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SECTION VI.

DISEASES OF THE EXCERNENT
SYSTEM.

Or all the classes of the physiological nosologists, this has been found most difficult to delineate and circumscribe. The business of excretion seems to be divided among many of the organs, which assist incidentally in its performance, while engaged in other functions. Thus the lungs, the liver, and the intestines, throw off much effete matter, while busied in digestion, absorption, and assimilation. The Kidneys are, perhaps, the only organs exclusively excretory; we know of no other function in which they are employed than mere elimination. Next to them, the Skin, perhaps, deserves to be considered in this point of view. Excretion is the most important office of the cutaneous integument, although by no means the only one.

I shall first treat of a few of the more important and familiar disorders which affect this extended surface: neither space nor opportu nity permitting a more comprehensive discussion.

Among the chief of the maladies in which the skin is especially implicated, are the EXANTHEMATA, or eruptive fevers, a group of diseases, so called, from the fact, that a cutaneous eruption, preceded or attended by fever, forms the prominent point in their history.

The characteristic peculiarities of the Exanthemata are the following: 1. They are Pyrectic or febrile; 2. Eruptive; the skin is affected by a special form of inflammation: 3. Self-limiting; they come to an end at a defined period: 4. Contagious: 5. Self-protective; they do not attack a second time. Variola, rubeola, scarlatina, exhibit all these properties; pestis, urticaria, varicella, dengue, erysipelas, pemphigus, are not proved to be self-protective nor self-limiting. Analogies are pointed out which dispose certain writers of authority to class among the exanthems, typhus (Perry), cholera (Horner), pertussis (Watt). These are contended to be self-protective, contagious, febrile, eruptive; the mucous membrane being the seat of the eruption. They are not self-limiting in the strict sense.

Vaccine has its own exclusive history; but like glanders and hydrophobia, it does not belong to the list of human maladies; being introduced from the lower animals.

The most familiar of the exanthems combine many circumstances of close analogy. A certain febrile disorder, with notable gastric derangement, precedes, by a pretty regular interval, a specific cutaneous eruption of definite character. The period at which this characteristic eruption makes its appearance, though subject to occasional and slight

modifications, is well known; it is transient in its duration, running a limited course, and then declining and passing away. Smallpox throws forth its eruption on the third day from the invasion of the disease, arrives at its height on the tenth, and then declines. The rubeolous eruption appears on the fourth, and declines from the seventh. Scarlatina shows itself on the surface on the second, and fades from the fifth.

They are contagious always, and often become epidemic also. They affect the human constitution but once; a rule which, however, is proved to be subject to occasional exceptions.

In the instance of smallpox and measles, the gastric disorder is notably diminished as soon as the eruption has appeared upon the skin; in scarlatina this relief is less observable.

The pathology of the exanthemata is specially obscure, although there is no want of theory or hypothesis on the subject.

The whole mass of fluids seems to be in some manner vitiated in these eruptive fevers; of which the best proof is found in the fact, that they are conveyed to the foetus in utero, when the pregnant mother is attacked. Such instances happen not unfrequently in variola, and, although more rarely, in measles also.

VARIOLA-(Smallpox.)

A well known, contagious, eruptive, inflammatory disease. It has been supposed to be indistinctly mentioned in ancient writings, as prevailing among the easterns, but we have no definite description of it until the sixth century.

Smallpox is usually treated of under the separate heads of distinct and confluent; which terms, however, refer not to any specific difference, but merely to the degrees of violence of the attack, with the amount and extent of the attendant eruption.

Variola commences, like other inflammatory fevers, with a rigor or shivering, followed by heat, pains in the head, back, and limbs, gastric oppression, nausea, and often vomiting, restlessness, anxiety, and muscular debility. Sometimes there is a soreness of the throat, with pain in the side and chest, cough and dyspnoea. In young children the invasion is not unfrequently marked by convulsions. These symptoms continue for two or three days; from 48 to 72 hours, when, it may be a little sooner or later, the skin of the face and breast exhibits an eruption, consisting of small papulæ, slightly projecting, and of red color, which afterwards spreads over the arms, and the rest of the surface. From the time of its appearance, the febrile symptoms decline, and, in a great measure, subside. These pimples, or papulæ, assume in a day or two the vesicular form, becoming distended with a thin serous fluid; they increase in number and size, and on or about the seventh and eighth are of a circular shape, with a depression in the centre of the great majority. The contained fluid soon becomes turbid. and purulent. In proportion as these pustules abound, the case is distinct or confluent. In the latter form of smallpox, they often run

together, so as to make a complete mask for the face, and on certain parts of the body, those, for instance, which lie always in contact with the bed, run into large patches and crusts. Where they are not in contact, the skin between and around them is inflamed, red and elevated. There is ophthalmia, and the face and eyelids are swollen, the mouth and throat are sore, and the patient spits largely a tenacious saliva. About the eleventh day, there is an abatement of the inflammation, both pustular and cutaneous. The pustules, or many of them, crack, and the contained fluid oozes out; they flatten, and by the fourteenth, have begun to dry and condense into a hard crust. From the twentieth, these crusts fall off, leaving, in a great majority of cases, a permanent depression or pit in the skin.

The case may thus terminate, without farther danger or inconvenience, and such is the history of a mild or distinct attack; but when the pustules are very numerous or confluent, we may have them spreading over and destroying the eye, extending into the throat and trachea, occasioning suffocation or severe pulmonary inflammation: and in such instances, a secondary fever arises, depending, probably, on the great degree of constitutional irritation, occasioned by so extensive and violent an inflammation of the mucous and cutaneous surfaces. This secondary fever invades at variable periods, from the eighth to the eleventh day. The tongue and mouth become dry; the pulse is very frequent and rather tense, but often feeble; the breathing is diffi cult; drowsiness comes on, increasing into coma, and the patient sinks exhausted with intolerable sufferings.

The prognosis is favorable in distinct smallpox; in the confluent form it is the reverse. Bad cases may be known from the first by an imperfect eruption, the vesicles rising very little, being rather livid than florid, and filling, or, as the phrase is, maturating, badly. If at any time the pustules flatten, and the skin becomes pale or livid, the danger is great, especially if the pulse and strength fail, and the mind is observed to wander. The occurrence of any urgent internal determination is to be dreaded, whether to the brain, as shown by delirium, coma, etc., or to the respiratory organs, with pain in the side or chest, cough and dyspnoea.

The sequelae of smallpox are often very serious. Deformity and blindness, with sometimes a permanent ophthalmia, a chronic diarrhoea, anasarca, occasionally follow it. The voice is, in some, permanently changed, and rendered disagreeable, by injury done to the soft palate. Scrofula is said to be excited to severe and rapid development, and the predisposition to pulmonary disease generally, but more especially, tubercular or scrofulous phthisis.

Autopsy. The variolous eruption is found, not only on the skin, the vascular network or rete mucosum being the seat of the pustules, but extends to the mucous tissue lining the mouth, fauces, pharynx, trachea, larynx, and rectum, and upon the conjunctiva. The structure and formation of the pustule in these positions, is not well made out. In the cutaneous integument it is multicellular. The pit is occasioned by the sloughing of a circular portion of the cutis vera.

In many subjects, the brain and its membranes are found dark with

vascular congestion. In others the lungs are engorged and hepatized, and the pleura inflamed.

Treatment. During the eruptive fever of smallpox, if we are aware of the nature of the case, there is little temptation to interfere, when the attack is mild. I know not that there is any risk or evil, in the ordinary management of fever prudently applied here. If at the time of access there are exhibited determinations to the head, lungs, stomach, &c., peculiarly violent and severe, the lancet may be used, and its effect aided by mild purgatives. The mercurials are supposed to exert here a peculiar efficacy, but of this I am not satisfied. Great gastric oppression, with foul tongue and fetid breath, require an emetic, especially if the retching be insufficient, and fail to empty the stomach of its crude contents and morbid secretions. Mild emesis can scarcely do harm, and is serviceable besides, by favoring a centrifugal determination of the fluids. It tends to relieve the infantile convulsions which precede the eruption.

Purgatives which may be used with moderation at the invasion of the eruptive fever, must be abstained from when the papulæ are forming upon the skin; after this the bowels should be opened by laxative enemata, if there be protracted costiveness.

The use of the warm bath should be one of the earliest measures in the management of the unwashed and ill clad of the lower class. It is beneficial to children attacked with convulsions, who may be relieved with the lancet cautiously employed, if the pulse be full and hard, and the face flushed; and on the other hand, if pale and feeble, may be tranquillized with small doses of the tinct. opii camph. The apartment of the sick should be well aired and perfectly clean. He should lie on a firm mattress, and if able, sit up occasionally. The cool regimen, so vastly preferable to the heating system anciently in vogue, must not, however, be carried to an extreme. It will, if urged, do harm, when the pulmonary symptoms are prominent. Nor do negroes in general bear it well, unless much modified.

Light mucilaginous drinks should form the only nourishment. The sore throat should be gargled often with tepid water, and the inflamed eyes washed from time to time with milk and other mild collyria, and carefully protected from light and other irritants.

To prevent the pitting, so much feared, many expedients are proposed. I have not confidence in any one of them. The resort to them in confluent smallpox and really severe cases is trifling, and in distinct smallpox there is little deformity left.

In the secondary fever, most advantage is derived from the mildly stimulating diaphoretics, as the infus. rad. serp., with slight additions of ether, camphor or ammonia. I employ opium, unhesitatingly and freely, when it is required to relieve the cough, dyspnoea, restlessness and other sufferings of the patient. It does not seein contra-indicated by any circumstances, but those which show a tendency to coma. I prescribe Dover's powder or the camphorated tincture.

In protracted cases, when the strength yields, cinchona is of much service. The infusion may be combined with other remedies. Extensive crusts are rubbed off occasionally by the motion of patients in bed,

leaving painful sores. These must be dusted with cinchona or finely powdered chalk, the pressure of the body frequently changed by the attendants, and extreme cleanliness inculcated.

If the "striking in" of the eruption, as the phrase is, occur, the pustules flatten and become indistinct, with failing pulse, and cold and livid surface, it is necessary to stimulate promptly and energetically, both by internal and external means.

The treatment of the convalescent requires much attention. He is covered with a new and highly susceptible integument, and is specially liable to the ill effects of exposure and alternations, from which he must be guarded strictly by proper clothing. His diet should, for a long time, be plain and unstimulating, though nutritious.

Variolous contagion is both palpable and impalpable. It may be communicated palpably by contact with the diseased person or with fomites, and by inoculation, or the direct insertion of smallpox matter into a wound. It is also capable of diffusing itself impalpably through the atmosphere. At what stage of the case a sick body becomes thus, a focus of contagion, is not clearly known-perhaps from the seventh day, when a peculiar odor or effluvium begins to be given off. It is strange to see so much stress laid upon the etymological meaning of the word contagion. Contact is undoubtedly necessary with the cause of disease, "causæ non agunt, ubi non sunt." It is altogether unnecessary to come in contact with the sick person from whom the contagious effluvium, the cause, emanates.

The latent period, the interval between infection and invasion, is also doubtful; it is usually rated at from nine to fourteen days. The effects of inoculation show themselves earlier-about the fourth day.

Smallpox attacks the same person but once-a rule clear and posi tive, though not without exceptions. This exemption gave great importance to the practice of inoculation, which enabled the subject to select his own time and circumstances for suffering the disease. It is difficult to account for the immense difference in violence and mortality between the casual and inoculated smallpox.

Variola is liable to many modifications in history and character, some of which have been pointed out and separated in common language by special denominations, while the strong similarity which they present to each other and to the common stock of all, is indicated in the use of a word now become familiar everywhere, Varioloid.

All the old writers speak of irregular forms of smallpox. Sydenham is particular in detailing the varieties which the disease offered, in the several years of its epidemic occurrence under his own notice. Lieutaud speaks of a "spurious smallpox," occasionally taken for the legi. timate. Parr tells us that "the varieties of smallpox are numerous." It was only among the English, and not by them until the time of Heberden, that Varicella (chicken-pox) was distinguished from smallpox. Morton, of the time of Sydenham, speaks of it as "mild smallpox." His contemporary must so have regarded it, if he met with it at all. And though it is usual to talk very positively of the distinctions between the two, yet we are not always able to mark them so clearly.

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