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VARIOLA;     6
ITS  NATURE AND  TREATMENT.
(READ BEFORE THE PHILADELPHIA COUNTY MEDICAL SOCIETY

           NOVEMBER, 1857.)
AN ADDENDUM.
          BY  y


ANDREW NEBINGER, M.D.
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         PHILADELPHIA:

COLLINS, PRINTER, 705 JAYNE STREET.

            1862. 
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VARIOLA;
ITS  NATURE  AND  TREATMENT.
(READ BEFORE THE PHILADELPHIA COUNTY MEDICAL SOCIETY
           NOVEMBER, 1857.)
AN ADDENDUM.
          BY  /

ANDREW NEBINGER, M.D.





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          -•'■';';.' WW
        PHILADELPHIA:
COLLINS, PRINTER, 705 JAYNE STREET.

            1862. 
4
• 
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   •
   Early in 1856, through the Committee on Meteorology and
Epidemics of the Philadelphia County Medical  Society, I had
the honor to call the attention of the Society to my "compensative
nutritive treatment" for variola.   The report of the  committee,
after being read before the Society, was by it adopted as its report
to the Medical Society of the State of Pennsylvania, and presented
to that  organization, at its annual session held in Philadelphia
May, 1856, and published in its Transactions of that year (Trans.
Med. Soc.  State of Pa., N. S., Part I. p. 176).   The brief account
of my "compensative treatment" embodied in the Philadelphia
County Medical Society's report to the State Society thus brought
before the profession, attracted from its novelty or from some
other cause, attention, and I was invited  by the "Business Com-
mittee" of the  Philadelphia County Medical Society to read a
paper before the Society upon Variola, in which I would set forth
my views in reference to that terrible disease.  To the committee's
flattering invitation I assented.  Accordingly, in  March, 1857, I
had the honor to read before the  Society the paper upon "The
Nature and Treatmext of  Variola," which I now  present
through the press to my medical brethren.  Since the reading of
the paper, we have in Philadelphia passed through a most severe,
long-continued, and destructive epidemic of variola—so destruc-
tive, indeed, as to have in 1861 produced a mortality of 778 cases.
During  this epidemic I have  put the "compensative nutritive
treatment"  again to the test, and have been so much gratified
with the results, that a high sense of duty to my fellow beings
counsels me to "cast my crust upon the waters," that it may float, 
4
through  the  instrumentality of the profession, to those whose
necessities may require it.
  A discussion upon "Variola, its varieties and treatment," took
place before the Philadelphia County Medical Society, November,
1861.  The discussion upon that occasion  was opened by the
reading of  a  paper by one of the Society's  distinguished mem-
bers, Dr. John Bell, and subsequently participated in by several
other members.  Part of that discussion I present as an adden-i
dum,  for the purpose of exhibiting the advance, the positive
improvement, the step in the right direction  in the treatment of
variola, during the roll of the past few years; also for the purpose
of giving support and countenance to the "compensative nutritive
treatment of variola," to which, from reason, reflection, and large
experience, I am warmly attached.
                                                    A. N.
  Philadelphia, May, 1862. 
              SMALLPOX:

.    ITS  NATURE  AND  TREATMENT.
  Since the days of Sydenham, but little, if any improvement,
or, if you choose, but little change, has been made in the general
or constitutional treatment of smallpox.   The treatment Syden-
ham suggested and practised, and for the promulgation of which
he was not only ridiculed, but rashly and coarsely denounced as
an innovator, and even as a murderer, as far as I am aware, is
substantially the  treatment  of the present  time—a treatment
essentially in all its characters, from first to  last, medicinal and
dietetic, reducing,  non-supporting,  and decidedly  antiphlogistic.
The  particulars of this treatment it would be useless for  me to
recount, as they are equally if not more familiar to you than to
myself.   But, as it is essential to my purpose, I shall briefly re-
mark that the Sydenham  treatment—the treatment of smallpox
of the day—is that the initiatory or febrile stage of the disease
shall  be treated with purgatives, cool drinks, neutral mixtures,
and light farinaceous diet; that  at  the subsidence of the febrile
and  the  introduction of the  papular  stage, the neutral  mixture
may be withdrawn, the purgatives and farinaceous diet continued;
and this treatment must be  pursued  through the papular, vesi-
cular, pustular, and desiccating stages, unless  the so-called secon-
dary fever should spring up, and spring up it will, if the case be
severe, whether of the distinct, semi-confluent, or confluent variety;
that upon the introduction of the secondary fever  the use of the
neutral mixtures must be resumed,  a tapioca and gruel diet given,
and the whole treatment, medicinal and dietetic, must be decidedly
antiphlogistic, unless, however, typhous symptoms present them-
selves, when a little beef-tea, a small quantity  of milk, and a little
wine-whey, and some tonic must be  administered.  This is the 
6
sum and  substance of the Sydenham treatment—the treatment
taught by the schools, enforced by practice in smallpox hospitals,
and clearly, forcibly,  and dogmatically set forth in all the books
I have met with, which contain articles upon variola.  With this
treatment in all its parts I shall not find fault—to it, as far as it
relates to  the initiatory or febrile stage, I yield  my acquiescence
and cordial  support.  Thus far  can I go, but no  farther.   For,
beyond this, I deem the treatment defective, inefficient, pernicious,
and I shall not refuse to say destructive.   The  Sydenham treat-
ment has  been largely developed out of the idea that smallpox is
an inflammatory affection, and hence demands in  all its stages a
marked and decidedly antiphlogistic or  anti-inflammatory medi-
cinal and  dietetic treatment.
  It has occurred to me that this view of the nature of smallpox
is an error; that it is  not essentially an inflammatory disease;
and that  any destructive' or threatening inflammatory affection
which  may  spring up is accidental—a complication, and  not an
integral or inherent part of smallpox; that variola is essentially
and radically a suppurative disease, or, in other words,  that it is a
malady in which a large or small quantity of pus, according as
the disease is severe or otherwise, is to be generated, and that as
a consequence of the generation of the pus, and the effort of
nature to  throw off the diseased portions of the  tissues attacked,
an erythema or inflammation is produced in the  tissues involved,
and that this erythema or inflammation is necessary and required,
to the successful, perfect, and safe development and passage of the
disease through all its varied and ofttimes severe and exhausting
stages.  Smallpox, I am convinced, is not an inflammatory dis-
ease ;  that it is not an affection in which its  regularly inflamma-
tory phase or part is the disease, or part  of the  disease, which is
destructive to life, but that it is one of the characters  of the dis-
ease, which is necessary to be produced and regularly developed;
that the disease may  run  its course regularly, naturally,  safely;
and if  such be the case, it follows that any treatment which may
interfere with, obstruct, retard, or prevent the system from beino-'
in a condition to get up, sustain, and carry on this essential, and,
if I may be permitted, I will say vital portion of the disease, is
certainly irrational, unscientific, and pernicious.
  If the inflammation of the tissues attacked by the eruption  of 
7
variola is necessary to the proper development of the disease, it
differs widely from the inflammatory actions or conditions which
we call  pneumonia, pleuritis, peritonitis, &c.  In these and  all
their kindred affections, the great end desired to be attained  is
the arrest, the destruction of the inflammatory  action, and the
prevention of the development of pus.  But no  sane physician
desires in smallpox to prevent the inflammation incident to the full
development of  a variolous pustule  or pock, knowing as he does
that the  pock cannot pass through all its stages of papule, vesicle,
and pustule, unless there be inflammation present, as an essential
condition; and if he does not desire to prevent, arrest, or destroy
this inflammation, now as there  is  none other in uncomplicated
smallpox, why regard variola as an inflammatory  disease, and
treat it as if this inflammatory feature was the dreadful, fearful
phenomenon of  the malady, and proceed with evacuants and by
semi-starvation  to give to it, and as a consequence give to the
patient his quietus ? I ask who ever knew a patient to die because
of the pustular or irruptive inflammation of smallpox ?  Who of
us have  not seen smallpox patients die, and have not, in some of
these instances, prognosticated their death because of the paleness
of surface, or the defective inflammatory action of the skin around
the pustules ?  Is it not a source of gratification to the well-in-
structed  physician, when he visits his smallpox patient, and in
examining the body, to find  each pock if it be a case of the dis-
tinct variety, or each cluster  if it be confluent, surrounded with a
decidedly marked and well-defined line  of inflammation,  each
pock well up, full, and elevated ?   And does he not deduce from
these conditions a favorable  prognosis ?   If, on  the  other hand,
he finds  the pock without the inflammatory ring, depressed, and
presenting the appearance of having had part of its contents re-
moved, he becomes filled with fear and  doubt for the  safety of
his poor  patient.  He quits his bedside with aching heart, and, in
answer to his patient's  friends' inquiries as regards his condition,
says " it is unfavorable, that his skin is too pale, and that the pock
is not filling properly." Would he in the instance of the first feel
himself justified  in endeavoring to reduce the inflammatory ring ?
And would  he in the second  instance hope to sustain his patient
and bring him safely through his attack by diminishing his food,
and increasing the doses of his evacuants ?  Certainly not!  Yet 
8
if he would bring the first to the condition of the second, he may
succeed, if the case be severe, by giving his evacuants at shorter
intervals, and by directing a  gruel  diet; or he may be able to
bring up the doubtful patient to the condition of the well-doing
and well-promising one,  if he  will discontinue the use of his
evacuants, and  ply  him well with such articles of diet as will
improve the quality of his blood by increasing the amount of
its fibrin—doing, in short, that which he would do to enable the
system to carry on any other suppurative disease.
  Indeed, the only view which  appears  to me to be rational in
regard to smallpox, is that it is a vast superficial phlegmon, and
here I cannot withhold a quotation from Dr. Watson's Article upon
Smallpox.  In referring to the varieties of the disease, he says
"the number of pustules indicates, in the first place, the quantity
of the variolous poison which has been reproduced in the blood.
In the  second  place, it is also a direct measure of the  extent to
which the  skin suffers inflammation.  Sometimes there are not
more than half a dozen pustules, sometimes many thousands.  If
all these were collected into one it would be an enormous phleg-
mon."  " For both these reasons," he remarks, " the system suffers
commotion, distress, and peril,  in proportion to the quantity of
the eruption."   Yet notwithstanding this  view,  that when the
pustules "are many thousands" in number, "if  all these  were
collected into  one, it  would  be an  enormous phlegmon," Dr.
Wratson suggests, nay, advises and  directs, the very  opposite
dietetic treatment to that which he would  advise to be pursued
in the  treatment of " an enormous phlegmon."  In treating " an
enormous phlegmon," would we reduce  our patient by evacuants
and give a gruel or toast and tea diet ?  Would we not sustain
the system with a  good and  generous diet to the end, that the
phlegmon, the suppuration, the generation of pus, should take
place with as little  reduction of the strength and forces of our
patient as possible;  and this we would do because we well know
that the production of pus in large amount is accompanied with
 exhaustion.  Does not the system suffer the  same degree  of ex-
 haustion, whether  pus of a  given  amount be generated in " an
 enormous phlegmon," or in the pustules of variola ?  And if to
prevent exhaustion from the production of pus, in the case of the
 phlegmon, from being  extreme, we direct a generous diet, why 
9
should we, in that other suppurative disease, where pus is gene-
rated equal in quantity to that  produced in an enormous phleg-
mon, pursue the  opposite treatment, and  give a poor gruel and
toast and tea diet ?   If it is the production of pus in the instance
of the phlegmon,  which demands a generous and sustaining regi-
men, why is it not, in the other instance, where the same material
is produced, and  that  in like quantity, required to produce the
same effect, the  support of  the system, the same  means to be
employed ? Or is the generation of pus, in smallpox pustules,
less exhausting than the generation of  the same matter in an ex-
tensive abscess ?                              •
   Smallpox, by  writers, and by common consent, has been
divided into several varieties:  the Distinct, Semi-confluent, Con-
fluent, and Malignant—these divisions being expressive of the
severity and extent of the disease; the Distinct variety being the
milder, the Malignant  the more deadly form of the disease.   It
is in the Malignant variety that we see variola in its most terrific
and uncontrollable aspect.  But, be the variety what it may, it is
always the same element, the same Materies Morbi, which is  at
work in the blood ; producing the phenomena which, when ar-
ranged and grouped together, we call variola, or smallpox.  The
changes which the Materies  Morbi of smallpox  produce in the
blood, in the Malignant variety of the disease are the same, which
are produced in the other forms of the malady; the only differ-
ence is that these changes are not so extensive; the difference is
only  in degree,  not in the  nature of the  changes.  We have
scarlatina, by  common consent, divided into several varieties,
scarlatina  simplex, scarlatina anginosa, scarlatina maligna.   No
one will pretend  to assert other, than that it is the same  Materies
Morbi which produces all the so-called varieties; and that the
difference is not  in  the nature of the element productive of the
conditions, but in the  degree of change  produced.  And may it
not with truth  be said, that the direct tendency, the nature of the
scarlatina poison is to  produce the malignant form of the disease,
which can only be regarded as  that form of the affection in which
the virus has produced, fully,  all its  phenomena, all its changes
in the blood, etc.   What is true of the  scarlet fever poison is true
of the  smallpox  poison.  The malignant variety of variola is 
10
that form of the disease in which  the  smallpox virus  has pro-
duced, fully, all its phenomena, all its changes in the blood, etc.
  Here  let us ask, what are the most prominent and attractive
changes produced by the variola poison as exhibited by the blood
when that fluid is  submitted to examination ?   A great diminu-
tion of the fibrin and the red corpuscles.  One writer* says: " The
characteristic lesions of smallpox are a certain deteriorated state
of the blood; it is found entirely  liquid and  serous,  and of a
dark color;  if coagula exist, they are small, soft, and very dark
in color."  Dr. Gregoryf remarks:  "To the most aggravated of
all  cases  of  smallpox, the  terms  malignant, or petechial,  are
generally applied, that from the earliest period of the disease,
petechiae  are observed; sometimes the extent  of subcutaneous
ecchymosis is immense; as the  vesicles advance to maturation
they fill, not with pus, but with a  thin ichor tinged with blood.
Hemorrhages break forth from all the mucous  structures of  the
body.   The  gums bleed often profusely.   There  is epistaxis,
spitting of blood, vomiting of blood, and the passage of blood at
stool." Who of us does not recognize in this portrait of malignant
smallpox, as drawn by Dr. Gregory, the very  likeness, the  coun-
terfeit presentment " of cases that we have seen."
  I cannot, here, in  exemplification of the broken-down  condi-
tion of the blood, the small amount of fibrin which it contains,
forbear giving the history of a case of malignant smallpox which
came under my notice and care about one year ago.  I was called
to a lady whom I was engaged to attend in her  second accouche-
ment.  The messenger who called upon me, stated  that Mrs. A.
was in labor and  desired my prompt attendance.  I repaired to
her residence as  quickly as possible, but, instead of finding  her
in labor, I discovered that she had  fever, and she informed  me
that she had had a rigor, and was then suffering with violent head-
ache and pains in the back  and lower extremities.   The pains in
the back, from their  severity and from her term of pregnancy,
according to her calculations, having expired, she regarded as the
pains of labor.  I, however, diagnosed smallpox, and this I the
more unhesitatingly did, from there having been two cases of the
* Dr. Meigs' Diseases of Children.
f Encyclopedia of Practical Med., Dr. Dunglison. 
11
semi-confluent variety of smallpox in  the house adjoining Mrs.
A's.   On the morning of the third day, when I visited Mrs. A.,
she informed me that she felt confident  that she was then in labor
and  had been for several  hours.   Upon making the  necessary
examination to discover if she was correct, I found the os uteri
well dilated, and the labor,  in all respects, in good condition.  In
due  time  I ruptured the  membranes, and within half an hour
afterwards she was delivered of a healthy and vigorous-looking
male child.  The expulsion of the babe was accompanied  with a
very unusual quantity of blood.   Presuming that the uterus had
not  contracted  on the placenta, I quickly placecf my hand upon
the  abdomen to  make friction upon the womb, that it  might
grasp the placenta firmly,  and the  hemorrhage by that  means
become controlled; but I was surprised to find that the  uterus
was  well contracted.  I examined to discover if the hemorrhage
continued, when,  to my astonishment, I found the blood flowing
from the patient in exhausting quantity.  I tied and divided the
cord, and  delivered the placenta with the full hope  and expecta-
tion that so soon  as it  should be removed from the uterus, and
that organ should contract completely upon itself, the hemorrhage
would cease.  But I was again doomed to disappointment.  The
womb emptied, and it well contracted,  the flooding continued,
abating only in violence, but still  the  amount discharged being
so great as to  produce exhaustion and threatened syncope.  In
due  time  I quitted my patient; when I visited  her  the morning
which succeeded  her  delivery, I found her literally  covered with
a  petechial variolous  eruption—epistaxis had set up, the hemor-
rhage from the uterus  had  increased, and a low form of delirium
existed.   The  second day after her  delivery she  died.  This
was a case, a  most violent case of malignant smallpox.   The
most curious, interesting, and instructive feature of the case (and
it  is because  of  that  feature I have recorded  it, and  here call
special attention to it), is that the  uterine hemorrhage went on
freely  and fearfully because of the defibrinized condition  of the
blood, notwithstanding the uterus  was firmly contracted upon
itself.
   If the analysis  of the blood of those who have died of smallpox
develops the fact  that  it is deteriorated, and that that deterioration
consists in its  being  entirely liquid, serous, of a dark color, its 
                             12

coagula small and soft; and if the blood  in  life  of a smallpox
patient is found to be so deficient m fibrin that hemorrhages result,
and that owing to  its deficiency in  quantity and quality these
hemorrhages cannot be stayed, I ask if that  kind of treatment,
the positive effect of which is to reduce the amount of fibrin, or
prevent, when it is deficient in quantity, an increased development
of that plastic  material,  can be the treatment  indicated in a
disease, the very nature and habit of which is to lessen or reduce
the sum of the fibrin below the  normal quantity ?   I have  not
created what I have here given as facts in regard to the condition
of blood influenced by the variolous  poison, nor have they been
created by any one to suit any special theory or hypothesis.  They
are demonstrable facts, which have been found to connect them-
selves with smallpox, both ante-mortem and post-mortem; and
I  have only produced them  here to  fix attention upon what
you know quite as well as those who have recorded  them: and
yet if they are facts, and very suggestive as regards the rational
treatment of variola, are they not extremely important ?
   A patient dies of a disease—no matter what.  After death, the
blood is examined, and it is found to be deteriorated.  It is  en-
tirely liquid and serous;  its coagula, if any exist,  small and soft;
in short, the evidence is that the fibrin, the building-up material,
the chief  sustaining element, the pabulum  of the blood, is deci-
dedly deficient in quantity and quality.  If that patient had been
given freely evacuants or exhaustants, and  had been severely,
rigidly dieted—small quantities only of light, farinaceous articles
of food given—would we  not say that such treatment had  had its
share and part in the production of the condition of blood which
we found to exist. At least, we would say that the evacuants  and
meagre diet had not had any counteracting power in preventing
such condition from springing up where there was a tendency for
its development by the morbific agent which produced the  dis-
ease.   In smallpox the facts are that the variolous poison, before
it destroys life, robs the blood of its normal quantity and quality
of fibrin; that, indeed, to produce death, it is necessary that the
blood should  be more palpably and attractively deficient in its
plastic material.  If such is the case, will evacuants, and a gruel,
and toast-and-tea  diet, sustain the blood?  Will  such food, in
the small quantities directed by the books  to be given,  furnish 
13
the system with the  elements necessary to get  the  fibrin up to,
and sustain it at, or nearly at, the normal degree in quantity and
quality ?   Who is prepared to answer in the affirmative ?
  In a regular, uncomplicated case of variola, will any medical
gentleman point out any inflammation that exists other than that
which is in the tissues attacked by the eruption ?   No other in-
flammation exists.  But what of this inflammation ?  Is it not an
essential part of the disease ?  Can we have a well and regularly
developed pock without that inflammation ?  Will not  that in-
flammation be the more decided, positive, bright, and well-marked,
in a patient  of vigorous  constitution, than it will be  in one  of
feeble and fragile constitution ?   Will not the grade of the in-
flammation about the pustules indicate the degree of vigor of the
system ?   The more exalted the  inflammatory action, the more
sthenic the system; the lower the grade of inflammation, the more
asthenic.  If there is in a regularly developed, uncomplicated
case of smallpox, no other inflammation than that which is abso-
lutely necessary to the proper development of the pock, then we
must have that  inflammation; its production is necessary to the
safety of the patient; and if necessary to the safety of the patient,
why should  we do anything which will have even the slightest
tendency to  prevent it from springing up, or to diminish it after
it has sprang up ?   Should we not do that which will sustain it?
 Can we do this by a liberal or free use of evacuants, and a defec-
 tive diet ?  Do we not give evacuants, and a gruel and toast-and-
 tea diet, when we desire to diminish or destroy an inflammation?
 Will not such treatment control inflammatory action  by dimin-
 ishing the quantity of fibrin in the blood ?  and when we withhold
 from the economy a due amount of nutriment, do we not do so for
 the purpose  of keeping down the development of fibrin ?
    Do not bleed in smallpox, say all the books and all the teach-
 ers, unless it shall be necessary to do  so to prevent damage being
 done by a congestion  of the brain, etc., and then bleed, carefully
 abstracting  no more than may be absolutely necessary, for, say
 they, the system will  require all  the blood to  support it in the
 last stages of the  disease. This is  good doctrine, it is true; it
 squares with all the facts, and is up to the wants and requirements
 of the disease.  But  suppose we should bleed, and it be in the
 instance of  an adult, smallpox  patient, and we abstract sixteen 
14
 ounces of blood, and we feel that by such abstraction of blood we
 have diminished the chances of recovery of our patient, for the
 reason that the blood has been deteriorated, or weakened, to use
 an expressive word, by the abstraction from it of sixteen ounces.
 In the teaching to save the blood is  recognized the fact that all
 its elements will be required to sustain the  patient, to meet the
 extraordinary drain or demand which will be made upon it during
 the progress and finale of the  disease.  What important differ-
 ence, however, can it make to the patient, whether you rob him
 of sixteen  ounces of his blood, and by thus  diminishing its
 vitalizing powers, you diminish his chances  of recovery, or you
 prevent his blood, by withholding a proper amount of food, from
 having its vitalizing powers sustained, and kept up equal  to the
 demand made upon it ?  What difference can it make to the pa-
 tient whether you impoverish his  blood  by bleeding, or by eva-
 cuants, or by giving a defective diet ?  To prevent impoverishment
 of the blood, for the reason assigned, the support of the system,
 at the close of the disease, we are warned and counselled  to the
 careful use of the lancet; yet what difference can it make whether
 the blood be impoverished by the use of the lancet, or the with-
 holding of such articles of food as will sustain the blood ?   Is  it
 not a little curious that the same books which teach that not any
 of  the blood should be abstracted, unless under peculiar circum-
 stances, because it will be required to  sustain the system in the
 closing stages of the disease, should also  direct food to be given
 in such defective quantities, and of such quality as is quite une-
 qual to the task of keeping up the blood, and  hence unequal to
 the task of supporting the system  in the closing stages of the
 disease ?
   In  a sthenic  inflammation  do we  not  prevent  the blood, if I
 may use the expression, from being kept fully fibrinized, for the
 purpose of controlling the inflammatory action ?  In smallpox the
 pustular inflammation is an essential portion of the  disease; the
 arrest, destruction, or disturbance  of it, interferes directly with
 the regular development of the disease; therefore, any treatment.
 the effect of which is to arrest, disturb, or destroy that inflamma-
tion, is unscientific, foils short of the requirements of the disease
—is pernicious and dangerous.  Hence, as evacuants, and a mea-
gre gruel, and toast-and-tea diet, control and reduce inflammatory 
15
actions, such treatment falls short of meeting the necessities of the
smallpox.  Again, do we not desire a sthenic condition  of body
in variola ?   If there  is any disease which, over and above all
others, requires for the safety of the patient a sthenic condition of
system, that disease is smallpox.   Are not the  direct tendencies
of the liberal use of evacuants, and the non-use of a generous diet,
to produce asthenia, to impoverish the blood—to rob it  of those
elements which are necessary to sustain, give force and  vigor to
the body ?   Is not the destruction and reproduction of tissues,
and the development of pus in large quantities, accompanied posi-
tively with exhaustion of the blood of its plastic elements ?  And
.will not that exhaustion be in a given ratio with the amount of
tissue destroyed and reproduced, and the quantity of pus  created ?
If such  be true, then as we have in smallpox a destruction and
reproduction of tissues, and the development of pus, we  must by
necessity have an  exhaustion of the blood of its plastic mate-
rials, in proportion to the amount of tissue destroyed and repro-
duced, and the sum of pus developed; to meet which, the Syden-
ham treatment, the every-day treatment in hospitals and in private
practice is evacuants, and gruel, tapioca, panada, and toast and tea
in small quantities.  Will not the chances of a smallpox patient's
recovery be lessened as the grade  of the disease advances from
the distinct variety  to that of the confluent variety—from the
variety in which there is but a  small destruction, and a small
reproduction of tissues, and a slight development of pus, to  that
in which there is a larger  destruction of tissues, and a greater
production of matter ? And will not this lessening of the chances
 of recovery of the patient be the consequence of the  exhaustion
 of the blood ? and will not this exhaustion  of  the  blood follow
 from the destruction  and reproduction of tissues, and the creation
 of pus ?  Can this condition be met—the exhaustion of the blood
 __and hence the exhaustion of the  patient prevented, by the ad-
 ministration of evacuants, and the giving a light diet of slightly
 nutritious articles, such as crackers, gruel, toast, etc. etc., and those
 in quantities vastly smaller than the person would require to sus-
 tain  him in  health, even though  he  lived  a passive life, a life
 accompanied with but little movement or activity ?
   Let us now turn to the books and see what in their own words 
16
they say in regard to the treatment of smallpox.   One author*
(than whom none stand higher, at least on this side of the Atlan-
tic, as a medical writer and teacher) says:  "After the appearance
of the eruption the regimen must  be still cooling, though food
somewhat more nutritious may be allowed, such as gruels, panada,
toasted bread, and tea, water crackers, roasted apples, oranges, or
grapes, milk and water, rennet whey, vegetable broths, etc., refer-
ence of course," continues the writer, " being always had, to the
degree of excitement  present.   The  diet, however, should  be
strictly antiphlogistic."  The same  writer further remarks, that
it often becomes necessary to support the system  under the pros-
trating effects of the abundant suppuration, and vast irritation of
the pustules, when,  therefore, an appearance of flagging  is pre-
sented, when the pulse begins to weaken,  the tongue  to become
dry and dark, and the extremities to show a want of due action,
recourse should be had to tonics, stimulants, and a nutritious diet,
proportionate to the apparent wants of the system."
  Here is recognized the true treatment, a treatment compensative
in its character—a treatment which presumes to make the supply
of nutriment equal to the wants and requirements of the economy
—but unfortunately the time for giving it is too long deferred.  If
after the system, from  the  prostrating effects  of "the abundant
suppuration and vast irritation of the pustules," begins to flag,
the pulse begins  to weaken, the tongue becomes dry and dark
and  the extremities show a want of due action," this  treatment,
this  administration  of "a  nutritious  diet, proportionate  to  the
apparent wants  of the system," should control the bad conditions
referred to—should  sustain the system—and drive back the tide
of typhous symptoms which had set in, and which, if not arrested,
would certainly overwhelm the  patient and hurry him onward
to dissolution, if this nutritious treatment should accomplish so
much after  such unfavorable symptoms had made their appear-
ance, might not the  same  nutritious diet, earlier  given, have pre-
vented the production of these bad symptoms f  Here, let us inquire
why the bad symptoms mentioned sprang up ?   We will let the
author we have been quoting make the reply.  "It is often," he
says, "necessary to support the system under the prostrating effects
* Dr. G. B. Wood. 
17
of the  abundant suppuration and vast irritation of the pustules."
It is then "the  abundant suppuration and vast irritation of the
pustules," which produce " the flagging of the system," dry tongue,
weakened pulse, etc.  If we know that the abundant suppuration
and vast irritation of the pustules produce so great a drain upon
the system, as to make it probable that these alarming effects may
arise, why  not  anticipate and prevent them from making their
appearance, by giving  the  "nutritious diet proportionate to the
requirements of the system," at a  period  so early in the course
of the  disease as will cause, by their digestion, the blood to be  so
constituted as to meet the requirements of the system supporting
it, under the  abundant suppuration and vast irritation of the pus-
tules?"
   Permit me here to  ask, if the  patient up  to  the  time  of the
development of the unfavorable  symptoms of flagging of the
system, dry tongue, etc., had been  receiving only gruel, toast and
tea, vegetable broths, and cracker panada, if the  development of
these conditions do not of themselves prove that such a dietetic
regimen was insufficient and unequal to the requirements of the
system; and the  recommendation of a more  nutritious diet,
with the hope of controlling the bad effects  of the abundant sup-
puration and vast irritation of the  pustules is  not  a  full and
complete recognition of the truth, that a  smallpox patient to  be
brought safely through his attack  must be supplied with food of
such quality and in such quantities as would be  given to sustain
the system in any other case, where  there is a large amount of
pus generated, and a  large quantity of tissue to  be reproduced ?
Suppose after these unfavorable symptoms have set  up, we should
 succeed in saving our patient  by the generous and nutritious
 diet;  would we not have accomplished  this by improving  the
 quality of the patient's blood—by increasing the quantity and
 quality of its fibrin, its plasma, its vitalizing  and sustaining ele-
 ments ?  Would the necessity for doing this have existed at this
 period of the  disease, if the patient  had  been using good and
 generous nutriment in large quantities, from the period the pap-
 ules  made their appearance?   If a  generous diet would  arrest
 the bad symptoms we have referred to, would not such a diet  by
 keeping the blood well up in its nutrifying elements, have largely
 tended to prevent the origin of  these morbid phenomena ?
       2 
18
  Few, very few smallpox  patients, whose  "systems flag, their
pulse grow weak, their tongues become dry and dark and their
extremities evidence a want of due action," will be brought safely
out of their attack by any treatment, no matter how stimulating
and  nutritious  it may be, if  such treatment shall not be com-
menced until these typhous symptoms shall have made their ap-
pearance.   If the patient has not been well sustained before, our
sustaining treatment for his cure will almost universally be then
too late.  Prevent, not cure, is the true doctrine, as these danger-
ous symptoms are the effects of an exhausted blood, that exhaus-
tion  produced by "the abundant  suppuration and vast irritation
of the pustules;" prevent this exhaustion of the blood, and as this
can  only be accomplished by giving nutritious articles of food,
oive them—and give them with an unsparing hand;  give them
abundantly, freely,  and without stint, and I would say, almost
without measure—while the blood is able to  carry on the suppu-
ration of the pustules, and to reproduce the disorganized tissues,
there will not be any good cause for fearing a fatal termination, if
the case be one of uncomplicated variola.
  The blood, to be  equal to the demand made  upon it, when
smallpox exists in a bad form, must be well constituted, and this
it cannot be if the  patient  receives a diet  made up  of  gruel,
panada, toast, and tea.  Such  food, in the small quantities given,
or the small quantities the  patient will or can take, would not
long sustain the body if there were no extraordinary drain going
on, no unusual  tax  levied upon the economy.   How, then, can
such a dietetic regimen sustain the blood when there is an un-
usual, an extraordinary drain set up by the production of pus
equal in quantity to that of " an  enormous  phlegmon," and the
disorganization of a vast amount of tissue ?  Any form or quality
of diet which is not competent to produce a-blood in which the
plastic elements are normal  or nearly normal—a blood which
will  sustain the system under ordinary circumstances, cannot  be
efficient under extraordinary  circumstances,  when, for example,
there is going on the generation  of a large  amount of pus, and
there exists the necessity for the reproduction of a large amount
of destroyed tissue,  as is the case in confluent variola.
  Dr. West, in his published Lectures upon Diseases of Children,
in treating of variola, says: " In cases of confluent smallpox, the 
19
          patient needs to be very closely watched during  the maturation
          of the pustules, for on the second or third day of this process the
)         vital powers sometimes  suddenly fail.  The  first indication of
          any such occurrence would be furnished by a subsidence of the
          swelling of the face and  hands, the paleness  of the skin in the
          intervals between the pustules, the collapse of the pustules them-
          selves, attended with a sinking of the temperature of the surface,
          a great diminution of the power of the pulse.   Such a state of
          the patient," the Dr. remarks,  " calls at once for the energetic em-
          ployment of stimulants  and the substitution"—mark you, substitu-
          tion—" of a generous diet for the previous meagre diet."  The re-
          commendation  here is virtually that, after the patient, by the use
          of a starving diet and the extraordinary drain upon the blood
          produced by the maturation of the pustules,  etc.,  exhaustion
          makes its appearance, presenting as its accompanying phenomena
          those mentioned by Dr. West, then " the energetic employment
          of  stimulants  and the substitution  of  nutritious  food for the
          previous  meagre diet" must  be  had recourse to.  But why this
          recommendation?  Had not the previous treatment, part of which
          was the " meagre diet," been given with an intention, and was not
          that intention the prevention or arrest of inflammation, and was
          not that end and intention attained, as evidenced by the subsid-
          ence of the swelling of the  face, the  paleness of the  surface of
          the  skin  between the pustules, and the great diminution of the
          force of the pulse ?  But lo! the end attained, behold the terrible
          consequences which follow, and  to counteract which " the ener-
          getic" employment of  stimulants and  nutritious food is directed.
          Now, if the patient should be  benefited by the  employment of
          stimulants and nutritious food, will not the benefit be manifested
          in  the paleness of the skin  being displaced by a redness, the
          temperature of the surface being exalted, the pulse increased in
          strength and volume, the tongue becoming moist—in short,  by a
          return to that  better  state which existed  previous  to the  skin
          growing pale, the pulse small, etc. ?   But, if this stimulating and
          nutritious treatment should bring back the patient to the condi-
          tion in which he was before the  threatening symptoms set them-
          selves up, will  it not have to be continued  day by day to sustain
          the  patient until the  desiccating stage has been safely passed
          through?  and if so, would it  have been any more  unwise to 
20
have given it before the bad conditions  made  their appearance,
and by its use have kept the patient with  the reddened skin, exalted
temperature of surface, full pulse, full pustules, and sthenic condi-
tion of system ?   If it  is safe  and wise  to get the system into
this condition, and there maintain it by such treatment, after the
unfavorable conditions referred to have made their advent, would
it not have been equally safe and wise to have kept the  system
sthenic when  it was so ?  If the stimulating and nutritive treat-
ment will have the happy effect of restoring the system  after it
had reached a great degree of  feebleness and exhaustion, would
not such treatment be competent to prevent the body from pass-
ing into  such alarming extremity ? and if so,  why not give the
nutritive diet and stimulants earlier ?
  So completely does the idea of variola  being an  inflammatory
affection haunt the minds of medical gentlemen, that the strictly
antiphlogistic regimen is pursued—the meagre diet is persisted
in until the blood becomes impoverished, and  vitality begins to
fade and grow dim, when, taking alarm, and then seeing that which
we ought to have foreseen, that  the generation of the pus and the
reproduction  of so much disorganized tissue would necessarily
get up  an extraordinary demand for the  plastic elements of
the blood,  and that this demand to be met would require the
introduction of nitrogenized articles of diet into the  system in
such quantities as will be competent to  keep  up the  plasma of
the blood  at, or nearly at a normal figure, we then commence
that which we should have commenced  before—" the  energetic
employment of a nutritious diet and of stimulants."
  The principle of action should be compensative—large demand
for plasma, large supply of food.   The  very  opposite, unfortu-
nately, of this to me natural and reasonable treatment, is recom-
mended  and  pursued in the management of  smallpox.  As a
general thing, the severer the case of  variola, the more attention
we give it; and the more attention it receives from  the physician,
the more strictly  enjoined will be the  meagre diet, the more
limited will be the supply of nutriment, until bad, or typhous symp-
toms develop themselves, and then to arrest them—to overcome
that which we had been no little, but nevertheless unwittingly,
instrumental  in producing by our starving diet—we  commence 
21
the use of a generous regimen, and thus endeavor to cure that
which we might have prevented.
  Without  tiring you  by  any comments  upon  the  treatment
recommended for variola by one or more writers, I will  submit
their recommendations to your consideration, and kindly ask you
to apply  my arguments to them.  Dr. Dewees,  in his articles
upon confluent smallpox, says:  "All animal substances must be
strictly forbidden, and if the body requires  support, the  farina-
ceous and mucilaginous  substances should  be  selected, such as
tapioca,, sago, arrowroot, and gum Arabic."*  Dr. Gregory says:
" In all circumstances the diet is to be regulated as in  other cases
of inflammatory fever'."f  Dr. Watson remarks:  "If the matura-
tion of the pustules should proceed tardily, if they should  not fill
up properly, nor their  contents become purulent,  then  strong
broths may be of use, even wine."  Here, in the face of authority
highly exalted, before which I have  been taught to bow with
almpst reverential awe,  and to whose dicta I have been instructed
to yield with almost abject submission, I pronounce my humble
dissent from the meagre dietetic regimen—the rice, tapioca, ar-
rowroot, and gum Arabic diet—in such cases of smallpox as by
the severity of that loathsome  and filthy disease patients have
their  lives endangered—and offer  in lieu thereof, my "compensa-
tive nutritive treatment," based, as I think,  upon the better idea of
the nature of smallpox, which does not see and comprehend it as
an inflammatory affection,  but  a suppurative tissue-destroying,
blood-exhausting, blood-defibrinizing  malady, requiring as part
of the treatment to meet those conditions, and to compensate for
the severe drain upon the blood,  the introduction in large quan-
tities of such  nitrogenized articles of diet as shall most easily,
most speedily, and  most agreeably to the  taste and comfort of
the patient, meet these  requirements.   Such a compensative diet
I have found, by a comforting and cheering experience of its use,
to be eggs and milk—two articles abounding largely in azotized
elements, easily obtained, and easy of preparation for the use of
the patient.
   As a synopsis of my dietetic  treatment  in  smallpox, I have

           * Dewees's Pract. Physic, p. 195.
           f Cyclopaedia of Practical Medicine, vol. iv. p. 170. 
22
here but little more to  say than what I have already said, and
which is embodied in the published " Transactions of the Medical
Society of the State of Pennsylvania."*   My practice has been in
all cases of smallpox, during the initiatory or febrile and papular
stages  of the  disease, to prescribe an  antiphlogistic,  medicinal,
and dietetic treatment; but to abandon this form of treatment as
soon as the papules begin to take upon themselves the vesicular
form, and then commence a treatment which, in all its essentials,
shall be supporting.
  In carrying out this treatment, I have not  found any diet so
useful, so grateful to the patient, or any which gave as little in-
convenience to swallow when the mouth, fauces, and throat were
studded with pustules, as a combination of eggs, milk, sugar, and
ice, made in the proportion of one egg well beaten—half  a pint
of milk, sugar and ice in quantities suited to .the taste and  desire
of the patient.  When the necessity for stimuli has  existed, as it
does in all cases of the confluent variety of smallpox, I have
added  brandy, or what  I think better, Monongahela whiskey,
because for purity it can  be more safely relied on, and can be
more readily obtained.   The quantity of this diet which I direct
the patient to  use in  confluent smallpox is half a pint, or a tum-
blerful, with a large  tablespoonful, or half an ounce, of Mononga-
hela whiskey added  to it, every two hours or every hour  and a
half during the day and night.  I have frequently had patients to
take as many  as twelve eggs, three quarts of good new milk, and
eight ounces of whiskey daily for several consecutive days—and
yet, with all this supporting and  stimulating diet, this most ex-
cellent proteine or  highly nitrogenized food,  these poor fellowrs
barely escaped sinking into the  grave, some of them having had
(notwithstanding they were so  vigorously supported  with food,
and  so actively stimulated) that peculiar feebleness and tremor
which  is always the unmistakable evidence of a breaking up  of
the vital forces—the threatenings of  dissolution.   Here  permit
me to ask if with all this, as some would call it, excessive nutri-
tive treatment, but which I would dignify with the appellation of
compensative nutritive treatment, these patients barely survived the
wasting effects of the disease, what would have been  the  result,

     * Trans. Med. Society of the State of Penna., N. S., Part I. p. 176. 
23
if, as is too often the case in smallpox, their diet had consisted of
a little toast and tea, a small quantity of animal broth, or a boiled
egg or two during the day ?   I know not what reply others .may
make, but I hesitate not te say that, instead of having had the
pleasure of giving them clean bills of health—restoring them to
their  families and  friends,  and of being  able now, all blurred,
scarred, and marked as  they are, of referring to them and holding
them up as the proud, living, active, moving  trophies acquired
by this humane treatment in the dreadful, fearful conflict as insti-
gated by smallpox, between life and death, I should have been
called upon in sadness to have written for them  passports to the
grave!  I would also remark that in the variety of cases of smallpox
to which I have been referring, I do  not restrict patients to eggs
and milk, but  permit them to use  meats, poultry, in short, any
food abounding largely in the proteine elements, and indeed I do
not only permit of their use, but urge those articles of diet upon
them, with the assurance that in such cases to eat is to live, to
abstain is to die, and this I do feeling confident that it is posi-
tively necessary that the patient should be given such articles of
food, that the  digestive  apparatus may have at  their disposal
such matter as will enable them to supply the blood with the
elements necessary to carry on a vigorous and rapid  maturation
of the pustules and all the offices of vitality.
   Before closing, I would be doing  injustice to  the subject if I
were not to make some remarks upon the so-called secondary fever
of smallpox—a misconception of the  nature of which, in my judg-
ment, has prevented many a patient from receiving  the supporting
treatment his condition required, and caused him to swallow many
an exhausting  dose, producing an aggravation of  his sufferings,
 and lessening the chances of his recovery.  Dr. Wood says, " Upon
 the occurrence of secondary fever, the  original  diaphoretic and
 refrigerant plan should be  continued in a degree  corresponding
 to the excitement and  strength of the  patient."*   Dr. Gregory,
 writing of  secondary fever, says: "When the  disease (smallpox)
 has been severe, and secondary fever has set in, the excitement is
 to  be allayed by occasional  doses  of  antimonial powder  with
 calomel, followed by an active aperient."f  Another author, in

             * Dr. G. B. Wood, Pract. Med., art. Smallpox.
             f Encyclopedia, Pract. Med., vol.  iv. p. 169. 
24
writing of smallpox in children, remarks that about the fifth or
sixth day of the eruption, at which time the maturation is nearly
completed on the face, and that  process is commencing on the
extremities, a  new fever, to which the technical term  secondary
fever is applied, makes its appearance.  This fever commences to
diminish when the suppuration is fully established, and disappears
about the time that desiccation is nearly completed on the face, and
has commenced upon the limbs."*   Dr. West, in his observations
upon secondary fever, remarks: " If the  eruption be more abun-
dant, and the accompanying secondary fever consequently severe,
an  antiphlogistic  plan of treatment must  be carried  out  more
strictly."f  Dr. Watson teaches, " that the  proper plan of man-
aging smallpox patients, during the continuance of the secondary
fever, is to keep the bowels moderately open by gentle laxatives
or enemata, and to give opiates once or twice a day.  The cooling
regimen must  now," says  the  Doctor,  "be given up, and the
strength of the patient must be supported by a nourishing diet."
It will be observed that in  the recommendations of the writers,
whose language I have quoted, there is, in the management of
secondary fever, a want  of  agreement.  Dr. Wood, in  secondary
fever, says, "The  diaphoretic and  refrigerant treatment must be
continued."   Dr.  Watson says,  " The  cooling  regimen must be
given up, and the strength of the patient supported by  a nourish-
ing  diet."  Dr. West directs in secondary fever that " an  anti-
phlogistic plan of treatment be strictly carried out."  "When
doctors disagree, who shall decide ?"
  Before advancing further, let us inquire what this so-called
secondary fever is ?  What produces it ?  What is its nature ?  I
think that even by a reference to the quotations I have given from
the different authors and teachers already named, or referred to,
we  shall have a solution of our queries.   About the sixth day of
the eruption, at which time the maturation is nearly completed in
the face, and that process is commencing in the extremities, secon-
dary fever  makes its appearance, says one of the writers.   Dr.
West says if the  eruption be abundant the  accompanying secon-
dary fever consequently will be severe, etc.  Without going further,
these two writers  unfold to us, as the cause of  secondary fever,

         * Dr. J. F. Meigs, Diseases of Children.
         t Dr. Charles West, Lectures on the Diseases of Children. 
25
        the maturation of the pustules—the generation of pus.  The fever
        is introduced when maturation commences, diminishes when sup-
f       puration is fully established, and disappears when desiccation is
        nearly completed.  ^The extent and severity of the fever is in due
        ratio with the number of pustules, the irritation of the skin, and
        the quantity of pus produced.   The conclusion to me  appears
        irresistible that  secondary  fever of smallpox is  a pustular  or
        suppurative fever—no more, no less.  If this  conclusion be cor-
        rect, the treatment  of secondary fever  is perfectly clear.  The
        efforts of Nature at the time secondary fever sets in, are to de-
        velop perfectly fhe pustules  and  to  reproduce the disorganized
        tissues, and this fever is only an effect of these efforts, it is  only
        one of the phenomena produced by the vis medicatrix naturee,
        which is at work endeavoring to rescue the patient from death
        and the grave.  Will we not oppose this  preservative power if
        we  administer  "refrigerants,  diaphoretics, antimonial  powder
        combined with calomel, and active  aperients, and  give  only a
        little of farinaceous articles  of diet ?"  Can  such be the proper
        treatment of a suppurative fever ?  Are exhaustants and a defec-
        tive diet the means indicated for the safe and  successful manage-
        ment of such a fever ? Secondary fever is as much a suppurative
        or pus-generating, concomitant fever as is the fever which attends
        the generation of pus in the instance of a phlegmon.  In treating
        a mammary abscess, for example, would we expect to benefit our
        patient by a strictly antiphlogistic plan of treatment—by refrige-
        rants, diaphoretics, evacuants, tapioca, and arrowroot. We would,
        when we discovered that resolution was impossible to hasten the
        development  of pus, and  sustain our patient, give a nutritious
        diet.   Just as little alarm,  too, as the suppurative fever, incident
        to  the  production of pus, would give  us  in the instance of a
        phlegmon, just so  little alarm, and no more, should the secondary
        fever of smallpox give us  while it remains  sthenic; and to have
        it remain so, or to cause it to be so if it has been otherwise,  we
        must sustain, not exhaust—we must feed well, not half-starve the
        patient.
           The time when secondary fever exists, it may be said, is the
        culminating period of smallpox—the period when the causes of
        exhaustion are at their maximum—the time when all the powers
        of  the economy are most beset, most heavily taxed.  Yet at this 
26
period, when certainly the most support is required, the treatment
recommended  by writers and teachers,  and that, too, which is
most practised, is to give the least support, and not only this, but
to add to the exhaustion incident to  the  disease, that exhaustion
which is produced  by the  use of refrigerants, diaphoretics, and
active aperients.
   To me the great object to be  attained in the management of
the so-called secondary fever of variola has been to keep it sthenic.
As the maturation of the pustules is the cause of that febrile con-
dition, its grade  will depend upon the vigor with which the ma-
turation or perfecting of the pustules goes on.  If they maturate
rapidly and promptly,  the fever  will be decided and sthenic; if
the pustules maturate slowly and doubtfully, then the fever will
be typhoid in  its form.  This  is the condition to fear, therefore
the condition to  prevent; and  as this can only be done by sup-
porting the system, or  by placing at its disposal such articles of
diet as will enable it to carry on the  maturation of the pustules
rapidly, promptly, and decidedly, I cannot  see any reason why,
during the  continuance of the fever, food  should be  withheld,
antimonial powder, calomel, and active  aperients  should  be ad-
ministered.  But I do see the positive necessity for the avoidance
of exhaustants, and the administration of a highly nutritious and
supporting diet; and  seeing  and regarding this necessity, my
practice has been to give liberally nutritious articles of food, and
I have abundant cause to be gratified with the good effects which
I have witnessed flow as consequences of their use.
   My treatment, when secondary fever has dawned, has not been
to alter or abate  in the least the use of my compensative, nutritive,
and stimulating treatment, but to continue it, rather increasing than
diminishing its vigor as the fever progresses.  This fever I desire
to sustain, regulate, not destroy; and this I accomplish by giving
freely and abundantly highly nutritious articles  of diet, and, if
needs be, stimulants.   The results of this treatment have  been to
me evidences of the correctness of my views of the nature of the
so-called secondary fever of smallpox. 
ADDENDUM.
           PHILADELPHIA COUNTY MEDICAL  SOCIETY.

     REPORTED BY WILLIAM B. ATKINSON, M. D., RECORDING  SECRETARY.

                          NOVEMBER 13, 1861.

      VARIOLA, ITS  MODIFICATIONS AND  TREATMENT.

  Dr. Bell.—This subject was selected for me by the  committee, to make
some remarks on this evening.  In restricting myself within these limits it
will not be necessary for  me to speak of the origin, symptoms in detail, and
morbid  anatomy of variola.   ********   ***  *  *  *
  The two most noticeable  varieties of variola, especially in reference to
prognosis,  are the distinct and the confluent.   The first is usually quite
manageable;  the second,  under any and  every kind of treatment, is, in a large
majority of cases, fatal.  The liability to the one or the other of these varie-
ties does not seem to depend  on age, constitution, or  previous habits.  *  *
  As pustulation advances on to maturation, the fever is greatly moderated ;
but with beginning desiccation comes, often, secondary fever, during which
the patient may sink beyond recovery.   ********  *
  In confluent cases, early recourse will be had  to a cordial and sustaining
treatment, by the use of ale or porter, and of wine or brandy, in gruel, farina,
etc., wine-whey, milk-punch, and nourishing broths.  One or more of these,
as may  be selected, should be regularly given at the prescribed intervals, by
night as well as by day.  In variolous, as in other  fevers, many a patient has
sunk  beyond recovery during the night,  especially  between  midnight  and
morning, for want of the  administration  of diffusible and nutritive stimulants
in alternation.  ******************
  Dr. Coates.—There  seemed to him a very serious contradiction between
the old alleged experience of so many years, ever since the time of Sydenham,
that the cooling  treatment was the most successful, and the recommendation
to give warm punch,  etc.  He did not believe that success  depended on
extremes or on exclusives, but believed that the  best results would  be  met
with from moderation in  the use of medical agents, and such a regimen as
comported best with the comfort of the patient.
  He had  seen  a case of a black  man with confluent smallpox bled in the
hospital; the oozing went on for twenty-four hours, and he died, though pro-
bably he did not  lose more than an  ounce and a half after the bleeding, which
was to ten ounces. 
28
  He doubted saving any great number of lives by any treatment.  *   *  *
  Dr. Condie.—In respect to the different forms or varieties of variola, he was
convinced that they had been multiplied by writers on  the disease to an unne-
cessary extent.  In a practical point of view, little was to be gained by any
other distinction than that which was based upon the extent and discreteness
of the eruption—the absence or  presence of petechia, or other serious affec-
tion of the skin, the character of the fever, and the dynamic condition of the
general organism by which the disease is accompanied.  ******
  In  respect to treatment, notwithstanding much good may be effected by
appropriate medication commenced at the very onset of  the  disease, and in
anticipation of the eruption, yet it must be borne in mind that every attempt
directed to procure an abortion of smallpox, to arrest it in any  of its stages,
will  fail.  The adoption  of proper  therapeutic measures previously to the
appearance of the eruption may have the  effect of reducing the violence and
diminishing the danger of the attack, but can  neither prevent it from occur-
ring nor from running its specific course.
  For smallpox there is no specific treatment.  Every case of the disease, as
it occurs, must be treated upon  general  principles, according to the indica-
tions presented.   Mild cases, occurring in patients who are temperate in their
habits and of a good constitution, a  purely expectant  treatment is all that is
in general demanded.   In more violent cases,  and in those which happen in
patients of bad  habits and impaired constitutions, the utmost watchfulness,
with a prompt  and decided course of treatment, will  be  demanded, and will
often be crowned with success.
  There is, perhaps, no disease in the treatment of which greater  attention
is required in respect to the regimen of the patient.  Without pure,  fresh air,
a proper temperature, the strictest cleanliness,  with a suitable diet and appro-
priate drinks, all other remedial  measures, however well adapted to the case
and  judiciously and faithfully administered, will fail to exhibit any curative
efficacy.
  Since the time of Sydenham, what has  been  termed the cooling treatment
has been very generally recognized as the one best adapted to smallpox. Dr.
Condie, however, feared that the " cooling treatment" has in some  instances
been carried  too far, and, in consequence, has been productive of harm rather
than benefit.  Attendant upon  many cases of the disease there is a manifest
tendency to a sinking of the vital powers of the patient, which tendency can-
not fail to be increased by such a cooling regimen  as Dr. Condie had seen put
in practice  during the  present epidemic—the patient being  kept in a cold
room, with a draught of air upon him, from open windows, night and day, and
allowed to partake freely of iced water or lemonade.   Some even carry " the
cold regime" so far as to subject  the surface of the patient's body to  sponging
with cold  water.   If there be any tendency present to  adynamia, such a treat-
ment must necessarily tend to confirm it.  Dr. Condie would not be under-
stood, however, as  countenancing a heating treatment in the cases of smallpox
as they ordinarily occur.   While he  deprecated an excessive cooling regimen,
he would at the same time insist  that there occur but  few cases  of the disease 
29
in which a well-ventilated apartment of moderate temperature, but free from
draughts, is not essential to the safety and comfort of the patient; and equally
as few in which he should not be allowed the free use of any simple cool fluid
as a drink.  **********  ****  *  **   **
  In respect to the propriety of depletion or of stimulation in the manage-
ment of smallpox, this must be decided by the circumstances of each separate
case—the general character of the prevailing epidemic being always, however,
taken into consideration.  In very few cases during the present prevalence of
smallpox, had Dr. C ondie found it necessary to resort to an active antiphlogistic
treatment.  In the  majority of cases which fell under his care, the treatment
pursued was such as would be demanded in the ordinary form of typhoid fever.
In general, a tonic and moderately stimulating treatment was indicated through-
out the attack.  In  the more severe cases, diffusible stimulants were demanded
to sustain the patient while the disease ran its course, and until the revival of
appetite and a renewal  of the powers of the stomach furnished the opportu-
nity for a resort to  tonics and a nourishing diet,  by  which  alone we can
reasonably hope to  restore permanent strength to the patient.   *   *   *  *
  In very nearly all the more severe cases, accompanied by a profuse erup-
tion, Dr. Condie had found that, during the stage of maturation, a full nourish-
ing diet, whenever it  could be taken, with a liberal use of alcoholic stimulants,
was essential to sustain the vital  forces.  Rich broths, oysters, stewed or
broiled chicken, tenderloin  steak, and such like  articles he has known to be
taken and relished, and believes that he has just cause for ascribing to their
use the preservation of his patients' lives in numerous instances.
  Dr. Nebinger would premise by  remarking that he  had taken no little
interest  in the treatment of smallpox.   If there  is  any one disease to which
he  had  given  more  deliberate consideration than  another,  that disease is
variola.   This greater consideration certainly had not arisen from any special
pleasure  he found in  coming in contact with so disgusting and loathesome a
malady, but had perhaps its cause or incitement  in his sympathies being
largely aroused for the patient, because of his  isolation from relatives and
friends, and the  offensive and forbidding character of the disease, especially
when it presents in the  confluent form—then the most terrific of all the exan-
themata.
  The petechial form of variola, which should be called malignant, the form
in which the vesicles  fill with blood, or rather with bloody serum, he had seen,
but had never been able to cure, and felt confident  that attacks of this form
of the disease  always prove fatal.   The confluent type of the disease is the
next most formidable, but is not necessarily fatal;  although, under  the best
management, it will march on to  a fatal termination.  The gentleman  (Dr.
Bell) who opened the subject, remarked, in regard to the confluent variety of
smallpox, that the large majority of all thus attacked die:  in this declaration
he is in harmony with all writers and authorities upon the disease.   Yet, while
this declaration is true, as far as  the experience  of  those are concerned who
treat variola after the  style and fashion, the manner and form of our dead,
and  yea, some  of our living  fathers in  medicine, he would remark with due 
30
and becoming respect and exalted consideration for these, the past and pre-
sent, that so far from the large majority of his confluent smallpox patients
dying, the majority recovered.  But then he did not treat smallpox as it has
been and is generally treated, or as the books and authorities  recommend.
His plan of treatment was, in the main, not only different, but vastly different,
from that taught by the books and practised by the profession. To this treat-
ment he had called the attention of the profession more than  once, and he was
happy to-say that he had met with some very gratifying responses from those
who had had the courage to step aside from the old, too well-beaten and too
oft-trodden track, to venture upon the new  and better one.  What is the
nature of confluent smallpox ?  The correct answer to this question will give
the only true indications for treatment of this form of variola.   What, then,
is confluent smallpox ?   It is  a disease in which  the patient's body is wrapped
up, as it were, in a thick sheet of pus, and in which there is nearly a complete
destruction of the external covering of the body and part of the cellular tissue
beneath the  skin.  Dr. Watson says,  the quantity of pus  generated amounts
to quarts.  This is, doubtless, true.   In the pustules, when fully developed,
the pus exists in a  semi-concrete or highly condensed form; but little more
than the solid constituents of the  pus being present, in consequence of the
liquid constituent  having, as the  pus was being  developed, evaporated  or
passed out of  the pustules by exosmotic  action.   Thus, then, the variety of
the disease under consideration is one in  which  nearly the  entire skin and
part of  the  subjacent cellular tissue are destroyed,  and quarts of pus are
generated.  With these  facts before  us, and duly  reflected  upon, it  is self-
evident  that great  exhaustion  must  necessarily result.  How shall we first
assist the organism  in developing the quarts of pus with as  little exhaustion
as possible, and this done, next enable it to reproduce the destroyed tissues?
The only rational answer is, by generously sustaining the patient.   But what,
under the circumstances, constitutes a  generous support? Will you  say
bread and tea, cracker,  panada, water-gruel, tapioca, and  arrowroot?  He
knows that  this is  the  diet generally of  smallpox patients, no  matter how
severe and exhausting the attack; or  rather, he would say, that such was the
diet until the patient had reached, or nearly reached, a fatal exhaustion, when
milk-punch, beef-tea, and such food are directed, and then too often presented
either too late or in too small quantities for the safety  of the patient.  Bread
and tea, water-gruel, and panada will  not, even  though you could induce the
patient  to partake freely of such diet, meet the requirements of an economy
being exhausted in  the  manner he  had referred to.  The necessities of the
system are great, and can only be successfully met by  the introduction of the
highest  order  of aliment, and that in large quantities.   He had  heard but
recently of a case of confluent smallpox ; the patient  was an adult male, who
was restricted to three glasses of milk-punch per day—the doctor in attend-
ance declaring that  a greater quantity would be injurious !   For one moment
reflect upon that.   Three glasses of milk-punch in twenty-four  hours, for a
man covered from head to foot with pustules, the  whole surface of his  body
being destroyed, and the necessity existing for its reproduction; and yet those 
31
pustules were to be perfected and the whole surface of the body to be repro-
duced out of three glasses of milk-punch per diem !  Need he say that slough-
ing of the skin and cellular tissue took place, and that the patient died ?  No,
he need  not.  You must know that, under such treatment, no other result
could follow.   " Three glasses of milk-punch, and three only; more would  be
damaging."   Why, if a well man was permitted to take as his only food but
three glasses of milk-punch every twenty-four hours, he would in a short time
starve to death on it.  Yet, gentlemen, this is the treatment given to confluent
smallpox  patients.  Is it wonderful that the great majority die?  But a few
weeks ago, he was called to see a woman laboring under an attack of confluent
smallpox, who had been treated by another physician.   He found her so ex-
hausted that she could not reply to his questions in  tones audible enough for
him to hear.  She was so exhausted that she could not sustain her head upon
the pillow in a line with her body, it falling from the pillow and approximating
the bed.   The  skin on her  face and  arm in many places were sloughing, and
he could, with but a slight effort, have stripped the arms  of the skin, such was
its condition.  This woman  was living—no, not living, dying—on toast and
water, arrowroot, and gruel.  He  at once ordered  her egg-nog, and set the
time it was to be given and the quantity.   He did not order but three glasses
in twenty-four hours, under the impression that more would be damaging; but
he directed  her to be given a glass every two hours.   On his second visit,
which was about twenty-four hours from the first, improvement  was manifest;
she was able to speak so as to be heard, and was able to sustain her head upon
the pillow.  Between his two visits she had taken twelve glasses of egg-nog.
Do not, at this announcement, be frightened from your propriety.  This treat-
ment was continued day after day, until she was  able to take other food.  And
under this, as some would and have called it, extraordinary nutritive treat-
ment, recovered.  The  proof of its utility is found in  its results.  Try the
treatment.  Put it to the test before you pronounce judgment upon it.  Be
assured it is worthy of a trial.
   He had recently treated a lad of seventeen years, who had a  most exhaust-
ing attack of confluent smallpox.   In  the house with him were  four others
who had the disease in  the distinct form.   The lad  referred  to did not come
into his  hands until the fourth day of the eruption.  He was  delirious—his
delirium closely resembling  the ravings of mania-a-potu.  He  had not slept
for forty-eight  hours, and it was with much difficulty he could  be restrained
and confined to his bed.  The doctor  succeeded in  controlling his delirium
and  produced  sleep  with opium.   As it was evident from the extent of the
eruption that the case would be a grave one, he commenced at once to sustain
him by the free use of eggs and milk. This was continued for three days, when
whisky was  added to the eggs and milk—of this (the egg-nog) he was given
as much as he could take.   It was manifest to the doctor that those who were
nursing  the boy had concluded that he would die, and as the duty of taking
care of him was a most disagreeable one, the impression that he could not get
well had its bad effect of preventing the free administration of the nutriment.
He felt a deep interest in the boy's recovery, and for the purpose of keeping 
32
his attendants from neglecting him, he visited  the lad three and four times
daily, while  he was extremely ill, and upon each occasion  gave him freely of
egg-nog.  This was one of the worst cases of smallpox he ever beheld.  His
eyelids were not separated for eleven days.  The entire surface of his body
was covered with the eruption.  The skin in several  places was gangrenous,
and he  became  emaciated as  he never  saw a smallpox  patient emaciated
before.
   Now this  lad drank quarts upon quarts of egg-nog and  milk, and yet with
all this  extraordinary nutrition, he  became  extremely  prostrate, much ema-
ciated, and had gangrene of the skin.  What would  have been the result if
he had been given the water-gruel treatment ? There cannot be any difficulty
in determining.   The patient, under  high and free  nutritive  treatment, reco-
vered, and he now lives  to proclaim  the utility of generous nutrition in con-
fluent smallpox.
  After the first three days, the period which precedes the eruption, medicine
ceases to be, as a general matter, of any use.  The great, the pressing indica-
tion is food, and it matters not what the food  is so that the patient  takes
enough of it to meet the requirements of the economy.  Dr. N. employs milk,
eggs and milk, and egg-nog, not that there  is anything of special importance
about those  articles of diet, only that they are as grateful to the  patient as
any food which  can be presented, and  give  as little  pain to the pustulated
throat and mouth as  any food which can be given.  Yet. for the generous
nutrition which he recommends to be  of positive service, it must be com-
menced  early.   It will not do to  put off supporting vigorously the patient,
until prostration begins to manifest  itself—our nutrition, then, be it ever so
generous, may be without benefit.   That the blood may be so sustained as to
meet all the  pressing wants of the economy, we must commence early.  Com-
mence immediately upon the papular stage closing and the vesicular stage
opening.  Passing from milk to eggs and milk, and  from eggs and milk to
egg-nog, as the pustules develop and  the disease progresses.
  Much stress has been placed upon what the  books and teachers call the
secondary fever of variola.  He must enter his objection to this name, for the
febrile disturbance which springs up during the development of the pustules,
and subsequent to their development.  He objected to the  name because it is
an improper one, and is well calculated to lead to false ideas of pathology and
improper treatment.  The fever should be called pustular, maturative, or irri-
tative fever,  as it would  then express the cause, upon which its development
and continuation  depends.  But what of  this secondary, or irritative fever?
Why shall we, as the books direct, withhold at this period generous diet from
the patient ?  Will its absence diminish  the fever ?  Or, is it important to the
safety of the patient that it should be diminished ?  Do we not desire that this
fever shall be sthenic; and can  we have it such, by allowing  the blood  to be
exhausted by the demands made upon it to perfect the pustules ?  Certainly
not.  If we desire this fever to be vigorous, and the patient's condition not to
become typhoid, we must sustain-I repeat we must sustain—the patient and
that most generously.  A moment's  reflection cannot bring  us to any other 
33
conclusion than that it is an outrage of common sense, an outrage upon the
patient, and a violation of the plainest  teachings of pathology, to withdraw
food from, or to refuse to give it, with  an unsparing hand, because a fever
exists as a phenomenon of the development of pus, or the maturation of almost
innumerable pustules.  Do we not sustain well, in all other cases where pus
is being developed to any large extent; and is not the practice justified by its
results ?  Why, then, should we refuse generous dietetic support  in that pus-
tular disease in which,  Watson says, as  has already been remarked, quarts of
pus are generated? No patient with confluent smallpox was, he felt confident,
ever destroyed by a generous  and abundant supply of food.  He  was equally
as confident that many such now sleep the slumber of death because they were
not vigorously sustained with food.  The time for the management of grave
cases  of variola with water-gruel, toast-water, and panada, and for the second-
ary, or more properly  the irritative fever, to be  regarded as  an  opposing, a
contraindicating phenomenon to the free introduction of food, is fast  passing
away.  A better time for the poor, unfortunate smallpox patient is at hand.
  Some one has said to-night that there  had been no improvement in the
treatment of smallpox since  the  days of Sydenham.  He begged to be in-
dulged in  the declaration that this is not correct.  In the days of Sydenham
the starvation treatment, the gruel diet was the food, but, although this treat-
ment is still too largely practised, he knew that it was not so universally fol-
lowed as was the case a few years ago, and that there are those who, although
they do not sustain  their smallpox patients to the extent that he does, yet
they repudiate the gruel and  panada diet, and give food with  a freedom that
would appal Sydenham himself.  The members are not unacquainted with the
fact that his practice is not small, and that the field of his labors is in one of
these  localities in which Dr. Jewell has correctly stated that variola has been
very prevalent. It cannot be that he should not have had a liberal percentage
of these cases to treat,  and yet he had but one case of death to occur, and that
was a man whose habits were bad, and whose attack of confluent smallpox had
been preceded but a few months by an attack  of secondary syphilis.
  Dr. Bell asked how many  cases Dr. X. had seen in the  late epidemic ?
Had he seen thirty ?
  Dr. N. could not say how many, but  he presumed he had  seen more ;  but
this was a mere guess,  as he had not any account of his cases at  hand from
which he could make any positive assertion as to their number.   But he was
confident as to having had but one fatal  case during this epidemic.
  Dr. Bell. Then the doctor has been more fortunate than any physician yet.
  Dr. N. remarked that many of his cases were light, and required but little
treatment.   But as regards being more fortunate than any other physician,
that, he presumed, might be accounted for by the other fact that but few sus-
tained their smallpox patients as generously as he did.
  Dr. Jewell.  How many were confluent cases ?
  Dr. N.  As far as he could now call to mind, five were such.
  Dr. N. said he had found much  relief to his patients, from the burning and
itching of the  face, to follow from  the use of an ointment made of lard and
      3 
34
Uquor  sodas chlorinata, in  the proportions of one ounce of the lard to two
drachms of the solution of  the chlorinated soda.   This he directs to be freely
applied to the face at short intervals.
  Dr. Carson asked if he had employed glycerin.
  Dr. N.  He had not.
  Dr. Burns,  after thirty-five years' experience, could fully agree with Dr.
Nebinger.  For many years, after the period of excitement had passed,  he
had stimulated freely.  There is  a great waste of vital fluid, and the patient
requires sustaining.  Hence he gave beef-tea, punch, etc.  The last epidemic
had been one of the most violent character, and required early and free nutri-
tion, and with satisfactory results.   For twelve years he had employed iodine
externally.   At the period when  pustulation was commencing, he applied the
tincture of iodine in its full strength, and then painted with collodion, repeat-
ing it every day. The inflammation is thus controlled, and the air is prevented
from acting on the skin.  Small pits are left, which, in a few months, disap-
pear.   He had tried  it in a case on one  hand, leaving the other naked, and
there was a marked difference.
  Dr. Remington was happy in being able to add his testimony in favor of the
stimulating nutritive treatment pursued in the advanced or suppurating stage
of confluent smallpox, and so highly eulogized by our friend, Dr. Nebinger.
He had been  called upon to treat a most aggravated case in its confluent
form, early last spring, occurring in a young man, aged about twenty years,
and  said to have  been vaccinated some five years  since, homosopathically.
Hemorrhage from the bowels supervened on the twelfth day of the disease,
which, in a  few days, yielded to the tinct. ferri chloridi.   This formidable
case was also attended with delirium, stupor, intense suffering, great  intu-
mescence of face, and soreness of the scalp, with entire closure of the eyelids
for a week or ten days.  Circumscribed sloughs of the cutis appeared, and  on
the maturation of the pustules, which coalesced on the face, and formed a
regular incrustation of half an inch in thickness, giving rise to an intolerable
fetor, notwithstanding powerful disinfectants of chlorinated soda and  glycerin
were  freely employed.   There were positive symptoms of  great prostration
present, and this  exhaustive drain, by so extensive a suppurating surface
made on the powers of life, was compensated by the liberal exhibition of eggs,
custards, jellies, with brandy, milk-punch, essence of  beef, mush and milk, ice
cream, and oysters.
  The- patient's eyes escaped unharmed, although his hair fell off, and his
hearing was greatly impaired for some months.   He had since learned that
he had completely recovered from both  these annoyances, and enjoys a full
return of vigorous health.
  It is quite evident  to the practical observer that  medicine has but a very
limited  control over this  loathsome scourge, and therefore  our chief  duty
consists in restricting its extension by interposing  vaccination; employing
moderate evacuants  by salines in  the  commencement, a properly regulated,
cooling regimen, and free ventilation, followed, in the advanced and suppu-
rating stages,  with a generous, nutritive,  stimulating  diet.  *  *  *  * 
35
                                NOTE.

  From March, 1861, to June, 1862—a  period of sixteen  months—I treated
seventy-nine cases of variola.  Of these, four proved fatal—one a male aged
35 years, the case referred to in the debate:  the second was a girl of 15 years;
her attack was of the confluent variety : the third a girl of 7 years; the form
of the disease in her  case  was the  discrete: the fourth  was a babe  of 18
months; its attack was confluent.  Thus my statistics exhibit a mortality of
4 in 79 cases, or 1 in 19.75.
                                                                A. N.