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Levy on Measles in the Adult.
do not absolutely characterize inflammation of the bronchi; for we observe them whenever these become the seat of active or passive congestion, as after the first week of typhoid fever, and in the advanced lesions of the heart. A simple hyperæmia
of the bronchial mucous membrane, analogous to that which, directed on the reticular texture of the skin, determines the production of the spots of measles, may give rise to symptoms of bronchitis. Later, in a certain number of cases, inflammation does supervene, but it participates in the special nature of the congestion which has prepared the way for it. In this way we explain the rubeolic catarrh, to which we may add coryza, angina, ophthalmia, and diarrhea.
“ If the patient is surrounded by a temperature and the care his case requires, this follows the phases of the exanthem and does not survive it. If, however, he is imprudently exposed to the cold, the severity of the weather renders it difficult to protect him from this, or if he is predisposed to diseases of the respiratory organs, then it is by no means uncommon to find this morbillous hyperæmia of the bronchi pass into an inflammatory type, and retard convalescence, however regular the course of the eruption may have been. The measly eruption, too, may become propagated throughout the whole extent of the bronchial tree, and from the very commencement of the rubeola symptoms of a deep-seated bronchitis may coincide with those of the exanthem. Nine of our patients offered striking examples of this. The case now becomes serious. The frequency of the circulation increases in an inverse degree to the amount of respiratory surface which remains disposable in the lungs. Wherever it is invaded by the exanthem, the bronchial surface re-acts less vigorously on the air, or may become totally unfit for this function. The more narrow the field for hæmatosis is rendered the more must the blood be hastened in its course to bring it a greater number of times in contact with the air. Hence violaceous colour of the face, especially of the mucous orifices; rapidity of pulse (120 to 140), and of inspiratory movements (48 to 60); rhonchus audible at a distance; vibratory and sub-crepitant râles heard over the entire chest ; obstinate, harsh, paroxysmal cough, followed by the laborious expectoration of small quantities of tenacious and viscous matters, or of a white, foamy froth; an ever-increasing anxiety; and at last delirium. This is the spectacle such patients present, and, without the promptest aid, they rapidly fall into a state of asphyxia.”
Complications.—(1.) The co-occurrence of several simultaneous eruptions was only observed towards the end of the epidemic. Eight patients then furnished examples of this. In three, varicella was commingled with the rubeola. In one, rubeola, varioloid, and miliaria were observed simultaneously : and, in another, with variolous pustules on the face, there was a scarlatina suffusion on the trunk, and spots of measles on the neck and limbs. In two other cases the measles was complicated with urticaria, and in another a purpura, which required 23 days for its cure, appeared. (2.) The most common complications were affections of the chest, in the form of bronchi-pneumonia, of which six examples are cited, one of these proving fatal, in consequence of the patient's neglecting its treatment, the eruption pursuing its normal course. (3.) Diseases of the digestive organs have rarely offered complications. These complications have also been equally rare in the various instances of measles in the adult which have on former occasions come under M. Levy’s notice; while MM. Rilliet and Barthez noted the occurrence of gastro-enteric phlegmasia in 46 out of 167 cases of measles occurring in children. He agrees with MM. Blache and Guersant, that this difference is rather due to the cachectic condition of the children, who formed the object of those researches, than to
K K *
the mere effect of age-a condition resulting from a long residence within the walls of a hospital, and usually leading to an entero-colitis or pneumonia.
Consecutive Diseases.—“ The question of diseases consecutive to measles is of a great importance in practice; but science is far from being in possession of a sufficiency of materials for its solution. The difficulties it gives rise to depend upon the complexity of the etiological elements. We are constantly exposed to the deduction from the simple succession of two facts of a relation of causality which does not exist between them. Has the so-called consecutive disease closely followed the measles ? It may depend upon the constitution of the subject, and upon the influences which modified it prior to the attack. If an interval bas elapsed between the one and the other, who can say whether the new affection, whatever relationship it may seem to have with the measles, is not due to causes which necessarily escape the physician? However this may be, we were well placed to follow the ulterior phases of the health of our measles patients. On the one hand our observations extend over a period of thirteen months, and on the other hand scarcely any of the patients we have treated for the disease have quitted the garrison, but remained under the eyes of our colleagues in the different regiments, whose attention having been drawn to them by the memoranda we had placed on their tickets of dismissal, they were subjected to an attentive superintendence, and, in the case of their diseases requiring their return to the hospital, they were again consigned to our clinical wards."
In this manner 16 patients who had been attacked with measles came again under the author's care, and of whose cases he presents an analysis. The results, to which we can alone refer, are that eight of these cases presented examples of non-tubercular and eight of tubercular affections ; the former consisting of bronchitis, pneumonia, or pleurisy, or two of these combined.
“ The most general fact which results from the tables is, that all the diseases supervening after or springing up with measles have fallen upon the respiratory organs. Must we hence conclude that this disease impresses on these a greater aptitude to phlegmasiæ ? Clinical observation replies affirmatively. Bronchial hyperæmia is one of the determinations of rubeola upon the internal tegument. Inflammation of the bronchi frequently spreads even to their capillary divisions
, and lobular pneumonia is added in a great number of cases. These are facts acquired by science, and which the observation of our predecessors had long since established, with less anatomical precision, and according to different etiological views, which however detract nothing from the proper signification of facts. 'Infantes,' says Sydenham, in 1670, præsertim huic malo (spirandi difficultati et tussiculæ importuniùs urgenti) sunt obnorii, quod morbillis jam faces. sentibus se ostendit, unde in peripneumoniam conjiciuntur, quæ plures jugulat, quam aut variolæ ipse, aut symptoma quodcumque ad eum spectans morbum.'
“ Is the tuberculization which we have noticed in one half these cases at all connected with this inflammatory habitude of the respiratory organs, with the progressive anæmia of the patients who have suffered from rubeola, and who do not become re-established, or with any specific and not yet defined influence belonging to this eruptive fever? These problems will never obtain a rigorous solution. It is impossible to say whether these eight examples possess only the value of a simple coincidence with measles, or whether this has played a more active and direct part in the production of the tubercle. If it were established that the frequency of bronchial and pulmonary inflammation suffices to lead to its secretion, what we have already said of the power of measles to excite inflam. mation would furnish a reply to the question. Tubercle shews itself sufficiently 1817]
Levy on Measles in the Adult.
frequently in children who have had measles ; for, according to both Rilliet and Barthez, there is about one exainple of this in every eleven cases. M. Andral believes that measles accelerates the softening of pre-existing tubercle, an opinion which the facts we have collected do not positively confirm. Without carrying this discussion further, as it can lead to no certain proof, by reason of the insufficiency of clinical observations, we cannot admit with M. Rufz, 'that there does not exist in science a more hazardous proposition than the pretended influence of measles in the development of tubercle. So many judicious observers of all epochs (Hoffmann, Stoll, Frank, Rayer, Guersant, &c.) have seen phthisis succeed to rubeola, that the relation which they have believed themselves able to perceive between these two affections, though deprived of the sanction of a positive demonstration, cannot be altogether destitute of truth. The facts above reported incline us to this opinion. Whether in the case of adults or children, the practitioner should examine with the greatest solicitude the state of the res, piratory organs, both during the course, and after the disappearance of the disease.”
Antagonism.—Measles seems to exert a certain salutary action against some of the chronic diseases of the skin ; obstinate eczema, impetigo, &c., disappearing after the induction of congestion of the cutaneous sur. face by the new disease. MM. Blache and Guersant have also seen certain neuroses, as chorea and pertussis, cured under the influence of measles. M. Levy mentions two or three facts, shewing the occasional effect of the discase in inducing a suppression of long-standing gonorrhæa.
Mortality.–Of the 120 patients six died ; a mortality far less than that attendant upon the disease in infancy. According to MM. Rilliet and Barthez, observing the disease however in a very bad class of subjects, uncomplicated measles is cured in five out of six cases, while, in the complicated form, one-half the cases fall victims. But these statements cannot be generalized, for in 1837 M. Levy had 16 deaths in only 60 adults.
“ Still, the general result of our observations leads us to recognize that the measles causes a smaller proportion of deaths among adults than among children; and this difference, which we are unable to express in figures, but in our opinion is certain, is explained by the following circumstances. A greater resistance of the organism: a less liability to lobular pneumonia : a greater facility of clinical examination, and certainty in treatment. For the rest, the rubeola of adults, like that of children, follows the course of each epidemic. The prognosis depends essentially on that unknown quid divinum which measures out to epidemics their proportion and sphere of energy. Meteorological conditions of themselves furnish no element for such appreciation. The serious epidemic we witnessed in 1837 coincided with a mild temperature, while in that at Metz, during December, January, and February, the thermometer was almost always between 0° C. and 10° C.' It is important to distinguish the mortality as arising from the rubeola itself from that dependent upon the consequences of the affection. Not one of the deaths occurred during the eruption nor immediately after its delitescence. Between the period of admission and that of death a delay of froin 12 to 38 days occurred. T'he danger proceeds not then from the exanthem itself, but from the complications and consequences. 'If,' says Stoll, (Aphorism 578) more die in the small-pox than from its consequences, more die from the consequences of the measles than from the disease itself, and perhaps as many in this as in the other.'”
Treatment. This is much the same as in the measles of children. In the precursory stage, hygienic means alone are called for, and no attempt need be made to treat the diarrhea, vomiting, &c., which occur during the evolution of the eruption. The character of the epidemic must however determine us much on this point. Retrocession is not so grave an affair as is sometimes believed, and does not necessarily call for special medication. On its occurrence, the most careful exploration of the condition of each organ must be repeatedly made, in order to detect and meet any complication that may interfere with the progress of the eruption; but, this not being detected, an intelligent expectation is the best and safest practice. Suppose a splanchnic congestion or internal inflammation has become developed, it will be better to combat this directly, than by any endeavour to excite a tegumentary revulsion by the various internal and external stimuli usually recommended. “ Of all the exanthematous eruptions none so fugaceous as that of measles; and could we recall it to the surface, it is very doubtful whether the partial hyperæmia of the dermis, which constitutes it, would prove powerful enough to displace a phlegmasia which had fixed upon so vascular an organ as the lungs." The great difficulty is of course the treatment of the
pulmonary complications. “It might seem that men of from 18 to 30 years of age would bear bleeding better than children. It is not so. The inflammation here is not of a simple and legitimate character, but more approaches congestion in its nature; and is frequently accompanied by nervous erethism or prostration of strength.” Bleeding induces rapid anæmia ; and, on comparing his observations made at different epochs, M. Levy finds that this is not dependent upon the character of different epidemics ; but that it is one of the consequences of the general modification which this disease impresses on the organism. Blisters are of some use ; but the means from which he has derived most benefit is the tartar-emetic, given in nauseating doses in capillary bronchitis and in contra-stimulant doses in secondary pneumonia. In the first of these cases he gives it only on alternate days, so as not to distress too much the digestive organs. In the second, if the subject is strong, he precedes it by a venesection, and follows it by a blister. In some patients, Kermes mineral is supported better than the antimony; but it is a much more uncertain medicine.
We have confined ourselves to giving an analysis of this interesting little Essay. As opportunities for observing the disease on a large scale in the adult are rare in the civil practice of this country, and as the experience of our military hospitals is not communicated to the medical public with the promptitude and regularity it ought to be, we believe an account of the opinions of so good an observer as Dr. Levy will prove acceptable to our readers.
Ledoyen and Burnett's Disinfecting Fluids.
I. COPY OF REPORTS AND COMMUNICATIONS ON M. LEDOYEN's
Disinfecting Fluid, with Supplement. Ordered by the
House of Commons to be printed, 1st July, 1847. II. COPY OF REPORTS ON SIR WILLIAM BURNETT's DISINFECT
ING Fluid. Ordered by the House of Commons to be printed, 20th July, 1847.
In noticing these two Parliamentary papers, we must protest in limine against the very objectionable misapplication of the term disinfecting,” as employed in both. A vast deal of error and confusion has been introduced into medical reasoning by the vague and unsettled use of the words infect, infection, disinfecting, and so forth. Every one, we presume, will admit that they should all have a correlative signification, and that this signification should be definite and unfluctuating. In recent numbers of this Journal, we have sought to attain this important end by limiting the term “infection” to denote that power or quality of certain maladies to propagate themselves by effluvia given off from the bodies of the sick, and becoming diffused through the surrounding atmosphere. It must be quite obvious that, unless some such definitive restriction be adopted, it will be utterly impossible to argue with any degree of intelligible precision, far less to determine with scientific accuracy many of the questions connected with the important subjects of the origin and dissemination of febrile diseases, as well as of the best means of checking their growth or arresting their progress. We are well aware that many medical writers, and those too of bigh repute, have used the words in question in a larger and more comprehensive sense than that which we think wise. Still, without almost any exception, they have very generally been employed in reference to the production and presence of morbific effluvia. It is for this reason that we object so strongly to the employment of the term " disinfecting" in the sense of “ stench-destroying,” or even of “putrefaction-arresting ;” and we therefore cannot but regret that Sir William Burnett should have given the sanction of his high authority to the perpetuation of such a misnomer, -calculated, as it is, to convey an erroneous impression to the public. It is not at all to be wondered at that M. Ledoyen, and the great trumpeter of his nostrum, Colonel Calvert, should have fallen into the blunder; if blunder it can be called in their case, seeing that they claim for their fluid the property not only of destroying all noisome smells, but even of “disinfecting patients suffering with infectious disorders." We shall presently see what evidence or proof can be adduced for this assertion. When M. Ledoyen, or rather Col. Calvert in his name, applied to the British Government for assistance in order that (to use his own modest words) “this country may, by publishing it here in Great Britain, spread the beneficent works of the Creator, who has given by his wisdom to man this important discovery to prevent disease, "Lord Morpeth very wisely committed the investigation of the said "extraordinary discovery" (for so it is termed) to Dr. Southwood Smith and to Messrs. Grainger and