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This writer mentions Hare's “ Difficulties and Discouragements” as a melancholy letter. Did he not know that the whole is a fine piece of irony ?
Art. V. Description and Treatment of Cutaneous Diseases. Order 3.
Rashes. Part I. containing the Varieties of Rubeola and Scar. latina. By Robert Willan, M.D., F.A.S. 4to. 18s, sewed.
s the commencement of Dr. Willan's elaborate work on
cutaneous diseases, has already fallen under our review, we have at present to notice the publication of a 3d number, containing an account of the measles and scarlet fever. These diseases compose the first part of his 3d order, Exanthemata ; a term which he translates by the word rashes, and describes to be a redness of the skin, varying as to extent, continuity, and brightness of colour, and occasioned by an unusual quantity of blood distributed to several of the cutaneous veins, in some instances with partial extravasation.'
Our medical readers will perceive that the term is here applied in a new sense, and that the definition is limited to the character of the eruption, independently of any general affection of the system. Dr. Willan's arrangement is confessedly artificial, founded not on any supposed resemblance or analogy between the nature of the diseases, bur merely derived from their external appearance; and therefore we cannot be surprised to find that the present order consists of a different assemblage from those which have been usually allotted to it. The other affections classed as exanthemata, besides the measles and scarlet fever, are urticaria, roseola, iris, purpura, and erythema. - We shall postpone our remarks on the system in general, until we arrive at the termination of the work, when we shall have a better opportunity of comparing its different parts with each other.
Dr. Willan's account of the measles is full and satisfactory: but the symptoms and progress of this disease are well known, and have been so accurately described by preceding writers as to leave little room for offering any new information on the subject. The disease is highly contagious, particularly to children; yet the author supposes that some previous state of the body is requisite, in order to render it susceptible of the infection. Infants, he observes, are less liable to it than children at a more advanced age: but he has never met with any individual who is wholly unsusceptible of it, as is the case with the small-pox. Three varieties of the disease are pointed out; the rubeola vulgaris, rubeola sine catarrho, and rubeela nigra: the first of these varieties, as the name implies, being the common form of the disease. Dr. W. remarks that, in addition to the usual exanthematic eruption, a few miliary vesicles occasionally make their appearance; and he says that the fluid from these vesicles has produced the disease by inoculation, but it does not seem that the symptoms were milder than in their usual form. He is decidedly of opinion that it is improper to check the eruption, when it has become visible, by cold or by purgatives; an opinion which is sanctioned by the concurrent testimony of all writers. He does 110t appear to have experienced the effects which would result from repressing the fever at its commencement; a practice which, although of doubtsul success, probably would be less injurious than repelling the eruption when once formed. The constitutional symptoms and the eruption generally disappear about the same period, and leave the patient nearly free from complaint ; sometimes, however, the pectoral affections return with increased violence, and are either immediately fatal, or prove ultimately mortal by inducing pulmonary consumprion.
During the first period of the disease, little medical treatment is necessary, except an attention to diet and temperature. When the symptoms become severe in the latter stage, the most active practice is to be adopted; bleeding is frequently ne. cessary, and should be employed where the oppression of the chest is considerable. It was formerly the custom, in all cases, to bleed at the commencement of the disease: but in modern times, when the antiphlogistic plan is pursued with more caution, and we are less influenced by systematic views, the lancet is not employed until particular symptoms indicate its use.
Rubeola sine catarrho is described as a complaint in which the eruption exhibits the usual features of measles, but is unattended by fever. It is with difliculty distinguished from other cutaneous eruptions, and appears not to secure the constitution against the feverish measles; whereas the author never met with an instance in which this latter affection occurred twice to the same individual.
Dr. W. closes his observations on measles with some remarks on the cases described by Sir W. Watson, under the title of “putrid measles," as occurring among the children at the Foundling Hospital in the years 1763 and 1768.
He supposes these to have been, in fact, the scarlet fever, a conclusion which he draws from considering the symptoms as related by Sir W. Watsın, the lities under which he entered the cases in ilie Hospital bocks, and the unsetiled state of medical
opinion at that period respecting the nature of the scarlet fever, and its connection with the measles : a point which is more fully illustrated in the subsequent section. After an interval of so many years, it is perhaps impossible to form a decided opinion on this matter : but we chink that Dr. WilJan's reasoning is at least extremely plausible ; and until we shall have an opportunity of again observing the symptoms de scribed by Sir W. Watson, we must consider the existence of the putrid measles as very problematical
We next proceed to the Scarlatina. Dr. Willan disposes the varicuies which this disease assuries under three heads, to which he gives the specific names of simplex, anginosa, and maligna. In the first, a moderate degree of fever prevails, which continues for three or four days, attended with an exanthematic eruption, but without any swelling, inflammation, or ulcer of the throat. Its general appearance is not very unlike that of the measles; and, as we afterward learn, they have been very frequently confounded together. The diagnostics are, however, for the most part, sufficiently well marked; and they are very accurately laid down by Dr. Willan, as consisting in ihe different period at which the eruption becomes visible, in the appearance of the efflorescence, in the accompanying symptoms, and in the manner in which the disease declines. In the scarlatina anginosa, (which is perhaps the most usual form that occurs in this country,) besides the fever and efflorescence, the tonsils are considerably affected with swelling and inflammation ; which frequently proceed so far as to produce slight ulceration and sloughs in the throat. The symptoms of this species are admirably detailed; and we regret that our limits will not permit us to quote them at full length. With the exception of the state of the throat, the symptoms of the scarlatina anginosa resemble, in every respect, those of the scarlatina simplex, but exist in an aggravated form.
Scarlatina malignu presents an appearance materially different from the two others, and is altogether a much more formidable complaint. Its peculiarities are thus stated by Dr. Willan :
• It's symptoms on the first day are nearly the same as in the Scarlatina anginosa ; but some of the following peculiarities are af. terwards observable :
• 1. A small indistinct, and irregular pulse ; a brown or black incrustation of the tongue, teeth, and lips +
• 2. A dull redness of the eyes, a dark red flushing of the cheeks, deafness, delirium, or coma alternating with frettulness and vio lence :
• 3. Breath extremely fetid ; a rattling and laborious respiration, partly occasioned by a thick tough phlegm clogging the fauces ; a
constriction of the jaws, and painful deglutition ; a fulness and lived colour of the neck, with retraction of the head :
4. Ulcerations on the tonsils, and adjoining parts, covered with dark'sloughs, and şurrounded by a livid base : the tongue is often 80 tender that a slight touch produces excoriation :
• 5. An acrid discharge from the nos' rils, causing soreness, or chops, and even blisters, about the nose and lips, the fluid discharg. ed being at first thin, but afterwards thick and yellowish:
6. The rash is usually faint, excepting in a few irregular patches; and all of it presently changes to a dark or livid red colour. It ap. pears late, is very uncertain in its duration, and often intermixed with petechiæ. In some instances the rash suddenly disappears a few hours' after it is formed, and comes out again at the expiration of a wetk, continuing two or three days: in one case numerous patches of it appeared a third time, on the seventh day from the second eruption ; these remained for two days.'
It is a curious fact that in this which is the most violent form of the disease, the characteristic efflorescence is seldom 80 considerable as in the other varieties,' and sometimes is entirely wanting. This circumstance led to much uncertainty in the nosology of scarlatina ; and from this cause, until within a few years, the identity of the different species was not acknowleged. On this subject, Dr.Willan observes:
• It is truly singular, that the slightest of all eruptive fevers, and the most violent, the most fatal disease known in this country, should rank together, and spring from the same origin. Experience, however, decides that the simple Scarlet Fever, the Scarlatina anginosa, the Scarlatina (or angina) maligna, and the scarlet ulcerating Sorethroat without the efforescence on the skin, are merely varieties of one disease. That all of them proceed from the same source of con. tagion, is evident; because, under the same roof, in large families, some individuals have the disease in one form, some in another, about the same period. According to the state of the air, the soil, climate, or season of the year, one form predominates over all the rest, and gives the general character to every epidemic Scarlatina.'
Another point respecting scarlatina, which has been the ground of much controversy, is whether the disease can occur twice to the same person.
The affirmative was formerly adopted by many eminent practitioners, and is still maintained by some men of respectability : but the contrary is the position most commonly received, and that which is supported by the greatest authorities.
Dr. Withering, whose experience and judgment were so well known, was decidedly of this opinion; and the suine was also maintained by the late Dr. Currie.
Perhaps the history of no disease of modern times, cer tainly of none so important, is involved in so much obscurity as that of scarlatina. Dr. Willan has taken particular pains with this part of his work; and he has displayed an unusual share of learning and acuteness in tracing its progress, as it, from time to time, became known under a variety of ap. pellations, in all the different parts of Europe, during the last ihree centuries. We have some reason for supposing that it was observed by Aretæus, Acetius, and Aricenna : but the first unequivocal account is by Ingrassin, a Neapolitan, who wrote in the beginning of the 16th century. It appears that the term rubeola was originally applied to scarlatina, and that morbilli was the name given to the measles. During the 16th and 17th centuries, it occurred in almost every part of Europe, frequently committing the most dreadful ravages. It was called by a variety of names; and very different opinions were entertained respecting its nature, and its relation to other diseases. Morton was the first English writer who distinctly described it, but he imagined it to be only a variety of the measles. The term scarlatina seems to have been first applied to it by Sibbald. Even until the middle of the 18th century, it still continued to be very imperfectly understood; and while by some writers it was regarded as only a variety of the measles, others supposed that the different varieties were each distinct diseases. This opinion was adopted by Dr. Fothergill; whose treatise, published about the middle of the last century, contributed very largely to diffuse a more general knowlege of the complaint. As far as we are able to ascertain, Dr. Clark of Newcastle was the first writer who distinctly described the three varieties, and yet considered them as only species of the same disease; an opinion which was afterward decidedly embraced by Dr. Withering, and, in consequence of the authority of his name, has been since very generally admitted. :
After the history of this disease, we proceed to the method of treating it.---The scarlatina simplex requires little medical aid. The scarlatina anginosa was formerly treated on the antiphlogistic plan, but ihis is now very generally given up by the English practitioners. Emetics, which were first brought into notice by Dr. Withering, form a principal part of the remedies; to which Dr. Willan, from his own experience, and that of Dr. Stanger, adds the oxymuriatic acid. Blisters are generally allowed to be inapplicable. We regret to learn that the affusion of cold water is only beginning to be employed in Lon. don. From the account given of its effects in the “Medical Reports," we should conceive it to be a more important remedy in scarlatina than in typhus itself. In the scarlatina maligna, bleeding, blisters, and purging, are highly injurious ; and on the continent, where they are still employed, th-y are productive of the worst effects. Dr, Fothergill först pointed