TREATMENT OF FEVER.

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minims of tincture of squills to the mixture of serpentaria and ammonia.

The treatment of fever with bowel irritation is often most embarrassing; though the difficulty may perhaps be often avoided, where the case comes sufficiently early under our notice, by the rigorous exclusion of all the influences, whether in the form of medicine, or diet, or external circumstances, which tend to favour this complication. On this account, all irritating purgatives should be avoided, amongst which must, as regards this disease, be included the saline ones, from their effect upon the secretion from the small intestines; and, at the commencement of every fever, where a laxative is indicated, and there is reason to apprehend a possibility even of this complication, the safest that can be used is the hydr. cum cret., followed by the castor-oil, or where we are afraid of the latter offending the stomach, the hydr. cum cret. with rhubarb. The same precaution is necessary in regard to diet-it should from the first be of the most unirritating character; barley-water, milk and water, or even milk with bread, should constitute the whole, excepting perhaps a little tea. Milk, when not disagreeable to the patient, is perhaps the best article of diet in fever, until stimulants become necessary, and is to be preferred to the beef tea so much used in our hospitals, as being less likely to cause or increase diarrhoea. There can be little doubt that the tendency to diarrhoea is much increased by impure air, especially that loaded with effluvia from organic matter, and therefore ventilation and cleanliness are here of special importance. In cases of fever with bowel complication, we may allow of a lower temperature than in some other forms; as, for instance, chest-affections.

One great rule is to avoid officious practice: the best medicine will generally be found to be the bicarbonate of soda in peppermint water, with a little mucilage; when the bowels are much relaxed, a clyster should be administered of about two ounces of starch, with from half a drachm to forty minims of laudanum, or an ounce of syrup of poppies. When the diarrhoea is excessive, chalk-mixture with some additional astringent, as a little tincture of catechu or about fifteen grains of extract of log-wood; though it is better, if possible, to prevent the diarrhoea by careful diet than to restrain it with astringents. When the powers of life appear to be failing, the serpentaria should be used with about fifteen grains of aromatic confection, and, if necessary, from three to five of sesqui-carbonate of ammonia; wine and brandy are not so early admissible in this as in the other complications; but the former may be administered in arrow-root when the pulse becomes feeble and the tongue brown. When there is much irritability of stomach, which is not an uncommon occurrence, besides the application of sinapisms, the occasional use of a tea-spoonful of brandy in a wine-glass of soda-water will often give great relief.

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XXVIII.

ERUPTIVE FEVERS.

THE general laws of idiopathic fever are those of the exanthems. Of these, indeed, typhus might be reckoned as one, excepting that the exanthems are generally more definite in their symptoms, course, and character, under every variety of climate, season, age, and habit of body: they are, in fact, the results of specific agents upon the system, producing respectively their specific effects, in every instance, similar in kind though varying in intensity. They are characterised each by its peculiar rash, efflorescence, or eruption, whence the terms exanthem (from Cavew, effloresco), and eruptive fevers. They have also each its period of incubation or interval between exposure to the poison and invasion of the febrile symptoms; the period of eruptive fever; the period of maturation of the eruption; and in most, the secondary fever. The fevers to which this description applies are, small-pox, measles, scarlatina, the slight disease varicella or cowpox; probably also, the plague, and in most respects erysipelas.

They have also the peculiarity that one attack protects the individual from a second of the same form of epidemic; this law does not, however, apply to plague, and is reversed in the case of erysipelas. Individual exceptions also occur in all.

In the cases of small-pox, measles, scarlatina, and plague, we have pretty certain evidence not only that the poison of these diseases is communicated by intercourse with those labouring under them; or in other words that they are contagious, but that they never arise from any other cause than this specific contagion, exhaled probably by the breath of persons affected by them, and also existing in the emanations from the surface of the bodies, as is shown by their communicability by inoculation, and by their conveyance in clothes from affected persons; but also that as we now witness them they are never produced in any other way. This is not true in the case of erysipelas though it is undoubtedly contagious-and has been questioned in regard to scarlatina; though the occurrence of what are termed sporadic cases of the latter, or single cases, in which no such communication can be traced, may possibly be accounted for by the extreme subtlety of the poison.

Notwithstanding that the cause of the majority of these diseases is contagion, this contagion is controlled by a variety of circumstances, affecting not only individuals but the whole population of any town or district, as is shown by their spreading at times with great rapidity, and at times assuming a peculiar virulence. These epidemic influences are, no doubt, dependent in a great measure upon obscure atmosphere or telluric conditions; but they are also greatly aggravated by circumstances arising out of the habits and conditions of various populations: such are the deficiency of ozone or allo

tropic oxygen, existing in very densely populated districts,-the effluvia arising from defective drainage, and the filth in the dwellings of the masses, the allowing noxious particles to accumulate, from the want of personal cleanliness, and the like.

The pathology of these eruptive fevers may be summed up as the combination of an inflammation of the surface of a specific character, with a constitutional fever, of a typhoid type; but this local inflammation is not the cause of the fever, since in all cases it follows instead of preceding it. The internal inflammations also which occur are of a specific character in each respectively, and, therefore, to be regarded as the effects of the poison. The danger in these fevers depends not so much upon the extent of the external inflammation, since it is so important a part of the pathology of some of them, that there is danger in arresting the course of it-as upon the internal inflammation, and also upon the affection of the general system, especially the depressing influence of the morbific agent upon the circulation.

Small-pox is characterised by a tolerably uniform period of incubation, varying from seven to twelve days, and an eruptive fever of about forty-seven hours, a period of from seven to eight days from the appearance of the eruption to its completion, and, in severe cases, secondary fever of three or four days more.

The fever of small-pox commences, like most others, with chilliness and languor, quickly followed by heat, with a dry skin, severe headache, and, in the majority of cases, an intense dull aching pain in the loins; sometimes nausea and vomiting, a hard frequent pulse, a whitish, furred, and rather dry tongue. These symptoms are not all present in every case at the commencement even of a severe attack. Much stress is laid by some authors upon the pains in the loins, and it is, perhaps, one of the most frequent concomitants of the eruptive fever; and its occurrence, when small-pox is at all prevalent, should, to say the least, excite our suspicions. Sickness is another frequent symptom at this period, but not so common as the last-mentioned, and to say the least, it is not so constant in this as in the inflammatory fever of scarlatina. Some severe cases commence with convulsions, and others, which are still worse, with violent delirium or coma.

After the fever has lasted, as before stated, about forty-eight hours, though the period admits of variation of from thirty-six to sixty, the eruption begins to make its appearance. To this it is most important to pay close attention, as up to this period, our diagnosis between small-pox and some other exanthems, can be only conjectural. It first appears at least thirty-six hours from the commencement of the fever (which is later than in scarlatina, but earlier than in measles), first of all in the face, in which respect also it differs from scarlatina, and consists, in the first instance, of minute elevated. papulæ, which feel to the finger, like small beads, or millet-seeds. These are often surrounded by an erythematous efflorescence, which, however, generally disappears after two or three days. After the face, the eruption generally appears in the wrists, the trunk, and last

of all, in the lower extremities; and, in general, the last papula do not show themselves till two days after the first; that is to say, that the eruption begins upon the third day of the fever, but fresh papulæ do not cease to come out till the fifth. The papulæ or pimples gradually enlarge, and ripen into pustules, showing a depression on their tops, on the second day. This appearance is important, as affording a distinction from the vesicles of varicella, in which the depression is not observed till later; the suppuration is complete on the eighth day of their appearance, when the pustules breaking, scabs or crusts begin to form, which fall off in four or five days more, the suppuration and incrustation observing the same order as to time in different parts of the body, as did the eruption of the pimples. This description of the progress of the pustules applies pretty exactly to all varieties of the disease. There is, however, a great difference in their number, and, in the same proportion, in the severity of the disease, the number of the pustules being, as a general rule, an exact measure of the extent to which the morbific poison has taken effect; and to which that highly sensitive and important structure, the skin, has been involved in the inflammation. In some cases there are but a few scattered over the body; in others, they are crowded together in great numbers; and that may be the case to such a degree, that there is not, as it were, room for them to remain separate, but they coalesce and run into one-another. This circumstance affords a means of distinction into two important varieties.

As long as the pustules are distinct, and retain individually their circular form (though they may be very numerous), the disease is called variola discreta, but when they coalesce and unite into irregu lar clusters, or patches of suppuration, it is termed variola confluens. In the variola discreta, or distinct small-pox, the eruption follows pretty accurately the course which has been indicated, the pustules becoming turgid and globular from being filled with pus, but retaining their central depression, from the pus being deposited not so much immediately under the cuticle, as in the areolar tissue, by which the summit of the pustule is, as it were, bound down to the cutis. As the pustules fill with pus, the parts most affected by them, as the face and wrists, become swollen, so much so that the eyes are sometimes completely closed; at the same time, there is often a feeling of tightness about the fauces, as if from swelling, and the salivary secretion is much increased. About the eighth day, a dark crust forms on the pustule, the cuticle cracks, and allows the escape of the pus, and the pustule gradually shrivels and dries, forming a scab, which, in a few days more, falls off, leaving a red skin, which does not disappear for several weeks, or a permanent depressed scar which remains for life. In this variety of small-pox the fever may be very severe at the commencement, but it subsides as soon as the eruption is complete, and recurs, after the maturation of the pustules, for three or four days in the severer cases, constituting the fever of maturation. It is by the appearance of the pustules in the face that we judge of the variety to which it belongs, according as they are distinct or confluent in that situation. Sometimes, when the pustules are nume

CONFLUENT FORM.

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rous, they touch without inosculating or uniting, when the pock is said to be cohering, constituting what is in truth a severe form of the distinct.

The confluent form manifests throughout a greater intensity and virulence in the morbid poison. The eruptive fever is more violent, and the cerebral oppression and disturbance far greater; the fever, nevertheless, being of a more decidedly typhus character, the pulse being more feeble at the same time that it is more frequent, and the tongue more disposed to be brown; the eruptive fever is shorter, the pimples making their appearance earlier about the face, but not coming out with the same regularity as in the distinct form, accompanied by a rash not unlike that of scarlatina, so much so as with shortened eruptive fever to give rise to some difficulty in the diag nosis. Sometimes, too, the eruption is not unlike that of measles, but as regards the diagnosis from the latter disease, the shortness of the eruptive fever will prove an assistance. The pimples are also less regular in their development than in the distinct form, for, though the papulæ soon lose all resemblance to that of either scarlatina or measles, by filling with fluid at their summits; they have more the character of vesicles, containing a whitish fluid which afterwards degenerates into a brownish colour, and do not plump up into true pustules: there is often all this time a livid appearance in the surface, between the confluent pustules; the swelling of the limbs and salivation is also greater than in the other variety; sometimes there are spots of purpura. There is in this form of small-pox a remission rather than intermission upon the coming out of the eruption, and this remission is often but slight, and on the fifth or sixth day rigors occur, marking the fever of maturation; but about the eighth day of the rash, and the eleventh of the fever, being the time at which the maturation is complete, there sets in the secondary fever, the intensity of which is the characteristic of the confluent disease. This is the most perilous period of the disorder; indeed, a large proportion of the fatal cases die from the tenth to the fourteenth day of the fever, rendering the second the most perilous week. Some, indeed, die of this disease in the first week, the nervous system being overwhelmed by the disease, and the patient dying of syncope. In the second week, most deaths occur, the patients dying from apnoea, through affection of the air-passages; though subsequent deaths take place, either from asthenia, owing to a want of power to recover from the depressive influence of the disease, or from the effects of some complication.

The internal inflammations which accompany this disease are mostly those of mucuos membranes, the conjunctivæ of the eyes and the lining of the fauces being commonly inflamed early in the disease, that of the trachea and bronchia generally at a later period; a low form of pneumonia may also occur towards the termination.

After the disease, especially in the severer cases, inflammations are apt to occur, which run quickly into suppurations, affecting especially the subcutaneous areolar tissue, and the eye, sometimes the joints, the pleuræ, or the lungs : empyema is a common sequel.