ROSEOLA.

The eruptive fever called roseola, or rose rash, sometimes called false measles, is an affection of very little importance, exclusive of the liability of confounding it with rubeola and scarlatina.

The eruption is preceded by symptoms of constitutional disturbance for one or two days. These symptoms are, cephalalgia, loss of appetite, with sometimes nausea and vomiting, and occasionally diarrhoea, chilly sensations, febrile movement, and general malaise. In young children convulsions may occur. The constitutional disturbance is more or less marked and frequently very slight. The affection of the throat and the affection of the air-passages, which belong to the history of scarlatina and rubeola in the stage of invasion, are wanting in roseola.

The eruption appears in the form of rose-colored spots or patches which are not elevated, the redness disappearing momentarily on pressure. It appears on different parts of the body, not commencing on the head and extending over the body as in rubeola. Frequently it appears on the body and extremities and not on the face. It continues for twenty-four or fortyeight hours only in the majority of cases. It disappears without desquamation, and is liable to return. It is sometimes accompanied with considerable pruritus. The affection has neither sequels nor complications. It may, however, occur in the course of other affections, especially in the stage of invasion in varioloid, in articular rheumatism, and in epidemic cholera after reaction. It has no gravity. One attack affords no protection against reenrrences. It is oftener presented in females than in males. It prevails not infrequently as an epidemic, and chiefly during the summer season. Some authors consider it to be contagious.

Attention to the foregoing points will suffice for the discrimination of the affection from scarlatina and rubeola. It does not call for treatment.

The use of the balsam of copaiva by some persons induces an efflorescence analogous to that of roseola. A variety of the affection belongs to the history of syphilis.

SUMMARY OF THE MORE IMPORTANT DIFFERENTIAL CHARACTERS OF VARIOLA, SCARLATINA, RUBEOLA, AND ROSEOLA.

Period of Incubation. The average period in variola from 10 to 14 days; in scarlatina from 1 to 6 days; in rubeola from 6 to 10 days.

Stage of Invasion. - Duration in variola from 2 to 3 days; in scarlatina from 1 to 2 days; in rubeola from 4 to 5 days; in roseola from 1 to 2 days. In variola, whitish or ash-colored spots in the mouth and fauces, and sometimes a cutaneous efflorescence; lumbar pain in a marked degree. In scarlatina, efflorescence and sometimes exudation in throat; febrile movement often notably intense. In rubeola, coryza, irritability of eyes, hoarseness, and loud barking cough.

Stage of Eruption.-In variola, eruption appearing first on face and wrists and gradually extending over cutaneous surface. The eruption at first maculated, next papular, next vesicular, more or less of the vesicles umbilicated, and finally the eruption pustular. The eruption aborting at different stages in cases of varioloid. The eruption in varicella differing in being vesicular at first, the vesicles not umbilicated, and not becoming pustular; also in the short duration of the stage of eruption. The febrile move

ment in variola remitting or ceasing with the appearance of the eruption. In scarlatina the eruption frequently appearing on the chest and upper extremities before, or simultaneously with, its appearance on the face and neck. The eruption rapidly diffused over the cutaneous surface. The eruption of a scarlet color, not elevated, assuming the form of patches with irregular or serrated borders, or existing continuously over the whole surface. The tongue resembling a ripe strawberry. In rubeola the eruption appearing first on the head and gradually extending over the cutaneous surface. The color a dull or deep red. The eruption elevated, and the coalescing papules grouped in crescentic forms. Febrile movement not diminished at the time the eruption appears. In roseola the eruption appearing irregularly on different parts of the cutaneous surface. The color rose-red. The eruption not elevated. The febrile movement slight. No affection of the throat or air-passages.

Stage of Desquamation.-In variola, concretion of pus and the formation of crusts or scabs. In scarlatina the epidermis exfoliated sometimes in branny scales and sometimes in large flakes or patches. In rubeola, desqua mation frequently wanting, and, when it occurs, always furfuraceous. In roseola, no desquamation.

Complications and Sequels.--In variola, no special tendency to any par ticular complications or sequels, but erysipelas, furunculi, and subcutaneous abscesses not uncommon. In scarlatina, a special tendency to renal disease, leading frequently to general dropsy and involving danger from uræmia. In rubeola, tendency to pulmonary affections, viz., capillary bronchitis, diphtheritic laryngitis, and pneumonitis, more especially the latter. Liability to tuberculous affections after recovery. In roseola, no complications nor sequels.

DENGUE.

The following succinct account of the epidemic affection commonly called dengue, an unclassical name of uncertain derivation, is based chiefly on communications by Prof. Dickson, Dr. Wm. T. Wragg, Dr. Henry F. Campbell, and Prof. Fenner, describing the affection as it occurred in Charleston, S. C., Augusta, Ga., and New Orleans, in the year 1850. Prof. Dickson's name is especially identified with the affection from his having been the historian of its visitation in this country in 1828, and he has contributed more largely to what is known respecting it than any other writer. Collated abstracts from the communications just referred to are contained in a report of the Committee on Practical Medicine to the American Medical Association in 1851, of which committee the author of this work was chairman. For a fuller account of the affection than is consistent with the scope of this work, the reader is referred to that report, and to the writings of Dickson.1

The affection prevailed extensively in the West India Islands in 1827 and 1828, and about the same time in many parts of the Southern States of this country. An affection supposed to be the same prevailed in Philadelphia in 1780, and was described by Rush. It was then, as since, frequently known as the breakbone fever. Other epidemics supposed to be identical have occurred at various periods in other parts of the world. Cocke and Copland apply to an epidemic affection supposed to be the same the name scarlatina rheumatica.

The development of the affection is either abrupt or slow. The symptoms attending its development are anorexia, chilly sensations, but rarely a pro

Transactions Am. Med. Association, vol. iv., 1851.

nounced chill, languor, lassitude, and general malaise. These symptoms exist in some cases for only twenty-four hours, but in other cases for several days before the affection is fully developed.

After the access or forming period follows a febrile stage or a paroxysm of fever. The duration of the febrile movement varies from nine hours to three or four days, the average duration being about thirty-six hours. During this stage, and sometimes during the access, acute, often excruciating, pains in the head, eyes, muscles of the neck, loins, and extremities are prominent traits of the affection; hence the name breakbone fever. The pains diminish or disappear with the cessation of the fever, and the patient, who had taken to the bed with the onset of fever, is now able to sit up, and complains only of debility; perhaps he returns to his accustomed avocations. But in four or five days the pains often return, with frequently a recurrence of the febrile movement, debility, and malaise, compelling a return to the bed.

In the great majority of cases, an eruption occurs at a variable period after the febrile paroxysm. The eruption presents, in different cases, a diversity of characters. It resembles in some cases very closely the efflorescence of scarlatina. In other cases it is not unlike the eruption of rubeola. It is sometimes papular, like either lichen or urticaria, and it is sometimes vesicular, like either sudamina or varicella. Erysipelas and purpura are occasionally observed. Hemorrhage from the nose, mouth, bowels, and uterus occurs in some cases.

The convalescence is often tedious; the recovery of strength, appetite, etc., is apt to be slow. The average duration of the disease is about eight days. Relapses are not infrequent. As regards incidental events and sequels, convulsions, in children, occasionally usher in the attack; delirium, like that of delirium tremens, has been observed succeeding protracted vigilance, and in pregnant women miscarriage is apt to take place. A rheumatic condition of the joints, abscesses, boils, and carbuncles are not infrequent sequels.

The extent of prevalence of this epidemic in Charleston and other places is remarkable. Dickson states that all the members of numerous large households were attacked without a single exception, and of his own family, eleven in number, he alone escaped. Wragg computes the number of cases at one time in Charleston at 10,000, and during the epidemic seven or eight-tenths of the population were affected. All classes are attacked, persons of either sex, children and octogenarians. As an illustration of its universal prevalence, the editor of the Southern Medical and Surgical Journal, in his issue for December, 1849, apologized for typographical errors by saying that "the editor, publisher, and printers were all suffering from breakbone fever." In the village of New Iberia, Louisiana, the population in 1851 did not exceed 250. Dr. Duperier states that in six weeks 210 of the inhabitants of this village, and about 40 from the neighborhood, had gone through the disease.

The duration of epidemics is brief, ceasing usually in six or eight weeks. Of the circumstances giving rise to the special cause, nothing definite is known. Dickson regards the affection as contagious. This opinion is opposed by the rapid and almost simultaneous diffusion of the affection, by the limitation of its prevalence to towns or within a circumscribed area, and the short duration of epidemics. It is an affection chiefly occurring in warm climates, and prevails especially in cities and large towns. To the latter rule there are, however, striking exceptions.

This affection, although extremely distressing, and quently severe symptoms, is very rarely, if ever, fatal. sity is in striking contrast to the absence of danger.

presenting not infreIts apparent inten

The affection is self-limited, and there are no known means of arresting or abridging it. The treatment, therefore, consists of palliative measures. Opiates to relieve the pains, restlessness and vigilance, are indicated. The degree of suffering, in some cases, warrants the use of chloroform by inhala tion. Rubefacients to the spine and in other situations are useful. Alcoholic stimulants, given pretty freely, have been found beneficial. During convalescence, tonic remedies and hygienic measures to promote appetite and the recovery of strength, are indicated.

CHAPTER IX.

Diphtheria-Anatomical Characters-Clinical History-Pathological Character-Causation

Diagnosis-Prognosis-Treatment.

Of the constitutional affections, exclusive of the essential fevers, which remain to be considered, one of the most important is the affection now commonly known as diphtheria. This affection has prevailed at times as an epidemic, in various parts of the world, from a remote period. It has been described by writers in different countries and epochs, under a variety of names, such as, ulcus Egyptiacum vel Syriacum, cynanche maligna, angina maligna, angina gangrænosa, morbus suffocans vel strangulatorius, Garrotillo, malignant sorethroat, epidemic croup, etc. In this country, until within the last few years, it has occurred rarely, and to a limited extent, during the present century. It was described by Bard, in 1789, under the name, angina suffocativa. The distinctive characters of the affection were very clearly elucidated by Bretonneau, in 1821, 1825, and 1826, who applied to it the term diphtherite, whence originated the name diphtheria. This name, the significance of which relates to the most characteristic local event, viz., the formation of a false membrane, has, to say the least, the negative merit of not involving any hypothesis concerning the pathology of the affection.

ANATOMICAL CHARACTERS.-The characteristic feature, as just stated, is the presence of a false membrane, that is, the local affection is an inflammation attended with the exudation of lymph. This feature is the rule in serous inflammations, but in diphtheria the mucous membrane especially is the seat of the local manifestation of the disease, and in mucous inflammations the formation of a false membrane is exceptional.

The faucial mucous membrane, in the vast majority of cases, is primarily affected, and, in a certain proportion of cases, the local affection is limited to this situation. The first appearance is redness of the fauces accompanied by more or less swelling of one or both of the tonsils. The exudation, at first thin and semi-transparent, becomes opaque and more or less thick. It is at first soft, like exuded lymph in other situations, but becomes more or less dense and firm. The lymph is deposited successively in layers, forming a stratified false membrane. This is white or ash colored, but it may become dark and even black from decomposition and the imbibition of blood. It may also be colored by remedies and by matters vomited. The patches of exudation present well-defined abrupt margins. When unusually thick, the false membrane resembles wet parchment or chamois leather. Examined microscopically, it shows fibres, granules, the epithelium proper to the ma cous membrane, to which it adheres more or less closely, pus globules, blood

globules, and occasionally cryptogamous vegetable productions. It is essentially identical, as regards gross and microscopical characters, with the false membrane in true or diphtheritic croup.

Different cases differ in the extent of the affection within the fauces. One or both of the tonsils may be alone affected. These bodies are sometimes greatly swollen so as almost to meet, and in other cases they are only moderately enlarged. The exudation may extend over the posterior part of the pharynx, the palatine arches, the uvula, and, forward, over the greater part, or the whole, of the soft palate. It may be uniformly diffused in these situations, but is oftener in distinct irregular patches. Redness extends beyond the margins of the exudation, and the parts affected, other than the tonsils, are somewhat swelled. With the forceps the false membrane may be detached in strips or patches, and the mucous membrane beneath is simply excoriated or deprived of its epithelium. Frequently bloody points are apparent on the surface from which the membrane has been detached. Ulcerations and gangrene are rare. The false membrane when thick, loose, and dark or black, however, presents an ulcerated or gangrenous appearance, which is implied in some of the names formerly given to the affection. Sooner or later, if life be sufficiently prolonged, the false membrane is thrown off. The exfoliation sometimes takes place in three or four days, and it is sometimes delayed even to twenty days. Not infrequently it is followed by a second, and sometimes a third, and even a fourth formation of false membrane.

The lymphatic glands of the neck, and especially those behind the angle of the lower jaw, are more or less enlarged, painful, and tender, in the great majority of cases. As a rule, the amount of enlargement corresponds with the affection within the throat. If the latter be limited to one side, the glands on the same side may be alone affected. The glandular affection rarely proceeds to suppuration.

The diphtheritic exudation within the throat is to be discriminated from the follicular secretion, which is sufficiently common, especially over the tonsils. The latter is a pultaceous deposit, not membraniform, not removable in strips or patches, and may be seen to dip into the follicles. Pharyngitis with follicular secretion is often called diphtheria. This term, however, is correctly applied only to cases in which a true diphtheritic exudation exists. During the epidemic prevalence of diphtheria, cases of simple pharyngitis, or of pharyngitis with follicular secretion are often rife. The affection in these cases may be due to the epidemic influence, but the disease is comparatively trivial, and, hence, the rate of fatality in different collections of cases of so-called diphtheria will vary according to the accuracy of diagnosis, or the strict observance of the proper application of the name.

In mild cases of diphtheria the disease manifests itself locally in the fauces alone, but in cases of more or less severity and danger the diphtheritic affection extends to other situations. The posterior and anterior nares, on one or both sides may be the seat of inflammation and exudation. The Eustachian tube is sometimes involved. The mucous membrane of the cheeks and gums may present patches of, or be completely coated with false membrane. The eye is sometimes invaded, and the diphtheritic conjunctivitis involves considerable danger of destruction or impairment of vision chiefly from opacity of the cornea. The diphtheritic inflammation sometimes invades the œsophagus, and may extend quite to the stomach. A more serious extension is into the larynx. The disease then involves the morbid conditions which exist in true or diphtheritic croup. As in croup, the inflammation and false membrane extend to the trachea, and may extend into the bronchial tubes, reaching, in some cases, the tubes of small size. As a rule, however, it does not extend beyond the trachea. In the cases in which the parts adjacent