THE

NORTH AMERICAN

MEDICAL AND SURGICAL

JOURNAL.

CONDUCTED BY

HUGH L. HODGE, M.D. CHAS. D. MEIGS, M.D. FRANKLIN BACHE, M.D. B. H. COATES, M.D.

AND

R. LA ROCHE, M.D.

NON DOCTIOR, SED MELIORE IMBUTUS DOCTRINA.

VOL. II.

PHILADELPHIA:

PUBLISHED BY J. DOBSON, AGENT.

JESPER HARDING, PRINTER.

1826.

Eastern District of Pennsylvania, to wit

BE IT REMEMBERED, that on the 31st day of March, in the 50th year of the Independence of the United States of America, A. D. 1826, Hugh L. Hodge, Franklin Bache, Charles D. Meigs, Benjamin H. Coates, and Rene La Roche, of the said District, have deposited in this office the Title of a Book, the right whereof they claim as Proprietors, in the words following, to wit:

"The North American Medical and Surgical Journal. Conducted by Hugh L. Hodge, M. D., Franklin Bache, M. D., Chas. D. Meigs, M. D., B. H. Coates, M. D., and R. La Roche, M. D. Non doctior, sed meliore imbutus doctrina. Vol. II."

In conformity to the act of Congress of the United States, intituled, "An act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, during the times therein mentioned;"—and also to the act, entitled, "An act supplementary to an act, entitled, "An act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, during the times therein mentioned," and extending the benefits thereof to the arts of designing, engraving, and etching historical and other prints."

D. CALDWELL, Clerk of the Eastern District of Pennsylvania.



CONTENTS

OF VOL. II.

No. III.

ORIGINAL COMMUNICATIONS.

ART. PAGE.

I. Description of the Gangrenous Ulcer of the mouths of children. By B. H. Coates, M. D., one of the Physicians to the Philadelphia Children's Asylum, &c. 1

II. Case of Purpura in an Infant, attended with extraordinary symptoms. By R. M. Huston, M. D. 24

III. History of the Natural and Modified Small Pox, or of the Variolous and Varioloid Diseases, as they prevailed in Philadelphia, in the years 1823 and 1824. By John K. Mitchell, M. D., and John Bell, M. D., attending physicians at the then Small Pox Hospital. With a plate. 27

IV. Remarks on the Pathology and Treatment of Yellow Fever. Arranged from the notes of Dr. J. A. Monges, of Philadelphia. 53

V. Remarks on the Prophylactic Treatment of Cholera Infantum. By Joseph Parrish, M. D., one of the Surgeons to the Pennsylvania Hospital. 68

VI. Case of Neuralgia cured by Acupuncturation. Communicated by J. Hunter Ewing, M. D. 77

ANALYTICAL REVIEWS.

VII. Researches into the Nature and Treatment of Dropsy in the Brain, Chest, Abdomen, Ovarium, and Skin. By Joseph Ayre, M. D., &c. 79

VIII. An Essay on Venereal Diseases, and the Uses and Abuses of Mercury in their Treatment. By Richard Carmichael, M. R. I. A. With Practical Notes, &c. By G. Emerson, M. D. 109

IX. Remarks on some Means employed to destroy Taenia, and expel them from the Human Body. By Louis Frank, M. D. Privy Counsellor of her Majesty, Maria Louisa, Duchess of Parma. 114

X. Researches, Physiological and Pathological, instituted principally with a View to the Improvement of Medical and Surgical Practice. By James Blundell, M. D., Lecturer on Physiology and Midwifery at the United Hospitals of St. Thomas and Guy. 119

XI. An Inquiry into the Nature and Treatment of Diabetes, Calculus and other Affections of the Urinary Organs. By William Prout, M. D., F. R. S. With Notes and Additions, by S. Colhoun, M. D. 125

MEDICAL LITERATURE.—RETROSPECTIVE REVIEW.

XII. Tractatus de Ventriculo et Intestinis, cui praemittitur alius, de Partibus continentibus in Genere, et in Specie de iis Abdominis. Authore Francisco Glissonio. Lond. 1677, 4to. 138

QUARTERLY SUMMARY OF MEDICAL AND SURGICAL INTELLIGENCE.

ANATOMY, 155

1, Papillae of the Tongue. 2, Villi of the Stomach and Intestines. 3, Minute distribution of the Vessels of the Liver. 4, Trachea perforating the Aorta. 5, Monsters. 6, Malformation of the Heart. 7, Acephalous Mummy. 8, New Anatomical Plates. 9, A Manual of Osteology. 10, Soemmering's Work on the Anatomy of the Ear. 11, Does the conjunctiva run over the Cornea?

PHYSIOLOGY, 158

12, Electro-Galvanic phenomena of Acupuncturation. 13, Variations in Milk. 14, Hyoscyamus dilates the Pupils of the Eyes. 15, Worms in the Eye. 16, Digestion.

PATHOLOGY, 161

17, Dothinenteria—Pustules of the small Intestines. 18, Dr. Broussais. 19, Whooping Cough. 20, Antiperistaltic Globus—Globus Hystericus. 21, Non-contagion of Yellow Fever.

THERAPEUTICS, MATERIA MEDICA, AND THE PRACTICE OF MEDICINE, 166

22, Iodine. 23, Non-mercurial Treatment of Syphilis. 24, Cancer treated by Antiphlogistics. 25, Essential Oil of Male Fern as a remedy in Cases of Taenia. 26, Tincture of Bastard Saffron for the expulsion of Taenia. 27, Oil of Turpentine in Taenia. 28, Action of the Oil of the Euphorbia Lathyris. 29, Medicinal Properties of the Apocynum Cannabinum or Indian Hemp. 30, Remarkable Effects from the external application of the Acetate of Morphia. 31, Cure of Urinary Calculi, by means of the internal use of the Bicarbonate of Soda. 32, Attempt to cure Abdominal Dropsy by exciting Peritoneal Inflammation. 33, Artificial Respiration. 34, Secale Cornutum. 35, Animal Magnetism. 36, Sketch of the Medical Literature of Denmark, Sweden, and Norway. 37, Erysipelatous Mumps or Angina Parotidiana. 38, Taenia. 39, Scrophula. 40, Digitalis.

SURGERY, 192

41, Dr. Physick's Operation for Artificial Anus denied to have been performed. 42, Gangrenous Sore Mouth of Children. 43, Operation for Phymosis. 44, Lunar Caustic on Wounds and Ulcers. 45, Haemorrhage from Lithotomy. 46, Extirpation of the Parotid Gland. 47, Aneurism from a Wound, cured by Valsaiva's method. 48, Protrusion and Wound of the Stomach. 49, Oesophagotomy. 50, Retention of Urine, caused by a Stricture of the Urethra, relieved by a forcible but gradual Injection. 51, Tracheotomy. 52, Fistula Lachrymalis. 53, Aneurisma Herniosum. 54, Extirpation of the Two Dental Arches affected with Osteo-sarcoma. 55, Traumatic Erysipelas. 56, Obliteration of a portion of the Urethra, remedied by an Operation. 57, Artificial Joint cured by Caustic. 58, Epilepsy cured by Trephining.

MIDWIFERY, 205

59, Gastrotomy. 60, Caesarian Operation, performed with safety to the Mother and Foetus. 61, Extirpation of the Uterus. 62, Uterine Haemorrhage.

CHEMISTRY AND PHARMACY, 208

63, State in which Morphia exists in Opium. 64, Peculiar Principles of Narcotic Plants. 65, Relative quantities of Cinchonia and Quinia with indention in the most esteemed Varieties of Peruvian Bark. 66, Sulphate of Quinia, extracted from the Cinchona Bark, exhausted by Decoction. 67, Analysis of Rhubarb. 68, Alkaline Lozenges of Bicarbonate of Soda. 69, Presence of Mercury in Samples of Medicinal Prussic Acid. 70, Proposed Method of preparing Protoxide of Mercury by precipitation, for Medical Employment. 71, Goulard's Extract of Lead.

QUARTERLY LIST OF AMERICAN MEDICAL PUBLICATIONS, 214-16

No. IV.

ORIGINAL COMMUNICATIONS.

ART.

I. On the Epidemic of 1825 in Natchez, Miss. By Ayres P. Merrill, M. D. 217

II. History of the Natural and Modified Small Pox, or of the Variolous and Varioloid Diseases, as they prevailed in Philadelphia, in the years 1823 and 1824. By John K. Mitchell, M. D., and John Bell, M. D., Physicians at the then Small Pox Hospital. (Concluded from page 53.) 238

III. Cases of Nervous Irritation, exhibiting the Efficacy of Cold as a Remedy. By S. Jackson, M. D. 250

IV. Remarks on the Pathology of Jaundice. By G. B. Wood, M. D. 260

V. Account of a Case in which a New and Peculiar Operation for Artificial Anus was performed in 1809. By Philip Syng Physick, M. D., Professor of Surgery in the University of Pennsylvania, &c. Drawn up for publication by B. H. Coates, M. D. 269

VI. Observations on Asphyxia from Drowning, to which is added a Case of Resuscitation. By Edward Jenner Coxe, M. D. 276

ANALYTICAL REVIEWS.

VII. Traite Zoologique et Physiologique, Sur les Vers Intestinaux de l'Homme. Par M. Bremser, D. M. Traduit de l'Allemande par M. Grundler, D. M. P. Revue et Augmentee de Notes. Par M. de Blainville, D. M., &c. Avec un Atlas. Paris, 1824.

Anatomie des Vers Intestinaux, Ascaride, Lombricoide, et Echynorhynque Geant. Memoire Couronne par l'Academie Royale des Sciences, qui en avoit mit le sujet au Concours, pour l'annee 1818. Avec 8 Planches. Par Jules Cloquet, &c. &c. A Paris, 1824 297

VIII. Precis Theorique et Pratique, sur les Maladies de la Peau. Par M. S. L. Alibert. 2 Tomes. 8vo. Paris, 1810-1820. 322

IX. Thoughts on Medical Education, and a Plan for its Improvement; addressed to the Council of the University of London. Dictu Necessaria. Plin. London, 1826.

Projet de Loi, presente aux Chambres dans la Seance du 14 Fevrier 1825, par S. E. le Ministre de l'Interieur, Sur les Ecoles Secondaries de Medecine, les Chambres de Discipline, et les Eaux Minerales Artificielles. 344

MEDICAL LITERATURE—RETROSPECTIVE REVIEWS.

X. Recherches sur le Tissu Muqueux, ou l'Organe Cellulaire, et Sur Quelques Maladies de la Poitrine. Par Theophile Bordeu, Docteur en Medecine des Facultes de Paris, et de Montpelier. Paris, 1767, 12mo. 376

QUARTERLY SUMMARY OF IMPROVEMENTS IN MEDICINE AND SURGERY

ANATOMY, 395

1, Notice of a Double Male Foetus, by W. E. Horner, M. D., &c. 2, Imperfect Development of the Cerebral Organs in Monsters. 3, Imperforate Vagina. 4, Fallopian Tubes. 5, Monsters. 6, Foetus grafted into the Chest of another. 7, Foetus without a Stomach, Head or Anus. 8, Congenital Hydrocephalus, with Transposition of the Viscera. 9, Unusual Arrangement of the Aortic Branches.

PHYSIOLOGY, 403

10, Influence of the Great Sympathetic Nerve on the Functions of Sense. 11, Cutaneous Absorption. 12, Abstinence. 13, Hippomane Mancinella. 14, Cutaneous Absorption. 15, Regeneration of Divided Arteries. 16, Mineral Poisons.

PATHOLOGY, 406

17, Are we followers of Dr. Broussais? 18, Influenza. 19, Diarrhoea Infantum. 20, Tetanus. 21, Small Pox.

THERAPEUTICS, MATERIA MEDICA, AND THE PRACTICE OF MEDICINE. 411

22, Tincture of Iodine in Gonorrhoea, Bubo, Scrofula, &c. 23, Acetate of Lead and Tincture of Opium in Dysentery. 24, Powers of Digitalis in Palpitatio Cordis. 25, Tartar-Emetic Ointment in Epilepsy. 26, Antiphlogistics in Recent Cases of Epilepsy. 27, On the Efficacy of Nitrate of Silver in the Treatment of Zona or Shingles. 28, On the Remedial Effects of Camphor in Acute and Chronic Rheumatism. 29, Examination of the Question, whether the Medical Use of Phosphorus internally, is useful, injurious, or equivocal. 30, Nitrous Acid and Opium in Dysentery, Cholera and Diarrhoea. 31, Tartar Emetic in Pneumonia Biliosa. 32, Bark of the Ampelopsis in Catarrhal Consumption. 33, Obstinate Vomiting cured with Extract of Marigold. 34, Vomiting of Fat and Blood. 35, Rupture of the Spleen. 36, Chilblains cured with Chloride of Lime. 37, Local Spontaneous Combustion. 38, Dr. Painchaud on Tic Douloureux. 39, Duration of Life among the Romans. 40, Difference of Mortality from 1775, to 1825. 41, New Method of Percussion of the Thorax. 42, Acid Nitrate of Mercury. 43, Effects of Ardent Spirits. 44, Colombo Root. 45, Poison of Mushrooms. 46, Antisyphilitic Decoction of Zittmann. 47, Acetate of Ammonia, a Remedy for Drunkenness. 48, Mortality of Leeches. 49, Black Drop. 50, Doses of Calomel in days of yore. 51, Buying a good Practice. 52, Sore Nipples. 53, Anderson's Quarterly. 54, Antiquity of Cow Pox and Origin of Small Pox from it.

SURGERY, 431

55, Lithotritie, on Breaking the Stone in the Bladder. 56, The High Operation. 57, Sutures in Wounds of the Bladder. 58, Paracentesis Thoracis. 59, Stricture of the Oesophagus. 60, Wound of the Brain. 61, Luxation of the Metatarsus; the history drawn up by M. Dusol, D. M.

MIDWIFERY, 438

62, Uterine Haemorrhage. 63, Polypi of the Uterus. 64, Caesarian Section. 65, Case of Difficult Parturition. 66, Case of the Pelvis becoming enlarged.

CHEMISTRY AND PHARMACY, 440

67, L'Artigue's Process of preparing the Watery Extract of Opium. 68, Berzelius' Method of Detecting Arsenic in the bodies of Persons poisoned by it. 69, Action of Certain Metallic Substances on the Animal Economy.

QUARTERLY LIST OF AMERICAN MEDICAL PUBLICATIONS, 444-48



CONTENTS

ORIGINAL COMMUNICATIONS.

PAGE

ART. I. Description of the Gangrenous Ulcer of the Mouths of Children. By B. H. Coates, M. D. one of the Physicians to the Philadelphia Children's Asylum, &c. 1

II. Case of Purpura in an Infant, attended with extraordinary Symptoms. By R. M. Huston, M. D. 24

III. History of the Natural and Modified Small-pox, or of the Variolous and Varioloid Diseases, as they prevailed in Philadelphia in the years 1823 and 1824. By John K. Mitchell, M. D., and John Bell, M. D., attending Physicians at the then Small-pox Hospital.—With a plate. 27

IV. Remarks on the Pathology and Treatment of Yellow Fever. Arranged from the Notes of Dr. J. A. Monges, of Philadelphia. 53

V. Remarks on the Prophylactic Treatment of Cholera Infantum. By Joseph Parrish, M. D., one of the Surgeons to the Pennsylvania Hospital. 68

VI. Case of Neuralgia, cured by Acupuncturation. Communicated by J. Hunter Ewing, M. D. 77

ANALYTICAL REVIEWS.

VII. Researches into the Nature and Treatment of Dropsy in the Brain, Chest, Abdomen, Ovarium, and Skin. By Joseph Ayre, M. D., &c. 79

VIII. An Essay on Venereal Diseases, and the Uses and Abuses of Mercury in their Treatment. By Richard Carmichael, M. R. I. A., with Practical Notes, &c. by G. Emerson, M. D. 109

IX. Remarks on some means employed to destroy Taenia, and expel them from the Human Body. By Louis Frank, M. D., Privy Counsellor of her Majesty, Maria Louisa, Duchess of Parma. 114

X. Researches Physiological and Pathological, instituted principally with a View to the Improvement of Medical and Surgical Practice. By James Blundell, M. D., Lecturer on Physiology and Midwifery, at the United Hospitals of St. Thomas and Guy. 119

XI. An Inquiry into the Nature and Treatment of Diabetes, Calculus, and other Affections of the Urinary Organs. By William Prout, M.D. F.R.S. With Notes and Additions, by S. Colhoun, M. D. 125

MEDICAL LITERATURE.

XII. Retrospective Review.—Tractatus de Ventriculo et Intestinis, cui praemittitur alius, de Partibus continentibus in Genere, et in Specie de iis Abdominis. Authore Francisco Glissonio. Lond. 1677, 4to. 138

QUARTERLY SUMMARY OF MEDICAL AND SURGICAL INTELLIGENCE.

I. Anatomy. 155

II. Physiology. 158

III. Pathology. 161

IV. Therapeutics, Materia Medica, and the Practice of Medicine. 166

V. Surgery. 192

VI. Midwifery. 205

VII. Chemistry and Pharmacy. 208

QUARTERLY LIST OF AMERICAN MEDICAL PUBLICATIONS. 214

FOOTNOTES:



THE

NORTH AMERICAN

Medical and Surgical Journal.

JULY, 1826.

ORIGINAL COMMUNICATIONS.

FOOTNOTES:



ARTICLE I.—Description of the Gangrenous Ulcer of the Mouths of Children. By B. H. Coates, M. D. one of the Physicians to the Philadelphia Children's Asylum, &c.

Having had opportunities of witnessing the ravages and unmanageable character of this destructive disease, I have long and deeply felt the want of some written account, both of the malady, and of a proper mode of treatment. Some research and observation, made in consequence of this feeling, have terminated in the acquisition of more fixed ideas, and of a practice hitherto successful. This convinced me, that it became my duty to lay the result of these inquiries before the public, for the benefit of others. There is, perhaps, no stronger and more peculiar reason for wishing American physicians to write, than the opportunities they possess, of describing and recording many important varieties of morbid affection, which were either unknown to our predecessors, or the descriptions of which, uncombined and uncompared, are only to be found by searching among the more neglected tomes of a public library. Of this, the present case will afford a fair example; as well as an instance of an American physician, who had described the disease from nature, having, from want of encouragement, false modesty, or some other cause, kept it back from publication.

Ever since the establishment of the Children's Asylum, under the care of a committee of the guardians of the poor, of the city and liberties of Philadelphia, in the spring of 1819, this useful institution has been annually visited by the new and distressing scourge of which we are treating. It has here prevailed in a considerable number of cases, forming the principal source of anxiety and trouble during the winter season, and annually sweeping off its little victims, in a manner rendered peculiarly awful by its insidious approach, its loathsome effects, and its apparently uncontrollable progress. Various scattered cases of a similar affection have come within my knowledge, during the last few years; occurring in the practice of several physicians, as well as in my own. In no place, however, near Philadelphia, other than the above, has there existed, so far as I know, a sufficient number of cases at the same time, to enable a physician to examine it in much detail, or to make comparative trials of different modes of treatment, so as clearly to determine the most successful.

References to Authors.—The notices of this complaint given by authors, to which I have been enabled to refer, are few, and generally too scanty to supply much means of forming a satisfactory judgment, or a practice in which confidence can be reposed. They consist, principally, of the mere mention of an affection resembling that of which we treat; and, in some instances, it is even doubtful whether they are describing the same disease. No notice is taken of this affection in any of our common books; with the exception of the last edition of COOPER'S Surgical Dictionary,[1] and of UNDERWOOD'S work on diseases of children. It is there described under the erroneous title of cancrum oris. A reference is given to PEARSON'S Surgery; and the article in the Dictionary is taken exclusively from that work. As this is the only authority with which I am acquainted, that gives a tolerably full account of a disease somewhat similar to that of which we are treating, I have concluded to extract the whole passage, in the words of the author.

"The canker of the mouth is a deep, foul, irregular, foetid ulcer, with jagged edges, which appears upon the inside of the lips and cheeks; and is attended with a copious flow of diseased saliva.

"This disease is seldom seen in adults; but it most commonly attacks children, from the age of 18 months, to that of 6 or 7 years. When the ulceration begins at the inner part of the lip, it exhibits a deep, narrow, sulcated appearance, and quickly spreads along the inside of the cheek; which becomes hard, and tumefied externally. The gums are very frequently interested in this complaint, and, in such cases, the teeth are generally found in a loose and diseased state; matter is often found in their sockets, and abscesses sometimes burst externally through the cheek, the lip, or a little below the maxilla inferior: and it is not uncommon to see an exfoliation of the alveolar processes, or even of the greater part of the lower jaw. Among the children of poor people, where this disease is neglected or mismanaged at the beginning, a dreadful gangrene will sometimes supervene.

"The remote causes that give origin to this disease are not very obvious. I think it occurs most frequently among children that live in a marshy situation; that are sustained by unwholesome food; and where a due attention to cleanliness has been wanting. The cancrum oris has been described by some writers, as a complaint very common in England and Ireland, where it is sometimes epidemical among infants. It, however, is commonly seen in other kingdoms, and prevails more especially in those houses where a great number of children are crowded together. I am not able to determine whether it is or is not contagious.

"But adults are not wholly exempted from this morbid affection, and it is not easy in all cases, to distinguish the cancrum oris from a cancerous or venereal ulcer in the mouth; since the uvula, tonsils or fauces may be the seat of each disease. I have seen ulcerations on the uvula and tonsils, with all the marks of a venereal sore, in patients where the presence of such a virus could not be suspected; and by treating them as canker of the mouth, they have been speedily cured.

"The canker of the mouth ought to be distinguished from aphthae, the epulis and parulis, scurvy, cancerous ulcers, venereal ulcers and exulceration from the use of mercury.

"The mode of treatment.—It will be proper,

"1. To remove the diseased teeth, bone, &c. if possible.

"2. To prescribe a milk and vegetable diet, and to allow a prudent use of fermented liquors.

"3. It will be adviseable to exhibit such remedies as, Peruvian bark; sarsaparilla; elm bark; mineral acids.

"The external applications that I have generally found successful have consisted of such as the following:

"Preparations of copper; a diluted mineral acid; burnt alum; decoction of bark with white vitriol; tincture of myrrh, &c."[2]

Of the above articles, those which we have indicated by italics are omitted in the last edition of COOPER'S Dictionary; and, in a former one, they are directly prohibited with strong reprobation. Nevertheless, it is among these that we have found, beyond comparison, the most successful one.

Mr. PEARSON prefixes to the preceding article a list of synonymes, with references to authors, in the manner of writers on natural history. They are as follow: Aphthae Serpentes.—SENNERTUS; Medicina Practica. Labrosulcium, seu Cheilocace.—ARNOLDUS BOOTIUS. Oris Cancrum.—MUYS. STALPAART VANDER WIEL. Gangraena Oris.—VAN SWEITEN. Gangrene scorbutique des Gencives.—Auctores Gallici.

Of these, SENNERTUS[3] merely mentions, under the article aphthae, that the latter sometimes spread around the fraenum and tongue, occasionally corroding the subjacent parts. He is so far from giving a clear description, under the head of Aphthae Serpentes, of any affection analogous to that we are about to record, that he quotes GALEN as remarking, very properly, that these are not aphthae at all, but putrid ulcers.

ARNOLD BOOTIUS, in his little treatise "de morbis omissis," of diseases omitted in the books, published in London, in 1649,[4] gives, from his own observation, an account of a disease, to which he applies the names above attributed to him. It differs from the cases which have attracted our attention, chiefly in its situation. He describes it as an ulcer, soon becoming black and foetid, corroding the inside of both lips, separating them widely from the gums and allowing them to fall outwards upon the face; thus producing a horrible deformity. Besides this, the author states, that a deep fissure usually extended down each half of the inside of each lip; thus adding four deep and ghastly ramifications to the ulcer. This shocking affection is stated to have prevailed extensively, both in England and Ireland; in which latter country the author practised and held several important offices. It occasionally became epidemic, and then destroyed great numbers of children. It principally prevailed between 2 and 4 years of age; though it was occasionally met with both earlier and later in life. It was frequently, but not always, accompanied with aphthae.

This disease was, in general, successfully treated by our author, with a decoction of "Chaerephyllum, Quinquefolium, Myrrhis, Rosae et Salvia;" in which was dissolved a "sat magna copia" of white vitriol.—A combination about as precise as some of the prescriptions which have been recommended to me, for the present disease, in this country. With this mixture, he touched the ulcers several times a day; and then washed them with a liniment of acetate of lead, aqua plantaginis, and oleum rosaceum. He also used issues in both arms; and confined the patient, in more obstinate cases, for drink, to a decoction of sarsaparilla, china, and several other articles, which we will spare our readers. To this disease, BOOTIUS devotes about five small 18mo. pages, forming his tenth chapter.

VANDER WIEL cites BOOTIUS, and expresses his belief, that the disease described by the latter was identical with one which he saw himself. This last, however, though described in a cursory manner, appears to resemble much more nearly the disease of the Children's Asylum; beginning in the gums, and extending to the adjacent parts. He treats it by the following lotion:

R. Mel. Rosar. [Symbol: ounce]i —— Aegyptiaci, [Symbol: dram]ij Olei Vitrioli, gtt. aliquot. misce.

Under this treatment, and by removing the teeth, when loose, the small number of cases he saw recovered in a few days.

VANDER WIEL was a practitioner in Holland; and, though he does not specify the fact, his cases were probably in a marshy country.[5]

MUYS, in a little treatise entitled "Chirurgia Rationalis,"[6] published in 1684, has an account of a disease, which is evidently supposed by PEARSON to be that which he describes. This also, however, appears to have been a "labrosulcium;" an ulcer between the lips and the incisor teeth. There is but little to be gathered from his paper; as it is principally occupied with an attempt to prove, that this ulcer is owing to an accumulation of acidity in the blood, increased, at this point, by the putrescence of particles of food which collect there. He illustrates this doctrine by an examination of a burnt rag under a microscope; and this he considers as in a state analogous to the gangrene. "Opinionum commenta delet dies," &c. We give his treatment; which is aimed at acidity.

R. Theriaci, [Symbol: dram]ijss Ung. Egypt. [Symbol: dram]iss Gum. Laccae, et Spirit. Sal. Armon. aa [Symbol: scruple]ij —— Cochleariae, [Symbol: dram]ij m. ft. ung.

To be softened with a little alcohol, the part washed with the mixture six times a day, and a rag moistened with the same compound left in the ulcer. Here we take leave of the Chirurgia Rationalis.

In the 14th volume of the Memoirs of the French Royal Academy of Surgery, are papers containing accounts of two cases, which have some points in common with the disease of which we treat; but the identity of at least one of which it is hard to establish. The first piece is entitled, "Sur la gangrene scorbutique des gencives dans les enfans. Par feu M. Berthe."[7] The author is described, in a note, as a young surgeon of great promise, who was carried off by an early death. M. BERTHE commences by quoting FABRICIUS HILDANUS; who describes a gangrene of the gums, occuring principally at about 4 years of age, and of which all the patients died. FABRICIUS takes the occasion to give a caution to young surgeons, to avoid being too sanguine in predicting recovery from gangrenes. Next a case is given us, drawn from M. SAVIARD, in which death was the result. This author seems, subsequently, to have had somewhat better success, but at the expense of horrible disfigurements; such as great holes through the cheek, and the loss of a large piece of the jaw; which, indeed, are described as having been worse than death. In another case, recorded by M. POUPART, in the "Histoire de l'Academie des Sciences," this affection terminated in death; preceded, however, and in the opinion of the author, caused, by the production of two tumours, one by the side of the tongue, the other inside of the cheek. This is not at all unlike the progress, which will be hereafter mentioned to have taken place in many of the Asylum cases.

M. BERTHE then remarks, that the greater number of instances of gangrene of the gums had terminated unfavourably.

His own patient was ill from April to September, 1753; and exhibited swelled and bleeding gums, frequently projecting beyond the teeth,—black and foetid stools, foetid urine, and ecchymoses over the surface of the body. He treated it with antiscorbutics, internally and externally, and apparently with success. The patient, however, relapsed in January, 1754; when M. BERTHE proceeded to a very different, and far more severe treatment. The gums were pared away, in many successive operations; and the wounds were washed with aluminous water. A roll of linen was, during the intervals, kept fastened in the patient's mouth, for the purpose of allowing the escape of the fluids of the part; which he apprehended to possess a putrid character, and to aggravate the original disease, whenever they passed into the stomach. At length, his patient recovered, and continued well.

It appears to the writer of these notes to be hardly necessary to state, that M. BERTHE evidently mistook the disease; the latter being in reality scorbutic, and not a single symptom of gangrene being described during its whole history.

The same, however, cannot be said of M. CAPDEVILLE; whose "Observations sur les effets rapides de la pourriture des gencives" appear in the same volume with the foregoing, and immediately subsequent to it.[8] This writer's case took place after a fever, and no tumefaction of the gums nor ecchymoses of the skin are mentioned as occurring in it. M. CAPDEVILLE attended this case in consultation, in 1764; and complains of too feeble means being employed, as the case was trusted to antiscorbutics. This treatment ended in death. M. C. refers to VAN SWEITEN, whose correct account we shall mention; and it is evident that it was the disease of the Children's Asylum: though he manifests a strong propensity to connect it with scorbutus, and the "blanchet," or a species of aphthae, which destroyed a great number of children in the Foundling Hospital, in 1746. Reference is also made to cases which occurred in "La Pitie," under the care of CHOPART. Of these, a very scanty account is given. They terminated in death; after a treatment by lotions of honey of roses and spirit of vitriol, with emollient and resolvent cataplasms.

VAN SWEITEN, in the article devoted to the consideration of gangrene,[9] has left us a far more exact description of the disease, into which we are inquiring. Practising in a marshy country, he had frequent opportunities of meeting with it; and his account of it, and his mode of treatment, though brief, are every way worthy of the close, practical inquirer into nature, and the sound medical philosopher. His description is not unmixed with strong expressions of horror and commiseration at its ravages. He describes it in a manner so similar to that in which it now prevails, that no doubt can exist of the identity of the diseases. He acknowledges, however, "rubedo, calor, dolor," among its symptoms. Cochlearia, theriaca and similar articles, according to him, are almost always injurious. If no foetor exist, (and, of coarse, no actual mortification,) he applies a solution of sal ammoniac or nitre, with some vinegar or lemon juice; sometimes as a lotion, sometimes by keeping a rag imbued with it always in the ulcer. Hard rubbing he reprobates. If the disease have made progress, and foetor exist, muriatic acid is used: in the less aggravated stages, diluted with honey of roses and water; in the worst cases, pure. This practice he states never to have failed him, unless where the bone was affected.

In an early edition of Dr. UNDERWOOD'S Treatise on Diseases of Children, in the library of the Pennsylvania Hospital, no mention is made of this disease; although an article is devoted to "gangrenous erosion of the cheek." The account is wholly borrowed from a work by Mr. DEASE, of Dublin, "on the diseases of lying-in women," &c. also in the library. Mr. DEASE describes this affection as occurring from 2 to 6 or 8 years of age; especially in unhealthy children, including such as have been subject to worms. The whole body often appeared cold upon the approach of the disease. A black spot then occurred, but without marks of inflammation, on one of the cheeks or lips. The whole cheek was sometimes destroyed, and the lower jaw fell down upon the breast. Muriatic acid, infusion of roses, the effervescing draught, and, in the decline of the disease, bark, broths, jellies, and wine, besides magnesia or rhubarb, to remove the putrid matters swallowed, were the internal remedies employed. The parts were washed and injected with muriatic acid, diluted with chamomile or sage tea; and afterwards dressed with the acid, mixed with honey of roses, and, over this, a carrot poultice. By this practice, Mr. DEASE lays claim to almost total success.

In the Philadelphia republication of Dr. UNDERWOOD'S book, taken from the sixth London edition, there is an article entitled Cancrum Oris. The author appears to have read PEARSON'S account; but as his description does not at all agree with the disease of which we are treating, nor with that of Mr. PEARSON, we shall not stop longer to analyse it.

I have no doubt, from views that will be hereafter developed, that many of the above writers have had cases similar to those which we are about to describe; but have mistaken them, from the want of a sufficiently early and close inspection of the ulcers. In the second stage, this disease much resembles an inflamed sore between the lips and gums, extending to the latter; although I hope to prove that this state of things is secondary.

Locality of the Disease.—The Philadelphia Children's Asylum is situated in South Fifth street, between Prime and Federal streets, in the district of Southwark. The soil is what is called alluvial, or rather diluvial; as is well known to be the case with all that district, lying south of Philadelphia, as well as the southern part of the city itself. The house was built, and for many years occupied, as a mansion, by the head of a most respectable and wealthy family. Its situation possesses some of the qualities usually selected in choosing the site of a country seat. The buildings stand on a swell of ground, leaving an open lawn, now interrupted by several unoccupied streets, and extending, on the right hand, to the banks of the Delaware, and, on the left, to the Navy Yard and part of the suburb of Southwark. Towards the north, it is not far from the edge of a thickly built appendage of the city.

The district immediately south of the Asylum is marshy, and has long been noted for the prevalence of intermittent fevers; but the slightly elevated site of the building had been generally healthy, and continued so, till the universal and distressing epidemic, which infested all the outskirts of Philadelphia, in 1822 and 1823. Even at this period, the persons resident at the Asylum, were far from suffering so severely as the adjacent neighbourhood; and, since those years, it has again become, in general, tolerably healthy. In 1819, 1820, 1821, and 1822, a lot, situated at a short distance, on which were deposited the contents of a number of privies, proved a source of great inconvenience, and some disease, at the Asylum. This focus of effluvia, together with the general and copious use of similar materials in manuring the adjacent fields, occasioned an intolerable stench, and generated diarrhoeas, in the early part of the spring. When the grass and weeds, however, were grown sufficiently to protect the surface of the soil from the sun and wind, this effect entirely ceased; and I know not that any other inconvenience was experienced from the same source, unless we attribute to this, as may fairly be done, the destruction of the purity of the well. This formerly afforded very good water; and, since that period, it has much improved. When the corporations of Southwark and Moyamensing shall introduce, as it is to be hoped they will, the Fairmount water into their streets, one remaining cause of inconvenience and ill health, will be removed from the Children's Asylum.

Prevalent Diseases.—Ophthalmias and furuncular eruptions, the latter principally on the face, are epidemic every year; generally in the spring and early summer months. When prevalent in the city, the measles, small pox, and varioloid disease have reached the Asylum; the scarlatina has, at no period, I believe, been peculiarly troublesome there. Intermittents, which were anticipated by many, from the nature of the situation, have seldom, if ever, prevailed in the house, to any very considerable extent. One of the worst visitations which it has experienced, in this respect, was in the autumn of 1823. In many cases, it was in patients who had been labouring under disease of this description, that the ulcer we are about to describe exhibited itself; but it was by no means confined to those who were known to have so suffered. Many, perhaps, most of the children affected, were free from any apparent ailment; although it is by no means impossible that the little, uncomplaining subjects were, at the time, labouring under what has been called "febricula" or "inward fever."

Regimen.—To the impurity of the water we have already adverted. The diet of the children furnishes them with meat every day, with the exception, during a part of the existence of the institution, of two days in every week. Molasses was freely used; indian mush was greatly in demand; and the breakfast and supper were of bread and milk. During the summer months, this diet was abundantly nourishing; but in winter, it was thought that an additional quantity of animal food was desirable; and, accordingly, it was, during the two last winters, given every day.

Description of the Disease.—The ulcer of which we speak, may begin in many parts of the mouth. In by far the greater number of cases, however, it commences immediately at the edges of the gums, in contact with the necks of the teeth, and, most generally, of the two lower incisors. A separation is found here; which exhibits a slight loss of substance at the extreme edge of the gums, and, as far as I have observed, a whitishness of the diseased surface. In some instances, though not very frequently, this is preceded by a slight swelling and redness. In this state, the disease may continue for a long time; and I have reason to believe, that patients have remained thus affected, during the whole period of three months, for which I attended the Asylum. At one time, when the disease was at its height, threatening several patients with destruction, I found upwards of 70 children, out of a population amounting to about 240, more or less affected with these ulcerations. No remarkable change is at this stage observable in the functions of the little sufferer; except a general air of languor and weakness. The appetite and the muscular activity continue, but are somewhat reduced; not sufficiently, however, to disable the child from attending school, taking the air, or continuing his ordinary practices. In this state, no symptoms of irritation have been at all discovered. The skin is cool during the day, no pain is complained of; and no account has ever been given me of any nocturnal paroxysm of fever. It would appear to be purely a state of asthenia. We are, however, by no means certain, that there was no concealed irritation in the system. We were, of necessity, obliged to depend, in a great measure, upon the reports of nurses, and other females; and these were liable to overlook, or mistake for mere weakness, the signs of an obscure disease. In this manner, commencing cases were frequently not discovered, and nothing was done, till the affection had made further progress; and this continued until the ascertained existence of the epidemic in the house, combined with the recollection of its former ravages, had excited an alarm, which led to the inspection of the mouths of all the children in the institution.

The disease, in this form, must be within the curative powers of nature; as, if this were not the case, we should hear of more numerous unfavourable terminations. It has seldom, however, if at all, been within my power to witness this tendency; and, when not controlled by a particular treatment, the cases have almost always either remained stationary, or increased in severity. Its first progress is, most generally, by extending to the edges of the gums round other teeth; frequently affecting a large portion of the dental arches. A very early progress is, however, mostly effected, down the length of the tooth, in the direction of the socket; and, in this way, the disease commits great and unsuspected ravages. When it reaches the edges of the bony socket, the tooth begins to be loose, and when drawn, exhibits portions of the fang, including parts which had been contained within the alveolus, entirely denuded of their periosteum. Indeed, from observation, I should say, that the latter membrane was the part, which was the most peculiarly liable to injury and death from this disease; and it is by no means clear, to my apprehension, that this is not frequently the commencement of the complaint. The injury generally proceeds with augmenting rapidity; especially when it has affected the deeper parts: and it is while in the act of rapidly spreading, that it occasions gangrene.

In the production of gangrenous sloughs, it much resembles the descriptions usually given of sloughing ulcers. A portion of the parts immediately subjacent to the ulcer loses its life; this rapidly separates; and, before or after a complete removal, a fresh slough is formed in the same manner. The sloughs are generally black, with ash-coloured edges. I have not been able to discern a change of colour, the production of vesicles, or any material tumefaction, as antecedent to the gangrene. There is generally, by this time, an increased heat in the parts; with the sensation termed "calor mordens." The discharge now, for the first time, becomes acrimonious; giving pain when it comes in contact with cuts in the finger; and excoriations are produced on all parts in contact with the sloughing ulcerations; as the lips, the cheeks, the tongue, and the adjoining surface of the part where the ulcer is situated.

As soon as the external gangrene has reached the level of the edge of the bony socket, and frequently much sooner, the adjacent portion of the latter is found deprived of its life; forming a necrosis. The death of the periosteum in the socket, at least that of the fang of the tooth, precedes, by some interval of time, that of any portion of the bone itself.

When gangrene is formed, a fever of irritation is generally developed. In regard to the time at which this takes place, there is a great diversity in different constitutions. It has appeared to me to depend, principally, upon the inflammation of the mouth, which is secondary to the original disease, and, in most cases, to arise from the acrimony of the discharge. It is aggravated by loss of rest, want of nourishment, and, probably, by putrid matter finding its way into the stomach. To the latter cause I also refer a diarrhoea, which almost uniformly comes on, towards the close.

There are accounts of a similar disease having begun on the inside of the cheeks. I have, however, never seen a well-marked instance of this; the cases which were supposed to be such having, in every instance, been also found to exhibit ulcerations at the edges of the gums. That the disease spreads from the gums to the cheek, is a fact which have often seen exemplified. It is, indeed, the most usual termination of bad cases. After producing gangrene and necrosis in the gums and alveoli, and after the discharge becomes, as above stated, acrimonious, a gangrenous spot is not unfrequently found about the opening of the Stenonian duct, on the inside of the upper or lower lip, opposite the incisors, in some other part of the inside of the lip or cheek, or in more than one of these situations at the same time. Whether this be owing to excoriation from the discharge, or to some other cause, I cannot say; it has, however, in every instance which I have seen sufficiently early to witness its rise, been subsequent to the symptoms previously described.

When the gangrene reaches the cheek or lip, however, very active inflammatory symptoms are uniformly developed. In the cellular substance of these parts, they assume the well known characters which have been attributed to the phlegmonous species. We have a great thickening, forming, in the cheek, a large, rounded, prominent tumour, with great heat and pain. Sometimes redness is perceived externally; but, more frequently, the great distension of the skin of the cheek seems to empty the cutaneous vessels; giving to the part, a smooth, polished, dense, white appearance, very much resembling the effect of a violent salivation. I have no doubt that this is the tumour described by POUPART, and alluded to in an earlier part of this paper. Great thickness and hardness have always occurred, in the other situations where this gangrene has approached the external cellular masses of the face; in the lip, however, they are less remarkable, perhaps from the smaller amount of cellular matter. After reaching this stage, a black spot is frequently seen on the outer surface of the swelling. This spreads rapidly; and has always been, in my own experience, the immediate harbinger of death. It is proper to state, however, that I have heard it said, that cases had recovered in this city, in which the gangrene had produced a hole through the cheek. Under what physician's care this occurred, I have never learned.

In two cases it commenced in the fauces; and was marked by the same unsuspected progress. In one of these, the little patient was remarked to be languid, but had no positive external marks of disease. The mouth was examined, and found healthy; but no suspicion of the real situation of the disease was entertained, till after 3 or 4 days more, when he complained of a slight sore throat. A large gangrene of the tonsils, half-arches and pharynx, was now found; and the event need hardly be told.

The closing stage of this affection is marked by large gangrenous patches in the gums; deep fissures between these and the teeth; the latter loose, or falling out; large pieces of the alveolar processes, often containing the roots of several teeth, in a state of entire necrosis; the whole lining membrane of the mouth suffering a violent excoriation; the whole adjacent external cellular substance, hard and swelled; large gangrenous spots in the inside of the cheek or lips, occasionally extending quite through to the outer surface; a total incapability to sleep, or to take the least food; fever; a swelled abdomen, and diarrhoea.

Dissection.—The inspection of the body after death had never thrown much light upon this obscure affection. Since I began to prepare materials for this paper, I have been able to dissect but one subject. The appearances were as follow:

Exterior, emaciated.

Alimentary canal, externally and internally, altogether in a natural state, except what appeared to me to be owing to the subsidence of blood to depending portions of the intestines. The mucous membrane was carefully examined throughout its whole length; but not being at that time aware of the importance, attached, by some pathologists, to small rednesses in this organ, it is highly probable that some such may have been overlooked.

Liver and Spleen, enlarged, but of a natural appearance.

Heart, thoracic oesophagus, and one kidney, (the other not examined,) natural.

Lungs, containing much mucus in the bronchial cavities. The fore part of their substance contained much hepatization.

Pathology.—The nature and production of this disease are certainly very obscure. We may, however, as in other branches of knowledge, attempt to develop and record what knowledge we possess respecting it; carefully separating truth and reason from conjecture. We have already said, that its access was very frequently preceded by no marks of visible disease, or at least none that attracted attention. The little subjects were, apparently, in merely a drooping or enfeebled state. In other instances, the ulceration followed a common remittent or intermittent fever; insomuch that, at one time, whenever a child was brought to the nursery for fever, it was expected, as a matter of course, that his mouth would become sore. In the other cases, as we have already had occasion to say, it is quite possible that a concealed "inward fever" may have existed; and this is rendered the more probable, by the circumstance of their losing their appetites. In the instance where the body was opened, we have seen that the original disease was hepatization of the lungs; and yet it is quite probable, that this affection had caused, as it often does, that species of disease, which a rapidly spreading pathology refers to a slow inflammation of the stomach and intestines. With regard to marks of this last not having been detected by me, it is evident that I am in the same situation with a very numerous body of other observers.

The local appearances, at the commencement, did not appear to be of an inflammatory nature, at least generally. If the gums were really the first part affected, it was not so; as these parts when inflamed, as they frequently are in affections of the teeth, exhibit decided soreness, pain, swelling, and an increase of redness. The ulcerated part was, in about nine cases out of ten, paler than natural; and then neither soreness nor increased heat was perceptible, except in a few cases, in which the mouth was generally hotter than natural, though it was not, in a striking manner, referrible to the gums. In a few cases, distinct redness, and a slight swelling, were perceptible round the ulcer. These patients generally did better than the others.

If, on the other hand, we suppose the original derangement to have taken place in the periosteum, we shall be enabled, more easily, to explain some of the phenomena. We then reason thus: The whole of the body had shrunk considerably, from disease, and, the circulation being deprived of a part of its usual vigour, the periosteum, a part possessed of little vitality, was unable to bear the additional extension, which it underwent, across the unyielding bone of the tooth. The blood ceased to circulate in it, and it died. Ulceration of the adjacent parts followed, as a matter of course; and these parts, especially the periosteum, being possessed of but little sensibility, the sympathies of the other parts of the system were but little interested, until an extensive portion of the mucous membrane of the mouth, or a mass of cellular substance, became affected. We certainly see that, in every case but two, the disease commenced in contact with the teeth. This doctrine will also explain the rapid and deep penetration of the ulcer along the roots of the teeth; and the destruction of the bone. We may recur to the statement, that a portion of the fang of every loose tooth was always found deprived of its periosteum.

In the two cases excepted, we have seen it apparently begin in the mucous membrane of the fauces; and indeed the manner in which it generally spreads from the gums to the cheek and lips, seems to me, unquestionably, to indicate a greater liability than common to gangrene in more than one part of the mouth.

The soreness and pain of the socket, which forms a part of most tooth-achs, might have been reasonably expected here; but neither was ever complained of, even when the teeth were loosening: and, as no fever existed at this time, the original irritation can hardly be considered as inflammatory; excepting perhaps the cases which exhibited redness, and slight swelling of the gums.

Is this disease scorbutic?—I never observed ecchymoses, nor in more than a single instance any the minutest red specks upon the cutis, which might be thought to resemble petechiae. The patients never fainted; the gums were never spongy, nor did they bleed more than those of any other child would have bled, under an equal degree of violence. I however requested my friend, Dr. HARRIS, who has had ample opportunities of making himself acquainted with scorbutus, to see some patients with me. He complied, with his usual kindness, and pronounced their disease not at all to resemble the scurvy.

The teeth.—But few cases occurred during the second dentition; and it is doubtful whether any one took place during the first. It should be remarked, however, that children under 2 years, were not admitted to the institution, unless by deception on the part of the parents. No child ever lost a tooth of the second set; and, indeed, the second dentition seemed often to cure the complaint. The greater number of cases occurred between 2 and 5 years of age, but some as late as 8 or 10. In several instances, the ulcer destroyed a portion of the enamel capsule; and the teeth were then cut, with very perfect enamel upon the lower part, while the bone was entirely bare at the ulcerated portion of the capsule. This singular fact proves that no inflammation of the capsule, sufficient to interrupt the function of its remaining portion, took place in consequence of the opening of its cavity.

Prevalence of this disease in our own country.—Many elderly persons remember during different periods of their lives, a tradition and particular instances of a formidable disease of the mouth, by the name of "Black Canker."[10] Round Philadelphia, it appears to have been rare. Having been informed by a friend, that the disease had prevailed extensively at Salem, New Jersey, under the notice of my friend, Dr. THEOPHILUS R. BEESLEY, I addressed a letter to that gentleman, to which he furnished me with an obliging and instructive reply, which I have unfortunately mislaid. Numerous cases have occurred, in that vicinity, within the last 30 years; and were, in general, successfully treated by the women. Cases seldom came under the view of physicians, until gangrene had commenced; and of these, many died: so that the old women were generally more in vogue for its cure, than the regular practitioners. Dr. BEESLEY, Dr. VANMETER, and my friend Dr. E. Q. KEASBEY, had met with much of this complaint; and the result of many of their observations had been combined in a thesis, written, but, according to our unfortunate custom, not published, by the younger Dr. VANMETER. It was there considered as a sequela of intermittent and slow remittent fevers, and seldom occurred but in marshy districts, and among the poor. It generally prevailed between the ages of 2 and 10 years. Of the remedies employed we shall again speak. Dr. SAMUEL TUCKER has also seen it in marshy situations near Burlington. I have heard of its existence on the Schuylkill. Dr. PARRISH has for several years noticed a stage of this complaint, under the name of "a disease resembling the effects of mercury," in his private lectures. Drs. PHYSICK, HARTSHORNE, HEWSON, MEIGS, WOOD, RHEA BARTON, and REMINGTON, and several others who will pardon me for omitting their names, have also met with cases.

Prevention.—Our precautionary measures should be directed to the predisposed or commencing state already described; to the prevention and cure of fevers, to the removal of "febricula," and other internal disorders, and to the general restoration of strength. Finally, its commencing stage should be watched, and promptly met; and success, I believe, will always attend our endeavours.

At the Children's Asylum, all the weakly children were made to take bitters, of different descriptions; and Dr. SYLVESTER'S antiscorbutic drink, composed of cream of tartar and juniper berries, infused in water. As the disease declined in the house, under this administration of bitters, it is highly probable that they had a preventive agency. I much question, however, whether Dr. SYLVESTER'S drink was productive of any advantage.

One question of some importance yet remains. Has mercury any agency in producing this affection? The salivary glands have never been observed to be affected in it. Dr. PARRISH informs me, that, after a strict examination, he has come to the conclusion that the previous use of mercury does not bring on, or aggravate this complaint, as he has noticed it. I have made the same observation; and, not being peculiarly sparing of the use of calomel in fevers, have had opportunities to verify it. I think I can add, that, in some cases, by shortening and moderating an attack of fever, calomel has been useful in preventing the ulceration. Given during the progress of one, and that a fatal case, it did not appear to aggravate it.

There is no evidence whatever tending to excite the suspicion of contagion.

Treatment.—A variety of remedies had been tried within my knowledge; most of them with but little success, and one or two with somewhat better. Feeling much disappointed with the results of my practice, in the small number of cases which fell under my care in the spring months at the Asylum, as well as elsewhere, I wished to exchange with another physician for a period when the disease was more prevalent; for the purpose of studying it, and making comparative trials of different remedies. Dr. JOS. G. NANCREDE was so polite as to indulge me. Having then a large number of patients under my care, I was enabled to make more extensive observations, and with more precision; the results of which course gave me the first satisfaction I had ever felt relative to this disease. Trials were made of every thing that was suggested by friends, and generally upon 4 or 5 selected patients at a time. Thus, choosing them in the ulcerative stage, and having several at a time before our eyes, the result was seen in a very few days, much sooner than if patients had been successively subjected to the remedies; and no material time was lost in appealing to the article which appeared to answer best.

The remedy which beyond all comparison succeeded best, was sulphate of copper. The usefulness of this substance, though known at Salem, New Jersey, was discovered, at the Asylum, by the mistake of a nurse. It had been previously used, in lotions of the strength of gr. ij or iij to the ounce of water; and with little advantage. Observing that the empirical remedies said to have succeeded, were, as I considered them, immoderately strong, I furnished the nurse with a common solution of sulphate of copper, and with a vial containing 72 grains of the sulphate in an ounce of water, for the purpose of being progressively added to the other at different periods. This stronger solution was applied, by mistake, instead of the diluted one; and it was the first remedy which had produced a rapid tendency to a cure. I finally settled down, after various trials, in the employment of the following:

R. Sulph. Cupri, [Symbol: dram]ij Pulv. Cinchonae, [Symbol: ounce]ss Aquae, [Symbol: ounce]iv m.

S. To be applied twice a day, very carefully, to the full extent of the ulcerations and excoriations.

The cinchona here is not absolutely necessary; but operates by retaining the sulphate longer in contact with the edges of the gums.

Simple ulcerations and small gangrenes, as well as the troublesome excoriation, when not in the last stage, yielded promptly to this remedy; the good effect being generally visible from the first application.

Dr. FOX, my friend and fellow-labourer in the Asylum, had already taught me that it was important early to extract the teeth. I was not, however, sensible of the full extent of this rule, till after examining the fangs of some of them which were drawn. The separation of a portion of the periosteum from the fang, within the socket, which was universally found whenever the tooth was loose, among two or three hundred specimens, proved the existence of the disease in a deep, narrow crevice, into which it was impossible, by any contrivance, to insinuate the lotion. This cavity was laid open by extracting the tooth; and when the remedy was applied, the sanatory effect was surprisingly prompt. From this period, forwards, the universal rule was to extract all teeth, the moment they were discovered to be in the slightest degree loose; and "the blue wash" above described, became the standing remedy.

It is at all times a dangerous boast for a physician to make, to say that, in the treatment of any complaint, he has always succeeded. He is frequently not credited; and he can never know at what moment disbelief may be borne out by his subsequent failures. A faithful adherence to fact, and justice to the medical art, oblige me to say that it was owing to the observation of these means, that I never had an opportunity of making a dissection, after the one mentioned in a preceding page. Upwards of 120 ulcerated gums came under my notice in the course of three months; of which 70 were affected at one time. Of these, by far the greater number would, unquestionably, have escaped gangrene. The experience of past winters, however, and that of the preceding autumn, justifies the belief that there would have been several gangrenous cases, and some deaths; unless interrupted by remedial means. Some 3 or 4 suffered small spots of mortification, and one, by the delay arising from the tardy report of a nurse, suffered necrosis in a portion of an alveolus; but they were speedily arrested, and the production of more such cases, I believe, prevented, by the employment of the above means.

I have been once, since then, called in consultation to a case in which this remedy failed; but this was only two days previous to death, and during the existence of swelled cheek, and of a thick gangrenous eschar, and it was in fact only once imperfectly applied.

The farthest advanced of all the cases which I have seen, since that time, relieved by this remedy, was in the practice of my friend, Dr. R. M. HUSTON. He aided it by the application of a poultice with lead-water to the external surface of the cheek. This was thought to be productive of much relief.

Great attention and care are requisite on the part of the physician, to see that every part of the ulceration and excoriation is made visible, and brought under the influence of the applications employed. Without this entire knowledge of the extent of the evil, the result will be failure. The disgusting sloughs and discharge, and the fear of an imaginary contagion, make the nurses very unwilling to introduce their fingers into the reluctant little patient's mouth, and without this scrutiny all is in vain. The physician is compelled to set the example, to try the looseness of the teeth with his own fingers, and to ensure the nurse's entire knowledge of the extent of the disease.

Dr. BEESLEY writes that the women in his neighbourhood, frequently used considerable roughness in applying the lotions. Certainty is absolutely necessary.

After the remedy had been thus accidentally discovered in the Asylum, and used for a few days, I received Dr. BEESLEY'S letter mentioned above; and I then learned that the sulphate of copper was the principal dependence of the physicians at Salem. As, however, I had never seen Dr. VANMETER'S thesis, the use of it at the Asylum was new to me.

An excellent remedy, and one on which the sole dependence should be placed, were we not in possession of one which possesses a decided superiority, is one which was communicated to me by Dr. PARRISH. It is as follows, including a slight correction made by the apothecary:

R. Sulph. Zinci, [Symbol: dram]i Aquae, [Symbol: dram]ij Solve. Dein adde, Mellis Despum. et Tinct. Myrrhae, aa [Symbol: ounce]ij

To be used in the manner described above. Some bad cases yielded to the following:

R. Sulph. Zinci, [Symbol: dram]ij Aquae, [Symbol: ounce]i m.

It is useful to record failures and unsuccessful trials; as they serve to deter others from unnecessary risk. We therefore record the following as not having succeeded in our hands:

R. Mellis et Tinct. Myrrhae, aa [Symbol: ounce]i m.

The same, with the addition of powdered bark.

R. Aluminis, [Symbol: scruple]ij Tinct. Myrrhae, et Mellis, aa [Symbol: ounce]ij m. R. Pulv. Cinchonae, [Symbol: ounce]i Myrrhae et Pulv. Carbonis. a [Symbol: ounce]ss m. et adde Succ. Limonum, q. s. ad massam faciendam, qua illineantur gingivae.

Caustic potassa; and nitrate of silver.

Pyroligneous acid, both pure and variously diluted with water. This had but a very limited effect, even in destroying the foetor; and I am by no means sure that it was of any use in arresting the disease.

Muriatic acid, though praised by such high authorities, did not seem productive of any distinct useful effects. Nitric acid, variously diluted, and sulphuric acid, which was tried in one case, diluted with an equal quantity of water, were entirely useless.

Of constitutional treatment, the disease seemed to admit very little. In the early stage, the means employed, were the same mentioned above as means of prevention. It was by no means evident that any of these were useful in retarding the progress of the complaint. Towards the decline of the worst cases, aromatic sirup of rhubarb, with magnesia, were employed, to remove the putrid matters swallowed; and to relieve the diarrhoea which generally took place, by the astringent operation of the first mentioned medicine. It is extremely doubtful whether these means were productive of any benefit.

* * * * *

While the above was in press, I have met with the article, "Gangrene de la bouche des enfans," in the Dictionnaire de Medicine; written by M. MARJOLIN. The author in the Dictionnaire des Sciences Medicales, has given nothing material but references to some of the writers mentioned above; with one or two which were not within my reach. M. MARJOLIN has evidently identified the disease. He cites FABRICIUS HILDANUS, though we have not found a distinct account of it in that writer's works. He remarks that it is identical with the necrosis infantilis of SAUVAGES. He also refers to SAVIARD, VAN SWEITEN, whom he justly mentions with the highest praise, UNDERWOOD, BERTHE, CAPDEVILLE, M. BARON, and the inaugural thesis of M. ISNARD. As we have no means of referring to the two last, we must judge of them by M. MARJOLIN'S statements. He observes the dissimilarity of BERTHE'S case. From the thesis of M. ISNARD, he gives us an account of the disease which corresponds very nearly, indeed, with that of VAN SWEITEN, and with the appearances observed at the Children's Asylum.

"Almost all the infants affected with this disease in the hospitals of Paris," says M. MARJOLIN, "sink under it." He recommends, after VAN SWEITEN, the use of muriatic acid, which he mixes with honey in equal proportions. Thick sloughs he cuts away with a bistouri or with scissors. MM. JADELOT, GUERSENT, and BARON, have employed the actual cautery with success in several instances. M. MARJOLIN has cured three cases; one by the actual cautery, one by caustic potassa, and a third by muriate of soda! which, he believes, will always destroy the foetor. It would be interesting, undoubtedly, to make repeated trials of this simple remedy; and we shall endeavour to do so in cases which admit of delay.

FOOTNOTES:

[1] Vol. I. p. 319, Anderson's edition.

[2] Principles of Surgery; by JOHN PEARSON. Lond. 1788. p. 262, et seq.

[3] Opera omnia. Vol. II. p. 271. In the Loganian Library.

[4] Ibidem.

[5] See CORNELII STALPAART VANDER WIEL Observationes Medico-Anatomicae. p. 167. Note by the editor, P. STALPAART VANDER WIEL. Amsterdam, 1687. In the Loganian Library.

[6] In the Loganian Library.

[7] Page 193.

[8] Page 217.

[9] Commentaria.—Edit. Lugd. Bat. 1742. Vol. I. pp. 766, 767.

[10] This name may be either from the ancient English or the low Dutch; if the one, by tradition, if the other, from the use of it by medical men. Cancrum is an odd grammatical blunder; being, in reality, nothing but the accusative of Cancer, put instead of the nominative. The latter name was, as is well known, frequently applied by the older surgeons, in a vague manner, to any terrific and unmanageable ulcer; and, in particular, it was often applied to gangrene. The error appears to have been first made by Pearson, and copied by Mr. Cooper. Compare Muys and Vander Wiel, with Pearson, at the above references.



ARTICLE II.—Case of Purpura in an Infant, attended with Extraordinary Symptoms. By R. M. HUSTON, M. D., &c.

On the 28th of August last, A—— V——, after a moderate labour of four hours' continuance, was delivered of a female child. About a month previously, she had laboured under an attack of intermittent fever, which yielded, in a few days, to the ordinary treatment. She was 23 years of age, an English-woman by birth, had generally enjoyed good health, and was as well as usual at the time of her confinement. Her labour was strictly natural, and her delivery accomplished without any extraordinary assistance.

At birth there was nothing remarkable about the child. Its breathing was natural, its skin of the usual colour and appearance; in short, all the common indications of a continuance of life and health were present. A few hours, however, after birth, it became uneasy, cried much, and showed signs of colic. The nurse, supposing these symptoms to arise from flatulence, administered some warm tea; but without any apparent advantage. On the following day, I saw it again, and learned, that it had evacuated a considerable quantity of urine, and some intestinal matter, of the ordinary appearance after birth. The spasms continuing at intervals, a teaspoonful of castor oil was ordered, to evacuate any remaining meconium, that might lie in the bowels, producing irritation; upon the presence of which, it was presumed the spasms depended. It operated well, but without producing the desired relief. On the next day, viz. forty-eight hours after birth, a number of bluish or purple spots were observed on different parts of the child's body, but most numerous on the extremities. They were of various sizes, from that of a mustard seed, up to that of a grain of Indian corn. Some were slightly elevated, but most of them were not in the least so. In the majority, there was a minute central spot, or little point, more red or pink coloured than the blue areola, by which it was surrounded. In many instances, these little points projected, so as to become manifest to the touch. In the course of twenty-four hours, the spots, which had first appeared, began to decline, leaving a greenish mark, very like the remains of a bruise; but much more rapidly than these declined, others of larger size appeared on different parts of the child's body.

On the third day after birth, large blotches appeared, one behind each ear. These rapidly increased, until they covered the whole extent of the parietal bones, and considerably elevated the skin, giving it a puffy or tumid appearance, like that caused by a blow from a large or blunt instrument. The parts soon became hot and tender to the touch; and this tenderness extended over the greater part of the scalp. A blotch, similar to those upon the exterior surface, was likewise observed within the mouth, covering the whole extent of the palate bones. The child experienced great difficulty in swallowing after the third day; and the nurse thought the spasms were often excited by attempts of this kind.

But the most singular feature of the case was the appearance, on the night of the second day, of a discharge from the vagina, resembling the menstrual flux. It resembled that flux in colour, consistence, want of coagulability, and in being, withal, accompanied by a considerable quantity of slimy or mucous matter. Every diaper which was used during that night, and the greater part of the next day, was stained more or less with this discharge. It was also observed, that, during the flow of this fluid, the spasms ceased; and that, whenever the discharge was suppressed, even for a very short time, they uniformly returned. In this manner they alternated at intervals of a few hours, until the occurrence of the death of the child, which happened on the eighth day after birth.

As this case is related more for its singularity than from an expectation that any practical suggestions will be furnished by its perusal, but few remarks will be necessary, either upon its pathology or treatment. Although it will be perceived by the scientific reader, that the disease observed, differed materially from any of the forms of purpura, described by systematic writers on diseases of the skin; still I apprehend it may be justly considered as more nearly allied to that genus, than to any other.

The spots were evidently caused by an effusion of blood beneath the cutis, and the presumption is strong, that it issued from the little point discoverable in the centre of each spot. Those points were, in all probability, arterial. That they were arterial terminations, I think is evident, from the great extent to which the cellular membrane was injected, especially over the parietal bones. The force exerted must have been very considerable to elevate so large a portion of scalp, and yet no pulsation could be discovered in any one of the points.

But whence came the vaginal discharge? That it issued from the vagina was most certain; but whether it was furnished by that canal, or by the uterus, was not ascertained. To assert that it was menstrual, would be hazarding more than a prudent regard for truth would justify. But, if not, why the pain and spasms which preceded it, and the alternation of these symptoms with each other? and, especially, why the slimy appearance, mixed with red matter, without a trace of any thing like coagula? Certainly we do not find these appearances in ordinary cases of haemorrhage. So that there is no other way of accounting for the discharge in this case, except by considering it as having been secreted by the vessels of the parts from which it came.

From the difficulty which the child experienced in swallowing, but little food could be taken; and the same difficulty precluded the administration of medicines. What caused this impediment could not be ascertained, but it was supposed to result from a spasmodic action of the muscles of the part.

The only medicine attempted to be given was a weak infusion of bark, and this was soon abandoned.

The spots, particularly the large ecchymosed surface on the head, exhibited no change in appearance, when viewed superficially, a few hours after death. No other examination was permitted.

FOOTNOTES:



ARTICLE III.—History of the Natural and Modified Small-Pox, or of the Variolous and Varioloid Diseases, as they prevailed in Philadelphia in the years 1823 and 1824. By JOHN K. MITCHELL, M. D., and JOHN BELL, M. D. attending physicians at the then Small-Pox Hospital. With a Plate.

In a question of less moment, some apology might seem due for once more directing public attention to that which has been so oft discussed and described by many eminent physicians and experienced observers. But, if descriptions of any disease be valuable; if to record faithfully an evil be among the first steps for its removal and prevention; and, still more, if additional confidence, derived from enlarged experience, can be imparted to the means hitherto adopted to guaranty the human frame against a mortal and loathsome malady, our efforts at this time may claim the favourable notice of our professional brethren, and of the community at large.

Sedulously abstaining from the parade of erudite research or indulgence in speculations, however ingenious, it is our intention to describe with accuracy all that we saw; and if, in so doing, we shall be found repeating what others have said before us, and proposing inferences previously drawn, the observations and deductions are to be considered as not the less our own, since we only speak from conviction, founded on the evidence presented to our senses. Our opportunities for accurate judgment were most ample, being derived as well from an attendance of nine months on the hospital for the reception of the poor, labouring under the disease, as from one of us prescribing, during a part of the time, for the Philadelphia Dispensary, added to the cases furnished us by private practice, and very many others, the records of which have been kindly placed at our disposal by professional friends.

The ravages committed by the small-pox in Baltimore, and the fact of many who had been previously vaccinated having been attacked by the disease during the years 1821 and 1822 were notorious to us all, but were productive of little alarm in Philadelphia. The non-appearance of the scourge in the greater part of the period, when the former city was suffering under it, justified, to a certain extent, this feeling of security, and seemed to call more on our sympathies for our neighbours than on our fears for ourselves.

In the month of September, 1823, some cases of fever, with pustular eruption, first arrested the attention of the medical faculty, some of whom were, of course, called on to render professional assistance. The residence of some of the persons, thus attacked, in Water street, and their emigration from Europe, naturally induced a suspicion of this disease being no other than the small-pox, imported by, or brought in with them. Very nearly about the same time, however, some scattered cases of a similar eruptive disease, were noticed in the upper or western portion of the city, without our being able to trace any intercourse or connexion between these and the others in the lower or eastern part, viz. Water street.

The first return of death from small-pox, furnished by the Board of Health, was in the week between the 13th and 20th of September. The next was between the 4th and 11th of October. From this time to the end of the year there was a progressive increase of mortality, and the annual return for 1823, presented no fewer than one hundred and sixty deaths by small-pox. The greatest mortality in any one week was thirty-three, from December 20 to 27. During the months of January, February and March, 1824, the disease prevailed extensively, and was fatal to many. In the following months its violence subsided, and in the month of June our attendance on the temporary hospital[11] was discontinued, in consequence of a resolution of the Managers of the Alms House to close it. Though a few patients were afterwards received into it, yet the malady soon disappearing, justified its final closure. The annual return for 1824 exhibited three hundred and twenty-four deaths by small-pox. The entire mortality from this cause was four hundred and seventy-three, in a period of twelve months, from November 1, 1823, to November 1, 1824. The deaths before the first, and after the second date, were but eleven.[12] Contagious as this disease unquestionably was, we cannot, at the same time, withhold our belief of its having been in a measure subjected to epidemical influences, viz. in a particular character of the seasons and atmospherical changes. It is then within our province, as historians of events, rather than as expounders of causes, to present our readers with a summary account of the weather during the years 1823 and 1824. We do this both from a sense of duty, considering it as pertinent to our present labour, and from a wish to encourage others by our example to preserve and transmit the meteorological registers, in their respective districts, of those years, marked by new or aggravated diseases.

METEOROLOGICAL REGISTER.[13] Winds Days. Snow & - Rain N. W. N. E. Mean Variat. Variat. Water. to to 1823. Temp. Therm. Barom. Inches. S. W. S. E. - - - - - The January, 31 44 0.94 3.38 22 8 February, 25 42 1.17 1.93 22 6 temperature March, 37 52 1.65 6.87 21 9 April, 55 47 1.08 1.77 16 14 of May, 61 52 0.88 1.60 19 8 June, 68 46 0.65 0.87 20 10 the July, 72 30 0.58 6.12 23 6 August, 72 35 0.60 4.68 21 8 wells September, 63 51 0.61 3.46 15 12 October, 53 42 0.60 2.02 21 9 and November, 38 38 0.81 2.47 21 9 December, 34 31 1.07 7.37 21 10 springs, - - For the year, 50-3/4 88 1.70 42.54 242 109 in - - - - - 1824. and January, 36 48 1.25 3.67 24 7 February, 31 59 1.55 3.94 21 7 near March, 40 39 0.71 2.63 16 15 April, 50 45 1.08 4.54 22 8 Philadelphia, May, 60 44 0.88 1.59 24 7 June, 73 46 0.69 6.09 25 5 July, 74 30 0.38 8.80 19 8 is August, 70 36 0.45 6.39 20 11 September, 64 41 0.65 6.60 17 7 52 deg. October, 54 43 0.65 1.53 23 5 November, 42 38 0.89 2.49 24 6 Fahrenheit. December, 37 43 0.95 2.11 24 7 - - For the year, 52-1/2 85 1.55 50.38 259 93

1823.

Maximum of Therm. 91, June 19. Maximum of Barom. 30.45, Nov. 29. Minimum " 3, Feb. 7. Minimum " 28.75, March 30. — ——- Variation, 88 1.70

1824.

Maximum of Therm. 90, June 8. Maximum of Barom. 30.45, Feb. 6. Minimum " 5, Feb. 2. Minimum " 28.90, Feb. 26. — ——- Variation, 85 1.55

The amount of water which fell in rain and snow during the four years, from 1822 to 1825, inclusive, was,

1822. 1823. 1824. 1825. Inches, 35.20 42.54 50.38 33.26

We next subjoin a summary of deaths by fever, erysipelas and measles, in the above period; being more desirous of narrating all the circumstances associated with the appearance and continuance of the small-pox, than of insisting on them as supporting causes or necessary connexions. It will appear from the accompanying statement, that the diseases febrile and eruptive were in number, violence and mortality unusually great, in the above mentioned years, as we discover by comparison with the returns for 1822 and 1825.

Deaths by Fevers. Erysipelas. Measles. Small-pox. 1822 510 4 0 0 1823 758 24 156 160 1824 654 28 102 324 1825 375 12 38 6

In New York and Baltimore, the coincidence between increase of fevers, measles and erysipelas, and the mortality from small-pox, is not so well marked.

In New York—Deaths by

Fevers. Erysipelas. Measles. Small-pox. 1822 393[14] 6 1 0 1823 192[15] 13 117 18 1824 191[16] 14 100 394 1825 445 20 53 40

In Baltimore—Deaths by

Fevers. Erysipelas. Measles. Small-pox. 1821 400 0 2 21 1822 430 1 4 122 1823 304 2 175 2 1824 183 3 14 2 1825 138 0 9 3

We now proceed to give a brief sketch of the disease called the natural small-pox, (occurring in persons unprotected by previous vaccination or inoculation,) and the deaths from which are given in the above statements. We must, in advance, insist on the great diversity in the appearance of the eruption in different individuals; so great, that an attempt to make an accurate picture of one case pass for a faithful representation of the many, must be deceptive and injurious.

In the premonitory symptoms, constituting the characters of the fever precursory to the eruption, there was considerable uniformity: the complaint of nearly all those attacked being at first chills and rigors; pains in the loins, head and limbs, with thirst and want of appetite; with which were soon associated gastric uneasiness, and in many, soreness of throat, rendering deglutition painful, hoarseness and weeping eyes. The duration of these symptoms, aggravated by febrile exacerbations, varied from one to three days, more usually the latter, after which the eruption begins to appear. It is first seen round the forehead and temples, near the hairy scalp; then on the cheeks and breast and back; on the arms near the shoulders; the abdomen and thighs; and subsequently on the fore-arms and hands, and finally on the legs and feet. The appearance of the eruption is that of red or scarlet papulae, presenting to the touch a sensible resistance, but not much raised, and without roughness or hardness. These papulae, becoming more and more defined and elevated, are after a day or two converted into vesicles, with small elevated centres or bodies of a yellowish-white, and more diffused red and somewhat hard bases or margins. The redness extending as the eruption becomes copious, converts the skin, especially of the face, neck, and hands, into a red ground, from which project, in relief, the whitish vesicles. Similar appearances, but of a less marked nature, owing to the eruption being more scattered, are found on the trunk. The vesicles, containing at first a thin, semi-transparent fluid, become gradually larger, fuller and yellower, and filled with a thick, tenacious matter. This change is completed, and the pustules are entirely formed, after a lapse of time from the first eruptive effort, which varies from the fifth to the ninth day, and is occasionally longer. The mean for the beginning of maturation, or the finishing of the secretion of matter in the pustule, may be received as five days for the face, and eight or nine days for the body generally. The stages of the eruption, as regards its appearance, may be very properly called papular, vesicular, and pustular. This last having attained its height, completes what is termed the period of maturation, during which the pustules retain their fulness and spheroid figure; and exhibit the greatest proportion of whitish-yellow shining surface of their body, and diminished extent of redness at their base. A yellow dry point on the summit of the pustule, which loses thereby somewhat of its former spheroidal shape, by becoming flatter, or slightly indented, indicates beginning desiccation, at which time the body exhales that peculiar odour, so unpleasant, and so readily recognizable, after it has once been perceived. There is no uniformity in the size of the pustules on the body generally, nor any equality among them on a particular part: more usually one larger and fuller is surrounded by others less so. Nor is it to be supposed that the changes above mentioned are gone through in regular succession on all parts of the surface, uniformly. It was no uncommon thing to see the eruption papular on the legs, vesicular on the trunk and arms, and pustular on the face, at the same epoch. One part even, as the arm for instance, has exhibited to us the three forms at the same time.

Maturation complete and desiccation going on, the pustules break, and have their thin coverings converted into a yellow hard coat or crust, to which adheres the pus that was not removed by absorption, and the residue, by evaporation of its watery part, is now converted into a scab of varying thickness, firm and prominent in its centre, and made up outwardly of concentric circles. The margins of the pustules, before of a distinct red, now assume a bluish-red or purplish colour, and the skin begins to desquamate.

The constitutional sympathies, or the symptoms in the milder and regular variety of the disease, are not of any great violence or intensity. The premonitory pains, diminishing or disappearing, after the coming out of the eruption, leave in their place a regular fever. The action of the heart and capillaries is hurried during the papular and vesicular stages; but becomes more equable while maturation is going on. During the former period, the loaded and not unfrequently furred tongue evidences disordered stomach, the cravings of which are for cold drinks. The somewhat laborious respiration may, in some cases, depend on the swelling and soreness of the fauces and pharynx; in others, on the eruption extending along the lining membrane of the larynx; whilst in others, it may be caused by bronchial engorgement.