become normal. Morbillous catarrh gives rise to a characteristic expectoration. I speak of what is seen in adults and in children of the third age. As you know, infants at the breast, and children under four or five years of age, do not expectorate. The sputa, at first mucous, clear, MEASLES. 217 and limpid, becomes thick, globular, greenish yellow, perfectly iso- lated from one another, swimming in more or less glairy slightly opalescent mucus : they are nummular, as in some phthisical cases. On the eighth day, the erruption begins to disappear: it leaves the face and fades on the trunk. On the ninth day, it has com- pletely left the limbs. The symptoms which then remain are slight ophthalmia, coryza, deafness, and cough, which go on gradually decreasing for seven or eight days, when they totally cease. The period of desquamation now commences. Classical authori- ties speak of a furfuraceous desquamation consisting of an epidermic dust resembling small scales of bran; but if you minutely examine what is taking place, you will find that there is not one in ten patients who exhibit a trace of this sort of desquamation. How- ever, when the skin is covered with perspiration—and perspiration is not uncommon in measles—the epidermic scales adhere to the linen, because the exfoliation is exceedingly thin. The desquama- tion is best seen on the face, because the face, where there is less perspiration than on other parts of the body, is not covered. But even there, the desquamation is often imperceptible: when it is apparent on the face, it is at the eighth day, just as the eruption is beginning to fade, and then you may see the little exfoliations of wdiich I have been speaking. A diagram of t-lie actual range of temperaturqin a case of measles, exactly corresponds with what one would suppose, from clinical observation, to be correct; and it graphically represents to the eye the course of the fever. In the prodromic period, during from one to four days, the temperature gradually rises, and does not attain its maximum elevation till the eruption has reached its maximum de- velopment. I have already said that the defervescence and the fading of the eruption are coincident: I now add, that when we look at the diagram of the range of temperature, we see that the defer- vescence is so rapid, so sudden, that in one night the natural temperature of the body is established. In severe cases, the defer- vescence is not quite so abrupt, though still very rapid, and during the subsidence of the fever, slight exacerbations occur from twenty- four to forty-eight hours. You see, therefore, that defervescence in measles is not lagging as in scarlatina: the very opposite is its character. So essentially characteristic of measles is this rapid defervescence, that it may be concluded that the case is anomalous, and that complications are going to arise, whenever the temperature 218 MEASLES. remains high after the eruption has begun to fade. The highest temperature observed has been 420,8. In the researches of Dr. Hugo Siegel, the most common range was between 390,4 and 40o,6. I have now, gentlemen, briefly described the course of normal, simple, regular measles. Having given this rapid sketch, we are now better enabled to study the unfavourable symptoms and complications, because they are related to the normal phenomena of the disease. In children, the principal complications are convulsions and false croup; both in children and in adults, catarrh and epistaxis. During the period of invasion, children are frequently carried off by convulsions and catarrh. On the first day, at the very onset of the fever, convulsions often attack children having a tendency to nervous affections. Such subjects are liable to be seized with convulsions when fever is setting in, whether that fever be dependent upon measles, small-pox, scarlatina, an intestinal affection, or a simple pulmonary catarrh, just at the moment of the first rigor announcing the febrile con- dition. I say just at the moment of the rigor ; and I will tell you why I say so. If you reflect on the nature of a rigor, you will per- ceive that it is really a convulsion. Study it isolated in a particular part of the body—for example, in the lower jaw. The rigor shows itself by the chatterkig of the teeth, caused by alternate contrac- tion and relaxation—more or less rapid—of the muscles which raise the lower jaw; the muscular contractions are involuntary and violent. This, as you know, is precisely the definition of a convulsion. When the shivering is general, it is accompanied by headache, violent pains along the vertebral column, and shaking of the whole body produced by the violent and convulsive jerks of the muscles. We have, in fact, real fits of continuous eclampsia, less the cerebral phenomena. How easy then is the transition from a rigor to a fit of convulsions ! This consideration will lead you to understand why it is generally at the very first rigor of a fever, when the nervous system is in a specially excited state, that convulsions occur. When once the stir-up is given to the nervous system, the first attack is followed by a second, and by succeeding fits, which recur under the influence of any moral or physical excitement, or in consequence of a some- what decided external impression, such as is felt on awaking from sleep, when the nervous system emerges from the state of repose in which it had been wrapped. MEASLES. 219 Convulsions at the beginning of an attack of measles, unless they recur frequently, are not of very serious import. During the period of invasion, two or three fits are not in themselves alarming; but if they go on continuously for one or two days, the child may be carried off in one of them. Unfortunately, medical intervention has a large share in the misfortunes which follow in the train of eclampsia. Nothing alarms a family so much as convulsions; and nothing, I confess, is more frightful. Medical men are sent for in every direction: the practitioner arriving at the end of the crisis and observing only the apoplectic phenomena, loses, sometimes, self- possession, and in the flurry of the moment is liable to make many mistakes. He begins by applying four, six, or eight leeches behind the ear: he sees in the case cerebral congestion, which seems urgently to demand abstraction of blood, with a view to diminish the vascular engorgement. If the patient is a child under four years of age, this treatment will render him anaemic, and so place him in the very condition most apt to produce the evil from which it was intended to save him. Perhaps he orders cold baths, and prescribes cold water to be affused over the head and shoulders of the child when in the bath. The baths and affusions are repeated two or three times during the course of the day. Nevertheless, at this very time, the patient, perhaps, had coryza and pulmonary catarrh. A cold affusion, if accomplished in a few seconds, might do no harm under such circumstances; but that cannot be said of prolonged immersion, and far less of the application of ice to the head, which is often prescribed in such cases. The morbillous catarrh, always in itself an affection sufficiently severe to make us endeavour to moderate it, cannot but increase under the influence of such measures. There is, unfortunately, no exaggeration in what I have now said. How many physicians who though doubtful of the utility of the means they order, yield to the demands by the relatives of the patient for active treatment—for something energetic—for a great demonstration—in cases where the disease itself is terrible and rapid. The treatment by leeches and baths, though a murderous treatment, is so entirely in accord with the theories and prejudices of the public —always ready to dogmatise in medical matters—that were it not for the grave objections to its employment, it would often be difficult to abstain from having recourse to it. The danger is increased by the ignorance of so me, and the want of energy of other practitioners. 220 MEASLES. In other cases, persons who, though physicians, are strangers to our art act in a way still more disastrous. They pour boiling water upon, and surround with cloths soaked in boiling water, the legs of unfortunate children, and so determine in them the occurrence of evils worse than those which they seek to avert. Who has not heard of the frightful accidents, the horrible scalds caused by the medical application of water or some other boiling fluid, which annually result in the death of many children ? Who among us has not had occasion to see or to hear related such cases ? But how oblivious of them are many practitioners w hen called in to children in convulsions—how they hasten to have recourse to that brutal treatment which I now so emphatically condemn! The con- tact of towels soaked in boiling water with the skin is much more prolonged than the contact which takes place in accidental scalding. In an accidental scald, the subject is conscious: at the first sensa- tion of pain he proceeds to tear off his clothes, and to beseech others to help him in doing so. But in the coma consecutive to convulsions, the patient feels nothing; and by allowing the scalding cloths to remain so long in contact with the skin those who ought to afford succour kill, when they believe they are saving. When patients sacrificed by this treatment do not succumb under the influence of pain, they are either carried off by the violence of the inflammation, or they sink exhausted by the suppuration. Those who recover, have cicatrices of greater or less depth, which may— according to their situation—give rise to very great deformities. I have several times seen untoward occurrences of this descrip- tion. Among other examples, I saw one in the person of a man who was at one time my master, and who stood in a similar relation to some of you. Marjolin, in the course of an attack of typhoid fever, fell into a profound coma, to rouse him from which, boiling water was applied to his thighs. He retained to the last the deep scars which resulted from this medication, and which singularly complicated his malady, and long retarded his convalescence. When a child is seized w ith convulsions at the onset of measles, have the wisdom to wait: abstain from boisterous practice: inquire w hether the patient is subject to eclampsia, and whether the fits pass off without the interference of art. If your inquiries are answered in the affirmative, very little treatment will be necessary; for in general, the initiatory convulsions of eruptive fevers subside spoil- MEASLES. 221 taneously, without our requiring to interfere. Abstraction of blood, prolonged baths, scaldings with boiling water, blisters (which act in a manner analogous to scaldings), and active purging, far from being useful, aggravate the disease: they trammel its progress, retard the period of eruption, and originate complications which are often fatal. There are exceptional cases, in which a first fit of convulsions at the beginning of an eruptive fever is fatal. I have often related the particulars of a case which occurred under my own observation in the Necker Hospital. A child of two years of age, who presented no symptoms of cerebral affection, was seized with convulsions, when I was in the very act of examining him. I stated to the pupils then present at the visit, the probable course of the symp- toms : I spoke to them of the tonic, which preceding the clonic form would last fifty or sixty seconds, involving the muscles of the extremities, chest, and abdomen, and keeping them in a rigid state as at the commencement of an attack of epilepsy. But on two minutes having elapsed without the rigidity giving way, I began to be alarmed: ere half a minute more had passed, we observed the face become suddenly blue, and the blue colour gradually got deeper; when, all at once, the muscles became relaxed. The child ■was dead. However exceptional this and similar cases may be, you may meet with cases of the same kind in your practice. It is essential, there- fore, to be able to foresee the chances of bad luck, and to make reservations in announcing your prognosis. I am now speaking only of convulsions at the beginning of measles and small-pox ; for convulsions at the onset of scarlatina are not exceptionally but always very unpropitious. You have, gentlemen, very recently seen in our nursery wards, two children, one of whom recovered, after having had all the symp- toms of croup, but of false croup, at the beginning of an attack of measles; and the other died of croup, but of true croup, during convalescence from the exanthematous disease. I cannot tell you how often families are dismayed at the explosion of these unfavourable symptoms during the first four or five days of an attack of measles in which no eruption has yet appeared. The child, after having in the first instance shown nothing more than the symptoms of a slight catarrh, is suddenly seized with alarming oppression of the chest accompanied by a hoarse cough, wheezing MEASLES. inspiration, very laborious respiration, and fever. If there are no cases of measles among those with 'whom the patient is living, the diagnosis is very embarrassing, and one is apt to believe that the malady is that form of acute laryngitis known by the name of pseudo-croup. This error will be immaterial, unless the practitioner interferes, as sometimes happens, in a deplorably hurtful manner. The mistake will not prove injurious, provided he act under the correct conviction that pseudo-croup is seldom a serious affection, and that after some agonising moments, more terrible perhaps to the heart of the mother than hazardous to the life of the child, the un- favourable symptoms subside. I sliall afterwards have to return to the differential diagnosis of acute laryngitis and croup. I presume, however, that it is a subject with which you are familiar. But when you have diagnosed pseudo- croup, take care that you do not allow yourselves to be worked upon by the anxieties of a dismayed family, take care that you do not yield to their very natural impatience; take special care that you do not commit the too common blunder of applying leeches to the neck or the base of the chest. In itself, and in the treatment of false croup, this proceeding is not necessarily dangerous; but if the loss of blood should be great—as it may be—it may involve danger. You very often cannot tell in a child when the bleeding will stop ; and excessive bleeding will produce anaemia, which will interfere with the natural course of the disease, of which the laryn- gitis was only the precursor. Besides, though the treatment may not in itself be dangerous, it is useless, and for that reason ought not to be employed. Graves, who wTas not well acquainted with diphtheritic affections, having seen but few cases, pointed out a method of treating false croup, similar to that which I recommended to you: it consists in gently pressing a sponge soaked in warm water—very warm, but not hot enough to scald—under the chin, and on the front of the neck. This operation is repeated in ten or fifteen minutes : it produces a sort of determination to the skin, under the influence of which the symptoms subside in a remarkable manner, the cough at the same time losing its hoarseness. In addition to great efficacy, this medication has the recommendation of extreme simplicity : by it unaided wTe can generally remove symptoms, for which without it we should have to administer emetics. My remark only applies to the laryngeal symptoms; for w'hen they disappear, there still remains the bronchial catarrh, the constant companion of morbillous MEASLES. 223 fever, and which, in the progress of the case, may become a threat- ening feature. Suffocative catarrh is often a serious complication of measles, both in adults and children. About three or four days prior to the development of the eruption, the fever becomes exceedingly violent, oppression of the chest supervenes, accompanied by a moist cough, which, in children, succeeds the hoarse cough of laryngismus stri- dulus ; and auscultation informs us of the existence of sub-crepitant rales throughout the whole extent of the lungs. When these symptoms occur at the second or third day of the period of invasion, they generally imply danger; but the sub-crepitant rale, if unac- companied by oppression of breathing, is not so alarming. Capillary catarrh, unconnected with any specific cause, is a very serious malady, particularly in children. It is much more dangerous than lobular pneumonia or pleurisy. There is nothing to cause surprise in the statement, that when it is under the dominion of a specific poison, such as the morbillous poison, it is a still more formidable affection. The skin is either almost or altogether free from eruption; for the whole force of the disease is directed to the bronchial apparatus. Under such circumstances, patients, especially children, sink in three or four days, without any cutaneous eruption having appeared. The malady might, therefore, be mistaken for simple catarrh, though really morbillous catarrh. It is often abso- lutely impossible to establish a differential diagnosis between the two affections, unless we have some characteristic symptoms to guide us, such as epistaxis, coryza, otitis, or lachrymation; and this difficulty is enhanced when we do not know w'hether there are any cases of measles in the patient’s family or neighbourhood. In the adult, the form which this catarrh takes is pretty nearly the same as in children. The oppression of breathing is quite as great; on the first or second day, the expectoration assumes a peculiar character: at first it is thin limpid mucus, but about the third day it presents a puriform aspect, the patient expectorating mouthfuls of mucus exactly like pus from an abscess. The sputa are not nummular, and floating in a slightly opalescent serosity like the sputa of normal measles on the seventh, eighth, ninth, and tenth days of the disease, often unnecessarily frighten both patients and their physicians; but they are muco-purulent, like the sputa accompanying the suffocative catarrh of the aged. Although the suffocative catarrh of measles is a somewhat less MEASLES. dangerous affection in adults than in children, it must still be looked upon in adults as exceedingly dangerous, and as resisting the most energetic treatment. It generally proves fatal in a few days; but sometimes the patients go on for a week or more, in which case the capillary bronchitis becomes peri-pneumonia, pseudo-lobular pneu- monia, or lobular pneumonia. The latter may be either compli- cated or not complicated with pleurisy, and when uncomplicated in this way, it is much less dangerous. Emetics, with ipecacuanha at the head of the list, antimonials, the precipitated sulphuret of antimony, and a succession of large blisters to the chest, are the therapeutic means to employ in this fatal form of catarrh, and in the forms of pneumonia by which it is followed. Too often they are powerless. Urtication is another means of treatment which may produce immediate benefit in certain cases. When the eruption has not appeared on the fourth day, and catarrhal symptoms are present, I order the body of the patient to be scourged with nettles twice or thrice in the twrenty-four hours, so as to produce an abundant erup- tion on the skin. This urtication is less painful than might be supposed, and produces an immediate effect. Although the fever does not subside, the oppression of breathing diminishes gradually as the determination to the skin augments. It is a curious fact that on the second day of this treatment, the nettle-rash, even wffien the small nettle urtica wens (more active than the large nettle wtica dioica) has been used, is notably less, and at last, after three or four days, the application produces no effect. This arises from the system having become habituated to the poison, and not from the vitality being so impaired that the organism is no longer acted upon by it. We see precisely the same tolerance of this poison ex- hibited by country girls who take hold of, and carry in their naked arms with impunity, the very same nettles which at first stung them smartly. Urtication then is of some use in children, and still more in adults, in the treatment of morbillous catarrh. The difference in the degree of efficacy probably depends upon the affection being more severe in the former than in the latter. There are other, though less important complications of the onset of muscles. I refer to epistaxis and otitis : the latter is often misunderstood. Epistaxis is an ordinary phenomenon of measles, and wrhen mo- derate, is certainly not a serious symptom; but it is sometimes so profuse as to endanger the child’s life, or permanently injure his future health. It is treated by applying to the forehead, and causing to be drawn up into the nose, ice and iced water. These measures are good. Astringents, also, prove successful. But the most successful practice is to inject into the nostrils water as hot as the patient can bear. The injections of strong solutions of sulphate of copper and sulphate of zinc, a decoction of rhatany, and a solution of perchloride of iron are excellent haemostatics. The perchloride oi iron, however, has the inconvenience of causing the formation of a large coagulum which occasions pain : two or three days later, on removing it, to relieve the patient from discomfort, a renewal of the haemorrhage is apt to be produced. But when other means have failed, and the case is urgent, I never hesitate to use perchloride of iron. Sometimes, it is also necessary to have recourse to plugging. MEASLES. 225 The diagnosis of otitis is generally simple in the adult, who can explain what he feels; but it is not so in the child incapable of de- scribing his sensations, and only making known his sufferings by cries, leaving us to find out the cause and seat of pain. The ex- cessive pain produces delirium, which is often of a very violent cha- racter, and the fever increases. To those not previously instructed on the subject, the formidable array of symptoms will appear inex- plicable. When a child is beyond the age of dentition, or when, though not beyond it, has no determination of blood to the mouth; when on careful examination we can find no hernia, no distension of the abdomen, no badly fixed pin pricking, nothing in a word to ex- plain the constant and piteous cries, we may conclude that there is otitis. Almost invariably, in thirty-six or forty-eight hours, this conclusion will be confirmed by suppuration showing itself in a discharge from the ear. It is important to bear in mind these facts, so that you may avoid erroneous therapeutical measures and adopt a useful plan of treatment. You may, therefore, rest satisfied with in- jecting into the external auditory passage some soothing balsam, or a little belladonna dissolved in water or oil, in place of pursuing a too energetic practice to the detriment of the patient. Belladonna and henbane suffice to calm the pain; but unfortunately, they are inadequate to prevent the serious evils which otitis brings in its train, and of which I will speak when considering the complications of the third period.1 1 See page 231. 226 MEASLES. In enumerating the symptoms which accompany the eruption, I stated that it was generally along with it that diarrhoea appeared. It is rarely a serious symptom : and in simple cases, it even seems to constitute a favourable crisis, when it comes simultaneously with the exanthem on the skin. It would seem that at the moment when the morbid ferment has attained its maximum activity, at the mo- ment when the desjoumation (to use Sydenham’s expression) is going to declare itself with all its energy, there cannot be too many emunctories open. The diarrhoeal catarrh, particularly in children, seems an advantageous addition to the coryza, ocular catarrh, and bronchial catarrh. In adults, diarrhoea is an unusual occurrence on the day of eruption. As I have already said, this diarrhoea is sometimes very profuse, the patients having ten or even fifteen stools in twenty-four hours. There is, however, no cause for alarm at such an occurrence, provided the eruption, the fever, and the other symp- toms are following the regular course; but if the intestinal flux is exceedingly profuse, and continues beyond its natural period, and if at the same time the eruption does not come out well, and the eyes have a sunken appearance, there is danger. We must then lose no time in interfering, because in young children so circum- stanced, there is a risk of the case becoming choleriform. Even if the diarrhoea, lasting more than twenty-four hours, is as violent on the second as on the first day, it becomes necessary to interfere. The heroic remedy in such cases is opium. It arrests the intestinal flux; and in virtue of its diaphoretic powers, favours the develop- ment of the exanthem, by acting on the skin. I cannot too earnestly impress upon you the necessity of caution in administering opium to children. They are so exceedingly sensitive to its action that an infant of one year, or under that age, may be stupefied, and remain in a drowsy state for two days, from taking a single drop of laudanum, that is to say, the thirtieth of a grain of opium. Tor so young a patient with the diarrhoea now under consideration, I prescribe half a drop of the laudanum of Sydenham to be given in divided doses, in lime water, during twenty hours. To prepare the potion, you add one drop of lauda- num to two teaspoonfuls of an infusion of coffee: having thrown away one half of this mixture of laudanum and coffee, you add to the half which remains, sixty drachms of lime water. This potion ought to be administered in spoonful doses during the twenty-four hours. MEASLES. 227 It often happens that the morbillous catarrh of the intestines exhausts itself by attacking the large intestine, producing that special form of colitis characterised by tenesmus and glairy, bloody stools. Let me remark in passing that the term dysentery applied to this form of colitis is very inappropriate. Dysentery is an epidemic disease—specific, contagious, independent, and special in its character. If it is colitis, it is colitis of an altogether special nature, and quite different from the colitis of measles—as different as the morbillous is from the scarlatinous exanthem, though both eruptions are cutaneous—as different as eczema is from small-pox, though the pustules of both greatly resemble each other. It is very necessary to establish the distinction between morbillous colitis and dysentery, for the former is much less dangerous than the latter. Morbillous colitis generally terminates in spontaneous recovery. When it goes on too long, it can be stopped by administering albuminous injections; or, if a more rapid result be desired, employ an injection of ioo grammes of distilled water containing in solution from 5 to io centigrammes of nitrate of silver, or an injection formed by dissolving in the same quantity of water from 25 to 30 centigrammes of sulphate of copper or sulphate of zinc. By such means you will be able to stop the diarrhoeal colic, which comes on at the fifth or sixth day of measles, and is seldom a more serious symptom than the irritation, often rather violent, which affects the upper lip under the influence of the coryza. Between these two symptoms there is a great analogy: they only differ in respect of their seat. Having now passed in review the different complications of the period of invasion in measles—convulsions, false croup, suffocative catarrh, epistaxis, otitis, and diarrhoeal colic, I come to the compli- cations of the second period, called the period of eruption. Strictly speaking, these complications do not belong to the second stage. For example, the capillary catarrh which often accompanies this stage, began with the disease. In many cases, no doubt, it more specially belongs to the second stage, inasmuch, as though it begins to show itself in the first stage, it does not assume a serious cha- racter till it bursts forth about the sixth or seventh day of the disease, that is to say, on the second or third day of the second stage, or period of eruption, taking the form of suffocative catarrh, lobular, or pseudo-lobular pneumonia. In a word, simple catarrh is a symptom naturally belonging to the period of invasion, whereas suffo- 228 MEASLES. cative catarrh, peripneumonic catarrh, and pure pneumonia, belong more to the period of eruption. Peripneumonic catarrh, lobular pneumonia, and pseudo-lobular pneumonia, the extreme consequences of capillary catarrh, are always the most formidable complications of measles, being much more dangerous than pure pneumonia or pleurisy: it is by capillary catarrh and its consequences that the greatest number of morbillous patients are carried off. When in a case which has gone on regu- larly till the seventh day, you then observe the eruption grow pale, and next day find an increase of fever, you have reason to apprehend a complication; and almost invariably that complication will be found to be pulmonary. In the adult, it may be an attack of pure pneumonia; but that is not usual, broncho-pneumonia being the most common form of the pulmonary affection. In children, this broncho- pneumonia, this peripneumonia is, I may say, the absolute rule, so rare are the exceptions: the inflammation of the pulmonary paren- chyma is merely an extension of a previous bronchitis, in wrhich the catarrhal element still predominates. It is all the more important to have clear views on this point in etiology, and upon the nature of the pathological process, that they at once explain the cause of the great danger of this complication of measles. The pneumonic com- plication nearly always proves fatal in children under three years of age. In an epidemic which I observed at the Necker Hospital in the years 1845 and 1846, out of twenty-four children who had measles, twenty-two died of peripneumonic catarrh: the other two escaped the terrible thoracic complication. This statistical fact enables you to estimate the frightful severity of this affection, which, however, is met with much more frequently in hospital than in private prac- tice. Still, in some epidemics, it commits cruel ravages beyond nosocomial influences; and the physician who considered measles a mild disease till he encountered one of these epidemics, will after- wards modify that opinion. Thirty-seven years ago, when I began the practice of medicine, the first two patients to whom I was called were persons suffering from measles, one a girl of eleven, and the other a female servant of twenty-one years of age. Both sunk under broncho-pneumonia, which in one of the cases was com- plicated with pleurisy. At that period, I came to the conclusion that measles might prove a serious malady: from that time, many years elapsed without my losing a single case, child or adult, from the disease, and then I met with the disastrous epidemic at the MEASLES. 229 Necker Hospital. This year I have again seen a great mortality in my own private practice, and in consultation with my colleagues, both among children and adults, from morbillous peripneumonic catarrh. Whenever, therefore, about the eighth day of measles, the fever, which ought to subside on that day, continues; when the sub- crepitant rales, heard on auscultation from the fourth day of the disease, and which at the time the eruption came out (or at least about the second or third day of the period of eruption), ought to have become less fine, do not undergo that modification, there is reason to fear untoward pulmonary symptoms. The broncho-pneu- monia is at first only characterised by general signs, and by the per- sistency and greater intensity of the fever; but by-and-bye, the bronchial blowing will exist as a pathognomonic indication of the affection, under which, sooner or later, the patients will succumb. The nature of this complication explains its obstinancy. Catarrh is the most obstinate of all pulmonary affections, as well as the most uncertain in its course. Does not the simplest cold sometimes last longer than a pneumonia ? Do not these inveterate bronchial affec- tions keep people coughing for months, while a pure inflammatory pneumonia is generally a transient illness? We can, therefore, understand the persistency of a pulmonary affection in which the bronchitic element predominates. Apart altogether from the mor- billous influence, bronchial catarrh is an exceedingly tedious malady in children. Its custom is to give way for a short interval and then reappear, subsiding and reappearing, it may be, two, three, or four times before final recovery is established at the end of two or three months. Likewise, after the lapse of two or three months, it may prove fatal. As the pulmonary affection in measles is essentially catarrhal, it is not surprising that the broncho-pneumonia should last thirty or forty days both in adults and children. Independent of catarrh, its essential element, morbillous broncho-pneumonia possesses a virulence of its own, which is the expression of a prin- ciple, specific, contagious and septic, which increases its obstinacy and severity. The same obstinacy which characterises morbillous peripneumonic catarrh is met with in other external manifestations of measles. Thus, the simple ophthalmia, which is part of the disease, may go on for months. This exanthematous ophthalmia, as it has been called by Wardrop, is sometimes formidable, leading to granular 230 MEASLES. and ulcerated conjunctiva, phlyctaenula, and pterygion. Mackenzie states that he has seen cases in which the eye was destroyed by violent muco-purulent ophthalmia consequent on measles. Such cases, however, are rare. In general, the affection is limited to a more or less decided redness of tbe conjunctiva, accompanied by intolerance of light, moderate pain, and lachrymation : but I repeat, that these ophthalmic affections are very obstinate, from the influence of the specific morbid cause on which they depend. Cases of puru- lent ophthalmia often have their starting-point in measles. The remarks which I have now made on inflammatory affections of the conjunctiva are equally applicable to inflammations of the nasal mucous membrane. Are there not many children and adults who, free before measles from all these evils, have afterwards chronic eczema of the nasal fossae, eczema invading and causing tumefaction of the upper lip, and sometimes extending into the posterior nares, even into the Eustachian tube, where it occasions swelling, which in its turn causes deafness P These inflammations of the eyes and nose may lead to serious consequences. "When child or adult of scrofulous diathesis is attacked by measles, the latter may, like scarlatina, give development to the already declared or hitherto latent morbid tendencies. These morbillous inflammations may be the starting-point of the evolution of the scrofulous diathesis, which will put its stamp on the lesions of which we are speaking, determining glandular swellings going on to suppuration, and leaving indelible cicatrices. These manifestations of diathesis are not the only manifestations of this kind to which measles may give rise. In children who have been rapidly carried off by it, we often find bronchial glands more or less considerably engorged. Just as in scarlatina, we find engorge- ment of the glands of the neck, and in dotliienteritis engorgement of the glands of the mesentery, so in measles we find engorgement of the bronchial glands. This condition is the consequence of the inflammation of the bronchial tubes, just as cervical adenitis is the consequence of the pharyngeal sore throat of scarlatina, and mesen- teric adenitis the consequence of the intestinal inflammation in putrid fever. When the catarrhal inflammation of the bronchial tubes is of long duration, and the patient is in subjection to the tubercular diathesis, the glandular engorgements assume the characteristics of that diathesis: on dissection, we find the glands converted into MEASLES. 231 tubercular masses. This remark is applicable to childhood, adoles- cence, and adult age. At all ages, measles may occasionally become the cause of the development of tubercles, when the individual carries within him the hereditary germ of the disease; and tuber- cular disease runs its course with much greater rapidity when its start has been accelerated by the exanthematous fever. It is under such circumstances that phthisis takes the acute form: it is rapid, but it differs greatly from the galloping consumption of typhoid form, regarding which I shall afterwards have to speak to you. I have already told you that measles may determine an attack of otitis. It is generally only a catarrhal affection : but the inflamma- tion may extend from the external auditory passage to the middle ear, whence it may be continued to the mastoid cells and petrous portion of the temporal bone. The situation of the patient is then very hazardous : for caries of the bone may lead to abscess of the brain, and inflammation of the mastoid cells may produce purulent infection. One of your masters, Professor Gosselin, has found that inflammation of the osseous tissue, or more correctly osseous phle- bitis, is the most active of all the causes of purulent infection; and this condition exists when there is inflammation of the mastoid cells and temporal bone. I am indebted to my former pupil Dr. Peter for the particulars of a case which beautifully illustrates what I have now been saying. On the 3rd April, 1865, Dr. Peter was sent for to Boigneville, to see in consultation a boy of twelve years of age who was dying from the after-disorders of measles. Two months previously, he had had the eruptive fever at one of the colleges of Paris. During his con- valescence, his relations resolved to take him home with a view to hasten his recovery. At that time he had no cough, nor other symptoms of thoracic complication: moreover, he was of a robust breed; and there was nothing to lead to the supposition that tuber- culosis was impending. All that remained of his attack of measles was an inflammation of the left ear, from which there was a profuse discharge of exceedingly fetid greenish pus. Six days before the consultation with Dr. Peter, the young convalescent had been seized with violent shivering, soon followed by sudden intense pain in the right scapulo-humeral articulation. Prom that time he kept his bed, lost his appetite, and had daily paroxysms of fever with re- peated rigors. Pour days after the attack of pain in the shoulder, lie had a similar seizure in the right coxo-femoral articulation. 232 MEASLES. When Dr. Peter saw the patient, there were enormous swellings in the right shoulder and right haunch, and an oedematous puffiness over the chest, abdomen, thighs, and the parts in the vicinity of the affected joints. He could not in any degree spontaneously move the affected joints, and every movement communicated to them by others occasioned frightful pain. He was in a high fever, the pulse beating 160 in the minute : he had dyspnoea, with fine rales dis- seminated over the chest: and was in a state of constant low delirium. He was, moreover, suffering from jaundice, the date of which could not be ascertained, and regarding which there did not seem to be anxiety. Two facts were elicited by percussion over the liver; viz. that it was greatly enlarged, and that at certain points it was painful on pressure. Dr. Peter, connecting the jaundice with the state of the liver, the state of the liver with the articular lesions, the articular lesions with the pains which had preceded and the shivering which had accompanied them, concluded that it was a case of purulent infection; and he likewise inferred that there were metastatic abscesses in the liver, perhaps also in the lungs, and that there was unquestionably suppuration in the joints. Without hesi- tation he recognised as the starting-point of the purulent infection, the deep-seated otitis, with its associated caries of the mastoid cells and petrous portion of the temporal bone. Everything concurred to justify this induction. There was the character of the suppuration —its profuseness, and excessive fetor (so characteristic of osseous suppuration), and its abrupt suppression on the occurrence of the shivering and articular pains. This diagnosis was accepted by the physician in charge of the case, who had, however, at first concurred with a physician of a neighbouring town in the perfectly inadmis- sible hypothesis, that it was a case of acute tuberculosis of the arti- cular extremities. The unhappy parents, dismayed at Dr. Peter’s prognosis, called in my friend Dr. Blache next morning, who made exactly the same diagnosis. Tb* patient died during the day. I entirely concur in Dr. Peter’s diagnosis. I feel convinced that there was purulent infection in this case; and making a retrospective review of other cases I have seen, but have not very exact notes of, I explain them in the same way. Be guarded then, gentlemen, in your prognosis, when you meet with deep-seated otitis as a sequel of measles or scarlatina : be assured that the inflammatory action is not simple, that it derives an exceptional gravity from the eruptive MEASLES. fever, and exists in a subject whose organism has been thereby seriously impaired. Gangrene of the mouth and vulva occur as sequelse of measles, particularly in hospitals appropriated to young children. These affections are well known to the sisters attached to the service of the hospital in the rue de Sevres : when they have to nurse cases of measles, they take double precautions to secure cleanliness, particu- larly in respect of the little girls under their charge. When these precautions are neglected, small excoriations are seen on the vulva. In themselves, there is nothing serious in these excoriations, which are produced the more easily that the mucous membrane of the genitals is not more exempt than the other mucous membranes from morbillous influences. But if the patient is in the midst of concen- trated epidemic influence, such as too commonly exists in a children's hospital, the excoriations on the vulva may become a way of entrance for gangrene. The affection may at first escape notice, but a con- siderable swelling soon appears at the side of the labia majora and probably extends into the groin. The skin over the tumour is of a bright red colour, the subjacent tissues are hard, and examination by the touch leads to the diagnosis of a deep-seated abscess. On separat- ing the vulva, we discover pultaceous concretions of a whitish, some- times of a greyish colour: they have generally a very foetid odour, and sometimes extend back to the anus. Under such circumstances, there is no time for temporising: energetic treatment must be imme- diately resorted to. The day after the appearance of the concretions, the cellular tissue may be in a state of gangrene, and the labium sphacelated in its entire thickness. The gangrene may invade the vagina, and even perforate the peritoneum, in which case death rapidly ensues. The danger can only be averted by prompt and vigorous treatment. Cauterize the parts with fuming hydrochloric acid, nitrate of silver, or sulphate of copper; and if the caustics are not sufficient to stop the progress of the gangrene, you must resort to the actual cautery, then your sole resource. Diphtheritis may sometimes also have measles as its starting-point. When such is the case, it generally assumes a malignant character, whether developed in the mucous membrane of the vagina, or in the folds of the skin, where in children the nature of the skin is so similar to that of mucous membrane; or whether, as is most usual, it appears on the mucous lining of the mouth, pharynx, and nose. Purpura is another serious complication of measles, regarding 234 MEASLES. which I said a word at the commencement of this lecture. It pre- sents itself in a form very different from the morbus Timnorrhagicus of Werlhoff, and very different also from the acute purpura with which we are acquainted. I have only seen two cases of this com- plication of measles. Fifteen or sixteen years ago, I was asked to meet Dr. Coqneret in consultation, in the case of a girl of five years of age who had just had an attack of measles. The fever had been constantly accom- panied by stupor, which is unusual in this disease. The eruption came out: but the exanthematous patches were of a dark colour— that haemorrhagic hue which does not disappear under pressure of the finger. On the eighth day, slight delirium supervened, and epistaxis, which had occurred with usual moderation during the first period, became much more profuse. The relations, alarmed at the nasal haemorrhage, called me in. The child had lost a great deal of blood. We recommended nasal injections of decoction of rhatany, of very warm water, of a solution of sulphate of zinc, and of a solution of sulphate of copper. The epistaxis moderated. After some hours, however, other haemorrhages supervened : she had haematuria, bloody stools, and haematemesis. Finally, within two days, ecchymotic spots appeared on the back; and the child sunk in a state of extreme anaemia. We did not obtain an autopsy: but judging from what I have seen in the bodies of persons dying under similar circumstances, I think we should probably have found ecchy- mosis around the kidneys, under the peritoneum, and also perhaps (as is occasionally met with) under the coverings of the heart, and under other visceral membranes. It thus appears, that in certain conditions difficult to appreciate, but in which very probably the epidemic constitution plays its part, the poison of measles may impart a special character to this terrible form of haemorrhage, just as small-pox does sometimes, with this difference, that in black small-pox the haemorrhages -generally occur in the first, and in measles, in the last period of the disease. Dr. Chairou in a remarkable work, to which a prize was adjudged by the Academy of Medicine, has given the history of a very severe epidemic of measles which prevailed at Eueil in 1862. It was characterised by the exanthem not having much intensity, and in being accompanied by profuse perspiration, and a vesicular eruption analogous to the miliary rash . of lying-in women. Dr. Chairou proposed to give it the name of sweating-measles [rougeole-sueite]. MEASLES. 235 For my own part, I do not believe in such a complication of measles as sweating properly so called, any more than I believe in lying-in women being attacked by miliary fever. However, the Eueil epi- demic was characterised by very unusual phenomena. From the first, in addition to epistaxis and vomiting, typhoid complications were observed, and at a later period of the attack, thrush, aphthous ulcerations, and ulceration of the periosteum leading to necrosis of the maxillary bones. Numerous abscesses in the face and neck were seen, such as are often observed in small-pox and scarlatina. The other mucous membranes were often coated with diphtheritic secre- tion, and the skin, under the influence of blisters or from other causes, was liable to excoriations. To these symptoms, convulsions were frequently added, and their occurrence, even at the beginning of the attack, almost invariably foretold a fatal issue. The mortality from this epidemic of measles was as great as that resulting from ordinary epidemics of typhoid fever. As I have already stated, the nervous complications of measles generally occur at the beginning of the attack: they may, however, recur in the last stage of the disease, when they are not dependent on the fever itself, but on some superadded cause. For example, when broncho-pneumonia and peripneumonia supervene in children who have had convulsions at the period of invasion, these pulmonary affections may occasion a return of the convulsions, which are then preceded and followed by cerebral disturbance characterised by stupor. The fits last for two, three, or four days, or sometimes only for a few hours or minutes : they generally carry off the patient. The nervous complications of the last stage of measles, which origi- nate generally in a formidable chest affection, are never met with in infants. Measles, then—the complications of which I have now reviewed— may terminate in convulsions; but it must be remembered, that convulsions at the beginning of the disease are not serious, whereas in the last stage—that is, after the eighth day—they involve the worst possible prognosis. LECTURE VII. RUBEOLA. Very Liferent Disease from Measles. — Stands in the Same Delation to Measles as Chicken-pox to Small-pox.—Does not produce Catarrh of the Mucous Membranes.—No Serious Sequela. —May attack the same person more than once, and does not confer Exemption from Measles. Gentlemen :—A great many physicians fell into the same sort of confusion regarding rubeola as that which still prevails regarding chicken-pox. Rubeola was once considered a modified form of measles, just as chicken-pox has been looked on as modified small- pox. Although some authors still confound variola and varicella, all agree that there is an essential difference between rugeola and rubeola. Though they admit that there is at first view an apparent similarity between the latter two, they describe rubeola, the exan- thematous fever, about which I am now going to say a few words, as a perfectly distinct nosological species. This disease was known to old authors under the various names of ruleola, roseola, and exantheme fugace: it is called essera Vogelii by Borsieri. Rubeola is, like measles, characterised by an exanthematous eruption consisting of irregular spots, the outbreak of which is almost always preceded by febrile phenomena. The general symp- toms which show themselves usually for one or two, and rarely for three or four days, are much less marked than in other eruptive fevers. Sometimes, they do not amount to more than a slight feel- ing of discomfort. Generally, however, the feeling of discomfort is considerable, and is accompanied by well-marked fever, rigors, head- ache, loss of appetite, urgent thirst, excitement, or, it may be, by great prostration. In very young children, it is not unusual for the disease to set in with vomiting, diarrhcea and convulsions. RUBEOLA. 237 The circumstance, however, which at once distinguishes rubeola from measles is the absence in the former of catarrh (ocular, nasal, and bronchial), an essential prodromic phenomenon of morbillous fever. The lachrymation, coryza, and cough which belong to measles are never seen in rubeola. There is a great difference between the eruption of the two dis- eases. The rubeolic do not, like the morbillous patches, project from the surface of the skin. The rubeolic patches are paler, larger, more distinct from one another, and more isolated by inter- vals of unaffected skin: they disappear under pressure by the finger, and immediately reappear when the pressure is removed : they occasion intense itching, and are, to use Vogel’s expression, ardentes et prurientes. They are situated on all parts of the body, but are most abundant on the trunk and limbs. They do not present the regularity of the morbillous patches in the way they come out, their progress, and mode of disappearing. Exceedingly fugitive, remaining visible for twenty-four or forty-eight hours, they in some cases disappear, without desquamation and without leaving any trace of their pas- sage ; and they disappear and reappear alternately for seven days. When once the eruption has finally disappeared, the malady is at an end, and there is nothing to fear from complications so threat- ening in convalescence from measles. Nor are there, as in the latter, any unfavourable symptoms to be dreaded in the prodromic or eruptive stages. Eubeola is the mildest of the eruptive fevers. It is never a serious malady, and always terminates spontaneously without the physician being required to interfere. It has sometimes prevailed as an epidemic, as Erank states; and though the contrary has been held, I believe that it is a contagious disease. I do not say that it is contagious in the same degree as measles, but among the various causes of rubeola, I hold that contagion incontestably has a place. The leading fact which enables us to separate rubeola from ru- geola, is that an attack of the one does not protect from an attack of the other, any more than an attack of varicella protects from an attack of variola, or of variola from varicella. Again, the same person does not generally contract measles more than once: but one attack of rubeola does not protect from other attacks. Borsieri, indeed, has said that a person who has had it once is more liable to have it again:— “ Qui sernel Us laboravit, facile iterum pluriesque prehenditur.” 238 RUBEOLA. Persons of all ages and both sexes take rubeola; but women are more susceptible to it than men, and children are more susceptible than either. A hot season, or to speak more correctly, a high tem- perature, by exciting to copious perspiration, has a great influence upon the production of the rubeolic exanthem. I shall have occa- sion to return to this subject when I specially discuss the question of sudoral eruptions. I will then tell you how to distinguish the varieties of rubeola occurring in the course of other diseases. Por the present, I will only remark that syphilitic rubeola cannot be in- cluded among them. Nature, pre-eminently specific, has placed a special stamp upon the venereal disease of which a form of rubeola is a characteristic manifestation : the course and duration of rubeola syphilitica point out that it is not a variety of the exanthematous fever I have been speaking of, but an affection belonging to another nosological group. LECTURE VIII. ERYTHEMA NODOSUM. A Specific and Separate Disease.—Successive Eruptions.—Articular Pains.— General Symptoms.—A Possible Manifestation of the Rheumatic Diathesis. Gentlemen :—You will only find a few lines devoted to the sub- ject of erythema nodosum [ erytheme noueux] in your pathological text books. Authors seem only to mention it, that it may be re- membered as one of the principal varieties of erythema, the whole history of which they give in one short chapter. Their descriptions appear to me insufficient; for the malady, a case of which I am going to show you in the wards, deserves to occupy a much larger space in nosological manuals. Correctly speaking, and notwithstanding the generic title by which it is known, and to which for want of a better name I adhere, erythema nodosum is no more a variety of erythema than small- pox is a variety of ecthema, although, considered by itself, the variolous pustule often resembles, and may be mistaken for, a pus- tule of erythema. Erythema nodosum is a specific and separate disease, which manifests itself locally by characters so precise as not to admit of being mistaken. It also presents a group of general symptoms necessary to be taken into account. They almost always precede the appearance of the erythematous eruption, and are no more dependent upon the local cutaneous affection, than the pro- dromic fever of small-pox or measles is subject to the influence of the eruption which is going to come out. The local manifestations of the erythematous eruption seem so very well known, that it might be sufficient to indicate them in a few words. I think, however, that it will be useful to describe them in detail. Any one of you will be able to recognise at a glance the 240 ERYTHEMA NODOSUM spots more or less regularly oval, elevated towards the centre, the size of which varies from that of a few millimeters to two or three centimeters, of the diameter of a pea, a hazel-nut, or even a walnut. They project above the skin, forming real knobs or nodes. They rapidly increase in their elevation above the skin, and become small hard tumours of peculiar aspect. They are circumscribed in such a way as to look as if their base was set in the thickness of the skin and cellular tissue, and as if they could be seized between the fingers. On their first appearance, they are of a red colour, which is the brighter the less the distance is from the centre, and this colouration extends beyond the nodosity. Passing from red to violet-red, it afterwards acquires a yellowish ecchymotic tint, or, gradually fading, gives place to a bluish tint, most decided towards the circumference of the nodosity, and easily disappearing under the pressure of the finger. I have never seen these tumours pass into a state of suppuration, although on pressing them I have felt a sensation of deep-seated fluctuation: in a few days spontaneous resolution has taken place. According to Professor A. Hardy, howr- ever, erythema nodosum may become chronic by the appearance of a succession of eruptions during several months, or even, it may be, during one or two years. When the disease takes this chronic form, the nodes on the legs sometimes become elongated, and then soften and ulcerate. The ulcerations are round, excavated, and of a greyish colour at the bottom : they resemble syphilitic ulcers. The attentive observation of the patient, the existence of non-ulcerated nodes, and an examination of the history of the case will prevent you making an error in diagnosis. This unusual aspect of the disease, this chronicity of erythema nodosum whether accompanied or not by ulceration, according to my colleague of the St. Louis Hospital, is dependent on a scrofulous taint. I dare not affirm, gentlemen, that the chronic erythema which I have described to you is the same disease of which M. Hardy speaks. Possibly, an anomalous cuta- neous affection suggested to that able physician an opinion which I hesitate to adopt. The favourite seats of erythema nodosum are upon the legs and arms, in situations where the skin is separated from the bone by a very thin layer of soft parts—on the forearm at the posterior edge of the internal aspect of the ulna, and on the leg on the inner aspect of the crest of the tibia. It is in this latter situation that the charac- teristic nodulated form of the tumours is most conspicuous. So ERYTHEMA NODOSUM. sensitive to pressure sometimes are the nodes over the tibia, even when lightly pressed, that the patients cannot tolerate the pain caused by the weight of the bed-clothes. The nodes are usually disseminated, separate [discretes, distincUe], and few in number; but at other times, they are more numerous, and in some cases become confluent from new nodes springing up beside former ones, and the two sets getting blended together, so as to form patches of greater or less size, of a more or less bright red colour, with irre- gular edges, somewhat resembling erysipelas, in their general ap- pearance. Although erythema nodosum has a predilection for the situations I have mentioned, it not only appears on all parts of the skin, but also on the mucous membranes. In a woman, whose case I am about to recall to your recollection, you saw an erythematous patch on the conjunctiva of the left eye. This patch on the conjunctiva is a pimple rather than a true node; and the spots on the thighs, arms, neck and face in erythema nodosum are generally papular. By- and-bye, when I come to speak of papular erythema, I will recall to your recollection the differences between the two forms of erythema, mentioning at the same time the phenomena common to both, and by which they seem to be assimilated; but I will now anticipate what I have to say by remarking, that it is very rare to see a case of erythema nodosum without pimples, while nodes are seldom seen in papular erythema. The eruption does not always all come out at once, but sometimes in successive crops, fresh nodes appearing in succession before their predecessors have faded. New crops go on appearing at longer or shorter intervals, the period of eruption being sometimes thus pro- longed to twenty-one days. The duration of the acute stage of the disease is from one to twenty-one days. So long as the general symptoms continue, and the fever does not abate, the appearance of new spots may be expected. I shall now state what took place in the case to which I have just alluded. The patient, a woman of 57 years of age, was admitted on the 15th December to bed No. 25 bis in our St. Bernard ward. She said that she had been ill for ten days: she complained of general discomfort, headache, articular pains in the left shoulder, and want of appetite : the tongue was red, the skin hot, and the pulse 100. I detected erythematous spots on the right thigh, and internal aspect of the right elbow. No abnormal sound was heard in the heart on 242 careful auscultation. Next clay, a spot appeared on the right arm, and a new spot on the left, in the same situation as the other. In respect of hardness, the spots resembled syphilitic gummse. On the 17th December, the eruption appeared on the external aspect of the left thigh, and the fever continued unabated. On the 18th, the spots were still more abundant, and some of them were papular. The tongue, red at the point and edges, was covered with a whitish fur. The pulse was still 100, and the skin hot. On the 20th December, we observed spots on both arms over the inferior portion of the ulna. On the thighs, the spots were confluent; and round one of the knees, the confluence was so great as at a first glance to suggest erysipelas. This was the day on which we saw an erythe- matous spot on the conjunctiva, at the outer angle of the left eye. There was some abatement of the fever: hut on the 22nd, it had regained its former intensity. On the same day, there was a fresh crop of spots; and the patches on the right thigh, some of which were as large as a five franc piece, were bright red, and very painful. The pain in the shoulder was more violent than when my attention was originally directed to it, and it was increased by the slightest pressure. The erythematous spot on the eye had faded, and there only remained in its place a little injection of the conjunctiva. O11 the 23rd and 24th, new spots appeared on the legs : on the 24th, however, the fever subsided considerably, and the pain in the shoulder greatly diminished. No fresh spots appeared after the 25th. From that day the patient felt much better, and convales- cence began. She left the IIotel-Dieu, completely recovered, during the first week of January. Convalescence, gentlemen, is sometimes tedious, almost as pro- tracted as in some putrid fevers. The articular pains which precede and accompany the eruption seem to me to be characteristic of erythema nodosum. The general symptoms consist in a universal feeling of discomfort, in lassitude and aching of the legs, headache, want of appetite, and a loaded state of the digestive canal; and in fever more or less severe during a prodromic period which varies in duration from one to five days. II hen once the eruption is accomplished, recovery generally takes place in one, two, or three weeks; but again I repeat, that the duration of the malady may he much more protracted, and that so long as the general symptoms continue new eruptions may be looked for. ERYTHEMA NODOSUM. ERYTHEMA NODOSUM. 243 Articular pains are complained of almost at the same time that the general symptoms set in ; they sometimes continue as long as the eruption lasts, and even after it has disappeared. They come on spontaneously, are aggravated by pressure, are sufficiently acute to hinder movements, and sometimes even entirely to prevent them, as was the case in a young woman in our St. Bernard ward who kept her fingers flexed from inability to extend them. They are sometimes limited to a single articulation, and in other cases, as in the young woman just referred to, they extend to all the joints. The pain is sometimes as acute as in pure rheumatism; but I have never seen redness or swelling in the situation of the affected parts ; nor have I ever found signs of cardiac lesion. The existence of these articular pains seems to indicate that ery- thema nodosum is of the nature of rheumatism. The best authors have pointed out the mutual relations of rheumatism and erythema nodosum. This has been done in France by Dr. Bouillaud,1 and in Germany by Professor Schcenlein, who has given to erythema nodo- sum the name of rheumatic purpura. Dr. Bazin, an accomplished physician of the St. Louis Hospital, has not hesitated to place it at the head of his pseudo-exanthematic erythematous arthriiicles; and Bayer2 has described a papular erythema occurring in persons suf- fering from acute rheumatism, which to the eyes of Dr. Bazin is erythema nodosum itself. I was formerly in the habit of attaching a great deal of importance to the articular pains, and tried to subdue them by giving prepara- tions of sulphate of quinine, or veratria. Afterwards, from a study of the natural course of the disease, I perceived that they generally yielded without the intervention of art, and I then restricted my treatment to keeping the patients in bed, and telling them to avoid chills. These hygienical means and cooling drinks now constitute my whole treatment of these pains. "When the stools are slimy, and indicate a loaded state of the digestive canal, I endeavour to correct that state by administering mild purgatives. Erythema nodosum is not a common disease of children, but I cannot exactly say that it is rare among them. One of my pupils lately told me that he had seen it in two brothers, one aged two and a half and the other four years of age. 1 Botiillaxjd :—Traite Clinique du llhumatisme Articulaire. Paris, 1840. 2 Hayek:—Traite des Maladies de la Pcau. Paris, 1835. LECTURE IX. ERYTHEMA PAPULATUM. Differs from Erythema Nodosum in the Form and Seat of the Eruption, and in the Severity of the Symptoms.—Rheumatic Character. Gentlemen:—Although erythema papulatum [erythemepajouleux] and erythema nodosum have obvious affinities with each other, I should not wish you to take up the idea that they are identically the same disease. They have undoubtedly something in common, just as small-pox and chicken-pox have something in common ; but in my opinion, they possess characteristic differences which allow us to regard them as two distinct species. Recall, gentlemen, the marked difference between the physiognomy of disease in two women whom you saw with erythema nodosum, and in three patients with erythema papulatum, two of whom are in the St. Bernard ward, and one in the St. Agnes ward. The patients with erythema nodosum pre- sented, relatively to the other group, very mild symptoms, though the cases were severe for the affection; while the three with erythema papulatum had very formidable symptoms, so formidable in one of them as to occasion death. Do not suppose, gentlemen, that the disease is formidable in proportion to the intensity of the eruption, as is the case in small-pox and scarlatina. The forms, the seat and the mode of evolution of the eruption are so various as to establish the diversity of the nature of the two diseases. Again, erythema papulatum is accompanied by serious pulmonary lesions, and some- times by articular rheumatism and endocarditis, whereas erythema nodosum has no such accompaniments, or at least is not attended by pulmonary lesions. You will easily understand this distinction, when I recall to your recollection the history of cases which you have had an opportunity of studying with me in the clinical wards, ERYTHEMA PAPULATUM. 245 and which you will be able to compare with the history of cases of erythema papulatum. Let me first recapitulate the case of the man who occupied bed No. 24 in St. Agnes's ward. He was an assistant-cook, who had lived in Paris for the four months preceding his attack, during which period he had enjoyed good health. He was admitted into hospital on a Friday. On the previous Sunday, he had felt, as precursory symptoms, stiffness and pricking in the eyes. He also experienced pains in the wrist and joints of the middle finger, which on the following day became so violent as to interfere with the movements of the parts affected, to the extent of preventing him from opening and shutting the hand. In the evening of the same day, he had pains in the knee. There were, however, neither fever nor loss of appetite. Prom the Sunday also, he had perceived on his hands an eruption of uniform redness. On the Tuesday, the backs of both hands, the cheeks, and the fore- head were covered with pimples, and there was some fever. Upon his admission into hospital, I observed this papular eruption, upon a ground of a winy-red hue, raised above the parts of the skin which were not affected. Besides some pustules of acne on the inferior extremities, we saw a small patch of erythema nodosum on the left leg : this patch was painful. In no other situation than those named did we find any trace of eruption, except in both conjunctivse, the sclerotics of which were injected with livid red. The edges of the eyelids were also red. On the Thursday following—the seventh day after admission and the twelfth from the beginning of the attack— I observed a little obstruction of the lungs characterised by cough and mucous sub-crepitant rales in the posterior part of the base of the left lung. The patient, nevertheless, asked for food and did not remain in bed. Two days afterwards—on the fourteenth day of the malady—the erythematous patches were much paler, but new pimples had come out in the situations in which they had been first seen. Por forty days, his general condition was very unfavourable, and the fever continued. There were five or six successive eruptions. The patient became exceedingly thin; and on the sixtieth day from his seizure, he was as -weak as if he had had an aggravated attack of dothienteria. I11 connection with the case now detailed, I will relate that of a woman who lay in bed No. 11 of St. Bernard's ward, in whom the disease proved rapidly fatal. Her age was sixty. She had long suffered from pulmonary emphysema, and on admission had bron- 246 ERYTI1EMA PAPULATUM. cliitis accompanied by fever, and a state of stupor which to me did not seem to be dependent on the state of the bronchial tubes. Tor several days, the chest was auscultated with very great care, with a view to discover whether there was any point affected with peripneu- monia. Three days after admission, erythema nodosum was detected on the legs and erythema papulatum on the backs of the hands. This woman, by occupation a washerwoman, had had several attacks of rheumatism, and it was through exposure to cold and damp that she had contracted the catarrh which brought her to the hospital. The bronchitis soon became general, and on the twentieth or twenty- first day terminated fatally, having become complicated with double hypostatic pneumonia. On examination after death, we found sero- sanguinolent engorgement of the lower third of both lungs, and a muco-purulent fluid in the minute bronchial tubes. You have lately watched the evolution of erythema papulatum in a woman who occupied bed No. 33 of the same ward, and whose life was in great jeopardy for more than fifteen days. I regard her case as one of the most conclusive I have met with in support of my opinion, that erythema is essentially a constitutional affection. Here are the facts drawn up by M. Dumontpallier:— “A young woman of thirty-eight years of age, who, though a rheumatic subject, had enjoyed very fair health for several years, was admitted to the St. Bernard ward with all the symptoms of an attack of fever. She had general prostration, lassitude, pains in the legs, quick pulse, foul tongue, nausea, sweating, and constant headache. The patient had had these symptoms for several days, but there was nothing in their duration, nor in the predominance of any one of them, to lead us to suppose that the case was an erup- tive fever; nor was there any ground for believing that an organic lesion existed. She merely stated that some days before she came into hospital, she had had pain in both knees. On the day of her admission, there was no trace of articular swelling, and no joint was the seat of decided pain : nevertheless, the persistence of the sweat- ing and fever, combined with the dull white colour of the skin, suggested rheumatic fever. There was from her first day in hospital, moreover, a slight blowing sound audible over the apex of the heart. The question arose:—Was this abnormal sound the result of a fesion originating in previous rheumatism, or was it dependent upon exist- ing sub-acute endocarditis ? She had neither palpitation nor pain in the region of the heart. Not finding anything to account satis- ERYTHEMA PAPULATUM. 247 factorily for the continuance of the general symptoms for so many clays, and having abandoned the hypothesis that they belonged to an eruptive fever, I examined the skin, to see whether I could dis- cover any trace of an ephemeral eruption. The examination was not without results: on the arms and fore-arms, as well as on the thighs and legs, I observed an eruption of papules of various sizes. On the external aspect of the middle of the left arm, they formed slightly elevated confluent patches: they were of a rosy colour, soft to the touch, and disappeared on slight pressure, reappearing on the pressure being removed: it was observed that the papules were in several places grouped in such a way as to present the appearance of semicircles. Similar isolated patches were seen on the palmar aspect of the left arm and fore-arm. The patient wras not aware of the existence of the eruption, which had occasioned neither heat not itching. On the anterior and external lateral aspect of the thighs and legs, there were a very few similar patches, which were but little elevated. She was astonished when we pointed out to her nodulated spots on the anterior surface of the leg: these spots were pale red, elevated above the surface of the skin, and rested on a bump as large as a small filbert-nut: here we undoubtedly had erythema nodosum. On the following days successive eruptions appeared, and they were beyond the possibility of doubt erythema- tous. In point of fact, new papules and new bumps appeared in crops, just as successive crops of eruption come out in chicken-pox on the arms and legs. The bumps were confined to the legs and one of the thighs. The erythema papulatum was particularly well marked in the left arm, in the situation of the insertion of the deltoid muscle: several crops of papules appeared there successively, and after three or four crops the papules were as red and raised as on any other part of the body. Simultaneously with each erythematous eruption, there was a febrile exacerbation, accompanied by rheumatic pains in the knee-joints, wrists, ankles, hands, and feet. The skin continued moist. Auscultation, which, from the day of the patient's admission, had revealed the existence of sub-crepitant rales throughout the whole of the posterior part of the chest, soon after- wards disclosed double pleurisy, unaccompanied by stitch in the side, and attended by very little cough. Over the inferior angle of both scapulae, a blowing sound and egophony were heard. There was also effusion on both sides which did not ascend higher: it was more persistent on the left than on the right side. The fever lasted ER YTHEM A P A PULATU M. for fifteen days after her admission. For the last two days, how- ever, of that period, it was more moderate, the perspirations were less profuse, and there were no longer articular pains. There was no fresh eruption, and the old papules had entirely disappeared. The bumps were no longer appreciable to the touch, and no traces of their former existence remained except ecchymotic staining of the skin. The appetite had returned, the tongue was good, and the double pleurisy was undergoing resolution.” Upon comparing with each other all the facts in this case, you will find that they possess a common physiognomy. There was violent and continuous fever, profuse perspirations particularly at night, a very formidable pulmonary affection, and an illness lasting much longer than could have been anticipated from the first symptoms. I do not wish, gentlemen, to omit stating some circumstances which seem to tell against my opinion. As I mentioned to you already, I have often met with erythema nodosum and erythema papulatum differing from each other, but have never seen a case of erythema nodosum in which there were not numerous papules, and I have sometimes met with true nodes in erythema papulatum. A gain, in both we meet with articular pains and even endocarditis, though not so frequently in erythema nodosum as in erythema papulatum. I do not consider, however, that because these phenomena are common to both diseases, both are, therefore, identical. It is no more necessary to believe that, than to hold that scarlatina and small-pox are identical because a scarlatiniform eruption has been seen at the beginning of an attack of modified small-pox. There is unquestionably a great similarity between the ataxo-adynamic symptoms of typhoid fever and of pyaemia, but no one will deny that these two diseases are essentially distinct and different. In the cases which I have laid before you, it is difficult to avoid seeing a confirmation of the views of my colleague at the St. Louis Hospital, Dr. Bazin, regarding the arthritides. According to him both erythema nodosum and erythema papulatum are arthritic affections. Though they differ in form, he holds that they are identical in essence : they both spring from one common diathesis—the arthritic. This doctrine, eminently medical, explains our meeting with in the same patient on the one hand evidence of previous articular rheu- matism, and on the other, the co-existence of the cutaneous erup- tions with cardiac and pulmonary affections. It is not then ery- E R Y T H E M A PAP U L A T U M. thema papulatum which is formidable, but the diathesis of which it is an expression. There are, however, cases of erythema papulatum exceptionally mild, which may in this respect be compared with cases of ery- thema nodosum. There is at this very moment in bed No. 33 of the St. Bernard ward a woman of fifty years of age in whom ery- thema papulatum is very confluent on the face and neck, and still more on the hands and fore-arms, but who is without fever, arti- cular pains, gastric or pulmonary symptoms. Hence it is evident, that there are degrees of severity in erythema papulatum, as in any other eruptive disease; but this does not in any way go to prove that as a general rule one of the twro is a much more serious malady than the other. Gentlemen, erythema papulatum like erythema nodosum declares itself by general symptoms—by general discomfort, fever, and a suburral state of the digestive canal. These prodromic symptoms are usually met with, though they were absent in our patient in the St. Agnes ward. The duration of the prodromic period is variable, and lasts from one to five days. Along wflth these general symptoms, there set in, as in erythema nodosum, articular pains which are sometimes of such severity as to impede, or even completely pre- vent, the movements of the body: these pains continue during the eruptive period, and are often prolonged till after its conclusion. Endocarditis occurs in some cases, as you have had an opportunity of observing. Erythematous rheumatism, like scarlatinous rheu- matism (which is much less severe and less obstinate than acute articular rheumatism), often assumes an exceptionally intense form. The eruption consists of patches of a winy redness, sometimes placed near each other, and sometimes disseminated : they may be either quite round, or they may be of irregular shape. These patches, constituted primarily by small tumours painful to the touch, fade, flatten, and pass from a red to a violet-red colour. M. Hardy says that the patches are sometimes complete circles surrounding portions of sound skin. The eruption ends with slight desquamation. Vesicles have been observed on the patches : their duration is very ephemeral: they dry up quickly, leaving no trace behind, whether they burst or whether they disappear in consequence of their serous contents being absorbed. The eruption is often indolent. It may be accompanied by a feeling of heat, burning, or itching. It is a characteristic circumstance that 250 ERYTHEMA PAPULATUM. the eruption has a preference for the hands, fore-arms, face, and neck. It is less frequently seen on the inferior extremities, differing in this respect from erythema nodosum, which prefers the continuity of the limbs, and particularly the parts, where there is only a very thin separation between the skin and the bone. Erythema papu- latum lasts for fifteen or sixteen days. The treatment ought, as in simple erythema nodosum, to be re- stricted to precautionary and hygienical measures. When the arti- cular pains are not severe, no interference is called for. When the thoracic complications assume a formidable character, and when the rheumatism becomes general and invades the heart, the treatment required will just be that which is appropriate in cases of pleurisy, broncho-pneumonia, or polyarthritic rheumatism. LECTURE X. ERYSIPELAS; AND IN PARTICULAR ERYSIPELAS OF THE FACE. Pathology of Erysipelas.—Almost always an Exciting Cause, in- dependent of Individual Predisposition and General Cause.— May Supervene in the Course of Epidemics.—Severity increased by Traumatic Influence.—General Symptoms dependent on In- flammation of W'ound and Lymphatic Vessels.—Delirium has not the Signification attributed to it in Erysipelas.—Erysipelas sometimes Contagious.— When not a Complication of another Disease is a Milcl Affection which Subsides Spontaneously.—The Treatment ought to be Expectant. Gentlemen :—We have at present several patients affected with erysipelas—a young girl in bed No. 6 of the St. Bernard ward, a young woman of twenty in bed No. io of the same ward, and a young man between twTenty-five and twenty-six years of age, occu- pying bed No. 8 in the St. Agnes w'ard. The manner in which these three persons wrere seized was very nearly similar, and in all of them the erysipelas of the face has assumed the same form. In bed No. 4 of the men’s ward vre have seen a fourth patient with erysipelas; but his case has been invested with special interest in consequence of the course which the disease has taken. This man, from the date of his admission, had a very violent sore throat, with consequent affection of the sub-maxillary glands. At my first examination of him I predicted that by the next visit the case would have declared itself as erysipelas of the face; and the event justified my prognosis. My opinion was founded on the pre- sence of certain phenomena, to which I directed your special atten- tion. Three days previously, the patient had experienced exceed- ingly severe pain in the throat; next day, the sore throat was well ERYSIPELAS. marked; and on the day following, the severity of the pain had increased, while at the same time intense fever set in and a large glandular swelling formed at the angle of the lower jaw. On de- pressing the tongue and examining the pharynx, we found a vivid redness of the uvula, veil of the palate, and pillars of the tonsils. From these symptoms, I came to the conclusion, that the case was either catarrhal sore throat, or erysipelatous inflammation of the pharynx. But as catarrhal sore throat is in general not nearly so painful as erysipelas of the pharynx; as the swelling was not so great, as the redness was less vivid, as the fever was more severe and the cervical glands more swollen than is usual in the former, my ultimate diagnosis was erysipelas. With my diagnosis thus settled, I had to wait till the malady should proceed to the nasal fossae, and by that route reach the face. Well! the erysipelas which during the night had begun to appear at the orifices of the nostrils, forthwith extended to the nose; next morning, the pain of the throat and the redness of the pharynx had disappeared, and the malady pursued precisely the same course which we see it follow, when we wratch its evolution on the skin. From the nose, it ex- tended to the cheeks, from the cheeks to the eyelids and forehead, whence it advanced to the hairy scalp, and so on it proceeded, till it had made the circuit of the head, resting from two to four days in one situation and then invading the adjoining place. It is very important to be acquainted with this line of march which erysipelatous inflammation follows. Ten years ago, my friend Dr. Gubler was the first to point out that erysipelas of the face is only a propagation of the disease from the pharynx,1 and not a metastasis as had before that been often repeated.2 The propagation may proceed, as was also shown by the same able physician, in an inverse order; that is to say, the erysipelas may begin in the skin, and proceed from it to the mucous membranes. Erysipelatous in- flammation of mucous membranes must not be confounded with other kinds of inflammation to which they are liable. In a practical point of view this is very important. No doubt, I shall have occasion to return to this topic in the course of my lectures. But 1 Gttblek :—Societe de Biologie, 1856. 2 Upon this subject, see the more recent researches of Y. Coknil, entitled “ Observations pour servir a l’histoire de PErvsipele du Pharynx [Archives Ge- nerates de Medecine, 1862] ; and J. Ciure :—“ De l’Erysipele du Pharynx.” [These Inaugurate']. Paris, 1864. ERYSIPELAS. 253 to-day, gentlemen, the subject on which I have to address you is erysipelas of the face. Do not suppose that it is my intention to give you a complete history of the disease; for that you will find in the text-books which are in the hands of all of you. Chomel and Blache, in the Diction- naire de Medecine, and MM. Hardy, Behier, and Yalleix, in their treatises on internal pathology, have given exhaustive descriptions of erysipelas. I only propose, therefore, to speak at present upon some specialties in its pathogeny and treatment. Surgeons for the most part are agreed that when erysipelas appears in the wards of a surgical hospital its presence is dependent upon traumatic influences. A patient, for example, after having undergone a trifling operation, such as the opening of an abscess with the lancet, or the making of a small cut in the skin for some other purpose, is, after an interval, affected with general discomfort: the glands in the vicinity of the wound become enlarged, those of the groin for instance, when the wound is on the inferior extremity, and those of the elbow and axilla, when it is on the hand. The erysipelatous redness soon appears. In such cases, the cause of the affection is evident: everybody readily recognises its mode of deve- lopment : the existence of a predisposing cause either in the indi- vidual or in the circumstances with which he is surrounded is admitted: the existence is admitted of an epidemic constitution of the atmosphere in consequence of which the most insignificant ope- ration, at other times unattended by any such risk, is immediately followed by erysipelas. But the affection so arising is always traumatic, and you must be careful to distinguish it from what is called medical erysipelas. Many physicians are of opinion that medical erysipelas is not under the law to which surgical erysipelas is subject. According to Chomel and Blache, erysipelas is never the result of an external cause, and they say that if sometimes an accessory cause contribute to its production, it is only in a secondary manner. I think it is nearer the truth to say, that in the immense majority of cases both classes of causes are in operation. It is so, in the circumstances to which I have just alluded, when during an epidemic, cases of erysipelas seem to arise spontaneously; that is to say, without any appreciable exciting cause. Such of you as have attended the surgical wards know, that one or two years may elapse during which an attack of erysipelas is an unusual occurrence after an operation 254 ERYSIPELAS. however serious, and that at other times, the surgeon cannot make the slightest use of the bistoury without exposing his patient to this risk. This is the present state of matters. There is also now pre- vailing one of the severest epidemics of puerperal fever which has in recent times desolated the Maternity Hospital, where sixty patients have died within ten months from this terrible pestilence. At the very time when prudence compelled the physicians of that establishment to shut it up, and send the women to be confined in the other hospitals, erysipelas broke out in a severe form in a great . many of the surgical services, among those who had wounds. The coincidence of puerperal fever and traumatic erysipelas has been pointed out long ago, and Graves has taken up the subject with pre- cision in his clinical lectures: but it is to the Clinical Hospital of the Paculty of Medicine of Paris that we must specially refer for proof of the occurrence of this coincidence, as there, under the same roof, separate wards exist for surgical patients and for lying-in women.1 It is, therefore, an incontestable fact that under certain atmo- spheric conditions—under the influence of an unknown something in the air—individuals become disposed to take erysipelas from slight causes which would not have produced it at other times. Graves believes in this, and also in contagion. This is a subject to which I shall by-and-bye return, but I may now remark, that even when contagion operates, immediately exciting causes generally play a part not hitherto sufficiently appreciated. Observe with attention, and you will see, that the erysipelas described under the names of medical and non-traumatic (in contra-distinction to that termed surgical and traumatic), has almost always a starting-point, which though it cannot strictly speaking be called a wound, is at least a lesion—a very slight lesion it may be in some cases. In three of our patients, this was placed beyond doubt. The youug girl of bed Ho. 6 St. Bernard's ward had a suppurating pimple at the angle of the eye, which she scratched, and so excited in it an increase of inflammation. Prom this little breach of con- tinuity, erysipelas started which progressively invaded the cheeks, forehead, and hairy scalp. 1 See the report of the long discussion on puerperal fever in the Academy of Medicine :—“ De la Fievre Puerperale, de sa Nature et de Son Traitement Paris, 1858. ERYSIPELAS. 255 The woman occupying bed No. io had long had eczema of the nose, and there it was that the erysipelas commenced. From the nose, it extended to the eyes, face, and hairy scalp; in which latter situa- tion it is now beginning to show itself, after having become extinct in the other places. In the young man occupying bed No. 8 of the St. Agnes ward, erysipelas took the same course, having had likewise eczema of the nose as its exciting cause: and this is the third erysipelatous attack which this young man has had, the starting-point in each of them being his chronic eczema of the nose. Again I say, therefore, observe carefully the cases you meet with, and in nearly every one of them you will find a small lesion of the integuments at some point on the face, such as the corner of the eye, the nose, the lips, behind the ear, or in the hairy scalp. This you will find in many cases to be a herpetic ulceration of the face, or of the mucous membrane of the throat; and sometimes inflam- mation of the gums dependent on the presence of a carious tooth. Finally, while it is quite necessary to take into account personal predisposition, and still more to admit the influence of a general predisposing cause (the nature of which is unknown though its existence is universally admitted by all physicians), a determining cause is also required for the production of erysipelas. This deter- mining cause plays an essential, and not a secondary part, in the development of the disease. If we grant that under certain circumstances, under epidemic in- fluences, erysipelas is developed independently of traumatic causes, and quite spontaneously, it must also be admitted, that there are others in which it may at first be supposed that the determining cause is absent, but in which it is afterwards discovered. You no doubt recollect a woman admitted into the clinical wards for erysipelas of the face and hairy scalp, in whom there seemed no proof of the disease having had a lesion of the integuments as its starting-point. Upon her admission, I carefully questioned her, when she denied having had any previous affection which could account for the attack: she affirmed that she had had no sore place on the ears, eyes, nose, or throat, and no breach of continuity of any description on the face or head. Here, then, seemed a case in which erysipelas had come of itself; but subsequently, upon resuming my interroga- tions, the patient mentioned that she had had violent pain in the ear, which for some time had affected her hearing, or, to use her own 256 ERYSIPELAS. expression, had made her hard of hearing. She then recollected that along with the pain in the ear and deafness, she had had at the same time an affection of the glands of the neck, that two days afterwards there appeared behind the left ear a red, smarting patch which successively took possession of the face and hairy scalp; and the presence of which we noticed at the time of her admission. Going back thus to the starting-point, wre have been enabled to follow the course of the affection of the skin, and again to prove that a case which might have passed with many physicians as belonging to the class of erysipelatous cases reputed medical bore a great analogy, in respect of its starting-point, to what is called surgical or traumatic erysipelas. There ends, however, the analogy; for that which we call trau- matic influence \_traumatisme\ in speaking of erysipelas, is a some- thing which imparts to that disease a formidable character altogether special. The truth of this proposition is demonstrated by what is seen after wounds of the face, and still more after wounds of the hairy scalp. The appearance of cerebral symptoms is looked upon as a usual arid unfavourable occurrence in erysipelas of the head, while in reality such symptoms are not generally met with except in erysipelas of traumatic origin—using the term traumatic in its strictly accurate acceptation. This probably depends upon recently denuded vessels becoming the seat of violent inflammation and pro- ducing much greater disturbance of the economy than results from erysipelas determined by a small and partially cicatrised excoria- tion, or a herpetic ulceration of the nose, ears, or eyes. From this point of view7, but only from this point of view7, it is necessary to establish a distinction between surgical erysipelas which is often, and medical erysipelas which is seldom, fatal. It is of the latter that I have now to speak. Medical is the name given to the erysipelas which proceeds from an internal cause. One reason why physicians give it this descrip- tive name arises from the circumstance that in numerous cases, the appearance of the cutaneous inflammation is preceded by fever, general discomfort, and disorder of the digestive function, indicating the impress of a pathological modality upon the economy. Con- sidering erysipelas, then, as an eruptive fever, it has, following the example of Borsieri, been placed in the same nosological category as small-pox, scarlatina, measles, and all the exanthemata. That, in my opinion, gentlemen, is a mistake. I do not deny ERYSIPELAS. 257 that in some cases the fever precedes the inflammation, but this is a rare occurrence, the rule being that the local inflammation precedes the general febrile excitement. It is not sufficiently observed that precisely the same phenomena occur in erysipelas of the face as in erysipelas of other parts of the body, whether the cause be external or internal. A person, for example, has a wound on the foot or leg which becomes inflamed and very painful, the lymphatic vessels and glands connected with it sw'ell, and fever sets in, but some days elapse before the erysipelas appears around the wound. In this case, the fever cannot be looked on as similar to the pro- dromic fever of the exanthematous fevers : its existence is perfectly explained by the inflammation of the wound and lymphatics. The inflammation of the lymphatic vessels, or at least of the glands, pre- cedes the appearance of the erysipelas: this is undeniable. Even Borsieri, wdiile he called erysipelas an eruptive fever, stated that glandular engorgement was a symptom of the beginning of the attack : in the paragraph w'hich he devotes to erysipelas he says :— “ Illud etiam memoria probe tenendum est quod crebis ex obser- vationibus constitit, si erysipelas artubus inferioribus incubiturum sit, inguinis et femoris glandulas conglobatas, vasis cruralibus additas, antequam se exerat, leviter dolere atque intumescere con- suevisse, axillares vero ac cervicales, si brachiis aut sujoerioribus loch immineat.” Chomel, too, with whose views regarding erysipelas you are acquainted, mentions that painful swelling of the lymphatic glands in the neighbourhood of the seat of the disease is one of its most remarkable and constant phenomena. On the other hand, gentlemen, we must not exaggerate the importance of this fact, and say with Blandin that erysipelas is nothing more than lymphitis. Yelpeau has conclusively shown that lymphitis and erysipelas are very different affections; but the renowned surgeon of La Charite has in his turn fallen into the opposite extreme, in maintaining that adenitis is consecutive to erysipelatous inflammation of the integuments. Besting my opinion on my own personal experience, and on the authority of such observers as Chomel, I hold, that almost always the glandular engorgement precedes the outbreak of the erysipelatous inflamma- tion, and also that it is dependent upon a local lesion in the situation of the lymphatic vessels communicating with the swollen glands. Like the woman of whom I have just spoken, patients will tell you that they have had, for example, an excoriation of the ear, or that 258 ERYSIPELAS. there .was something the matter with the ear: they will also com- plain that the movements of the neck are accomplished with diffi- culty and occasion pain. There is, therefore, I hold, an inflammatory action anterior to any characteristic manifestation of erysipelas; and this action is quite sufficient to produce the general symptoms. Finally, the prodromic fever of erysipelas, if this name be allowed, is a symptomatic fever [ une fievve avec matiere] : it is a fever symptomatic of the inflammation propagated in the lymphatics communicating with the local lesion. This fever continues for one, two, or three days : the erysipelas then appears, and forthwith pro- ceeds to the different parts of the face and hairy scalp, remaining stationary in one place for three or four days, and fading in the rear of its progress as it advances to another point. It advances rather slowly, taking eight or nine days, or sometimes more, to complete its circuit of the head. In a few exceptional cases, when it has gone once round the head, it makes a second circuit, starting gene- rally from the place first affected. This repetition of the course is less frequently seen in erysipelas of the face than in that of other parts of the body. The great severity of the general symptoms is a remarkable feature of erysipelas. There are few diseases in which the fever is so high, and the gastric symptoms so urgent. By some the gastric symptoms are regarded as the cause of the erysipelas, but I believe that the very opposite of that proposition is the truth, or in other words, I hold that the gastric disturbance is dependent upon the in- flammation of the skin. I have often recalled to your recollection experiments of M. Cl. Bernard, which show that when fever is ex- cited in an animal, the normal gastric and intestinal secretions are arrested. These results are often confirmed by what wTe see in medical practice; and in my opinion, the disturbance of the diges- tive functions, generally met with in erysipelas, is obviously the con- sequence of the fever. Delirium occurs in erysipelas of the face, independent of these gastric symptoms. It is, at least in its aspect, a formidable symptom. There are very few cases which do not present cerebral symptoms when the erysipelatous inflammation reaches the hairy scalp. The patient occupying bed No. 8 of the St. Bernard ward has been de- lirious for two days, and his delirium will probably still continue for two or three nycthemera: it is not likely to cease till the erysipelas has in succession invaded and abandoned the different parts of the ERYSIPELAS. 259 skin of the head. Notwithstanding their apparently serious cha- racter, the nervous symptoms do not alarm me : experience has taught me that what is called medical erysipelas, provided it be not complicated with any other disease, is not a dangerous malady. The prognosis, however, is altogether different when it supervenes at the close of an acute disease, at the close of an attack of small-pox, scarlatina, dothienteria, diphtheria, &c., or during the course of a chronic malady such as phthisis, when it meets with a state of pro- found cachexia of the system. Erratic erysipelas [ erysipele ambulant] is also a more serious affection than erysipelas limited to the head: it jumps from one place to another, and ranges over the trunk and every part of the body. The greater danger of this form of the disease does not arise from the symptoms being more severe than when the erysipe- latous inflammation is confined to the face; for generally the fever is more moderate, and the occurrence of delirium is not so frequent. The greater danger consists in the disease being prolonged for one or two months, and so exhausting the patient's strength; unless, indeed, the physician, regardless of the high fever, prescribe nutri- tious diet with a high hand, there being no other means by wrhich the destruction of the vital powers can be prevented. Bat there are some cases in which certain symptoms supervene not sufficiently noticed by our classical authorities : I allude to the extension of the ery- sipelas to the mucous membranes of the mouth, bronchial tubes, and alimentary canal. In the course of my lectures, I shall, as I have already said, require to return to this important subject. It is un- necessary to tell you that in such extensions of the disease as I have just mentioned erratic erysipelas is difficult to conquer. Dr. Peter gives cases in which it passed from the face to the pharynx, and then to the respiratory passages : once established there, in obedience to the tendency of erysipelas to extend, it propagates itself by degrees in such a way as first to produce simple bronchitis, then capillary bronchitis, then broncho-pneumonia, and last of all death.1 It has been alleged that w7hen erysipelas begins in the nose and then appears on both sides of the face, it will not extend to the hairy scalp. I have seen cases which might be quoted in support of this opinion; but I have also seen others in which the erysipelas 1 Peter:—Article “Angines,” in the Dictionnaire Encyclopedique des Sciences Medicates. T. iv, p. 720. 260 ERYSIPELAS. began in the nose, proceeded to both sides of the face, took posses- sion of the hairy scalp, and made the circuit of the head. Sometimes the danger of a case of erysipelas is in the essential nature of the disease. There are, for example, cases proceeding from con- tagion which often terminate fatally, and from their very commence- ment awake the fears of the physician. There is reason to believe that in these cases erysipelas is only the external manifestation of a primary general affection of formidable character; or it may behave like diphtheria, which, in the first instance local, soon poisons the whole system. At the beginning of 1861, one of my colleagues mentioned to me that several persons living in the same house were suffering from erysipelas, which in some had commenced in the pharynx, and in others at the inner angle of the eyes or external opening of the nostrils. The individual who was first attacked died: the nurse who waited on him died soon after of the same disease; also, several members of the family, and the door-keeper— who had had occasion to come in contact with the deceased—expe- rienced serious attacks. In July of the same year, 1861, the Gazette des Hopitaux published an additional proof of the formid- able character of contagious erysipelas, in the history of the death of two of our young hospital pupils, MM. Gaston Reynier and Ernest Gruteau, who were carried off by this disease, contracted in the wards of M. Nelaton and M. Voillemier. Mrs. Reynier, the mother of one of these unfortunate young men, died a few days after her son, from erysipelas caught in her attendance upon him. Some months after these events, I was called in by my honour- able friend Dr. Paris, to consult with him in the case of M. E., upon whom one of our ablest surgeons, Professor Nelaton, had divided the frsenum, for the purpose of facilitating the introduction of lithotriptic instruments. M. E. died from gangrenous erysipelas, of which the starting point was the trifling incision made by M. Nelaton in the frsenum of the prepuce. On the evening before his death, his wife, who had attended upon him with great solicitude, was seized with rigors : next day, she had violent sore throat, and twenty-four hours afterwards, exceedingly severe erysipelas of the face, which carried her off at a time when she seemed to have entered upon convalescence. The maid of this lady, who had like- wise waited assiduously on M. E., took ill along with her mistress. Her attack was specially characterised by violent sore throat, and erysipelas limited to the eyelids. Finally, gentlemen, you remember ERYSIPELAS. 261 to have seen, in June 1862, in bed No. 4 of the St. Bernard ward, a girl of twenty-three, with moderate erysipelas of the face, which had come on during her attendance on her master when he was suf- fering from phlegmonous erysipelas of the leg. Spontaneous erysipelas, therefore, though generally a mild disease, is sometimes malignant, fatal, and contagious, as was pointed out by Graves. This malignity may either be inherent in the contagium, or dependent upon a special condition of the recipient. It is traumatic or surgical erysipelas, specially infectious, which is also so exceedingly contagious. Traumatic cases supply us with some mournful series of facts in proof of the contagious character of erysipelas. Dr. Pujos of Bourdeaux, in a paper, to which the Academy of Medicine awarded a prize in 1866, has reported illustra- tions of this remark, which, with your permission, I shall now quote in an abridged form. A sportsman injured his right foot with his gun. The wound, in itself serious, was rendered more so by consecutive haemorrhage, and became complicated with erysipelas on the fifteenth day. The disease invaded the entire limb, gangrenous patches appeared, and adynamia supervened, which led to death on the twentieth day from the accident. The brother, a healthy young man, who had minis- tered to deceased during his fatal illness, was seized, without any local cause, with spontaneous erysipelas of the face, which extended to the hairy scalp, and became complicated with adynamic symptoms. He died on the eighth day. The sportsman's daughter, a child of three years of age, had a slight burn on the hand which became the seat of erysipelas. The disease extended to the arm and chest, the symptoms at the same time assuming a formidable character: ultimately, the extent of the disease became limited, and the child recovered. The family laundress, after washing the linen of the household, was seized with phlegmonous inflammation of the hand, from which she recovered. The sick-nurse had erysipelas of the face and head: she had no ataxic symptoms, and recovered. But this history is not yet complete ! A sister of charity who had been entrusted with the irrigation of the foot of the wounded sportsman, was forced by fatigue to discontinue her duties: she then felt pains in the right arm, which afterwards became very severe, and were accompanied by nausea, vomiting, and prostration. A large phleg- monous abscess opened in the arm, and was followed by several others in different parts of the body : there was a profuse discharge 262 ERYSIPELAS. of unhealthy pus : sloughs formed: the general symptoms became more and more complicated; and at last the patient sunk under the most excruciating pain. The religious community to which this sister belonged wras in excellent health when she returned to it unwell. Upon her return, however, different adynamic maladies, of a more or less severe character, showed themselves in a form at least infectious if not contagious. Health was restored to the com- munity by the sisters evacuating the convent, and going to the country. Prior to this, however, nine sisters wrho had waited upon, and dressed the abscesses of the diseased, or who had attended upon some of their sick sisters, had severe attacks of illness from which two of them died. Dr. Pujos also quotes the case of a woman, who died in an adynamic state from spontaneous erysipelas of typhoid type. The physician and two sick-nurses who attended upon her died of erysi- pelas contracted during their attendance; and a female servant in the family took the disease, but recovered after having been in great danger. Dr. S., successor to M. G., also became ill; but his malady was not erysipelas, and he recovered from it by taking hygienical care of himself. Allowr me to quote some additional cases which occurred in this sadly instructive epidemic. At the hospital of Bourdeaux, Dr. G. observed a man who was admitted for an affection of the eye, and placed near a patient with phlyctenoid erysipelas; and wTho forthwith took erysipelas in a rather severe form. The starting point was in this case a slight excoriation of the lip : the disease, which was phlyctenoid, accompanied by intense fever, invaded the face and hairy scalp, and then ceased wuthout endangering life. The father of M. G., also a physician, came to attend on his son. On the third day after his arrival, he was seized with sore throat, which was followed by phlyctenoid erysipelas of the face and hairy scalp, accompanied by some general symptoms. He recovered. The sister-in-law ofM. G., senior, having come to Nantes to see him, fell ill, and passed through a similar illness. She recovered her health, but lost her hair. Another series of contagious cases commenced with a sailor who had erysipelas of the face around a pimple attributed to the bite of an insect. There was in the first instance erythema: erysipelas then declared itself, which invaded the head, was accompanied by pros- tration, and speedily ended in death. A woman ■who had attended 263 EBYSIPELAS. on the sailor, and the woman’s husband, were similarly affected, and both died. The captain of the ship to which the deceased sailor belonged also took erysipelas, but soon got well on going to sea. Erysipelas, as I remarked, is a very dangerous malady, when it is a complication of some other disease, which from its nature, or pro- tracted duration, has already put in hazard the patient’s life \ when, for example, it occurs in children along with typhoid fever. It is still more dangerous when it supervenes in the course of the adyna- mic pneumonia of old people, or when it attacks lying-in women and new-born infants. With reference to wrhat I have already said regarding the epi- demic influences which prevailed in 1861, when a terrible epidemic of puerperal fever raged in nearly all the asylums for women in childbed, erysipelas of the face, not generally a dangerous disease, often assumed a bad character, and cruelly contradicted our prognosis. It was also observed that the malady wras to a certain extent con- tagious. One of my medical colleagues has called attention to some such cases, and I have also seen cases of the same description. I met in consultation my honourable colleague M. Higgins in the case of a young American lady, who in the sixth month of nursing was affected with abscess of the mamma. The abscess was opened by M. Nelaton: some days afterwards, erysipelas appeared in the wound, and then extended over the chest. The husband of this lady, an officer of the United States navy, left his ship in the Mediter- ranean to spend some days with his wife. When travelling by railway, he got an insignificant excoriation of the leg. In less than two days after his arrival in Paris, erysipelas showed itself around the little wound, which soon became a diffuse abscess; and for nearly three weeks his life was in danger. Excluding exceptional cases, and epidemic influences, erysipelas of the head is not a formidable disease. Erom 3831 to 1835, a period of four years, during which I acted as the substitute of Pro- fessor Eecamier in this hospital, I had only one death in 57 cases. The patient who died was admitted with erysipelas of the hairy scalp, complicated with violent delirium : she died two days after admission. An acute disease in which the mortality is less than one in fifty, may certainly be called benignant in its nature; and perhaps you cannot name another which is equally so. Eor example, compare bronchitis with erysipelas, and you will find—circumstances being the same and the proportion being kept—that the former kills more than the latter. I am more and more confirmed in this con- viction by the cases which I have collected in my private practice, in the practice of my colleagues, and in the different hospital services which I have conducted during the last twenty-eight years. I have no doubt sometimes seen erysipelatous patients die, but I must say that the fatal issue has been much more frequently caused by the treatment than by the disease. The majority of those who died had been subjected to treatment which I look on as most deplorable; and to which I cannot too earnestly call your attention, for the purpose of putting you on your guard against employing it. When a patient suffering from erysipelas is placed under my care, my rule is to abstain from every kind of treatment. I prescribe a lavement for those who are constipated, and if the constipation continue, I give ten or fifteen grammes of castor oil. This is not very active treatment. You may call it homoeopathy if you like ! Such, however, has been my plan for twenty-eight years; and, thanks to it, I cannot recollect losing more than three patients from erysipelas during that period. My treatment, then, of erysipelas of the face is expectant. I keep my patients in bed, for it is above all things important, both in the acute stage and during convalescence, to prevent them from catching cold, for exposure to cold leads to relapses. I prescribe slightly acidulated diet-drinks : if the bowels are confined I assist nature by giving laxatives, if the vomiting is violent, I combat it by purgatives. But, gentlemen, I give nourishment—I give nourish- ment even when there is fever—even when there is delirium. So far from prostrating tbe patient by withdrawing blood, by bleeding him at the arm, or leeching him behind the ear; in place of making it my rule to administer emetics, and give purgatives in repeated doses; instead of placing the patient on very low diet—I remain with folded arms spectator of a contest, from which I know nature will come forth victorious, if I refrain from disturbing her operations. And I again repeat, that of the great number of cases of erysipelas which I have attended, three only have had a fatal termination: the others spontaneously recovered. That is a fact which I ought not to be afraid to proclaim. In erysipelas, as in a certain number of other diseases which pursue a natural course, we physicians require to beware of trying to direct nature when we see the pathological phe- nomena proceeding regularly, for our ill-timed intervention will only disturb the natural course of the disease, and injure the sick man who has sought our succour. ERYSIPELAS. ERYSIPELAS. 265 I think it right to go minutely into these views, because you are entitled to receive from me an explanation of the manner in which I act, or rather abstain from acting, in respect of patients suffering from erysipelas. "When you have seen recoveries take place in the practice of other hospital physicians in cases treated on the heroic plan, by bleeding, purging, administration of emetics, application of blisters, cauterization of the affected parts with nitrate of silver— when you have seen recoveries take place in spite of that treatment, you may have been apt to believe that they were due to it, and that the remedies employed were sovereign and necessary. But before forming an opinion as to the effects of medical treatment in a disease, it is necessary to be acquainted with its natural history. The primary knowledge, in fact, which the practitioner ought to acquire is acquaintance with the natural history of diseases. In my practice, you observe, I adopt active measures in certain circumstances, and in others allow matters to take their own course, attentively watching the symptoms, howrever, and ready, if occasion require, to employ the therapeutic resources of medicine. To know wrhen to wait is in our art great knowledge; and prudent waiting explains many suc- cesses, particularly those which are sometimes obtained by the sect of Hahnemann. The erysipelas which seizes a person in the midst of health—not that which supervenes in the course of another disease—is one of the maladies which spontaneously terminate in recovery. This state- ment of course does not apply to that erysipelas which is only the expression of a special influence acting on the whole system. Bor example, during epidemics of puerperal fever, lying-in women often sink under erysipelas, but they sink from erysipelas under the same influence which causes other patients of the same class to die of peritonitis or pleurisy—or to express the idea more correctly, of an affection which is merely the expression of a general pathological condition, really the one cause of death. These important questions, gentlemen, I propose to discuss in my clinical course, when an opportunity is afforded of doing so in connection with puerperal fever. Meanwhile, I have a few words to say on the subject of erysipelas in new-born infants. 266 ERYSIPELAS OF NEW-BORN INFANTS. ERYSIPELAS OF NEW-BORN INFANTS. Affection often Puerperal.—Differs Essentially from Ordinary Erysipelas.— Generally Fatal. In bed No. 21 of our nursery ward, there is an infant, three months old, the subject of congenital syphilis, which, very recently, has been attacked by erysipelas. After spreading over the superior extremities, it reached the base of the chest. In this case, therefore, two diseases were combined, both of which generally prove fatal in very early life. But the erysipelas is already gone, and there seems every prospect of the syphilis being cured. Let me call your atten- tion to the special condition which has probably been the cause of this doubly fortunate result—that condition I believe to be age. The erysipelas of new-born infants is justly regarded as a dis- ease almost as certainly fatal as cerebral fever at a more advanced age. This is a fact which all physicians who have had charge of a children’s hospital can verify from their own experience j as I can, after having been twelve years attached to the Necker Hospital. I have found that infants who take erysipelas during the first fifteen or twenty days of life almost invariably die, no treatment being of the least use \ but that in those who pass that age, particularly when they get beyond the first month of extra-uterine life, and are thus more removed from their state of foetal existence—more individualised —erysipelas loses much of its formidable character. To the child of eighteen months or two years, erysipelas is not more serious than to the adult. Upon what then depends the gravity of the disease in newly- born infants ? Does it depend solely on their extreme youth and deficiency of vital power P No! Its formidable character in these subjects arises from quite different causes, which I pointed out long ago, and which have been thoroughly explained by Dr. P. Lorain in one of the most remarkable works which have been published on this subject.1 Twelve or fifteen years ago, I was struck by observing that during epidemics of puerperal fever at the Maternity Hospital, a great many children were admitted to my nursery wards at the 1 P. Lorain : These Inaugurate “ Sur la Fievre Puerperale chez la Femme, le Foetus, et le Nouveau-ne.” Paris, 1855. ERYSIPELAS OE NEW-BORN INFANTS. 267 Necker Hospital with purulent ophthalmia, peritonitis, and erysi- pelas. I at that time applied the term puerperal to all these affec- tions, and in my published lectures stated that all the children in question had the same disease, only that in some it showed itself in forms different from those it assumed in others. I was then of opinion that epidemic puerperal fever presides over the pathology of new-born infants, just as much as it presides over the pathology of recently delivered women. This view hardly transpired beyond the class-room of the Necker Hospital: it did slip into the columns of some medical journals, but it did not at that time obtain general publicity. To Dr. P. Lorain the merit is due of having given it full publicity, and of having demonstrated categorically the truth of the doctrine of which I had caught a glimpse. To him science owes its right to regard this view as the expression of well-observed facts. To enable you to understand this question, upon some parts of which I wish to touch, I require to give you a succinct analysis of the work of Dr. P. Lorain. During the epidemic at the Maternity, where this able and laborious observer was a resident pupil, he collected the information of which the following is a summary. Of 106 still-born infants, 10 were found to have died from peri- tonitis, and three of the mothers of these ten infants were carried off by puerperal fever after delivery. Of 193 infants born alive, 50 died of the very same affections which proved fatal to the lying- in women. The most frequent causes of death wrere peritonitis, numerous abscesses, purulent infection, phlegmonous swellings, erysipelas, gangrene of the limbs, putrid infection, or some other remarkable septic condition. Mother and child often had the same disease, but sometimes its form and seat were, and at other times were not the same in both ; for example, a child sometimes died of peritonitis and its mother of purulent infection, or the child of pu- rulent infection and the mother of peritonitis. In 30 cases in which recently born infants died of peritonitis simple, or compli- cated with erysipelas, meningitis, or numerous abscesses, mother and child were in ten instances carried off by the same affection. The infants of fifty women who recovered after having had puerperal symptoms died of peritonitis. Trom these facts, the details of which I recommend you to read in Dr. Lorain's excellent thesis, the author proves that it is the same epidemic influence which affects mothers and their offspring. The existence of this influence cannot be disputed, when we recollect ERYSIPELAS IN NEW-BORN INEANTS. that new-born infants very seldom die from the lesions I have just named, except during epidemics of puerperal fever. We cannot deny that there is a bond of pathological community between mother and infant, similar to that which unites the tree’s trunk with the branch which proceeds from it. This is admitted in respect of other maladies, such as syphilis and small-pox. Who is unacquainted with cases of individuals presenting at birth the scars of variolous pustules ? There is not a year, I may say there is hardly a month, in which I do not point out to you in our wards new-born infants suffering with syphilis engendered by a father or conceived by a mother affected with that disease. In such cases no one denies the existence of the pathological solidarity to which I have referred, and yet it is denied in respect of puerperal fever ! In districts where intermittent fevers are endemic, as in Sologne, Bresse, and some parts of Bourbonnais, infants are born with symptoms of marsh cachexia, nothing being wanting to mark this fact, even the hypertrophy of the spleen being found. Without hesitation we admit that these infants when still within their mother’s womb have been subjected to the influence of marsh miasmata. It would be easy to multiply similar illustrations; but still there is a dis- position to make puerperal fever an exception to the rule; and the opinion so ably maintained by Dr. Lorain has found obstinate oppo- nents. The day will come, however, when the truth which he has demonstrated with so much precision will be generally accepted. Mother and child then are both subject to the same morbific in- fluence. Let us now inquire, whether there is not a great similarity in the anatomical and physiological conditions of the two organisms which during gestation are one, and wdiich continue to be one, so to speak, for some days after birth. Acquaintance with the physio- logical, wall enable us to understand the pathological analogy. But before proceeding farther, it is indispensable to define what is meant by a new-born child [ enfant nouveau-ne] : and this I do by quoting Dr. Lorrain’s definition, which is to the following effect:— “ The infant comes into the wrnrld possessed of organs which have ceased to perform, and of other organs which have not as yet per- formed, their functions. It at once, without any transition, passes from one to another kind of life : it has not, like the young of other animals, a period of repose and physical recruiting, during wdiich the changes requisite for the new kind of existence are accomplished. It has been forcibly throwm into a new medium. The very first ERYSIPELAS OE NEW-BOltN INFANTS. 269 efforts of the organs hitherto in reserve are effective: at the very first moment after birth it breathes, and each succeeding inspiration is performed in the same manner as the first: the first mouthful of liquid swallowed brings into play the organs of digestion : every organ in fact responds to the appeal made to it by the new life, and proves faithful to the Power which created it. But it is not enough for the new-born infant to come into possession of its reserve organs, to make trial of them, to use them for all their purposes, and to live in completeness the new life : it also requires to get rid of the organs by which alone it once lived, but which have now ceased to be of any use. The period during which the new functions are perfected and the old organs disappear is the period of transition or metamorphosis : during it, the umbilical cord separates, and the navel becomes cicatrised : the epidermis cracks and falls off: the hair is renewed : the meconium is expelled: the umbilical artery and umbilical vein are obliterated; and the fovamen ovale is closed. The “ new-born” in fact is the creature in whom this progressive work of separation is going on, and the duration of the period in which it is accomplished is not less than a month.” Let us now return to the consideration of the anatomical and physiological conditions of mother and child. In the mother, after the birth of the foetus, the placenta is detached from, and expelled by, the uterus. It leaves the surface of the uterus to which it was attached denuded of mucous membrane—the protecting membrane by which it was previously covered. This denuded surface is not only in contact with the external air reaching it by the vaginal orifice, but also with fluids accumulated within the uterine cavity— first of all with blood, and afterwards with pus necessarily formed while the reparative process is being accomplished in the wound caused by the separation of the placenta. This, like all recent wounds, is an open door for the reception of contagia. It under- goes changes analogous to those wdiich often take place in the hos- pitals of large towns in the solutions of continuity made by the surgeon’s knife, and which are liable to become the starting point of general poisoning of the system, like a wound made by a lancet charged with virus. We find the very same anatomical conditions in the child. In the new-born infant, at the moment of its abrupt separation from its mother, at the moment when the functions of foetal existence are superseded by those of the new life, we observe that changes take 270 ERYSIPELAS OE NEW-BORN INFANTS. place which may be compared with those which occur in the organism of the mother. The umbilical cord falls off: having ceased to be of any use, when the placenta which joined the child to the mother was detached from the uterus, it withers up to its point of attachment to that sort of muff formed by the skin of the abdomen, the cutaneous muff which will afterwards be the navel. This is the point at which separation takes place, and this separation is the result of a necessary inflammatory process. Upon the fall of the cord, the umbilicus becomes the seat of a reparatory process analogous to that which takes place in the wound of the uterus. The remains of the cord become detached, and as a necessary con- sequence of this elimination there is slight suppuration, to which Dr. Lorain has very happily given the name of umbilical lochia [lochies ombilicales]. No expression could have been better chosen to express the truth. In the infant, exactly as in the mother, there is a wound: and with Dr. Lorain I say that the um- bilicus in the infant is analogous to the uterus in the mother. The umbilicus and the uterus equally present an open way for the entrance of infection; so that if both mother and infant are placed under the same epidemic influence, it is not surprising that both should contract the same disease, just as happens to hospital patients with open wounds when similarly exposed. And what is it that we see happen to these persons with wounds ? Phlebitis, metastatic abscesses, suppurating pleurisy, and erysipelas supervene. Analogous affections occur in lying-in women, with this difference, that peritonitis is the most common lesion in them, as might be expected from the direct effect produced by parturition upon the abdominal serous membrane: for a similar though stronger reason, the uterus and its appendages are still more often than the peri- toneum the first parts in which the disease declares itself. In newly delivered women it is the wound of the uterus, and in new-born infants it is the wound of the navel which is the starting point. The pathological analogy is still greater, as I have already said, from the circumstance that the child at birth represents a branch detached from the parent stem, which, for a certain time, seems to live by the life of the tree which produced it: the new-born infant may be com- pared to “ a layer” which cannot grow by itself till it has taken root. The new-born infant like the layer is not at first entirely nourished by its own sap—by blood which till some time has elapsed it cannot have made: it is still nourished by its mother’s ERYSIPELAS OF NEW'BORN INFANTS. 271 blood, it retains all the aptitudes of the maternal organism, from which it is hardly yet separated; and the diseases which it contracts under the same influences as the mother, will assume the same expression as in her. The erysipelas then of the new-born infant will not be ordinary erysipelas—it will be puerperal erysipelas, and possessed therefore of the exceedingly formidable character which belongs to puerperal affections. This formidable character depends less upon the small- ness of the vital power of resistance possessed by the subject, than upon the essential nature of the disease. You can now, gentlemen, explain to yourselves the recovery of the child of bed 21 in St. Bernard's ward. It recovered because it had got beyond the first days of extra-uterine existence, because it was three months old, because in fact it had ceased to be a “ new-born" infant. Erysipelas occurring during the first fifteen or twenty days of life is inevitably fatal. It generally begins to show itself at the pubes, and not at the umbilicus: it is characterised by a vivid redness of skin, and a hard, shining appearance of the subjacent cellular tissue. The infant at the same time falls into a state of great pros- tration: it suffers pain, and gives expression to its sufferings by cries : it has scarcely any fever. If the infant be vigorous, and at the time of its seizure in apparently good health, you will probably regard the affection as of little consequence. What risk is there in an erysipelas extending over not more than three or four centi- meters, accompanied by very little febrile excitement and by no disturbance of the functions, the little patient being quite in his usual state of health ? In spite of the deceitfully trifling appear- ance of such a case, you must be prepared for its unfavourable termi- nation; for to-morrow, the erysipelas will have extended to the scrotum or vulva, soon, it will have reached the thighs, and invaded the legs, spread over the other side, ascended to the abdomen and trunk, thus advancing, without fading on the parts first affected. At the end of two or three days, high fever will be set up. The infant will become exceedingly restless, get no sleep, and suffer from gastric symptoms, vomiting, and diarrhoea. He will cry incessantly from pain. A state of restlessness will be succeeded by collapse, which will close the scene on the fifth, sixth, or seventh day. On examining the body after death, pus will be found in the cellular tissue, sometimes suppurative pleurisy, more frequently phlebitis of the umbilical vein or of the vena porta, or peritonitis. Adopting the views of Dr. Lorain 272 ERYSIPELAS OF NEW-BORN INFANTS. I have long held that these lesions ought to be looked on as the extension of erysipelatous inflammation from the skin to the blood- vessels and internal parts. Erysipelas, phlebitis, peritonitis, &c., are manifestations of one sole disease. In some cases, we see peritonitis in infants, although the erysipelas was on the face and not on the abdomen: and sometimes, on examining bodies after death, we only find indications of the cutaneous inflammation, all the other lesions to which I have directed your attention being absent. Thus you see that the erysipelas of new-born children is an insidious malady. Its formidable character, I cannot too often repeat, depends upon the nature of the cause under the influence of which it is pro- duced, and not on the importance of the local lesion. I cannot sufficiently impress upon you how easy it is to commit serious errors of prognosis. Some of you may recollect a child of twenty-three days old which took erysipelas, when under the vaccine influence, but in the midst of an epidemic of puerperal fever. This infant was born at the Maternity Hospital, when decimated by that scourge : it was removed to the Hotel-Dieu on one of the latter days of March 1861, along with its mother, who was suffering from abscess of the mamma. You may remember what I said to those who attended my visit: notwithstanding the appear- ance of vital power in the little patient, though the health seemed excellent, though the cry was vigorous, and the fever moderate, I announced that death would take place within three or four days. I was mistaken: that very night the child died. In point of fact, the disease generally runs a course infinitely more rapid than the strength of the infant and the character of the symptoms lead one to expect. To me it has always appeared a strange fact—but it is one of which I have seen examples—that recoveries from this kind of erysipelas sometimes take place when abscesses form in the invaded parts. Within the last two years, I have seen three cases of this kind. I think the only interpretation of these recoveries is, that the progress of the disease to other parts is stopped by its exhausting its violence in one locality. In these cases, the affected part becomes much swollen, and the red colour of the integuments acquires a deeper shade. Lying-in women attacked by puerperal symptoms have also a better chance of recovery, when an abscess forms in the broad ligament or iliac fossa. In the beginning of 1861, you saw a child, twenty days old, ERYSIPELAS OF NEW-BORN INFANTS. 273 recover from general erysipelas, after the formation of a deep abscess on the back of the hand. In April of the same year, when an epidemic of puerperal fever, erysipelas, and boils was prevailing in our hospitals, I received into my nursery ward, an infant, twenty- seven days old, suffering from erysipelas. The erysipelas ran over the whole body from head to foot, and even re-invaded the parts which it had occupied and quitted; and yet for more than twenty days the infant resisted death. It had more than ten abscesses, situated on the feet, ankles, elbows, back, and other parts. It died from acute peritonitis. I freely admit that I have great difficulty in explaining why abscesses, which ought a priori to be serious com- plications, should on the contrary prove to be a sort of salutary crisis : but the facts are so striking, that however we interpret them, we must at least admit them. Gangrene is another common termination of erysipelas in new- born children. It arises quickly. Unlike abscesses, it exercises a very unfavourable influence on the whole economy, and in no form of the disease does death take place so quickly as that in which there is gangrene. This gangrene is dependent upon the puerperal state: it attacks infants under conditions precisely similar to those in which it attacks women with sphacelus of the vulva, vagina, uterus, and in fact of all the parts to which parturition imparts a traumatic condition. Finally, gentlemen, erysipelas in place of running its usual rapid course, may have a long duration; and in lying-in women we some- times see the puerperal symptoms proceed so slowly as to lead to hopes which are too often blasted. Sometimes, also, in new-born infants, the attack is prolonged beyond its usual duration, lasting for ten, fifteen, or even for more than twenty days, as you saw in one of our little patients in the nursery, who died on the twenty- third day. I am not acquainted with any treatment of use in the erysipelas of new-born infants : it is a disease which resists all the efforts of the physician. It is otherwise, however, with the erysipelas of infants who have passed the first month of life. In them, in all respects, it resembles the disease in adults, and all that we have to take into account is the organization and vital power of the subject. I have often employed a method of treatment in this erysipelas of children, which, in certain cases, has seemed to stop its advance: I refer to the ERYSIPELAS OF NEW-BORN INFANTS. application to the skin, by a hair pencil, of a solution of camphor and tannin in ether. The lotion ought to he applied both to the parts affected, and to the neighbouring unaffected parts. You recollect the case of a child, two months old, admitted with its mother to bed 14, St. Bernard's ward. A day or two afterbirth, this infant had had a small abscess behind the left ear, which left a slight wound. My attention was called to an erysipelatous redness occupying the angle of the left eye, and invading the eyelid, cheek, and nose. Although there was a little fever, the general condition of the child seemed satisfactory. It took the breast as usual, and digestion was accomplished in a regular manner. I employed the ether lotions containing camphor and tannin. From the first day on which they were used, the erysipelas did not extend beyond the limits it then occupied; and on the fifth day from the date of ad- mission, the infant, having completely recovered, left the hospital with its mother. LECTURE XI. MUMPS. A Specific and Contagious Disease.—Metastases.—Complications, You have seen a young man with mumps [oreillons\ in the last bed in the men’s ward. I eagerly seize the opportunity of speaking to you about a disease, of which, most probably, we shall not see another case here for a long time to come. This young man, six days before his admission into hospital, felt pains at the angle of the lower jaw, first on one side and then on the other. He at the same time perceived that the cheek and neck were much swollen. He had great difficulty in swallowing, and suffered from headache and fever. However, from the evening of the day on which the patient came under our observation the swelling had sensibly diminished. During the course of the dis- ease, metastasis to the testicles occurred. He left the hospital per- fectly recovered, and without having had any serious symptoms. When I ask students who come up to the Medical Faculty for ex- amination, to tell me what mumps is, many reply that it is an affection of the parotid glands which often supervenes during, or at the decline of severe fevers, scarlatina, measles, small-pox, dothien- teria, or puerperal fever; thus, confounding the disease upon which I am now going to address you with parotiditis. That, gentlemen, is a great mistake: parotiditis and mumps, even looking to the anatomical lesion only, are essentially different from one another. Parotiditis is an inflammation of the gland and of its cellular tissue : it supervenes during or after severe fevers, is susceptible of passing, and often does pass, into suppuration. But mumps is properly speaking only a simple engorgement {simple fluxion'] of the gland. This engorgement, as was correctly pointed out by our pre- decessors, is much more an affection of the inter-glandular cellular 276 MUMPS tissue than of the gland itself, and (unlike parotiditis) never termi- nates in suppuration. Moreover, while parotiditis occurs generally on one side only, both sides are almost invariably affected in mumps, though one is often more affected than the other. Mumps is a specific disease which, for many reasons, may be classed with eruptive fevers; and this I do, in point of fact, fol- lowing the example of some authors. Like the eruptive fevers, it is a specific malady, and like them, too, it is very contagious. It usually attacks young persons. Sometimes, however, it is met with in adults, and even in old people. In such cases, the disease can be traced to contagion; and of this Borsieri gives an illustrative case. Indeed it is only in very exceptional cases, that it is propa- gated otherwise than by contagion. Mumps does not attack the same individual more than once—a fact which is an additional point of resemblance between it and the eruptive fevers. A malady not severe, and of short duration—nec din, nec gravio- ribus, aut saltern non periculosis symptomatibus, si recte curentur, stipantur, brevique etperfecte resolvuntur—the mumps, “les ourles,” (for so it is still called), is never, except under circumstances which I will point out to you, attended with serious nervous symptoms ; and even in these exceptional cases, the life of the patient is seldom in danger. A fact, to which I propose forthwith to call your atten- tion is, that the older the person attacked, so much the more painful is the malady. Mumps, then, is characterised by a fluxionary engorgement [en- gorgement fluxionnaire~\ of the parotid glands, and of the salivary glands in general, for the sub-maxillary and lingual glands are often affected. The malady first makes its existence known by a painful bruised feeling which the patient complains of in the parotid region, and a difficulty in mastication, partly caused by pain, and partly de- pendent upon the disturbance of the salivary secretion, which is sometimes completely in abeyance. Even during convalescence, some patients are obliged constantly to drink when eating, from there being no insalivation of the food. There is more or less swelling of the affected parts: sometimes the swelling extends to the face, so as completely to disfigure the patient: occasionally, it spreads to the tonsils and intra-guttural cellular tissue, producing difficulty of deglutition. There is little change in the colour of the integuments, but it is not unusual for them to be slightly red. Mumps is a painful disease, and is often at its commencement MUMPS 277 accompanied by intense fever, but it subsides rapidly ; and at the end of seven or eight days, recovery has taken place spontaneously, and without leaving any traces of the passage of the disorder. But cases occur in which it terminates by metastasis, the parotid swelling disappearing abruptly, to attack in males the testicles, epididymis, and tunica vaginalis, and in females, the breasts or sometimes the labia. As a general rule, when this metastasis takes place, there is only slight constitutional disturbance excited by the new local in- flammation resulting from the morbid poison; but it sometimes happens that delitescence of the parotid engorgement takes place without the disease becoming completely fixed elsewhere, when general symptoms of very unusual character show themselves, alarming relations, disconcerting physicians, and causing the latter to adopt treatment which may prove very perilous. Permit me, gentlemen, to relate two cases in point which I have seen. In 1832, I attended a man, about thirty-five years of age, suffering from mumps. The symptoms were following their regular course, the pain had diminished, and the swelling in the parotid region was beginning to decrease. I had seen the patient in the morning, when he seemed quite as well as I had any right to expect; but in the evening, I was hurriedly sent for. I found him with a countenance of inexpressible anxiety; with face, pale and pinched; with pulse, small, rapid, and unequal; and the extremities cold. He had neither vomiting nor diarrhoea, nor any appreciable lesion of lungs or heart. I proceeded in accordance with the indications, giving ether and warm aromatic drinks, and moving sinapisms over the surface of the body. Meanwhile, I anxiously waited for the issue of an attack which had set in under such unfavourable auspices. Next morning, to my agreeable surprise, the patient had smart fever, a full pulse, and a moist skin. There was colour in the face, and a lively expression of countenance. But there was swelling of the scrotum, and one of the testicles, particularly the epididymis, was swollen and painful: in fact, there were all the characteristic symptoms of the most acute form of swelled testicle. I recalled to my recollection cases reported by Borsieri, and Morton’s febris testi- colaris : I felt reassured. I respected the local manifestation, which had been the means of relieving the economy from a threaten- ing state. A few days sufficed to accomplish the cure of the metas- tatic complication, and to restore the patient to perfect health. This case made a deep impression upon me, for it occurred when I was 278 MUMPS. young, and at the age when one forgets nothing. I resolved at the time, in the event of a similar case presenting itself to my observa- tion, to place the two together. Twenty years elapsed before this opportunity was afforded me. In 1853, I was summoned by my honourable friend Dr. Moynier, to meet him in consultation in the case of a student, seventeen years of age, about whom there was very great anxiety. This young man, when in the midst of apparently good health, (according to the state- ment, at least, of his parents and the principal of his educational institution), was seized with burning fever, extreme frequency of pulse, desponding tendencies, delirium, picking of the bed-clothes, vomiting, and the involuntary passing of serous stools: the symp- toms resembled those of the bad days of the third week of putrid fever, or the onset of those attacks of malignant scarlatina which prove fatal in a few hours. You can understand the dismay of the family and of the physician in presence of these symptoms. Dr. Andral had seen the patient from the commencement of the illness, and like Dr. Moynier had perceived the danger without being able to recognise its cause. Both were of opinion that the primary indication was to sustain the powers of life; and consequently, opium in small doses, sulphate of quinine in pretty full doses, and slightly cordial drinks were judi- ciously prescribed. On the following morning, when I met my two colleagues, the condition of the patient continued very much the same, but perhaps was not quite so bad. We were told of a slight complication which had arisen during the night—swelling of the scrotum, and a swollen painful state of one of the testicles. This was the only organic lesion in any respect noteworthy, and it cer- tainly was not of a nature to explain the terrible train of symptoms before us. All at once, the history of my first patient flashed across me, and I related it to my colleagues. I ventured to give a some- what less unfavourable prognosis, believing the affection to be matastasis of mumps. It was, however, incumbent on me to yield to the precise statement of symptoms laid before me, and the treat- ment of the preceding evening was, therefore, continued. Next day, there was much less swelling of the testicle and epididymis, the delirium, vomiting, and diarrhoea had ceased: there was still smart fever, but the pulse had more volume, and the skin was moist. In a few days, the young man was restored to his family, and to health. We now questioned him minutely. He told us that two or three MUMPS 279 days prior to the beginning of his illness, he had experienced a feel- ing of general discomfort, with pain in the throat, and swelling near the ear and at the angle of the lower jaw; and that he had caught cold in an excursion to the forest of St. Germain. He stated that the swelling diminished next day, and that it was on the fol- lowing day that the alarming symptoms appeared. About the date at which this case occurred, mumps were pre- vailing in a hoys’ boarding-school to which I was physician. I in- formed the principal that the malady was not of a serious character, hut I also stated that metastasis to the testicle was a possible occur- rence, so that in the event of any of the elder boys being affected in this way, he might not suspect the cause to be gonorrhoea. Some days afterwards, on visiting the infirmary of this school, I found one of these metastatic cases. Mumps was also at that time prevailing in young ladies’ boarding- schools, and I met with cases of metastasis in those institutions. As I have already said, the metastasis in women is generally to the mamnue. It is a remarkable circumstance that no case of metas- tasis of mumps to the ovaries has been recorded. As these organs are considered the analogues of the testicles, it might be supposed that they were specially the seat of the metastatic engorgements of which I am speaking. In some families, there is a peculiar tendency to this metastasis. Dr. Poinset told me that he and his two brothers had violent orchitis after mumps. The two cases, the particulars of which I have now detailed, are exceedingly curious, not in respect of the mere metastasis itself, for that is a fact pointed out by all authors, but on account of the symptoms during the accomplishment of the metastas is, before it was established. Many physicians, especially since the doctrine of the localization of disease has taken so sadly important a place in medical educa- tion—a place which, thank heaven ! it is daily tending to lose— many physicians, I say, have denied metastasis, to the extent at least of holding that the symptomatic phenomena do not show them- selves until the new lesion is developed. The hippocratic physi- cians believe that the morbid poison is afloat in the economy, that it comes in contact with all the organic elements, producing a va- riable amount of general disturbance precisely similar to what is seen during the period of invasion in eruptive fevers, when terrible 280 MUMPS. symptoms occur prior to the existence of any lesion of the solids, ceasing or decreasing as the local lesions show themselves. This is a question involving important clinical facts; and as it is only from such facts that we can derive a useful acquaintance with it, my duty is to bring them under your notice. The kind of metastasis now being considered by us proves the existence of a sympathy between the parotid gland and the genital organs: the existence of this sympathy is matter of common ob- servation, but its manifestation in an inverse order—that is to say proceeding from the genitals to the parotid—is a less familiar fact. A case of this kind, however, was observed by Dr. Peter when he was Professor Gerdy's interne. On May ist, 1855, a woman, twenty-two years of age, was admitted to La Charite Hospital. She had all the signs of violent inflammatory congestion of the right parotid region : there was swelling and pain, but neither redness nor fluctuation. The patient had anorexia and a little fever. The malady had commenced, four days previously, with great difficulty of moving the lower jaw : an hour after this symptom was expe- rienced, swelling supervened, and this was followed by pain. But the point of interest in this case was the statement of the patient, that many times before she had had a similar affection, always, how- ever, at the menstrual periods, and in substitution for the menstrual discharge. Her menstruation was irregular, and several times, for months in succession, she had been without her courses: she then suffered from headache, and swelling in the parotid region, (gene- rally on the left side), which was sometimes attended with loss of consciousness for an hour. On each occasion recovery took place quickly, after the application of leeches and cataplasms. That is not all: the patient stated that even more frequently than the affec- tion of the parotid glands, and always at menstrual periods, when the discharge was scanty, she had had a sort of thrombus of the left nympha, accompanied by acute pain and inability to walk. The symptoms continued for four or five days, and then terminated in slight hemorrhage from the nympha. The patient left the hospital on the 5th May, and was re-admitted to the same wards on the ist September, at a date which exactly corresponded with her catamenial period. On this occasion, there was again the same inflammatory engorgement on the left side. She stated that in June she had had parotiditis; in July, a thrombus occupying the left labium and nympha, followed by considerable lisemorrhage; in August, paroti- MUMPS 281 ditis ; and in September, she returned to the hospital with a repe- tition of the latter affection. Finally, on the 2nd November, Dr. Peter saw her in the out-patient’s room, with true thrombus of the left labium and nymplia. She did not then wish to come in to the hospital. Gentlemen, it is difficult not to see in this case the reciprocity of classical facts. Just as metastasis to the genital organs may take place in mumps, so was there, in Dr. Peter’s case, a metastasis to the parotid glands of an abortive catamenial congestion. Mark well, that in quoting this interesting case, I have not been discussing mumps: in this case, the affection was parotiditis, or at least inflammatory congestion of the parotid gland. But mumps as I have told you is a specific affection, analogous to the eruptive fevers, like them contagious, and like them not attacking the same subjects more than once. I have therefore quoted Dr. Peter’s case only as an additional and curious example of a kind of sympathy which is still unexplained. LECTURE XII. URTICARIA.1 A Distinct Nosological Species.—Sudoral Nettlerash \V eruption ortiee sudorale] is no more Urticaria than Morbilliform and Scarlatiniform Sudoral Eruptions are Measles and Scarlatina.— General Precursory Symptoms.—Exciting Causes. Gentlemen :—An officer of about thirty years of age, of good constitution, was seized, in the midst of perfect health, with symptoms wdiich at first presented an alarming character: the symptoms to which I refer were precordial oppression, intense headache, nausea, and high fever. They had set in during the evening, had continued all night, and had scarcely moderated when the physician arrived. At this time, the face was considerably swollen, and the swelling occasioned a very disagreeable feeling of tension of the skin; swelling in a less degree was observed over the whole surface of the body. The skin was covered with an eruption characterised by whitish blotches [elevures] surrounded by a slightly red areola. The general symptoms rapidly disappeared, the patient complained only of insup- portable itching, and had completely recovered within thirty-six hours from the commencement of the illness. Some time afterwards he had a return of the same malady, the symptoms being similar to those of the first attack. A similar eruption appeared on the skin, and it disappeared with similar rapidity, possibly under the influence of a mild laxative, which was administered on both occasions. This gentleman could not attribute either attack to any food he had taken. He only recollected that he had eaten a bit of sole on the evening before the first seizure, but he also remembered that it was 1 Fievre Orti4e : Febris Urticata of Vogel. URTICARIA. 283 perfectly fresli; and moreover, till then, lie had always eaten with impunity the various articles which often in others occasion urti- caria, such as mussels, various other descriptions of shell fish, and crabs. Urticaria was the affection from which the officer suffered; and in the very succinct account I have now given of it, you have recognised the description of the special form of exanthem, the absolute type of which is the eruption caused by the touch of the stinging nettle. I pointed out to you the other day nettlerash \V eruption ortiee\ occurring as a sudoral exanthem, but that eruption does not consti- tute the malady now under our consideration any more than morbilli- form and scarlatiniform sudaminal exanthemata constitute measles and scarlatina. Urticaria, the febris urticata, is a well-defined nosological species, although it originates under the influence of exceedingly various causes. These causes, however, only play a secondary part. They are the exciting causes [causes occasionelles~\ waking up according to the' idiosyncrasies of individuals a special predisposition, in virtue of which the morbific matter is formed, which is the real, or as the old writers would have called it, the immediate cause of the disease. Urticaria makes its presence known, like the eruptive fevers, by precursory symptoms, which continue, with variable degrees of intensity, for some hours, a day, or two days. These symptoms are general discomfort, headache, horripilation, rigors, precordial op- pression, lipothymia, and more or less difficulty in breathing, which is sometimes so great as to excite the fear that the patient will be suffocated. In some cases, nausea and vomiting occur; and there are also some cases in which there are colic, diarrhcea, and all the symptoms of indigestion, but this is when the exciting cause is the eating some particular kind of food. The symptoms are always accompanied by a well-marked febrile condition. It seems as if the morbific matter were formed in such quantity that the different emunctories are scarcely sufficient to eliminate it, or that before finding its natural exit, which is by the skin, it goes round—pardon the figure—knocking at every door, thus affecting the nervous system, the organs of respiration, and the organs of digestion. The patient soon begins to feel an unusual sensation of heat and itching at particular points in the skin, which forthwith become 284 URTICARIA. swollen. This swelling, quite appreciable by the eye, becomes gene- ralised over a more or less extensive surface, occasions a feeling of tension complained of by the patient; and finally, the characteristic eruption appears. The eruption which now occupies the face, and bye and bye other parts of the body—particularly the shoulders, loins, inner aspect of fore-arms, thighs, circumference of the knees—consists of blotches wdiich are of a rosy or bright-red, and sometimes dull- white colour, always surrounded by a red areola, and exactly resem- bling in form, extent, and general appearance the eruption pro- duced by the stinging of nettles, and sometimes by the stings of bees and wasps :—“ Forma, magnitudine et specie valde similes illis quas urticarum punctura, aut vesparum apumve ictus excitat.” The number of the blotches is variable: sometimes they are very few and quite distinct from each other; at other times they cover nearly the whole body, and become confluent. There is nothing determinate in their shape, which may be round, oval, or irregular. When numerous and confluent, they may resemble the eruption of scarlatina ; and the rapidity with which they come out, combined with the short duration of the precursory symptoms, in- creases the chance of a mistake in diagnosis, if sufficient elements for arriving at a correct opinion are not furnished by the tumefac- tion of the skin (sometimes great), the pruritus and tingling, and an attentive examination of the blotches. The pruritus and ting- ling, which give great annoyance to the patient, are increased by the warmth of bed. I have still to call your attention to a circumstance connected with the eruption which was pointed out by Koch, viz. that it may become developed on the inside of the mouth. This observation leads me to ask, whether the chest symptoms of which I have spoken, are not occasioned by an eruption or congestive state of the mucous membrane of the bronchial tubes analogous to the eruption and congestion seen on the skin. My opinion is that bronchial eruption may occur in urticaria, precisely as in measles. In the pyrexial exanthemata, the cutaneous manifestations occur in regular order, and follow a definite course, but in urticarious fever [fievre ortiee ] this is not the case. The total duration of the disease, including the prodromic period, is very variable, ranging between two and seven or eight days; but the individual blotches of eruption disappear very quickly, their duration being from four, URTICARIA. 285 five, or six minutes to one, two, or three hours. The eruption, then, does not come out all at once, hut in successive crops; and the precursory symptoms which announced the first appearance of eruption may recur again and again. Sometimes scratching causes the eruption to reappear in the places scratched. Urticaria spares neither age nor sex : it attacks old men, adults, and children; and women as well as men. A first attack, so far from being protection against a second, is a reason for expecting subsequent attacks, especially in those in whom it supervenes under the influence of exciting causes. In fact, some individuals cannot eat certain descriptions of food without bringing on symptoms of indigestion, or rather of true poisoning, soon accompanied by a more or less considerable urticarious eruption. It is impossible to state in general terms the kinds of food which produce these symp- toms, because so much depends upon idiosyncrasy. Shell-fish, par- ticularly mussels, crab, lobster, the ova of certain fish, and some kinds of fish (fresh or smoked) seem to be the articles of diet which are most powerful in exciting urticaria in some persons; whereas in other persons, similar results are caused by dietetic articles of a totally different description, such as pork, edible mushrooms, almonds, cucumbers, strawberries, raspberries, honey, &c. Lorry gives cases in which eating rice produced urticarious eruption. A predisposition to urticaria is sometimes hereditary. In Oc- tober 1861, I saw in my consulting-room, a lady of fifty, who was very subject to anomalous nervous symptoms, and who had been a martyr to urticaria during the greater part of her life. She had a son and daughter who had inherited from her this distressing in- firmity, which was as inveterate in them, as it had proved in their mother. Although urticaria is apparently a simple affection, it assumes in some persons an extraordinarily obstinate character, and becomes a real torment of existence. I have seen it last for years, renewing itself daily, and defying all treatment. Sometimes also, urticaria has a terrible influence upon the nervous system. I knew a young woman of twenty, who during the inva- sion-period of an urticarious fever was seized with nervous symp- toms of the most formidable character. She was struck down by profound stupor, paralysis of the lower extremities, and anaesthesia. In some cases, fortunately very rare, after the eruption has entirely disappeared, nervous symptoms—anaesthesia and amyosthenia, par- 286 URTICARIA. ticularly of the lower extremities, continue for a longer or shorter period. The hot weather of summer is often an exciting cause of urti- caria : but, as has been remarked by J. Franc, it likewise sometimes appears under the influence of cold, and disappears under the influ- ence of heat. Finally, it is also sometimes absolutely impossible to assign any cause whatever for the appearance of this disease. I will not speak to you, gentlemen, of chronic urticaria, or of urticaria tuberosa. They are forms of the disease which I have never had an opportunity of observing in the clinical wards; but my colleagues of St. Louis Hospital will show them to you, and make you acquainted with them. I have still a word to add on the subject of treatment. When urticaria occurs without any appreciable exciting cause, it is seldom necessary for art to interfere, as the malady spontaneously terminates in recovery. However, at the beginning of the attack, the adminis- tration of mild purgatives is sometimes indicated, with a view to divert a tendency to congestion from the respiratory organs to the intestinal canal. To moderate the symptoms, it is generally suffi- cient to order tepid baths, and cooling acidulated drinks such as orangeade and lemonade. But when urticaria is excited by the ingestion of alimentary sub- stances, it is necessary, without loss of time, to induce vomiting. After the action of the emetic, draughts containing ether may be prescribed—for example, a quarter of a tumbler of sugared water, containing from twenty to forty drops of sulphuric ether, may be taken every half hour. Ether is also indicated, when you wish to subdue spasmodic action. When urticaria assumes a chronic form, it sometimes resists the best devised modes of treatment. Some benefit, however, is obtained from frequent emetics, the preparations of quinine in large doses, and arsenical solutions. When urticaria appears as a natural crisis of a chronic affection of the mucous membranes, you must not interfere with it. Some- time during the year i860, I saw in consultation with my honour- able colleague Alfred Becquerel, a lady of sixty, who had been attacked in the spring with violent bronchitis. Soon after her seizure, symptoms of extensive vesicular emphysema supervened, accompanied by nocturnal attacks of orthopncea, and constant URTICARIA. 287 dyspnoea. It would be tedious to tell you all the therapeutic means I had recourse to. Suffice it to say, that they had all failed, when, about the end of January 1861, a violent coriza led us to dread an exacerbation of her symptoms, but on the contrary, a profuse urticarious eruption having appeared over the whole body, they all at once ceased. I felt that under the circumstances, I ought not to interfere with an eruption, which though undoubtedly very inconve- nient and very obstinate is not dangerous. LECTURE XIII. ZONA OR HERPES ZOSTER. Characteristics.—Accompanying Pains.—Inveterate Consecutive Neuralgic Affections. Gentlemen :—You recollect a man of 55 years of age, who occupied bed No. 10 in St. Agnes’s ward in April, 1859. Three days prior to admission, this individual was seized wtth acute pain behind the left ear. On the following day, there was a temporary cessation of pain; but on that day and the following, he perceived an eruption consisting of groups of blebs. These groups increased in number, and when the case came under my notice, occupied the situations which I am now going to describe. The eruption extended from the ear to the front of the chest: it was most abundant on the left shoulder and arm, within the triangle formed by the sterno-cleido-mastoid muscle the trapezius and clavicle. Over the pectoralis major muscle, about two centimeters below the clavicle, there was a group extending nearly five centi- meters. Behind the ear, over the mastoid process, we found the first which appeared; and between it and the other large group, in the space which I have described, there were other smaller groups. Some were also situated on the external aspect of the shoulder, and three on its posterior aspect. These groups were formed by blebs not yet completely developed, and the patient, who complained of their being painful, traced with his finger the course of different branches of the cervical plexus. He had a good appetite, no fever, and, as he expressed it, was in no way out of sorts. On the second day after admission, the eruption was perfectly bullous. The blebs desiccated in succession forty-eight hours after- 289 ZONA OR HERPES ZOSTER. wards, and the desiccation was complete on the sixth day, conse- quently, on the ninth day from the beginning of the disease. The neuralgic pains became less severe; and on the twenty-second day, the patient was quite well, and left the hospital. There were only visible some red spots where the blebs had been. Some months afterwards, another case of herpes zoster came under our observation. The patient was a man, thirty-eight years of age, employed as a servant in the wards. He had been aware of the existence of the affection for two days; but it occasioned no pain, and only some itching. Till the third day, which was the first day on which he had pain, he did not mention his ailments to me. The eruption began to the right of the tenth vertebra and extended from the vertebral column to the sternum : it consisted of four groups of vesicles of about the diameter of a small walnut, resting on a red surface. The pains were sufficiently acute to prevent the patient sleeping; but he had neither fever nor rigors, and complained of only a little general discomfort. On inquiring into the seat of the pain, we were struck by finding that it did not exist in the course of the zona, and was not excited even by pressure on the affected parts, though felt above and below them. The pain was acute, and was aggravated by the slightest pressure. On the eighth day, the patches of herpes zoster changed into very painful furuncular tumours; and soon afterwards, we found an engorged lymphatic gland in the intercostal space below them, and also, red lines leading from the eruption to the axilla, indicating inflammation of the lymphatics with its starting point in the furuncular tumours. These circumstances explained why the patient experienced pain beyond the seat of the eruption. At the beginning of the year 1863, another man acting as servant in the wards, was attacked with herpes zoster of the face, which I showed to Dr. Cusco, my honorable colleague in the hospitals. It was situated on the left side of the forehead. The eruption followed with remarkable anatomical regularity all the cutaneous ramifications of the ophthalmic branch of the fifth pair. It was most confluent in the parts where the external frontal branch spreads out into ascend- ing ramifications; it likewise extended to the eyelids, wdiere the divisions of the descending branches are distributed, and became more violent at the point of emergence of the branch of the nasal nerve which is distributed to the integuments of the lobe of the 290 ZONA OR HERPES ZOSTER. nose. The neuralgic pains were very acute, and continued long after the disappearance of the exanthem. There was also ophthalmia, accompanied by pain and photophobia. In 1862, I had previously seen, along with my honorable colleague Dr. Delpech, a man aged sixty with herpes zoster exactly similar to that now described. The photophobia continued for more than three months, and was associated with iritis. The very remarkable tendency which herpes zoster sometimes has to follow the course of the nerves is fully established by the cases which I have now related to you. You must not suppose, however, that the eruption always assumes the form which I have described. If you attentively look at its distribution on the chest in relation to the direction of the ribs, you will be convinced that it does not follow the course of the intercostal nerves. Generally, on the chest, the half girdle formed by the eruption is almost exactly perpen- dicular to the axis of the body, beginning, for example, at the seventh dorsal vertebra, and terminating directly opposite, at the sternum; but the ribs and intercostal nerves are very far from follow- ing a line perpendicular to the axis of the body. Portions of the vertebral column, and the ribs below the fifth rib, slope very much downwards, and form an angle of more than twenty-five degrees with the spine: theoretically, the zona ought to follow the same direction, but it does not do so, as you know from cases you have seen in the wards. It is evident, therefore, that it is not an absolute, though a general, rule that the bullous eruption of herpes zoster follows the course of the nerves. When the eruption appears on the legs, it does not encircle them like a bracelet or garter, but extends in the length of the limb. You recollect a man who occupied bed No. 8 of our St. Agnes's ward, in whom it was situated on the thighs and extended from the groin to the knee. In August, 1862, I saw in my consulting-room a patient in whom the eruption extended from the hollow of the axilla down to the hand, keeping rather to the palmar aspect of the forearm. In the patient of St. Agnes's ward, the herpetic patches were distributed exactly in the course of the principal divisions of the crural nerve, while in the other patient, it was very difficult to find any relation between their distribution and the course of the branches of the brachial plexus: in both patients, however, there were acute neuralgic pains in the part of the limb occupied by the eruption. Here then, gentlemen, is a singular disease, the specific nature ZONA Oil HERPES ZOSTER. 291 of which no one can tell. The eruption by which it is characterised consists of patches, individually variable in size, of a bright red erythematous colour, and having vesicles grouped upon them—or, more correctly, bull®, forming sometimes real blisters, more or less numerous and more or less large. These patches, separated from one another by healthy skin, form, when taken collectively, a sort of half girdle, a sort of zone, which has given the name of zona to the disease, and which is nearly always limited to half of the body, whether the eruption occupy the trunk or the face. On the thorax, its usual seat, the zone never passes beyond the middle of the sternum : on the abdomen, it stops at the linea alba, and behind, it never crosses the vertebral column. “ Perpetua lege” said de Haen, “ ab anteriore parte abdominis nunquam lineam albam, nunquam a postica spinam (maculae) transcendent.” The chest is the most usual situation of the eruption, but it is also seen on the abdomen, where it encircles the lumbar or iliac region, proceeding thence to the groin, and terminating on the anterior surface of the thigh, sometimes also invading the genital organs. When the zone occupies the thorax, it generally also invades the arm of the same side, presenting patches in continuation of the line of the girdle, either inside or outside of it, or both. In the first of our patients, the eruption was situated on the neck, shoulder, and upper part of the chest and back. Sometimes, it remains limited to the first of these regions: sometimes also, it is confined to the face; and in exceptional cases, it appears on the hairy scalp. It has been seen to extend within the mouth. Finally, in a still smaller number of cases, the limbs only are invaded. In all cases, however, there is only one side of the body affected. It is also important to recollect, that when herpes zoster affects the extremities, the groups of eruption, whether they follow or not the course of the superficial nerves, are always, as I have already said, disposed longitudinally, and not round the limb. The half girdle is sharply defined at both ends, and has a breadth of several fingers. The groups which compose it are sometimes rather close to each other, and at other times, rather distant. The eruption begins by the appearance of the red irregular spots of which I have spoken, and which come out the one after the other, showing them- selves in such a way in some cases, at the two extremities of the line, as to indicate that the succession of eruptions is just about to be completed. The patches at the extremities of the line are larger 292 ZONA OR HERPES ZOSTER. than those which intervene. Cazenave, from whom I have taken my description of the disease, says that “ if its progress he attentively observed, small elevations will be seen which have from the first the hue of the patch, and which increase in size and rapidly become true vesicles, quite distinct from one another, very transparent and resembling little pearls in colour. The development of the erup- tion is completed in three or four days. The largest vesicles are sel- dom larger than a large pea. When the eruption has attained its maximum intensity, the patch which constituted its base presents great redness, which generally extends one or two centimeters beyond the limits of the vesicular group. Each patch, therefore, has its phases of increase, and patches are developed one after another in the same way, till all constituting the demi-zone have been formed.” Cazenave continues : “ At the end of five or six days, the vesicles begin to diminish in size, and the liquid which they contain becomes muddy, opake, and sometimes blackish, as if it were sanguinolent: the vesicles become wrinkled, withered, collapsed, and are soon covered with small, thin, brown crusts which fall off in a few days. Every group undergoes similar changes, and about the tenth or twelfth day from the beginning of the disease the eruption has run its course. Nothing then remains except a few red stains, which gradually dis- appear. Nevertheless, it sometimes happens, even in the simplest cases, that in scratching the parts, the patient tears the vesicles, causing them to be succeeded by excoriations and sometimes by small ulcerations, which often greatly prolong the duration of the malady. This complication generally occurs at the base of the chest.” The mode of succession described by Cazenave is more apparent than real. I concur with the statement that the herpetic groups do not all appear on the same day ; but in general, by the third, or at most by the fourth day the eruption is complete. After that period, the vesicles enlarge, and unite to form large bullae, which forthwith become filled with transparent serosity around which the skin has a violet-red colour, and seems to yield a slightly slate-coloured exuda- tion. Between the eighth and eleventh days, the bullae become filled with pus, and go on bursting in succession till the fourteenth day, dating from the commencement of the malady. A great many vesicles, however, remain on the road, if I may be allowed the ex- pression, and disappear prematurely, or at least without having become filled with pus. Those which have reached the stage of ZONA OR HERPES ZOSTER. 293 suppuration burst, as I have stated, and the denuded dermis becomes covered with a blackish crust which comes off between the fifteenth and twentieth days, when the dermis, at first of a purple-red hue, by degrees loses its deep colour, until at the end of two, three, or four months, there is nothing visible excepting a white cicatrix similar to that left by a very superficial burn. It is a remarkable fact to which, gentlemen, I bespeak your special attention, that generally (though not always, as some have alleged) the eruption is developed in the track of the nervous filaments of which it delineates the course: thus, on the thorax, it may follow the course of the intercostal nerves, and in our first case, you saw how it delineated, so to speak, the ascending and descending branches of the cervical plexus. This circumstance is more than a mere des- criptive detail: this disposition of the eruption is related to another phenomenon, which, independent of the form of the disease, is a precise and definite characteristic of herpes zoster. This charac- teristic is the local pain, which almost always precedes and accom- panies the eruption, and often continues long after its disappearance. I am not at present speaking of the prodromic symptoms, the slight discomfort and feverishness which, either nearly or altogether, cease when the eruption has completely come out: I refer to the neuralgic pain in the future seat of the zona, the true, acute, pungent neuralgic pain—a sensation of roasting, of burning heat, a symptom from which the disease derived its old names ignis sacer,feu sacre, and feu de Saint-Antoine. These pains accompany the eruption, and I pointed out to you in our first patient, that they exactly followed the course of the articular and subacromial branches of the cervical plexus, and were increased by pressure on these parts just as pressure increases the pain of ordinary neuralgia. There are exceptions, gentlemen, to this rule, and the case of our second patient is one of these excep- tions. This individual had no prodromic phenomena, and none of the usual neuralgic pains. The pains which he did complain of on the third day of the eruption were situated beyond, that is to say above and below the eruption which it circumscribed, and were not neuralgic, but dependent upon inflammation of the lymphatic vessels. At the beginning of March 1861, I was sent for in haste to a lady of sixty-three, who, with the exception of some attacks of gout, had generally enjoyed good health. She had excruciating pain in the left lumbar region, which caused her to utter piercing cries, and although she had no vomiting, her gouty constitution led me to 294 ZONA OR HERPES ZOSTER. suppose that she was suffering from the passing of renal calculi. Next morning, when the pains were a little subdued, I observed an herpetic eruption occupying the surface over the place which had been the seat of such exquisite suffering, and I was thereby imme diately enlightened as to the nature of the malady. In forty hours from the onset of the attack, the eruption was complete, extending from the spine to the linea alba. The persistence of the neuralgic pain after the disappearance of the eruption is, particularly in old people, one of the most remark- able characteristics of herpes zoster. The pain, which always pos- sesses the same acute character, which always produces the same intolerable sufferings, often continues, not merely for months, when the marks of the bullae are still on the skin, but may even continue for several years. I knew an old lady who had herpes zoster when seventy years of age, and who after the lapse of fourteen years still experienced most excruciating pains, particularly during the night. I have at present under treatment a lady of sixty who for the last five years has been horribly tormented by the pains which belong to this disease. There is a curious circumstance in the case of this lady, which I have observed in several other cases: the mere con- tact of her clothes sometimes produces indescribable suffering, although superficially there is a sort of cutaneous insensibility, which continues long after the pains leave her. I am not quite sure that herpes zoster is not sometimes conta- gious like erysipelas of the face. On the 20th August 1862, I was sent for by Dr. Brossard to see with him an old Jewish lady living in rue Montmorency. She was suffering from softening of the brain. Six weeks before our visit she had had very painful zona on one side of the chest. Her son, aged thirty, who waited on her, took the disease at the commencement of his mother’s convales- cence. Although the prognosis of this disease is not unfavorable, seeing that it does not endanger life, it is unfavourable in one sense, for it leaves many persons, old people at least, martyrs to those intole- rable pains which make both patients and physicians despair of a cure. The pain, and its persistence after the disappearance of the erup- tion, long ago engaged the attention of observers. Lorry in his treatise “ De morbis cutaneis ” and, about the same time, Geoffrey, and Borsieri pointed out and insisted upon this circumstance. It ZONA OR HERPES ZOSTER. 295 did not escape the notice of Alibert, Bayer,1 and many others; and more recently Dr. J. Parrot has ably discussed the subject of zona and of the pain, one of its predominating symptoms, which pain he classes, as I do, along with neuralgic affections,3 Dr. Bazin, my distinguished colleague of the St. Louis Hospital, has found it necessary to distinguish two kinds of zona—one arthritic and of the nature of rheumatism, and the other herpetic. Arthritic zona may often originate in moist cold, and in changes of temperature. It occurs most frequently in adults, and almost never in old people. The disease when met with in infancy is arthritic in the vast majority of cases. Herpetic zona, on the other hand, is most common in old age. It is often brought on by mental emotions, and is accompanied by jaundice in a certain number of cases. Its vesicles are pretty equal in size, and grouped in a regular manner. The bullse which I have described to you are, on the con- trary, most frequently met with in the arthritic form. Herpetic zona is often preceded, and is generally accompanied by, neuralgic pains. These pains sometimes decrease in severity during the erup- tion, to return as before with the eruption : they are then only a secondary symptom. Dr. Bazin says that the neuralgic pains have been known to continue for months and years, to follow an intermittent course, and at last to be replaced by other neuralgic pains in situations different from those which were in the first instance the seat of the neuralgia. Binally, herpetic zona generally has as antecedents, hemi- crania, dyspepsia, and other herpetic affections. In relation to these doctrines, recollect the persistence of pains following zona in the aged patients of whose cases I have just been speaking. To prevent the vesicles from being torn, the only means which require to be employed during the acute stage are powdering the affected parts with starch, and during the latter days, bathing them. Some have recommended cauterization with the nitrate of silver, but the expected beneficial results have never been obtained from this treatment. Bor the pains subsequent to the eruption, it is useful to employ frictions with the mixture of belladonna, or a so- lution of atropine or of morphia : subcutaneous injections with the same solutions may also be advantageously resorted to. Blying 1 Bayer Traite Theorique et Pratique des Maladies de la Peau. Paris : 1835, T. i, p. 330. 2 J. Parrot:—Union Medicale, Mars, 1856. 296 ZONA OR HERPES ZOSTER blisters and vapour douches have also been employed. Often, how- ever, every kind of treatment fails; and I know patients, chiefly women, who have for years been tortured by these neuralgic pains. Acquaintance with the nature of herpetic zona led Dr. Bazin to adopt a rational method of treatment. He gave arsenical prepara- tions with success in the obstinate neuralgia consecutive to zoster ; and so accomplished cures in cases which had resisted narcotics, narcotico-acrids, and cauterization. His method of treatment ought to be imitated. LECTURE XIV. SUDORAL EXANTHEMATA. Multiplicity of Forms.—Cutaneous and Mucous Exanthemata.— Physiological Causes.—Antagonism of the Secretions with the Shin and the Intestinal, Respiratory, and Urinary Mucous Mem- branes.—Exanthemata produced by Medicinal Agents.—Sudoral Exanthemata becoming Purulent in Lying-in Women and others. —Analogies between Sudoral Exanthemata and Exanthemata Produced by a Virus, or Eependent on Diathesis. Gentlemen :—During the hot season, you have often observed the spontaneous development of cutaneous eruptions in a great many patients. These eruptions are concurrent with profuse per- spirations, and are most abundant in those parts of the body which are most constantly bathed in sweat. You have observed them most frequently in the children of our nursery-wrard, that is to say in children under two years of age. The greater frequency of these affections in very young children arises from the manner in which they are clad—on the swaddles and flannel binders in which they are always enveloped, and by which they are kept in a state of con- tinual sweating. You have been struck by the multiplicity of forms which these efflorescences assume—you have seen them as erythe- matous, scarlatiniform, and morbilliform patches, as urticaria, or as vesicular, pustular, and papular eruptions. You could not fail to be struck with the rapidity of their development, and the generality of their localization; nor could you but be surprised at their short duration, some disappearing with marvellous ease, either sponta- neously, or under the influence of very mild treatment. Finally, gentlemen, you have had an opportunity of watching their trans- formations : you have seen patches quickly succeeded by vesicles, 298 SUDORAL EXANTHEMATA. pustules, or papules, and have often observed a combination of these different forms of eruption in the same patient. Although the study of these affections is apparently of small im- portance, it really possesses a much higher practical interest than is generally supposed. I hope to be able to prove this to you when I come to speak of symptoms met with *in the great pulmonary and digestive organs, and which are somewhat analogous to the appear- ance of these cutaneous efflorescences upon the internal skin—the mucous membrane. We will therefore study the relations which may exist between the sudoral eruptions and the affections of the mucous membranes to which I alluded. The number and variety of sudoral eruptions associated together in the same individual, and their transmutations, even when pro- duced by the same cause, is an important fact. My friend Dr. Duclos of Tours, in his excellent work on sudoral eruptions, (published when he was my interne at the Necker Hospital), shows most conclusively, though in opposition to the views of many der- matologists, that it is impossible to establish distinction of species upon anatomical characters alone, as these characters differ ac- cording to the epoch at which they are studied, merge into one another, and do not retain specific characteristics throughout their duration. To enable you to understand the subject now under discussion, it will be indispensable, as we proceed, that I recall to your recollec- tion some points connected with the physiology of the skin. The cutaneous system is endowed with excreting and secreting functions. It excretes a certain amount of gaseous matter—carbonic acid gas, hydrogen, and nitrogen : it excretes liquids which it has secreted, the sweat containing solid matter, partly in a state of solution, and partly undissolved : finally, by its sebaceous glands, it secretes and excretes fatty products. When these different secretions and ex- cretions take place in a normal manner; when on the one hand, in relation to quantity, evaporation, which is constantly going on, and secretion balance one another; when, on the other hand, in relation to quality, no alteration takes place in the composition of the pro- ducts, there is no unusual cutaneous manifestation. But, if under the influence of a high temperature, or of any other exciting cause, the excretions become more abundant, though unchanged in quality, symptoms of irritation are soon seen. This irritation is partly pro- duced by a precursory increased determination to the cutaneous SUDORAL EXANTHEMATA. 299 organs; and also partly by the deposition of an abnormal quantity of solid matter on the surface of the skin. These phenomena of irritation account for the exanthemata of which I am now speaking. If an individual sweat profusely, even though he is in the pleni- tude of health, these special sudoral efflorescences will be observed : they will at times be very painful, and may bear the aspect of measles, roseola, urticaria, &c. I say the aspect only, and not the real characters. However great a similitude they may bear to the eruption of measles, they essentially differ from it in respect of the rapidity of development, absence of general precursory symp- toms, shortness of duration, and absence of the symptoms which belong to measles. There are cases, however, in which the diagnosis presents some difficulty, as for example, when the eruption supervenes in children attacked with feverish catarrh, the result of a chill. In such a case, it is often impossible to establish the differential dia- gnosis on the first day: it is necessary to wait, for the surest way to avoid error is to observe attentively the progress and consecutive characteristics of the malady. So is it also with sudoral scarlatiniform eruptions. During an epidemic of scarlatina, which prevailed at Paris, I was called in to a young girl supposed to have the current malady. After a paroxysm of fever accompanied by very profuse sweating, induced by the great heat of the weather and confinement to bed, an eruption iden- tical in appearance with that of scarlatina came out over a great extent of the skin. The absence of the specific sore throat, the natural colour of the tongue, and the character of the general symptoms led me to conclude that the exanthem was sudoral. Next day, it had disappeared; and none of the symptoms which so often complicate scarlatina supervened. These facts, gentlemen, are very sufficient to explain certain alleged second attacks of measles and scarlatina, and also the mildness of some supposed anomalous cases of these eruptive fevers. Excessive perspiration, then, is in itself a cause of sudoral exan- themata. And precisely analogous consequences result from the excess of other secretions than those of the skin. Does not a too copious secretion of tears, which are perfectly inoffensive so long as they are secreted in not more than sufficient quantity to lubricate the surface of the eye, irritate the conjunctiva, and produce bright redness of the eyelids and even of the cheeks ? Hence you observe, that an exaggeration of the normal secretion 300 SUDORAL EXANTHEMATA. may lead to symptoms of irritation and inflammation in the mucous, as well as in the cutaneous membrane. Many cases of diarrhoea originate in causes analogous to those which produce sudoral exanthemata on the skin. Gentlemen, you are acquainted with that sort of reciprocity which exists between the cutaneous, intestinal, and urinary secretions. You are aware that inasmuch as they all act on the composition of the blood, from which they ought to remove certain matters useless for the maintenance of life, none of them can undergo any change without disturbing the equilibrium which existed between the secretions in relation to their influence on the blood. Hence it arises, that the diminution or augmentation of one secretion neces- sitates the augmentation or diminution of another : this is termed the antagonism of the secretions. Sometimes individual peculiarities, idio- syncrasies, exist, in virtue of which the elimination of products which ought to be excreted is accomplished by one emunctory rather than by another. Thus, in one person the skin will be, so to speak, more open than in another, and the least increase of the temperature of the atmosphere, the slightest exertion, or a little febrile excitement will cause profuse perspiration; while another will not be made to perspire by the greatest heat of summer. But in compensation for deficient elimination by the skin, the latter will probably pass large quantities of urine, and have frequent stools; for it is essen- tial that elimination take place by some channel. Some individuals are at once seized with diarrhoea on exposure to a rather warm tem- perature, or on sleeping with an excess of bedclothes. They call in their physician to set them to rights, and he calls the attack acute enteritis : he is right, for the affection really is enteritis, just as the cutaneous exanthem caused by excess of heat is an inflammation of the skin. Both are the results of secretion, and consequently of increased determination to the parts; but the fact is not suffi- ciently recognised that both are phenomena of the same class. When, therefore, with a view to check excessive perspiration, we recommend the patient to diminish his covering, we augment in place of diminishing the intestinal flow. This effect is equally brought about, whether we give medicines which increase the de- termination to the intestine, or supplement the precautions against cold already taken by the patient. There is also an antagonism between the secretions of the skin and those of the pulmonary mucous membrane; for as you know, gentlemen, abrupt suppression of the normal cutaneous exhalation 301 caused by a chill excites a mucous flux from the lungs, just in the same way that it excites a diarrhoea. These considerations will enable you to understand how it is that certain bronchial catarrhs are of the same nature as the cutaneous and intestinal affections of which I have been speaking, whether the determination to the mucous membrane of the respiratory passages be primary from individual predisposition, or whether that determination, after mani- festing itself in the skin, and ceasing there, from some particular influence, had declared itself in the pulmonary organs. Certain therapeutic indications obviously arise out of the con- siderations now stated. The production of diaphoresis by the action of appropriate drinks on the interior, is sometimes a successful means of treating bronchial and intestinal catarrh, and of removing alarming and unexplainable symptoms. But even when perspiration is excited for a therapeutic purpose, we may meet with sudoral eruptions. Prom among the cases which I could adduce in support of this proposition, I select the following communicated to me by Dr. Dumontpallier. A child of four and a half years old, of a nervous temperament, but who generally enjoyed good health, was seized during the month of August, without any appreciable cause, with irregular intermittent diarrhoea. The child did not lose his appetite; but nevertheless, he grew pale, and went on losing strength, when, two days after a fit of great excitement, the diarrhoea became so severe, that within twenty minutes he had several stools : they were first yellowish, then serous, and at last choleriform. Neither vomiting nor cramps supervened, but the patient fell into a state of profound prostration, and, at the same time, the extremities became cold. The eyes were sunken, and the nose pinched: the pulse was small, thready, and very rapid: death was supposed to be impending. Proceeding to the most urgent indication, wdiich was to restore the threatened powers of life, the child was made to take a dessert-spoonful of brandy mixed with quantity of infusion of tea. The little patient was restless for a minute or two, and then fell into a calm sleep. During this sleep, his face was bathed with a profuse warm sweat; and the pulse rose. During the night, a little restlessness was ob- served, and the child directed his hands to various parts of the body, as if for the purpose of scratching himself. About six oJclock in the morning, his mother perceived that he was red from head to foot; and the physician, who had not left him, found that the whole SUDORAL EXANTHEMATA. 302 SUDORAL EXANTHEMATA. surface of the skin was covered with a sheet of strawberry redness, which was more conspicuous on the hands and feet than on any other situation. Rejecting the idea of an eruptive fever, of which the child had had no precursory symptoms, the diagnosis was re- served. The pulse was full, and less rapid. His sleep was tran- quil, interrupted only by the itching. Trom the time at which the cutaneous reaction began, he had had no more stools. By noon, the danger was averted : and the scarlatiniform eruption had become pale, as well as less general. In its place, on different parts of the body, there were patches of urticaria, two of which, however, only remained till evening. The natural colour of the skin was restored : and the diarrhoea was at an end, for he had not had a stool for forty-eight hours. The intestinal functions, however, remained some- what sluggish for a time, the child being only able to digest meat nearly raw. But in the course of a few days, under the influence of tonics and bitters, health was completely re-established. It happens sometimes, though very seldom, that the symptoms to which I have been directing your attention show themselves simul- taneously in the skin and the mucous membranes: thus, in some individuals, violent exercise always brings on both sweating and purging. All the emunetories seem in such persons to be scarcely adequate for the depuration of the blood from its superfluity of excre- mentitious matter. Here we see occurring physiologically, the same thing which we have already studied as a pathological occurrence in measles. I pointed out to you that the exanthematous determination takes place in measles simultaneously, and from the beginning of the attack, in the skin, intestinal canal, and air passages; as is mani- fested by the cutaneous eruption, the diarrhoea, and the bronchial catarrh. Hitherto, gentlemen, I have spoken only of the effects produced by a change in the’quantity of the elimination : I have now to consider the consequences of a change in its quality, of the formation of new bodies, various in their nature and origin, as manifested by different affections of the cutaneous and mucous organs. Although modifications in the quality of the matter eliminated are not always physically and chemically appreciable, they are, even when not thus appreciable, indisputable, as can be analogically shown. In a great number of cases, chemical analysis demonstrates in the sweat, substances which have been absorbed internally : some- times their presence is made known by physical signs, as is the case SUDORAL EXANTHEMATA. 303 when the sweat exhales the special odour of copaiva in persons who have taken that drug. Now, as in certain cases, these alterations manifestly coincide with the existence of cutaneous affections, are we not entitled to conclude that they also occur in the other cases in which these cutaneous affections occur, although we cannot physically or chemically prove that alterations on which they depend have taken place in the sweat ? In the' absence of physical charac- ters, and chemical tests, the point is established by what I may call pathological tests. A person, for example, lives on exciting diet, and under its in- fluence, different exanthematous affections supervene, such as urti- carious eruptions, which appear on some individuals after eating some kinds of shell-fish, mussels for instance, and crabs; in others, the same effect is produced by eating pork; and in others, again, by taking a variety of articles of food, the nature of which it would be difficult to specify. In point of fact, it is impossible to state in general terms, the conditions under which these eruptions take place, idiosyncrasy having beyond doubt the largest share in their production. Although we cannot in these cases demonstrate physi- cally or chemically the modification which the sweat has undergone, it is evident that a modification has taken place, from the fact, that the affections of the skin determined thereby take place, although there is not the slightest increase in the quantity of the perspiration. This fact will be made much more palpable by what I am now going to say regarding exanthemata produced by certain therapeutic agents; for in these cases no one will deny that an alteration has taken place in the sweat, although in numerous instances that alteration is appreciable only in its effects. A patient, for example, takes opium to the extent of producing stupefaction. We know that under such conditions opium generally produces profuse sweating; and we also know that it is the most powerful and most energetic of all sudorifics. When, carried by the torrent of the circulation, it presents itself to the different emunctories, and particularly to the cutaneous emunctory, which is specially charged with its elimination : it there causes an irritation, and an eruption is observed on the skin, which may consist of red erythematous patches, pseudo-morbillous spots, vesicles, or true papules, if the action of the medicine have been long continued. Here then is a substance which imparts a peculiar quality to the excreted sweat, and determines a state of inflammation or irritation 304 SUDORAL EXANTHEMATA. of the skin, a transient state it is true, but nevertheless a state very different from that produced by a mere superabundance of natural sweat. This difference is not shown in the form, but in the inten- sity of the exanthem. So much is this particular inflammatory state dependent upon the special modification which the sweat has undergone in its composition, that in some cases we see the opium- exanthemata supervene when there has been no increased perspi- ration. Belladonna given in certain doses also produces eruptions. In the case of this drug, the exanthem is generally scarlatiniform, as it also is when produced by datura stramonium, mandragora, and most of the poisonous solanese. The effects which turpentine, and still more the effects which copaiba produces on the skin, are known to everybody. After con- tinued use, and sometimes from the first day of taking them, the employment of these medicines is followed by sweats, the odour of which distinctly proclaims the agent which has produced them. Papular exanthemata result from their employment, and when their use is long continued, vesicular eruptions appear. Similar results sometimes follow the use of cubebs pepper. The eruptions are exceedingly fugitive, and do not in general continue longer than the period during which the perspiration retains the characteristic odour imparted to them by the drugs. These medicinal exanthemata have been, and are sometimes still, confounded with syphilitic roseola. Prom a scientific point of view, this is a deplorable mis- take; and from a practical point of view, the error is even more deplorable, because it leads to the institution of antisyphilitic treat- ment, when our therapeutic measures ought to be limited to those required in simple gonorrhoea, devoid of all specific character. This remark applies to the exanthemata which appear after the administration of iodide of potassium—an eruption which assumes an eczematous and then a pustular form, generally consisting of pustules of acne situated chiefly on the shoulders and face. There are persons, as you know, who cannot take even the most moderate doses of this medicine without having these eruptions, and suffering from pains in the throat, coryza, and intolerable lachrymation. When these pustules occur in the course of antisyphilitic treat- ment, they may be supposed to be of a syphilitic character, unless they are very carefully examined. A mistake of this kind at the beginning of the treatment would matter little, but at a later period, SUBORAL EXANTHEMATA. 305 it might be serious, by leading to the prolonged use of a medicine which ought to be discontinued. The resemblance which I maintain exists between sudoral cuta- neous exanthemata and some affections of the mucous membranes is peculiarly well marked in the class of cases I am now speaking of. The coryza, lachrymation, sore throat, and pustular affections pro- duced by the iodide of potassium are all symptoms of the same class. Being all essentially dependent upon the action of this medicine, they all rapidly disappear upon its use being discontinued, and they all equally resist every kind of topical treatment so long as it is being taken. These remarks are applicable to the eruptions produced by copaiva. When they supervene, there is an action on the skin of a nature similar to that which the medicine usually excites in the mucous membranes. Copaiva, turpentine, and all the oleo-resinous bodies, cause a congestive determination to the mucous membranes, which explains their beneficial influence in gonorrhoea, urethritis and bron- chial catarrh : the balsams act by inducing a substitution, by exciting a therapeutic congestion which modifies the morbid or inflammatory state which we wish to subdue. When this fluxionary condition proceeds too far in the intestinal canal, the result is a kind of diarrhoea which may be regarded as analogous to sweating. Many other substances produce similar effects on the skin and mucous membranes. The substances I have mentioned are those which are most employed in medical practice, and they are also those which most frequently produce sudoral exanthemata. I must not, however, omit to mention a concluding illustration. A patient, for example, takes mercury in large doses, and so brings on violent inflammation of the mouth and salivation. These symptoms become so violent that fever is excited, and with it profuse sweating sets in. The blood, changed in its character by the mercury, upon presenting itself to the cutaneous emunctories, there produces mercurial eczema that serious vesicular affection which Alley has described under the name of “ hydrargyria.” Sudoral exanthemata are observed during the course of a great many diseases. The sweat, altered in its composition, acts as an irritant, and the eruptions of which we have been speaking super- vene, whether or not there be an increase in the quantity of per- spiration. A patient has a large suppurating sore in some part of the body. SUDOitAL EXANTHEMATA. Absorption of pus takes place—not purulent absorption, nor absorp- tion of putrid matter—but that kind of absorption always going on of the fluid part of pus, and of the materials dissolved in it. This exchange of materials between pus and the economy does not seem to exercise any injurious influence upon the system, provided the pus has not undergone any alteration. However, in persons with purulent collections, we sometimes observe a slight febrile excite- ment recurring at intervals, and followed by a critical sweat, as if the economy was getting rid of some of the matter imbibed from the abscess. It is under these circumstances that we see exanthe- matous affections, very various in form, but chiefly vesicular, and when the perspiration is profuse and long-continued, the eruption consists of pemphigoid bullae. The squamous form is also some- times observed. Indeed, it is unusual for a person to be laid up with protracted suppuration, without the skin becoming the seat of more or less extensive furfuraceous desquamation. There are some people, whose blood, to use the common expres- sion, is poisonous [yenimeuaf]. Under the dominion of a true sup- purative diathesis, the smallest wound, the slightest excoriation becomes the starting point of interminable suppuration in some people, an ophthalmia or coryza resisting every kind of treatment. In patients of this diathesis—chiefly children—you will often see eruptions, vesicular and pustular generally, supervene even after perspirations which are not very profuse. The miliary fever of lying-in women is nothing more than a sudoral exanthem. The solution of continuity in the surface of the uterus caused by the detachment of the placenta necessarily sup- purates during the reparative process, and thus places the woman in the condition of a wounded person, in point of fact, in the condition of the person in whom we were supposing that there was absorption of the constituents of pus. Both in one and the other, when pro- fuse perspiration is induced, when that deplorable custom is adopted of covering the patient with an excess of bed-clothes, we see erythematous patches and measly spots in addition to the vesicular eruption which constitutes the miliary affection. Beware, gentlemen, of supposing that these cutaneous eruptions are never serious. As I have just mentioned, Alley has shown that a general eczematous eruption may result from the excessive absorp- tion of mercury, causing a terrible fever, and nervous symptoms which are often followed by speedy death. SUDORAL EXANTHEMATA. 307 A similar result too frequently occurs in the miliary fever of lying- in women. Miliary fever is not, as I have already remarked, a specific affection: it is merely a sudoral exanthem. It supervenes, when the woman has been shut up in a hot room, smothered with bedding, and neglected in those matters of cleanliness, more neces- sary to her after parturition than when in health. The perspiration secreted in unusual quantity, and impregnated with morbid elements imbibed from the surface of the intestine and from the mammse, produces an irritation of the skin which assumes serious proportions. Very recently I was sent for by my honourable friend Dr. Patouillet to see a young recently confined lady. Her nurse was an old woman imbued with the prejudices of last century. The lady had been kept without change of linen, soaking in the lochial discharge, and smothered with a mass of blankets for the alleged purpose of pro- moting the secretion of milk. Prom the sixth day of her illness, she had a scarlatiniform eruption; and four days later, she had, over the whole body, a confluent and frightfully violent eczema. Lever kindled in her countenance, delirium supervened; and this poor young lady died a victim to prejudices equally disgusting and dangerous. These eruptions are most frequently met with in the disease called* puerperal fever, and in purulent infection, to one of the forms of which puerperal fever has a great resemblance. Diarrhoea and bronchial catarrh, so common in puerperal fever and purulent infection, are produced by the same mechanism as sudoral exan- themata, that is to say, by the irritation carried to the external and internal tegumentary surface through the medium of the serosity of the pus in process of elimination by the natural emunctories. These symptoms supervene when, from the suspension of the cutaneous secretion, emunction has to be accomplished solely by the mucous membranes, or when the congestion arises simultaneously in the skin, respiratory passages, and intestinal canal. The miliary eruption of dothinenteria has perhaps no other origin than sweat altered in composition by the absorption of putrid elements. Let me remind you that vaccinal eruptions [eruptions vaccinates] are likewise sudoral exanthemata. I refer to eruptions essentially fugitive and very varied in form, and not to the eruptions of acci- dental vaccinal pustules to which I formerly directed your attention. Sudoral exanthemata are also met with in small-pox during the period of desiccation. They generally assume the pustular form, but SUDORAL EXANTHEMATA. it is impossible to inoculate sinall-pox by using the pus contained in these pustules. Perhaps these exanthemata consecutive to small- pox are due to the presence of the elements of pus in the sweat; for variolous patients may he compared to persons under the dominion of the great suppurations to which I formerly referred. The intensity of the fever, the smartness of the reaction in the skin, and the alteration and modification of its secretions explain the production of the miliary eruption in scarlatina. The mechanism by which the eruptive fevers accomplish their manifestations on the skin and mucous membranes has the greatest possible similarity to that which is in operation in the sudoral exan- themata. In both cases, there is a morbific matter in Contact with the blood, which matter journeying with the blood presents itself to the different emunctories, and produces an irritation in them, the result being an eruption. The pathological lesion is equally pro- duced by morbific principles traversing the emunctories, whether the agent be medicinal such as opium, belladonna, copaiva, and mer- cury, or pathological such as the elements of pus, the putrid elements of dothinenteria, the virus of small-pox, measles, or scarlatina. But in the eruptive fevers, the manifestations are always uniform, spots and patches being always produced by the same cause, whereas in the sudoral exanthemata very varied effects proceed from the same cause. In the latter, they are transient, like the cause which pro- duces them: in the former, they are more persistent, for it is essen- tial that, in accordance with a law almost invariable, the elimination of the morbid matter should follow a natural course. The facts are similar in respect of chronic exanthematous affec- tions related to acquired diatheses such as the syphilitic, or to original diatheses such as the herpetic and the scrofulous. But just as in acute diseases, the exanthematous manifestations take place in hours, days, or at most in -weeks, so in diathetic diseases they are accomplished more slowly, and continue for a longer time. In syphilis, the cutaneous eruptions appear a month, two months, or even a year and more after the system has been infected. In the herpetic and scrofulous diatheses, they may even not appear till after a lapse of five, ten, twenty, or forty years. So true is this that sometimes it may not be till a late period of life that a person descended from herpetic or scrofulous parents, and bearing a con- stitutional resemblance to their organism, as well as to their external forms, shows signs of a diathesis till then silent. SUDORAL EXANTHEMATA. 309 The manifestations, according to the diathesis, are always of the same class, whether the action of the morbific principle be on the skin or on the mucous membrane. In respect of syphilis, all admit that this is the case : in the attacks of coryza, sore throat, and laryn- gitis which so frequently supervene in the second period of that disease, no one fails to recognise the influence of the venereal virus. It is visible in morbid vascularity, eruptions, and ulcerations : there are other cases in which if these lesions exist, they escape our means of investigation in the living subject, but the effects wrhich we do see are not, on that account, the less dependent on the same cause. For example, diarrhoea, as I will tell you when I come to speak of certain anomalous effects of constitutional syphilis, sometimes super- venes as one of the earliest symptoms of the disease, being con- nected with the intestinal determination produced by the action of the morbid poison on the mucous membrane of the digestive canal. In respect of the herpetic diathesis, do we not every day see its manifestations in the mucous membranes ? And, in relation to the transition of the affection from the external to the internal integu- ment, do we not constantly see persons under the influence of the herpetic diathesis take in succession eczema of the upper lip or in- ferior orifice of the nasal fossse, or chronic coryza, leading sooner or later to ozsena? Here, the affection of the Schneiderian mem- brane is merely a propagation of the eczema, by continuity of tissue, from the external to the internal integument. In other individuals, granular sore throat will supervene, an affection of the nature and possessed of all the inveteracy of herpes, and which, like an herpetic affection, will give way when the diathesis manifests itself elsewhere in the economy. In other cases, the result will be deafness, caused by the extension of the lesion to the Eustachian tube. In coryza and sore throat you can follow, so to speak, step by step the march of the malady: you can see it approach nearer and nearer to the deep-seated parts : you can, for instance, see an eczema of the labia majora invade the vagina, attack the uterus, and so become the cause of obstinate leucorrhoeal discharges. Herpetic affections of the mucous membranes are sometimes, also the first manifestations of the diathesis. At other times, they are consecutive to the disap- pearance, spontaneous or from treatment, of other affections of a similar kind occupying a larger or smaller surface of the skin. Manifestations of the herpetic diathesis are not confined to the mucous surfaces of wrhich I have spoken, but are also met with in 310 SUDORAL EXANTHEMATA. those of deeper seat, such as the bronchial tubes and digestive canal. How often do we see a herpetic subject, when suddenly cured of a cutaneous affection, become a sufferer in the organs of respiration or digestion—a sufferer from bronchitis, dyspepsia, or intractable diarrhoea ! Examples of this throwing inwards of herpes [repercussion des dartres] as our predecessors called it, cannot seriously be called in question. Let me quote a case in point pub- lished by my colleague Dr. Noel Gueneau de Mussy: — “ Some time ago,” says my scientific friend, “ I attended a lady of about sixty years of age, who for a long time had had chronic eczema of the right temple and cheek : she stated that the malady was extending, and she wished at all hazards to be freed from it. For some time, I opposed her entreaties; but at last, yielding, I prescribed depurative drinks, mild purgatives once a fortnight, and the application of a mercurial pomade to the seat of the affection. The eczema disappeared: but this was followed by an obstinate diarrhoea setting in, which did not yield till after two or three months of treatment, and then the eczema resumed possession of the parts which it had so long occupied.” “It is difficult,” adds Dr. Gueneau de Mussy, “not to admit that there was something else here than the mere effect of deriva- tion, and difficult to avoid explaining by the diathetic condition, the intestinal catarrh which continued with such obstinacy in spite of a regulated diet and rational treatment.”1 Do you not find, gentlemen, that there is a great resemblance between Dr. Gueneau de Mussy’s case and that which takes place in sudoral diarrhoea ? Do you not find in it an example of that law of compensation and supplement, which I pointed out as existing for the two great emunctories, the skin and the mucous membrane of the digestive organs ? Other cases might be mentioned, in which dys- pepsia, bronchial catarrh, and inflammation of the cervical glands have followed herpetic affections of the skin. I have likewise seen sudoral symptoms occur simultaneously in the skin and mucous membranes: and the diathetic manifestations of syphilis, herpes, and scrofula may occur simultaneously in both integuments. The possibility of these diathetic symptoms affecting internal organs is a fact of the highest importance, as it leads to therapeutic measures of daily application. Sulphurous mineral waters are re- 1 Gttembatt de Mtjssy .—Traits de l’Angine Glanduleuse. SUDORAL EXANTHEMATA. 311 raarkably efficacious in the treatment of certain bronchial, intestinal, uterine, and vesical catarrhs, depending upon the herpetic diathesis, because they exercise a remedial influence upon it. You are going perhaps to send your catarrhal patients to Cauterots, Bagneres-de- Luchon, Aix, and Enghien; but before doing so, ascertain whether they ever had herpetic manifestations in their youth, or at any time in the course of their lives. You will then know -what you are about. Gentlemen, thoroughly realise the fact, that some catarrhal affec- tions are simply exanthemata of the mucous membranes. A chronic bronchitis, for example, has come on under the influence of a chill, but the chill was only the exciting cause which determined the direction of a fluxion, in virtue of which the herpetic principle was carried to the mucous membrane of the respiratory passages, just as it is carried in other cases to the vagina and uterus, or, still more frequently, to the skin. All the considerations into which I have now entered lead to practical conclusions. It is important to know whether cutaneous exanthemata proceed from mere excess, or from vitiation of the natural secretion of the skin. How often has the most simple hygienic advice given in virtue of such knowledge enabled a patient to get rid of an affection which must otherwise have become a very obstinate disease. You may thus have it in your power to snatch from death patients suffering from the general eczema so formidable in hydrargyria, or you may save lying-in women by having the courage to remove their superfluous bed-clothes, to have them washed several times a day, or even plunged in a bath. Under the influence of these simple means, they will almost imme- diately lose their sleeplessness, burning heat of skin, and unbearable itching. I cannot sufficiently impress on you the magnitude of the services you may be able to render to your patients, if you thoroughly realise the importance and frequency of sudoral exanthemata; and if with a view to cure them, you have the courage to fight against the deplorable prejudices propagated by physicians of a former century, and which it is your duty to endeavour to eradicate. LECTURE XY. DOTHINENTERIA, OR TYPHOID FEYER. Specific Lesion.—Furuncular Eruption of the Intestine.—Intestinal Perforation.—Peritonitis without Perforation. Gentlemen :—A young man of eighteen, who had lived in Paris only for the two previous years, was admitted to St. Agnes’s ward on the 19th February, 1859. He had been ill for eight days. His illness commenced with debility, lassitude, pains in the limbs, repeated rigors, headache, and distressing insomnia. At first, he struggled against these symptoms, but at the end of four days, he was obliged to keep his bed. I found him lying on his back, and feverish, with a rapid pulse, and dry hot skin. The tongue was dry, red at the point, and covered with a slight whitish fur. There was gurgling in the right iliac fossa, but no abdominal tympanites. On the 22nd February, there wras tympanites, and diarrhoea. The fever was great, and accompanied by delirium. Next day, the ab- domen was covered w7ith an eruption of rosy lenticular spots. On the 26th and 28th, there was an increase of severity in the symp- toms. On the last-mentioned day, the tongue and teeth were fuli- ginous, the diarrhoea continued, and the stools were passed involun- tarily. As there was retention of urine, it became necessary to use the catheter. On the 29th, the delirium was less violent, the fever had subsided, and the tongue was not so dry. On the 30th, the improvement was still more visible: the abdomen felt soft: he was able to pass his water naturally : the skin looked healthy, the pulse had fallen to 92 from 108, which it was in the early days of his attack : and his intellectual faculties were clear. Recovery pro- ceeded continuously till the 18th March, when, it being complete, he left the hospital. The entire treatment in this case consisted of lavements of infu- DOTH IN ENTER IA. 313 sion of camomile, administered twice in the twenty-four hours, on the 28th and 29th February, and on each of these days a draught composed of twenty grammes of balm-water, one gramme of am- monia, arid forty grammes of syrup of orange-peel. In accord- ance with my usual practice in similar cases, I ordered the patient to have every day some spoonfuls of meat-soup and beef-tea. In the history of this case, gentlemen, you have recognised the disease generally known by the name of typhoid fever, a disease of which it is very unusual for us not to have some cases in our wards. It is one of the maladies most commonly met with in practice, and is found in all temperate climates. It is endemic in some places, spe- cially so in the great centres of population, and this is perhaps more particularly the case in Paris, where every family pays a heavy tri- bute to it, where foreigners, on coming to reside, are soon attacked by it, and where, as an epidemic, it periodically spreads very cruel desolation. As, probably, there is not one of you who is not brought into contact with this disease at the very threshold of his medical career, I am desirous, without attempting to discuss the whole sub- ject, to enter upon some considerations in connection with the cases which you have seen, calling your attention to certain peculiarities which they presented, and instructing you in what my experience has taught me. You are aware that, at present, under the name typhoid fever, are included all the varieties of the nosological species formerly known as the synochus putris of Cullen, the putrid fever of Stoll, the malignant nervous fever of Huxham, the mucous fever of Eoederer, the bilious fever of Tissot, and the adynamic or ataxo-adynamic fever of others. It is the same disease which MM. Petit and Serres1 have called entero-mesenteric fever, and which Bretonneau has described under the name of dothinenteria [dothienenterie], to indicate the spe- cial nature of the intestinal affection which characterises it—a furun- cular eruption on the intestine—from SoOiriv, a pimple, pustule, or furuncle, and eWcpov, the intestine. This name—dothinenteria—is now the prevailing name of typhoid fever. Names are not of much consequence if there is an exact un- derstanding as to the meaning attached to them, for then they cannot give a false notion of the thing named. The term “ typhoid” has been substituted for “ putrid/' “ malignant," and “ adynamic," 1 Petit et Sekees :—Traite de la Fievre Entero-Mesenterique. Paris, 1813. 314 DOTHINENTERIA. but it is a term quite as faulty as they are. Conveying as they all do the idea of an essential character, of a special symptom, that par- ticular symptom ought—according to the laws of good nomencla- ture—to be always found in the disease, and never found in any other disease. But this is very far from being the case in respect of the malady now before us. On the one hand, typhoid phenomena, even the phenomena of putridity, malignity and adynamia are often wanting in the fever called “typhoid,” “putrid,” “ malignant,” and “ adynamic;” and on the other hand, they are often met with in diseases essentially different from it. The preferable name then is dothinenteria, because the furuncular eruption on the intestine is as constant and special in this disease as the pustular eruption on the skin in small-pox. It is the name I prefer, though I still employ those of “ typhoid fever,” and “ putrid fever,” in conformity with universal usage. Dothinenteria is an acute, febrile, and general disease, bearing more than one striking point of resemblance to the eruptive fevers. Chiefly attacking young persons, not occurring in general more than once in the same subject, and being undoubtedly contagious, it has three characteristics common to it and the eruptive fevers ; and like them, it also has, as a special character, anatomical lesions, consist- ing in it of an eruption on the skin, and an eruption on the intes- tine. The former, called the rosy lenticular spots [taches rosees len- ticulaires], is much less characteristic than the latter, although some have wished to make the cutaneous eruption the stamp of the dis- ease, and to look on the intestinal lesion as only a secondary and consecutive sign. The rosy spots are often wanting; and, to quote from statistics, I may mention that Chomel, in seventy cases, could not find any trace of eruption in more than sixteen, though it was searched for at all stages of the disease. If it be argued, that the absence in some cases of the eruption on the skin, no more disproves the exanthematous nature of dothinenteria, than variola sine variolis disproves the exanthematous character of small-pox, I reply, that cases of variola sine variolis are infinitely more exceptional than cases of typhoid fever without rosy spots. In some localities, as at Paris, the spots are found with sufficient constancy to justify our looking out for them as the most obvious pathognomonic sign, but there are other places in which attentive observers have never been able to see them. They were entirely wanting in different epidemics in Touraine. Par be it from me, however, to dispute the sympto- DOTHINENTERIA. 315 matic value of this eruption in the cases in which it is present. What I say, gentlemen, is, that the cutaneous eruption of dothinen- teria cannot he regarded as the essential character of the disease— that essential, specific character is the intestinal lesion. On the 21st of June last, you had an opportunity of seeing the nature of this lesion in the body of a patient examined in your presence. On our opening the intestines, you sawr the mucous mem- brane covered with a copious eruption formed by the glandules, agminate of Peyer in a very turgid but not in an ulcerated state, some of them being in relief, to the extent of the thickness of a silver five franc piece : some of the solitary glands were equally turgid; and the mesenteric glands were enlarged. The patient was admitted to the clinical wards on the 14th of June, and died four days afterwards. We could obtain no information as to the date at which the dothinenteria commenced. Still, the nature of the intestinal lesions, the glands of Peyer being turgid but not ulce- rated, informed me that the disease had not lasted more than twelve or fourteen days. The anatomical researches undertaken for the elucidation of this subject by Bretonneau in 1818, and subsequently, when I was his pupil at the hospital of Tours, have enabled me to study the pro- gress of the changes which take place in The glands of the intes- tine, and to describe from day to day the changes which they pre- sent. I have published the results of my labours; and you will find them in the Archives Generates de Medecine for January 1826. The characteristic dothinenteric eruption, formed at the expense of the aggregate and solitary glands of Peyer, does not begin to appear till the fourth or fifth day, and sometimes, according to Professors Chomel and Louis, (from whose opinion I differ,) not till the seventh or eighth day. It is progressively accomplished in two days, all the glands destined to be implicated not becoming simultaneously af- fected ; but the eruption is complete, at the latest, by the seventh day of the disease. The aggregate glands become turgid, and in- creased both in length and breadth : the solitary glands project into the intestine: at the same time, the mesenteric glands communi- cating with the aggregate and solitary glands, share with them the pathological changes which are going on, and become enlarged. The turgescence of the glands goes on increasing up to the ninth day. On the tenth day, one of two things occurs:—resolution begins, or the affection continues and proceeds through all its stages. 316 DOTHTNENTERTA. In the first case, the turgescence of the aggregate and solitary glands of Peyer, and of the mesenteric glands begins to decrease, and goes on gradually subsiding up to the fourteenth day, at which date the affected glands are still a little swollen; but by the end of the third week, resolution is complete, excepting that the mesenteric glands do not quite regain their normal condition till a short time later. In the second case, some patches of the aggregate glands of Peyer proceed towards resolution, whilst other patches go on increasing in size: the same may be said of the solitary glands, some of which proceed to resolution, and others become more and more affected by the disease. The mesenteric glands, however, have always decreased in size. On the twelfth day, the intestinal affection, till then pimply [boulonneuse] becomes to some extent furuncular \_furonculeuseJ. The diseased glands become prominent, presenting the appearance of red conical granulations [_fongosites], with slight erosions on their summits, which increase in size, till they form on the fourteenth or fif- teenth day a core \un bourbillon] of reddish tissue, deeply stained with an ochre hue by the bile, which at this period of the disease is abun- dant and has a special tint: the sphacelated tissue is adherent at its base, and is implanted in of an extensive ulceration. On the following day, the core is entirely detached, and in its place there is a deep ulceration, at the bottom of which, generally, is the muscular coat of the intestine. Sometimes five or six ulcerations of this description may be seen on one patch of the aggregate glands of Peyer, giving it an irregular fungous appearance, so as to render it difficult to recognise the existence of the gland which is the seat of this disorganization. All around, isolated ulcers occupy the place of the solitary glands, which have been destroyed by the same inflammatory action. The mesenteric glands, in colour resembling the lees of wine, are for the most part so soft, that when cut into, or pressed between the fingers, they become almost a pulp. After the seventeenth and eighteenth days, the edges of the ulcerations are less prominent, the depth of the ulcers has dimi- nished, and the intumescence by which they were circumscribed has begun to disappear. By the nineteenth, twentieth, and twenty-first days, the ulcerations have become superficial, and have a tendency to cicatrise. About the twenty-fifth day, cicatrization is complete; but generally, the cicatrices are not consolidated till the thirtieth day. Some ulcerations, however, remain for fifteen, twenty, or DOTHINENTERIA. thirty days longer, particularly in the glands situated at the extre- mity of the small intestine. Such is the intestinal eruption of dothinenteria, and such are the different phases through which it passes. The lower portion of the ileum is the situation for which it has a preference; and when the eruption only occupies from three to ten inches of the small intes- tine, the portion occupied is the lower end of the ileum : the nearer the eruption is to the ileo-csecal valve, the more confluent is it. I have never found spots beyond the second portion of the jejunum, ascending towards the duodenum and stomach: they become more numerous in the large intestine, the nearer they are to the caecum. Gentlemen, you will always find these intestinal lesions on ex- amining the bodies of persons who have died of typhoid fever, whatever form it may have burned, whatever may have been the variety or intensity of the symptoms, provided death has taken place after the fifth day, the period at which these lesions begin to appear. In connection with the intestinal lesion, I ought to mention a theory of Yirchow. According to this celebrated anatomist, and according to contemporary histologists, the follicular crypts of the intestine, the Peyerian patches on the one hand, and the Malpighian tufts of the spleen on the other, have the same structure and func- tions as the lymphatic glands : they are formed of a gland-tissue. And as it is looked on as proved that the lymphatic glands produce the wrhite corpuscles, it follows that hypertrophy of the follicular crypts, Peyerian patches, and Malpighian tufts in typhoid fever lead to the superabundant production of white corpuscles, or in other words, to leucocythsemia, at least in the first stage of the disease.1 At a later period, the excessive formation of the constitutional ele- ments of lymph and nuclei distend, and ultimately destroy the reticulated texture of the glandular tissue. This of course termi- nates the leu cocythee mia. This description is substantially nothing more than a statement of facts disclosed by microscopic observation. The solution of the question is not advanced one step. In cholera and other diseases, there is a similar superabundant production by the Peyerian glands, while the progress of the symptoms and of the anatomical lesions is very different from those of typhoid fever. In this difference resides the essential character of the disease. The symptoms and 1 Virchow :—La I’athologie Cellulaire. [Traduction de Paul Picard.] 318 DOTHlNENTElilA. the lesions are different, because the morbid impetus—or whatever else you like to call it—is different. We are obliged, therefore, not- withstanding the microscopical investigations, and even in conse- quence of them, to inquire into the causes which produce the dis- ease, into the contagion, the epidemic influence, the nature of the symptoms, and the specific characters of dothinenteria, of which the intestinal lesions, as well as the lesions in other parts of the body, are the effects and not the cause. Gentlemen, you perceive by the description which I have given you, that the intestinal eruption proceeds writh an order and pre- cision, which can only be compared to what wre see in distinct small- pox. As I do not wish to leave an erroneous impression on your minds, it is necessary, however, to state that while the description wdiich I have given applies to the majority of cases, there not un- frequently occur modifications in the form and progress of the intestinal exanthem, which it wrould be useless to point out here, but which impress on it characters somewhat different from those I have assigned to it. Cases have been adduced in which there wras no appreciable altera- tion of Peyerh glands, but they are as exceptional as cases of small- pox without eruption, and possibly they were cases of the “ typhus fever ” of the English, or the “ typhus exanthematieus ” of the Germans. Let me add that there are some formidable diseases which for the first few days by simulating dothinenteria, throw off their guard unobservant and inexperienced physicians. You have seen a considerable number of cases in which the general symptoms at first consisted only of a feeling of discomfort, lassitude, pains in the limbs, and a certain amount of uneasiness in the bowrels — the tongue, slightly red at the point and edges, covered w’ith a thin whitish fur, was a little swollen, so as to show the marks of the teeth—there wTas anorexia, with little or no fever, and the pulse sometimes even below the normal frequency—the skin was some- what dry—and there either were no stools, or the bowels were as regular as usual. We sometimes see our patients continue in this condition for from twelve to thirty days, without the symptoms being sufficiently urgent to oblige them to take to bed; but at other times, after this stage has gone on for twelve or fourteen days, formidable symptoms all at once set in, it may be without appreciable cause, or it may be from indigestion caused perhaps by eating quite mode- rately, and then the disease declares itself by more characteristic 319 symptoms, and with more or less severity. Well! in these cases of mild dothinenteria, to which the term “latent” has been applied, you will have been able to verify the existence of the intestinal eruption quite as well as in cases attended by the most dangerous symptoms. Nevertheless, it must not be supposed that the furuncular erup- tion is the entire disease, that the disease is nothing more than an inflammatory affection, an enteritis, as is alleged by those who have given it the name of “ follicular enteritisnor must we suppose that the general are more under the influence of the local symptoms, when the intestinal lesions are deepest and most extensive. The enteritis wdiich characterises typhoid fever has at the autopsy a special character, but it is only one of the elements of the disease. As Laennec remarked, the alterations in the intestinal canal which occur in typhoid fever are no more the cause of its general symptoms, than the variolous, morbillous, and scarlatinous eruptions are the causes respectively of small-pox, measles, and scarlatina. So far, however, from the eruptions being the causes of these diseases, there are some cases (very exceptional I admit) in which they are wanting, and they are always developed after the symptomatic manifestations of the fever. Einally, if in the mild cases, the dothinenteric erup- tion may consist only of very distinct spots, cases have been adduced in which (from death occurring suddenly in consequence of a per- foration of the bowel) there has been seen an eruption very confluent in character and presenting numerous ulcerations; while, in contrast, there have been found affected only one or two Peyerian patches in other cases in which death occurred about the fifteenth day of very violent attacks of typhoid fever. My opinion may be summed up in a few wrords :—as a general rule, in dothinenteria, contrary to the general rule in other eruptive fevers (particularly in small-pox and scarlatina), the severity of the general symptoms hears no relation to the intensity of the eruption. The eruption, though it be a local symptom, is not the less deserving of our serious consideration, for it explains the consecu- tive abdominal pains which continue for weeks and months, after recovery from typhoid fever; and also, because it is very frequently, during the attack, the starting point of a mortal complication. About the fifteenth or sixteenth day, at the time when the fleshy core separates, an ulceration forms, which, destroying more or less deeply the coats of the intestine, may proceed in a few days to per- foration. During the period of the cicatrization of the ulcers, we DOTHINENTERIA. DOTHIN ENTERI A. must bear in mind the risk of intestinal perforation, which by pro- ducing very acute peritonitis, carries off the patient with frightful rapidity: You will see such occurrences not only in severe typhoid fever, but even in those cases which are so mild as to be difficult of diagnosis. You are acquainted with the symptoms of peritonitis resulting from perforation. Whether it occur during the progress of the disease, or during convalescence, the individual is suddenly seized with violent pain in the bowels : this pain is increased on pressure, and rapidly extends to the whole abdomen. At the same time, hiccup, nausea, and intractable vomiting of green and leek-green matter set in : a pale, collapsed countenance tells of the pain and anxiety which is being endured: there is considerable fever, and the pulse is small and rapid: there is suppression of urine: the skin is covered with a viscid sweat; and the patient sinks within a period more or less brief. On examination after death, wre find the lesions met with in cases of very acute peritonitis; and on examining the intestinal canal, we soon find the perforation, which has been the starting-point of the mischief, and which is always situated in one of the ulcerated Peyerian patches. Sometimes there are several perforations; but there are cases in which we cannot discover any, however attentively we look for them : moreover, there are cases in which it is difficult to see the slightly prominent patches of Peyer, which present no traces of inflammation or ulceration. These are the cases in which we have to do with spontaneously developed peritonitis, a subject on vdiicli my friend Dr. Thirial has communicated an interesting wrork to the Hospitals’ Medical Society.1 Here is one of the cases which he gives. A girl of twenty-one had typhoid fever in a mild form. After the malady had gone on for about twenty days, she was entering upon convalescence, and beginning to take food, when, after strong mental emotion, she was suddenly seized with very alarming symp- toms, pains in the bowrnls, bilious vomiting, great change in the countenance, depression of pulse, and general prostration. Prom these symptoms, exceedingly well informed physicians without hesita- tion diagnosed peritonitis, the result of intestinal perforation. Twenty leeches wrere immediately applied to the abdomen. On the following day, there was no improvement in the state of the patient. It wras 1 Thirial :—Numbers 83, 84, and 85 of Union Medicale for 1853. DOTHINENTERIA. 321 then resolved to have recourse to narcotics in large doses, thus adopting the practice from which Stokes of Dublin had in similar cases obtained beneficial results. Twenty-five centigrammes of the thebaic extract were prescribed to be taken within twenty-four hours. Complete abstinence from fluids, and absolute immobility were also enjoined. Notwithstanding this treatment, the vomiting continued: the tongue became dry; and there was no improvement in the other symptoms, with the exception of the abdominal pain. Prom the first day, it was tolerably bearable, and had nearly ceased by the third day, the patient not feeling it, unless pretty strong pressure was made on the abdomen. The treatment was continued; but in the evening the patient died, that is to say, in seventy-two hours from the onset of the alarming symptoms. The autopsy established the existence of peritonitis. The intes- tines, throughout the greater part of their extent, were covered with a layer of coagulable lymph, which was soft and recent. The cavity of the pelvis contained four or five ounces of a milky fluid of purulent character. The mesentery was in particular covered with pseudo-membranous deposits of very slight consistence, and of va- riable thickness. Notwithstanding the most diligent search, not the slightest intestinal perforation could be detected. The intestinal canal was found to be perfectly healthy, excepting that towards the end of the ileum, particularly at the ileo-csecal valve, there were four or five patches, not prominent, but presenting a blackish colour: these were Peyerian glands which had been diseased, but had reached the period of resolution. In no situation in the intes- tinal canal could ulceration or erosion be discovered. The other abdominal organs were healthy : the spleen was small and firm: the liver was normal: the posterior part of the lungs were a little gorged. Two similar cases are described in the work of Professor Jenner of London. Possibly some of' the cases of alleged recovery from intestinal perforation are nothing more than cases of this class ; but still, gentlemen, the case I am about to narrate, and which you have had an opportunity of observing in the clinical wards, explains the possi- bility of recovery, and the mechanism by which it is accomplished : it also showrs how peritonitis without perforation is produced by what may be called propagation. You recollect a woman who lay in bed No. 31 of St. Bernard's DOTHINENTERIA. ward. Three days before admission, she had left the St. Louis Hospital, where she had had a severe attack of dothinenteria, which had lasted six weeks. She was thin and pale, and had a great deal of fever. She complained of pains in the lower part of the abdo- men, which were increased on pressure. She had diarrhoea, and was vomiting yellowish bilious matter. There was considerable en- largement of the liver and spleen. My diagnosis was—peritonitis consecutive to typhoid fever; and I thought that she had had a relapse of the fever, from observing some recent rosy spots on the abdomen. Six days after her admission, the symptoms of peritonitis seemed to be subdued, after the administration of minute doses of calomel —five centigrammes, divided into ten doses, having been given daily. The pains were less severe, and the abdomen had regained its natural softness. But there were very alarming chest symptoms. Bespiration was difficult and hurried. On auscultation, we heard, before and behind, on both sides, numerous mucous and sibilant rales: they were most abundant in the lower and posterior region of the right side, where they were likewise finer and sub-crepitant: in the same situation, there was dullness on percussion. She spoke in a brief and panting manner. There was more fever than on the previous days. On the following day, there was a profuse mucous expectoration which adhered to the vessel, and some of which'had a slight ochreous tint, showing that bronchitis had penetrated to the extreme rami- fications of the tubes, and was gaining the pulmonary parenchyma itself. The cough, the stethoscopic signs—that is to say, the fine mucous and sub-crepitant rales—and the dullness at the base, con- firmed this diagnosis. Still, as there was neither blowing sound nor crepitant rales, I could not pronounce the word “pneumonia.” In five days, all these symptoms had yielded. Notwithstanding the diarrhoea, I had given the precipitated sulphuret of antimony in daily doses of 50 centigrammes, administered in pills, each contain- ing 10 centigrammes. A drop of laudanum was ordered to be taken with each pill. The cough and expectoration were less. The normal sound returned to the part in which dullness on percussion had been observed: only the sibilant and coarse mucous rales were audible; and the breathing was easier. The abdominal symptoms however continued without change; and there was only a little diarrhoea, which at last yielded to the sub-nitrate of bismuth DOTHINENTERIA. 323 combined with chalk, to the extent of 4 grammes of each given daily, divided into eight doses, till the twelfth day, when continuous delirium set in, along with general puffiness unaccompanied by albuminuria, and an aphthous condition of the mucous membrane of the tongue and mouth. In consequence of these new symptoms, I prescribed cinchona, to the extent of a gramme a day, in coffee with- out milk. The symptoms continued without intermission for four days; and then the patient died, on the fifteenth day from the date of her admission into the Hotel-Dieu. At the autopsy, we found the usual lesions of peritonitis. All the intestines were glued together by false membranes, which were easily torn. The adhesions formed pouches filled with pus; and there was no trace of any effusion into the abdominal cavity of the contents of the intestine. On the concave surface of the diaphragm, iu the small hollow, the parietal peritoneum was red, presenting vas- cular arborizations and purulent striae. On exposing the intestine, the serous surface of which was covered by purulent matter and vascular arborizations forming red patches, we saw, towards the lower portion of the ileum, spots of a blackish brown colour, around which there irradiated vascular arborizations more conspicuous than elsewhere. The corresponding portion of the peritoneum was thickened, and puckered like the edges of that kind of purse which is shut by pulling running cords : all the folds of the serous membrane converged towards the black spots of which I have spoken. On opening the intestine, we found that these spots corresponded to the ulcerations which had de- stroyed the mucous and muscular coats of the bowel, and had reached the peritoneal coat, which formed their floor. These ulcerations of Peyer’s glands, characteristic of dothinenteria, were from eighteen to twenty in number, and were situated in the lowest meter of the small intestine, and the nearer they were to the ileo- csecal valve, the more confluent were they. In that situation, the whole surface was one vast ulcer, deeply excavated, and jagged at the edges. In the last foot of the ileum, in the centre of two large ulcerations, there were perforations with thin blackish edges, and of the size of a twenty centime piece. In the ulceration nearest to the caecum, blackish filaments were floating, the remains of the furuncular core, in the seat of which the perforation had taken place. The explanation of the absence of intestinal matter in the peri- 324 DOTHINENTERIA. toneum is the stopping up of the perforations by the intestinal adhesions, and the manner in which the convolutions were glued together. The whole of the lower portion of the intestinal canal was arborised: the arborizations were placed closest together where they were nearest to the ulcerated parts. The mesenteric glands were swollen, softened, and reduced to a reddish pulp. The tissue of the spleen and liver, both of which were considerably enlarged, was soft, and broke down under pres- sure. The lungs were congested, but not hepatised. The encepha- lon presented no appreciable lesion. This case, gentlemen, as I have already said explains how the reparation of intestinal perforations, as reported by Stokes and Graves of Dublin, as well as by other physicians, may take place; and it also points out to us the pathogeny of peritonitis occurring in dothinenteria without perforation. The peritonitis may be the consequence, as in our patient, of ulceration reaching the peritoneal coat of the intestine, which it does not destroy, but in which it excites inflammation. Supposing the ulcerations to be very few in number, and very far apart from one another, the inflammation developed in the corresponding por- tion of peritoneum may remain within a very limited space, and be devoid of danger; but supposing, either that the ulcerations are numerous and confluent, or that the inflammation of the peritoneum steadily creeps on, as in erysipelas, the peritonitis, becoming general, may destroy the patient. These cases of partial peritonitis, then, explain the possibility of recovery when perforation of the intestine has taken place. Per- foration does not occasion death, except by the violent and general peritonitis set up by the passage of the contents of the bowels through the perforation into the cavity of the peritoneum. Now, when adhesions have been formed between the intestinal convolu- tions consecutively to the inflammation of their serous covering, the passage of the contents of the bowels is prevented, because the ulcerated openings are shut up by the gluing together of the intes- tines : and wre can understand these adhesions continuing sufficiently long to allow cicatrization of the solution of continuity to be accom- plished, and the patient to recover. It was by the operation of the mechanical cause which I have now explained that the woman in the case under consideration did DOTHINENTERIA. 325 not succumb in consequence of the perforation. She died from general peritonitis produced by the extensive ulceration of the in- testine reaching the serous membrane, and not from sudden general peritonitis consecutive to perforation and escape of faecal matter ; for, as I pointed out to you at the autopsy, the convolutions of intestine were glued together in such a manner as to prevent that escape. In respect of diagnosis, the symptoms are the same whether the peritonitis be or be not the consequence of perforation. It has certainly been alleged that peritonitis consecutive to perforation may be recognised by the spontaneousness and excessive acuteness of the pain declaring itself first in the region of the caecum and second portion of the ileum, the situation in which perforations are most common, soon extending to the whole abdomen, and being aggra- vated by pressure; and it has also been alleged that in peritonitis consecutive to perforation, there is always suppression of urine. These signs, however, are of very little use as guides to a dif- ferential diagnosis, which can only be established by an examina- tion of the body after death. Were such a differential diagnosis possible, it would have some importance in respect of prognosis, because peritonitis without per- foration is not so serious as peritonitis from perforation, which is almost inevitably fatal. The impossibility of ascertaining during life the nature of this abdominal complication justifies our worst fears as to the issue of a case in which it exists. Finally, gentle- men, you can understand from what I have said, that, considering the alterations to which the intestinal canal is liable in dothinenteria, you ought to be reserved in your prognosis in this disease, recol- lecting that even in cases in which the appreciable signs are indica- tive of a mild attack, at the very time when your patient seems to be out of danger, and you are going to announce his recovery, you may witness the symptoms of that terrible complication, intestinal perforation, or of peritonitis without perforation, a complication which though less formidable, is very dangerous. Intestinal Hemorrhage.—Haemorrhagic Putrid Fever. A woman, aged 64, was admitted to the Hotel-Dieu on the yth March, 1859, where you saw her lying in bed No. 31 of St. Bernard’s Ward. I call your attention to her age, because, as a general rule, dothinenteria only attacks young subjects. This woman 326 DOTHINENTERIA. died on the seventh day after admission, having been carried off by a complication regarding which I now wish to speak. When she came into our wards, she was delirious, and in a state of great prostration. The bowels were in a sluggish condition : pressure over the iliac fossa did not occasion gurgling-, and there was no diarrhoea. The pulse was 108 : there was a little dyspnoea, with some sub-crepitant rales at the base of the right lung. The spleen was not enlarged. We learned that the illness began with headache and shivering. Next day, I observed spots on the abdomen, possessing some of the characters of typhoid spots. Three days later, their typhoid character was undoubted. On that day, there wras marked ameliora- tion of the symptoms. In the evening, my chef de clinique, M. Moynier, saw the patient taking some meat soup with appetite, and complaining that it was insufficient in quantity : three hours later, abdominal haemorrhage set in so profusely that the blood inundated the bed, and flowed over on the floor of the ward. In less than an hour, the patient was dead. At the autopsy, the upper portions of the small intestines were found to be healthy; but in the lower portions, the following lesions were seen. The Peyerian patches were very much affected. At about six or eight centimeters from the ileo-csecal valve, one of the patches was ulcerated in such a way as to expose the bare peri- toneum : its edges were turgid, and its surface was covered with detritus exhaling a foetid odour. A little higher up, there were other patches of about one or two centimeters ulcerated, so as to lay bare the muscular coat of the intestine. The patches were hypertrophied, and softened. The solitary glands were also in a very diseased condition. The intestine contained a large quantity of blood, which had imparted a reddish black colour to the mucous membrane. There was no faecal matter in the intestinal canal. The mesenteric glands were blended together in an enormous mass of fat. Prom the lesions now described, it is evident that the disease had reached its fourteenth or fifteenth day. In size, the spleen was natural, but it was of a very soft consistence. The liver had lost its natural consistence, and was hypertrophied. Both lungs were congested. The heart was distended with black clots. There was no lesion of the brain. This is the third case which I have seen within seven years of a person dying of intestinal haemorrhage in the course of an attack of DOTHINENTERIA. 327 dothinenteria. In the two other cases, the patients did not die from the immediate consequences of the loss of a large quantity of blood, as in the woman whose case I have detailed. One of them was seized on the twenty-third or twenty-fourth day with intestinal haemorrhage, which recurred at intervals during three or four consecutive days. Death took place in consequence of these successive haemorrhages, the patient having been reduced to a state of anaemia and profound de- bility. The other patient, on the nineteenth day of the typhoid fever, had ataxic nervous symptoms, when a moderate attack of haemor- rhage supervened, after which a great improvement was observed in the condition of the patient, which continued for eight days. Then, however, the nervous symptoms returned, and she had a second and a third attack of haemorrhage. The nervous symptoms, in place of becoming calmer, as after the first loss of blood, increased in severity and carried off the patient. Intestinal haemorrhage is a frequent complication of dothinenteria : it is perhaps even more common than is generally believed, judging from the fact, that it is often not till the autopsy that its existence is revealed: in such cases, on opening the intestinal tube, we may find a greater or less quantity of blood, none of which has passed below the ileo-caecal valve. While a somewhat profuse haemorrhage into the bowel might be suspected during life from the general symptoms, such as increased debility and a sudden paleness of the skin, a more moderate loss of blood might escape notice. Generally, the haemorrhage shows itself externally; and, according to the nature of the case, the blood is passed almost pure, in a state which though not pure admits of easy recognition, or in a very altered state: when it has remained long in the intestine, it is a blackish matter re- sembling tar in appearance. You will read, and you will hear said by everybody, that these haemorrhages are formidable complications, and increase the danger of the disease. This is the opinion of the most reliable physicians; but nevertheless, when thus expressed, it is far too absolute; and as for myself, I confess, that after holding that opinion for a long time I now profess the opposite doctrine, believing that hemor- rhages in typhoid fever, so far from possessing the character of danger imputed to them, are usually of favourable augury. Such is also the opinion of Graves. When I read this proposition for the first time in the clinical lectures of the Dublin professor, being still under the dominion of opposite views in which I had been educated, 328 DOTHINENTERIA. I was amazed that a man of such sterling merit and high repute should disagree with me in a matter which I believed I understood. However, the opinion of so great an authority caused me to reflect, and reviewing the cases which I had seen, I recollected recoveries in cases in which haemorrhages had occurred. I, therefore, from that time directed my attention more diligently to the point: and I now say, that while the three cases of which I have just spoken seem to confirm the prevailing idea as to the gravity of intestinal haemorrhages in typhoid fever, I can cite as a set off to them a much greater number in support of the doctrine of Graves. Without going beyond our wards in search of examples, I will recall two cases which occurred under your own observation. A girl aged 20, of good constitution, was admitted to bed No. 5, St. Bernard's ward, on the 14th October, 1857. She had been ill for eight days, but had not been obliged to take to her bed till the fourth day. The dothinenteria followed its regular course, without presenting any other symptoms than considerable weakness accom- panied by very moderate fever and diarrhoea, till the 18th October, the twelfth day of the attack, when profuse intestinal haemorrhage occurred: she nearly filled a chamber-pot with blood, which was black, fluid, and very foetid. The haemorrhage recurred next day, when the discharged blood was similar to that passed on the first occasion; and on the following day, the stools were still black and foetid. The general symptoms were not such as to occasion much alarm, and from that time they became sensibly less severe; from day to day the fever abated, and on the 17th November, the patient, having entirely recovered, left the hospital, a month after admission. It was a remarkable circumstance in this case, that notwithstanding the enormous quantity of blood lost 011 two occasions, the patient, who naturally had colour in her face, did not lose it, and did not seem to be weakened. Last year, a man, aged 27, tall, of good constitution, but having a pale complexion and fair hair was admitted on the 10th of June, to bed No. 16, St. Agnes's ward. He had been ill for eleven days with putrid fever, the symptoms of which were well marked and severe. He had lately come to reside at Paris, where he was employed as a day-labourer. Por a week he had been feeling languid, and complaining of violent headache, when, on the 7th June, he was obliged to keep his bed. The abdominal symptoms preponderated, DOTHINENTElilA. 329 and were characterised by considerable tympanitic distension, and by profuse and frequent stools. There was high fever, delirium, and a very dry state of the tongue. On the 23rd June—the 24th day of the dothinenteria—the patient had during the day three copious motions, consisting of liquid black blood mixed with some clots. Immediately after this haemorrhage, I observed a marked improvement. In the evening, it was noted that the fever was moderate; that there was no abnormal heat of skin; that there was an appearance of greater comfort; and a desire for food. The tongue, however, continued foul and sticky, with its centre red and dry. Next day, I found that the patient had had three ordinary diarrhceal stools since the haemorrhage of the previous evening. The tongue was moist, without being red, and at its base, there was a thin yellowish white fur. The pulse, till then above 120, had come down to 80. The patient, however, was suffering from an ecthymatous eruption, which from the first week of the fever had been out on the hips, back, and thighs. Over the sacrum, the pustules had become converted into large superficial sloughs, not involving the entire thickness of the dermis : their base was of a greyish hue. With a view to get rid of the complications occasioned by the contact of the affected parts with the urine and excrementitious matters, and from the pressure of the dorsal decubitus, which the patient constantly main- tained, it occurred to me to make him lie on straw covered only by a sheet, a practice adopted at the Salpetriere with the gdteuses to prevent excoriations of the seat. In accordance with my usual plan, the patient had taken nourishing diet throughout his attack: and now the quantity of broth was increased. The sloughs cicatrised, such of the pustules of ecthyma as had not ulcerated dried up, and the general condition of the patient was satisfactory, when on the 26th, a new intestinal haemorrhage supervened, complicated with epistaxis and an efflux of venous blood through the mouth from the nasal fossae. Notwithstanding this new complication, convalescence was speedily and satisfactorily completed, the patient being soon able to leave the hospital. These cases are conclusive. I could add others, likewise derived from my own practice, as well as others observed by physicians of recognised eminence. Thus Dr. Eagaine of Mortagne, states that in four hundred cases which he saw, eleven had intestinal haemorrhage, 330 and all the eleven recovered.1 Very recently, Dr. Juteau of Chartres read, before the Medical Society of Eure-et-Loir, a very interesting paper on an epidemic of dothinenteric fever, in which he stated that five of his patients had had intestinal haemorrhage, and that all of them recovered. I would not wish, however, to be represented as saying that these haemorrhagic complications, hitherto looked on as always serious, are really quite free from danger. They are in too many cases exceedingly serious. The haemorrhage may by its profusion destroy the patient, just like any other loss of blood; and you have heard of death resulting from intractable epistaxis. Intestinal haemorrhages, are also formidable, when, by recurring they exhaust the patient and cause him to fall into a state of anaemia and debility, leading to extinction of vital power, and ataxic nervous symptoms such as occurred in one of the three cases I mentioned. Finally, in- testinal haemorrhages really are serious complications of typhoid fever, when, occurring along with bleeding from the nose, gums, lungs, urethra, or along with sub-cutaneous haemorrhage, they are symptomatic of a dyscrasia against which the resources of art are powerless. I am now speaking of the haemorrhages which consti- tute one of the characteristics of the disease to which our prede- cessors gave the name of “ putrid fever” as a distinctive term, and which at present we call “ haemorrhagic putrid fever f but in these cases it is not, strictly speaking, the loss of blood which kills: death is the result of the peculiar morbid condition which constitutes putridity. We had very recently, in our St. Bernard ward, bed No. 5, an example of this haemorrhagic putrid fever. The patient was a woman aged 22. She stated that she had always enjoyed good health; and that she had been confined four months previously. She had been ill for five days; and a short time before her seizure she had menstruated as usual. Her illness began with headache, vertigo, singing in the ears, accompanied by obvious deafness and fever. All these symptoms were present when I first saw the patient. The skin was hot, and the pulse 108. The patient complained of general lassitude, pains in the limbs particularly in the legs, and rachialgia. She also complained of pain in the throat, DOTIIINENTERIA. 1 Hagaine :—Memoire sur unc Epidemie de Eievrc Typhoide qui regna a Moulius-la-Marclie pendant les annees 1855, 1856. DOTHINENTEUIA. 331 but nothing particular was visible there. The tongue was very foul. There was a little cough, accompanied by the expectoration of stringy mucus. The patient complained that she could not sleep; and she had disturbed reveries. When spoken to, however, she answered questions with precision. In connection with the digestive organs, the symptoms observed were nausea and constipation. I prescribed 5 centigrammes of calomel, to be followed in a quarter of an hour by one gramme of the powder of jalap. During the night, there was noisy delirium mingled with speak- ing and laughing. There was no expression of hebetude in the countenance: there was not much fever, and the skin was mode- rately hot: the tongue was red, and covered at the base with a very thick slimy fur. On drawing the nail lightly across the skin of the forehead, abdomen, and arms, I observed that the “ tache cerebrale” was very distinctly produced, and that it remained for some time. I prescribed calomel in small doses, viz., 5 centigrammes divided into ten portions, of which one was to be taken every hour. On the third day after admission, and the eighth of the disease, the delirium was less violent, and the patient answered questions. The tache cerebrale was very obvious, and remained for a long time : the bowels were sluggish : the pulse was 108 : the gums were bleeding. The treatment of the previous evening was continued. Next day, there wras still delirium and deafness. The pulse was rapid and very soft. Diarrhoea was still absent. There were some rosy lenticular spots on the abdomen. The gums continued to bleed; and on causing the patient to lie on her face, we saw large ecchymoses on the posterior surface of the body, particularly on the trunk and arms : they were also seen on the anterior aspect of the chest, round the left breast. The ecchymotic spots were prominent in their centres. On auscultation, some sub-crepitant rales were heard on both sides, and a blowing sound over the right infra-spinous fossa. I ordered four grammes of the powder of cinchona, to be taken in infusion of coffee: also, a mixture of four grammes of eau de Rabel, four grammes of syrup of rhatany, and 100 grammes of water—to be taken in doses of a dessert-spoonful. Tor diet-drinks, iced Seltzer water and iced milk were prescribed. The excite- ment and delirium continued; and diarrhoea supervened. The ab- domen was not tympanitic. The thoracic complications increased. The breathing was loud ; and the blowing sound, still audible in the 332 DOTHINENTERIA. right infra-spinous fossa, was also heard at the base of the left lung. I substituted a gramme of sulphate of quinine for the cin- chona, the same formula for its administration being adhered to. On the eleventh day of the disease, the woman died. The cere- bral symptoms continued till the last. The chest symptoms had increased, the blowing sound being audible from base to apex in both lungs. The dyspnoea had become intense, the inspirations being fifty-six in the minute. The pulse was 136. Blood was flowing from the mouth. The autopsy was made on the following day. We found no trace of haemorrhage in the intestines. In the lower portion of the ileum, three of Peyer's patches were softened, but not ulcerated. Some of the solitary glands were turgid. The mesenteric glands were congested, and of a rosy colour. The spleen was enlarged, and in colour was deep-red, like the lees of wine: its parenchyma was pulpy. The liver was soft. The posterior portion of the lower lobes of both lungs was the seat of apoplectic engorgement: the pulmonary tissue was soft and blackish. The membranes of the brain were only slightly injected. What is the mechanism by which intestinal hemorrhages take place in putrid fever ? At the autopsy of persons who have died of dothinenteria we often find bare mesenteric vessels at the bottom of the intestinal ulcerations. Hence it might be supposed, that these hannorrhages are attributable to the rupture of a mesenteric vessel during the process by which the furuncular core is eliminated. Still, for the most part, if not always, this is not what occurs. The blood is exuded by the mucous surface, exactly as it is in hemate- masis and epistaxis, as well as in many other similar circumstances. The immediate cause of this sanguineous exhalation is an essential change in the blood, which is in a dissolved state, a fact you can verify by examining the blood abstracted from patients in our hos- pital wards which are under the charge of physicians who have re- course to bloodletting in the treatment of typhoid fever. Such of you as have attended the excellent clinical lectures of my honour- able and very accomplished colleague Professor Bouillaud, the most ardent advocate of this antiphlogistic method of treatment, are aware that the blood drawn in such cases from a vein, or obtained by cupping, presents a fluidity very different from that taken in acute inflammatory diseases such as pneumonia and acute articular rheumatism. This particular condition of the blood, seen in a DOTHINENTERIA. 333 very high degree in the haemorrhagic putrid fever, (a case of which I have just detailed to you), this decomposition of the blood is also met with in other fevers, for example, in yellow fever, that singular malady in which haemorrhages from the stomach and bowels are so pathognomonic, that in some regions of South America, and in the Antilles, where the disease is endemic, its common name is vomito negro or black vomit. In scarlatina, diph- theria, measles, and small-pox, the blood is generally in this dis- solved state, and to it are attributable the intestinal, renal, and nasal haemorrhages met with in them, and of which I mentioned cases when treating of these diseases. Neither in these diseases nor in yellow fever are there intestinal ulcerations to which we can attribute the haemorrhages. Still, we can understand how the in- testinal lesions of dothinenteria may favour the tendency to exudation of blood, just as in haemorrhagic small-pox, measles, and scarlatina, or in diphtheria, an excoriation of the nasal mucous membrane may favour the production of epistaxis, or a surface denuded by a blister may more readily become the seat of cutaneous haemorrhage. So far is ulceration of the intestine from being a condition essen- tial to the production of haemorrhages, that they often come on at a period of the disease very far removed from that to which ulceration belongs. Tour years ago, I was sent for to meet Dr. Olliffe in consultation, in the case of a young English woman who had been seized with in- testinal haemorrhage. In this patient, the haemorrhage occurred at the ninth day of putrid fever, a period at which the existence of ulcers was very improbable, as they are seldom formed till the fourteenth, fifteenth, or sixteenth day. The haemorrhage continued for two days, and was so great as to cause extreme anaemia. On the four- teenth day of the disease, however, an obvious improvement took place in the patient’s general state, and in seven days afterwards, she had completely recovered from the typhoid fever. All that remained of her attack was the anaemia consecutive on excessive loss of blood. I have asked myself whether the influence of a prevailing “ me- dical constitution” might not sometimes explain the occurrence of these haemorrhages. Some years ago, I was meeting with them in typhoid fever, and at the same time was also meeting with passive haemorrhages in other diseases :—I had at that time cases of pur- pura haemorrhagica, black small-pox, and numerous examples of the petechial scarlatiniform eruptions, which I have pointed out to you as occurring at the beginning of varioloid affections. You have seen me treat intestinal haemorrhages with preparations of rhatany and sulphuric acid. I generally prescribe a mixture of four grammes of eau de Rabel, forty grammes of syrup of rhatany, and one hundred grammes of water, ordering it to be taken during the day in doses of a tablespoonful. To prevent a recurrence of the haemorrhage, I rely on cinchona: I prescribe four grammes of the powder of yellow cinchona to be taken daily in a small cup of coffee without milk. As a means of arresting the flux, this remedy certainly does not produce a sufficiently rapid effect; but for cor- recting the disposition to a recurrence, cinchona in powder is undeniably efficacious. Essence of turpentine has also been lauded by Graves in the treatment of these haemorrhages. DOTIIINENTEllIA. Granular and Waxy Degeneration of the Striated Muscles in Typhoid Fever.—Nature and Consequences of this Degeneration.—Special Course of the Rise and Fall of Temperature in Typhoid Fever: this is Characteristic.—Parallelism between the Course of Tem- perature and the Fvolution of the Intestinal Lesions. A distinguished anatomist, Professor Zenker, when the prosector of my friend Dr. Walther of Dresden, discovered the existence of interest- ing anatomical lesions in typhoid fever—granular and waxy degenera- tion of the striated muscles.1 Rokitansky had previously examined very thoroughly the subject of the fatty variety of granular dege- neration : Air chow afterwards gave a very exact description of waxy degeneration which he regarded as connected with myositis, and he explained by this secondary alteration the rupture of muscular fibres observed most frequently in cases of typhoid fever : but Dr. Zenker has studied with the greatest care, and upon a considerable number of subjects, the different phases of the alterations which take place in muscles in typhoid fever. You must remember that this kind of degeneration is not peculiar to typhoid fever: it has been observed in several other diseases. Without inquiring what it may be in the 1 Zenker : Sur les Alterations des Muscles Volontaires dans la Fievre Ty- phoide. [Archives Generates de Medicine, 1866.] I am indebted to this work for most of the details which I give above on the degeneration of muscles n typhoid fever. DOTHINENTERIA. 335 abstract, let us now describe what has been observed in relation to it in dothinenteria. In typhoid fever, different groups of striated muscles are subject to degeneration, variable in intensity and extension, but not less constant than the characteristic dothinenteric lesions of the mucous membrane of the intestines. This degeneration is either granular or waxy. Granular degeneration, when examined with the aid of the microscope, is found to be characterised by a deposit of extremely minute molecules in the contractile tissue of the muscular bundles. This induces very great fragility in that tissue, so that during life, muscular contraction may cause rupture of the affected fasciculi. In waxy degeneration, the contractile tissue of the primary mus- cular fasciculi is transformed into a colourless and perfectly homo- geneous mass, presenting a very decided waxy lustre. The transverse striae and the nuclei have entirely disappeared, and the sarcolemma remains intact as in granular degeneration. The waxy looking sub- stance is a protean body, resulting probably from a transformation of the fibrin or syntonin. The altered fasciculi are always found to have acquired increased volume, and are sometimes twice their natural diameter. As in granular degeneration, they are found to have become exceedingly fragile, and to be the seat of numerous transverse fissures. In addition to the rupture of muscular fibres, the rupture of vessels may likewise occur, as a consequence of granular or waxy degeneration : and this leads to small ecchymoses, or infiltrations of blood, more or less extensive in proportion to the thickness of the altered muscle, and the diameter of the ruptured vessel. These haemorrhages occur most frequently in the second or third week of the disease. Suppuration is a sequel of muscular degeneration which occurs much more rarely than rupture of vessels. But it would appear that degeneration of the contractile tissue is not always the cause of the suppuration, which latter may be the result of irritation seated in the perimysium (or envelope of the primary fasciculi). It is, therefore, the perimysium which would suppurate. Generally, there is only cellular proliferation of the perimysium, that hyperplasia being limited to the work of muscular regeneration: but there may be a greater amount of local irritation, so as to cause the limits of 336 DOTHINENTERIA. normal hyperplasia to be exceeded, in which case there will be more cells formed than can advance through the stages required for their becoming contractile tissue: the cells which are in excess will therefore be devoted to destruction, and be transformed into pus. This is the histological explanation of the inflammation, and subse- quent suppuration of, the muscular tissue. The association in the same muscle of granular and waxy dege- neration, according to Dr. Zenker, does not prove that the waxy, which is the more serious of the two, is the ultimate result of the granular. From their very commencement, the two forms of dege- neration are distinct from each other. To the naked eye, the following are the appearances which altered muscles present:—they seem perfectly intact, when the degeneration is but little advanced, which explains how this condition escaped notice prior to the employment of the microscope: when the lesion is greater, there is a very apparent change of colour, and in pro- portion as the degeneration increases, the discolouration becomes more decided: the muscles have at first a rose-grey tint which, becoming gradually paler, is finally yellowish grey, with sometimes a very slightly reddish or brownish colour. The discolouration pro- ceeds by small spots or lines corresponding to the points where there is degeneration. "When cut into, the altered muscles present an appearance resembling the flesh of fish. During the first phases of the degeneration—the second and third week of the dothinenteria—the affected muscles are in general very tense, smooth on the surface, and in their substance dry, friable, and easily torn. They are increased in bulk, which arises from the thickening of the degenerated primary fasciculi. In the more ad- vanced stages of the degeneration the muscles are relaxed, the sur- faces of a section often present a humid aspect, and there is even sometimes more or less infiltration of serum not only into the muscle, but also into the loose cellular tissue which surrounds it, there being no similar infiltration in other parts of the body—a circumstance which proves that it is the result of the morbid changes in the muscle. My friend Mr. Walther has frequently seen on the living subject, over the recti muscles of the abdomen, a slight oedema cor- responding to the lesion I have been describing, and recognisable by making strong pressure upon the part with the finger. I confess to you that I have not been so fortunate as to find this appearance. According to Professor Zenker, muscular degeneration always DOTHINENTERIA. 337 occurs in typhoid fever : in every autopsy he has found it, when he looked for it. The waxy is much more common than the granular alteration: Professor Zenker met with the former seventy and the latter only nine times. The process of degeneration is generally at its height towards the end of the second week, from which it may be inferred that alteration commences as early as the disease itself. It continues with undiminished intensity during the third and fourth week. It is about this period that absorption of the detritus of the altered muscular tissue seems to take place: this leads to softening of the muscles, often accompanied by serous infiltration, and the possi- bility of observing, like M. Walther, a little oedema during life. These details in pathological anatomy are too full of interest, for me to refrain from making you acquainted with them. The con- stancy of the occurrence of muscular degeneration in typhoid fever proves that it is an integral part of the disease, and the generaliza- tion of the lesion shows that it is not the accidental result of a morbid action exclusively local, but the expression of a general disturbance of the economy: the muscular system is attacked, just as the other systems are attacked. Here again, however, gentlemen, I much fear that a consequence has been mistaken for a cause. It is evident that the weakness and disorder of the locomotive functions which cause the patient to totter from the very beginning of an attack of dothinenteria cannot be due to muscular degeneration, inasmuch as it does not then exist, or at least has only begun. The functional disturbance is caused by the morbid state of the cerebro-spinal system. The general disturbance of all the functions, and the special disturbance of the muscular system, which we see in dothinenteric patients arise from imperfect innervation. It is at a later stage of the disease that granular and waxy degeneration of muscles is produced by altera- tions in nutrition, consequences of disordered circulation. Disorder of the circulation produces hypersemia everywhere, and everywhere consecutively, either pseudo-inflammations, (long ago described,) or the forms of degeneration upon which I have been addressing you. It is, then, in a somewhat advanced period, and particularly during con- valescence, that the granular and waxy degeneration of the muscles affords a physical explanation of the feebleness which is felt. Be- sides, I cannot refrain from remarking that the degeneration affects in the greatest degree the recti muscles of the abdomen and the 338 DOTHINENTERIA. adductors of the thighs, which certainly are not the principal mus- cular performers in the act of locomotion. We must therefore, while we record as interesting the anatomical details which I have given you, seek elsewhere for the cause of the long continued feebleness of dothinenteria: the cause is exhaustion—exhaustion from the morbid poison which produced the fever—exhaustion from every kind of affection of the nervous system, such as sleeplessness, delirium and convulsions—exhaustion from diarrhoea—exhaustion from suppura- tion in the situation of the sloughs—exhaustion from embarrassment in sanguification—exhaustion, finally, from inanition. Is there not in this more than enough to account for the feebleness, without requiring to seek an explanation of it in the partial alteration of the muscles ? And do you not agree with me in thinking that it amounts to a sort of trifling to give or to accept such an explanation ? Gentlemen, I am now going to give you an account of the valuable clinical information which the thermometer furnishes in dothinenteria. At the beginning of this fever the temperature rises slowly, just as the symptoms are slow in developing themselves. During the first three, four, or five days, the temperature is from eight tenths of a degree to one degree higher than on the previous evening, while on each succeeding morning there is a slight remis- sion of about five tenths of a degree from the temperature of the previous evening. Thus, in each twenty-four hours, there is observed an increase of temperature both in the morning and even- ing, as compared with the morning and evening of the preceding day, although there is every twelve hours a slight remission in the morn- ing, as compared with the temperature of the preceding evening. Here is a table exhibiting this movement of temperature, as it occurred in one of our patients during the first four days :— Day of the disease. Morning. Evening. Exacerbation between morn- ing and evening. Remission be- tween evening and morning. Rise between mornings. Rise between evenings. Degrees. Degrees. Degrees. Degrees. Degrees. Degrees. First . . 37- 38.2 1,2 1 Second . 37-8 39-2 M 0.4 0.8 I. Third 384 39-8 1.4 0.8 0.6 0.6 Fourth . 394 40.4 I. ) 0.4 I. 0.6 5- 1.6 Definitive elevation of temperature up to the evening of the fourth day 3°.4. DOTHINENTERIA. 339 This table drawn np by my chef de clinique, M. Peter, shows you at a' glance the progressive ascent of the temperature, which, although there was a daily remission every morning from the tem- perature of the previous evening, had a positive increase every twenty-four hours both morning and evening. You will also observe from the table, that if the temperature had always remained in the morning at the point at which it was on the preceding evening, there wrould have been at the end of the fourth day a definitive elevation of five degrees, but as it fell every morning, the actual increase was only over the temperature of the first day. The table also shows you, that on the evenings of the third and fourth days, the temperature was oscillating at about 40 degrees, that is to say, between 39°.8 and 40°.4. This is about the usual tem- perature at that period; and for a long time the average of the evening exacerbation is 39°.5. From these facts, which were first ascertained by Thierfelder the following conclusions have been deduced by "Wunderlich :—When the temperature is 40° from the first or second day of the attach, the disease is not typhoid fever: and again:—When by the evening of the fourth day, the tem- perature has not attained 39°-5, the disease is not typhoid fever. Need I, gentlemen, insist upon the clinical importance of these statements? With their assistance you can from the very first make a differential diagnosis between dothinenteria, ephemeral fever, and an eruptive fever, such for example as scarlatina, and at the fifth day of a case hitherto doubtful, you will be furnished with data for stating that it is not dothinenteria. Let me give you the proof of this statement, derived from an excellent little work by Dr. Ladame of Neuchatel, from which I have taken numerous extracts:— “ At the beginning of January 1864,” says this young physician, “ I was appointed to take the place of one of the internes of Pro- fessor Griesinger who had charge of the typhoid fever patients in the building set apart for contagious diseases in the cantonal hospital of Zurich. The cases at that time were very severe and numerous, and the student whose post I took was ill of the fever, which he had contracted by contagion. When I had been but a few days on duty in the fever wards, I was seized one morning, during the cli- nical lecture, with slight shivering, great prostration of strength, anorexia, and violent headache. I went to bed under the conviction that I was at the commencement of an attack of typhoid fever. In 340 DOTHINENTERIA. the evening I took my temperature. The thermometer rose to 40 degrees ! Notwithstanding the high fever from which I suffered, I was quite tranquillised as to my state. Next morning, convalescence began. The only treatment I had wras low diet, cooling drinks, and one centigramme and a half of acetate of morphia."1 I have just told you that in our patient the temperature gradually rose during the first four days of the first wreek. In the three last days of the same week, it was 4o°.6 in the evening, and fell be- tween six and eight tenths of a degree in the morning. This is what generally takes place in the second half of the first week: the evening temperature keeps up to at least 39°.5, and usually to 40° or more, the morning temperature, according to the researches of Wunderlich, always remaining half a degree lower. Hence you perceive, that if you are called to a patient who has been con- fined to bed for some days, and has symptoms which lead you to suspect dothinenteria, you can decide that it is not that disease if the thermometer does not indicate an evening temperature of 39°-5j or if it on any one morning show the normal temperature of 370. At the end of the first stage, that is to say of the first week, the temperature has reached the point at wrhich it will remain during the wdiole course of the fever. It oscillates about 39°-5, which it rarely exceeds in the evening, and in mild cases almost never attains in the morning. In some severe cases, the temperature exceeds 39°.6 in the morning as well as in the evening. I have hitherto spoken of the diagnostic indications furnished by the thermometer. I now proceed to speak of it as a guide to pro- gnosis. According to Wunderlich and Ladame, it is during the second week that one can best prognosticate the course of the dis- ease from thermometrical observations. 1. If the evening temperature is maintained between 39°-5 and 40°, and the morning temperature remain always from half a degree to a degree lower than that of the previous evening, the attack will probably be mild, and convalescence begin about the third or fourth week, particularly if the temperature commence to fall a little between the eleventh and fourteenth days. 2. When during the second week, the temperature of the morn- ing is maintained at 390 or 39°.5, and when the evening tempera- ture reaches or exceeds 40°.5, without any commencement of a dimi- 1 Paul Ladame :—Le Thermometre au Lit du Malade. Neuehatel: x866. DOTHINENTERIA. nution of heat being observable by the middle of that week, there is a certainty that convalescence will, at the soonest, not begin before the fourth week. 3. All irregularities of temperature occurring during the second week demand attention. 4. Even when the temperature does not rise above 40°, the absence of a remission during the latter half of the second week, or an increase of temperature toward the end of that week, are always unfavourable signs. 5. The case is very serious, when the temperature is at 40° or more in the morning, and 410 or more in the evening; or when, towards the end of the second week, the temperature goes on in- creasing. Speaking generally, it may be stated that a temperature of 410 is not often met with, and in general only in cases which terminate in death. Mark the great prognostic value of this figure ! A temperature of 4i°*5 or 420 indicates inevitable death. The prognosis is also unfavourable when the morning temperature reaches or exceeds 40° for several days in succession. Let me here notice, in relation to prognosis, this very high temperature, and extreme frequency of pulse. Dothinenteria is not a disease in which the pulse is very frequent, the normal range being from 100 to no. When it gets up to or above 120 in an adult suffering from this fever, the prognosis is as unfavourable as when the temperature reaches or exceeds 410. 6. From the commencement of the third week, the mild and serious cases can be distinguished from each other with the greatest precision. In the mild cases, there are great remissions of heat in the morning, the morning temperature being a degree and a half or even two degrees lower than that of the previous evening. During this week, the morning temperature becomes normal, and the evening temperature likewise goes on falling rapidly, but does not reach the normal standard till about the middle of the fourth week. In bad cases, on the other hand, the temperature remains what it was during the second week; and it is only at the end of the third, or begin- ning of the fourth week, that great remissions of temperature take place. 7. Defervescence never proceeds so rapidly as in exanthematous typhus.1 It takes place in different ways. The most usual manner 1 See the Lecture on Typhus in this volume. 342 DOTHINENTETtlA. is by the temperature beginning to fall considerably in the morning, even when, as I have just said, the evening exacerbations continue the same for some days; thus you may have, I repeat, a normal heat in the morning, while the evening temperature may still be 390 or even 40°. At other times, defervescence goes on in a regular and parallel manner, morning and evening, during a period of eight or ten days. 8. Convalescence may be said to have begun, when the evening temperature has returned to its natural standard of 370. 9. The temperature generally rises at the time of death, or a few hours before it. Drs. Thomas and Lade found the temperature as follows immediately before death in fourteen cases :— Live times, from 40°.25 to 40°.7o. Twice, „ 4i°.i2 „ 4i°.2ij. Seven times, „ 420 „ 42°>75.1 In seven of the cases, therefore, the temperature reached or ex- ceeded 420, a temperature which according to Wunderlich is hyper- pyretic, and only met with in cases which terminate in death. Under such circumstances, there is almost always a predominance of nervous symptoms, such as furious delirium, excessive restlessness, exhaustion, and paralysis. Nevertheless, in contrast to these cases, I ought to tell you that there are others in which the temperature is normal, or very low. The pulse is at the same time small and very frequent: the skin is covered with a cold sweat: the extremities are livid: and in a word, the patient dies in a collapse, which is sometimes preceded by haemorrhage. Finally, there are cases in which death takes place although the temperature has neither been very high nor very low: the patients die exhausted after a profuse and obstinate diarrhoea, accom- panied by tympanites, and nervous symptoms of no very great severity. The thermal condition and the intestinal lesions follow an almost strictly parallel course. You will remember I told you that the alteration in the glands of Peyer and in the solitary glands begins on the fourth or fifth day; and I have now to say, that it is from the same period that the temperature rises definitively to somewhere 1 A. La.de :—Reclierches sur la Temperature dans les Maladies. Geneve 1866. DOTHINENTERIA. 343 about 39°-5 or 40°. There is, therefore, you see, a parallelism between the two phenomena. I have also told you that in mild cases the lesion of the Peyerian patches may be proceeding towards resolution: now, in mild cases, it is precisely at this time—about the middle of the second week—that we observe the great morning remissions of temperature. The parallelism continues : at the end of the third week, resolution of the Peyerian patches may be com- plete ; and that is the period at which the evening temperature becomes normal. I also told you that in the most severe cases, resolution proceeded in certain patches, whilst others increased in size, and became more and more affected; so that in this way, the intestinal lesion continued till the third or even fourth week; and we have just seen that in severe cases defervescence does not begin till that period : here again is parallelism. To sum up : In the first period, or the period during which the intestinal lesions are formed and developed, and which extends from the first day of the attack to the second half of the second week, the fever is continued or slightly remittent, that is to say, that in the morning and evening the temperature is febrile: in the second period, or period of resolution, embracing the third week and more, the fever is intermittent, that is to say, the temperature is febrile in the evening, and normal in the morning. During convalescence, there is no fever, and the temperature is either normal or low both in the morning and evening. Pinally, to give a general idea of the thermal movement in typhoid fever, it may be said that there is a slow and gradual upward movement of the curve from the beginning of the disease; then a state, nearly stationary, in which there is only a slight morning descent; after which comes a regular but a slow defervescence. In conclusion let me add, that when defervescence does not take place at its proper time, or when the temperature rises at the time at which defervescence ought to begin, there is a complication for which, if its nature is not evident from the symptoms, you ought carefully to search. There again, gentlemen, the thermometer may assist you in dealing with an insidious affection.1 1 Alf. Duclos Quelques Recherehes sur l’etat de la Temperature dans les Maladies. Paris, 1864. Hietz Article “ Chaleue ” dans le Dictionnaire de Medecine et de Chirurgie Pratiques, T. vi. Paris, 1867. 344 DOTHINENTERIA. Bos?/ Lenticular Spots.—Successive Eruptions.—Miliary Eruption.— Blue Spots. I have already said, gentlemen, that while I disagree entirely from those authors who hold that the rosy lenticular spots constitute the specially characteristic eruption of dothinenteria, and who look on the intestinal lesion as a secondary affection, I do not the less admit that the cutaneous eruption is of very great importance in the symptomatology of the disease. The slightly prominent rosy papules, which disappear under the pressure of the finger, do not begin to show themselves till from the seventh to the tenth day of the fever, and it is not unusual for their appearance to be even longer delayed; but when this delay occurs, the general symptoms, which till then have been very mild, become strongly marked. It was so in the case of a young man in St. Agnes's ward, who after having shown us no symptoms for fourteen days, except a little prostration without fever, and a slightly saburral tongue, was, at that period of the attack, and coincidently with the appearance of the cutaneous typhoid eruption on the abdomen, seized with symptoms of the most serious character. There are also cases in which the cutaneous eruption never appears during the whole course of the disease, a fact to which I have already called your attention, by mentioning that in some epidemics of certain departments in Trance, it had not been met with. This eruption does not come all out on the skin at once, as is the rule in the exanthematous fevers. Some papules first show them- selves : on following days others consecutively appear. Each papule considered by itself has a duration of from three to fifteen days, and those which appear first are fading when new ones are coming out. The total duration of the whole eruptive period averages eight days, but it varies between the extreme terms of three days and twenty days. Its profusion and prolonged duration generally coincide with an exceptional severity, or, to express it more correctly, with a greater prolongation of the disease. You have been frequently in a position to verify this statement for yourselves in numerous cases which have been brought under your notice. Thus, in two cases in which there was a total absence of the rosy lenticular spots, you saw recovery take place at the end of the third wreek, reckoning from the time at DOTHINENTERIA. which the patients were obliged to remain in bed, till the day on which convalescence was thoroughly established. This wras also the duration of the illness in six other individuals who had the usual number of spots, but it was longer in eleven patients in whom you saw a very confluent eruption. The coincidence which I am point- ing out, in the confluence of the spots and the severity of the disease, is never more evident than when the eruption after having disap- peared comes out again once or several times. Simultaneously with the appearance of new spots, which are often more nu- merous than their predecessors, the general symptoms acquire new intensity. A woman, aged nineteen, who occupied bed No. 25 of our St. Bernard ward, wras attacked, eight days before admission, with head- ache, pain in the abdomen, and a feeling of general lassitude, pros- tration, and pains in the limbs. The abdomen was not tympanitic, but pressure caused gurgling in the right iliac fossa. The fever was rather moderate. Typhoid spots were visible when the patient was admitted into hospital: that first eruption disappeared, and a second showed itself on the eighteenth day, at a time when there had been an amelioration in the general symptoms for four days. Simulta- neously with the second appearance of the spots, there was a re- newal of the other symptoms in an aggravated form : the prostra- tion was greater, the fever higher, and the diarrhoea more profuse than before. Five days later, the severity of the symptoms sub- sided : and on the twenty-seventh day from the beginning of the attack, the patient was quite convalescent, and five days afterwards was in a state to leave the hospital. In the case which I am now going to relate, there were two reappearances of the cutaneous eruption. The patient was a young woman whom you saw occupying bed No. 30 in the same ward. When received into the Hotel-Dieu, she had been ill fifteen days, and ten days confined to bed. She had all the symptoms of typhoid fever. We found numerous rosy spots. They had disappeared on the thirteenth day of the attack : next day, an improvement was observed, there being less diarrhoea, tympanites, and prostration. Three days later, the patient experienced nausea : there was a re- newal of the abdominal tympanitic distension, and at the same time gurgling was perceived. There was high fever ; and a new eruption as abundant as the former. The severity of the symptoms after a time abated. The spots were completely faded on the twenty-seventh DOTHINENTERIA. day; and on the thirtieth, convalescence seemed sufficiently secured to enable the patient to be allowed a little solid food; but, on the thirty-fourth day, there set in, for the third time, abdominal pains, gurgling, nausea, vomiting, and diarrhoea. The tongue was red, dry, and destitute of epidermis: the skin was hot; and the urine contained albumen, which coagulated on the application of heat. On the morrow, a new eruption of rosy spots appeared, which re- mained till the fortieth day of the disease; and on the forty-fifth day convalescence was definitively established. In neither of these cases, could any cause be assigned for the severe relapse of the dothinenteria; but relapses are sometimes attributable to errors in diet, to a fit of indigestion, so difficult to guard against in self-willed patients. This occurred in a third case in which there was a return of the symptoms. The patient occupied bed No. 5 of St. Bernard’s ward. On the twenty-eighth day of her dothinenteria, this woman, who was entering upon her convalescence, had a fit of indigestion, and was very soon afterwards seized with delirium and fever. On the fol- lowing day, an eruption of rosy spots—which had been observed since her admission to hospital and had disappeared—again came out. The relapse was not of long duration. The general symptoms abated: the spots had faded away in five days from the date of their reappearance, and by the end of the fifth week recovery was complete. The existence of this exanthematous eruption at periods very remote from that before which it has generally disappeared, may sometimes lead to mistakes; and when one has not observed the disease from the beginning, when there is a want of precise in- formation regarding the previous history of the case, the dothinen- teria may be supposed to have reached a more advanced stage than it really has. An autopsy recently performed in your presence has a very interesting bearing on that point. A man, aged thirty, was brought to the hospital with all the symptoms of very severe putrid fever. The delirium was violent, the fever intense, the skin hot and dry : the abdomen was tympa- nitic, and covered with a very confluent eruption of rosy lenticular spots. Although the persons who brought him to the hospital told us that he had been ill thirty-five days, the profuse eruption led us to believe, considering the general rule of the disease, that the typhoid fever dated back only sixteen or eighteen days. We inquired DOTHINENTERIA. 347 whether the patient had not had some other malady before that under which he laboured at the time of his admission to the hospital. The patient died; and on opening the body, it was found that the typhoid fever really did date back to a period thirty-five days before wre saw him. We found intestinal ulcerations nearly cicatrised. The erup- tion which he had on admission was therefore a second eruption. To explain the intensified returns {recrudescences) of the fever and the successive eruptions, we must suppose that the morbid poison has not exhausted itself in the first outbreak, and that the economy, to get rid of it, requires repeated efforts. These returns of the fever are neither relapses {recliutes), nor still less are they new attacks {recidives) : it is the same attack, the symptoms of which, temporarily interrupted, recur under the influence of the same morbid cause which produced them in the first instance. However com- plete the symptoms may be, and although the eruption reappears, the characteristic intestinal lesion never returns. In the patient wrhose case I have just brought before you, wre only found cicatrised ulcerations : there was no trace of a renewal of the intestinal ulcer- ation. The possibility of the symptoms returning at a time when con- valescence is supposed to have begun ought to make the physician very cautious. When at this period he thinks that he may feed up his patient, he ought to proceed with very great prudence, and avoid being guided by the appetite of the patient, which is often deceitful: lie ought in particular to be exceedingly reserved in his prognosis during the whole course of dothinenteria, as cases which seem at first to be exceedingly mild, may one day have a very serious exacerba- tion. In reference to successive eruptions, I vmuld say, that while they do not absolutely imply danger, they at least indicate that the case will be more protracted than usual, and consequently that recovery will be retarded. I have still to mention two other forms of eruption to which I have often directed your attention at the bedside of the patient. I am not at present referring to petecTiicey those small spots of a violet- red colour which do not disappear under pressure of the finger, true sub-cutaneous ecchymoses which belong to the history of haemorrhagic putrid fever, and still more to the history of typhus. I refer to the miliary eruption and the blue spots. The transparent miliary vesicular eruption Ja miliaire pellucide] improperly called sudamina, generally appears between the eleventh 348 DOTH INENTEltl A. and twentieth days and sometimes later, and consists of small blebs of round or oblong shape like tears, which are filled with a trans- parent fluid. This eruption is sometimes very profuse, but there is a great difference in respect of the number of blebs. The situa- tions which it occupies are the abdomen, particularly in the vicinity of the groins, the front of the neck, and the anterior part of the axillae: in some cases, it extends over the entire trunk, and also appears on the limbs. This eruption is hardly visible, unless you are very close to the patient, but it is easily recognisable by the touch, on account of the sort of rugosity of the skin caused by the small blotches of which it consists. It is never seen on the face. It is more usual to meet with this exanthem in typhoid fever than in any other disease, but it is by no means peculiar to it; and I agree with Huxham and Professor Bouillaud in regarding it as simply the symptom of a symptom, miliary eruption being generally the consequence of sweating. You have seen in many patients an eruption of spots of a blue colour. These blue spots, you have remarked with me, are only seen in exceedingly mild cases terminating favourably. Is this a mere coincidence, or is the eruption of blue spots an inherent cha- racteristic of a mild form of the disease? These are questions which I cannot solve. Intestinal Dothinenteric Catarrh.—Its Specific Character.—Predomi- nance of Intestinal andPulmonary Catarrhal Affections constitutes the Forms of the Disease called “Abdominal” and “Thoracic.” We had, gentlemen, in bed No. n ter of St. Agnes's ward a youth who came into the Hotel-Dieu five days ago with giddiness, headache, high continued fever, the tongue red at the point, thirst, anorexia, some fits of cough, and a profuse diarrhoea. At first, there was room for supposing the case to be one of incipient typhoid fever, and for a moment I did entertain that idea. The diarrhoea, however, had set in so suddenly, and had from the very first been so severe, that I hesitated: the symptoms seemed not to be those of the enteritis which accompanies putrid fever, but those rather of simple intestinal catarrh. I deferred my diagnosis ; for it is espe- cially necessary in such circumstances not to pronounce a too abso- lute opinion. In twenty-four hours, the fever had abated, and on 349 DOTHINENTERIA. the third day it entirely ceased : the general symptoms likewise im- proved, the headache became less severe, the appetite returned, and with these changes for the better, the diarrhoea also stopped. In fact, this youth who, at the most, had been ill six days, had, at the end of these six days, regained his usual health. I should certainly, gentlemen, have played a lucky game, if I had given at my first visit a decided opinion based upon the symptoms which were then present. If without allowing the case for a mo- ment to follow its natural course, I had begun active treatment, in place of confining myself to prudent waiting, I might have believed, and I might have told you, that I had cured a case of dothinenteria in six days, as some physicians wdio do not take into account the specific character of the disease assert they can do, and as homoeopaths particularly pretend to do. I should have deceived myself like these physicians, and like these homoeopaths :—I speak of honest homoeo- paths, for it is necessary to distinguish between the honest and dis- honest of that sect. Of the dishonest homoeopaths, the great majority, grossly ignorant, and without any kind of medical creed, only see in homoeopathy a road to riches, by attracting to themselves the public, always favourable to the mysterious; while others, still more culpable, shameless charlatans of the worst description, edu- cated in our art, knowingly deceive themselves in deceiving their patients. But by the side of these dishonest men, thoroughly deserving of the contempt into which they have fallen, there are others, educated, conscientious, and convinced of the truth of the doctrine which they have embraced : it wTas to them only that I made allusion. Well! wrhen these practitioners fancy that they have arrested in their career maladies which must pursue an inevitable course, it is because they do not regard this inevitability from the same point of view with me. Let me explain myself by giving you an illustration of my meaning. We know before hand, when we inoculate small- pox or cow-pox, that the morbific germs will grow up and produce a disease, the characters of which will be rigorously determined by, and absolutely dependent upon, the nature of the cause whence they spring—as absolutely—the comparison is strictly correct—as abso- lutely as the germ of a plant growrs up reproducing the characters of the species which furnished it, and of no other species, the acorn reproducing the oak, and the seed of corn reproducing corn. In dis- ease, though wre cannot lay hold of the first cause, the same thing 350 DOTHINENTERIA. takes place, that is to say, different causes engender diseases of dif- ferent species having respectively their special symptoms and pecu- liar career; and, to return to our subject, the morbific cause which engenders simple intestinal catarrh, will not engender the catarrhal enteritis of dothinenteria any more than the virus of small-pox will engender scarlatina: each has its own special characters and course, and I am not of those who believe that the one can be transformed into the other, unless it be under peculiar circumstances, as for example, when, under an epidemic influence, an individual seized originally with a simple intestinal catarrh is attacked with putrid fever, which then puts its stamp on the non-specific enteritis. To continue still farther our comparison derived from the germination of the seed, I would remark, that while it is difficult, even after long practice, to distinguish the different kinds of plants at the period when there is nothing to be seen but the nascent leaflets in the cotyledons of the seed, while we must wait till the formation of the plant is more advanced before we can tell the family, genus, species, and variety to which it belongs, it is also difficult to distinguish the particular disease with which one has to do, so long as it is only be- ginning to manifest itself. Hence the frequency with which simple intestinal catarrh is mistaken for the intestinal catarrh of dothinen- teria ; and the frequent necessity of allowing some days to elapse before pronouncing a decided diagnosis. It is, therefore, an im- mense point in medicine to know the natural course of diseases, and to wait a little till their characters are precisely drawn : before be- ginning treatment, it is necessary to know whether the case is one in which our intervention ought to be active, or one in which we ought to rely on the unaided therapeutic efforts of nature, satisfying ourselves by being always ready to assist nature should that be requisite. The intestinal catarrh of dothinenteria is a catarrh of a specific character, and we may use means for moderating it, just as we adopt means for moderating other catarrhs; but if we try entirely to remove it, we shall fail. The diarrhoea which characterises it is one of the most frequent symptoms of the disease; but no more than the other symptoms is it proportionate to the extent or intensity of the intestinal lesions. It may set in during the first twenty-four hours, or not till the third day, the ninth day, or even not till a more advanced period; and in some exceptional cases, the intestinal flux is absent, and sometimes even there is obstinate constipation during 351 DOTHINENTERIA. the whole course of typhoid fever. You have seen several examples of this in the clinical wards. In the generality of cases., the stools are few and scanty at the beginning of the attack, and vary during the remainder of its course in number and character. Sometimes a patient has only one in twenty-four hours, while another patient has more than twenty. The evacuations are liquid, yellowish, greenish, or sometimes they consist of a stercoraceous pulp, or they have a semi-liquid consist- ence : their odour is fetid, and sui generis. The motions are seldom accompanied by severe pain, and never or almost never with gripes : they may be passed involuntarily, as when the patient is in a state of delirium or stupor, and likewise when he is in no such circum- stances. The catarrhal feature of the disease is also met with in the pulmo- nary apparatus, where auscultation always reveals a certain amount of bronchitis characterised by dry, moist, sibilant, and mucous rales, which are heard from the beginning or at least from the first days, of the attack. The cough is generally in proportion to the abun- dance of the rales : the expectoration, which is exceedingly small in quantity, consists of mucous sputa. The catarrhal affections do not always coexist; and when the abdo- minal symptoms occur alone, or when they dominate over the other symptoms, “ abdominal” is the name given to the form of the dis- ease. It is chiefly in the mucous form of dothinenteria that we meet with this almost exclusively abdominal character in the symptoms. Thoracic complications, whatever may be the leading general symptoms, may assume great intensity, and then there may be either an exacerbation of the ordinary bronchial catarrh, or inflammation of the pulmonary parenchyma : the existence of pneumonia is ascer- tained by hearing fine crepitant rales and bronchial blowing on auscultation, and by dullness on percussion over the affected part. On examination after death, the lung is found to be highly con- gested, and hepatised, and to tear in handling, a condition which I remarked in the case of the young lad of St. Agnes’s ward, the particulars of which I will afterwards recapitulate. This pneu- monia occurring in the course of typhoid fever is one of the most serious complications : it very greatly imperils the patient, and wdien it does not lead to an immediately fatal issue, it prolongs and thwarts convalescence. DOTHINENTERIA. You saw to-day, in bed 28 of St. Bernard’s ward, a woman pre- senting an example of what is called the thoracic form. But in her case, bronchial catarrh, without parenchymatous inflammation, is the leading symptom. The patient had bronchitis when she came into the Hbtel-Dieu on the 15th of August last. She has resided in Paris for the last two years: she has generally enjoyed good health. She was confined seven months ago, when, fifteen days before she came into our wards, she was seized with headache, ab- dominal pain, and slight diarrhoea. Prom that time, she was dis- tressed by sleeplessness. When we saw her for the first time, she had a copious eruption of rosy lenticular spots. The circumstance which especially attracted my attention was, that the chief complaint this woman made was of difficulty in her breathing, which was loud and quick. On percussion of the chest, we found that the sounds elicited were everywhere equally clear: on auscultation, we heard rales in every part of the chest—mucous rales which were coarse at the upper part, and finer at the base of the lungs. The fever was very moderate. This patient is still in hospital, and in the report of her case, which is taken regularly day by day, you will see that her slight abdominal symptoms had subsided by the 19th of August, that by the 21st the stools had become natural, and the fever had left her: but that the pulmonary symptoms had improved very slowly. Por some days, the expectoration has become more and more abundant, and has assumed a muco-purulent appearance : the plessimetric and stethoscopic signs remain as before, and there is no decrease in the dyspnoea. To-day, the thirty-second day of the disease, you see this woman still very much in the same state in respect of her bron- chitis. You will find her seated on her bed, always suffering from oppressed respiration, and frequent fits of coughing. Her spittoon contains a large quantity of muco-purulent expectoration. The digestive functions, however, seem to have returned to their natural state, the appetite is restored, and she eats half the ordinary daily diet of a patient. There is very little feverishness. Forms of Dothinenteria, viz.—the Mucous, Bilious, Inflammatory, Adynamic, Ataxic, Spinal, Cerebro-spinal, and Malignant. A mason, aged sixteen, born in the department of Haute-Vienne, DOTH1NENTERIA. 353 and who had only been resident in Paris for a few months came into the IIotel-Dieu on the 14th June, and was placed in St. Agnes’s ward. When I saw him next morning, he could not give the least information as to the beginning of the malady from which he was suffering. He was in a state of high fever : the pulse was 100, regular, but soft. There was profound coma : he had been de- lirious during the whole night: and I observed convergent stra- bismus of both eyes. The tongue was red and dry; the abdomen was tympanitic, with gurgling in the right iliac fossa, and diarrhoea. The symptoms became more severe every day, and on the 17th, I noted that the limbs were rigid. On the 19th, five days after his admission to hospital, the patient died. On the morning of his death, his appearance was deplorable; the eyes were haggard : the nostrils, lips, and teeth were covered with black sordes: the tongue, dry and covered with little cracks, lay motionless between the upper and lower teeth: the abdomen was tympanitic : the pulse was thready, and exceedingly quick : the skin of the hands was cold, clammy, and blue as in cholera, while that of the body was dry and burning. At the autopsy, we found great gaseous distension of the intes- tines : the glands of Peyer were swollen, but not ulcerated, some of them forming an elevation of the thickness of a five franc piece: some of the solitary glands were swollen: the mesenteric glands were enlarged. The spleen was hypertrophied, measuring seven- teen centimeters in length and thirteen in breadth. Its tissue was easily reduced to a thin pulp. The liver, blackish and soft, broke down under the least pressure, making it difficult at first sight to dis- tinguish its two component tissues. The lungs, black, gorged with blood, and softened, tore easily : they did not contain any apoplectic sanguinolent masses. The heart, pale, and anaemic, contained some clots. The membranes of the brain were only slightly vascular : there was neither opaline nor even discoloured effusion in the sulci: there was no thickening of the membranes, nor were they adherent to the substance of the brain. The brain when sliced presented only a slight appearance of bloody points. Gentlemen, during the two months which preceded the occurrence of this case, you saw two other typhoid fever patients in whom the symptoms which predominated were similar to those which we met with in this young man. One was a man and the other a woman : both recovered. A month after leaving the Hotel-Dieu, the woman 354 DOTHINENTERIA. was received into La Pitie Hospital, having had a relapse. The man, aged eighteen, w'hose life was for a long time in danger, left our wards on the thirty-fourth day, completely recovered from the attack of typhoid fever, and also from sores over the sacrum which had formed during the severe period of his illness. These are cases of adynamia typhoid fever, which our predecessors considered a distinct disease; just as the mucous, bilious, inflam- matory, ataxic, and malignant forms were looked on as separate diseases till the progress of pathological anatomy, influenced mainly by the labours of Bretonneau, showed that they were not different species, but simply varieties of one species. Nevertheless, in reducing all the varieties to a pathological unity, specially based on the constant existence of the dothinenteric eruption, it is impossible to deny that predominance of a certain class of phenomena gives a particular stamp to the dothinenteria, which it is important to take into consideration at the bed of the patient, in respect both of prognosis and treatment. Is not this predominance of particular pathological manifestations conspicuous in other diseases, upon which it, in the same wray, impresses its own character ? Bor example, does not pneumonia, generally an acutely inflammatory disease, become, under certain circumstances, bilious, adynamic, ataxic, or malignant ? In consequence of dothinenteria having a greater tendency than any other disease to present variety of dominant symptomatic phases, the older physicians, unable to grasp the pathological unity of this variety, regarded each different form as a distinct disease. The simplest form of dothinenteria is the mucous: it is distinguished from the others by its purely negative characters, there being no decided predominance of one or several symptoms. You have seen numerous examples of this form. To it belonged the cases in which the patients reached the hospital in a state of prostration approaching insensibility, complaining of a little headache, and feeling giddy. Some have had sleeplessness, and others slight delirium. The fever was moderate, and the pulse was often below the normal standard. You have sometimes observed epistaxis at the beginning of an attack: but it is generally absent, and the course of the disease is not influenced by its presence or absence. You have seen that the leading symptoms are connected with the digestive functions. The patients complained of want of appetite, an insipid taste in the mouth, and rather urgent thirst. The tongue, DOTHINENTERIA. 355 saburral to a slight degree, was covered with a thin whitish fur : it was moist, swollen, retained the impression of the teeth, and was red at the point and edges. In some cases, there was vomiting. Some patients had profuse bilious diarrhoea, while others had obstinate constipa- tion. Gurgling in the right iliac fossa was always observed. Aus- cultation established the existence of bronchitis characterised by sibilant, sonorous, and mucous rales, with occasional fits of coughing accompanied by mucous expectoration. In some patients, the rosy lenticular spots were wanting, while in others, they came out in suc- cessive eruptions. This mucous fever is a mild form of dothinenteria, but nevertheless an attack may be prolonged for twenty, thirty days, or longer. I have always seen it terminate favourably; but you must remember that in this mild form of the disease, as well as in the still milder cases to which the designation of latent typhoid fever has been given, death may occur from an unforeseen perforation, from haemorrhage, or from one of those spontaneous attacks of peritonitis of which I have spoken. Convalescence is often very slow; and when this has been the case, I have seen relapses which were worse than the original attack. Under the prevailing influence of certain medical constitutions, the disease assumes the bilious form. Although this form has lately occurred pretty frequently in town, we have not met with any well- marked cases of it in the clinical wards. Gentlemen, you know the characteristics of the bilious form of dothinenteria. The saburral condition is more decided than in the mucous form. The com- plexion is yellow, particularly on the alee of the nose, and in the naso-labial hollow : the sclerotic has an icteric hue : there is greater want of appetite than in the mucous form, and the patient com- plains of a very bitter taste in the mouth, accompanied by nausea, and vomiting of yellowish and greenish matters. The fur upon the tongue is thicker than in the mucous form of the disease, and has a greenish-yellow appearance, particularly at the base. There is also more headache. The bilious is generally combined with one of the other forms of which I am going to speak. The inflammatory is likewise generally combined with other forms of the disease. It is characterised at the commencement of the attack by intense fever, a pulse which is full and often bis feriens, a moist heat of skin, and, in a word, with the symptoms of general febrile plethora. This inflammatory condition, which, according to the prevailing medical constitution, is frequently met with, rarely 356 DOTHINENTER1A. continues from the beginning to the end of an attack : it usually gives place to an adynamic or ataxic state. Except in this last form—this state of prostration—the collapse of the animal functions, particularly of muscular contractility, is one of the most constant generic characters in all the varieties of typhoid fever. When it is not in excess of its usual degree, it does not call for more anxious consideration than any other symptom ; but when it becomes the predominating character of the attack, and when with the prostration of the functions of animal life, there is com- bined collapse of the organic functions more immediately essential to the maintenance of life, a condition exists to which is given the name of adynamia. This adynamic typhoid fever, of which I have brought under your notice several examples, was characterised in our patients by extreme softness of the pulse, by very deep and protracted stupor, by very great insomnia, by quiet delirium, by muttering, by picking the bed-clothes, by deafness, and by paralysis of the bladder requiring the use of the catheter. You recollect a woman who in her delirium refused to take food, and to whom it was necessary to administer soups by the oesophageal tube. In this form of the disease, the tongue is clammy, and trembling, and the tongue, gums, and teeth, are covered with black sordes. There is profuse diarrhoea, and an extreme degree of tympanites. In some epidemics intractable vomiting has been observed. In this form of the disease, you will observe that the perspiration, breath, and urine have a foetid smell. There is a tendency to hsemorrhages ; and also to sphacelus, as is indicated by sloughs forming in the seat, the heels, and over the great tro- chanters, caused by pressure, contact with excrementitious matters, and still more by the general condition of the patient. The symp- toms which I have last mentioned—the very great foetor of the breath, sweat, and urine, and the tendency to hsemorrhage and sphacelus—have been given as the characters of putridity, which must not be considered as quite the same with adynamia. This putridity is compatible with a high temperature, a turgid and very injected state of the skin and mucous membranes, a great increase of the pulse, and, in a word, with high fever; the causus of our predecessors was nothing else than this congestion, although true adynamia has as its leading characteristic a state of fever either sus- pended or notably below that which is absolutely indispensable for the complete and regular accomplishment of the long sequence of pathological operations of which the organism is the theatre. DOTHINENTERIA. 357 The adynamic form of dothinenteria is serious, but less serious than the ataxic form, and medical treatment can often do a great deal to assist the failing powers of nature. The therapeutic indica- tion is to excite reaction, and to fulfil that intention, stimulants and tonics are evidently the appropriate remedies. Generous wines, and cinchona in various forms constitute the basis of the treatment. Stimulants such as ether and camphor, excitants such as ammonia and the acetate and carbonate of am- monia ought to be administered for the purpose of awaking—if I may use the expression—of awaking the organic powers, while tonics ought to be employed for maintaining them. As tonics auxiliary to cinchona, I may mention infusions of wormwood, serpentaria, anise, cascarilla, and all similar remedies. Malaga wine is preferable to other wines, whether Trench or Spanish : it may be given in spoon- ful doses every two hours, every hour, or even at shorter intervals, the quantity taken in the twenty-four hours being from 125 to 250 grammes. The ordinary tisane of the patient is a vinous lemonade with the addition of Seltzer water. Cinchona is prescribed in the form of extract, in doses of from four to ten grammes, in draughts; or in the form of powder, in a cup of infusion of coffee without milk; or the sulphate of quinine may be ordered in doses of a gramme and upwards. As a beverage, a weak decoction of the bark sweetened with lemon syrup is employed. If the stomach does not tolerate this beverage, the decoction, with the addition of camphor, may be given as a lavement; or sulphate of quinine may be administered in the same manner, combined with musk, as in the following formula :—sulphate of quinine, from one to four grammes; sulphuric acid, enough to dissolve the sulphate; musk, two grammes; and water, a hundred grammes. Tomentations of wine and camphorated alcohol are employed. In the clinical wards, I have seen benefit result from placing the patient in a mustard-bath. Two kilogrammes of the flour of mustard, made into a soft paste with water, are tied up in a coarse cloth and put into the bath: the cloth is pressed sufficiently to give a yellow colour to the water.1 Under the influence of such baths you have seen improvement take place, the general aspect 1 The mustard generally used in Trance is a much feebler irritant than English mustard, so that in place of two kilogrammes (a little more than four pounds) it would be, perhaps, sufficient to employ two pounds of English mustard.—Translator. 358 DOTHINENTERIA. becoming better, the pulse regaining volume and diminishing in frequency, the blueness of the extremities giving place to the natural colour of the skin, and the abdomen becoming softer. This treatment is repeated every twenty-four hours : it is not discon- tinued till, under its influence, the skin has regained its warmth, till the pulse has become firmer, and the senses, the motor apparatus, and the intellect, have emerged from their state of stupor and lethargy. It is especially in this class of cases that we require to give nourishment to the patients in accordance with my plan: this is a cardinal point in the treatment of dothinenteria ; but I will reserve what I have to say upon this subject till I come to discuss it in a special manner. In the ataxic form of dothinenteria the symptoms are of an entirely different description. There is no prostration, nor collapse of the animal functions; but they are in a state of disorder, incoherence, and discord. When the ataxia involves the vital functions over which the sympathetic nervous system presides, and the active and constant exercise of which is essential to the continuance of life, wre say that the form of the disease is malignant. We must not, how- ever, confound malignity with ataxia, a term which embraces everything, and strictly speaking specifies nothing, for its application has been limited, as I now limit it, to the cases in which the co- relation of the animal functions is broken up. Ataxic typhoid fever, then, is characterised by disturbance of the nervous system: the cerebral symptoms consist in more or less violent delirium, accom- panied by cries, vociferations, disturbed sleep, nightmare, halluci- nations of every kind, convulsions, tetanic contraction of the limbs, strabismus, picking the bed-clothes, spasmodic jerking of the ten- dons, and sudden exaltation followed by as rapid a collapse of the muscular power. There is intense fever. The patient complains of excessive lassitude, cramps, very severe pains particularly in the lumbar region, and violent headache. This is the most mortal of all the forms of dothinenteria: it destroys patients as if by a thunderbolt. We have seen it carry off in four days a young girl brought by it to our St. Bernard -ward. Tive days previously, she had been in perfect health. I am enabled by a special circumstance to fix with precision the date at which her attack commenced: she was present at the public fetes given to celebrate the Emperor’s marriage, and on the following day expe- 359 DOTHINENTERIA. rienced the first symptoms of the disease from which she died. It began with violent pain in the head, and a state of insomnia dis- turbed by dreams and frightful nightmares. When brought to the Hotel-Dieu, she complained of racking headache, accompanied by pains, which were dreadful in the limbs, and still more dreadful in the loins. The fever was intense; the pulse was very rapid; and the skin was burning, dry, and coloured. When this young woman was admitted into our wards, she was subjected to the cold affusion. From this she experienced a little temporary relief, but on the same evening she succumbed to the violence of the symptoms, which had never ceased for an instant. The autopsy disclosed the existence of one of the most confluent dothinenteric eruptions which I ever saw; and it is a remarkable fact, that this was seen at the fifth day of the disease. In my early medical studies, I saw an exactly similar case in the practice of my illustrious master, Bretonneau, at the hospital of Tours. The predominance of ataxic phenomena may sometimes depend on the nervous temperament of the patients, or on moral emotions experienced before or during the attack; but generally, it is dependent on the character of the epidemic, and the prevailing medical constitution. Having now spoken of the symptoms referable to the brain, it is necessary that I should point out to you those to which dothinenteria gives rise in connection with the spinal marrow, to which the late Dr. Fritz, an observer of the greatest merit, has directed special attention.1 I refer to lumbar pains, very similar to those which occur so often in small-pox, accompanied sometimes, but not so fre- cjuently as in that disease, by incomplete paralysis of the lower extremities, or more generally by cutaneous and muscular hyper- esthesia, and by lancinating pains in the extremities: there are also rachialgic pains of greater or less severity in the dorsal region, often a very intense pain in the neck, shooting to the occiput, impeding the movements of the head and neck, and sometimes causing, like the pains in the inferior extremities, a feeling of incon- venient stiffness in the muscles; and finally, there is acute sensibility to pressure made over the spinous processes of the vertebrae of the region of pain, thus indicating a true spinal hyperaesthesia. 1 G. Fkitz :—Etude Clinique sur Divers Symptomes Spinaux dans la Fievre Typlio'ide. Paris: 1864. 360 DOTHINENTERIA. These symptoms, which are almost never absent, generally con- tinue till about the middle or end of the first week, and then disap- pear, just as happens in respect of the cerebral symptoms in a great many cases. But this is not the invariable course of events. And occasionally, just as cerebral disturbance is seen to be the predomi- nating feature of an attack, so spinal symptoms may occupy the leading place in the symptomatology of dothinenteria, and continue to do so till the advanced phases of the malady. But it is important to observe with Fritz, that even in cases in which the spinal symptoms have attained a very remarkable degree of severity, the autopsies, as well as the clinical observations during life, show that there was neither inflammation of the spinal marrow nor of its membranes accidentally complicating the typhoid fever. At the very utmost, it is oidy in an exceedingly limited number of cases, that one can in part attribute the spinal symptoms to con- gestion of the membranes of the spinal cord: generally, the cord and its coverings present no appreciable material lesion. We may, therefore, admit with Fritz, that there is a spinal form of typhoid fever, when spinal symptoms predominate, just as we allow that there is a cerebral form when cerebral symptoms predo- minate. In the cases of which I speak, the complete series of spinal symptoms may be observed : thus, in respect of sensibility, and occu- pying the most important place, is cutaneous hypereesthesia extending over a great part of the body, sometimes involving the four extremi- ties, the trunk and the neck, and often accompanied by muscular hypereesthesia; then there is hypersesthesia extending from the atlas to the sacrum; then again there is, but not so frequently, rachialgia accompanied by shooting pains in different parts of the body, and suffering of almost unbearable severity in the superior, and occasion- ally, though not often, in the inferior extremities; also, pain in the loins; violent pains in the chest; bi-lateral and symmetrical neu- ralgic pains in the trunk ; anomalous sensations of cold, formication, a feeling of pricking along the spine or in the limbs. Finally, along with this exaltation of the sensibility, we may have its extinction or perversion; for example, analgesia and anaesthesia of the skin, and muscular anaesthesia. There is quite as much diversity in the disorders of the motor system : for example, we meet with paralytic symptoms, numbness of the extremities, paraplegia, partial paralysis of the respiratory muscles, constipation, retention of urine, paralysis of the sphincters, spas- DOTHINENTERIA. 361 modic affections, dysuria from spasm, spasmodic contraction of the respiratory muscles and muscles of the extremities, stiffness of the muscles of the neck, contraction of the limbs, and even tetanic symptoms. In conclusion, let me point out, with Fritz, a special group of symptoms having its origin in the medulla oblongata, such as ex- treme dyspnoea independent of any affection of the respiratory pas- sages or muscles, spasm of the pharynx and larynx, convulsive cough, aphonia, alalia, inability to use the tongue in mastication, spasmodic or rythmic contraction of the sterno-mastoid and trape- zius muscles, and paralysis of the pharynx. The spinal symptoms of typhoid fever are often accompanied by cerebral, thoracic, and other symptoms of great severity. The con- currence of spinal with formidable cerebral symptoms constitutes the cerebrospinal form of Wunderlich, which presents some diffi- culties in diagnosis. It is not by chance or indifferently that the spinal symptoms show themselves : in children, in young women, and in anaemic subjects, the spinal marrow seems to be peculiarly liable to be seriously affected in dothinenteria. Independently of the treatment which ought to be pursued, in accordance with ‘indications of which I will speak when reviewing the general question of treatment in typhoid fever, the cold affusion is of essential use in the ataxic form of the disease. When lecturing on scarlatina, I told you what the cold affusion is, and how it ought to be administered. The mode of application is the same in typhoid fever. I will only remark that you will not meet with that opposition to its employment on the part of the relations of the patient, which is so often encountered in cases of scarlatina and other eruptive fevers. They have no dread of an imaginary driving in of the eruption, and consequently you are left much freer in your movements. If circumstances prevent your using the cold affusion, you may have recourse to cooling lotions, such as bathing the skin with vinegar and water. Tepid baths, particularly at the beginning of the disease, are of undoubted benefit: the patient may remain in the bath as long as he can bear it. I will now go back to the subject of malignity, that I may point out the differences between it and ataxia. Malignity, as I have already said, is a kind of ataxia, but it is an ataxia of those organic functions the regular and continuous exercise of which is indispen- 362 DOTHINENTERIA. sable to life. Here, the morbific cause having struck directly in its essence the force presiding over vital functions, the co-relation of which is broken; and there is not only collapse as in ady- namia, but annihilation, existence being threatened with an imme- diate and insidious termination. The older physicians perfectly understood these differences, recognising a true, primitive, proto- pathic malignity, declaring itself all at once at the beginning of the disease, and a secondary, deuteropathic malignity supervening at a later stage. You cannot do better, in relation to this subject, than to read the aphorisms of Stoll on febrile debility and malignity. Malignity arises in two very distinct ways. It may be depen- dent on causes in themselves injurious to life, such as mental emo- tions, depressing passions, and vegetable or animal septic poisons, to which probably belong the morbific principles which engender epidemic, endemic, and contagious diseases—principles which vary in their activity according to the epidemic, and according to the nature of certain unknown influences. At other times, the conditions which give rise to malignity belong exclusively to the individual. Those which are known generally depend upon impaired vital energy arising from prolonged excess of any kind, or upon excessive san- guineous or other discharges consequent upon previous diseases. Any morbid cause taking the economy by surprise when under such conditions, may bring on maladies which will assume the character of malignity. The characteristic signs of malignity are the occurrence of symp- toms having no apparent relation to the nature of the disease, the constitution or temperament of the patient, or the ordinary influence of external or internal modifying causes; and great anomalies in the symptoms, for example, the exclusive predominance and confused mixture of some symptoms, such as very high temperature associated with very feeble pulse—the alteration of symptoms, such as ex- treme cold succeeding burning heat—the moderation and apparent regularity of the symptoms during the first period of the disease, and their fatal severity at a more advanced stage, without any appa- rent or adequate cause. Other signs of malignity are sadden de- bility, disorder of the circulation, irregularity of the pulse, great acceleration of the respiratory movements; also, great dyspnoea, of which the patient makes no complaint, and which is neither ex- plained by auscultation during life, nor by examination of the thoracic organs after death. This malignity is met with in every species of fever, in inter- mittents (then called “'pernicious"), and in eruptive and non-erup- tive continued fevers. Thus, we have seen malignity in scarlatina, measles and small-pox; but malignity is more commonly met with in typhoid fever, in combination with its simple, adynamic, and ataxic forms, and constituting a variety of the disease, which has been erroneously regarded as a distinct species, and designated “ ma- lignant fever." DOTHINENTERIA. 363 Parotitis and Deafness as Prognostic Signs of Dothinenteria. Gentlemen, such of you as have attended my clinical wards for some years, must have seen patients affected with parotitis at the termination of dothinenteric attacks. Yery recently, you may have observed this occurrence in a young man of twenty, in St. Agnes's ward. This is what the old physicians would have called a crisis or metastasis; but I call it a very evil-boding complication. The significance of parotitis is very differently regarded; some look on it as always a serious complication, while others consider its appear- ance as an announcement of the favourable termination of the dis- ease. Tor iny part, gentlemen, I regard parotitis as a very formid- able complication : it is an affection from which I have almost never seen dothinenteric or other fever patients recover. It is not so with deafness, in respect of which, however, differ- ences have to be established. When the deafness is only on one side, the prognosis ought to be guarded : there is reason to fear a lesion of the organ of hearing, and suppuration often supervenes, resulting it may be from simple catarrh of the mucous membrane of the ex- ternal auditory canal, or—and then the case is more serious—in an alteration in the petrous portion of the temporal bone, which leads to affections of the brain. I saw an example of this in a woman who died from an affection of this kind, developed spontaneously and without antecedent typhoid fever; at the autopsy we found, as you will recollect, inflammation at the base of the brain. When the deafness occurs on both sides, I generally look on the prognosis as favourable; I have often called your attention to this point, stating that I have almost never seen persons die from dothinenteria who had been deaf on both sides during the course of the disease. In these cases, I look on the deafness as depending upon the propa- gation of the catarrh to the Eustachian tubes. I do not say that 364 DOTHINENTERIA. the deafness is the cause of these patients recovering; but simply that I have rarely seen dothinenteric patients die who had been deaf on both sides. Without being able to explain this clinical fact any better than those who have stated it before me, I state it to you, and ask you to verify it in your practice. Dothinenteria may at first Simulate Intermittent Fever ; and Marsh {Intermittent] Fever may likewise at the beginning of the attack Simulate Dothinenteria. Gentlemen, there is in bed No. 29 bis of our St. Bernard ward a woman twenty-eight years of age, ill of dothinenteria, whose case up to the fifteenth day presented peculiarities which I must point out to you. This woman has been resident in Paris for the last four years and a half, and up to her present illness, has always enjoyed good health. One day, without any known cause, she had a feeling of a sort of feebleness. Next day, she sat down as usual to her needlework, going to the shop where she worked, although she experienced a certain degree of discomfort, and had less ap- petite than usual. She tried to eat, but digestion was difficult. This condition continued for five days, and was accompanied by weariness and pains in the limbs, some pain in the loins, nausea, several fits of vomiting, and a very constipated state of the bowels. She stated that once in two days, she had had, about four o'clock in the afternoon, an attack of shivering followed by heat and then by sweating; and she informed us that these paroxysms of fever soon came on every day, assuming a double-tertian type, a fact which she indicated by mentioning that they were more violent one day than another. She was a native of Champagne; and had never had intermittent fever. When she entered the Hotel- Dieu, on the 1 ith June, she stated that she had been so ill since the 4th as to be obliged to keep her bed, and discontinue her occu- pations. When I saw her for the first time, she had very moderate fever, but on the previous afternoon the fever had been very high; and every evening it returned. There was enlargement of the spleen, which extended several finger breadths beyond the false ribs. There was obstinate constipation. The day after the patient's arrival, a mild purgative was prescribed. On the third day, the DOTHINENTERIA. 365 fever was continuous. There was no diarrhoea, but the tongue was red, clammy, and coated with a thin dirty fur. On the fourth day—the sixteenth from the beginning of the disease—we found rosy lenticular spots on the abdomen, and one of the same spots afterwards appeared on the face. This fever which began as an intermittent, at first tertian and then double-tertian, became remit- tent and then continued, and was in point of fact an exceedingly well-marked case of dothinenteria. There is no novelty, gentlemen, in this case. Those who have read the writings of physicians of past ages know that those great masters of the healing art were struck with similar cases, which you will find recorded in the works of Sydenham, Morton, Huxham, Yan Swieten, Stoll and many others. While they pointed them out, however, they did not explain them as I do: they saw in them a transformation of intermittent into putrid continued fever, produced under the influence of bad diet, and bad treatment, when, for example, cinchona had been given too soon, in too great quantity, or for too long a time. Now, as I pointed out to you, when speaking of intestinal catarrh, in particular circumstances, whilst one morbid cause is acting upon an individual, and has already affected him with a disease, a new malady may supervene and place its stamp upon that which previously existed; but this is not trans- formation, and, correctly speaking, there is no such thing as a real transformation of one disease into another. We can in this way understand the mistake of those illustrious practitioners of whom, in spite of their errors, we must say what Eontaine said of the poets:—“We cannot go in advance of the ancients : they have left us only the glory of following them well.” In point of fact, gentlemen, the great masters of whom I speak— less informed than the moderns in the detailed information fur- nished by pathological anatomy, ignorant of means of investigation which we possess, such as auscultation, brought all at once to a very high degree of perfection by Lsennec its inventor—the Sydenhams, the Yan Swietens, the Stolls, and a host of others, inspecting nature with scrupulous attention, knew the patient better than we know him, though we know better how to make the diagnosis of the lesion. Bead the magnificent descriptions which they have given us; and when they refer to diseases of which all the manifestations were accessible to their observation, I doubt whether you will find in modern authors anything to compare to them. Even when some 366 DOTHINENTERIA. features are wanting in the picture, still, with what vigour is the sketch drawn! Guided alone, however, by the phenomena which they observed with marvellous sagacity, they could not avoid falling, and in point of fact did fall, into inevitable errors. Thus, with respect to typhoid fever, which they saw presenting itself with very different symptoms, they found themselves under the necessity of making as many species as there are forms of the disease: they were unable to gather them up into one bundle, which Bretonneau accomplished when he discovered that whatever other symptoms might be present in typhoid fever, there was one lesion which was characteristic and constantly met with. If our early predecessors had found the specific intestinal eruption, they would have had like us their testing sign to distinguish the disease in a precise and positive manner; they would have avoided confusion; they would no more have mistaken dothinenteria under its different aspects, than they would have mistaken small-pox, scarlatina, or measles. But since their day, how many steps has it taken to arrive at the truth! Prost, in his work, published in 1804, entitled “La Medecine Eclairee par V Ouverture des Corps ” was first: he described, upon the whole, very well, some of the alterations of tissue peculiar to dothinenteria, the ulcerations which he met with being in his opinion the last stage of a phlogosis, of which the first stage was redness : afterwards, finding this redness in the intestines of all persons dying from different diseases, provided they were not ansemic, he concluded that intestinal inflammation was almost always the cause of death, a false notion, which at a later period was taken up by Broussais, and gave birth to the celebrated doctrine of the Val-de-Grace, entirely founded on a heresy in pathological anatomy. Seven years after the treatise of Prost, MM. Petit and Serres wrote their work—“ TraitSde la Fievre E?itero-mesenterique —they advanced a little nearer to a conception of the truth, by establishing the specific character of the intestinal lesion, which they very justly compared to small-pox or cow-pox ; but they were still far from grasping the true bearing of the facts, for, not realising what was due to the progress of the eruption, and not perceiving that the lesion varies in appearance according to the stage of the disease, they recognised three varieties of the fever, viz., the simple, the papular, and the ulcerous. Then came the remark- able labours of Bretonneau, which shed a perfectly new light upon DOTHINENTERIA. 367 the history of fevers, and by using which no one in the present day can be deceived. Dothinenteria being in the present day characterised in an exact manner, we have nothing to do with the transmutations which our predecessors were in the habit of pointing out: we no longer see intermittent fevers change into putrid fevers, though we observe that under certain circumstances the latter at their commencement assume the aspect of the former. It often happens that on interrogating and attentively examining the patient, we find a more or less con- spicuous group of symptoms not met with in marsh fevers, and commonly occurring in continued putrid fevers, which put us on the way to a correct diagnosis. To such groups of symptoms belong headache, insomnia, and vertigo; also, softness of the pulse, tendency to diarrhoea, and gurgling in the right iliac fossa brought on by pressure over the part. Besides, after the first paroxysms, the type itself of the fever assists in clearing up the nature of the case. The further we are from the onset of the disease, the shorter is the interval between the paroxysms: at first, there is a paroxysm of fever once in two days, then it occurs daily, or the type becomes double-tertian, as in the woman of bed No. 26 bis; then the fever in place of being intermittent is remittent, and so by degrees assumes the continued type, with which at last it is completely invested. Trom the begin- ning, the case is so absolutely dothinenteric, and so removed from the nature of an intermittent transformed into a continued fever, that if the patient were to be carried off about the seventh or eighth day by an accident, before the disease had become permanently invested with its own external characters, the specific intestinal lesion would be seen at the autopsy. Enlargement of the spleen, which occurred in the case I have just described, may lead to an error in diagnosis. Splenic enlargement which exists in nearly all cases of marsh fever, of which indeed it is the anatomical characteristic, is likewise present in nearly all cases of dothinenteria. There is a circumstance which may perhaps serve to distinguish the one from the other : in putrid fever, there is engorgement of the spleen from the beginning of the attack, which often diminishes as the malady goes on, whereas in marsh fever it is at first slight, but increases with each repetition of the febrile paroxysm, till at last it sometimes attains an extraordinary size. It is particularly in districts where marsh fevers are endemic, and in 368 DOTHINENTERIA. persons who have not been long absent from such localities, that we see dothinenteria begin by showing the intermittent type. We had an example of this in a woman who presented at the beginning of the fever symptoms similar to those experienced by the patient who occupied bed 29 bis: she had lived for a long time in a district where intermittent fevers were always prevailing. Change in the type of a fever also occurs in an inverse order; and it is likewise in places poisoned by emanations from marshes that this is observed. A true marsh fever which has at first shown itself with the continued type, and has simulated dothinenteria, soon assumes the regular intermittent type, and, as the case advances, becomes tertian, double-tertian, or quartan. The term “ intermittent” cannot, therefore, be reserved, as is usually the case, to designate only one species of fever, the pheno- menon of intermitting being a very variable sign, and one met with in every kind of fever, as I have just said. Consequently, I think we ought to substitute for the term “intermittent” fever, the term “marsh” or “palustral” fever. Now, marsh fever is just as inca- pable of being transformed into dothinenteria, as is dothinenteria of being transformed into marsh fever; but it is quite necessary to know that changes of type take place. A case of marsh fever, which at the beginning was a strongly marked intermittent, may become continued, though this is not a frequent occurrence; just as a marsh fever may at first be continued, and soon assume in a well marked manner its own intermittent type. Cases collected in the Trench possessions of Africa, (where our military physicians have elucidated this important question), have conclusively shown that marsh fevers undergo these changes of type. Science and art are particularly indebted to Dr. Boudin for having cleared up this point in nosology better than any one who preceded him.1 The malady, then, does not change its nature when it undergoes change of type: under all its different forms, it remains the same marsh fever; and the proof of this is that it is always as necessary in treating it, to have recourse to cinchona (or its substitutes, such as the arsenical preparations lauded by Boudin,) when intermittents become remit- tent, as in those which are continued before they assume their ordinary type. 1 Boudin :—Traite des Fievrcs Intermittcntcs ; 1842.—Traite de Geo- graphic Medicate; Paris, 1857, T. ii, p. 530. 369 DOTHINENTERIA. If then, gentlemen, you are practising in a district where marsh fevers are not endemic, do not be too confident as to the character of the intermittents you meet with, when they are not quartans nor well-marked tertians :—be distrustful of them when they are double- tertians, but particularly when they are quotidians. Before admi- nistering cinchona or sulphate of quinine, wait, and observe whether the type is not going to change : it may not be long till you see the intervals between the paroxysms become shorter and shorter, and the paroxysms become less and less paroxysmal, so that, for example, if during the first three or four days, the rigors continued for an hour accompanied by chattering of the teeth and great discomfort, by the fifth, sixth, or seventh day, they will not last more than half an hour, and by the eighth or ninth day they will be quite transient. But whilst the paroxysm becomes less defined, its duration becomes longer every day, the continued form of fever becomes more and more decided, and very soon dothinenteria is fully characterised. On the other hand, if you are practising in a locality where marsh fevers generally prevail, do not be in a hurry to begin the treat- ment of a malady, which though it commenced with the symptoms of continued fever, may present the paroxysms of a remittent at the end of four or five days. You will probably soon' see the fever assume a well marked paroxysmal character. Though the manner in which the old physicians interpreted the facts was erroneous, the facts themselves were not the less real; and they were right, when, following the precept of Hippocrates, they refrained from interfering with an intermittent till after the seventh paroxysm. By acting thus, you will avoid the risk of being led to believe that you have reduced an incipient dothinenteria to the pro- portions of a regular intermittent fever which can be easily cut short by cinchona, when in reality you have only had to do with a marsh fever which had at first the continued type. On the other hand, if you have a case of mild synocha, such as is so common at Paris, which in the beginning of the attack assumes the intermittent type, and in general terminates spontaneously in recovery, you will not make the mistake of supposing that you have cured a real inter- mittent fever, whether it be with cinchona or the sulphate of quinine, or with pretended febrifuges such as the bark of the horse chesnut, table-salt, &c. recently extolled, and which owe their appa- rently successful results to the fact of their having been administered in cases similar to those of which I am now speaking. Finally, 370 DOTHINENTERIA. when you perceive that you have to do with a case of dothinenteria, exhibiting at the outset the phenomena of intermittent fever, you will not have to take blame to yourself for having had recourse to unsuitable treatment, nor will you accuse cinchona of having changed a fever which is not generally serious into a formidable disease. Contagion.—Conditions under which Dothinenteria occurs. Opinions, gentlemen, are still divided on the question of the contagiousness of dothinenteria, but the number of the disbelievers in contagion is daily diminishing. We cannot attain the solution of so complex a problem in Paris, where, as in all large towns, we want the information necessary to enable us to trace cases up to their origin. The question has, however, been answered by physicians practising in small places, where it is easy to know the patient who was first seized. It is, therefore, to physicians who are so situated that the question has to be put. On examining the reports annually received by the Academy upon. epidemics prevailing in the departments, one becomes con- vinced that the contagious character of typhoid fever is among the ascertained facts of science. So far back as 1829, the fact wras announced by Bretonneau, by Gendron of Chateau-du-Loir, and by Leuret: it was repeatedly confirmed by Letanelet, Lombard, Mayer, and Thirial, and more recently by Piedvache, Letenneur, Ragaine of Mortagne, and many others. Without seeking to accumulate further proofs in support of my proposition, I will confine myself to making you acquainted with some characteristic facts, which have already been placed before the Academy in the report I was commissioned to present on the epi- demics which prevailed in Prance in 1857. By quoting exactly the narrative of the observers themselves, we shall be better enabled to see the degree in which the term contagion is applicable to the trans- mission of dothinenteria. The importation of the disease into the locality where it is spreading, by an inhabitant who has contracted it elsewhere, can almost always be made out, if the circumstances are carefully inquired into. When the malady is once installed, its propagation goes on by a series of transmissions, which are some- times very easy, and at other times impossible, to follow. DOTHINENTERIA, 371 At Maylargues, in the department of Lot, according to the report of Dr. Mayneur, there arrived about the end of November 1856, a soldier discharged from the army of Africa : a month afterwards, he died of typhoid fever. Towards the close of his illness, a woman, a neighbour who had attended upon him with the most careful assi- duity, took the same disease, and died. A brother of the soldier, aged sixteen, also died of it on the 6th of March. Two of his sisters, in the same month, contracted the disease successively, and reco- vered after tedious convalescence. The female neighbour whom I have mentioned, communicated the disease to a son, aged seventeen, who died on the 32nd of May. In a short time after this, the fever struck down so many people, that it became impossible to follow its progress. Dr. Moussillac states that typhoid fever was imported to Carriol (Gironde) by a young workman, a cooper, who came home sick to his relations. The family, consisting of seven individuals, lived in a large well-ventilated house : they all took the disease in a severe form, and three of them died of it. The disease radiated from that centre, showing itself in persons in communication with those affected; and the persons so contracting it, by removing to other and sometimes distant localities, took it with them to places where it had not previously appeared. The epidemic of the arrondissement of Ambert (Puy-de-D6me), observed by Dr. Mavel, seems to have originated in a manufactory. The house-servant fell ill on the nth July : he was taken to his home in a village, distant two kilometers, where he was attended by his wife: he recovered. His wife took the fever, and died. A sister-in-law and an uncle, both of whom had waited on him, con- tracted the disease, and died of it. Soon afterwards, every house in the village had cases of typhoid fever. A woman, who "was cook in the factory, and her sister, who was a work-woman there, upon feeling the first symptoms of the disease, were taken home to their family, a distance of five kilometers : one died, and the other reco- vered. The malady soon spread in their village; and one of the villagers who took the disease, having been removed to his home at a little distance, marked by his arrival the beginning of the epidemic in that place. On the 31st May 1857, says Dr. Pourrier, I was called to Audon- le-Romain (Moselle) to a young man of twenty, who had arrived from Paris, where he had been unwell for some days. He had all 372 KOTHINENTEllIA. the symptoms of typhoid fever, and the intestinal affection was very acute. Companions who came to see him were, after him, my first patients j and subsequently, his father, brother, and two sisters were successively struck down by the disease. So long as field- work kept the inhabitants of Audon away from their dwellings, the fever, though scattered about in the village, remained limited to a small number of individuals; but when harvest was finished, and the people remained constantly with the sick, a general infection of the community took place, and at one time, among the 442 inhabi- tants, there were 40 cases. A workman of Anderny went to work at Audon during August: he there contracted the disease, and on his return home gave it to his wife and father-in-law7. Up to his return, there had been no cases of typhoid fever in Anderny. A man, aged sixty, went on business to Audon, and notwithstanding of his advanced age, took typhoid fever on returning to the village wThere he resided. When he had been ill for fifteen days, his son aged twenty, took the disease, and soon afterwards two daughters aged respectively seven- teen and thirteen. If, adds Dr. Founder, people are so sceptical as to see nothing more than coincidence in all this, I ask wrherein will they see the relation of cause to effect ? Dr. Keignier mentions the following circumstances. On the 29th July, 1855, a girl aged twrenty-four, called Theobald (de Trombern) experienced the first symptoms of an attack stated by a physician to be typhoid fever. The Theobald family wras in easy cir- cumstances in the village : the most assiduous cares were adopted with a view to overcome the disease; and at the end of six weeks, the patient v7as re-established in health. This remained an isolated case for eight days : a second case then occurred in the next house : some days later, there were new cases in another house : but none of the persons affected had had any communication with the girl Theobald. The contagious character of the epidemic afterwards became wrell marked. It is worthy of notice that the earliest case of the disease occurred in the first house of the village on the north- eastern side, and that the subsequent cases appeared in order of suc- cession from house to house, till the opposite or south-western extremity was reached. A boy, twelve years of age, cow-herd to the mayor of Bievres (Aisne), whose wife and daughters successively had had typhoid fever, contracted it, and brought it with him to his village, Orgeval, distant three kilometers, and wiiere there had been no case of the DOTHINENTERIA. 373 kind. He there communicated it, to a female relation who waited on him, and she gave it to another female relative who came from the other end of the village to assist her. From that time, typhoid fever spread in the village. Nor was that all: a young man, em- ployed as a servant in the house at Orgeval, took the disease, was sent to his home, a distance of six kilometers, whither he carried the disease, which became epidemic in the place. This case and others of the same kind are mentioned by Dr. Pierme, a resident practitioner under whose observation they occurred. At Chamouille, in the same department, Dr. Guipon who observed the disease with scrupulous exactitude from the beginning of its outbreak, has published an account of the epidemic accompanied by an ingeniously expressive little map of the localities. A young man, Louis Meurice, took typhoid fever, without any known cause, between the 26th June and the 13th July 1857. His aunt, living at Bertrand’s mill, two kilometers from Chamouille, brought the dis- ease into her house, where her husband and three children took it in succession between the end of July and 1st October. The woman died; and on her death one of the sick children was taken to Cha- mouille, to the house of a woman called Millepas, forty-five years of age, who after attending on the child, took the fever, and was under treatment from the 15th September to the 1st October. Eight days afterwards, a woman, her neighbour, took to her bed. On the 17th September, a woman of the name of Deguay, aged forty, who had attended upon the patients at the mill, contracted the fever, and suffered under it from the 17th October to the 3rd No- vember. Two months after its first appearance in Chamouille, the fever became epidemic there. In a population of 224, there were 27 attacked. Similar facts were observed in the epidemics of 1856. Typhoid fever was carried to a hamlet in the department of Loir-et-Cher, by a young man who went there to be attended upon by his family. His father and mother, two brothers, a sister, and the house-servant, all of whom were almost constantly with him, con- tracted the disease: the sister and the servant died. The young man, who was a servant at Pont-Levoy, was succeeded in his service by a person who was lodged in the room which his predecessor had left: in a short time he also took the disease. M. Yvonneau, who gives these details, traced out with praiseworthy care the history of the spread of the fever within these narrow limits of the epi- 374 DOTHINENTERIA. demic, and the documents which he has furnished on the subject may be profitably consulted. At Paris even, unexceptionable facts of the same description have been pointed out; and one was recently communicated to me by Dr. Pirmin, under whose observation it came. M. de G., aged twenty-four, employed in the service of the Western It ail way took fever at Batignolles. He was removed to his brother's house in the rue Suresnes, where he was waited upon by his mother, who was recalled to Paris, after an absence of twro months, to attend upon him. On the twenty-second day, this lady felt the pains, lassitude, and prostration characteristic of the beginning of the fever, and she very soon had all the symptoms of thoroughly con- firmed dothinenteria. Prom the examples I have now given, the contagious nature of dothinenteria is incontestable. When in opposition to these positive facts, negative facts are adduced, and an exaggerated importance is assigned to them; when we are asked to explain why it is so rare to see persons contract the disease in our hospital wards from the patients who have it; when we are referred for example to the state- ment that of 439 cases observed at the Hotel-Dieu by Chomel and Louis only 10 began in the hospital—we mention, among other possible explanations, that the individuals who thus escaped may at some former time, have had the disease. An explanation of a more general character consists in the admission which must perhaps be made, that the energy of the contagium is less when cases are only occurring sporadically, than when typhoid fever is prevailing as an epidemic. As it is frequently impossible, notwithstanding the most pains- taking researches, to discover the origin of the contagion, and as it is obvious that typhoid fever at some time or another had a beginning, wre cannot refuse to admit the possibility of its arising spon- taneously, although we hold that it is a contagious disease. Let us see then under what conditions it is developed. Some of the condi- tions must be sought in the individual himself, and others external to him. The first are the exciting causes, the chief of which is contagion, the second are the predisposing causes. Both classes of causes are difficult of recognition. Were I to discuss the influence of an atmosphere vitiated by putrid emanations, the influence of spoiled articles of food and contaminated drinks, I should be occupy- ing your time with trivialities, because these are nothing more than DOTHINENTERIA. 375 hypothetical causes. I will pass over these topics as well as the influence of mental emotions, excessive fatigue, constitution, tem- perament, which have great importance in the opinion of many, and briefly consider the influence of age, overcrowding, and accli- matisation. Dothinenteria is a disease of adolescence and youth. However, it is not so unusual as was long supposed for it to attack children, and even those of a very early age. At Paris, and in other places where the disease is endemic, it is very frequently met with in childhood: there are cases mentioned in which it occurred in children between two and seven months: and the nearer we come to the age of puberty, the more common is dothinenteria. In my own family, my daughter's three children had it. The disease is generally milder before than after puberty : still, even in childhood the disease often terminates fatally, and I lately saw a little girl of five and a half die of it after having been ill for little more than twenty days. Between the ages of eight and fourteen, dothinenteria becomes more common; and it is between the ages of fourteen and thirty that persons usually contract typhoid fever. You have remarked that in the different epidemics of which I have been speaking, cases were mentioned in which the patients were forty and forty-five years of age: you recollect the case of a woman of sixty-four, who died of intestinal haemorrhage, and at whose autopsy we found dothinenteric ulceration. MM. Lombard and Fauconnet of Geneva have recorded similar ages of typhoid fever patients, and they even mention a case which proved fatal in a man of seventy, at whose autopsy they found the characteristic lesions of the Peyerian patches. Dothinenteria then, does not spare old people, though it is not a common disease in advanced life. If overcrowding does not of itself engender the disease, it is at least a powerful auxiliary in producing it, as it favours contagion, increases the severity of the attack, and is even the cause of its assuming the most deadly epidemic character. In respect of acclimatisation, you have had an opportunity in our own patients of verifying a fact to which the attention of physicians has long been directed, viz. that persons coming to Paris from the provinces are very often attacked with typhoid fever soon after their arrival. In the cases registered during the first six months of this year, you will see it noted that a very small number of our patients belonged to Paris, and that those who did, had lived in it only for 376 DOTHINENTERIA. periods of seven years, six years, four years, two years, eight months, five months and two months. But if we bear in mind that what is observed in dothinenteria is likewise observed in small-pox, and scarlatina, we shall be less inclined to consider non-acclimatisation as a predisposing cause. We shall recollect that among the numerous young persons of both sexes who ceaselessly crowd to Paris, some to complete their education, the majority to pursue occupations of many kinds, the greatest num- ber, having lived in country places where typhoid fever only prevails at occasional intervals, have not paid their tribute to the disease, and are consequently in a condition to become immediately subject to the influence of the contagion, wdiich they everywhere encounter in a populous city where the disease is in permanence. I have already told you, that if adults born in Paris take the disease less frequently than new comers, it is because the former have generally had dothin- enteria during childhood or early adolescence. I will conclude what I have to say on the etiology of typhoid fever by mentioning a curious fact first pointed out by Dr. Louis le Cottier, a physician at Mazieres. Pie says that typhoid fever, within forty years, broke out as an epidemic three times among the inha- bitants of the farm of Haut-Verger in the commune of Chapelle- Baton (Deux-Sevres), and upon each occasion, the outbreak oc- curred after the cutting down of a wood upon the outskirts of which the farm house is situated.1 Though I cannot explain this fact, I do not consider it the less deserving of being here mentioned. Treatment of Dothinenteria.—Regimen of the Patients. Gentlemen, you observe that in a great number of cases of dothinenteria, I remain almost passive. When it follows its natural course, when the symptoms and special complications do not demand active measures, my treatment is limited to prescribing infusion of camomille as a tisane, acidulated drinks such as lemonade or orangeade, and water sweetened with gooseberry or cherry syrup. The intervention of art is generally useless in the eruptive fevers, to which dothinenteria presents striking analogies. Their pro- gress is but very slightly modified by the available resources of medicine. When the cases are mild, recovery takes place sponta- 1 See the Union Medicate, for 5th January, 1858. DOTHINENTERIA. 377 neously • and a judicious physician will avoid disturbing the cura- tive efforts of nature by unseasonable meddling. On the other hand, when the cases are severe, the disease often shows threatening tendencies as it advances, and then our interference may be of real benefit. But such fortunate occasions are more frequently met with in scarlatina, measles, and small-pox than in dothinenteria, yet in all of them we are most commonly obliged to recognise our im- potence and submit to consequences which we cannot prevent. Indications for recourse to active treatment present themselves, however, much more frequently in dothinenteria than in the other eruptive fevers. This arises from the circumstance that dothinen- teria, much less precisely characterised, much less distinct in its symptoms than is generally the case iu scarlatina and measles, and still more in small-pox, is accompanied much oftener than they are by manifestations which, while they do not take away any- thing from its nature, impart to it that great diversity of form which I have pointed out, and against which we have to contend : it also arises from the various forms, even the mildest, being subject to local complications of greater or less severity, which play an im- portant part in the course of the disease. In speaking of the adynamic and ataxic forms, I stated that in the former, the efforts of the physician ought to be directed to the support of the failing powers of nature, and that as the therapeutic indication is to promote reaction, it is necessary to have recourse to stimulants and tonics: I at the same time entered into some details. With reference to the ataxic form, I said that cold affusions were decidedly useful in moderating the excitement and irregularity of action in the nervous system. I have already explained my treatment of intestinal haemorrhage. When there is very severe bronchitis, or when there is pneumonia, I give antimonials, and I produce counter-irritation of the skin, by applying a lotion of the tincture of iodine. This is a powerful counter-irritant, and one the effects of which can be regulated : it has not, moreover, the inconveniences of a blister, which sometimes, as you know, gives rise to a gangrenous sore. I have still to recapitulate the measures I pursue in ordinary cases, particularly in respect of diet, not only the diet during the course of the disease, but likewise in convalescence. I look upon dietetic management as the chief feature in the treatment, and I attribute the success which I have had in typhoid fever to the 378 DOTHINENTERIA. dietetic plan which I follow. So much importance do I attach to dothinenteric patients having proper food, that it is by dietetic means, aided by medicines, that I endeavour to subdue the symp- toms referable to the digestive canal, and to regulate its functions as much as possible. It is in this way that I moderate profuse diar- rhoea, correct obstinate constipation, modify a suburral condition, and restore impaired appetite. When the bilious or suburral condition is very decided, you have seen me begin by giving ipecacuan as an emetic. I generally pre- scribe three grammes of the powder divided into three equal parts, directing one to be taken every ten minutes till vomiting is induced. This treatment not only modifies the suburral state, but likewise exercises a beneficial influence on the diarrhoea. When the stools are excessive both in number and in quantity, I usually begin by ordering a saline purgative:—for example, 25 or 30 grammes of the sulphate of soda, or of the tartrate of potash and soda, medicines which probably act beneficially by modifying the intestinal secretions. This treatment is particularly indicated in cases in which the diarrhoea is accompanied by a certain degree of meteorism: in such cases, the saline purgative may with great advantage be repeated several times. When I do not succeed in thus obtaining the expected modification of the intestinal secretions, I prescribe what are called absorbent powders. One of these powders, containing 50 centigrammes of subnitrate of bismuth and an equal quantity of prepared chalk, may be given with benefit from three to eight times in the twenty-four hours, the frequency of the repe- tition being regulated by tlm severity and obstinacy of the symptoms. I also often give the English mixture, which I thus formulate:— Prepared chalk, 30 grammes, Syrup of orange peel, 30 „ Water, 90 „ I also frequently order the powder of Columbo root in doses of 50 centigrammes up to a gramme. Finally, when these prescrip- tions prove ineffectual, I have recourse to more energetic alteratives. I then prescribe 5 centigrammes of nitrate of silver,1 to be taken in five doses, at intervals of an hour. The following is my formula Crystallized nitrate of silver, 5 centigrammes, Water, a quantity sufficient to dissolve the nitrate. 1 Five centigrammes—that is, five hundredths of a gramme—are about five sevenths of a British grain.—Translator. DOTHINENTERIA. 379 Add to this solution, enough of crumb of bread to make a mass, and then divide the mass into five pills of equal size. If, as sometimes happens, there is constipation in place of diar- rhoea, I open the bowels by giving ten or fifteen grammes of castor oil, a purgative which in the circumstances is very much to be preferred to the neutral salts, the operation of which is soon over, and is succeeded by a tendency to confinement, an inconvenience which does not attend the employment of castor oil. When the con- stipation does not yield to castor oil, I prescribe 5 centigrammes of calomel in the form of pastel, and a gramme of the powder of jalap, the latter to be taken a quarter of an hour after the former. If, notwithstanding this treatment, the constipation still continue, I repeat the calomel, and in place of giving jalap after - it, I give ten grammes of senna in the form of a very concentrated infusion, mixed with infusion of roasted coffee. Generally, howrever, the regular evacuation of the bowels, and also the removal of meteorism when present, may be accomplished by the patient taking daily, night and morning, a lavement of infu- sion of camomile. In the mucous form of dothinenteria, which is sometimes very tedious, you have seen me stimulate the appetite by administering bitters, such as the decoction of quassia, cinchona, &c. and prepa- rations of strychnia, such as 5 centigrammes of the powder of nux vomica, or some of the bitter tincture of Baume, which derives its stimulating properties from St. Ignatius' bean. According to the nature of the case, the patient may take one, two, or three drops of this tincture immediately before his soup. I now come to the subject of diet. Perhaps, gentlemen, it has seemed strange to you that I should insist so positively upon the necessity of giving nutriment to dothinenteric patients, not merely as most of my colleagues now do, at a somewhat advanced period of the attack, when the -fever is moderate and the tongue less coated, that is to say towards the end of the first or beginning of the second week, but from the very commencement, and during the whole course of the malady. In point of fact, I require my dothinenteric patients, from the very first, to take daily two small portions of a soup made without meat, and also some tablespoonfuls of meat broth, dis- regarding the repugnance to food which some patients show, and without being deterred even when there is vomiting, which is apparently a contra-indication of feeding. In cases where there is vomiting, 380 DOTHINENTERIA. I advise that broths made with and without meat should be given daily in such quantities as can be borne. This practice is now recommended by a great number of the hospital physicians of Paris, as was shown by an interesting discus- sion on the subject in the Societe de Medecine des Hopitaux, in October 1857, in which I asked to take part, with men whose opinion is of undoubted weight. Some of these gentlemen, my honourable professional brethren Drs. Legroux and Barth for in- stance, do not allow their patients to have nourishing diet till about the eighth day, while Drs. Aran, Behier, and others entertain views similar to my own, and force their dothinenteric patients to take food from the beginning of the attack. In this discussion, Dr. Cahen, judiciously appealing to the experiments of Chossat on inanition, pointed out that medical observation and physiological experiment entirely agree in showing that very low diet is injurious in diseases of long duration. Chossat had indeed seen that entire abstinence caused the body to lose forty-two thousandth parts of its wreight, and that death was the inevitable result when the loss amounted to four tenths of the original weight. Mr. Cahen says that in typhoid fever we see great loss of flesh rapidly supervene, and that it even proceeds to emaciation. He asks wdiether it is not probable that death in these cases is less the result of the pro- gress of the disease, than of wasting of the body having reached a point incompatible with the continuance of life. In these cases, the individual feeds upon his own body, and it is with a view to prevent this autophagy, which brings either death or very dangerous symptoms in its train; it is to support the system in its struggle with an exhausting disease of long duration, that there is a paramount necessity of vigorously prescribing suitable food. I say suitable food; for while the low diet to which patients were condemned when medical practice was ruled by the deplorable doctrines in vogue at the beginning of the century, while a ridicu- lous abstinence from food is productive of the evils which I have pointed out, care must be taken not to fall into the opposite extreme of those wdio are not afraid to give solid food at the beginning and during the course of continued fevers. There is a great distance in the dietetic scale between the broths and light soups which I declare to be indispensable—between the tenuis victus as Hippo- crates called that famous diet-drink, barley-water—and the minced DOTHINENTERIA. 381 butcher-meat which some physicians compel their unfortunate patients to swallow. “ Opportunism medicamentum est opportune c'lbus datuswrote Celsus; and “ in alimentis medicamenta sunt ” repeated Aretseus. The doctrine which I maintain is as old as medicine itself. Prom the time of Hippocrates—who devoted a book to the subject—to our own day, the great practitioners of the past have always at- tached much importance to dietetics, which they have looked on as embracing the most powerful therapeutic resources of our art. Morton says that with the assistance of food well regulated from the beginning of the attack, he has seen fevers cured by the efforts of nature, without any recourse having been necessary to the pom- pous arsenal of pharmacy; while cases which at first were mild have become malignant under a repetition of copious bleedings, and the abuse of emetics and cathartics. Permit me, gentlemen, to fortify my opinions on this subject by the authority of Graves, a man whom I regard as the most emi- nent clinical teacher of our age, whom I delight to quote, whom I constantly consult, and whose work ought to be your vade-mecum. Allow me also to appeal to the authority of a man who, in our own Prance, has equalled the illustrious physician of Dublin, and who has left behind him the light of a brilliant career : need I say, that I refer to Bretonneau! These two illustrious physicians may, to a certain extent, be said to have passed their youth in con- tending against the abuse of abstinence from food in fevers; and to them is chiefly due emancipation from the yoke of prejudice imposed on practitioners, by the school of Broussais, to the great detriment of patients. Allow me then, gentlemen, to translate some paragraphs of Graves upon the subject now before us :— “ In a disease like fever, which lasts frequently for fourteen, twenty-one, or more days, the consideration of diet and nutriment is a matter of importance; and I am persuaded that this is a point on which much error has prevailed. I am convinced that the starving system has in many instances been carried to a dangerous excess, and that many persons have fallen victims to prolonged abstinence in fever. * * * Let us examine the results of protracted abstinence in the healthy state of the system. Take a healthy person, and deprive him of food! What is the consequence? 382 DOTHINENTERIA. First, hunger, which after some time goes away, and then returns again. After two or three days, the sensation assumes a morbid character, and instead of being a simple feeling of want and a desire for food, it becomes a disordered craving attended with dragging pain in the stomach, burning thirst, and some time afterwards, epigastric tenderness, fever, and delirium. Here we have the super- vention of gastric disease, and inflammation of the brain as the results of protracted starvation.” “ Read the accounts of those who perished from starvation after the wreck of the Medusa and Alceste, and you will be struck with the horrible consequences of protracted hunger. You will find that most of the unhappy sufferers were raging maniacs, and exhibited symptoms of violent cerebral irritation. Now, in a person labouring under the effects of fever and protracted abstinence—whose sensi- bilities are blunted and whose functions are deranged—it is not at all improbable that such a person, perhaps also suffering from delirium and stupor, will not call for food, though requiring it; and that if you do not press it on him, and give it as medicine, symptoms like those which arise from starvation in the healthy sub- ject may supervene, and you may have gastro-enteric inflammation, or cerebral disease, as the consequence of protracted abstinence. You may, perhaps, think that it is unnecessary to give food, as the patient appears to have no appetite, and does not care for it. You might as well allow the urine to accumulate in the bladder, because the patient feels no desire to pass it. You are called on to interfere where the sensibility is impaired, and the natural appetite is dormant; and you are not to permit your patient to encounter the horrible consequences of inanition, because he does not ask for nutriment. I never do so. After the third or fourth day of fever, I always pre- scribe mild nourishment, and this is steadily and perseveringly con- tinued through the whole course of the disease.” “ Again, let us see how close a resemblance the symptoms gene- rated by long continued denial or want of food bear to those which are observed in the worst forms of typhus. Pains of the stomach, epigastric tenderness, thirst, vomiting, determination of blood to the brain, suffusion of the eyes, headache, sleeplessness, and, finally furious delirium, are the symptoms of protracted abstinence, and to these we may add tendency to putrefaction of the animal tissues, chiefly shown by the spontaneous occurrence of gangrene of the lungs. It has been shown by M. Guislain, physician to the hospital DOTH1NENTERIA. 383 for the insane at Ghent, that in many instances gangrene of the lung has occurred in insane patients who have obstinately refused to take food. Out of thirteen patients who died of inanition, nine had gan- grene of the lungs. * * * * It is not, therefore, wrong to suppose that when a system of rigorous abstinence has been observed in fever, and when food has been too long withheld, because, forsooth, the patient does not call for it, and because his natural sensibilities are blunted and impaired—it is not, I say, unreasonable to infer that gastric, cerebral, and even pulmonary symptoms may supervene, analogous to those which result from actual starvation.”1 Gentlemen, I require to add nothing to these true and eloquent paragraphs of Graves, who said to his pupils :—“ If you are at a loss for an epitaph to inscribe on my tomb, you may use these words—He Ted Tevers.” 2 We are not, however, prevented from inquiring into the causes of the terrible symptoms produced by inanition. The normal constitution of the blood is the condition under which all the processes of interstitial nutrition take place, and good nutri- tion is the condition essential to the performance of the functions assigned to the different organs. It is by alimentation that the blood is renewed; and whenever there is a deficiency from that source in the elements required for the reconstitution of the blood, the nutritive processes are carried on at the expense of the materials of the living organism. The animal will then live upon itself; and as it will be unable to derive from its own substance all the elements requisite for sanguineous renewal, the quality of the blood will forthwith become anomalous, and the organs which the blood is designed to restore, will themselves become fundamentally altered in structure. The organs being thus altered, will supply the already altered blood with elements still inferior; and thus there will be established a vicious circle—the circle of autojghagy as Bretonneau called it—a circle in which the disorganisation of the blood and the tissues goes on constantly increasing, till it ultimately attains a point 1 Graves :—Clinical Lectures on the Practice of Medicine. Second edition, edited by J. M. Neligan, M.D. Two volumes. Lublin: 1848. Yol. i, p. 117 —119. The quotation in the text is an exact reprint from the work of Dr. Graves —not a translation of Dr. Trousseau’s Trench version.—Translator. 3 Quoted at p. 253 of Dr. Murchison’s work. 384 DOTHINENTEllIA. at which the functions, which, at first were merely disturbed, become completely deranged and disassociated, death constituting the climax of this gradual destruction of the economy. The most essential part of the treatment, then, is to give nutri- ment. We must observe the state of the patient with respect to strength, so that we may be able to put him into a condition to resist the fever by which he is being devoured: according to the degree of weakness, and according to the supposed duration of the disease, it is necessary to give food more or less frequently, but always in small quantity, and in the liquid form. The age, tem- perament, and habits of the patient, ought also to be taken into consideration, as is remarked by Jodocus Lommius in his little tract “ Be curanclis febrihus continuis,” a work several chapters of which are devoted to the consideration of the diet suitable to the different periods of the disease. Although I lay particular stress upon regular feeding in dothiu- enteria, although, as you have seen every day, I oblige the patient to take light soups, I also wait longer than others before I allow him to return to a more substantial diet. At the decline of the fever, some of my professional brethren, discontinuing the low diet which they had imposed up to that period, allow solid food to be taken; but I insist at that period upon the necessity of restricting the patients to light farinaceous food, and during convalescence (even when it is fairly established), I am among those who keep them on the shortest commons. Having been careful to maintain the strength during the whole course of the malady, however long its duration may have been, I have nothing to fear in my patients from the disastrous consequences of abstinence and inanition; and can more easily protect them from the unfavourable occurrences to which they continue liable at the very time that they suppose their recovery to be complete. I thus avoid bringing on attacks of indigestion, which, though they may not cause serious gastro-intestinal mischief, nor (as sometimes hap- pens) fatal peritonitis, may nevertheless lead to relapses, or may retard restoration to health. During the convalescence of dothin- enteric patients, it is, therefore absolutely necessary to resist their demands for food, when, as is usually the case, they have a craving appetite. There are cases, however, in which it is requisite during conva- lescence, to return quickly to a very substantial and very tonic kind DOTHINENTERIA. 385 of feeding, proceeding always with extreme caution. That is the period during which occur the symptoms of which I am now going to speak, and which are most frequently met with in persons exhausted by a rigorously low diet, or by haemorrhages. Affections u’/iic/i occur during Convalescence.— Gastric Disturbance. — Vomiting. —Diarrhoea.—Nervous Symptoms.— Vertigo.—De- lirium. — Impaired Mental Power. — Paralysis. — Dropsical Effusions. The convalescence from typhoid fever is sometimes interrupted by gastric disorders, which, unless very carefully attended to, may deceive the physician from their seeming to demand treatment the very opposite of that which they really require. I refer to vomiting and diarrhoea, both particularly apt to occur in those who have been reduced by starvation. It seems as if the stomach and intestines, having forgotten how to perform their allotted functions, can digest nothing. The smallest quantity of liquid food, or even of tisane, is at once rejected by the mouth; and there is a notable increase in the number of the alvine evacuations. The patients are exceedingly weak, their circulation is languid, and their temperature is perceptibly lowered. Not only are the liquid ingesta vomited, but there is regurgitation of mucous and bilious matter of a colour successively varying from yellow to apple-green, bottle-green, leek-green, greenish-blue, or even pure blue. Under the belief that the powers of the stomach are inadequate, and that the symptoms are the result of gastritis, the use of every kind of food is suspended : the patient is given skimmed milk, chicken-broth, and mucilaginous drinks, which, far from calming the disorder of the functions, increase it. When I come to speak of dyspepsia, and its different forms, I will tell you that gastritis, regarding which so much that is erroneous has been stated, is a rare disease; and that, on the contrary, the food apparently most calculated to excite inflammation of the stomach is that which is most easily borne. I now refer to symptoms connected with the nervous system, to disorder of the function of secretion, the best means of subduing which is to give solid food. In these cases, it is not broths and soups that one must prescribe, but grilled or roasted meat in small quantities, fermented liquors, and good old wine in moderation. In some cases, eating what are called heavy kinds of meat, such as pork, is the only means of subduing obstinate vomit- BOTHINENTERIA. ing. Under the influence of this regimen, the digestive canal by- degrees recovers its tone, and soon digests as before: the vomiting stops, and the diarrhoea gradually ceases. But, gentlemen, beware of mistaking the symptoms of which I have been speaking for the relapses which occur from errors in diet. In the latter, there is real indigestion. The fever also is rekindled, the stupor recommences, the exanthematous spots reappear on the skin, and (as in cases which I have described to you) the dothin- enteria seems to take a new start. In such circumstances, it would be exceedingly dangerous to insist upon feeding the patients with nutritious aliment. On the contrary, it is necessary for some days to subject them to a rigorous low diet—to restrict them to emollient drinks and farinaceous food; to give chalk and bismuth; and to wait till the storm is past, before returning to a more generous diet. Vertigo dependent on autophagij is more common than the other pathological phenomenon of which I have just been speaking. I will not, however, at present stop to consider it, but will reserve what I have to say regarding it till a future occasion, when I shall have to discuss the general subject of vertigo arising from disordered digestion. But delirium is, of all the nervous symptoms which demand the attention of the physician during convalescence from putrid fever, that which is most commonly met with : if its possible occurrence is not foreseen, and its cause is not attentively sought out, it may lead to the belief that there is a serious cerebral affection. We had a singular illustration of this remark in the case of a patient who occupied bed No. 16 of St. Agnesis ward. This young man, at the twenty-ninth or thirtieth day of a putrid fever, in which he had had copious intestinal haemorrhage about the end of the second week, was convalescent, when he was seized with delirium, more continuous and more violent than he had had even when the disease was at its height. All the other symptoms, however, were for a long time in abeyance: regular stools had succeeded to the diarrhoea, and there was no longer any pulmonary catarrh : there was no fever, the pulse was only 64, and the temperature of the skin was natural. The cerebral symptoms might have led one to believe that there was a lesion of the brain similar to that observed by Piednagel in a certain number of cases, a lesion consequent upon irritation or sub- DOTHINENTERIA. 387 acute inflammation of the pia mater and grey substance, and bearing some resemblance to what is sometimes met with in persons sinking under the general paralysis of the insane. My colleague of the Hdtel-Dieu supposes that the delirium of the convalescence from typhoid fever is caused by the persistence of this inflammation, which in other respects [he regards as an unimportant affection, and as not at all serious, inasmuch as it is very curable. The proposition stated in this way is far too absolute. I at once grant that the dis- turbance of the intellectual faculties is dependent upon an altered state of the encephalon : I admit that this alteration may be the result of congestion and inflammation of which we can find traces on examining the dead body; but it is also a fact, that often no such traces are discoverable. Without giving an opinion as to the nature of this affection, it may be stated, that, be it wrhat it may, it is an alteration produced under the influence of a septic malady which produces radical changes in the fluids, and acts specially upon the nervous system : and it may likewise be stated, that in proportion to the length of time during which this influence operates upon the economy, is the duration of the period required for a return to a normal condition. But disturbance of the intellectual faculties may also arise from the individual having been exhausted by great loss of blood, or by starving; the brain under such circumstances being deprived of its natural excitant, the blood. Now, the organ of the intellectual faculties will be longer in resuming its original activity, in proportion to the longer or shorter duration of the state of feebleness, exactly as is the case with the muscles, which, when they have been inactive for a long time, do not all at once regain their power. And possibly, this state of feebleness, or cerebral atony, is the most common cause of the symptoms of which I have been speaking. To sum up :—If the delirium and vertigo which supervene during convalescence from typhoid fever, and that hebetude which the patients retain for even from five to ten months after recovery, and which some never lose, are referable to a subacute inflammation of the membranes and cortical substance of the brain, there is gene- rally no appreciable organic lesion, and the pathological phenomena seem to be dependent upon cerebral ansemia resulting from debility, and requiring to be treated by tonics and stimulants, exactly like muscular debility, to which I have compared it. The correctness of these views is shown by the delirium ceasing and the intellectual 388 DOTHINENTEIUA. faculties returning to their normal state under the influence of gene- rous diet. You saw a patient wdio occupied bed No. 8 of our St. Bernard's ward, who after remaining in a state of imbecility for six weeks after recovery from severe putrid fever, regained simultaneously her intellectual faculties and her muscular power. In such cases, it would be a serious blunder, leading to aggrava- tion of the symptoms, to resort to antiphlogistic treatment, from an idea that there existed inflammation or congestion. In a case similar to that of the woman in St. Bernard's ward—the case of the man who occupied bed No. 16 of St. Bernard's ward—you saw me pre- scribe stimulants and tonics, wine and coffee, as well as solid sus- taining food. Typhoid fever is not the only disease which is succeeded by dis- order of the intellectual faculties : it occurs after all septic diseases— after small-pox, scarlatina and diphtheria—and it is always by the same kind of treatment that the cure has to be brought about. Still, it is a cardinal point, a matter of absolute necessity, to proceed with very great caution, so as not to exceed reasonable bounds. While the diet is essentially tonic and reparative, it must be kept strictly within the limits of the digestive power : you must not go on at too great a speed from a desire to proceed without loss of time. If the quantity of food taken is in excess of the digestive capability of the individual, the gastro-intestinal symptoms will be aggravated, in place of being subdued, the vomiting will continue, and increase in severity—the diarrhoea will assume a much greater intensity, and the patient will succumb under the inveterate conse- quences of indigestion. The different forms of paralysis which supervene during con- valescence from dothinenteria also belong to the same class of symptoms as those which we have just been considering; like vertigo, delirium, and mental debility, the different paralytic affec- tions originate in shock of the nervous system, in organic and functional modification throughout its entire extent, caused by the morbid poison, which, having in the first instance acted directly on the nervous system, continues so to act during the whole course of the disease. We can understand that the longer the duration of the malady, the more numerous will be the symptoms indicative of disturbance of the nervous centres, such as stupor, prostration, im- paired muscular contractility, delirium, and convulsive movements: we can understand, I say, that the more decided the adynamic or DOTHINENTERIA. ataxic symptoms are, the more time will be required for things to return to their normal state. Putrid fevers, when the attacks are severe and protracted, often leave patients in a state of very great weakness, from which they emerge with difficulty, and which some- times continues for several months. It is likewise after these dangerous forms of dothinenteria that we meet with the paralytic affections now under consideration. The paralysis is sometimes general, affecting not only motion and sensibility, but also the senses, the patients being deaf and blind, as well as unable to move: sometimes also, it is localised, in which case it is generally seated in the lower extremities ; at the same time implicating the bladder, so as to cause retention or incontinence of urine, micturition being either ail overflow of the bladder, or the result of the inability of the paralysed sphincter to retain the urine : there is also sometimes paralysis of the rectum, the patients involuntarily passing their stools. You must beware of being misled as to the nature of these cases : you will often meet with patients who seem to have this description of paralysis of the sphincters, when it really does not exist. You remember in bed No. 4 of St. Agnes's ward, a young man who for several days soiled his personal linen and the sheets. In him, as in others, this proceeded from mental debility, or, more correctly speaking, from the laziness resulting from that debility. It is sufficient in such cases to make the patients ashamed of their dirty habits, and to threaten them with low diet in the event of their not discontinuing them : you will particularly observe cases of this kind in children. Finally, paralysis may locate itself ex- clusively in the organs of the senses, producing a longer or shorter continuance of blindness or deafness. A restorative regimen and tonics are the only means by which we can get rid of these untoward symptoms. The diagnosis of these paralytic affections seems so simple, as to preclude the necessity of saying a word on the subject; but never- theless, cases occur in which you might find yourselves at fault. The case of our patient in bed No. 4 is a proof that one has to distin- guish between a true and apparent paralysis. The following history, communicated to me by a physician in town, will show you how much complexity there may be in this diagnosis. A girl, twelve years of age, had a serious attack of putrid fever : during convalescence, she was absolutely unable to walk. Her phy- sician having recommended exercise in the open air, she was taken out in a little carriage, but as no improvement occurred under this 390 DOTIIINENTERIA. treatment, she was sent into the country. No amendment had taken place in her condition, when by mistake, she was one day left alone locked up in her room. Great was the surprise of her at- tendants, when, on their return, they found the door open, and the patient on her feet: to liberate herself from confinement, she had walked. The relations exclaimed that a miracle had been wrought; but unfortunately, the miracle was not a complete cure, for on the following day, the paralysis returned, and at present, according to the information which I received from the attending physician, the patient is still unable to walk. In this case, gentlemen, the paralysis was certainly not a conse- quence of the fever: paralytic affections consequent on fevers do not terminate so suddenly, and when they have ceased, do not so quickly return. Though I did not see the patient, I think I may say that her affection was hysterical paralysis, for paralysis is often simulated by one of those strange whims which get into the heads of that singular class of patients called hysterical. If, as an objection to this opinion, it be said that the youth of the girl hardly allows us to suppose that her case was of this class, that at her age there is unfeigned lightheartedness, while the affection con- demned her to long-continued rest and prevented all participation in the games which constitute so large a part of the occupation of childhood, I reply, that hysteria is not a rare disease, even in children of twelve years of age. In cases of this kind, we must have re- course to moral more than to what are considered strictly medical means of cure. I have recently been studying, in a convalescent dothinenteric patient, a form of paralysis which may occur as a sequel to any severe disease, but which i's most frequently observed after fevers. It is the consequence of the disease itself—of its duration and seve- rity. There is in small-pox, as you know, a form of paralysis, which, on the contrary, is a concomitant of the rachialgia, of the invasion-period of the disease. This form of paralysis, occurring at the beginning of a fever, is a very important element in the diagnosis: and I am not aware that it has hitherto been observed at the commencement of any pyrexia except small-pox. I have, however, just seen an occurrence of this kind in a young woman, occupying bed No. n of St. Bernard's ward, who, some days after her admission, presented all the symptoms of typhoid fever. Here, in a few words, is this case. DOTHINENTERIA. 391 Some years previously, the patient, on the rapid disappearance of eczema of the lower extremities, became affected with paraplegia, which continued for a whole year. She became pregnant, and from that time the paralysis gradually diminished. Her pregnancy was not attended by any serious symptoms; but her confinement took place at the seventh month. For the six following years, she had very satisfactory health, till eight days before she came into hos- pital, when she complained of fever, lassitude, pains in the limbs, loss of appetite, and nausea, but no diarrhoea: she made special complaint of inability to stand. On examining the patient, I found that she moved the lower extremities very feebly, and said that they were the seat of lancinating pains : she also complained of pain in the dorsal region of the vertebral column, upon percussing or making pressure over it. I thought that there was myelitis, and that it was the cause of the rheumatism. There was nothing to lead me to suppose that it was a case of variolous paraplegia, as the patient had none of the symptoms of the invasion-period of small- pox, and had had the paraplegia for eight days w7hen I saw her. There was neither stupor nor diarrhoea, and the pulse was not bound- ing. It wras, therefore, to my great surprise that three days after the patient came into our wards, that is to say, eleven days from the commencement of the paraplegia, I observed an eruption of rosy lenticular spots on the abdomen. The paralysis soon disappeared, and did not return in the course of the disease, nor during conval- escence. The typhoid fever, which was mild, pursued its normal course, and its duration was not more than three weeks. Here, then, is an example of paraplegia occurring at the com- mencement of typhoid fever. It is true, certainly, that the para- plegia occurred in a subject who had previously suffered from it for a whole year: still, the case deserves to be mentioned as one of clinical importance : it is an example of the “ spinal” form of the disease, more particularly described by G. Fritz, and of which I have already spoken. It is important to distinguish these forms of paralysis from that muscular debility which is always observed in convalescents from dothinenteria, and which is partly dependent on nervous exhaustion, and partly on that alteration of the muscular tissue which I have already described. I told you1 that the contractile tissue of very 1 See p. 334 et seq. 392 DOTHINENTERIA. many, if not of all, muscles underwent, to a greater or less extent, granular or waxy degeneration: and that some weeks are required for the absorption of the degenerated tissue, and the formation of new contractile tissue in its stead. During this period, there is necessarily great embarrassment in the muscular movements. The forms of dropsy which sometimes supervene during, and in convalescence from, typhoid fever, as well as in connection with all serious fevers, are symptoms of the same class as those we have just been passing under review. Like the nervous symptoms, they are all dependent upon a bad general state of the economy, upon the adynamia into which organic life has fallen, but more particularly upon the special alteration of the blood, which singularly favours serous effusion into the cellular tissue and serous cavities. When we recollect the frequency with which albuminuria is met with in the course of typhoid fever, one might be induced to believe that the dropsies of which I am now speaking were associated with an albuminuria symptomatic of disease of the kidney. But the albu- minuria met with is either quite transient and purely functional, in no way connected with any real or permanent change of structure in the kidney, or it is coincident with the renal lesion characteristic of Bright’s disease, as in cases observed by Bayer, Barthez and Billict, Christison, Gregory, and others. But in the consecutive dropsies of typhoid fever, no trace of albumen is found in the urine. A fact, not less remarkable, to which the attention of physicians has been called by that laborious observer Dr. Leudet of Bouen1 is, that the dropsies consecutive to dothinenteria occur much more frequently in some localities than in others, and that the influence of the pre- vailing medical constitution has something to do with their produc- tion. At Paris, for example, we rarely see them, while foreign physicians meet with them frequently, and describe them with great minuteness. During ten years which Dr. Leudet studied in the hospitals of Paris, and was constantly in the habit of taking down the particulars of numerous cases of typhoid fever, he never once saw dropsy following that disease, but after having been for a much shorter period a physician to the Hotel-Dieu of Bouen he there collected eight examples. These dropsical effusions, occupying almost exclusively the sub- 1 Leudet:—Archives Generates de Medecine. Oct. 1858, DOTHINENTERIA. 393 cutaneous cellular tissue, are generally limited to the lower extre- mities, where the oedema is greatest on the most depending parts, around the malleoli, and on the posterior aspect of the feet, and poste- rior aspect of the thighs. But sometimes there are partial effusions into the subcutaneous cellular tissue of the upper extremities: and sometimes also, there is oedema of the face, limited occasionally to one side, as in a case recorded by Virchow, in which it was asso- ciated with obliteration of the internal jugular vein. Ascites some- times occurs. Finally, the anasarca may be general: either appear- ing simultaneously in the different parts of the body, or being at first localised, and then spreading. The oedema is generally moderate in degree : in exceptional cases it is considerable, and may be compared to that which supervenes when there is organic disease of the heart. It bears no relation to the severity of the dothinenteria; and causes of debility, such as profuse evacuations and intestinal haemorrhages, do not seem to have any effect in producing it. Transitions from heat to cold, which are such marked causes of scarlatinous anasarca, do not here seem to possess a similar influence. Though the appearance of the dropsical affections which come on passively towards the second or third week of the fever, without any initiatory symptoms, is sometimes coincident with a febrile exacer- bation, a copious eruption of sudamina, or an acute bronchitis, they generally disappear in fifteen or twenty days. When they continue long, they retard convalescence, but in other respects are not serious. They yield to dietetic management, and a purely tonic treatment demanded by the state of general debility under which they have arisen. Gentlemen, the oedema of which I have been speaking is seen unassociated with albuminuria in some other pyrexise. I have often observed it in measles, and on examination the urine has generally been found to contain no albumen. But another kind of oedema which I have observed in dothinenteria, is that which is connected with obliteration of a vein: it is a real phlegmasia alba clolens. I very recently met with a case of this kind in one of my nieces aged twenty-four. She was seized with painful oedema about the fortieth day from the beginning of the fever. Virchow’s case, which I have just mentioned, is of the same description. 394 DOTHINENTERIA. Local Complications which Supervene During, and at the Decline of Dothinenteria, 1. Softening of the Cornea. A woman suffering from a very severe form of putrid fever was admitted to bed No. 8 of St. Bernard's ward. During the third week, when the nervous symptoms were very severe, the eyelids were incompletely closed during sleep, leaving the inferior segment of both cornese exposed. After some days, the conjunctiva was injected, and the eyes became bleared: twenty-four hours later, there was real catarrhal ophthalmia. On carefully examining the globes of the eyes, it was easy to see that the cornese were swollen, and had a whitish, macerated appearance : there was also intense photophobia, and the patient, though in a state of stupor, complained of her eyes, even when not obliged to raise the eyelids. Her sight was very much affected. It seemed evident to me, and to all who went round with me at the visit, that the cornese were completely softened, and vision hopelessly lost. This softening of the cornese, which, gentlemen, you have fre- quently observed, not only in the course of dothinenteria, but also in all diseases accompanied by cerebral disturbance, is one of the most serious complications; and one of which I was for a long time unable to understand the mechanism. I have at last, I believe, found it out: and, what is more important, I think I have discovered a very simple means of curing the affection. It is quite possible that others may claim along with me the honour of this little discovery. Should what I am about to bring under your notice in a few words have been previously observed by others, I shall in that circum- stance find a cause of congratulating myself on having given my sanction to a little-known practical fact. We see, every day, our professional brethren claiming the honour of priority with a zeal which excites in me very little desire to follow their example. Let it be understood, then, that I will surrender, whenever it is neces- sary, all my rights over the treatment of softening of the cornea in bad fevers. But before telling you what my treatment is, before following out the history of the woman to whose case I have recalled your atten- DOTIIINENTERIA. 395 tion, I am anxious to explain to you the mechanism by which, in my opinion, softening of the cornea takes place. You have often observed in putrid fevers, that patients sleep with their eyes half open: under such circumstances, it almost always happens that the globe of the eye is turned upwards, and the cornea entirely concealed. No other inconvenience results from this con- dition of the eyelids, except an inflammatory affection of the con- junctiva, and if this conjunctival inflammation be, which I willingly admit it is, dependent upon the general state of the patient, as is the inflammation of the bronchial tubes and back part of the mouth, I cannot but also admit that it is aggravated by the inability to wink, as is seen in persons suffering from paralysis of the facial nerve. You all know that patients with paralysis of the seventh pair of nerves, being unable to shut the eye or to wink, have always more or less irritation of the mucous membrane of the eye : and in some cases, this irritation proceeds to inflammation, and even to softening of the cornea. The patients themselves know how to ward off these consequences, by moving their eyelids with the assistance of the finger sufficiently often to supply the place of winking; but during sleep, unless they take special precautions, the globe of the eye is left exposed to the air, and in the morning they awake with irritative congestion, pain, and blearedness of the eye. In all severe fevers, the eyes remain partially open, and if the stupor continue sufficiently long, or be excessive, they are night and day in the condition similar to that of persons affected with paralysis of the seventh pair. Recollect also the fact, that in putrid fevers the sensibility is blunted, and that the irritation caused by the contact of the air with the conjunctiva is not felt, so that the necessity for Avinking is not experienced. The same thing takes place with the eye which occurs in respect of the nostrils, which become filled with dust and other foreign bodies floating in the air, because, from the parts not being sensitive to the presence of foreign bodies, the patient does nothing to get rid of them. Reflect for a moment on the theory of winking, and you will per- ceive the reason of the frequency of the symptoms of which I have been speaking. There are three pairs of nerves concerned in wink- ing. In the first place, there is the fifth pair—the sensitive pair— which transmits to the brain the impression of pain caused by con- tinuous contact of the air, and drying of the cornea—the impression which imparts the necessity of winking. In the second place, there 396 DOTHINENTERIA. is the seventh pair—a motor pair—which conveys to the sphincter of the eyelids the command to wink. Finally, there is the third pair of nerves—also a motor pair—which sends a branch to the levator palpebrre, and which consequently presides over the elevation of the upper eyelid. But there is still another nerve which I have to mention, and that is the lachrymal, which comes from the ophthalmic branch of the fifth pair, and presides over the secretion of the tears, which serve more than the ocular mucus to ac- complish the ultimate object of winking—lubrication of the con- junctiva. You can now understand that the performance of an act so com- plicated as that of winking, an act which requires the agency of so many nerves, should be disturbed, or even suspended, during such a disease as dothinenteria, which in so high a degree impairs the action of the whole nervous system. You must also bear in mind that in severe fevers, there are other special conditions quite independent of the causes (to a certain extent physical) of which I have been speaking. In virtue of causes, very imperfectly understood, but essentially connected with the nature of septic diseases, the mucous membranes become the seat of congestions, which may be somewhat active or somewhat passive, and which easily proceed to inflammation and even to sphacelus. In the ordi- nary train of symptoms in septic fevers, we also meet with ophthalmia, coryza, sore throat and laryngitis, and inflammatory affections of the genitals of young girls, upon which latter class of affections I shall afterwards have to make some special remarks. You will then better understand how inflammation of the cornea, caused by absence of winking, easily passes into a state of softening, which is really a kind of gangrene. Let us now revert to the clinical facts. Along with Dr. Grenat, I attended a young man suffering from a nervous disease, which was deficient in distinctive characters, but presented symptoms indicating that it was a connecting link between brain fever, and putrid or common typhoid fever. There was slight congestion of the conjunctiva, arising as much from the fever itself as from the want of winking. One of the cornese became softened, and the patient lost the eye. This unfortunate occurrence having made me reflect, it occurred to me that if the greatest part of the evil originated in the fever, the constant exposure of the eye to the air from want of power to 397 D01HINENTER1 A. wink was an important, and perhaps the principal, cause of the ulti- mate mischief. I forthwith took steps to be able to accomplish that which in point of fact I afterwards put in practice with great success in our patient of No. 8 St. Bernard's ward. It seemed to me, as well as to those who were present at my clinical visits when I examined this case, that the woman must in- evitably lose her sight. To me the case appeared as hopeless as it appeared to others; but I nevertheless resolved to try the plan which I had settled in my own mind was the proper treatment. Having completely closed the eyelids of the patient, I placed on them two pledgets of soft cotton, which I kept in their places by means of a moderately tight bandage. This little apparatus was arranged at the morning visit. During the day, the pain was less severe, and it altogether disappeared during the night. When I examined the state of matters next morning, I found to my great satisfaction that the cornese had their normal colour, and excepting that the conjunctive were a good deal blood-shot, the eyes had com- pletely returned to their natural condition. There was still some imperfection of vision; but the photophobia was gone. The treat- ment was continued for three days, at the end of which period the apparatus was removed. The general nervous symptoms had some- what subsided : the stupor had nearly quite disappeared; and from that time the eyes were closed during sleep. Although during con- valescence a severe attack of cholera supervened, and although that was succeeded by colitis, presenting some of the characters of epi- demic dysentery, there was no return of the ocular symptoms. The following case was observed by my friend and colleague Dr. Ambroise Tardieu. A man took scarlatina; and from the beginning of the attack had septic symptoms. The eyelids remained in a state of partial closure, and the lower segment of the cornea became soft- ened, precisely as in our patient. Already, there was acute pain, photophobia, and a considerable affection of the sight. Suddenly, erysipelas of the face supervened, and simultaneously took posses- sion of both eyelids, causing complete occlusion of both eyes for four days. Upon the erysipelas subsiding, the patient opened his eyes, when Dr. Tardieu was very pleased to find that the eyes, which he supposed lost, were perfectly restored to their natural state. Although in this case, gentlemen, the disease was not the same as that now under our consideration, the complications were identical, 398 DOTHINENTERIA. as were likewise the means employed to subdue them—means, how- ever, which in Dr. Tardieu's case, nature herself applied. The treat- ment consisted in the occlusion of the eyelids, a measure simple and of easy application which I beseech you not to forget. 1. Affections of the Larynx.—Necrosis of the Cartilages of the Nose.—(Edema of the Glottis supervening during Dothinenteria, and necessitating Tracheotomy. Gentlemen, early in March, 1858, a young man of eighteen, sent to Paris by a physician of Aix, was placed in our wards, to be treated for an affection of the larynx, which had necessitated tracheotomy. On admission, he was still using the tracheal tube, which he could not discontinue without being immediately seized with violent suffo- cative paroxysms. The laryngeal affection w7as stated to have commenced eight months previously in the course of severe typhoid fever, which, according to the written statement forwarded by my colleague, had assumed the adynamic form, and had lasted for thirty days. To- wards the end of the attack, the patient was seized with almost complete aphonia, which not only continued, but became aggravated at the commencement of convalescence. Respiration at the same time became more difficult: expiration was performed with suffi- cient freedom, but inspiration was laborious and accompanied by snoring and whistling sounds. There was no pain occasioned by making pressure over the larynx; and no cedematous swelling could be detected at the upper orifice of the air-passage, by introducing the finger far back into the throat. The dyspnoea was to a certain extent intermittent, or I should rather say was remittent, for it never quite ceased, although it diminished during the day, and in- creased during the night in severity. The parts at the entrance of the larynx wrere cauterised, and two setons were inserted over the thyroid cartilage; but no benefit resulted from these measures. Eighteen days after the commence- ment of the laryngeal symptoms, asphyxia being threatened, it became imperative to perform tracheotomy to save the man's life. Erom the date of the operation, the patient's health became com- pletely re-established, so that he came to Paris to get rid of the tracheal fistula, which he regarded as an irksome infirmity rather than as a malady. However, on his arrival at the Hotel-Dieu, he 399 was still complaining of some embarrassment in his respiration; but this ceased from the time of our substituting a wider tube for the tube which he had been wearing. I made several attempts to relieve him entirely from the neces- sity of using the tube, with a view to closing the wound in the trachea, and restoring entrance for the air by the upper orifice of the larynx; but on each occasion, the excitation of suffocative paroxysms showed me that the air-passages were not free. After having been six weeks in our wards the patient, discouraged, left the Hotel-Dieu, that he might apply to others from whom he had better hopes. Several of you may remember a case similar to, if not identical with, that now narrated, which came under our observation during last year. In it, however, you had the opportunity of following the laryngeal affection, step by step, so to speak, through all its phases. The patient was a young man of twenty. He was placed in bed No. 4 of St. Agnes's ward, labouring under one of the severest forms of dothinenteria, in which ataxo-adynamic symptoms predominated, and left behind them long-continued disturbance of the cerebral functions: during convalescence, he was in a sort of imbecile state. During the third week of this young man's illness, I observed symptoms involving the respiratory organs : there was dyspnoea, but the most characteristic indications were hoarseness and cough. O11 examining the back part of the throat, I was enabled to ascertain that there was undoubtedly swelling of the epiglottis, and was led to suspect that it extended to the aryteno-epiglottidean folds— perhaps even to the mucous membrane of the larynx and the vocal cords. By means of regular insufflation several times a day of alum and tannin, there was a great amelioration, but not a complete cessation of the symptoms: under these circumstances, he asked, and was granted, his dismissal. Believing, however, that there was deep-seated mischief, localised probably in the cartilages of the larynx, I told you that there was necrosis of one of the cartilages, and stated my fears as to the fate of this young man: my impression was that in a few days he would return to the hospital in a worse condition, and requiring serious surgical intervention. In point of fact, ten days afterwards, he did return. My pre- diction was fulfilled : the symptoms had assumed a formidable seve- rity. Respiration was oppressed ; expiration, which was whistling, DOTHINENTERIA. 400 DOTH1NENTE1UA. was less laborious than inspiration: the cough was exceedingly hoarse, there was an almost total absence of voice, and it was only by very great exertions that this unfortunate young man could make himself understood. Nevertheless, the oppression not having pro- ceeded to the last degree, and there being no threatening suffocation, I made a new attempt to subdue the symptoms, using the same means which had at first been successfully employed. I prescribed insufflations of alum and tannin, but no abatement of the symptoms resulted from that treatment. With a view to give him a last chance before resorting to tracheotomy, I looked on the case as possibly one of syphilitic laryngitis, although only too well con- vinced of the accuracy of my diagnosis, and although I had hardly any hope of obtaining more favourable results. Profiting, therefore, by the time granted me, by the wTant of urgency in the symptoms, I administered preparations of iodine; but under this treatment, the oedema of the glottis increased, and, on the 18th July, there was a renewal of the threatening of suffocation : and from asphyxia being imminent, it became imperative to resort to tracheotomy. The operation wras performed late in the evening by the interne on duty, M. Warmont, a distinguished hospital pupil, and next morning, at the visit, I found our patient in good spirits, and asking food. Some weeks afterwards, he finally left the hospital, breathing freely by the wound in the trachea, thanks to a tube of very large calibre which had been inserted. When he wished to speak, he closed the tracheal opening; and though his voice was still very hoarse, it was easily heard. He afterwards came to see us occa- sionally, and from time to time we have had accounts of him. Two years after the operation, he was still breathing through the tube, which he could not close completely without being threatened with suffocation. His general health was excellent: at his last visit, we found that he had gained a considerable amount of flesh. He had resumed work as a coppersmith. To render his infirmity more supportable, and for the purpose of concealing it as much as possible, he had invented a somewhat ingenious apparatus: he had adapted to his tracheal canula a long caoutchouc tube, which passing under his neckerchief and descending along his body, opened in the side pocket of his trousers. When he wished to speak, he put his hand into his fob, without, as formerly, having to put his finger to his neck. He was, however obliged to renounce this contrivance, as it interfered with the freedom of his breathing. Some days ago, I DOTHINENTERIA. 401 learned that he continued in the same state of health, but was still wearing the tracheal canula. Cases of oedema of the glottis, similar to those now related, occur not unfrequently in the course of, and during convalescence from, severe continued fevers, I say severe fevers, because they are ob- served not in dothinenteria only, but likewise in scarlatina and small- pox. At present, to speak only of what occurs in putrid fever, I may mention that my lamented colleague Sestier, in 274 cases which he collected, gives 10 cases in which oedema of the glottis supervened during convalescence from typhoid fever. These cases were not en- couraging, for they all proved fatal: in five of them, tracheotomy was resorted to.1 In contrast with these unfortunate cases, I can quote others of a more favourable character, in addition to the two which I have already related. In the Gazette Hebdomadaire for August 1859, you will find a report in relation to this subject, by Dr. Charcot, of cases published in Germany, in which the proportion of successful cases wras great—seven in nineteen. What ought most to surprise you, gentlemen, is that cases of oedema of the glottis consecutive to dothinenteria are not more numerous, seeing the frequency of the lesions under'the influence of which this affection may be produced. I have related to you the only two cases of this affection which I have met with as sequels of dothinenteria since I have occupied this clinical chair; so that I have had 110 opportunity of verifying by dissection the appearances which others have seen in similar cases. But that I may make my remarks on this subject as complete as possible, I will quote three cases, the first from my former pupil Dr. Louis Genouville, the other two from Dr. Second-Ferreol.2 Dr. Genouville's case was that of a person admitted to the Hos- pital of St. Anthony, to the wards of my colleague Dr. Bergeron. The patient was at the end of a severe attack of adynamic putrid fever, when, a few days after his arrival, he was seized with a suffo- cative paroxysm which imperatively demanded tracheotomy. On the second day after the operation, when he seemed sufficiently well to be allowed, at his own request, to discontinue the tracheal tube, 1 Sestier :—La Bronchotomie dans le cas d’Angine Laryngee (Edemateuse. [Archives Generalcs de Medecine, 1850.] 2 Bulletins dc la Societe Anatomique, for 1857 and 1858. 402 DOTHINENTERIA. he was suddenly carried off by a suffocative attack. On opening the body, the mucous membrane of the larynx was found to be gangrenous, and this condition extended back to behind the ventri- cles : the arytenoid cartilage was entirely destroyed: the inferior constrictor muscles of the pharynx and the crico- arytenoid muscles were sphacelated. The bronchial glands were black, and exhaled the characteristic odour of gangrene. In the situation of the ileo- csecal valve were seen the morbid appearances which belong to dothinenteria. In this history, there is nothing said of oedema of the glottis, but I nevertheless deem the case deserving of mention, for gangrene of the larynx and necrosis of the cartilages are lesions associated with oedema of the glottis, although gangrene is not so commonly met with as other morbid alterations of which there are notices in the cases reported by Dr. Second-Perreol, which I am now going to relate. One of his patients, a man of twenty-two years of age, had had a seriously complicated attack of ataxo-adynamic putrid fever : he had gangrenous sloughs over the sacrum, and the surfaces to which blisters had been applied on the calves of the legs were sphacelated. On the 22nd December, he went into La Pitie Hospital, under the care of my excellent friend and colleague Dr. Noel Gueneau de Mussy, and at the end of January was convalescent: his wounds, however, were not cicatrising, and numerous subcutaneous purulent collections formed, which had to be opened. He had been subject to loss of voice before his typhoid fever, and had a return of this affection during the convalescence. He was not only voiceless, but had likewise difficult respiration, and the inspiration was whistling, particularly during sleep. By cauterising the superior orifice of the larynx with nitrate of silver, these symptoms were temporarily mo- derated, but again increased when speaking was attempted. They soon became of such a character that suffocation was imminent, and tracheotomy necessary. The patient died during the operation. The autopsy showed a slight cedematous infiltration of the aryteno- epiglottidean folds: both vocal cords were swollen, and presented slight superficial erosions. The larynx contained a large quantity of muco-purulent fluid, which, when pressure was made on the cricoid cartilage, flowed out through a fistulous opening, situated posteriorly and a little to the left side of the cricoid cartilage. This opening communicated with a collection of pus, bounded on one DOTHINENTERIA. 403 side by the sterno-thyroid, and crico-thyroid muscles, and on the other by the mucous membrane of the larynx. A great part of the left half of the cricoid cartilage had disappeared. There was a loss of substance, very irregular in shape, constituted by the de- struction of the superior circumference of the ring, and involving three fourths of its height. On each vocal cord there was observed a small club-shaped polypus with a slight pedicle, and about the size of a lentil. These two small polypi, attached opposite to each other, were floating loose; and by falling down over the orifice of the glottis they could very well close it completely. These polypi may not have much complicated the necrosis of the larynx, but they accounted for the aphonia to which the patient was liable prior to his attack of typhoid fever. The subject of the second case was a young man of seventeen years of age, who likewise was received into Dr. N. Gueneau de Massy’s wards with typhoid fever. The attack, apparently slight at first, was marked, during the second week, by adynamic symptoms of, however, no great severity. On the morning of the eleventh day after his being received into hospital, he showed signs of ex- citement : the voice was hoarse, and sounded as if it were stifled: inspiration was noisy and whistling, while expiration was more easy. Frictions with croton oil on the neck, cauterizations of the superior orifice of the larynx with a solution of nitrate of silver in three times its weight of water, applied by means of a sponge, did not stop the symp- toms, which indeed, by the evening, had become considerably aggra- vated. Redness was then visible on the isthmus faucium, and when the finger was directed to the orifice of the larynx, the epiglottis was distinctly felt to be swollen, so as in shape to resemble a round cushion with a central hole, and to extend towards the aryteno- epiglottidean folds. The patient died during the night. At the autopsy, the isthmus faucium had a permanent bright red colour, and the glands in that situation were swollen, as were like- wise the papillae circumvallatse of the tongue. There was a large cedematous infiltration, with vascularity of the sub-mucous cellular tissue, situated at the orifice of the larynx, around the epiglottis : in form somewhat spherical, and resembling a cherry, it extended into the interior of the larynx, and over the vocal cords, which were eroded at their free margins. At the anterior horn of the left arytenoid cartilage, at the insertion of the vocal cord of the same side, there was a small, oval, greyish erosion, with fringed irregular 404 DOTHINENTERIA. edges, which led to a deposit of concrete pus in the sub-mucous cellular tissue of the gouttiere des loissons from two to three centi- meters long by one and a half broad. The arytenoid cartilage pre- sented to the eye no appreciable alteration, but its anterior apophysis was found denuded at the bottom of the erosion already described. The necroses of the larynx, which in the cases now detailed gave rise to the affection improperly termed oedema of the glottis, have, (following a mechanism which I will afterwards explain) as their starting-point ulcerations which are almost always met with in this region in dothinenteria, as has been pointed out by Chomel. The term oedema of the glottis, I call improper, because the affection really occupies the glottis itself less than the aryteno-epiglottidean ligaments, that is to say, than the superior orifice of the larynx. I will afterwards return to this point, when I come to consider in a special manner the history of oedema of the glottis. These laryngeal affections, described with the greatest possible care by Louis, exist so constantly, that that physician gives ulceration and partial de- struction of the epiglottis as one of the secondary anatomical charac- ters of dothinenteric fevers, placing them in that category along with ulcerations of the pharynx and oesophagus. So characteristic are these appearances in his opinion that he says :—“ If found on examining the body of one who has died from an acute disease, they will establish with nearly perfect certainty, and without going any farther, that the affection was typhoid fever.”1 The cartilages of the nose may be affected by dothinenteric necro- sis. We are indebted to one of our accomplished hospital colleagues Dr. Henri Roger for the account of a very curious case of necrosis of the cartilage of the septum. It occurred in a young man, who, when convalescent from very severe typhoid fever, attracted the attention of his physicians by an unusual phenomenon: he had a perforation of the nasal septum, through which he could make his two fingers meet. There was shown to exist, in fact, an ulceration with perfectly rounded edges, bleeding at some points, and at others covered with crusts which circumscribed a complete destruction of part of the septum, which was found to present a perforation of the size of a five centime piece. The cicatrisation of the ulcerated soft parts was soon completed, but the perforation of the septum remained. It was of an oval form, and situated three millimeters above the ori- 1 Louis:—Kecherclies sur la Fievre Typhoide, p. 321. Paris: 1841. DOTHINENTERIA. 405 fice of the nostrils. The only functional disturbance which it occa- sioned was a snuffling sound of the voice, which at first was con- siderable; and then gradually diminished. Dr. Henri Roger very properly classes this case with those of necrosis of the larynx. It is, however, much more rare, for neither Rokitansky nor Griesinger mention it. There is no example of it quoted by Cruveilhier; and I have never seen one.1 These lesions admit of explanation, without the necessity of sup- posing a special localisation of the disease analogous to that which takes place in the intestinal canal. There always exists in dothinen- teria, in a degree more or less marked, that irritation, that catarrhal condition of the respiratory passages to which I have called your attention: and on the other hand, it is known how much in this fever the tendency to ulceration shows itself, wherever there is in- flammation or even mere irritation of the mucous membranes. You have not forgotten, I presume, what I told you, to the effect, that in septic diseases the mucous membranes become the seat of half- active, half-passive congestions, which readily proceed to inflamma- tion and even to sphacelus, a fact which explains the ophthalmic affections of which I have spoken—the coryzas, sore throats, inflam- mations of the genitals, and laryngitic attacks which, in fact, all belong to the common cortege of septic fevers. With this fact in your minds, you will not be astonished to meet with a tendency to ulceration, a tendency which is sometimes found where it would hardly be looked for. For example, Dr. Charcot had a case in which there was ulceration of the gall-bladder. It may, therefore, be said that there is a sort of ulcerous diathesis in dothinenteria; but independent of this diathesis, of this dyscrasia of the blood, which constitutes one of the characters of putridity, ulceration is one of the consequences of inanition, as has been demonstrated by the beautiful experiments of Chossat.2 Likewise, there are no circumstances under which ulcerations of the larynx, nose, pharynx, oesophagus, &c. are more common than when the dothinenteria has been of the putrid form, adynamic, or when the course of the disease has been protracted, or when the diet of the patient has been kept too rigorously low. I intend, as I have 1 H. Roger:—Bulletin de la Societe Medicate des Hopitaux de Paris. T. iv, p. 427. 2 Chossat :—Reclierclies Exnerimentales sur l’lnanition. Paris: 1843. 406 DOTHINENTERIA. already said to reserve my remarks on the mechanism of cedema of the glottis, as I propose to devote an entire lecture to the considera- tion of that affection. There still remains a question for our consideration. When once oedema of the glottis has been ascertained to exist, ought tracheotomy to be immediately performed ? Ought we to wait for violent suffo- cative paroxysms P Ought we to wait till asphyxia is imminent ? You have seen, gentlemen, what I did in the case which came under your own observation. At the first examination, I diagnosed cedema of the glottis : paroxysms of suffocation occurred, but I still postponed opening the trachea, and instituted treatment, which, although I was not sanguine as to its success, nevertheless gave a chance of obviating the necessity of operating. I held myself in readiness for every eventuality : I caused the patient to be closely watched, resolving to perform tracheotomy whenever, from the suffo- cative fits becoming frequent and violent, asphyxia should become imminent. The young man was not operated on till it would have been dangerous to have waited longer. Such in my opinion is the proper course to follow; for after balancing the indications for and against opening the trachea in oedema of the glottis, I would say that it is wrong to wait till asphyxia has proceeded so far as to render death imminent. To wait the arrival of that critical moment would be to run the risk of failure from the patient sinking during or im- mediately after the operation, in consequence of his having fallen into a state of stupor and collapse from which it might be difficult to rouse him. On the other hand, it would be eqnally wrong to be in a hurry to operate as soon as severe and well-marked attacks of suffocation had occurred, and it would be equally objectionable to operate as soon as oedema of the glottis had declared itself; for under both of these conditions, there are cases in which recovery takes place without tracheotomy. These recoveries seldom occur when the oedema depends upon necrosis of the cartilages of the larynx, because the necrosed portions with hardly an exception, absolutely require to be eliminated, and this elimination cannot take place till repeated inflammations have been excited; and under their influence infiltration of the aryteno-epiglottidean folds is produced. Some- times, also, the vocal cords are infiltrated, as I will afterwards explain to you. Nevertheless, gentlemen, it is quite possible for this elimination to take place without involving these consequences. When this occurs, 407 recovery is the result of the unaided efforts of nature, as is exempli- fied by the following case, which occurred in the practice of my colleague Dr. Herard, physician to the Lariboisiere Hospital. A young woman of twenty-two had a very tedious convalescence from typhoid fever. After the lapse of about three months, she was suddenly seized with severe dyspnoea accompanied by loss of voice. From that time she had had occasional attacks of suffocation, during which the inspiration in particular was exceedingly painful. Six months later, the aphonia was almost absolute. The few sounds emitted by the patient wrere hoarse, guttural, and accompanied by a little hissing noise. Respiration was very much oppressed : inspira- tion, which was noisy and somewhat wheezing, brought the muscles of the chest into strong action. The patient had at the same time a frequent and very distressing cough, but it did not come in fits: the sound of the cough was very deep. There was a little sero-mucous expectoration slightly streaked with blood. The patient’s general condition was good; her countenance had a natural appearance; she was plump; and had regained her strength. Examination of the respiratory apparatus only furnished negative signs. On applying the stethoscope over the larynx, a very decided whistling sound was heard: it was very rough during both inspira- tion and expiration, but particularly during inspiration. Externally, there was no sign of structural change in the larynx—no cicatrix, no fistula, no crepitation on pressure—nothing to indicate lesion of the cartilages. On introducing the finger into the throat, it was im- possible to detect any increased volume of the aryteno-epiglottidean folds; and a sound was easily introduced into the larynx, Some days later, the patient experienced more discomfort in the larynx: she thought that she felt a moveable body which occasionally got across the throat. All at once, during the evening, she was seized with a real and very severe paroxysm of suffocation; and after a violent fit of coughing, she ejected by the mouth two small osseous sequestra. On the immediately following days, the aphonia remained as before. The cough was distressing, and had all the characters of laryngeal cough. The larynx, when pressed, was slightly painful, but unless pressure was made, there was no sensation of pain in it worth noticing. At the end of a month, slight improvement showed itself. There was less cough; and the vocal sounds, though still very incomplete, were uttered with more ease. DOTHINENTERIA. 408 DOTHINENTERIA. At the end of a residence of seven months, the patient left the hospital. Her general health was then unexceptionable : utterance was nearly natural, though the voice was still rather hoarse, guttural, and deep. There was no cough, and no pain in the larynx, even on pressure. The state of the chest continued satisfactory. In conclusion, when oedema of the glottis supervenes during con- valescence from, or in the course of, dothinenteria, after trial has been made of the available therapeutic resources of medicine, such as insufflation of alum or tannin, cauterizations with nitrate of silver, and, when practicable, scarification of the oedematous aryteno- epiglottidean folds, we must be ready to perform tracheotomy —and that early rather than late—that is to say, when the suffoca- tive paroxysms have become frequent and of increased severity and duration, and the respiration more embarrassed in the intervals between the fits. The more the patient has been reduced by the antecedent malady, the less delay ought there to be in operating. 3>—Sloughs.—Erysipelas.— Colliquative Suppurations.—Paraplegia Consecutive to Infiltration of Pus into the Spinal Canal producing Infiammation and Suppuration of the Spinal Marrow. Gentlemen, the tendency to sphacelus, which is one of the charac- ters of the condition to which the name putridity has been given in severe fevers, is never more decided than in adynamic dothinenteria. It is the principal cause of the sloughs which you have so often ob- served in our patients. They occur chiefly in parts subjected to continuous pressure, such as over the sacrum, great trochanters, and, as Chomel has noted, sometimes even, over the occiput. Continuous pressure, then, contributes its share in causing mortification of tissues : the contact of faeces, and urine, by constantly soiling the parts, un- doubtedly also assists in producing that result. It is necessary, therefore, that the patients should be kept exceedingly clean, and that their position should be frequently changed, so as to prevent the injurious consequences of pressure continued too long on the same part of the body. With a view to obviate the inconveniences which arise from the roughness occasioned by folds in the sheets on which the patient lies, napkins of vulcanized Indian rubber have been invented for placing under the seat: they are stretched across, and fixed at each side of the bed. By this contrivance, a perfectly smooth and soft surface is obtained : and these napkins have, moreover, the DOTHINENTERIA. 409 advantage of being easily kept clean, as that can be accomplished by wiping them with a wet sponge. When one has not at command an apparatus of this description, the pelvis of the patient may be wrapped up in a chamois skin, such as is used for washing car- riages : it is fixed in front, so that whatever position the patients get into, they are always in contact with a smooth soft surface. These chamois skins can be obtained anywhere; and they are very easily washed. Another plan suggested—a plan you saw me put in prac- tice with one of our male patients—consists in making the patients sleep on straw, in accordance with the system adopted with the gatenxx of the Bicetre and Salpetriere. The straw absorbs the fluid part of the excrementitious matters, which by their contact wTould have irritated the skin; and in this wray one of the causes of gangrene is removed. Unfortunately, these different measures often prove insufficient; for, as I told you, the principal cause of sloughing in dothinenteric patients is the tendency to mortification which belongs to the disease. How great this tendency is is seen by the facility with wdiich surfaces to which blisters have been applied become gangrenous, even when the blisters have been applied to the front of the chest and insides of the thighs, surfaces on which there can be neither pressure, nor soiling by urine or faeces. It also often happens that pustules of ecthyma in different parts of the body, and the bites of leeches become the starting point of sloughs of greater or less size, and of more or less depth, irrespective of pressure or irritation from ex- crementitious matter, causes to which some physicians—as I think erroneously—attach very great importance. The sloughs which occur so frequently in dothinenteria sometimes become exceedingly serious complications. They may occasion erysipelas, which, developing itself around a slough, may spread widely, invading a great part of the skin, or ex- citing febrile action, which exhausts the patient, already much reduced by the long duration of the putrid fever. Prom their number, extent, and depth, the sloughs are in them- selves serious complications; for when they do not lead to a fatal termination, they exceedingly retard convalescence. Gangrene often 1 See p. 329.—The gateux of the Bicetre, and the gdleuses of the Salpetriere arc the patients in the respective hospitals who, from mental imbecility, or paralysis of the sphincters, pass their excrements either without regard to decency, or involuntarily.—Translator. 410 DOTHINENTERIA. proceeds from the skin to the cellular tissue, then reaches the muscles, and destroys them. Its destructive power affects even the bones, which it leaves denuded and necrosed. Under these circum- stances, there are large deep ulcerations yielding a putrid sanguino- lent discharge; and ere long, life is terminated by the vain attempt of the organism to struggle against profuse and constant sup- puration. Moreover, the extensive ulcerations of the skin produced by the sloughs—as well as boils, carbuncles, and buboes—may lead to the absorption of putrid or purulent matter. Professor Andral mentions a case in which numerous metastatic abscesses supervened after an attack of small-pox.1 It is natural to suppose that in some cases the dotliinenteric ulcerations of the intestines may become the starting point of puru- lent fever. On the 16th December, 1861, a case of this description was observed at the anatomical theatre of the Hotel-Dieu. The autopsy to which I refer was that of a man of twenty-seven, who died, in the wards of my colleague Dr. Horteloup, during the seventh week of typhoid fever. The symptoms which the man had latterly presented were such as are frequently observed in the last week of dothinenteria, just when convalescence ought to be beginning, and which consist in an exacerbation of symptoms, and the appearance of new typhoid and ataxic complications. When the intestines were being removed from the body, that they might be opened, it was observed that the most fleshy part of the left psoas muscle was swollen out into a tumour. When this was cut into, chocolate-coloured pus spurted out, the quantity evacuated being estimated at nearly ioo grammes. Dr. Horteloup's interne, who made the autopsy, informed us that the patient had never pre- sented the signs usually attributed to psoitis. I at once remarked that the psoas abscess must be metastatic, and that from appearances there were numerous similar abscesses in the lungs. The lungs were in fact studded with small purulent collections, such as are commonly seen in the fever dependent upon the absorption of pus: similar purulent collections were found in the liver. We discovered nothing to explain the fact of purulent absorption, except extensive dothinen- teric ulcerations in the lower part of the ileum. 1 Andbal Clinique, T. I. p. 278: 3me 6dit. DOTHINENTERIA. 411 A similar case, in which recovery took place, is reported by MM. Castelnau and Ducrest.1 There is still another complication of dothinenteria, which, although I have not seen it, may be met with. I allude to an inflammation of the spinal marrow and its membranes, which has a slough over the sacrum as its starting point. You have seen a case of this descrip- tion, though not in connection with putrid fever. The case, how- ever, naturally claims notice in relation to the point now before us. Similar cases are also described in classical works. My colleague Professor Nelaton remarks, in his “Elements de Eathologie Chirurgicale,” that, as a consequence of the sloughs which form over the sacrum, “ there sometimes occurs an exceedingly serious complication, easily explained by the anatomical relations of the parts. The lower outlet of the sacral canal is closed by a fibrous band extending from the sacrum to the coccyx; and this band is itself involved in the mortification. The spinal dura mater and arachnoid are also perforated, and a putrid sanies flows into the arachnoid cavity, producing all the symptoms of spinal meningitis, and ere long causing death.” This statement is quite a description of the case of the patient whom you lately saw in bed No. 8 of St. Agnes’s ward. Having presented the signs of acute myelitis, with sloughs over the sacrum, and typhoid symptoms, she sank delirious after an illness of six weeks. On examination after death, the entire posterior aspect of the space between the trochanters was found to be occupied by a slough. The sacro-coccygeal ligament was destroyed: the vertebrae were to a considerable extent denuded : and a probe could be intro- duced into the sacral canal. The membranes within the sacral canal were reduced to a greenish pulp, and it was impossible to recognise the arachnoid. There was a great quantity of pus as high up as the seventh dorsal vertebra: it seemed to have originated in the slough of the integuments. Up to the seventh dorsal vertebra, the membranes of the spinal cord were thickened, but above that, they were in a normal condition. Down to four centimeters above its termination in the canda equina, the spinal cord, throughout its whole extent, was unaltered by any morbid affection. There, it was 1 Castelnau et Ducrest :—Recherclies sur les Abces Multiples compares sous leurs differents rapports. Paris : 1846. 412 DOTHINENTERIA. in a softened condition, and under a jet of water it became disin- tegrated. There was no lesion of the encephalon. This was evidently not a case of dothinenteria: but you can very- well understand that consequences similar to those now described might follow from sloughs arising in connection with dothinenteria, and it is on that account that I have related this history. 4.—Spontaneous Gangrene of the Limbs. Among the local complications which may supervene during the course, and in the decline, of dothinenteria, one remains to be men- tioned, which is very much rarer than any of those to which I have as yet directed your attention. I refer to spontaneous gangrene of the limbs, an affection to which in recent times particular attention has been paid. I have not seen any cases of this complication; but you will find some reported by most trustworthy physicians. Among others I would mention those which Dr. Gigon of Angouleme has made the subject of a paper entitled “Note sur le Sphacele et la Gangrene Spontane's dans la Fievre Typhodde ;’n and two cases read, on the 14th January, 1857, before the Hospitals Medical Society, by Dr. Bourgeois of Etampes. To them I will add the following case, communicated to me by my chef de clinique, Dr. Leon Blondeau, who saw it when interne at the Children's Hospital. A boy of ten years of age was admitted, on the 3rd December, 1847, to the wards of Baudelocque. He fell ill at the beginning of November; and from the accounts of his illness given by his family, there could be no doubt that he had had adynamic putrid fever. On admission, that of which the little patient most complained, was great pain in the right leg, in which, however, neither change of colour nor swelling could be seen. Baudelocque had the idea that the pain was caused by the formation of one of those deep- seated phlegmons which are sometimes met with in severe fevers: he, therefore, prescribed mercurial inunction over the seat of pain. Ten days afterwards, however, gangrene began to show itself in the foot. The boy was then taken into the surgical wrards of M. Paul Guersant. 1 Gigon.—See Union Medicate for 24 and 28 September, 1861. 2 Bourgeois.—See Archives Generates de Medecine, for August, 1857. DOTH1NENTERIA. 413 Tlie entire surface of the right foot was of a purple colour which was deeper on the internal aspect, from the tip of the great toe to the first line of tarsal bones. This violet hue, which might be compared to that of a nsevus, extended to the third interosseous space of the metatarsus. Upon the ankle and internal malleolus, the veins were marked by greenish brown subcutaneous lines, like those seen in putrefying dead bodies. The feeble heat still retained by the parts in this mortified condition was more attributable to pre- cautions taken to keep the foot wrapped up in flannel and wadding, than to the temperature of the foot itself. There was complete absence of pulsation in the right tibial artery. On the internal and posterior surface of the right leg, at the junction of its upper and middle thirds, and in the course of the artery, a large hard cord was felt: it was felt most distinctly at the tibial insertion of the gastrocnemius internus. The slightest pressure over that place occasioned acute pain. On that side of the limb, the pulsations of the popliteal artery could not be detected, but the pulsations of the crural artery had the same force, frequency, and rhythm as in the left thigh. The inguinal glands wrere swollen : those of the right side were the largest, and the most painful on pressure; and over them the skin was of a pale red colour. The pulse at the wrist was small, very compressible, and 100 in the minute. The patient was in a state of great excitement, and seemed to be suffering much pain. Six leeches were applied to the seat of pain in the leg, with appa- rently the result of giving some relief, *by diminishing the acuteness of the constant pain: but the sphacelus went on increasing, the livid colour of the skin became of a deeper shade, and spread itself over a larger surface. Tonic regimen and tonic medicines (including cinchona as the chief) were prescribed. The limb was at the same time kept enve- loped in opiated poultices. On the 16th December, three days after the boy’s admission into M. Guersant’s wrard, there was a complete demarcation between the gangrenous and non-gangrenous parts. Next day, the vascular cord could not be felt; and the fever had subsided. On the 39th December, the gangrene seemed to be perfectly circumscribed in the region which I have just described: it appeared to be very super- ficial, and not to go deeper than the skin. Over the malleoli, and 414 DOTHINENTERIA. in particular over the malleolus externus, some brownish lines were visible, formed by veins gorged with stagnant blood. The boy com- plained of very acute pains in the affected parts, which were, in general, most severe at night. The pains in the legs had com- pletely ceased. The general condition of the patient was very satisfactory. Notwithstanding the severity of the lesions, the boy— after having had his foot amputated—perfectly recovered, and left the hospital on the 17th May 1848. In this case, gentlemen, the gangrene, which supervened in the wane of an attack of dothinenteria, undoubtedly originated in ob- literation of an artery. The question, however, still remains, whether the arterial obliteration was the consequence or the cause of arteritis, the existence of which arteritis was characterised by the presence, in the course of the artery, of an indurated cord, painful to pressure. My own opinion is that in this case, as well as in the two cases of Dr. Bourgeois of Etampes which I am about to relate, as likewise in cases published by Dr. Gigon of Angouleme, and Dr. Patry of St. Maure, the primary cause of the gangrene was the formation of a clot-plug, this clot having been either formed in situ, constituting the thrombus of Yirchow, or being a migratory clot, the embolus of the German professor. This clot, acting as a foreign body on the inner surface of the vessel had excited inflam- mation in it, which inflammation in its turn had produced plastic products, and in this way the stoppage in the artery had been in- creased, and its obliteration had at last been completed. The subject of the obliteration of vessels by self-made clots [caillots autoch- thones] —to use the current' term of the day—is of so much im- portance that I must devote one or more of our meetings to its consideration. It is, moreover, so often met with in practice, that we shall certainly have an opportunity of returning to it; and I, therefore, reserve our special study of it and its bearings upon clinical instruction. Let us now return to the subject more immediately before us. The cases of Dr. J. Bourgeois of Etampes are even more interesting than the case I have just related to you, from the circumstance that in them the sphacelus was deeper and more extensive, in one case involving the whole of the leg, and in another case involving both legs, causing in both instances amputation of limbs by the unaided efforts of nature. In the young girl, the subject of his first case, there came on, in DOTHINENTERIA. 415 the wane of a mild attack of dothinenteria, acute pain in the right leg, which was neither red nor swollen, but in which there was a notable diminution of motor power and sensibility, and a reduction in temperature : after a few days, the leg was quite cold. The skin soon assumed a colour which at first was dark grey, then copper-red or brick-red, and quickly afterwards became clear violet with nume- rous streaks. The physiological sensibility of the leg was so com- pletely extinct that a pin could be pushed in its whole length without causing any annoyance. An irregularly fringed line, sepa- rating the obviously mortified from the still living parts, extended from the tuberosity of the tibia to the upper third of the calf, and encircled the leg. The integuments losing their violet hue, became more and more slate-coloured. At the point of contact of the healthy and diseased parts, a deep ulceration formed, from which there was every day a flow of greyish, very fetid pus. The knee was slightly painful: in the thigh, there was no pain. The toes and the foot dried up, but the leg, well nourished, long retained its natural size. The patient's condition, however, improved from day to day. She was kept on restorative diet, and tonic medicines. The leg was covered with powders of an absorbent, aromatic and septic character. The soft parts very soon separated: the living flesh re- tracted, leaving between the healthy and mortified parts a space of from four to five centimeters, in which were seen the two bones of the leg, perfectly denuded, dry, and almost white. To rid the patient of a fatiguing weight, and a source of exhalations more or less injurious, the bones were sawn through at two centimeters from the wound, which had a sound red appearance, and was even beginning to cicatrise at its edges, and to contract. Twenty days afterwards, two small rings of bone were detached; and then cicitrization was soon completed. The girl left the hos- pital, having regained her fresh looks and plump appearance. The stump was exactly similar to stumps obtained after amputations per- formed at a selected spot, and in the best possible manner, according to the rules of art. Dr. Bourgeois states that he did not find any swelling in the course of the great vessels. It is probable, however, that in this, as in the other case I related, the gangrene was the consequence of oblite- ration of the popliteal artery. This remark is applicable also to Dr. Bourgeois' other case, which I am now going to narrate. No painful cord caused by the obliterated artery was observed, al- 416 DOTHINENTERIA. though it was noted that there was an entire absence of pulsation in the arteries of the mortified limb. Here is an abstract of the case. The patient was a boy of twelve years of age. At about the third week of a moderate attack of mucous fever, and just when convalescence seemed to be beginning, he was seized in both legs with very acute pain, which was most severe in the right: the pain was increased on pressure, but was unaccompanied by any swelling. There was a decrease of temperature in the legs: the thighs pre- sented nothing abnormal. After two or three days, the surface of the right limb assumed a greyish tint, which passed into a copper- red, traversed by numerous streaks. The pain was most intense below the tibio-femoral articulation. The integuments had lost their sensibility, and the paralysis was complete. A deeply indented line had separated the living from the sphace- lated parts. Scarcely a week later, similar changes were occurring in the left leg. The patient was admitted to the hospital at Etampes, where Dr. J. Bourgeois observed the progress of the malady from clay to day. The boy died after nine months of dreadful suffering. The natural separation of the dead parts was, you observe, waited for. Although it was obvious that there were some objections to thus allowing the dead parts to remain, it was supposed that as they were perfectly dry, and far separated from the stump, the evil consequences could only be very slight. It is to be regretted that there was no autopsy. Had an examination of the body been made after death, there would probably have been found not only an obliteration of the vessels of the thigh, the pulsations of which were felt during life, but of the popliteal arteries; and thus a complete explanation would have been afforded of the spontaneous gangrene of the limbs, without the necessity of having recourse to the very questionable hypothesis of disturbance of the functions of the nervous system, or without requiring to invoke, with Dr. Bourgeois, a metastasis, of which really I can form no conception. Two of the cases observed by Dr. Gigon of Angouleme presented a remarkable similarity to those which I have already laid before you, with these differences, however, that it was not an inferior ex- tremity which was sphacelated, but the right superior extremity, and that the gangrene was moist and not dry. This latter difference is explained by the affected part being different, and—as the autopsy DOTHINENTERIA. 417 showed—by the vascular obliteration being in the veins and not in the arteries. “ In two patients,” says Dr. Gigon, u suffering from very severe typhoid fever with symptoms of putridity of the humours, there arose in the right arm, considerable swelling, which was greatest in the neighbourhood of the axilla. The hand and fore-arm were least swollen. The arm was at first red, and painful to the touch, and then it swelled to twice its natural size : its skin became purple, its temperature fell, its sensibility became obtuse, numerous phlyctsenm (filled with a yellow or reddish fluid) showed themselves, and some brown patches appeared below the shoulder and towards the elbow. Incisions, large and deep, made both before and behind, throughout a great part of the length of the arm, were hardly felt by the patient: the subcutaneous cellular tissue was deeply gangrenous, and infiltrated with pus. Shreds of gangrenous cellular tissue became detached, along with portions of aponeurosis, and there was a dis- charge of sanious, reddish, putrid purulent matter. The symptoms of general prostration increased greatly at the same time; and led to speedy death. In one case, eight days, and in the other nine days, elapsed between the appearance of the swelling and the fatal issue. The gangrenous affection seemed to be much more serious in the superior than in the inferior extremity. The autopsy showed that in both cases there had been inflammation of the superior portion of the subclavian vein, with formation of a complete clot-plug, which adhered to the inside of the vein : the clot was of pretty firm con- sistence, of a rose colour, and acted as a stopper. Less tenacious ramifications of the clot extended into neighbouring veins, such as the superior scapular, the axillary, the cephalic, and external mam- mary : in the subclavian vein, the internal surface was of a very deep red, this colour, as the vessel advanced, diminishing towards the ramifications : the venous coats were more friable than natural, and thickened. The mechanical obstacle to the circulation was, in my opinion, the cause of the moist gangrene of the arm.” Dr. Patry of St. Maure1 reports the case of a patient who had simultaneously dry and moist gangrene in different parts of the same inferior extremity. The dry gangrene occupied the foot and leg, which were black, dried up, and shrunken : the moist gangrene 1 Patry :—Gangrene des Membres dans la Pievre Typlioide. [Arclives Gcnerales cle Medecme, fcvrier et mai, 1861.] 418 DOTHIN ENTE 111 A. was spread over the whole thigh, which was purple, swollen, and denuded of epithelium in several places. On examination after death, the crural artery was found to be increased in size, and com- pletely obliterated at its upper part by black clots, which broke down easily, and were not adherent to the interior of the artery: in the popliteal portion of the vessel, the clots were friable and harder, and some of them were adherent to its inner surface: the arterial coats were red, injected, thickened, and had lost their elasticity. The crural vein was obliterated by consistent black clots, which, however, did not adhere to the internal tunic : its coats were thick- ened, injected, of a deep red colour, and did not collapse when cut. The dry gangrene of the foot and leg is evidently explained by the obliteration of the popliteal artery, which took place before the ob- literation of the crural artery, in which the clots were more recent, softer, and non-adherent. The moist gangrene of the thigh was equally the result of the obliteration of the crural artery and the crural vein: there was a combination of gangrene arising from suspension of the arterial circulation, and of oedema from arrest of the venous circulation. Dr. Patry has also given the very curious history of a young man who, at the twentieth day of an adynamic dothinenteria, suddenly felt a very acute pain, proceeding from the left angle of the inferior maxilla to the parotid and temporal regions. In forty-eight hours from the commencement of this pain, the left ear sphacelated. Sub- sequently, the parotid and temporal regions became cold, and assumed a purple colour, while bullae, filled with a blackish fetid fluid, appeared on their surface. Pour days later, the sphacelus had extended to the forehead, to both eyelids, and to the cheek, as far as the com- missure of the lips. In spite of these frightful disorders, the patient survived twelve days. At the autopsy, the external carotid artery was found to be obliterated by two clots, one of which, situated in the upper part of the vessel, was hard, friable, colourless, and adhe- rent ; and the other, more recent, and striated lower down, was of a deep black colour, and tolerably consistent. In the situation of the upper clot, the arterial canal was injected, thickened, and more easily torn than natural: the inner coat had lost its smoothness and transparency. The jugular veins were in a normal state. In connection with this case, Dr. Patry mentions that he saw, in 1843, in the hospital practice of Dr. Charcellay of Tours, a man who was, during dothinenteria, attacked with gangrene of the DOTHINENTERIA. 419 whole of the left side of the face, and who was for five months a sufferer from this complication. Both the right and left superior alveolar arches were destroyed, and the patient was obliged to wear a bandage over the left side of the face, so as to conceal the hideous enlargement of the mouth. To complete this series of abridged cases, it is necessary to add, that the typhoid fever in which the complications arose was cha- racterised by finding, during life and after death respectively, the symptoms and lesions peculiar to that disease—a fact which both Dr. Gigon and Dr. Patry are careful to state. If obliteration of an artery or vein is the undoubted cause of sphacelus of an entire limb, or of a great part of a limb, arising in the course or at the end of dothinenteria; if this obliteration of vessels, if the arteritis or phlebitis which have been active agents in producing it, have for starting point a sanguineous clot, the formation of which (as I re- marked when speaking of embolism) ought to be attributed to a peculiar dyscrasia of the blood met with in other diseases very different in their nature from typhoid fever—it is also indisputable that the mechanical cause acts much more energetically in dothinen- teria, from the circumstance that a notable tendency to mortification of tissues is one of the characteristics of the putridity at times so strongly marked in that fever. LECTUBE XVI. TYPHUS. An Infectious Disease like Dothinenteria.—Differs from Dothinen- teria in the Absence of Intestinal Lesions.—The two Fevers are distinguished from each other by the Aggregate of the Symptoms, and their Thermal Variations. Gentlemen Although, from the nature of the instruction which it is my duty to impart to you, there is a propriety in con- fining myself to the consideration of the clinical cases which come under your observation, and to their elucidation from the results of my personal experience, I still think that I may to-day speak to you about a disease which we have never had an opportunity of seeing in our wards, but which is certainly well known to you by name. I speak of typhus, which, at least in the totality of its general symptoms, presents so great a resemblance to dothinenteria that the question of the identity of the two diseases, after having been for a long time under discussion, is still far from being settled, although .the partisans of non-identity seem now to be the majority. Epidemic in some countries—notably so iu the Britannic Isles— where after having reigned exclusively, first in Ireland, and then in Scotland, it seems now to be permanently installed in some of the manufacturing towns of England, particularly in London, where, in recent years, it has committed great ravages. Erom the accounts of the disease—described under very various names1—furnished by old and modern authors, it appears that epidemics of typhus, originating 1 Fievre Pestilentielle, Febris Pestilens : [Fracastor, 1546.] Typhus ties Camps, Typhus des Prisons: [Sauvages, 1759.] Fievre Petechiale, Febris Petechialis: [Sennertus, 1641: Selle, 1770, Borsieri, 1785]. Typhus Exan- thematicus: [German authors.'] Spotted Fever, Typhus Fever. [.'English authors.] 421 TYPHUS. under the influence of the same causes, and propagated by contagion, have in all periods of history, appeared at various epochs, in the old world and in North America. Trance, though not exempt from epidemics of typhus, has suffered less from them than other countries. Without going back to remote periods, it will be sufficient to remind you that during the first fifteen years of the present century, typhus, following the armies which were then overrunning Europe, broke out on several occa- sions in a considerable number of places in Trance ; and that it has since reappeared, for example, at Toulon in 1820,1829, 1833, 1845, and 18511: at Rheims in 18393 : at Strasbourg in 18543: and that in 1856, imported from the Crimea, where our soldiers imbibed its germ during the war in the East, it declared itself in several other towns, among which were Marseilles, Avignon, and even Paris, where, as you know, in the military hospital of Yal-de-Grace, it prevailed as an epidemic from January to May of this year 1856.4 I have said that typhus seems always to arise under the influence of the same causes. This is a point upon which all physicians are agreed. All admit that the morbific matter, the poison, the miasm which engenders the disease, can be spontaneously developed wherever great masses of human beings are accumulated, as in the great centres of population, in armies concentrated within a space too small in relation to the number of persons, in prisons, and in ships. This is particularly the case in ships used as penal hulks, if the men are exposed to bodily fatigue, mental anxiety, moral suffering, and dieted with food bad in quality, and insufficient in quantity. But I also stated, that when typhus is once developed in a locality, it often spreads by contagion, when one cannot point to any other cause for this propagation taking place. Bear also in mind, that in respect of typhus, as in respect of all other contagious diseases, it is not necessary that the contagion be transmitted by persons who 1 Ker.vcdken :—Typhus dans les Bagnes de Toulon. [Arch. Gen. de Mede- cine, T. Ill, 1833.] Eleury :—Histoire Medicate de la Maladie qui a regne parmi les condamnes du bagne de Toulon, 1829. [Mem. de VAcad, de Medecine, T. Ill, 1853.] Barraillier:—Du Typhus Epidemique a Toulon. Paris, 1861. 2 Laxdouzy :—Arch. Gen. de Medecine, 1842. 3 Eorget :—Preuves Cliniques de la non-identite du Typhus et de la Eievre Typho'ide. [Comptes rendus de VAcad, des Sciences, 9 Octobre, 1854. * Godelier :—Memoire sur le Typhus observe au Yal-de-Grace. [Bulletin de VAcad. de Medecine, 1856, T. XXI, p. 889.] 422 TYPHUS. have the disease: it may be carried by individuals who have not, and who have never had, the malady, the morbific germ of which they are the means of transmitting. This fact—an incontestable acquisition of science—suggests the fear that from the constantly increasing intercourse between the two countries, typhus, at present in permanence in England both in the epidemic and sporadic form, will pass over into France, and establish itself among us for a longer or shorter period. It is, therefore, my duty, gentlemen, to give regarding this disease some information, which you may soon, perhaps, have to make use of in practice. This information I will take from a work published by Dr. Mur- chison, physician to the Fever Hospital of London.1 Dr. Murchison discusses the question of the identity or non- identity of typhoid fever and typhus, and declares himself a believer in their non-identity. This is a subject to which I shall have to return. Dr. Murchison states in the preface to his book, that after having been brought up in the opposite belief, he was led by his own observations to adopt the views of Drs. Stewart and Jenner, and that therefore his present opinion cannot be attributed to precon- ceived ideas. The invasion of typhus is usually sudden, but it may be preceded by a slight indisposition of one or several days’ duration, charac- terised by general lassitude, vertigo, a little headache, and loss of appetite. Without premonitory symptoms, the patient is seized with transient irregular rigors, followed by moderate perspiration : he complains of frontal headache, prostration, and a bruised feeling rendering every kind of movement painful, of pains in the loins and limbs (particu- larly the thighs), and of loss of appetite. During the first two or three days, although the skin is hot, even burning hot, he constantly com- plains of cold, and places himself close to the fire. The tongue is large, pale, covered with a fur which is at first white, and soon be- comes yellow or brown. The taste is vitiated : there is thirst, more or less urgent, which causes the patient to desire every kind of drink, but he soon loathes them all except cold water. Sometimes, there is nausea, and much more rarely, vomiting of bilious matters. The abdomen, generally supple, and sunk rather than distended, is neither 1 Charles Murchison Treatise on the Continued Fevers of Great Britain. London, 1862, TYPHUS. 423 the seat of the slightest pain, nor is even sensitive to pressure. The bowels are generally constipated. The urine is thick and high- coloured. Usually, the pulse is full, but compressible: in some cases, it is hard and bounding, while in others, it is irregular and intermittent. There is a notable variety in its frequency : it some- times rises to 120, and may afterwards go up to 150, which is one of the most threatening symptoms which can occur; or it may, on the contrary, remain below the normal standard, even falling so low as 28. This is frequently an indication of feeble action of the heart, which in such circumstances contracts twice for each arterial pulsation. Respiration is more or less accelerated: and there is frequently decided oppression of the breathing, Accompanied by cough and mucous expectoration, under which circumstances there are heard on auscultation sonorous rales, indicating the existence of bronchial catarrh. The face is red : the margins of the eyelids are- swollen, the conjunctive injected, and the eyes suffused with tears. At first, the expression of the countenance indicates languor and fatigue, but it soon becomes sad, heavy, and stupid. Trom the beginning of the attack, there is vertigo, singing in the ears, rest- lessness, and often complete insomnia, while it also happens that the patient says that he has not slept, although his attendants have seen that he had been asleep for hours. This sleep, however, is dis- turbed by distressing dreams, and by awakings with a sudden start: after three or four nights, the patient speaks in his sleep or in a semi-delirious state between sleeping and waking. When he awakens, he is conscious of what is passing around him, although his memory and intelligence are a little confused. From an early period, and rapidly, the prostration of the muscular force goes on increasing. He walks with tottering gait: when asked to hold out the hand, it is seen to tremble : this tremulous movement is also observed in the tongue, when an attempt is made to protrude it beyond the mouth. The feeling of debility and exhaustion soon becomes so great that about the third day from the beginning of the disease, the patient is unable to leave his bed. Between the fourth and seventh day—generally about the fourth or fifth day—the eruption appears on the skin. It consists of nu- merous irregularly shaped spots, varying in diameter from a mere point to three or four lines. The spots are either isolated, or they are grouped like pieces of marquetry in irregular forms, often re- calling the appearance of the eruption of measles. At first, they 424 TYPHUS. are of a dirty rose colour, or they present a sort of bloom, and are slightly elevated above the skin : they disappear when pressed by the finger : from the first or second day, they become of a darker brown shade, no longer disappear, but only become pale, when pressed by the finger. Their margins are ill-defined, and blend in- sensibly with the general hypersemic hue of the skin. They usually appear first on the abdomen, then on the chest, back, shoulders, and thighs: in some cases, their first appearance is on the backs of the hands. They are most frequently met wfith on the trunk and arms, and are rarely seen on the neck or face. They are always most obvious on the dependent parts of the body • and in doubtful cases, it is on the posterior parts and the back that they ought to be looked for. Besides the superficial spots, there are others paler, and less distinct from one another, which, from their being apparently situ- ated under the epidermis, are called sub-epidermic. When these sub-epidermic spots are abundant, they give the skin a wavy marbled aspect, in contrast writh the darker and better defined spots for- merly described, although sometimes both spots seem to be blended together. There is great variety in the appearance of the eruption of typhus, according to the relative abundance of the -wavy or dis- tinct spots. In some cases, there is a profusion of both kinds, and in other cases, there are not many of either. There is also a diver- sity in the appearance of the eruption, dependent upon the greater or less degree in which it is confluent. The marble-like spots con- stitute what Jenner has described under the name of the mulberry rash, and which other physicians have called measly or rubeolous. In two or three days the eruption is complete; or, at least, if new spots appear at a later date, they do uot attain a full development. The severity and duration of the malady are proportionate to the quantity of the eruption and the darkness of its hue. Such is typhus during its first six or seven days. Towards the end of the first week, the headache ceases, and deli- rium supervenes. The delirium varies in its character : occasion- ally, it is, at first, acute, the patient screaming, talking incoherently, and being more or less violent. He will, unless placed under re- straint, get out of bed, wralk up and down the room, or even, jump out at the window. This state of violence is generally fol- lowed by a period of collapse, during which the patient is calm, and speaks mutteringly in a low voice. As a rule, the delirium is not violent, even at its commencement. Whatever may be its form, it TYPHUS. is accompanied by insomnia, and its manifestations are excited by speaking to the patient. The expression of the countenance becomes more sombre, sadder, and more stupid, the prostration at the same time increasing from hour to hour. The symptoms of nervous ex- citement are generally most severe in the evening and during the night, while the prostration is greatest in the morning. At this period of the disease, the tongue is tremulous, dry, brown, and rough in the centre: sordes accumulate on the teeth and lips: the bowels remain confined. The pulse ranges between 100 and 120 : it is sometimes full and soft, but more frequently is small and feeble. In respect of the respiratory movements, there is also a great varia- tion : the inspirations vary from twenty to thirty in the minute, but they may retain their normal frequency, or they may fall as low as eight, when the pulse is small, and the action of the heart exceed- ingly disturbed. Again, respiration may be spasmodic or jerking: this is the case when the cerebral symptoms are very severe, as when there is delirium followed by coma. Finally, respiration may also be irregular, the inspirations succeeding one another with extreme rapidity; and also, it may be purely diaphragmatic, the muscles of the chest being seemingly paralysed. This nervous respiration does not depend on any affection of the respiratory apparatus, and is an extremely serious symptom. The breath of the patient is foetid. The skin, colder than during the first week, dry, or slightly glutin- ous, exhales a peculiar odour, which may be compared to the smell of rotten straw, of deer or of mice, but which is really a smell sui generis. The colour of the eruption becomes darker; and towards the middle of the second week, there appear true petechise of a purple or bluish tint, which may be developed in the centre of many spots, with the brownish red of which the margins of the petechise become gradu- ally blended. After three or four days, consequently about the tenth or eleventh day from the beginning of the malady, cerebral oppression, or stupor, takes the place of nervous excitement. The stupor at first alternates with the delirium, which is greatest during the night. There is extreme prostration: the patient lies on the back, groaning and muttering incoherently, or he remains quiet and at rest, but showing a tendency to get down to the bottom of the bed. He is quite unable to raise himself up, or even to turn on his side : he is raised with very great difficulty; and is wholly indifferent to sur- rounding persons and things. At this stage, there are often tremors, 426 TYPHUS. startings of tlie tendons, and picking of tlie bedclothes: the look is haggard, and there is an expression of stupidity in the countenance : the conjunctivae are injected, the eyelids are nearly closed, and the pupils are contracted. Deafness is common. When addressed in a loud voice, the patient looks around him with an astonished gaze, and when told to put out his tongue, he opens his mouth, and keeps it half open till ordered to shut it. These are the only indications of consciousness which he gives, and they, even, are sometimes wanting. His mind, however, is far from being inactive: he dreams the most frightful dreams, which he implicitly accepts as realities, and of which he retains a complete recollection after his recovery. His thoughts turn upon the' events of his past life. He fancies that he is persecuted by the persons around him, even by his dearest relations: he compresses years into hours, and in a few hours imagines that he has lived a life-time. Those only who have ex- perienced this mental suffering can form an idea of its intensity. The teeth and lips are covered with sordes : the tongue is hard, dry, brownish black, gathered up into a sort of ball, and is either pro- truded with difficulty or not at all. The abdomen is flaccid, or sometimes tympanitic. The bowels are confined, or, two or three times a day, stools of rather diarrhoeal character are passed involun- tarily. There is an increase in the quantity of urine, but it is paler than natural, and below the normal specific gravity: it is passed involuntarily, or there is retention, necessitating the use of the catheter. The skin becomes still colder, and is occasionally some- what moist. There is an increase in the number of petechial spots. The parts of the body subject to pressure, particularly the sacral region, become red and soft, and are apt to ulcerate. The pulse is rapid, ranging between 120 and 140, small, often of an intermittent character, irregular, and scarcely perceptible: the cardiac impulse, and the sounds of the heart, have either become diminished in intensity, or have ceased to be audible. The patient may remain in this condition, with life in the balance, for some hours or several days, till at last stupor merges into profound and fatal coma : or, he dies from asphyxia, consecutive upon sudden engorgement of the lungs: or, the pulse becomes imperceptible, the skin being cold, livid, and bathed in profuse sweat, death generally taking place without a return to conscious- ness, but without stertor occurring, and being apparently the result of syncope rather than of coma. TYPHUS. 427 The issue is not, however, always fatal. Towards the fourteenth day of the disease, a more or less sudden amelioration may occur. The patient falls into a calm sleep, which lasts for several hours, and from which he awakes a new man. At first, he is bewildered, and does not know where he is : by-and-by, he recognises his attendants and friends, and becomes aware of his extreme weakness. His extremities retain their sensibility, but when he attempts to move them, they seem as if they did not belong to his body. The pulse has become stronger and less rapid: the tongue is clean, and at the edges is moist: there is some desire for food. These symp- toms of amendment are often accompanied by slight perspiration, diarrhoea, or sediment in the urine. After two or three days, the tongue becomes quite clean, the • appetite insatiable, and the pulse normal, or even, it may be, very slow. There is a rapid return of strength. Convalescence, in fact, is complete. Gentlemen, this picture, drawn by Hr. Murchison, represents to you a case of uncomplicated typhus. The disease, however, pre- sents great varieties in respect of severity, and the relative pre- dominance of adynamic or ataxic symptoms. In cases of average severity, the tongue is never dry nor brown, the pulse is never above 100, and the eruption is never petechial. A slight confusion of memory and the intellectual faculties, with disturbed sleep, seem to be the only cerebral symptoms which show themselves. Local complications, however, may modify the progress and character of the attack. Of these complications, which vary with the epidemic and the locality, the most common are affections of the respiratory organs. Chest complications generally supervene insidiously, the usual symptoms of cough and expectoration being insignificant or wholly wanting, and the patient making no complaint of pain. Under such circumstances, the rapid breathing, and lividity of the counten- ance, are the only signs indicative of a pulmonary affection; but rapid breathing is not in itself a conclusive sign, because, as I have already said, it is a frequent accompaniment of fever, and may exist in a very aggravated form irrespective of any important lesion of the respiratory organs. Moreover, if dyspncea dependent on an im- portant lesion declares itself by lividity of the face and hands, that lividity does not appear till the complication on which it depends is far advanced, and often not till it is irremediable. f When, therefore, there is the least doubt as to the nature of the 428 TYPHUS. affection, the chest ought to be examined by auscultation and percussion. Bronchitis is perhaps the most common of all the complications of typhus. In some epidemics, it is met with in the majority of cases. In Ireland, bronchitis is so usual a complication, that the typhus of that country has been called catarrhal typhus; and German physicians, including Rokitansky, who have derived their knowledge of typhus from descriptions of it as seen in Ireland, believe that it is nothing more than a thoracic form of dothinenteria. Bronchitis may be the first symptom of typhus, or it may come on during the course of the disease, and continue during its decline. It is necessary to watch carefully all cases in which there are bronchitic symptoms. There is no immediate danger, when the only signs of pulmonary affection are an occasional cough and some scattered sibilant rales: but when the prostration increases, the thoracic inflammation is liable to extend suddenly, and at the same time insidiously, and to become more or less associated with hypostatic engorgement. Under these circumstances, coughing and expectora- tion being impossible in consequence of paralysis of the bronchial muscles, the catarrhal secretion accumulates in the bronchial tubes, and induces asphyxia. I have thought it best to give you a nearly exact translation of Dr. Murchison’s description of this complication, on account of the frequency of its occurrence; but it will suffice merely to enumerate the others. Hypostatic engorgement of the lungs is described as a complication of typhus. Coming on generally at a more or less advanced period, about the eleventh or fourteenth day, sometimes earlier—as early sometimes as the seventh day—and being usually associated with bronchial catarrh, it is the most common cause of death in English typhus. Hypostatic engorgement must not be confounded with that acute pneumonia, in which there is exudation of plastic lymph into the pulmonary cells and intervening cellular tissue—a form of pneumonia which is very rare. Hypostatic engorgement sometimes terminates in pulmonary gangrene, particularly in persons, who, prior to their attack, have been ill-fed. Pleurisy is another but a rare complication of typhus. When it does occur, it is latent. Phlegmasia alba dolens often supervenes in the decline of typhus, but less frequently than in the decline of typhoid fever. Purulent infection with articular abscesses is rarer still. When it does occur, TYPHUS. 429 it proves rapidly mortal. Scorbutus is a complication met with in some epidemics. The symptoms by which it shows itself are a great tendency to syncope, spots of purpura, and hsemorrhages by the nose, bronchial tubes, stomach, intestines, and bladder. Imbecility, and sometimes mania (as in typhoid fever), occur as sequels to, but not as complications of, typhus. The same remark applies to paralysis, which may be general, or partial. There may be hemiplegia, paraplegia, or paralysis of the bladder, or paralysis affecting the instruments of motion or sensation, or both at once. The paralysis may also affect the organs of the senses—of hearing, for example, leading to deafness which frequently comes on in the course of typhus, continues after convalescence, and is often associ- ated with otorrhcea and inflammation of the external ear;—and of sight, occasioning a certain degree of amaurosis. These paralytic affections of typhus are generally transitory, but sometimes they continue for life. Erysipelas of the face, erysipelas of the hairy scalp; oedema of the inferior extremities, in some cases anasarca, at times dependent on renal disease; gangrenous affections of parts subjected to constant pressure, and gangrene of the limbs similar to that which we have seen in dothinenteria; coma; eruptions of furuncular or pemphigoid character; inflammations of the cellular tissue; parotitis; buboes;—such are the principal complications which have been described as rendering unfavourable the prognosis of typhus. The inflammatory form of typhus is characterised by the intensity of the febrile action, and acute delirium. It is most commonly met with in the young and vigorous, and chiefly among those in com- fortable circumstances. The ataxic form is characterised by the predominance of nervous symptoms, such as delirium, somnolence, and subsultus tendinum. The fever is said to be adynamic, when there is great prostration, involuntary evacuations, a tendency to syncope, coldness of skin, and a slow pulse. It is said to be ataxo- adynamic or congestive, when the symptoms are those of congestion. Typhus has been called siderant \i. e. influenced by the stars], when it proves fatal within a few hours or days. It is said to be mild, when, as generally happens in sporadic cases, it runs through its stages without showing any serious symptoms. The disease is some- times so mild, that, were it not for the presence of the characteristic eruption one might suppose that the affection was a simple synocha. 430 TYPHUS. Under the name of typMsatidn a petites doses, Dr. Felix Jacquot, a French physician often quoted by Dr. Murchison, has described an aggregate of symptoms met with in persons constantly exposed to the contagion of typhus, and who are not otherwise affected by the poison. These symptoms are general discomfort, slight fever, loss of appetite, sleeplessness, occasional confusion of ideas, and a feeling of general fatigue. Real typhus sometimes declares itself in this way under the circumstances referred to; but in general, only the symptoms now enumerated occur, and they disappear on the patient leaving the poisoned atmosphere. The diagnosis of typhus presents no difficulty, when the charac- teristic cutaneous eruption exists. When this is absent, typhus may be confounded with dothinenteria and other diseases characterised at some periods of their course by typliic symptoms. However, inde- pendently even of this specific eruption, typhus can be distinguished from typhoid fever by an aggregate of symptoms which I shall have to bring under your notice when I discuss the question of the iden- tity or non-identity of the two pyrexise. As to the diseases in which the occurrence of typhoid symptoms may lead to difficulty of diagnosis, an attentive observation of the phenomena will prevent mistakes. Hitherto, gentlemen, I have said nothing regarding the researches which have been made into the temperature of typhus. I reserved my remarks on that point, that I might make them in connection with the subject of diagnosis. Thermometrical investigation fur- nished valuable indications which enabled me to form a definite opinion in respect of a case which you had an opportunity of ob- serving in our wards, and the particulars of which I am now going to lay before you, from notes taken down by one of my worthy pupils, Dr. Alfred Duclos of St. Quentin.1 On Saturday nth June, there came into my wards a man, aged 27, of good constitution, who had lived in Paris for three years and had from January last been treated for pulmonary inflammation. On the Thursday, the patient had been suddenly seized with very intense headache, rachialgia, feebleness of the legs, particularly of the right leg, in which, from that date, he complained of lancinating pains. Respiration was difficult and sighing, but he had neither 1 Duclos :—Quelques Recherches sur l’etat de la Temperature dans les Maladies. These Inaugurate. Paris, 1864. TYPHUS. 431 cough nor haemoptysis. On the Wednesday, there was neither vomiting, diarrhcea, nor epistaxis. On the day of his admission into hospital—the fourth day of the fever—we found a considerable number of papular spots. Next day—June 13th—the eruption was confluent on the trunk and fore-arms, sibilant rales were heard in the chest, and there was stupor. There was no diarrhcea. On the 13th June, the sixth day of the fever—there were vomit- ing, epistaxis, and fine sub-crepitant rales at the base of both lungs. Dry cupping was ordered, but by mistake the cupper scari- fied. On the 14th, there were stupor, delirium, sub-crepitant rales, and gurgling in the right iliac fossa. The eruption was very con- fluent, and so great was the confluence that on the fore-arms, the eruption was so like that of measles, as to lead me to think that the case might be one of anomalous measles notwithstanding the symp- toms of dothinenteria which existed. On the 15th, the eruption was gone, but the general condition of the patient, including the deli- rium and stupor, remained as before. On the i<5th, the patient passed his urine involuntarily : he had no diarrhoea: but he had hemiplegia, an unusual occurrence in dothinenteria—there was a very decided want of power in the right arm and leg, as well as distortion of the features. He was cupped at the nape of the neck; and a draught was administered containing twenty-five centi- grammes of musk. The delirium and stupor disappeared: the patient answered with precision the questions which were addressed to him, and from that day took his full share in conversation. Two days later, he was able to leave his bed, but there was still a manifest remaining feebleness of the right side. He remained permanently hemiplegic, an occurrence which sometimes follows typhus, but is never a sequel of dothinenteria. In this case, in which I long hesitated in my diagnosis, exami- nation of the thermal index enabled me to affirm that the disease was typhus. This is what I observed :—on the fifth day of the disease, the thermometer in the evening indicated 40°.4: next day— the sixth day of the malady—there was a slight remission in the fever, and the thermometer fell to 39°.8, to rise again in the evening to the same point whence it had fallen in the morning. On the seventh day, there was a somewhat remarkable fall in the evening temperature: it had fallen to 40°, a circumstance attributable to the abstraction of blood by cupping. On the eighth day, the evening temperature was 4