452 OF HEAD SYMPTOMS BY ANTIMONY AND OPIUM. and Dover's powder are the best means of relieving both these morbid conditions; the remedy being given either once or twice a day, or more frequently, according to the urgency of the symptoms. The amount of abdominal pain and tenderness must be ascertained every day; and a few leeches must be applied to either iliac region if the tenderness seem considerable, or if the child appear to suffer much from pain in the abdomen, or if the diarrhoea be severe. If depletion be needed, the application of but a small number of leeches will generally meet the requirements of the case, while copious bleeding is neither useful nor well borne. Even in children of ten years old I never apply above four or six leeches, and it is very seldom that any occasion arises for a repetition of the bleeding. The application of poultices of linseed meal or scalded bran to the abdomen, and their frequent repetition, is a very valuable means of relieving the griping pain which often distresses children; and in most cases it is desirable to make trial of them before having recourse to depletion. There is but one other class of symptoms likely to occur during the first week of the fever, to the management of which I have not yet referred; namely, those signs of cerebral disturbance which are sometimes so serious as to call for treatment. The early occurrence of delirium, though it generally implies that the disease will assume a rather serious character, yet does not of itself indicate the necessity for taking blood from the head; but if the child be quiet and generally rational during the day-time, and though dull yet not in a state of stupor, while the delirium at night is of a tranquil kind, and interrupted by frequent and tolerably quiet slumber, it will generally suffice to apply cold to the head, and to keep the apartment cool and absolutely quiet. The irritability, excitability, and restlessness at night, accompanied by loud and noisy delirium, from which the child gets scarcely any respite all night long, are frequently arrested at once by an opiate. Unless some abdominal complication should forbid its employment, the tartar emetic is in these cases a most valuable adjunct to the opium.1 A draught containing five minims of laudanum, and a quarter or a third of a grain of tartar emetic, will be a suitable anodyne for a child of five years old, and may be repeated night after night with almost magical effect. When the delirium at night is succeeded during the daytime by an almost equally distressing condition of excitement, accompanied with a burning skin, and a very frequent though feeble pulse, the continuing the tartar emetic in slightly nauseating doses, combined with smaller quantities of laudanum, every four hours, will often be of essential service. If, however, there be any injection of the conjunctivæ, or if the head be in a marked degree hotter than the surface generally, or if any other indication of disorder of the brain be present besides the delirium and excitement, leeches should be applied to the head, though depletion should in these cases be used sparingly; and after the abstraction of blood by the application of half a dozen leeches, The remarks of Dr. Graves, in his Lectures on Clinical Medicine, vol. i. p. 207, on the use of Tartar Emetic and Opium in Fever, are little less applicable to its management in the child than in the adult. TREATMENT OF HEAD SYMPTOMS-DEPLETION. 453 we should return to the tartar emetic and opium, remembering that we have no active inflammation to combat, nor even that intense cerebral congestion which we occasionally meet with under other circumstances, and safety from which is found only in very active depletory measures. Depletion is also called for in cases, not very commonly met with, in which even at an early period of the disease there is a great degree of stupor, and apathy, with a dilated and sluggish pupil, but little complaint of thirst, and none of headache or local suffering. By the cautious abstraction of blood we may here sometimes anticipate the development. of the more alarming head symptoms, which, if we leave the patient alone, lulled into a false security by the absence of any signs of active mischief, will not fail before long to manifest themselves. As a general rule, indeed, it must be our object in the management of this fever to anticipate the head symptoms as far as possible, to keep down the excitement and quiet the delirium by tartar emetic and opium, or by the local abstraction of blood: a purely expectant course of practice is neither wise nor safe. The head symptoms, which come on slowly and almost imperceptibly at a more advanced stage of the disease, are sometimes very unmanageable. Depletion is no longer of service, but blisters may be applied to the occiput and nape of the neck with advantage; they should, however, not be kept on so long as to produce complete vesication, but only for a time sufficient to obtain their counter-irritant effect, and to allow of their reapplication in the same neighbourhood, if not upon exactly the same spot, on the next day. The unfavourable termination of the disease in this stage is, I apprehend, due, in the great majority of cases, to the development of some previously latent tendency to tubercular hydrocephalus; while the more active head symptoms, which are met with at an earlier period, are often merely the result of functional disturbance, and therefore often yield to wellconsidered treatment. In mild cases of the disease, the expectant treatment, usually appropriate during its early stages, may be continued throughout its course; great caution being exercised, as the child begins to improve, to prevent its committing any error in diet. When severe, however, the second week often brings with it a train of symptoms that require many modifications in the plan of treatment. The vital powers need to be supported, and the nervous system requires to be tranquillized; and this is to be attempted by means similar to those which we should employ in the management of fever in the adult. The mere diluents which were given during the previous course of the fever must now be exchanged for beef or veal tea or chicken broth, unless the existence of severe diarrhoea contraindicate their administration; in which case we must substitute arrow root, milk, and isinglass, for animal broths. In a large proportion of cases nutritious food is all that will be required; but wine is sometimes as essential as in the fevers of the adult; and the indications for giving it are much the same in patients of all ages. Even though wine be not necessary, I generally give some form of stimulant during the second and third weeks of the affection. The 451 TREATMENT OF REMITTENT FEVER. prescription' which I usually follow is one much praised under such (No. 34) 1 R Acid. Hydrochlor. dil. m xxxij. Spt. Æth. Sulph. co. 3j. m xx. Syr. Rhæados, ziv. Mist. Camph. Ziiiss. M. 3iv. 6tis horis. circumstances by Dr. Stieglitz, of St. Petersburgh, the chief ingredients of which are ether and hydrochloric acid. It seldom disorders the bowels if they be not much disturbed at the time of commencing its administration; while, if this be the case, a small dose of Dover's powder, as a grain or a grain and a half at bed-time, will be doubly useful, both in checking the tendency to diarrhoea, and in procuring sleep for the child, who, without it, would probably be watchful and delirious all night long. While any severe abdominal symptoms are present, I abstain from the use of the acid mixture, but give the mercury with chalk, and Dover's powder, every four or six hours, to which I occasionally add an opiate enema at bed-time, and support the strength by food and wine as may be necessary. The only complication that is apt to be troublesome is the bronchitis. Usually, however, the cough to which this gives rise is an annoying rather than a dangerous symptom; and it is in general more harassing at the commencement of the affection, and again when convalescence is beginning, than during that time when the graver symptoms are present. A little ipecacuanha wine, nitrous ether, and compound tincture of camphor, will usually relieve it, to which it may occasionally be expedient to add the application of a mustard poultice to the chest. The convalescence is often extremely tedious; the child is left by the disease not only extremely weak and emaciated, but with its digestive powers greatly impaired. It is often many days before the stomach is able to digest any solid food; even a piece of bread will sometimes irritate the intestines, and bring on a return of diarrhoea. The appetite seems sometimes quite lost; tonics either do no good, or are actually injurious by rekindling the fever; or symptoms supervene which seem to threaten the development of tubercular disease, a consequence that not very seldom follows severe attacks of remittent fever. Under such circumstances, change of air, and the removal, if possible, to the sea-side, are often the only means of restoring the child to health; a means which you may recommend with the more confidence since it hardly ever fails to be successful. SMALL-POX. 455 LECTURE XXXVIII. SMALL POX-checked but not extirpated by vaccination-its chief mortality among children-rate of mortality in cases of the disease undiminished during the last fifty years. Its symptoms-their early differences from those of the other exanthematacharacters and progress of the eruption-peculiarities of confluent small-pox-dangers attending the maturation of the pustules, and the secondary fever.-Treatment. MODIFIED SMALL POX-its low rate of mortality-its peculiarities. CHICKEN POX-its symptoms, and differences from small-pox. UNTIL the commencement of this century, the disease to which I wish to-day briefly to call your attention possessed a degree of importance far greater than that which attaches to it at present. Before the introduction of vaccination, the small-pox was a disease of almost universal prevalence, causing at the least eight per cent. of the total mortality of this metropolis, and disfiguring for life thousands whom it did not destroy. Its loathsome character, and its formidable symptoms when it attacked the constitution at unawares, led to the adoption of variolous inoculation, by which the disease was communicated in a mild form, and under favourable conditions; and persons having undergone comparatively little suffering, and having been exposed to still less danger, enjoyed by this means almost complete immunity from subsequent attacks of small-pox. But, great as its benefits were, variolous. inoculation perpetuated at all times, and in all places, a disease which would otherwise have obeyed the general law of epidemics, and would have had its periods of rare occurrence as well as those of wide-spread prevalence. Thus, as has been well observed, while the advantages of the practice were great and obvious to the individual, to the community at large they were very doubtful. No such drawback exists to detract from the benefits of vaccination, though unfortunately our present experience does not altogether justify the sanguine expectations entertained concerning it by its first promoPeculiarities of climate oppose a serious barrier to its successful introduction into some countries, and even in our own land individuals are occasionally met with in whom vaccination altogether fails, or over whom it seems to extend but a partial or a temporary protective power. But I will not enter on the question of the merits of vaccination, nor of the circumstances that impair its preservative power, or call for its repetition for though the subject is one important alike to the physician and the philanthropist, I have had no opportunities of forming a judgment concerning it which are not alike open to you all. In the writings of Dr. Gregory, physician to the Small-Pox Hospital, and in the treatise on vaccination by Dr. Steinbrenner, to which the Institute 1 Dr Duncan Stewart's valuable Report on Small-Pox in Calcutta, and Vaccination in Bengal, 8vo., Calcutta, 1844, shews conclusively that the peculiarities of the Indian climate present obstacles to vaccination such as greatly to detract from its value; while it is to be feared that they are of a nature which the greatest care will never wholly overcome. of France adjudged a prize in 1835, you will find everything that either large experience or unwearied research can bring to its elucidation. Öne fact which it behoves us always to bear in mind, is, that albeit the prevalence of the disease has been greatly checked by vaccination, small-pox is still one of the most fatal maladies of this country; and further, that it selects its victims, as heretofore, chiefly from among children and young persons,-nearly three-fourths of the fatal cases of this affection occurring before the age of five, and more than ninetenths before the age of fifteen years. In spite, too, of the increase of medical knowledge during the past fifty years, the proportion of small-pox cases that terminate fatally has been estimated by the best authorities to be as great now as it was half a century ago. To some extent, perhaps, the very diminution in the frequency of the disease may have had an unfavourable influence on its issue in individual cases; for practitioners, meeting with it now less often than medical men in former days were wont to do, are not so familiar with the meaning of those minuter variations in its symptoms, from which important practical conclusions might be drawn, by those who knew how to interpret them aright. Let me therefore urge you to watch every case of this formidable disease that may come under your observation with most minute care, lest you misinterpret the symptoms, or mistake the treatment of some patient affected with it, whose well-being may be dependent on your skill. For my own part, I cannot pretend to give you more than an outline sketch of its characters, and must refer you to the writings of others who have had greater opportunities of watching it than have fallen to my share, to fill up the portrait. The early symptoms of small-pox are those of approaching fever, and if any other febrile disorder be prevalent at the time of their occurrence they may possibly be taken for the indications of an approaching attack of the prevailing epidemic. There are, however, some peculiarities in the mode of onset of small-pox which are sufficiently characteristic of it even in the child, and which generally distinguish it from either of the other eruptive fevers. The sickness with which it sets in is in general severe, and the disorder of the stomach often continues for fortyeight hours, during which time vomiting recurs frequently. In measles there is comparatively little gastric disorder; and the vomiting that often ushers in scarlatina, though frequently severe, is not of such long continuance. In young children we lose those complaints of intense pain in the back which in the case of older patients often awaken our suspicion; but on the other hand, the severity of the cerebral disturbance is an important feature in the early stage of the disease. At the commencement of measles, the brain is in general but little disturbed; in scarlatina, delirium often occurs very early; but in small-pox the condition is one rather of stupor than of delirum, while convulsions sometimes take place, and continue alternating with coma for as long a period as twenty-four or thirty-six hours. Lastly, though the skin in small-pox is hot, it is neither so hot nor so dry as in scarlet fever; the tongue does not present the peculiar redness, nor the prominence of its papillæ, which are observable in scarlatina; neither is there any of the |