however, to receive the testimony of many able and distinguished physicians, who have carefully employed the nitrate in appropriate cases, that its efficiency is equal to what Dr. Brocklesby claimed for it, and that the results to which I called the attention of the profession in 1848 have been confirmed; and that cases thus treated are, to a great extent, exempted from cardiac complication; and that, if attacked with heart symptoms, the inflammatory process is mitigated and controlled; and also that the duration of the acute stage and the intensity of the inflammatory symptoms are diminished; and the convalescent period-which every one who recollects when acute rheumatism was treated by bleeding, calomel, antimony, and opium, knows to have been most tedious and protracted-at the present time is seen to be moderate and limited, the patients quickly recovering their vigour and bodily energy. One cause of this more favourable stage of convalescence arises from the diminished destruction of the blood corpuscles which occurs in cases of acute rheumatism treated by the nitrate of potash. That peculiar pallor and exsanguious look which was so characteristic of the convalescent stage of patients treated by bleeding and antimony is rarely seen to the extent formerly witnessed. There is thus less reparative work to be done. Nutrition and stimulants in moderation more quickly restore the blood to a healthy and invigorating condition; and the healthier, even ruddy, aspect which quickly follows such a treatment is the best proof that these principles of therapeutics are both practically and theoretically sound." ART. 19.-Remarks on the present Prevalence of Small-pox. By Dr. GEORGE Budd. (British Medical Journal, May 9, 1863.) It is impossible to consider the wonderful protection against their own recurrence given by small-pox and other members of that peculiar group of diseases which, as a rule, occur but once in life, without having attention arrested by the general mitigation of smallpox that results when the infection, instead of being received through the air by casual exposure, is given by inoculation-in other words, by direct implantation of the infectious matter on the skin. Before Jenner's memorable discovery of the power of cow-pox to protect from small-pox, when the practice of inoculation with smallpox matter prevailed in this country, it was estimated that, if the subjects for inoculation were well selected, small-pox communicated by inoculation was something like a hundred times less fatal than small-pox taken in the natural way. Notwithstanding the remarkable mitigation of the disease by inoculation, the benefits resulting from the practice to society in the aggregate were not, as is well known, so great as might have been expected. The mortality among those actually inoculated was indeed diminished in about the proportion just stated; but many persons neglected to be inoculated, or to have their children inoculated; many others entertained a prejudice against the practice; and these were worse off than they would have been if the practice of inoculation had not been introduced, because this practice, by multiplying sources of infection, greatly increased their chance of taking the disease. It is seen, indeed, by reference to the bills of mortality, that, after the practice of inoculation had become general, the number of deaths from small-pox increased rather than diminished. The effect of inoculation on the individuals inoculated, and on the race, which, through Jenner's discovery, had almost come to be a subject of mere historical curiosity, was again made of great practical interest by the outbreak in Dorsetshire, last summer, of the pustular disease in sheep, which from its striking resemblance to human small-pox has been termed variola ovina, or the small-pox of sheep. This disease resembles small-pox in the character of the pustules, in its severity, and in its communicability through the air and also by inoculation with matter taken from a pustule; but there is reason to believe that it is specifically different from human smallpox. The disease is not prevented by a previous vaccination with the matter of cow-pox, as small-pox in man is: it is not communicated to the shepherd; and all attempts to give it by inoculation to other domestic animals, even those most allied to the sheep, have failed. But, although apparently specifically different from human small-pox, it has been found, like human small-pox, to be very much less fatal when communicated by inoculation than when taken in the natural way; and many of the flock-masters of Dorsetshire, at the risk of multiplying sources of infection, had recourse to inoculation to save their flocks. The circumstance that inoculation mitigates this disease in sheep, as it does small-pox in man, warrants the inference that the mitigation by inoculation is not peculiar to this or that disease, but comes under some general law. Now, when inoculation for small-pox is practised on a person susceptible of the disease, this is what happens:-The development of a small-pox pustule immediately begins at the inoculated spot. On the third or fourth day after inoculation, there may be seen at this spot, on an inflamed base, a small vesicle, which can already be recognised as a small-pox vesicle by the peculiar depression or cupshape of the summit, that characterizes the vesicles of small-pox and cow-pox. Without much general illness, this vesicle becomes pustular and ripens, just like any individual vesicle of ordinary smallpox. On the evening of the seventh, or early on the eighth day, when the pustule at the inoculated spot is fully developed, fever occurs like the eruptive fever of natural small-pox, and issuing, as this does, on the second day, in an eruption of small-pox over the body. The disease runs its subsequent course exactly as natural small-pox does, except that, in the great majority of cases, it is much milder. There is, then, in small-pox resulting from inoculation a twofold development of the small-pox pustule. First, in point of time, there is the development of a single pustule at the inoculated spot; and when this pustule is ripe, or nearly ripe, a general eruption of small pox makes its appearance, to run its appointed course. In natural small-pox, on the contrary, small-pox pustules are developed once only. The virus has no visible effect for seven or eight days after infection; fever then sets in, issuing on the second day in a general eruption of small-pox. We may conceive, then, that in inoculated small-pox there is a double infection: one simply local, resulting from the engrafting of the small-pox at the inoculated spot, which takes effect immediately; the other a general infection, which, as in natural small-pox, produces a crop of small-pox pustules after eight or nine days; and as small-pox, when it has once run its course, modifies the system in such a way that the disease cannot occur in that individual again, so the development of the single pustule at the inoculated spot has the effect of gradually exhausting, as it proceeds, the original susceptibility to the disease, and thus mitigates the effect of the general infection. If this reasoning be just, the remarkable mitigation of small-pox effected by inoculation depends on the agency by which the disease prevents its own recurrence, and an important inference may be drawn. As cow-pox prevents future small-pox, at least for some years, as effectually as small-pox itself does, it may be inferred that, if vaccination be practised soon after the infection of small-pox is received through casual exposure, the development of the vaccine vesicle (which does not sensibly differ in rate of growth or appearance from the small-pox vesicle resulting from inoculation) will get the start of the small-pox infection, and thus have the same effect in mitigating the disease as inoculation with the matter of small-pox generally has. When, therefore, small-pox occurs in a house, immediate vaccination may be recommended to all the inmates who can be supposed to be susceptible of small-pox infection, not only to prevent future infection from small-pox, but also with a reasonable expectation of mitigating the disease, should infection have already taken place. By parity of reasoning, the mitigation known to be effected by inoculation in the small-pox, so-called, of sheep, would imply-what has not, that I know, been put to proof-that the disease in these animals cannot occur in the same individual twice. ART. 20.-Small-pox in London. By the Metropolitan Associate of Officers of Health. (British Medical Journal, May 9, 1863.) At a special general meeting of the Metropolitan Association of Officers of Health, held on the 25th April, at 8, Richmond-terrace, it was resolved unanimously to adopt the following circular, prepared by the General Purposes Committee, relating to the recent alarming progress of small-pox in the metropolis, and to the necessity of a combined effort to arrest the further diffusion of the disease: The Association having taken into their consideration the present prevalence of small-pox in London, deem it to be their duty to call the attention of the guardians of the poor and other local authorities of the metropolis to the subject. They regret to find that the epidemic is still on the increase. In some of the metropolitan districts the mortality has already attained alarming proportions. It can scarcely be hoped that others equally populous will remain exempt, unless energetic measures are taken to arrest the further progress of the outbreak. While there can be no doubt that the prevalence of the disease is mainly attributable to the neglect of vaccination, and to the defective and unsatisfactory manner in which the operation is too frequently performed, and that if good vaccination were universal, small-pox would be almost unknown, it is not the less apparent that the prolonged residence of infected persons in rooms occupied by others, the exposure of such persons in the streets, in public conveyances, or in the waiting-rooms in hospitals, and the absence of adequate means of isolation, have been the immediate agents in bringing about the recent rapid diffusion of smallpox. During the present epidemic, these causes are in operation to a far greater extent than they were in that of 1859-60. In consequence of the insufficient size of the Small-pox Hospital, and the absence of any other provision for the reception of cases, persons having small-pox are daily applying in numbers for admission into the general hospitals. Every such application is necessarily refused; the sufferer is sent back to his home, there to become, against his will, a source of infection to his neighbours. The Association are of opinion that, whenever a case of small-pox occurs in a populous locality, the patient ought, in the interests of public health, to be removed as soon as possible; and that, in order to facilitate such removal to the utmost, it is not only necessary to provide for the gratuitous conveyance of small-pox cases, but for their reception and treatment. For this purpose, it appears to them indispensable that, during the continuance of the present epidemic, temporary buildings or wards should be opened in such situations as may be best suited for the purpose, on the double ground of distance from inhabited houses and facility of approach. As regards vaccination, it is desirable that every facility should be offered for the gratuitous vaccination of all who are willing to apply for it, whether they have been previously vaccinated or not; and that the times and places appointed by the guardians for vaccination should be notified by bills posted in prominent places. It is further necessary that, in all those districts in which small-pox is prevailing, and in which there is reason to believe that vaccination has been neglected, personal inquiries as to the cause of this neglect should be made by inspectors temporarily appointed for the purpose, who should be empowered by the guardians to take proceedings under the Vaccination Acts Amendments Act, 1861, in all cases of wilful refusal to comply with the requirements of the law." ART. 21.-On the Use of Quinine in Small-pox. (Pacific Medical and Surgical Journal, September, 1862.) "In June, 1856," says Dr. Mouser, "I read an article on this subject before the Sacramento County Medical Society, founded on observations made in 1853. The article referred to was published in the first number of Dr. Morse's California State Medical Journal, July, 1856. "At that time I was fully convinced of the efficacy of the remedy, and resolved to give it further trial should opportunity offer. It has not been my fortune to meet with an opportunity to test it since until March of the present year, when I took charge of the Smallpox Hospital in this city. My first observations having been made in a malarious district (Sacramento), left me in doubt as to the propriety of pursuing the same treatment here, where intermittents are not so prevalent, and other diseases seem to be much less modified by malarious influences. "For the first two months I did not administer quinine to my patients, except where there seemed some special indication for it. I found twenty-nine patients in the house when I took charge of it, and admitted sixty more during the two succeeding months, making a total of eighty-nine treated during this time. Of these, forty-four were discharged cured, eighteen died, and twenty-seven remained. "At this time (May 20th) I commenced the use of quinine, and administered it in two-grain doses every three hours, to all of my patients, from the time they entered the house until all febrile symptoms had subsided and desiccation was fully established. After which I ordered the same dose three times a day until they were entirely well. From May 20th to August 1st, twenty-five were admitted, making the whole number treated fifty-two; of whom forty-five were discharged cured, one died, and six remained. During the prevalence of this epidemic, I treated thirty cases outside the hospital, nearly all on the same plan, without the loss of a single one. 66 Erysipelas prevailed to a considerable extent in the hospital, following closely the subsidence of small-pox, but was much less frequent after the adoption of the quinine treatment. "How much of the difference in these results depends on medical treatment, and how much on circumstances other than this, I do not pretend to say. We should not lose sight of the fact that an epidemic on the decline is said to be less fatal than at its commencement. There is one other circumstance that probably had an important influence in reducing the mortality in the last two months, which is, the difference in the accommodations first and last. When I took charge of the place, eight patients were crowded into each room, about fourteen feet square; but some time in May ample provision was made for room, so that there was no more crowding." |