AN ESSAY 
 
 PATHOLOGY AND THERAPEUTICS 
 
 SCARLET FEVER, 
 
 W 
 
 CASPAR MORRIS, M.D., 
 
 FELLOTT OF THE COLLEGE OP PHYSICIANS OF PHILADELPHIA, MEMBER OF THE AMERICAN 
 
 PHILOSOPHICAL SOCIETY, LATE LECTURER ON THE PRACTICE OF MEDICINE IN 
 
 THE PHILADELPHIA MEDICAL INSTITUTE, AND CLINICAL 
 
 LECTURER AT THE PHILADELPHIA HOSPITAL. 
 
 JlA^Zf 
 
 PHILADELPHIA: 
 LINDSAY & BLAKISTON 
 1858. 
 
•A* 
 
 Entered according to the Act of Congress, in the year 1858, by 
 
 LINDSAY & BLAKISTON, 
 
 In the Clerk's Office of the District Court, in the Eastern District of Pennsylvania. 
 
/ 
 
 pi- 
 
 TO HUGH L. HODGE, M.D., 
 
 Professor of Obstetrics in the University of Pennsylvania. 
 
 My Dear Friend : 
 
 A new edition of this little volume being called for, and he, our mutual 
 friend, under whose auspices the first was issued, having passed away from 
 the scenes in which you and I were wont to follow him with a feeling of 
 filial respect, — permit me to place your name on the new issue 5 and thus 
 to commemorate a friendship of thirty years, during which we have trodden 
 together the arduous paths of professional life, in the daily interchange of 
 those acts of brotherly regard which smooth the asperities of the way, en- 
 courage tapatient perseverance in toil, and cheer the spirit when flagging 
 and weary. The time is rapidly approaching for both — even for me, though 
 much your junior in years and yet farther behind you in the race, — when, as 
 the runners of old, we must transmit our lamps to younger competitors. 
 That in their hands they may burn more brightly, and by them be trans- 
 mitted with increasing illuminating powers to others again, is, I know, your 
 wish and expectation, as it is that of your grateful and respectful friend, 
 
 CASPAR MORRIS. 
 
PREFACE TO SECOND EDITION 
 
 The original edition of this work being exhausted; the publishers 
 have requested liberty to issue a second. No apology for complying 
 with this request is needed by the Profession. He who has been 
 longest engaged in the observation and treatment of the disease, will 
 look with respect and gratitude to any one who can throw light upon 
 its nature and furnish hints for its successful treatment; while the 
 younger practitioner will seek for counsel, with an avidity proportioned 
 to the violence of the cases he is called to treat; and will welcome 
 every — even the feeblest — effort to aid him in the management of a 
 disease than which none is more formidable in its character and un- 
 certain in its results. If the following pages lend increased strength 
 to the former, or afford instruction to the latter, I shall be abun- 
 dantly compensated for the labour bestowed upon it. They are the 
 result of more than thirty years observation in various public in- 
 stitutions as well as private practice; and each year of enlarged ex- 
 perience, confirms me in the truth of the principles here inculcated, 
 however imperfectly they may be set forth. 
 
AX 
 
 ESSAY ON SCARLET FEVER 
 
 So fatal have been the results in individual cases, so wide- 
 spread the devastation caused by the epidemic prevalence of 
 this disease, so interesting the period of life at which it com- 
 monly occurs, just as parental hopes are budding with pro- 
 mise, and the tendrils of affection entwining themselves the 
 most closely round the heart, that the very name is a signal 
 of distress, and its introduction into the family circle is looked 
 upon as the entrance of the angel of death with an irreprie- 
 vable warrant to destroy. The parent sits down in the eve- 
 ning the happy centre of a group of smiling objects of affection , 
 his heart swelling with delightful anticipation as his eye glances 
 around the circle ; and ere the next return of the same weekly 
 period, half of them slumber in the embrace of death. The 
 mother's nightly visit is paid to the couch of the only idol, 
 upon which her hopes are concentrated, and to which the sa- 
 crifice of anxious love is hourly offered, and leaves it sleeping 
 tranquilly, no forecast shadow giving sign of the coming sor- 
 row; the morning finds it stricken down by disease, and the 
 evening an inanimate corpse given over to the power of cor- 
 ruption. These are neither fancies, nor exaggerated images 
 of wo. There is not a practitioner of any extended experi- 
 ence but must acknowledge that he has not only witnessed 
 2 
 
10 AN ESSAY ON 
 
 such scenes, but been a miserable participator in their anxieties 
 and grief. Of many such instances it may be said with truth, 
 no skill could avert the result. Alas ! of too many, that well 
 meant but ill-directed effort — to use the language of Syden- 
 ham, applied by him to this very disease, " nimia diligentia 
 medici," has hurried them needlessly to the tomb. 
 
 Nor is it by the rapidity of its course, alone, that scarlet 
 fever is invested with its character of dread. Treacherous 
 beyond all other diseases, cases apparently the least violent, 
 "scarcely deserving the name of disease" in the earlier stages, 
 not unfrequently develop lesions of the most formidable kind 
 in their progress, and result in a fatal termination; while in 
 others, a train of painful and disgusting sequelae gradually 
 exhaust the strength by long continued suffering, and often 
 entail consequences which remain for years, or even during 
 life. It must be evident that such a disease demands the 
 most careful investigation into its character, cause, and treat- 
 ment. 
 
 I shall not postpone the consideration of these for any dis- 
 cussion of the various names by which it has been called, nor 
 of the propriety of the divisions which have been adopted by 
 different authors. Objections may be brought against, and 
 arguments adduced in favour of, most if not all these terms 
 and divisions. A name it must have, and Scarlet' Fever will 
 answer as well as any that can be proposed; though it will be 
 found, as we progress in the consideration of its symptoms, 
 that some cases have little and others none of the peculiar 
 eruption from which this term is derived. Divisions we must 
 make in order to classify the cases, and arrange properly our 
 ideas of its character and treatment; and the terms simple, 
 anginose, and malignant, will embrace most cases, though 
 there are others, which, not being reducible within the limits 
 of either of these classes, though evidently derived from the 
 same origin, I shall designate as irregular. It must be borne 
 
SCARLET FEVER. 11 
 
 in mind, however, that these are but various phases of one 
 disease, which fall into each other by imperceptible shades ; 
 so that while the cases which may be assumed as types of 
 each class have strong marks of distinction, there are others 
 which it is difficult to distribute to either. 
 
 The simple form being the normal condition of the disease, 
 it will disembarrass the subject of much difficulty to turn our 
 attention first to the description of it. There is no disease 
 the onset of which is more unexpected. Rarely, indeed, are 
 there the premonitory loss of appetite, languor, or headache, 
 so generally found in other febrile diseases. So decidedly 
 is this the case, that even when the known presence of the 
 disease in a family leads to anxious watchfulness, no devia- 
 tion from the usual habits marks the individual subject of 
 the next attack. The invasion is generally in the night. A 
 child spends the day in the most perfect enjoyment of health, 
 runs abroad freely, eats heartily, retires to bed as usual, 
 sleeps soundly during the earlier hours of the night, awakes 
 with sick stomach, vomits freely, throwing off the food taken 
 perhaps at the mid-day meal, becomes restless and fretful, 
 has great thirst and heated skin, and when returning day- 
 light affords opportunity of investigation, is found thickly 
 covered upon the face, neck, and chest with a vivid scarlet 
 rash, consisting of minute points interspersed upon a uni- 
 form efflorescence, which disappears under the pressure of the 
 finger, but is instantly renewed on its removal. The phy- 
 sician is sent for, and finds the pulse beating with a rapidity 
 almost pathognomonic of the disease, so that if precluded 
 from any other mode of investigation, he might, with but 
 little danger of error, decide the case to be one of scarlet 
 fever, from the extreme rapidity of the action of the heart. 
 There is no other disease in which there is the same condition 
 of the circulation, with the single exception of the fever of 
 puerperal women. The tongue is red and slightly coated with 
 
12 AN ESSAY ON 
 
 a white fur, through which frequent villi project, the surface 
 being white and the protruding points of a vivid scarlet co- 
 lour. He looks further, and sees the whole mucous membrane 
 of the mouth and fauces partaking of the same intense red- 
 ness, with stigmata thickly sown upon it. The child is restless 
 and distressed. Such would be the usual symptoms of the 
 invasion of a case of simple Scarlet Fever. 
 
 Ushered in thus suddenly, the disease pursues a rapid 
 course. Scarcely is the existence of the rash recognised be- 
 fore it is extended to the whole surface of the body; and 
 finally to the extremities, which it reaches by the third day, 
 at which period it begins to fade from the parts on which it 
 first presented itself; the entire course of the disease in its 
 primary stages being sometimes completed in four days, and 
 never extending beyond seven : the common termination is in 
 five days. There is not in this, as in the pustular and vesicu- 
 lar exanthems, a diminution of the febrile symptoms with the 
 appearance of the eruption. The rapidity of the pulse, which 
 is rarely less than 120 per minute, and the heat of the skin, 
 remain unabated throughout the entire course of the fever. 
 There is no disease in which the heat of the surface is greater. 
 Not only does it communicate a peculiar, pungent sensation 
 to the finger, but by actual, measured observation it sometimes 
 rises to 105°, 108°, or 110° of Fahrenheit. There is no 
 elevation of the rash essential to this eruption, which is often 
 attended by an itching almost as intense as that of urticaria; 
 but in some cases there are small papular elevations on the 
 arms and legs, and it is not at all uncommon to find suda- 
 mina, innumerable clear vesicles of very minute size, scattered 
 over the thorax and abdomen, which are very perceptibly ele- 
 vated both to the sight and touch. The serum they at first 
 contain is rapidly absorbed, or rather disappears, perhaps by 
 evaporation, leaving the cuticle to form minute glistening 
 scales, separating much sooner than the general desquamation, 
 
SCARLET FEVER. 13 
 
 which takes place at the close of the disease. These scales lie 
 on the red surface like fine bran, very perceptible from their 
 contrast of colour. The intensity of the eruption does not 
 mark the degree of violence of the disease ; some very mild 
 cases having a vivid universal rash, while in others equally 
 benign it is partial in extent and less bright in its hue. It 
 has been a common error to suppose that the more vivid the 
 eruption, the more favourable was the prognosis. Enlarged 
 experience disproves this assumption. Many fatal cases are 
 marked by a rash of an intensely bright colour and universally 
 diffused. 
 
 In these cases of simple scarlet fever the condition of the 
 digestive organs varies much. While in some there is an 
 entire loss of appetite, in others there is as constant a de- 
 sire for food as in health. The bowels are unaffected in the 
 simple form, and indeed in the primary stage of all the varie- 
 ties of the disease. The kidneys, too, maintain their healthy 
 functions during the first four days, but toward the close of 
 many cases the urine becomes scanty in quantity, and high- 
 coloured, though often destitute of any deposit. 
 
 The functions of the skin are impaired in proportion to the 
 intensity of the eruption. In some mild cases I have known 
 it to continue soft, and even perspirable, during the whole 
 progress of the disease. 
 
 Peculiar as was the appearance of the tongue in the be- 
 ginning, it becomes still more marked as the case advances. 
 The fur, which in the variety now under consideration is 
 never dense, is thrown off on the second or third day, be- 
 ginning generally to clear at the tip and edges, but in some 
 cases it is thrown off the whole surface simultaneously, and 
 it is left more entirely denuded than in health, of a colour 
 varying in intensity in proportion to the violence of the case. 
 Sometimes but slightly reddened, at others it assumes a hue 
 not much differing from that of raw beef, while the papillae, 
 elongated or swollen, are often seen to rest upon the smooth 
 
14 AN ESSAY ON 
 
 and glazed surface. This condition of tongue is doubtless 
 owing to the same process taking place in the mucous mem- 
 brane as that which is known as desquamation of the cuticle, 
 and it continues about the same length of time. 
 
 The symptoms are sometimes so mild, and the regular per- 
 formance of the functions of the nervous system is so little dis- 
 turbed by the disease, that the patient may pass through all 
 the stages without requiring any medical treatment. Some- 
 times the character of an entire epidemic is thus benign ; and 
 this must undoubtedly have been the case in that recorded by 
 Sydenham, who does not notice the anginose complication, 
 though he describes with his usual perspicuity the symptoms 
 as we have just given them. It will be found, however, when 
 we come to treat of the sequelge, that such cases are by no 
 means devoid of interest nor free from danger. It is an im- 
 portant fact in the history of the disease, that in London itself, 
 within the next half century, the epidemics of Scarlet Fever 
 were among the most malignant on record: thus teaching the 
 necessity of avoiding hasty generalization, into which, in this 
 instance, even Sydenham himself was betrayed. 
 
 It must not, however, be supposed that all cases of simple 
 scarlet fever are thus mild in their character. In some in- 
 stances from the intensity of the cause, and in others from the 
 peculiarity of the individual attacked, the nervous system feels 
 more decidedly the impression; and we then have symptoms of 
 a more formidable character. The vomiting or nausea, by 
 which, as I before remarked, the disease is almost invariably 
 ushered in, may be preceded, accompanied, or followed by 
 violent convulsions, which are often of a peculiar, tetanic 
 character. When the impression is less severe, there will be 
 frequent contractions of the muscles of the forearm, with 
 startings of the tendons, and twitchings of the fingers; and 
 occasionally there is coma, or even the wildest delirium, mani- 
 fested by screaming and frequent starting from slumber. On 
 
SCARLET FEVER. 15 
 
 the third or fourth day, it is no uncommon event to have the 
 patient complain of pain in the ear, or be overcome with 
 drowsiness, either of which conditions, after continuing twenty- 
 four hours, will in all probability be followed by the discharge 
 of a thin serum from the external meatus auditorius, which 
 excoriates the neighbouring skin, and gives rise to a vesicular 
 eruption in the adjacent parts. 
 
 As the rash fades it leaves the surface covered with a dry 
 cuticle, which separates in very thin scales successively from 
 the face, neck, chest, arms, and legs. The density of these 
 scales depends upon the part of the body and the violence of 
 the eruption. They are very delicate on the face, neck, and 
 arms, while from the hands and feet, where the cuticle is thick- 
 ened by pressure, it comes off in large patches, and may even 
 in some instances be brought away entire. This desquamation 
 is considered by some authors as an invariable concomitant 
 of the disease, it occurring even in those cases in which there 
 has been neither eruption nor heat of the surface. Dr. Graves 
 of Dublin relates many cases of this kind as having occurred 
 during an epidemic in that city, and ascribes the desquama- 
 tion in this disease, and in maculated typhus, to a specific in- 
 fluence of the peculiar miasm, rather than to an inflammation 
 of the dermoid tissue itself. It is certainly one of the most 
 uniform and characteristic features of the disease. 
 
 In the Anginose variety, we have the same series of events 
 as those just described, generally in an aggravated degree. 
 The rash may appear even more vivid, or it may be present 
 only in patches about the folds of the body and on the back 
 and abdomen, or about the flexures of the larger joints, or 
 sometimes only on the hands and feet. The nervous symp- 
 toms are more often manifested, and more violent when pre- 
 sent. There is very great tremor of the muscles and 
 disposition to sleep, and when aroused the child is fretful. 
 On looking into the throat there will be found not only the 
 
16 AN ESSAY ON 
 
 redness which has been described as marking even the 
 cases which have no anginose character, but also a swollen 
 condition of the tonsils and soft palate. These are sometimes 
 cedematous from the very commencement; and corresponding 
 with the internal disease, we find a tumour under one or both 
 angles of the jaw, which is circumscribed and limited in size, 
 and entirely different both in character and appearance from 
 the diffused swelling which will be noticed hereafter. This 
 tumour is not peculiar to scarlet fever, but is similar to that 
 which occurs in every case of inflammation of the tonsils. The 
 difficulty of deglutition is considerable from the very begin- 
 ning, and there is often stiffness of the muscles of the neck 
 and soreness on pressure in the triangular space between 
 the ear, the ramus of the jaw, and the sterno-cleido muscle. 
 The pulse has even greater frequency than -was noticed be- 
 fore, but generally less force, yielding more before the pres- 
 sure of the finger; corresponding in this respect with the ge- 
 neral want of tone of the whole system, the frequency evidently 
 depending not on inflammatory excitement, but on nervous 
 irritability. From the very commencement of the anginose 
 affection there is an abundant secretion of viscid mucus which 
 adheres to the surface of the tonsils and palate, and occasions 
 much annoyance, disturbing the sleep and causing the patient 
 often to start as though strangling; and when this condition 
 extends, as it very often does, to the mucous membrane 
 lining the nostrils, and they become obstructed also, the in- 
 terruption to the free access of air not only adds to the suffer- 
 ing, but materially increases the danger by preventing the 
 proper oxygenation of the blood, already vitiated by the in- 
 fluence of the specific poison. I have noticed in these an- 
 ginose cases, a peculiar odour of the breath resembling that 
 of chloroform; entirely dissimilar to the disgusting putrid 
 odour of the malignant cases which depends on the sloughs 
 in the throat. On examining the condition of the fauces 
 
SCARLET FEVER. 17 
 
 there will often be seen deposits of lymph upon the surface of 
 the tonsils, sometimes white, at others ash-coloured and even 
 darker, the colour depending upon the presence of effused 
 blood. These exudations have been mistaken for ulcers. In 
 general they may be easily removed either by gargle or other 
 mechanical agency, leaving the surface of the mucous mem- 
 brane beneath them like the adjacent structure. In other 
 cases they do cover ulcerated spots. This is, however, more 
 especially the case in that aggravated form which will claim 
 our attention hereafter. They are generally confined to 
 the surface of the tonsils, but occasionally extend to the fauces 
 and even to the larynx ; giving rise to one of the most for- 
 midable complications that can occur. I have seen this 
 deposit lining the nares even to the external orifice. The 
 inflammation, which appears to partake of the same character 
 as that of erysipelas, having, like it, a tendency to diffusion, 
 often extends from the fauces through the Eustachian tube 
 to the membrane lining the inner ear; giving rise to intense 
 otitis. Still more frequently the lining of the external 
 meatus takes on ulcerative action, as mentioned when de- 
 scribing the simple form. In either case the pain is severe, 
 and the ulceration sometimes destroys the soft tissues, and 
 even invades the bony structure of the ear; causing the loss 
 of the ossicula and leaving the patient subject to prolonged 
 offensive discharge and permanent loss of the sense of hearing. 
 As in the case of the simple disease, the tongue generally 
 casts off its coat about the third day, assuming a still more 
 angry appearance than that formerly described. Not unfre- 
 quently its edge, as well as the mucous membrane lining the 
 posterior nares and fauces, takes on ulcerative action, and then 
 the lymphatic glands of the neck become much enlarged and 
 exceedingly painful and tender to the touch. I have re- 
 peatedly seen both sides swollen, with effusion into the cellu- 
 lar tissue to such a degree as materially to impede the respi- 
 
18 AN ESSAY ON 
 
 ration of the child and totally to forbid deglutition. No more 
 pitiable object can be presented than one of these cases. .The 
 commissures of the lips so sore that they bleed at every move- 
 ment of the mouth ; the tongue red and polished ; the mucous 
 membrane of the fauces turgid and ulcerated ; the lymphatics 
 of the neck swollen; and the cellular tissue of the neck in- 
 filtrated with serum, till the hollow between the jaw and cla- 
 vicles is entirely filled, and the skin is stretched and looks as 
 though it were polished vellum ; the head thrown back to re- 
 move the pressure from the swollen throat and to facilitate the 
 access of air to the larynx; the nostrils distilling an acrid 
 sanies which is puifed out with a sputtering noise at every ex- 
 piration, and excoriates the lip and cheeks as it flows over 
 them, and even abrades the cuticle from the back of the hands, 
 instinctively applied to remove it from the nostrils, and thus 
 afford more freedom of respiration ; the eye balls turned up- 
 ward and the vessels of the conjunctiva injected; the corners 
 of the eyes ulcerated also, while a loathsome putrid odour 
 contaminates the atmosphere of the largest apartments, — the 
 wretched child lies unable to swallow, (even the smallest por- 
 tion of liquid taken into the mouth being rejected through 
 the nose,) and suffering all the pains of hanging; till the most 
 earnest prayer of the fondest parent is for its death. Yet 
 even from such condition we may hope for recovery. 
 
 In those epidemics in which the typhoid tendency is very 
 strongly marked, large abscesses are formed in the cellular 
 tissue of the neck, and gangrene and sloughing may take 
 place. This is especially likely to occur when leeches have 
 been applied or blisters, under an erroneous impression that 
 active inflammation was the cause of the swelling. 
 
 In the anginose form the stages of the disease are as regu- 
 lar as in the simple variety. They are not, however, always 
 so perceptible. This is caused by the accession of these se- 
 condary sources of irritation which give rise to a fever even 
 
SCARLET FEVER. 19 
 
 more intense than that which has already been described, 
 which naturally terminates on the fifth day. In the most 
 favourable cases the subsidence of the primary symptoms is 
 followed by the decline of the ulceration and consequent glan- 
 dular disease, and convalescence is established, until the oc- 
 currence of some of the sequelae, which will be noticed here- 
 after. In other instances these secondary results develop 
 themselves before the crisis of the primary disease has been 
 safely passed, and the febrile disturbance to which they give 
 rise, is mingled with that of the primary impression, and the 
 case is prolonged indefinitely. Cases are often met with in 
 which, instead of the extreme symptoms just mentioned, there 
 is only a slight ulceration of the mucous membrane of the 
 nares, which gives rise to symptoms resembling coryza, while 
 the rash is imperfectly developed in points about the flexures 
 of the limbs and folds of the body, sometimes taking even a 
 maculated appearance, and the whole case may be mistaken 
 for a cold with rash, and its true nature, not being suspected 
 in the primary stages, is first proven by the development of 
 more formidable symptoms in the second stage; or, if the 
 rash be better developed, there is sometimes difficulty in dis- 
 tinguishing the case from one of measles, as I have known 
 highly intelligent and experienced physicians at a loss. This 
 is more especially likely to occur in those instances where an 
 impeded respiration gives a darker hue than natural to the 
 eruption, which is thus assimilated to that of rubeola. 
 
 In Malignant Scarlet Fever there are all the indications of 
 great oppression of the vital force. There are vomiting, stu- 
 por, jactitations, violent pains of the arms and legs, with only 
 a partial development of the eruption, which is often found on 
 the hands and feet before it appears on the body or about the 
 head. The temperature of the body varies. In those cases 
 in which the prostration is extreme, it is cold; and the rash, 
 if it appear at all, has a livid hue, and may assume the sem- 
 
20 AN ESSAY ON 
 
 blance of purpura, and even be mingled with petechia and 
 vibices. In some cases the rash comes out imperfectly for a 
 time, and then disappears, re-appearing again so late even as 
 the seventh day. Instead of the general flush like the efflo- 
 rescence of the simple scarlet fever, there are only points 
 about the flexures of the limbs, or those parts of the body 
 which are kept the warmest. Often it does not appear at all, 
 the whole body being rather of a waxy paleness; at other 
 times there is an intense lurid erysipelatous flush, which is 
 even occasionally of a livid hue. 
 
 The condition of the throat and brain varies also ; I have 
 seen the brain intensely excited from the very onset of the 
 disease, though in general there is coma more or less profound. 
 The throat is swollen so as almost to render deglutition impos- 
 sible. The tonsils, uvula, and soft palate lie flaccid, looking 
 more like portions of purple velvet than living tissue ; coated 
 with black lymph in large portions, which, slightly loosened 
 at the edges, betray an ulcer beneath; a horrible ichor dis- 
 charges from the nostrils, and the room is filled with the most 
 offensive fetor. In many instances the powers of life are to- 
 tally prostrated from the very beginning. A child will be 
 running about in apparently perfect health one hour, " feeling 
 its life in every limb/' and manifesting its power in untiring 
 gambols, and the next may be found with a glassy and sunken 
 or upturned eye, feeble and frequent pulse, cold surface, great 
 jactitation, and will sink steadily to death in despite of every 
 effort; the sedative influence of the miasm being so intense 
 that no reaction takes place. The disease is not in fact fully 
 developed in these cases, and its real character might elude 
 detection were it not that the subsequent discovery of an im- 
 perfectly formed eruption about the neck, or the occurrence 
 of other cases in the same family or neighbourhood, afford 
 sufficient evidence of its true nature. Scarlet Fever, which, in 
 London, at the time at which Sydenham records his observa- 
 
SCARLET FEVER. 21 
 
 tion, was " scarcely to be called a disease," at the period at 
 ■which Dr. Fothergill wrote had assumed this malignant form. 
 Dr. Fothergill thus describes that epidemic: "It comes on 
 generally with such a giddiness of the head as commonly pre- 
 cedes fainting, and a chilliness or shivering like that of an 
 ague fit; this is soon followed by great heat; and these inter- 
 changeably succeed each other during some hours, till at 
 length the heat becomes constant and intense. The patient 
 then complains of an acute pain in the head, of heat and 
 soreness rather than pain in the throat, stiffness of the neck, 
 commonly of great sickness, with vomiting or purging, or both. 
 The face soon after looks red and swollen, the eyes inflamed 
 and watery as in measles, with restlessness, anxiety, and 
 faintness. The disease frequently seizes the patients in the 
 fore part of the day. As night approaches, the heat and 
 restlessness increase, and continue till towards morning, when, 
 after a short and disturbed slumber, (the only repose they often 
 have during several nights,) a sweat breaks out, which miti- 
 gates the heat and restlessness, and gives the disease some- 
 times the appearance of an intermittent. If the mouth and 
 throat be examined soon after the first attack, the uvula and 
 tonsils appear swollen; and these parts, together with the 
 velum pendulum palati, the cheeks on either side near the 
 fauces, and as much of them and of the pharynx behind as 
 can be seen, appear of a florid red colour. The colour is 
 commonly most observable on the posterior edge of the palate, 
 in the angle above the tonsils, and on the tonsils themselves. 
 Instead of this redness, a broad spot or patch of an irregular 
 figure, and of a pale white colour, is sometimes to be seen 
 surrounded with a florid red, which whiteness commonly ap- 
 pears like that of the gums immediately after being pressed 
 with the finger, or as if matter ready to be discharged was 
 contained underneath. 
 
 " Generally, on the second day of the disease, the face, 
 
22 AN ESSAY ON 
 
 neck, breast, and hands to the finger's ends, are become of a 
 deep erysipelatous colour, with a sensible tumefaction; the 
 fingers are frequently tinged in so remarkable a manner that 
 from seeing them only it has not been difficult to guess at the 
 disease. A great number of small pimples, of a colour dis- 
 tinguishably more intense than that which surrounds them, 
 appear on the arms and other parts. They are larger and 
 more prominent in those parts of the same subject, where the 
 redness is least intense ; which is generally on the arms, the 
 breast and lower extremities." In a later edition of his works, 
 1754, Dr. Fothergill adds a note which is perfectly charac- 
 teristic of the disease. He says, " The redness and eruption 
 have not accompanied this disease so regularly, during the 
 latter part of this winter, as they did in the preceding seasons ; 
 in some cases they did not appear at all; in others not till the 
 third or fourth day ; and, as I have heard, in some not till the 
 fifth, and even later." 
 
 "As the skin acquires this colour the sickness commonly 
 goes off, the vomiting and purging cease of themselves, and 
 rarely continue after the first day. The appearance of the 
 fauces continues to be the same, except that the white places 
 become more ash-coloured, and it is now discoverable, that 
 what at first might have been taken for the superficial cover- 
 ing of a suppurated tumour, is really a slough, concealing an 
 ulcer of the same dimensions. All the parts of the fauces 
 above mentioned are liable to these ulcerations, but they ge- 
 nerally are first discoverable in the angles above the tonsils or 
 on the tonsils themselves ; though they are often to be seen in 
 the arch formed by the uvula and one of the tonsils, and also 
 on the pharynx behind, on the inside of the cheeks, and the 
 base of the tongue, which they cover in the manner of a thick 
 fur. Instead of these sloughs where the disorder is mild, a 
 superficial ulcer, of an irregular figure, appears in one or more 
 of these parts, scarcely to be distinguished from the sound, but 
 by the inequality of surface it occasions." 
 
SCARLET FEVER. 16 
 
 " The parotid glands on each side commonly swell, grow 
 hard, and are painful to the touch; if the disease is violent, 
 the neck and throat are surrounded with a large cedematous 
 tumour, sometimes extending itself to the breast, which, by 
 straightening the fauces, increases the danger. Towards 
 night, the heat and restlessness increase, and a delirium fre- 
 quently comes on. This symptom, which appears in some 
 even on the first night, seems to differ considerably from the 
 like affection in other diseases. The sick commonly answer 
 the questions put to them properly, but with an unusual quick- 
 ness ; they talk to themselves incoherently when left alone, 
 and frequently betray the first tendency to this disorder by 
 affecting too great composure. This, for the most part, hap- 
 pens to those who sleep but little, for some are comatose and 
 stupid, and take little notice of any thing that passes. In 
 this manner they continue dozing two, three, or more days; 
 they commonly grow hot and restless towards evening, which 
 symptoms, and the delirium, increase as night comes on; a 
 sweat more or less profuse breaks out towards morning, and 
 from this time they are easier during some hours ; a faintness 
 only continuing, of which they frequently complain more than 
 of the rest of their sufferings. The disease seems to have no 
 stated period which can properly be called its 'Ax^ or height. 
 Some grow easier from the first day of the attack, but in ge- 
 neral the symptoms of recovery appear on the third, fourth, 
 or fifth day, and proceed in the following manner. The red- 
 ness of the skin disappears, the heat grows less, the pulse, 
 which was hitherto very quick, becomes slower, the external 
 swellings of the neck subside, (sometimes they continue to in- 
 crease and suppurate,) the sloughs on the fauces are cast off, 
 the ulcerations fill up, the patient sleeps without confusion, is 
 composed when awake, and his appetite begins to return." 
 
 " Thepu?se during the whole progress of this disease is ge- 
 nerally very quick, frequently 120 or more in a minute; in 
 
24 AN ESSAY ON 
 
 some hard and small, in others soft and and full, but without 
 that strength and firmness which usually accompany equal 
 quickness and heat in genuine inflammatory disorders." 
 
 "If a vein be opened soon after the distemper is come on, 
 the blood generally appears of a fresh florid red; the cras- 
 samentum is rather of a lax gelatinous texture than dense or 
 compact; the serum yellow and in large proportion." 
 
 " The urine is at first crude, and of a pale whey colour. 
 As the disease advances it turns yellower, as if the bile was 
 detected in it, and soon after the patient shows any marks of 
 recovery, it grows turbid and deposits a farinaceous sediment." 
 
 The various phases assumed by this disease in its malig- 
 nant character; the uniform severity of the individual cases, 
 and the wide-spread devastation which it causes by its pre- 
 valence, all demand a more extensive notice of this form than 
 of the milder. The vomiting and purging noticed by Dr. 
 Fothergill, have in some cases been so strongly marked as the 
 prominent features of local endemics of this disease, that it 
 has been mistaken for cholera, or thought to have derived a 
 mongrel character from the presence of the cause of that epi- 
 demic combined with that of scarlet fever. Such instances 
 are recorded in our medical journals as though of modern oc- 
 currence only. More careful investigation exhibits the fact, 
 that these varying symptoms have often before arrested the 
 attention of careful observers. 
 
 Dr. Benjamin Rush, in his Medical Observations and En- 
 quiries, thus describes the occurrence of this form of the dis- 
 ease in the yeftrs 1T83 and 1784, in Philadelphia: — " In most 
 of the patients who were affected by it, it came on with a 
 chilliness and a sickness of the stomach, or a vomiting which 
 last was so invariably present that it was with me a patho- 
 gnomonic sign of the disease. The swelling of the throat was 
 in some instances so great, as to produce a difficulty of speak 
 ing, swallowing and breathing. In a few instances, the speech 
 
SCARLET FEVER. 25 
 
 was accompanied by a squeaking voice, resembling that which 
 attends the cynanche trachealis. The ulcers on the tonsils 
 were deep, and covered with white, and in some instances, 
 with black sloughs. In several cases there was a discharge 
 of a thick mucus from the nose, from the beginning; but it 
 oftener occurred on the decline of the disease, which not uu- 
 frequently happened on the fifth day. Sometimes the sub- 
 siding of the swelling of the throat was followed by a swell- 
 ing behind the ears." 
 
 "An eruption on the skin generally attended the symptoms 
 which have been described. But this symptom appeared with 
 considerable variety. In some people it preceded, and in 
 others it followed the ulcer and swelling of the throat; in 
 some it appeared only on the outside of the throat, and on the 
 breast; in others it appeared chiefly on the limbs; in a few 
 it disappeared on the second or third day of the disease, and 
 never returned afterwards. I saw two cases of eruption with- 
 out a single symptom of sore throat." 
 
 " The fever which accompanied the disease, was generally 
 the typhus mitior of Dr. Cullen. In a few cases it assumed 
 symptoms of great malignancy. The disease frequently went 
 off with a swelling of the hands and feet. I saw one instance 
 in which the swelling was absent, but the patient complained of 
 very acute pains in the limbs, resembling those of rheumatism." 
 
 " In two cases which terminated fatally, there were large 
 abscesses ; the one on the outside, the other on the inside of 
 the throat. The first of these cases was accompanied by 
 troublesome sores on the ends of the fingers. One of these 
 patients lived twenty-eight, and the other above thirty days, 
 and both appeared to die from the discharge which followed 
 the opening of the abscesses. 
 
 " Between the degrees of the disease which I have described, 
 there were many intermediate degrees of indisposition which 
 belong to this disease. 
 
26 AN ESSAY ON 
 
 "I saw in several cases a discharge from behind the ears 
 and from the nose, with a slight eruption, and no sore throat; 
 all three patients were able to sit up, and walk about. I saw 
 one instance of a discharge from the inside of one of the ears 
 in a child, who had ulcers in the throat, and the squeaking of 
 voice. In some, a pain in the jaw, with swellings behind the 
 ears, and a slight fever, constituted the whole disease. In 
 one case the disease came on with a coma, and in several pa- 
 tients it went off with this symptom. A few instances occurred 
 of adults who walked about, and even transacted business until 
 a few hours before they died. 
 
 " The intermitting fever, which made its appearance in 
 August, was not lost during the month of September, (the 
 time at which the scarlet fever became prevalent.) It con- 
 tinued to prevail, but with several peculiar symptoms. In 
 many persons it was accompanied by an eruption on the skin 
 and a swelling of the hands and feet. In some it was attended 
 by a sore throat and pains behind the ears. Indeed, such was 
 the predominance of the scarlatina anginosa, that many hun- 
 dred people complained of sore throat without any other symp- 
 toms of indisposition. The slightest occasional or exciting 
 cause, particularly cold, seldom failed of producing the dis- 
 ease. 
 
 " The epidemic prevailed in Philadelphia, from September 
 throughout the winter. In the Spring it disappeared, but 
 spread afterwards through the neighbouring States of New 
 Jersey, Delaware and Maryland." 
 
 It will here be observed, that while the prevailing type of 
 the epidemic thus described is of that severe character which 
 brings it under that form of the disease which now claims our 
 notice, the occurrence simultaneously of cases of a milder 
 degree proves their dependence on the same catfse. Were it 
 necessary further to enlarge these quotations, I might add to 
 them similar descriptions of the disease, given by distinguished 
 
SCARLET FEVER. 
 
 writers upon medicine in each succeeding generation, and of 
 every nation which possesses a medical literature. But suffi- 
 cient has been said to enable the careful observer to recognise it 
 and its relation to the other milder forms of Scarlet Fever, if 
 called upon to combat its malign influence: we will pass on to 
 the consideration of the last of the four classes or groups of 
 cases, into which I have proposed to distribute the disease. 
 
 While the anginose and malignant are the predominating 
 types during every severe epidemic prevalence of the disease, 
 and the simple form that which is generally found in sporadic 
 cases, though it is occasionally the prevailing character of the 
 disease in wide-spread epidemics and through a long series of 
 years, those which I am now to describe are most often found 
 associated with the two former classes, occurring at the same 
 time, and either in the same households or in such circum- 
 stances as to prove their dependence on the same cause. The 
 very term Irregular, by which I have designated this division, 
 will at once convey the suggestion that it must be impossible 
 to give any general description which would embrace all the 
 varieties included under that term. By far the largest num- 
 ber of these cases owe their peculiar features to the condition 
 of the nervous system which gives rise in other febrile dis- 
 eases also, to that collection of symptoms which marks what 
 are erroneously called congestive cases. The vital forces are 
 overwhelmed by the intensity of the morbid impression, and 
 the patient dies without time being afforded for the disease to 
 develop its essential features; or, if the duration of the case 
 be more prolonged, so extreme is the force of the cause of 
 disease, or so inadequate the power of resistance, that the 
 development is only partially accomplished. The suddenness 
 of the invasion has been noticed already as one of the pecu- 
 liarities of scarlet fever. These cases are marked especially 
 by this sign. I have known an infant which had left home, 
 apparently in perfect health, for its usual morning airing, 
 
28 AN ESSAY ON 
 
 brought back within an hour with stupor and general muscu- 
 lar relaxation, cold surface, feeble pulse, and total insensibi- 
 lity ; no remedies that could be applied produced any reaction, 
 and it died within twelve hours. Two other children in the 
 same family were seized, within a few days, by scarlet fever, 
 which manifested the usual signs, and ran a regular course, 
 and thus placed beyond cavil the true nature of the case 
 which preceded them. In another instance, while visiting a 
 lady labouring under a chronic malady, my attention was 
 drawn by the mother to the unusually healthful condition of 
 an only child of two years old, gambolling on the floor. 
 Within twelve hours I was called to see it lying comatose and 
 convulsed, and within twelve hours more it was dead. A ma- 
 culated appearance of the skin after death, and the known 
 prevalence of scarlet fever in the vicinity, were here the only 
 grounds for assuming this to be the nature of the disease, as 
 there were no other children in the house to be subjected to 
 the poison. Dr. Kush, you will remember, reports "a few 
 instances of adults, who walked about, and even transacted 
 business, until a few hours before they died." 
 
 It is not many years since a Judge in one of our Courts 
 was seized with nausea while on the bench, and retired to his 
 home, where for two days he remained, scarcely willing to 
 admit himself to be sick, and reluctant to confine himself to 
 his chamber, though the rapid, feeble pulse, and an imperfect 
 eruption, too plainly indicated the nature of the affection ; 
 and on the third day he died, while in the act of shaving him- 
 self. A near relative, also advanced beyond the middle term 
 of life, who had not visited the house even, during the illness 
 of this gentleman, stood some time beside the corpse prior to 
 its interment, and himself died with similar symptoms within 
 a fortnight. 
 
 Dr. George Gregory, in his lectures on Eruptive Fevers, 
 delivered at St. Thomas' Hospital, London, reports the obser- 
 
SCARLET FEVER. 29 
 
 vation of cases of a somewhat similar kind. He says: " In 
 some extreme cases, the nervous system shall be so completely 
 depressed and subdued by the virulence of the miasm, and 
 the mass of the blood so thoroughly poisoned and disorganized 
 by it, that all the ordinary appearances of scarlet fever are 
 masked ; petechia, coma, and a sloughy state of the throat, 
 alone appear. Life rapidly yields under such an attack." In 
 confirmation of this assertion, he reports, as having passed 
 under his own notice, the case of a family in which " a mother 
 and two grown up daughters died. In each of the three cases 
 the nervous system was utterly prostrated, and in a state of 
 collapse. There was no violence, no delirium, no struggling 
 for breath; but the pulse was small, the skin cold, and the 
 whole system depressed by the intensity of the poison. Nei- 
 ther wine, brandy, nor capsicum could put any life into them. 
 They sunk, one after another, without any attempt to rally. 
 It was difficult to believe the disease Scarlatina, but the eldest 
 son took it in the usual form, and put the matter beyond 
 doubt." 
 
 A lady, near the close of gestation, after fatigue and ex- 
 posure, had the usual symptoms which result from " taking 
 cold," by which she was confined to the bed during two days, 
 and from which she apparently quite recovered. After an 
 interval of twenty-four hours, she was seized with a chill, fol- 
 lowed by fever, with exceedingly rapid pulse and slight swell- 
 ing and redness of the soft palate and uvula. There was 
 never, in the progress of the case, any great degree of inter- 
 nal swelling of the throat, and not the least about the neck 
 externally; cough and dysphagia, with an entire inability to 
 lie down, from the danger of suffocation, were the urgent 
 symptoms. The heat of the skin was very great, but without 
 any redness of the surface; the circulation continued exceed- 
 ingly rapid throughout the entire course of the case, and the 
 countenance was expressive of the greatest distress. The 
 power of uttering sounds was lost, and there were some slight 
 
30 AN ESSAY ON 
 
 deposits of lymph on the uvula. The difficulty of swallowing, 
 (amounting to absolute impossibility, so that an eminent prac- 
 titioner observing the shudder with which she turned from 
 water, though parched with thirst, suggested a resemblance 
 to hydrophobia,) loss of voice, rapid pulse, and great heat 
 of skin, were the prominent symptoms, which continually in- 
 creased in spite of the most energetic treatment, until she 
 died, on the fifth day of the disease, about twelve hours after 
 having given birth to a living child. I was assisted in the 
 treatment by three of the most eminent physicians of the 
 city, none of whom suggested scarlet fever as the nature of 
 the case. Examination of the body, after death, exhibited 
 with sufficient clearness the cause of the symptoms. A 
 small abscess between the posterior walls of the pharynx 
 and the vertebrae had caused the difficulty of swallowing, 
 while minute deposits of pus beneath the mucous membrane 
 on the arytenoid and cricoid cartilages, destroyed the voice. 
 These lesions could not, however, have caused death so 
 promptly, nor would they have given rise to the excessive 
 rapidity of pulse, and heat of skin. Within a week after 
 her death, two well marked and violent cases of scarlet fe- 
 ver, with severe anginose symptoms, occurred in the same 
 house: one in the person of the nurse who had waited upon 
 the case I have thus described, and the other in that of a 
 child. 
 
 There is an exceedingly interesting paper on this subject in 
 the K A. Med. Chirurg. Rev. for Nov., 1857, by Dr. Sutton, 
 of Illinois, in which he refers to the frequent occurrence, 
 during one epidemic, of cases in which the irritative action 
 fell with such violence on the alimentary canal that the chil- 
 dren died as though from cholera, to which disease the symp- 
 toms bore so close a resemblance that Dr. S. would have con- 
 sidered them such, had that disease been epidemic instead of 
 scarlet fever. Dr. Sutton states, that, simultaneously with 
 the occurrence of these cases, there was an epizootic disease 
 
SCARLET FEVER. 31 
 
 which proved rapidly fatal among the hogs, which are raised 
 in immense numbers in that State; and he says this affection 
 of the animals was an eruptive disease somewhat analogous to 
 erysipelas, but attended by violent purging. The coincidence 
 is an interesting fact, and valuable in the history of epidemics. 
 Dr. Fothergill records the observation of similar cases, in 
 which the force of the disease fell on the stomach and bowels. 
 
 As an instance of another variety, I may mention the case 
 of an infant, endowed with great vigour of constitution, taken 
 ill with febrile symptoms, accompanied by slight difficulty of 
 deglutition. No appearance of disease of the fauces was 
 manifest to the most careful examination, beyond a very slight 
 redness of the edge of the half-arches. Soon the voice be- 
 came enfeebled, and the respiration impeded, but without 
 cough. The pulse was very rapid, the shin hot and dry, but 
 bloodless, presenting a wax-like paleness. The glands about 
 the base of the jaw became swollen, the cellular tissues of the 
 neck infiltrated with serum ; the difficulty of swallowing in- 
 creased; the voice became stridulous. These symptoms grew 
 progressively worse till the child died, exhausted by the vio- 
 lence of the febrile reaction. Inspection of the body after 
 death exhibited a superficial ulceration of the mucous mem- 
 brane lining the larynx and upper part of the trachea, which 
 had given rise to the glandular swelling and oedema. The 
 rapidity of the pulse, heat of skin, and peculiar condition of 
 the neck, all combine to induce me to class this case, without 
 hesitation, with scarlet fever, which was prevalent at the time. 
 I have no doubt that well developed cases would have followed, 
 had there been other children in the family. Many similar 
 instances have fallen under my notice, which have been so 
 evidently connected with this disease as to forbid a doubt on 
 the subject. 
 
 Among this class of irregular cases must be included those 
 noticed by Dr. Graves, of Dublin, and Dr. Copland, of Lon- 
 
32 AN ESSAY ON 
 
 don, as latent cases, in which there is neither eruption on the 
 surface, nor sore throat, hut merely febrile disturbance, fol- 
 lowed by desquamation and anasarca. Such frequently occur 
 in certain epidemics. It is by no means unusual to meet with 
 cases where all the constitutional symptoms are well marked, 
 though the eruption is confined to the wrists, or flexures of 
 the joints, and is there limited to a small number of red points 
 only. I have met with many such, in families where other 
 cases were well marked. They are frequently fatal. 
 
 The course of the disease in the Malignant and Irregular 
 forms, cannot be reduced to the regularity which marks the 
 Simple and Anginose. In the simple, uncomplicated form, 
 the fever subsides from the 5th to the 7th day; and in fa- 
 vourable cases of the anginose variety, the primary lesions 
 disappear with it, and convalescence is fairly established. 
 When the ulceration of the throat and posterior nares is more 
 severe, the primary fever is, on the contrary, merged insensi- 
 bly into the fever of irritation produced by these lesions, and 
 the case may run an uninterrupted course of many weeks ; or? 
 which is more common, there maybe twenty-four or forty-eight 
 hours of interval between the subsidence of the primary symp- 
 toms and the occurrence of the secondary. The patient is 
 apparently convalescent, the pulse resumes its normal charac- 
 ter, the countenance recovers its expression of comfort, the 
 breathing is regular. Suddenly the skin becomes hot and 
 dry, the pulse quick; there is great prostration of strength, 
 and the submaxillary glands are found swollen and tender, 
 and there commences oedema of the neck, which increases ra. 
 pidly and extends to the face. An acrid serous discharge 
 commences from the nares, excoriating the parts over which 
 it flows, and, increasing steadily, obstructs respiration. De- 
 lirium and restlessness supervene ; the swelling of the neck 
 becomes greater and greater; and the patient dies, worn out 
 by irritative fever. This train of symptoms depends, I be- 
 
SCARLET FEVER. 83 
 
 lieve, on extensive superficial ulceration of the mucous mem- 
 brane of the nose and pharynx, the external swelling being 
 caused by the irritation of the lymphatic glands, and conse- 
 quent oedema of the cellular tissue adjacent. In the malig- 
 nant form, the patient may either sink into a comatose condi- 
 tion and die from the first force of the disease between the 
 3d and 9th day, or, if there be reactive force sufficient to 
 carry the case over these periods, there still remains the irri- 
 tation resulting from sloughing ulcers of the throat, abscesses 
 beneath the jaws, and ulceration of the nares and ears, to be 
 added to the depressing influence of the primary disease; and, 
 not unfrequently, acute meningitis supervenes, and causes 
 death, with the usual symptoms of that disease superadded to 
 those already described. Croup is also an occasional compli- 
 cation, either caused by the extension of the deposits already 
 described as frequently occurring on the tonsils, or by the 
 active inflammation of the larynx without any exudation. I 
 have seen it in one instance prove fatal when the atiginose 
 symptoms had been very slight indeed, and where the most 
 careful investigation could not detect the smallest exudation 
 in the fauces. In the anginose malignant forms, the extension 
 of the disease to the larynx and trachea is by no means un- 
 common, and I believe more careful observation will confirm 
 the suspicion I entertain, that the disease known as Diphtheritic 
 Croup — which begins with inflammation of the tonsils and 
 exudation of lymph, gradually extending to the larynx — is 
 one of the forms of the disease now under consideration. To 
 this conclusion I am led by having observed that such cases 
 are particularly prevalent at the times when we know the 
 scarlet fever influence to be most active, and from their evi- 
 dent dependence on some other cause than the mere vicissi- 
 tudes of temperature which give rise to the inflammatory 
 croup. The rapidity of the circulation, the tendency to gan- 
 grene of the throat, the general similarity of all the symptoms 
 
34 AN ESSAY ON 
 
 to those cases of undoubted scarlet fever in which the disease 
 extends to the larynx, the frequent occurrence of several cases 
 in immediate succession in a family, and its occurrence simul- 
 taneously with the prevalence of malignant scarlet fever, all 
 tend to the confirmation of this impression. 
 
 There has been some diversity of opinion as to the cause of 
 Scarlet Fever. That it depends on some unknown agency, 
 producing what is called epidemic influence, no one denies. 
 In what this influence consists it is impossible to determine, 
 with our present limited knowledge and means of observation. 
 Telluric emanations, sidereal, animalcular, and fungous influ- 
 ences, have all been invoked in their turn. In the present 
 state of our knowledge, and with our necessarily imperfect 
 means of observation, it were vain to attempt to decide be- 
 tween these rival claims;, a more important question demands 
 our attention, and should be carefully examined. Is it ever 
 propagated by contagion ? Is this disease, like Typhus Fever, 
 Yariola, &c, capable of producing a materies morbi, which 
 communicates to the persons around, the same disease as that 
 under which a given subject is already labouring? Is it self- 
 propagating? The evidence in the affirmative is so positive 
 that I cannot retain a doubt; so many well marked cases have 
 passed under my own notice, and so many more are reported 
 on authority quite beyond question, that I see not how any 
 one can hesitate. It is asserted by those who disbelieve the 
 contagiousness of the disease, that the instances in which 
 single cases occur in a large family or school, without exten- 
 sion to others, even where no precautionary measures are 
 adopted, are sufficiently numerous to disprove the influence of 
 contagion ; which, if characteristic of the disease, must ope- 
 rate equally at all times where it meets with subjects not pro- 
 tected from its attacks ; and they aver that its extension, when 
 this does take place, may be ascribed with greater propriety 
 to a general exposure to the epidemic influence, the operation 
 
SCARLET FEVER. 35 
 
 of which is acknowledged by all, than to contagion. Those 
 who thus reason, however, overlook the fact, that even the 
 diseases which all confess to be possessed of a power of pro- 
 pagating themselves are liable to the same uncertainty, and 
 prevail at times as epidemics ; the same individuals who escape 
 during one or more such seasons, falling victims at a subse- 
 quent period at which the cause is operating vith even less 
 apparent intensity. I have more than once known a single 
 case of small-pox to occur in a large family, without spread- 
 ing, though no precautionary measures were employed; and 
 what physician is there who has not been annoyed by the ne- 
 cessity for repeated insertions of vaccine virus, the suscepti- 
 bility to the impression either wholly absent, or too feeble to 
 be kindled into activity? This question of contagion is not 
 one of merely speculative interest. Its practical bearings are 
 highly important. Life, and interests only second in import- 
 ance to life itself, are involved in it. Facts, which prove 
 beyond a question that it may be communicated both directly 
 and indirectly, will be mentioned in the course of this discus- 
 sion, and many more might be adduced. Reference has 
 already been made to the case of a gentleman who died of 
 scarlet fever; a relative who had been alienated from him for 
 many years visited the body, and died, within a fortnight, of 
 the same disease. Those engaged in nursing cases of scarlet 
 fever, and often all the adult members of a family in which it 
 is present, are liable to sore throat and fever, without any 
 eruption, called by some authors Scarlatina Faucium. The 
 wife of a medical friend of mine, who was aiding in the care 
 of the children of a relative, was seized with this modified 
 affection, and communicated scarlet fever in all its integrity 
 to her own children. It frequently happens that children who 
 have had the disease while absent from home, communicate it 
 to others on their return during convalescence. This brings 
 naturally to our notice another question. Can the principle of 
 
36 AN ESSAY ON 
 
 contagion attach itself to the clothing or persons of those who 
 are not themselves affected by it? or can the disease be con- 
 veyed or communicated by them? Dr. Tweedie says he has 
 known many instances in which convalescents have communi- 
 cated the disease on their removal to a distance, '' though 
 several weeks had elapsed from the period of desquamation." 
 I should in such cases rather suspect the clothing as the ve- 
 hicle by which the disease was carried, than the person. But 
 though I thus express my belief in the transmission of the 
 disease by clothing worn by patients, or saturated with the 
 miasm by long exposure to it, my own observation leads me to 
 deny the possibility of the communication by mere transient 
 intercourse. I have never, in long continued and extended 
 practice, known the disease to occur in a family which I was 
 visiting for other complaints, during my attendance, nor have 
 I ever heard of an authenticated instance in which this has 
 occurred. I have, however, known an instance in which a 
 family had abandoned their dwelling immediately after the 
 occurrence of two fatal cases. The house was left uninha- 
 bited and closed during several months ; when a family, from 
 a distant city in which the disease was not prevailing, took 
 possession of it, and the furniture which had been allowed to 
 remain. Within two weeks the disease made its appearance 
 in the family, and proved fatal to several children. Dr. Per- 
 cival, of Dublin, than whom we can have no higher authority, 
 in writing to Dr. J. Mason Good, says, " Cynanche Tonsilla- 
 ris and Maligna, I consider with you a species of Roseola. 
 (This is the term applied to scarlet fever by Dr. Good.) All 
 have been produced by the same specific contagion, which in 
 one instance was imported here from England in a Pandora's 
 box containing plumed soldiers, which had served to beguile 
 the convalescent hours of a young family, and were sent by 
 them as a present to their quondam playmates in this capital." 
 Dr. Chapman refers, though incredulously, to the report of 
 
SCARLET FEVER. 6 I 
 
 Hildebrand, who believed himself to have carried the cause of 
 this disease to Padolia, in a cloak which he had worn during 
 the prevalence of it in Vienna, and which had been shut up 
 in a chest during a whole year. That greater intensity is thus 
 given to the cause of disease, I am quite confident. To this I 
 ascribe the prolonged retention of the power of production by 
 the furniture, in the case to which I have just alluded. Dr. 
 Copland remarks : " When fomites are shut up, and excluded 
 from imparting the retained miasm, the disease may be thereby 
 conveyed to distant or remote parts, and even without the 
 source of infection or the media of transmission either being 
 recognised or admitting of recognition." A very strong case 
 occurred under my own observation in the year 1845, proving 
 most conclusively the capability of transmission by fomites. 
 A new dress was sent from a house in the city of Baltimore, 
 in which scarlet fever was prevailing, to a family in a secluded 
 district of country in which the disease was not known. Se- 
 veral children who were present at the opening of the box 
 containing the dress, were seized simultaneously with the dis- 
 ease, which spread from them in the neighbourhood. Dr. El- 
 liotson asserted that every child admitted into one of the 
 wards of a Hospital in London under his care, during a period 
 of two years, was attacked by scarlet fever, notwithstanding 
 the utmost care in ventilation and cleansing. 
 
 The late Professor Hosack, of New York, in supporting the 
 doctrine of its contagious character, mentions the instance of 
 a family who deserted their house after a fatal attack of scar- 
 let fever. It was thoroughly cleansed and whitewashed, and 
 the family remained absent six weeks. Immediately on their 
 return, the disease re-appeared. There is one source of fal- 
 lacy in this case. The period of incubation, as it is termed — 
 the time which elapses between the exposure to the sources of 
 the disease and its development, during which the cause is 
 supposed to lie latent in the system, but preparing to exhibit 
 
38 AN ESSAY ON 
 
 its characteristic features — is more uncertain in this than any- 
 other disease of the same class. It is therefore not impossi- 
 ble that the germs of the disease may have been imbibed be- 
 fore leaving the house, either directly from the same source 
 as the first case, or mediately through it. No such suspicion 
 throws a shade on the instance I have mentioned before. The 
 following cases will prove as well the contagious character of 
 scarlet fever, as the uncertain duration of this latent period. 
 A lady came from a section of country wholly exempt from 
 this disease, to assist in nursing the child of a brother. Within 
 forty-eight hours after her arrival, she was herself seized with 
 a well-marked attack. This is the shortest interval between 
 exposure and sickening I have seen or read of. The longest 
 I have known was twenty-eight days. This case was equally 
 well marked. A gentleman, designing to spend the summer 
 in Europe, had engaged passage for himself and family, to 
 sail on the 1st of May. One of his three children was seized 
 with scarlet fever on the 1st day of March. Desiring that all 
 should have the disease, and be quite recovered before they 
 should leave home, no interruption of intercourse with the 
 other children was attempted; the two children who were well 
 were allowed free access to the room in which the sick one lay. 
 The second seizure occurred on the 16th of March, and the 
 third not until the 28th. Dr. Maton reports a case in which 
 twenty-six days intervened. From eight to fourteen clays is, 
 however, the usual interval; and though occasionally several 
 cases may occur simultaneously in a large family or school, it 
 is much more common that one should be first taken sick, and 
 another after an interval of greater or less duration, rarely 
 beyond ten days; and then the other members of the family 
 or household, who have not previously had the disease, are 
 seized at about the same time, or in more rapid succession ; 
 while the adults are all more or less brought under the influ- 
 ence of the disease, with sore throat and fever. This mode of 
 
SCARLET FEVER. 39 
 
 invasion by successive cases is almost uniform, and is certainly 
 more easily accounted for on the presumption of contagion, 
 than in any other manner. 
 
 The attempt has been made to impart the disease by inocu- 
 lation, but without success. This was to have been antici- 
 pated, as there is no analogy between this disease and variola, 
 which would lead to the presumption it could be thus commu- 
 nicated ; and the failure of this experiment cannot be cited as 
 evidence of the non-contagious character of the disease. 
 
 Whether introduced by contagion, or originating in some un- 
 known atmospheric changes, scarlet fever is very often epi- 
 demic. In this respect it manifests a peculiarity as decided 
 as in other points of character. It is often bounded by very 
 narrow limits. Not only will one part of a large city be 
 exempt while it prevails in another, but I have known it con- 
 fined to a single block of houses, while all the neighbouring 
 squares were healthy. Sporadic cases are frequently occur- 
 ring, but these are always mild, and generally of the simple 
 form, or with slight anginose symptoms. It often prevails in 
 this mild manner, or entirely disappears for several years, 
 until its malignity is almost forgotten, or may be even doubted. 
 This was decidedly the case in our city for many years before 
 1830. Dr. Emerson says: " It is a remarkable fact, that in 
 the twenty-one years from 1807 to 1827, inclusive, the total 
 mortality from scarlet fever was only 102 out of 53,000 
 deaths. Doubtless some cases were reported in the bills of 
 mortality under the vague title of sore throat, of which the 
 amount during the whole period referred to was 355; but, 
 with such additions, the proportional mortality from scarlet 
 fever would be trifling, compared with its ravages in more re- 
 cent years. Only one death was reported in 1827, not one in 
 1828. In 1829 there were 9, in 1830 there were 40. Since 
 the last named year, the mortality from this source has very 
 much increased, as will be apparent from the number of 
 deaths reported in the subsequent ten years, viz. : — 
 
40 
 
 
 AN ESSAY ( 
 
 )N 
 
 
 1831, 
 
 200. 
 
 1836, 
 
 240. 
 
 1832, 
 
 307. 
 
 1837, 
 
 205. 
 
 1833, 
 
 61. 
 
 1838, 
 
 134. 
 
 1834, 
 
 83. 
 
 1839, 
 
 225. 
 
 1835, 
 
 205. 
 
 1840, 
 
 244. 
 
 Making a total mortality from this cause in ten years, of no 
 less than two thousand and four cases." Dr. Emerson's con- 
 jecture that some scarlet fever cases were included in the 355 
 deaths from sore throat, is undoubtedly correct, as I know 
 there was an epidemic angina during the period embraced in 
 those returns. 
 
 It was in the year 1828, in which only one death from 
 scarlet fever is reported, I received an appointment in the 
 Dispensary; and the district allotted to my care was that in 
 which the epidemic, which began in 1829, and increased so 
 fearfully till the year 1832, first exhibited its ravages. The 
 contrast afforded by the comparison of the three years — 
 1827, '28, '29— with the three which followed, exhibits the 
 point I wish to illustrate. So remarkable is this feature of 
 scarlet fever, that repeatedly it has been described as though 
 it were a new disease — a whole generation of medical prac- 
 titioners passing without the appearance of an epidemic. 
 In the year 1831, a highly respectable physician, very ex- 
 tensively engaged in practice, told me he had never seen a 
 fatal case of scarlet fever; his testimony thus corresponds 
 with that of the bills of mortality for the period during which 
 he had pursued his professional career. There is no fixed 
 term of duration of these epidemic periods. In some in- 
 stances a grand epidemic cycle appears, composed of series of 
 minor epidemics. Thus, for instance, the table furnished by 
 Dr. Emerson, through the entire ten years, may be considered 
 one epidemic period, in contrast with the twenty which pre- 
 ceded; and yet it will be observed that during that period 
 there are two marked interruptions to the otherwise regular 
 
SCARLET FEVER. 41 
 
 average mortality. Though, as I have before remarked, the 
 epidemic visitations of this disease generally partake of the 
 typus or malignant character, it occasionally happens that 
 one may assume the sthenic form, and be attended with active 
 inflammatory complications. In this respect the history of 
 the past is instructive, as we shall find when we come to con- 
 sider the treatment appropriate to the disease. 
 
 The influence of seasons of the year and temperature in 
 favouring the origin of this disease or promoting its diffusion, 
 is very uncertain. By some writers the winter, and by others 
 the summer, is mentioned as peculiarly liable to its prevalence. 
 The most fearful epidemics which have fallen under my own 
 observation have been during the damp and changeable weather 
 of the spring and autumn months, extending itself from the 
 latter into the winter. In this respect, scarlet fever manifests 
 its affinity with measles, erysipelas, varicella and other febrile 
 eruptive diseases with which it is frequently associated. We 
 much more frequently, however, meet with isolated cases of 
 scarlet fever, which cannot be traced to any source of con- 
 tagion than of the other diseases mentioned: such cases do 
 not propagate the disease in others even when brought most 
 closely in connexion with it. 
 
 I have seen quite recently, during the intense heat of July, 
 one well marked and fatal case, in a large family of children, 
 without spreading to any other members, though no attempts 
 at isolation were made. Similar cases are familiar to every 
 physician. The access to the chamber was as free, and the 
 visits of the other children were as frequent, as the warmest 
 affection could dictate. The subject was the youngest child, 
 and an only daughter, and therefore tie least exposed to ex- 
 ternal influences; it were vain to attempt any solution of the 
 question from whence the miasm was derived which gave rise 
 to this case. Such instances are of frequent occurrence in 
 the history of scarlet fever, and if received without any inves- 
 4 
 
42 AN ESSAY ON 
 
 tigation of the circumstances which modify them, and without 
 regard to others of an opposite tendency, would shake the 
 faith of the most devoted believer in the contagious character 
 of the disease. There is, however, some peculiar want of 
 susceptibility to the impression of morbid poisons in this 
 family, as they had escaped with equal impunity, a few 
 months previously, when varioloid was brought into the house 
 by a relative, taken into it without the adoption of any pre- 
 cautionary measures, from a boarding-house where he had 
 sickened with that disease. It is a remarkable feature in the 
 case, however, that the servants enjoyed the same immunity 
 as the other members of the family on both occasions. 
 
 Some eminent teachers of medical science are disposed to 
 solve the difficulty growing out of the frequent observation of 
 such cases, in a very summary manner. Whilst they admit 
 them to be characterized by all the symptoms of scarlet fever, 
 so that we cannot in any way distinguish them from that dis- 
 ease, they think the mere absence of the power of propagation, 
 and the inability to trace them to any connexion with a pre- 
 vious case or epidemic influence, sufficient reason to consider 
 them an entirely distinct disease. Such is the opinion of 
 Professor Mitchell, and such appears to be that of Dr. Chap- 
 man, who, in his lectures on exanthematous fevers, says, 
 " Moreover I have repeatedly met with in the winter, and 
 uniformly, I think, when snow is on the ground, an affection 
 bearing a still closer resemblance to scarlatina. Children 
 acquire it, mostly, or perhaps exclusively, by becoming heated 
 from playing in the snow, and then suddenly chilled. The 
 collapse is often very considerable, followed by febrile reac- 
 tion, much cerebral disturbance, delirium, stupor, and some- 
 times convulsions, sore throat, nausea and vomitings, and by 
 an eruption so scarlatinous in its aspect, that it may readily 
 be mistaken for that disease. Nor is it scarcely less fatal. 
 Death I have known to take place from it in a few hours, 
 
SCARLET FEVER. 43 
 
 from an inability to arouse the system out of its torpor, or by 
 convulsions." 
 
 High as is the authority of Dr. Chapman, I cannot admit 
 the correctness of this view. While we know, on the one 
 hand, that the cause of this as of other diseases may lie long 
 dormant in the system, only waiting for exciting circum- 
 stances to develop its activity, and, on the other, that even the 
 most contagious diseases occur occasionally as sporadic cases, 
 it appears to be more in accordance with analogy to consider 
 such cases as scarlet fever, failing to diffuse itself, from some 
 unknown cause, than to erect a new form of disease distin- 
 guished from scarlet fever by no symptom, but this one nega- 
 tive characteristic. 
 
 In the month of December, 1832, the disease appeared 
 among the inmates of the House of Refuge for juvenile offend- 
 ers. It was prevailing in the city at that period, as will be 
 proven by reference to the table furnished by Dr. Emerson, 
 which exhibits the mortality of that year as the highest in the 
 ten years from 1830 to 1840. The discipline of this institution 
 is such as secludes the children almost entirely from communica- 
 tion with persons beyond its walls. This might therefore be 
 supposed to afford an unusually valuable field for observation 
 on its introduction and mode of diffusion. The difficulty we 
 encounter, however, in determining the manner in which it 
 was introduced, is one which exhibits the obscurity in which 
 the question is enveloped. I was at the time the attending 
 physician, and made a daily record of every case of sickness 
 requiring my care, in a book kept for that purpose. A few 
 cases of sore throat had been noted, within the fortnight which 
 preceded the breaking out of scarlet fever, one of erysipelas, 
 and several of varicella, all on the boys' side of the institu- 
 tion. 
 
 The first well marked case of scarlet fever, however, oc- 
 curred in the person of a visiter to the family of the matron. 
 
44 AN ESSAY ON 
 
 The second was that of a sister of the first; and the first cases 
 among the permanent inmates occurred at the time of the con- 
 valescence of the first patients, in the matron's family. Had 
 no cases of sore throat among the children preceded the first 
 well developed case, the presumption that the disease had been 
 introduced by her from without, would have been strong — nay 
 the proof might be called positive — especially as the apart- 
 ments occupied by the matron's family, were in that part of 
 the premises appropriated to the females, and it was among 
 the females the disease first diffused itself. The buildings are 
 extensive, surround a very large enclosure, and are so arranged 
 as to effect a separation of the sexes at all times. The disease 
 spread rapidly among the girls, five cases occurring simultane- 
 ously on the 25th of December. It did not reach the male 
 apartments until the 29th of that month, on which day one 
 boy sickened. Two other boys were taken on the 11th of 
 January, 1833. On the 19th a case of varicella was presented 
 among the boys, followed by several others within the follow- 
 ing week. Scarlet fever and sore throat without eruption, 
 continued to prevail among both boys and girls till the end of 
 March, amounting in all to sixty cases, without one fatal termi- 
 nation. If no case of sore throat with fever among the children 
 had preceded the sickness of the visiter, this history would 
 have been very decidedly favourable to the idea of the de- 
 pendence of the disease on contagion, and its introduction 
 from without by direct communication. That this was the 
 true history of the case, I am quite confident. This view is 
 confirmed by the manner in which it spread to her immediate 
 attendants, and the inmates of the apartment in direct com- 
 munication with her sick room. The interval also between 
 the first case and those which followed, was such as is most 
 conformable to the idea of its contagious character; and this 
 
 CD ' 
 
 is confirmed by the number then seized simultaneously. But 
 any positive decision as to the mode of introduction, is for- 
 
SCARLET FEVER. 45 
 
 bidden by the previous prevalence of sore throat, with fever, 
 among the children. The small proportion of those attacked, 
 only sixty in more than two hundred, may be attributed to 
 the discipline of the institution, which has an infirmary to 
 which every case of sickness is promptly removed, while the 
 healthy inmates always sleep in isolated cells, containing each 
 only one bed. It would not be possible to determine what 
 proportion of the inmates had been protected by a previous 
 attack. MM. Rilliet and Barthez, in recording their obser- 
 vation of the disease, in the wards of the Hospital for sick 
 children in Paris, appear to be able to trace every period of 
 its prevalence in that institution, that came under their notice, 
 to the introduction of a patient suffering with it, from whom 
 it spread to the children who had been brought in with other 
 diseases. 
 
 Among the circumstances which favour the idea of some 
 influence which is generated in the person of the sick, and 
 thus diffused from one individual to another, no slight degree 
 of importance is due to the fact that it is said to be unknown 
 in those distant colonies settled by Europeans, the voyage to 
 which is so long that the influence of the specific poison is ex- 
 hausted before the arrival of the vessel in which it might be 
 transported to their shores. Thus it is said to be unknown in 
 the thickly peopled and civilized colonies of Australia and 
 Van Dieman's Land ; and Dr. Gregory asserts that there is 
 no record of its prevalence in the Indian possessions of Great 
 Britain. If direct contagion, or the transportation of some 
 " materies morbi," eliminated in the progress of a case, be ne- 
 cessary to act as a ferment in diffusing the disease, and its 
 epidemic prevalence has never an independent origin, places 
 thus far removed from the old centres of civilization may for 
 ever remain exempt, unless we adopt the extreme view of Dr. 
 Elliotson, as quoted by Dr. Chapman, who believes the infect- 
 ing cause may be retained in the apartments where the dis- 
 
46 AN ESSAY ON 
 
 ease has once existed, a much longer period than that oc- 
 cupied by these voyages. He asserts that " all the children 
 admitted into a particular ward under his care, in one of the 
 London Hospitals, were seized with scarlet fever for two years, 
 in consequence of a patient with the disease having been in 
 the ward at that remote period, and this, in despite of white- 
 washings and other cleansings." The want of any regular 
 medical reports from those countries, leaves a doubt as to the 
 accuracy of the statement, that scarlet fever is unknown there* 
 The point is one well worthy of investigation, and our own 
 new settlements on the Pacific, will afford an excellent field 
 for careful observation. 
 
 I have made inquiry on this subject of several medical of- 
 ficers of the army who have been stationed in California. 
 Those with whom I have conferred have never met with the 
 disease in any of its forms. An intelligent non-medical re- 
 sident of San Francisco has informed me, that about two 
 years since, that town was visited by a fearful epidemic putrid 
 sore throat, affecting children, attended by " the formation 
 of membranes" in the throat and causing great mortality. 
 Whether this was diphtheritis, or scarlet fever of the malig- 
 nant form, could only be decided by the presence or not of cases 
 of the disease of the anginose variety. 
 
 Reasoning upon the probabilities of the case, we should be 
 disposed to the conclusion that it would be found to exist in 
 all parts of the world. The constituents of the atmosphere, 
 the physical arrangements of the material creation, the na- 
 ture of man himself, his tendencies and susceptibilities, have 
 ever been the same; it would be therefore but a natural pre- 
 sumption, that the diseases to which he is subject should un- 
 dergo no greater modification than results from the varying 
 habits which mark different stages of refinement or circum- 
 stances of wretchedness. Yet there is every reason for be- 
 lieving small pox was unknown on this continent until intro- 
 
SCARLET FEVER. 47 
 
 duced from Europe; and we have the distinct history of its 
 introduction to Western Europe detailed by the Arabian 
 writers. 
 
 True it is, that diseases supposed to be new, have from time 
 to time made their appearance, and diffused themselves in a 
 manner as mysterious as scarlet fever. Black death, sweating 
 sickness, cold plague, cholera, have each in successive ages, 
 performed their ministry, by thinning out the teeming popu- 
 lation of the earth, and then disappeared from observation. 
 But the imperfect records of these visitations, which have 
 been transmitted to us, leave room for the doubt whether they 
 have not been mere modifications of the same disease, or the 
 revival of plagues, the records of which have escaped from the 
 grasp of history. The great diversity in character, presented 
 by different epidemics of scarlet fever, when taken in con- 
 nexion with the known dependence of these several forms of 
 the disease on one common cause, appears to favour such an 
 assumption. Were it not so entirely established by testimony 
 beyond contradiction, who could believe that forms of disease 
 so apparently dissimilar as those assumed by scarlet fever in 
 its different epidemic visitations, depend on a common cause? 
 So frequently does this disease disappear from observation in 
 a given district, (and occasionally, as we have seen, even from 
 large cities,) so varying are the phases in which it presents 
 itself, and so uncertain are the traces of the mode by which 
 it has been introduced, that until further light is thrown upon 
 it, we must be content to believe that it does at times com- 
 mence anew from the operation of unknown influences. 
 
 Far from us be the worse than pagan infidelity, which would 
 overlook the interference of Divine Providence, in the order- 
 ing of times of sickness or of health. If heathen moralists 
 and heathen poets could recognise the interposition of the 
 gods, or seek to appease the rage of an incensed Apollo, it 
 were surely shame for those who live in the light of revelation, 
 
48 AN ESSAY ON 
 
 to rest on second causes only. It is, however, a duty incum- 
 bent on us as members of that profession to which the com- 
 munity intrusts the interests of health and life, to investigate 
 narrowly, all second causes and collateral circumstances, which 
 may furnish occasion for the origin, or facilitate the diffusion 
 of this, as of every other of the many diseases, which are em- 
 ployed as " scourges of humanity." False indeed were that 
 faith, alike unsound in its foundation and disastrous in its 
 application to man's necessities, which would teach us to lay 
 aside our reason and cease to exert our powers for self-protec- 
 tion. If variola may not be exterminated, nor cholera driven 
 from the pale of civilization, vaccination mitigates the horrors 
 of the one, and cleanliness and free ventilation, abate the in- 
 tensity of the other. So if scarlet fever depend for its diffu- 
 sion upon direct contagion, we may curtail its extent by pro- 
 per precautions, which are, however, onerous and inhuman, if 
 it have no such power of propagation. Each medical prac- 
 titioner should begin from the very commencement of his pro- 
 fessional career, a series of careful records of every fact which 
 can throw light upon such questions, not only with reference 
 to the disease now under consideration, but all others of a 
 kindred character. It is as much the duty of the physician 
 to foresee the coming evil, and recommend precautionary 
 measures, as to cope with disease in its individual manifesta- 
 tions in the chamber of sickness. The remarks of Dr. Rush 
 on this subject are scarcely too strong, when in speaking of 
 yellow fever, he says, " To all natural evil, the Author of na- 
 ture has kindly prepared an antidote. Pestilential fevers 
 furnish no exception to this remark. The means of prevent- 
 ing them, are as much under the power of human reason and 
 industry, as the means of preventing the evils of lightning 
 and common fire." 
 
 To trace down from remote ages, the mere record of the 
 early history of the disease would be an unprofitable consump- 
 
SCARLET FEVER. 49 
 
 tion of our time, too limited already for the investigation of 
 matters of greater importance. It is not uninstructive, how- 
 ever, to know that this same uncertainty, as to its origin and 
 mode of extension, has marked its character in every age; 
 and hence, before the free diffusion of knowledge, through the 
 agency of the press, put the members of the profession in pos- 
 session of more extended information as to what was passing 
 elsewhere, or had occurred in previous ages beyond the sphere 
 of their own observation, it was frequently reported as a new 
 disease. The earliest trace of its existence which has fallen 
 under my own notice, dates in the first century of the Chris- 
 tian era, and is found in one of the tragedies of Seneca, where 
 a chorus describes the devastation of Thebes by the plague, 
 with which that city was visited on account of the involuntary 
 incest of (Edipus, in the following terms: — 
 
 dira novi facies leti! 
 Gravior leto ! Piger ignavos 
 Alligat artus, languor, et segro 
 Rubor in vultu, maculaeque caput 
 Sparsere leves: turn vapor ipsam 
 Corporis arceni flammeus urit 
 Multoque genas sanguine tendit. 
 Oculique rigent, et sacer ignis 
 Pascitur artus. Resonant aures, 
 Stillatque niger naris aducae 
 Cruor: et venas rumpit hiantes. 
 
 To those who have retained their familiarity with classic 
 literature, it were an ungracious act to attempt to point out 
 the admirable adaptation of this description, to the malignant 
 form of the disease now under consideration. No poet or 
 philosopher of the present day could furnish a more accurate 
 delineation in the same number of words, unless himself fa- 
 miliarized with the disease by personal observation. Every 
 lineament traced by the poet, is admirably correct. The ad- 
 juration of the new form of mortality more dreadful than 
 death itself; commencing with languor of the limbs, while red- 
 
50 AN ESSAY ON 
 
 ness appears upon the face, and light spots are diffused over 
 the head, from whence the influence extends to the trunk, 
 while the parts about the jaws are distended with blood, and 
 the eyes are distorted and a red flush is diffused over the 
 limbs, the ears disturbed by ringing sounds, a black discharge 
 flowing from the nostrils, and gaping ulcers are formed in the 
 passages, all are highly characteristic. But that which Sene- 
 ca in the first century of the Christian era, considered a new 
 disease, has been called such many times in succeeding ages, 
 disappearing for a period of longer or shorter duration, only 
 to reappear in one of its several types. By the earlier me- 
 dical authors, whose works have been handed down to us in 
 imperfect fragments, all epidemic diseases were concluded un- 
 der the general term of Loimos or Pestilence; the whole fa- 
 mily of epidemics was thus grouped together. Slowly, one 
 after another was singled out for more accurate description, 
 but it was not till the beginning of the seventeenth century, that 
 scarlet fever was separately described, and then by the Spa- 
 nish and Italian authors under the terms Garotilla and morbus 
 strangulatorius, names in themselves sufficiently descriptive to 
 designate the disease. 
 
 Even long since that period, it was, by many, confounded 
 with measles, to which fact we may ascribe the mortality of 
 some nominal epidemics of that disease. The accounts given 
 by these authors refer to epidemics which prevailed in the in- 
 terval between 1610 and 1650, during which time it was 
 marked by fearful mortality. How completely it had lost its 
 formidable character when Sydenham describes its appear- 
 ance in London, in 1690 to 1695, may be inferred from his 
 assurance that it is "a disease more in name than reality." 
 It is true he refers to the possibility of the occurrence of coma 
 and convulsions, though he does not describe any angina. 
 Had Fothergill's reading been confined to Sydenham's account, 
 he might well have regarded the epidemic, which came under 
 his notice in the same metropolis in less than a century, as a 
 
SCARLET FEVER. 51 
 
 new disease. Equally great have been the subsequent changes 
 as recorded by the European writers, to whose works I must 
 refer for additional information on this point, and especially 
 to the elaborate article by Dr. Copland in the Dictionary of 
 Practical Medicine, and by Dr. Tweedie in the Cyclopedia of 
 Practical Medicine. 
 
 The earliest record I have been able to trace of its exis- 
 tence on this continent, reaches back to the year 1734-5, at 
 which time it was prevalent in America and Europe simul- 
 taneously; and so great was the mortality caused by it in 
 Boston, that we find the number of deaths in those years 
 raised from 458, the number of the year 1733, to 528 in '34, 
 and 617 in '35. At the same period the interments in the 
 burial grounds of Christ Church and St. Peter's in Philadel- 
 phia, rose from 96 to 144, and a like increase occurred in the 
 same places from a similar cause in 1742. When we recall 
 to mind the difficulty of communication between the colonies 
 at that early period, and the consequent infrequency of inter- 
 course, and reflect on the small probability that those who 
 were sick or so recently convalescent, as to carry about them 
 a contagious influence, could endure the fatigue and exposure 
 necessarily incident to the only modes of conveyance then 
 known, we shall be disposed to adopt the solution afforded 
 by the prevalence of a wide-spread epidemic influence, as the 
 means of propagation. I have derived these statements re- 
 specting the prevalence of the disease in this country, chiefly 
 from Webster's elaborate work on Epidemic Diseases, which 
 exhibits the dates at which it prevailed, and the general mor- 
 tality of each year, without giving any minute detail. 
 
 There is an exceedingly interesting paper by Cadwallader 
 Colden, Esq., of New York, published by Dr. Fothergill in 
 the 1st volume of the " Medical Observations and Inquiries by 
 a Society of Physicians in London," dated Coldenham, in New 
 York, October, 1753, which throws unexpected and important 
 
52 AN ESSAY ON 
 
 light on the history of the disease on this continent. The whole 
 document is one of great merit, and deserves to be borne in 
 mind as a favourable specimen of our earlier medical literature. 
 Mr. Colden remarks, "I have seen it only in my own family, 
 and in a few neighbours in the country, to whom I sometimes 
 give advice when they cannot obtain assistance otherwise, 
 having laid aside the practice of physic, upwards of twenty 
 years. What I chiefly learned was from the late Dr. Doug- 
 lass of Boston, a gentleman of great skill in medicine, and an 
 accurate observer, having corresponded with him while this 
 distemper was frequent in the part of the country where I 
 live." 
 
 "The first appearance of the throat distemper was at King- 
 ston, an inland town of New England, about the year 1735; 
 and as this town has no foreign trade, it may be concluded 
 that the disease was not imported. It spread from thence, 
 and moved gradually westward, so that it did not reach Hud- 
 son's river till two years afterward. It continued some time 
 on the east side of Hudson's river before it passed to the west, 
 and appeared first in those places to which the people of New 
 England resorted for trade, and in the places through which 
 they travelled. It continued to move westerly till, I believe, 
 it has at last spread over all the British colonies on the con- 
 tinent." 
 
 "Though what I have mentioned seems evidently to show 
 that the disease was propagated by infection, yet it did not 
 spread in the same manner contagious distempers usually do ; 
 for children and young people only were subject to it, with a 
 few exceptions of some few above twenty or thirty, and a very 
 few old people who died of it: neither did it spread equally in 
 all places that were equally exposed to the infection. The 
 poorer sort of people were more liable to have this disease 
 than those who lived well, with all the conveniences of life. 
 It has been more fatal in the country than in the great towns. 
 
SCARLET FEVER. 53 
 
 People of a scorbutic habit were most subject to it, and they 
 ■who fed on pork or lived in wet and low grounds. In some 
 places only a few persons or families were seized, while in 
 others all escaped. In some families it passed like a plague 
 through all their children, in others only one or two were 
 seized with it. Some were seized with it at such a distance 
 from the infected, that it could not be conceived in what man- 
 ner they could receive the disease by infection. Some fami- 
 lies had the disease mildly, while others, in the same place 
 and at the same time, had a most violent sort." 
 
 "Ever since it came into the part of the country where I 
 live (now about 14 years) it frequently breaks out in different 
 families and places, without any previous observable cause ; 
 but it does not spread as it did at first: sometimes a few only 
 have it in a considerable neighbourhood. It seems as if some 
 seed or leaven, or secret cause, remained wherever it goes ; 
 for I hear of the like observation in other parts of the country. 
 
 "In different years, and different persons, the symptoms are 
 various. In some seasons it has been accompanied with mi- 
 liary eruptions all over the skin; and at such times, the symp- 
 toms about the throat have been mild, and the disease gene- 
 nerally without danger, if not ill treated." 
 
 Such is the earliest record I have seen, by an actual intel- 
 ligent observer, of the disease on this continent; and it tallies 
 accurately in all respects with more recent observation. As 
 now, so then, it varied in the violence of its attack, in the ab- 
 sence or presence of eruption, and the degree of mortality; 
 and then, as now, the different forms prevailed simultaneously 
 and separately, and there were periods of epidemic prevalence 
 with occasional cases occurring sporadically. The same un- 
 certainty marks its commencement and mode of propagation. 
 
 Through the kindness of Dr. N. B. Shurtleff of Boston, I have 
 been favoured with a MS. copy of the tract of Dr. Douglass, 
 which I have placed in the appendix as an interesting link in 
 
54 AN ESSAY ON 
 
 the chain of the history of the disease. It is evidently the 
 production of an actual observer of the events chronicled, and 
 as the cotemporary record of the earliest occurrence of the 
 disease in the New World, is possessed of permanent value. 
 
 The next earliest notice of the disease on this continent by 
 a medical author that has met my eye, is an interesting manu- 
 script tract on the subject, by Dr. John Kearsley of this city, 
 now in possession of Dr. George W. Norris. He says: "In 
 the spring, summer and autumn of 1746," nearly ten years 
 from the time of its first appearance at Kingston, "and in- 
 deed some part of the winter of the same year, this disease, 
 since called, by the learned Huxham, Fothergill and others, 
 the angina maligna, or the putrid and ulcerous sore throat, 
 prevailed in this and neighbouring provinces, and spread it- 
 self with mortal rage in opposition to the united endeavours 
 of the faculty. Like to some new diseases, till their nature 
 and constitution are known, it swept away all before it. It 
 baffled every attempt to stop its progress, and seemed by its 
 dire effects to be more like the drawn sword of vengeance to 
 stop the growth of the colonies, than the real progress of a 
 disease. In the New England Governments, as their annals 
 no doubt will show, the stroke was felt with great severity. 
 Villages were almost depopulated, and parents were left to 
 bewail the loss of their tender offspring, till Heaven, at last, 
 whose almighty power we all must own, graciously checked 
 its baneful influence. This disease as it then appeared, and 
 since within these few years, had most of those symptoms tu 
 characterize it which those learned gentlemen, we have men- 
 tioned, have handed down to us. With us it generally affected 
 children, or those under puberty, whose lax solids and spongy 
 habits were more fitted to receive the floating miasmata of a 
 putrid atmosphere, than those whose textures are more solid. 
 It also affected those who lived in low, w T et, marshy places, 
 more than those who lived in higher situations. It happened 
 
SCARLET FEVER. 55 
 
 with us, as it did with them in England, after much cold wet 
 weather, succeeded by heat." At this period we find the bu- 
 rials in the grounds of Christ Church, Philadelphia, then the 
 principal place of interment for our citizens, except the " So- 
 ciety of Friends," rising to a number even greater than those 
 in the year 1741, in which a pestilence, the nature of which 
 is not recorded, prevailed in the city: and by the law that 
 more than one form of epidemic disease is never prevalent 
 at one time, we are justified in attributing this great increase 
 of mortality to scarlet fever. 
 
 That this disease should affect both sexes equally, might be 
 reasonably inferred from the want of any circumstance, which 
 should cause one to be more liable to its influence, than ano- 
 ther. From partial observations, varying conclusions on this 
 point have been reached by different authors. No accurate 
 results can be obtained by the most carefully arranged tables, 
 unless the observations be conducted on an extensive field. 
 Unhappily for humanity, as well as for the scientific character 
 of our country, the efforts made by the medical profession to 
 arouse attention to the importance of a uniform system of 
 Registration, have not yet accomplished an object so earnest- 
 ly to be desired. We are, therefore, compelled to resort for 
 extended statistical statements to foreign states. Thus while 
 the private observation of Dr. Tweedie in London leads him 
 to assert that it is more common in girls ; and from the same 
 source, Rilliet and Barthez reach the conclusion that it is 
 more common in boys, and Dr. J. F. Meigs thinks it "proba- 
 ble that while under puberty, it attacks the two sexes with 
 about equal frequency, and after that age it is most common 
 in females," the reports of the Registrar-General of England 
 and Wales, quoted by Dr. Gregory, show that in 1838, it de- 
 stroyed, in London, 747 males, and 777 females; in 1839, 
 1214 males, and 1258 females. Throughout England and 
 Wales (exclusive of the metropolis) in 1840, 8927 males, and 
 
56 AN ESSAY ON 
 
 8935 females. Though in each of these statements there is 
 an excess of females over males, it is so small a fraction of 
 the whole number, that it cannot fairly be ascribed to any 
 especial liability of one sex to the complaint. If the one sex 
 were more subject than the other to the disease, the difference 
 would be more marked. Extended observation would in all 
 probability change the result. Dr. Tripe furnishes us with 
 the following exhibit of a different proportion derived from the 
 same source. In the year 1848, the deaths from scarlet fe- 
 ver in London were 2473 males and 2294 females; being an 
 excess of males of 179. During ten years the aggregate mor- 
 tality of London of children under fifteen years, from all 
 causes, was 161,628 ; of which 85,028 were males, and 76,600 
 females, being an excess of males over females of 8,428. 
 
 But while I believe sex exerts no influence over this disease, 
 the relations which age bears to it are very important. It is 
 decidedly a disease of childhood, and that, not because all 
 persons are exposed to it in the earlier years of life, and those 
 who are susceptible take it then and lose their liability, but 
 because there is something in the condition of the system 
 during infancy and adolescence, which renders those periods 
 of life especially subject to the disease. Thus Dr. W. Doug- 
 lass, Dr. Kearsley and Mr. Colden all refer to the fact, that 
 the force of the epidemics they witnessed fell upon children, 
 and attempt to account for this fact, by reference to the sup- 
 posed lax state of the solids of the infantile state: though it is 
 supposed the disease then first invaded the colonies, and of 
 course the entire native born adult population was then first 
 exposed to the miasm. 
 
 Though it be true that scarlet fever is in an especial degree 
 a disease of infancy and childhood, all ages are, to a certain 
 extent, liable to it. I some years since attended the family of 
 an officer of the highest rank in the U. S. Navy, in which every 
 member was ill simultaneously with the most malignant form 
 
SCARLET FEVER. 57 
 
 of the disease, including his wife who was then fifty years old, 
 and died of the disease, a son who was more than twenty-five 
 years old, the servants and nurses, all of course heyond child- 
 hood. Parents and nurses often take the disease from chil- 
 dren. The reports of the Registrar General of Great Britain 
 are exceedingly interesting from the extensive field of obser- 
 vation they cover, and furnish us with the most important in- 
 formation on this and similar points. Thus, with regard to 
 that which now claims our notice, we find that during the 
 months of January and February, 1840, there were 345 
 deaths from the disease in London. Of this number 826 were 
 under thirteen years of age, and 19 only were adults. And 
 of 2614 deaths included in his fourth report for the kingdom, 
 2429 were children, 182 adults, and 13 aged persons. Of 
 21,304 deaths by scarlet fever in England and Wales, there 
 were under 1 year, 1291; 1 year old, 3102; 2 years, 3705; 
 3 years, 3386; 4 years, 2677; from 5 to 10, 5400; 10 to 15, 
 1056; 15 to 20, 268; 20 to 30, 228; 30 to 40, 130; 40 to 
 50, 56 ; thus proving that the period of greatest susceptibility 
 is from 5 to 10 years.* This proportion is even greater than 
 appears on the face of the table, since we must take into our 
 calculation the consideration of the large number of children 
 who have died of other diseases before they reached the fifth 
 year. Infants under one year are less liable than those who 
 are older, as is proven by the statement just presented. Now, 
 when we take into view the commonly conceded feet that the 
 proportionate mortality of adults is much greater than of chil- 
 dren, the real difference in liability will be found to exceed that 
 which appears to be represented by these numbers, great as 
 this is. The able and interesting digest of the mortality of 
 Philadelphia prepared by Dr. Wilson Jewell, exhibits a similar 
 result. That for instance for second quarter of 1857, exhibits 
 as the total mortality from scarlet fever 153 cases, of which one 
 - See Dr. Tripe, in London Medico -Chirurgical Review. 
 
 5 
 
58 AN ESSAY ON 
 
 only was an adult between 40 and 50 years old; 1 between 15 
 and 20; 36 between 5 and 10; 66 between 2 and 5; 31 be- 
 tween 1 and 2; and 11 only under 1 year. As regards sex, 
 there were 72 males and 81 females. Since the publication of 
 the first edition, I have met with the interesting case of a 
 lady with an infant two months old. She had a severe attack 
 of anginose scarlet fever, with great cerebral disturbance. 
 The disease was fully developed when I was first called to the 
 case. The secretion of milk was very abundant, and unchecked 
 by the disease. The infant had been exposed equally with the 
 mother to the cause of the disease, and also to the contagion of 
 the mother, having been nursed during the night, and was laid 
 in the crib by her side. The danger to it could not therefore 
 be increased, while the influence upon the mother of the inter- 
 ruption of lactation would be very pernicious. I therefore di- 
 rected that the child should be kept at the breast, which was 
 done with entire impunity. The secretion of milk was never 
 suspended, and the mother recovered. The infant escaped 
 then, but had scarlet fever some years subsequently. That per- 
 sons at the other extreme of life may suffer from it I know, 
 having seen it prove fatal in several patients not less than fifty 
 years old. 
 
 Dr. George Gregory says ; " This is one of the few diseases 
 to which the foetus in utero is liable. On the 28th of April, 
 1839, my youngest son was born, evidently suffering under 
 some form of fever. The throat was affected on the following 
 day, obviously from angina maligna. Eruption was never de- 
 veloped. The child drooped and died on the first of May." 
 As no attempt is made to show that the mother was labouring 
 under the disease at or shortly before the birth of the infant, 
 and it is not even asserted that it was prevalent in the neigh- 
 bourhood or family, there is great room to doubt the accuracy 
 of the decision that this was a case of scarlet fever. 
 
 Negroes are equally liable to this disease with whites, and 
 
SCARLET FEVER. 59 
 
 dark as may be their hue, there is a peculiar change produced 
 in it by the eruption where that is present, which is the re- 
 sult of the mingling of the florid tint with their peculiar 
 colour. When sudamina occur, their appearance is very 
 marked on the dark surface. The symptoms do not vary 
 from those of the white, nor is the mortality greater. 
 
 Before we dismiss finally the consideration of the nature 
 and laws of the specific cause of this disease, it is proper to 
 draw attention to the well established fact, that it is one of 
 those to which we are liable but once. Dr. Willan, whose 
 opportunities for observation were unusually great, and whose 
 authority is beyond question, says that in more than two 
 thousand cases which passed under his notice, he never met 
 with a second attack. Dr. Tweedie asserts that there are 
 well authenticated instances, but does not speak of them as 
 of his own knowledge. No instance of a second attack oc- 
 curred to Dr. Chapman, in his large and long extended ob- 
 servation. Dr. Currie, of Liverpool, was compelled by long 
 experience to "renounce the opinion he had early entertained, 
 and to confess that the same individual is liable to the disease 
 once only." Sir Gilbert Blane, on the other hand, asserts 
 that he met with one instance of scarlet fever occurring thrice 
 " without the least suspicion of ambiguity." Analogy favours 
 the idea that in this, as in all other diseases, there are such 
 exceptional cases. At an early period of my professional 
 course, I thought I had met with them frequently myself. 
 Longer and more careful observation has convinced me that, 
 in many instances, I had mistaken other diseases for scarlet 
 fever, misled by the similarity of the eruptions. There is a 
 form of eruptive fever caused by indigestion, closely resem- 
 bling this disease in its appearance, and like it making its in- 
 vasion very suddenly, which is often met with in childhood. 
 Such cases have undoubtedly been mistaken for scarlet fever, 
 and have given rise to some of the reputed instances of se- 
 
60 AN ESSAY ON 
 
 cond and third attacks. When occurring in the case of a 
 child with enlarged tonsils, which are liable to acute inflam- 
 mation from cold, or disordered stomach, the resemblance to 
 scarlet fever is very close. Such cases run a shorter course, 
 are not attended by delirium, nor is there the free secretion of 
 acrid mucus discharging from the nares. The pulse is not so 
 frequent, nor is the prostration so great. They are not fol- 
 lowed by desquamation or anasarca. 
 
 Secondary attacks may, however, occur, though less fre- 
 quently in this than some of the other exanthematous fevers. 
 A medical friend of great eminence has informed me that he 
 lost a member of his own family by a second attack. The 
 first was, when the child was but four years old, was irregular 
 in its character, the eruption imperfect, and not followed by 
 desquamation. There was an abscess in the neck, and long 
 continued ill-health succeeded. After an interval of five 
 years, the second and fatal attack supervened. There was 
 but little affection of the throat, but the rash was very vivid 
 and extensive, and death occurred from exhaustion of the vital 
 forces by the intensity of the febrile reaction. The absence of 
 desquamation after the first, and the occurrence of the second, 
 induce me to believe that the first was of the same nature as 
 those referred to above. Another medical friend has assured 
 me that a well-marked second attack occurred in his family. 
 
 In this disease, as in variola and measles, second attacks 
 are more frequent in those who have suffered from it in its 
 most severe forms, than when in the first instance it has been 
 mild. It would appear as though, in these persons, there was 
 a greater degree of susceptibility to the influence of the con- 
 tagious principle or epidemic miasm, while there are others 
 in whom this liability exists but slightly at any period of life. 
 This difference of susceptibility to the influence of the causes 
 of disease, is one of those mysteries which it is but little likely 
 we shall ever be able to solve. That of a given number of 
 
SCARLET FEVER. 61 
 
 persons, equally exposed to an epidemic influence, only a small 
 number yield to the impression, is well known; and contagion 
 itself finds the same exemption in kind, though not in degree. 
 More extraordinary still is the fact that this susceptibility 
 varies in the same individual, at different times, without our 
 being able to recognise the circumstances on which the fluc- 
 tuation depends. Present exemption affords no security from 
 future liability. Thus it can hardly be supposed probable 
 that the two gentlemen who fell victims to it when more than 
 forty years old, to whose cases I have already referred under 
 another head, had never been exposed to the cause previously. 
 About the same period, one of our most respectable physicians 
 died from the disease. He had been many years engaged in 
 a large practice, and must have encountered the complaint fre- 
 quently, and been subject not only to the epidemic influence, 
 but to direct contagion. In such cases the susceptibility must 
 either have been recently developed, or some unknown power 
 had caused it to lie dormant for vears. 
 
 In this respect the laws of scarlet fever are perfectly con- 
 sonant with those which govern the diffusion of other kindred 
 diseases. Thus, Dr. Watson records an instance of fatal small- 
 pox in the person of a lady beyond 70 years of age, who had 
 nursed two generations of her descendants in the disease, and 
 was therefore very naturally thought to possess an entire ex- 
 emption from liability to it. There is a certain amount of 
 susceptibility which is always present even in the persons of 
 those who have formerly had the complaint, as is evidenced by 
 the sore throat which affects them when engaged in nursing 
 persons sick with this disease. Such cases may indeed be con- 
 sidered as instances of secondary affections of a partial charac- 
 ter, especially as I have already proved that they are capable 
 of propagating the disease. There is one fact connected with 
 this branch of the subject which deserves to be impressed upon 
 our minds, as it will naturally suggest important precautions. 
 
62 AN ESSAY ON 
 
 We often find an error in diet, exposure to cold, or undue fa- 
 tigue, proves the direct agent in exciting the disease. In such 
 instances it is manifest that the specific cause was present in 
 the system, but kept in subjection by the conservative force, 
 until some accidental circumstance disturbed the balance of 
 health, and afforded the opportunity for development which 
 was needed. To caution persons against such exciting causes 
 when the disease is prevalent in a neighbourhood or has invaded 
 the family circle, is, therefore, the duty of the physician. 
 
 The mortality of scarlet fever varies greatly, in different 
 epidemics, occurs at different periods of the progress of the 
 individual case, and depends on various causes. Death may 
 occur from the first impression of the miasm, from depres- 
 sion of the vital forces, or from disturbance of the cerebral 
 functions, within the first twenty-four hours. If this danger 
 be surmounted, the case will probably be prolonged at least 
 to the end of the first week. The largest proportional mor- 
 tality is in the second week, and depends as the immediate 
 cause, on congestion of the brain and lungs, or the exhaus- 
 tion of the vital force. The prognosis is therefore necessarily 
 indefinite. So treacherous is the disease, and so liable to 
 serious complications and fatal sequelae, that it is best always 
 to give a guarded opinion as to the result. We may say, with 
 safety, that no case is so desperate in its symptoms as to shut 
 out the hope of recovery; but must at the same time admit 
 that none is so benign as to exclude anxiety. I still remem- 
 ber perfectly a lesson learned in the earlier part of my pro- 
 fessional career. I was attending the child of a clergyman; 
 of course, therefore, an object of attention for a whole con- 
 gregation. The case was one of the mildest I had ever seen; 
 scarcely any anginose affection, the rash florid, the nervous 
 centres unaffected. The progress of the disease was regular 
 till the fourth day. It was a Sydenham case, " scarcely 
 worthy the name of disease." Under these circumstances I 
 
SCARLET FEVER. 63 
 
 ventured to congratulate the mother on her happiness. The 
 disease was making fearful havoc in many families ; she would 
 be exempt thenceforth from the apprehensions in which she 
 had participated with all parents. The case became compli- 
 cated with laryngitis, and, forty-eight hours after, the child 
 was a corpse. I have, on the other hand, seen patients lie 
 utterly unconscious of surrounding objects, with a livid erup- 
 tion, entire loss of the power of deglutition, constant discharge 
 of putrid sanies from the mouth and nostrils, and uncontrolla- 
 ble jactitation — and others with convulsions and croup, — and 
 yet recover. It is therefore, my uniform habit to speak cau- 
 tiously of the lightest, and to encourage hope in the gravest 
 cases. 
 
 There is no doubt that the mortality among adults is greater 
 in proportion to the number affected than among children. To 
 pregnant and puerperal women, it is almost inevitably fatal. 
 This is not only the result of my personal observation, but it is 
 also the opinion of those whose experience is most extended. Dr # 
 Copland speaks of the pregna?it and puerperal states, as con- 
 ditions most unfavourable, "for the pregnant are prone to abor- 
 tion, and when that occurs the disease often assumes a most 
 dangerous form; and if the disease occurs soon after parturi- 
 tion, recovery rarely takes place, especially as observed in some 
 epidemics. In these latter cases the scarlet fever assumes the 
 appearance of, and can hardly be distinguished from the most 
 malignant forms of puerperal fever." Dr. C. quotes also Mal- 
 fatti, an Italian author, to the same purport. The character 
 of the prevailing epidemic should always be taken into con- 
 sideration in forming an estimate of the probable results of 
 any case, as in no disease is the mortality more variable. 
 This is proven by the personal experience of every practitioner. 
 We may, however, refer to the report of the London Fever 
 Hospital, given by Dr. Tweedie, as offering an illustration 
 which cannot be questioned; 644 cases were treated in that 
 
64 AN ESSAY ON 
 
 institution during the twelve years from 1822 to 1883 inclu- 
 sive. Of this number, thirty-eight died, being at about the 
 rate of 6 per cent, upon the whole series of cases. But when 
 we descend to the investigation of the annual mortality, we 
 find that while, in 1829, the rate was as high as one in six, 
 in 1832 it fell as low as one in forty. Dr. G. Gregory refers 
 to the observations of a Mr. Ward of Bodmin, who reports 
 four hundred and forty-two cases with thirty-six deaths ; of 
 these cases, three hundred and twenty-four were accompanied 
 by the eruption, and of these, twenty-six died. While of one 
 hundred and eight without eruption, ten died, thus making 
 but a small difference in favour of those cases in which the 
 skin is involved. Dr. Condie, of this city, reports two hun- 
 dred and sixty cases, of children under 12 years of age, oc- 
 curring during three epidemics of considerable extent and 
 severity, with 45 fatal results. Dr. G. Gregory states that 6 
 per cent, may be assumed as the medium rate of mortality. 
 
 Nothing can be more destitute of foundation than any at- 
 tempt to draw a justification for a particular mode of practice 
 from the proportion of the recoveries to any such average 
 rates of mortality. Widely various in intensity, as well as in 
 type of character, this disease must of necessity require diffe- 
 rent treatment under these different circumstances: and this 
 treatment must be directed and governed hj common sense 
 and good judgment acting under the influence of a knowledge 
 of the pathology of the disease, derived from the recorded 
 experience of other observers. 
 
 Though it be true, as I have before remarked, that the ge- 
 neral character of the prevailing epidemic will throw light 
 upon the probable result of the individual cases, there are ex- 
 ceptions to this rule. Not only do we find some cases of a 
 very mild character occurring at the time when the disease 
 is generally malignant, but the reverse also takes place, though 
 less frequently. As the general rule, whatever may be the 
 
SCARLET FEVER. 65 
 
 prevailing type, the character of the first case which is seen 
 in a family or school, will attach itself to most of the subsequent 
 cases; or rather, when the first are sthenic and regular, the 
 others will be so likewise. We often, however, meet with slight 
 and regular cases during an asthenic or malignant epidemic. 
 Thus the disease in the House of Refuge, was certainly very 
 mild, no death having occurred, though the type of the epide- 
 mic, then prevailing in the city, was severe. 
 
 The extent of the eruption affords no criterion by which to 
 determine the degree of risk or intensity. I have frequently 
 seen cases in which the whole surface was covered with a 
 vivid rash, prove fatal, and equally often have known the 
 ready recovery of those in which there was none, or but little 
 around the joints or on the body. 
 
 Simple scarlet fever is certainly much less likely to result 
 fatally than the anginose, and this less so than the malignant 
 and congestive, or irregular. The occurrence of convulsions 
 in any stage, or either form, is always an indication of great 
 danger. I at one time believed them a certainly fatal sign, 
 because I thought they indicated a necessity for bleeding, 
 either local or topical; but I have known several cases to re- 
 cover under a more rational treatment. Violent delirium, 
 manifesting itself by shrieks like those of meningitis, is also 
 of bad augury, no matter how slight may be the affection of 
 the throat ; so also is stupor with grinding of the teeth. Croup 
 is a very serious complication and should cause the physician 
 to watch the case in which it occurs, narrowly. The enlarge- 
 ment of the neck without a corresponding degree of swelling 
 of the tonsils and adjacent mucous membrane, is also of evil 
 omen ; especially when there is the acrid discharge from the 
 nostrils, which indicates the existence of ulceration of the pos- 
 terior nares. The continuance or increase of the febrile symp- 
 toms, after the fifth or sixth day, is also a bad sign, as it 
 proves the existence of some local lesion. A dusky or livid 
 
66 AN ESSAY ON 
 
 colour of the eruption is always a bad sign, whether it result 
 from the deficient aeration of the blood, or from a depraved 
 condition of that fluid, caused by the detention of effete mat- 
 ters which should have been excreted either by the skin or 
 kidneys ; and so are great sighing, and a feeling of faintish- 
 ness, and hurried respiration. Ulceration of the commissures 
 of the mouth and eyelids are unfavourable events, and so is 
 coldness of the surface, whether it be dry, or bedewed with 
 moisture. 
 
 The subsidence of the frequency of the pulse, and the di- 
 minution of the redness and swelling of the parts about the 
 throat, in the anginose variety, are circumstances which should 
 afford encouragement. Among the favourable signs, none 
 should be hailed with greater satisfaction than a warm per- 
 spiration ; whether it is found in the simple, anginose, or ma- 
 lignant form. Next to this is the diminution of the heat of 
 the skin, with or without moisture, provided it do not descend 
 to a degree of coldness less than the standard of health. 
 
 It is impossible to attach too great importance to the urine 
 as an exponent of the condition of the patient and the proba- 
 ble result of the disease. So long as the quantity is nearly 
 normal, and there is no deposit of blood or epithelial scales, 
 and no albumen is detected by the usual tests, there can be no 
 risk in giving a favourable prognosis. When it becomes scanty 
 and turbid, depositing blood corpuscles and casts of the tubuli 
 uriniferi, or epithelial cells, it is necessary to be more cautious. 
 The mere occurrence of anasarca with fever is not of itself a 
 cause of great apprehension, since a large proportion of such 
 cases yield to proper treatment. When the effusion takes 
 place in the ventricles of the brain, as manifested by coma, 
 or in the pleura, or pericardium, or cellular tissue of the lungs, 
 as exhibited by oppression of the breathing, there is more 
 cause for alarm. The previous health of the child is also to 
 be taken into consideration, as the peril is greater in the 
 
SCARLET FEVER. 67 
 
 cases of scrofulous, leuco-phlegmatic children subject to ca- 
 tarrhal affections, than in the sanguine and robust. An ob- 
 stinate continuation of the oedema, while the urine is abundant 
 in quantity and of a low specific gravity, is a bad symptom, 
 indicating serious lesion of the kidneys. Such cases generally 
 terminate in fatal convulsions. 
 
 Death may result from various causes, and at several stages 
 of the disease. The violence of the primary shock may be 
 such that the system may not react from it, or the reaction 
 may be so severe as to prove fatal. The nervous centres may 
 be so deeply impressed that death shall ensue from the de- 
 struction of the balance necessary to their healthy action. 
 From any of these causes it may occur within the first week 
 of the disease; nay, even within the first twenty-four hours. 
 Dr. G. Gregory thinks sixty hours, or the third day, the period 
 of greatest danger. But even when the first week has passed, 
 and the primary symptoms have yielded, the causes of mor- 
 tality still stand thickly around the course of the patient. 
 Inflammation of the larynx, the pericardium, or the kidneys, 
 may be developed and produce a fatal result; or the patient 
 may die from effusion in the ventricles of the brain, or the 
 thorax, or from the long continued exhausting effects of ab- 
 scesses or disease of the bones. 
 
 Each of these latter causes of death will of course leave a 
 corresponding lesion in the organ affected. But in those 
 cases where death has occurred in the early stages, it would 
 be irrational to expect to find any morbid appearances in this 
 more than other pure febrile diseases. The fatal impression 
 has been made on organs which express their changes by signs 
 which pass away with life and leave no trace behind; but by 
 some authors the brain is said to be more vascular than na- 
 tural in cases w r here there has been very violent delirium ; 
 and instances are reported of increased vascularity, and 
 others of opacity of the arachnoid, with effusion of lymph or 
 
68 AN ESSAY ON 
 
 serum into the ventricles, or gelatinous matter on the arach- 
 noid. In the malignant and anginose forms we shall of course 
 find the traces of the disorganization of the mucous membrane 
 of the fauces and adjacent parts which has been noticed during 
 life, and I have seen ulceration of the mucous membrane 
 lining the larynx, and abscesses about the cartilages. Dr. 
 Southwood Smith and Dr. Copland both refer to a diseased 
 condition of the solitary glands of Brunner and the agmina- 
 ted glands of Peyer in cases of scarlet fever, with great 
 vascularity and ulceration of the ilium, and enlargement of 
 the mesenteric glands. MM. Billiet and Barthez report the 
 same lesions. " The alimentary canal exhibits prominent 
 patches with an areola, somewhat effaced by the thickening 
 of the membrane, softened, and here and there of a bright 
 red colour. In some cases we have even met with a slightly 
 inflammatory enlargement of the mesenteric glands, and have 
 found the spleen enlarged and much softened.." They declare, 
 however, that the kidneys, " though red and congested some- 
 times, occasionally bleached, are not increased in size, and are 
 evidently healthy." They sum up the morbid appearances as 
 follows: " Congestion of the brain, of the serous membranes, 
 of the spleen, of the patches of Peyer, and of the follicles of 
 the intestines." Dr. Copland says, "The kidneys are always 
 congested, tumid, and often of a dark mottled colour exter- 
 nally." Dr. Copland also adds: "I have seen the vertebrae 
 of the neck, their ligaments and intervertebral substance se- 
 riously affected, caries of the former, with chronic inflamma- 
 tion, thickening, &c, of the theca, supervening, and occa- 
 sionally cervical paraplegia or general palsy." 
 
 Though there can be no doubt that the blood during life is 
 much changed from its healthy condition, there is nothing 
 peculiar in its state after death. It is reported to have been 
 found sometimes fluid, at others abounding in coagula, some- 
 times collected in especial organs, and at others more equably 
 
SCARLET FEVER. 69 
 
 distributed. The proportion of fibrine is said to be slightly 
 in excess in some instances. This -would result from any 
 local inflammation which might be set up on the progress of 
 the case. The spleen in some instances has been found en- 
 larged, soft, and reddened. 
 
 From a very elaborate article in the British and Foreign 
 Medico- Chirurgical Review for 1854-5, by Dr. Tripe, of Lon- 
 don, we derive the following facts. He describes the causes 
 of death in 128 cases. 
 
 Brain and Spinal Cord. Affections of these organs were 
 the cause of death in 14 cases out of the 128. Of these 14, 
 meningitis was the cause in 6. Passive effusion into the cere- 
 bral cavities in 7. Hemiplegia, (cause unknown,) 1. 
 
 The Larynx was diseased in three cases: 1 laryngitis, 2 
 croup. 
 
 Lungs and Pleura. Diseases of these organs were fatal 
 in no less than 40 out of the 128 cases. Of these, 3 were 
 bronchitis, 14 pneumonia, 4 pleuro-pneumonia, 7 pleuritis, 2 
 pleuro-pneumonia, with peritonitis. There was one case of 
 phthisis, 1 of oedema of the lungs, and 7 of non-inflammatory 
 effusion into the thoracic cavity. 
 
 Heart and Pericardium. Of the 128 cases, 12 were fatal 
 from diseases of the heart and pericardium, 4 being pericar- 
 ditis, 8 endocarditis, and 5 effusion into the pericardium, with- 
 out dropsy of the other cavities. There was jaundice in one 
 case, but none exhibited any disease of the liver. 
 
 Stomach, Bowels, and Peritoneum. Of 13 cases in the 128, 
 in two there was ulceration of the colon, with diarrhoea during 
 life, 2 ulceration of intestines, (what part not stated,) also 
 with diarrhoea during life ; 4 cases were fatal from peritonitis. 
 There was one case of disease of the mesenteric glands, and 
 three of ascites, without effusion into any other cavity. 
 
 Gangrene, Sloughing, Abscess, and Erysipelas, were fatal 
 in 9 cases out of the 128 : 3 cases of abscess, (2 of the neck 
 
70 AN ESSAY ON 
 
 and 1 of the joints,) 1 case of gangrene of the feet, 1 of 
 mortification, (part not mentioned,) 2 cases of suppuration of 
 glands of the neck, and 2 cases of erysipelas. 
 
 Uraemia. The prominent symptoms of ursemic poisoning 
 were manifested in 37 cases out of the 128. There were con- 
 vulsions in 27, (or convulsions and coma together,) 5 of coma, 
 1 of tetanic convulsions, 1 of epileptic convulsions, 2 of com- 
 plete suppression of urine, (convulsions and coma enumerated 
 as symptoms of these cases,) 1 of ursemia. 
 
 There are several complications which are met with in the 
 different forms of scarlet fever. Among these, the most pro- 
 minent place is due to the sore throat, which in the anginose 
 forms varies in degree, and is often attended by swelling of 
 the glands of the neck, impeding deglutition, even in some, 
 cases to the extent of entire interruption. It is by no means 
 an uncommon event for the food and drink to be returned 
 through the nostrils, instead of passing into the oesophagus. 
 Ulceration of the mucous membrane, and even sloughs of the 
 subjacent parts are found in extreme cases. Delirium is by 
 no means an unfrequent attendant of all the forms of scarlet 
 fever, and may be either wild and violent, or low and mutter- 
 ing. In the former case, which is confined to the simple and 
 anginose varieties, I have seen it amount to phrensy like the 
 most violent acute mania: it is frequently associated with 
 convulsions; in the latter, which belongs to the malignant, 
 with coma. Laryngitis is another serious complication which 
 may occur in either form of the disease, and at any stage of 
 its progress, and is always a formidable symptom. Especially 
 is this the case when it is attended by the exudation of false 
 membrane, which sometimes extends into the bronchia, and 
 sometimes spreads upwards into the nasal passages, and even 
 to the outer opening of the nostrils, lining the reddened mu- 
 cous membrane with a white firm layer of fibrinous deposit. 
 Violent rheumatic pains in the limbs are occasionally found in 
 
SCARLET FEVER. 71 
 
 the earlier stages, as well as among the sequelae, and there is 
 often more or less muscular rigidity of the neck. This may 
 even become a permanent lesion. 
 
 Ulcerations of the mucous membrane of the nasal passages, 
 and the extension of the inflammation through the Eustachian 
 tube to the internal ear, are also met with in some cases, 
 giving rise to the most intense suffering at the time, and in- 
 volving the disorganization of the organ of hearing. Pneu- 
 monia also occurs in this disease., but more frequently violent 
 affections of the heart, indicated by laboured respiration and 
 distress in the precordial region. Dr. Gregory describes the 
 case of a lady " who was seized with scarlet fever at the time 
 of parturition. The labour was long and severe; she per- 
 spired profusely ; the heart laboured violently. The next day, 
 scarlet fever appeared. The heart, exhausted by previous 
 efforts, gave way, and, in about fifteen hours from the appear- 
 ance of the eruption, became engorged. A frightful feeling 
 of suffocation supervened, and the pulse for a few minutes was 
 imperceptible at the wrist. This feeling subsided, but the 
 heart never regained its natural condition. Dyspnoea in- 
 creased, and in twenty- four hours more the blueness of coun- 
 tenance and incipient delirium showed that the lungs were 
 implicated, and that waves of ill oxygenated blood were per- 
 meating the brain. Twelve hours longer of this semi-asphyx- 
 iate state closed this sad and painful scene." 
 
 The Diagnosis of scarlet fever is not devoid of difficulty, 
 and is yet always important. The anxiety of parents is ex- 
 cessive. Often, very often, have I been called at a late hour 
 in the evening to see a child, suddenly seized with fever be- 
 tween the time at which it had been put to bed and the hour 
 at which the parents retired. The flushed cheek and restless 
 sleep had excited the apprehension of a mother, some of whose 
 friends had suffered from this devastator of the nursery. The 
 power of allaying these fears by the positive assurance that 
 
72 AN ESSAY ON 
 
 no such clanger was impending, is one of those which will 
 afford the physician as much gratification as any he can exer- 
 cise. His own satisfaction in the treatment of a case is also 
 much enhanced by certainty as to its character. Circum- 
 stances may arise in which it is most important to be able to 
 give a prompt decision. I once, needlessly, caused the dis- 
 missal to their homes, of the children of a boarding school, 
 thus interrupting the pursuits and materially interfering with 
 the interests of a most worthy family, and spreading alarm 
 into many others, by the hasty and erroneous determination 
 that one of the children had scarlet fever: founded upon the 
 elongation of the villi of the tongue, and a light fur, in a case 
 which proved to be catarrh fever. The opposite error might 
 have been still more disastrous in its results. The well-marked 
 anginose and malignant forms cannot be mistaken. It is only 
 in the simple and irregular cases that we are liable to error. 
 These, however, may give origin to the most violent and fatal 
 forms, and even the mildest cases may become serious in the 
 results, if not properly treated. In every case where there 
 is a sudden invasion of fever with sick stomach, and the oc- 
 currence of rash within forty-eight hours, scarlet fever should 
 be suspected. This suspicion should be retained for his own 
 guidance until the physician has carefully investigated the 
 entire history of the attack, and examined well the symptoms, 
 bearing in mind that important results may follow his deci- 
 sion. 
 
 There are several diseases which may be mistaken for sim- 
 ple or anginose scarlet fever. Measles was long confounded 
 with it. Sore throat with fever resembles it in some points. 
 The rash which often accompanies indigestion in children, is 
 very like it; and if these two conditions occur in the same 
 case, they produce a condition which it is difficult to distin- 
 guish from scarlet fever. The less frequent pulse at first, and 
 the subsequent absence of desquamation, afford our only means 
 
SCARLET FEVER. 73 
 
 of discrimination. There is a very mild form of disease, 
 known popularly by the name of "the scarlet rash," which 
 closely resembles it, and roseola has often been taken for it 
 by superficial observers. 
 
 There are several points of difference between measles and 
 scarlet fever noticed by authors. The period of incubation 
 is said to differ. When, however, we refer to the impossibility 
 of determining the time of exposure in many cases, and that 
 when this is known the mere fact of exposure will determine 
 the nature of the case, it will at once be evident that little 
 benefit can be derived from such an observation. I have, 
 moreover, already shown how very uncertain is the period of 
 incubation. It is quite certain, however, that measles has 
 never been known to occur so promptly after exposure as 
 scarlet fever. 
 
 The time after the development of febrile symptoms, at 
 which the eruption occurs in the two diseases in those cases 
 which pursue a regular course, is very different. The rash of 
 scarlet fever is observed often simultaneously with the febrile 
 invasion, and generally, if at all, within twenty-four hours; 
 that of measles does not show itself in less than seventy-two 
 hours, or on the third or fourth day. The invasion of scarlet 
 fever is marked by nausea or vomiting, thus fixing the sto- 
 mach and passages which lead to it as the organs involved. 
 The first stage of measles, on the other hand, is indicated by 
 catarrh, sneezing, redness of the conjunctiva, cough, and 
 hoarseness : thus exhibiting the tendency of the disease to fix 
 on the mucous membrane of the air passages. This difference 
 in the local tendencies marks the whole course of the disease 
 and its sequelae. In scarlet fever the ear, the nose, the fauces, 
 the kidneys, are the organs most commonly implicated; while 
 in rubeola the eyes, the bronchial mucous membrane, and that 
 of the alimentary canal, are most commonly the seat of the 
 complications and sequelas. And even in those cases of scarlet 
 6 
 
74 AN ESSAY ON 
 
 fever in which the larynx is involved, there is not the peculiar 
 hoarse cough of rubeola. 
 
 There is also a marked difference in the appearance of the 
 rash. The eruption of measles may be first seen about the 
 roots of the hair and behind the ears, in circumscribed well- 
 defined spots, which, as they spread, assume frequently an ar- 
 rangement which has been called crescentic, several spots 
 being grouped together, and surrounding patches of skin of 
 perfectly natural appearance. From thence it gradually ex- 
 tends itself downward over the whole person. In the regular 
 course of scarlet fever, there is a vivid efflorescence covering 
 the whole surface of the head and neck simultaneously, and 
 often even the whole trunk, leaving no spot unaffected. The 
 body should always be examined where scarlet fever is suspected, 
 as the first faint appearance of the rash on that part of the 
 surface which is habitually covered may be found even before 
 it is fixed upon the face and neck. The papular eruption 
 scattered through the efflorescence of scarlet fever, which 
 gives the appearance of stigmata, noticed in the description of 
 the disease, is unknown in measles. There is a marked dif- 
 ference also in the colour of the rash of the two diseases. In 
 scarlet fever it is of a florid or vermilion tint; in measles 
 there is at the very outset a dull lake colour. The first de- 
 clines by fading away; the last becomes darker or more 
 dusky. 
 
 In the sequelae of the two diseases, we find the most striking 
 evidence of their diverse origin and nature. 
 
 In scarlet fever we have affections of the brain, the kidneys, 
 the cellular tissue, ulcerations of the throat and ears, abscesses 
 about the neck, and rheumatic pains; and if any of the 
 affections of the air passages occur, it is evidently by mere 
 extension from the adjacent parts. In measles we have bron- 
 chitis and pneumonia, and sometimes diarrhoea. But while 
 there are these important and well-marked points of difference 
 
SCARLET FEVER. 75 
 
 between the two diseases, it must be conceded that we occa- 
 sionally meet with instances in which all our efforts at discri- 
 mination will be tasked during the progress of the case; and 
 it is even possible that in some there may be a mongrel dis- 
 ease, as though it were the result of a mixed influence, com- 
 mencing as scarlet fever and yielding in its course to the 
 influence of rubeola. Such were the cases which occurred 
 with fatal results at the Foster Home in the midst of the 
 intense cold of the winter of 1856-7. Scarlet fever of a 
 malignant type first attacked the children ; and immediately 
 on the subsidence of the primary stage, (on the fourth or fifth 
 day of the scarlet fever,) rubeola, with a well-marked cres- 
 centic eruption and violent catarrhal symptoms, commenced, 
 and went through its regular stages, followed by severe 
 pneumonia. The children who survived this complicated dis- 
 ease, were then attacked by whooping cough. 
 
 There is often in cases of variola or varioloid a diffuse efflo- 
 rescence on the second or third day, which very closely re- 
 sembles that of scarlet fever, and the resemblance is rendered 
 more embarrassing by the sore throat which so generally occurs 
 in variola. It may be distinguished from it by the character of 
 the febrile symptoms which accompany it. The restlessness 
 and gastric oppression and pain in the back, of the variolous 
 disease, sufficiently mark its character, and are never present 
 in scarlet fever. Neither is there in variola the frequent pulse 
 to which I have already referred as belonging especially to this 
 disease. That of the variolous impression is less frequent 
 and softer; the absence of the dotted points which are inter- 
 spersed through the efflorescence on the skin, and always ap- 
 pear in the throat, will afford assistance in determining the 
 nature of the case; in addition to which, the fever of variola 
 subsides on the occurrence of the eruption, while that of 
 scarlet fever is unabated. Attention to the symptoms affords 
 one of the best modes of discrimination in the eruption resem- 
 
76 AN ESSAY ON 
 
 Ming scarlet fever which occur in cases of indigestion in child- 
 hood and infancy; and the best additional diagnostic sign I 
 can furnish is found by looking into the throat. The erup- 
 tion of scarlet fever is always found there, if it affect the ex- 
 ternal surface. I do not mean the inflammation which consti- 
 tutes the anginose variety. Even in the most simple case the 
 mucous membrane presents an appearance quite analogous to 
 that of the skin. The projection of the elongated papillae 
 through the white fur on the tongue, once thought pathogno- 
 monic, is less to be relied on. I have been deceived by it. Not 
 so, however, the appearance of the tongue on the second or 
 third day. The sudden throwing off of the coat of fur, while 
 the surface is left red and glossy, is decidedly characteristic 
 and will never deceive, as it occurs in no other disease at this 
 early period. 
 
 The eruption which occurs about the third day of typhus 
 fever, bears a closer resemblance to that of measles than to 
 the one now under our notice. The age of the patient will 
 in this instance afford aid in forming an opinion, typhus fever 
 being more frequent in adult life, and scarlet fever in infancy 
 and childhood, while the history of the case will always enable 
 us to trace genuine typhus fever to its origin in direct con- 
 tagion or exposure to the peculiar circumstances which give 
 rise to it. 
 
 Such are the phenomena which usher in, and mark the pro- 
 gress of scarlet fever; and such the primary results of its im- 
 pression on the human system. We are now prepared to ar- 
 rive at some conclusion as to its character, which may be thus 
 expressed. 
 
 Scarlet fever is a febrile disease, dependent on a specific 
 miasm, resulting from unknown external influences; yet ca- 
 pable of re-production, and diffusing itself, both by direct con- 
 tagion and by the establishment of a peculiar condition of the 
 atmosphere within limited districts: the susceptibility to the 
 influence of this cause varies in different individuals and at 
 
SCARLET FEVER. 77 
 
 different periods of life, and is generally exhausted by one 
 attack : the morbid impression is made on the nervous sys- 
 tem, and transmitted to the circulating fluids through which 
 every part of the organization becomes subject to the in- 
 fluence, while the principal localization of diseased action is 
 in the capillaries of the skin and mucous membrane, which 
 covers the pharynx and lines the kidneys: it has a fixed du- 
 ration of from 120 to 160 hours, at the close of which period 
 the disease has a natural solution, unless the disturbance of 
 the functions has been so great as to destroy life, or local 
 lesions have been produced which maintain the irritative 
 action. 
 
 "We may now proceed to the consideration of certain results of 
 this impression, which are more durable than the disease itself; 
 quite distinct in their character, equally, perhaps more, to be 
 deprecated than the primary disease. 
 
 These are generally known as the sequelse, and as such, 
 have been occasionally referred to already. They may be 
 divided into two classes. 1st, Those which appear to be a 
 mere continuation of the local lesions developed during the 
 course of the disease, confined to the same vicinity ; sloughing 
 and ulceration of the throat, diseases of the ear, often ex- 
 tending to the bony structure, abscesses about the neck, and, 
 in some rare cases, disease of the cervical or dorsal vertebrae, 
 resulting in caries : and 2dly, those which are less directly con- 
 nected with primary causes and congestion of the kidneys. 
 
 It can scarcely be necessary to add any thing to the re- 
 marks already made on the subject of the affection of the 
 throat, when treating of that symptom in the description of 
 the anginose and malignant forms of the disease. It occa- 
 sionally happens, however, that the ulcerative process set up 
 from the very commencement of the case, continues long after 
 the primary disease has run through its regular stages ; and 
 extends itself upwards into the posterior nares, or downward 
 
78 AN ESSAY ON 
 
 into the pharynx, or even invades the larynx. This condition 
 gives rise to enlargement of the glands of the neck, and often 
 to oedema of the cellular tissue, and interferes sadly with the 
 freedom of respiration as well as with the act of deglutition. 
 
 A question has been raised, whether there is ever an actual 
 solution of continuity of the parts about the throat. Of this 
 there can be no doubt on the part of those who have seen 
 the anginose and malignant forms in their greatest intensity. 
 I have known the entire destruction of the soft palate, and 
 extensive sloughing of the adjacent parts even where recovery 
 has followed. 
 
 Disease of the internal ear is occasioned by the transmission 
 of the inflammation from the mucous membrane of the pharynx 
 by direct extension through the Eustachian tube to the inner 
 structure of the ear. It may either commence during the 
 course of the primary disease, and be prolonged after that 
 has reached its termination, or may be first manifested even 
 some weeks after the scarlet fever has seemingly disappeared. 
 It is sometimes ushered in by a rigour and deep-seated pain, 
 followed by purulent discharge, and in other cases, is first 
 manifested by discharge from the external meatus of a thin, 
 apparently serous fluid, which soon takes on the appearance 
 of unhealthy pus. 
 
 The cases which thus manifestly originate in the membrane 
 lining the external meatus generally yield speedily to appro- 
 priate treatment; while those which are dependent either on 
 the transmission of the inflammation along the Eustachian 
 tube, or in which that process has its commencement in the 
 internal ear, are of a much more serious character. In either 
 case permanent deafness may result; if both ears are affected, 
 reducing the child to the condition of a mute. I had a case 
 some years since in the person of a fine healthy boy of about eight 
 years old, in which the primary symptoms were all of the most 
 aggravated character. The swelling of the throat and ulcera- 
 
SCARLET FEVER. 79 
 
 tion of the mucous membrane of the pharynx and nares were 
 very extensive. As the primary disease subsided the irrita- 
 tive action of these local lesions took its place, prolonging the 
 duration of the case for many weeks. Finally, a chill, fol- 
 lowed by intense febrile reaction and extreme pain in the ear, 
 announced the extension of the disease to the internal ear. 
 Stupor, interrupted with violent shrieks, like those which 
 occur in acute meningitis, supervened: suppuration was esta- 
 blished, and the matter found its way to the surface by the 
 external meatus, and by an abscess over the mastoid process, 
 evidently connected with the cells of that portion of the tem- 
 poral bone. Caries of the bone followed, which continued for 
 several years, and though the general health of the child was 
 in great measure re-established, nothing had any influence in 
 arresting the disease of the bone, which continued to extend 
 itself until ultimately it reached the membranes of the brain, 
 and he died of acute meningitis. 
 
 Croup may also occur as a sequela of scarlet fever, a3 well 
 as during the primary stages of the disease; in either case a 
 most formidable complication. Some years since one of my 
 patients survived an attack of scarlet fever in which every 
 complication and sequela of the disease appeared to conspire 
 for her destruction. The disease was ushered in by convul- 
 sions. There was extensive sloughing of the soft palate, and 
 then as late as the tenth day the hard croupal cough gave 
 evidence of the invasion of the larynx. I attempted the ap- 
 plication of the solid nitrate of silver to the part, when to my 
 infinite dismay a large portion was broken off by the child in 
 its struggles and swallowed. I said nothing of the accident 
 to the parents at the moment, but calling for the salt cellar, 
 promptly administered a strong solution of the muriate of 
 soda. This not only decomposed the nitrate of silver, but 
 acted as a speedy and efficient emetic, and very probably 
 saved the child's life, by the vomiting induced, as to my great 
 surprise it recovered. 
 
80 AN ESSAY ON 
 
 Quite recently I have had under care, in consultation with 
 a neighbouring practitioner, the case of a young gentleman 
 of fifteen years, in which croup appeared to be caused by ex- 
 tension of the inflammation from the pharynx to the larynx 
 on the fifth day of the fever. It yielded to the active use of 
 emetics of ipecacuanha. 
 
 Still more frequently, the lymphatic glands of the neck be- 
 come implicated, and serous effusion into the cellular tissue 
 beneath the jaw impedes the deglutition and respiration, and 
 either accelerates the fatal catastrophe, or terminates in the 
 formation of large collections of pus, which may occasion hec- 
 tic irritation, and result in death after prolonged suffering. 
 
 The 2d class embraces lesions, which are more general in 
 their character; among which the first place in importance as 
 well as in order of time, must be assigned to that destruction 
 of the cuticle by the cutaneous inflammation which gives rise 
 to the process of desquamation, to which reference has been 
 already made. The process originally follows the same course 
 as the eruption, commencing about the face and neck and 
 thence extending to the body and limbs. It is first ob- 
 served upon the face about the sixth day, and extends gra- 
 dually to other parts of the external surface, occupying in 
 its progress 10 or 12 days. In some cases it is not com- 
 pleted before the 24th to the 30th day. The new cuticle is left 
 very soft and velvety, and exceedingly susceptible to impres- 
 sions of temperature. Much attention has been bestowed, 
 and very properly on the important question, how far other 
 sequelae, inflammation of the kidneys, dropsical effusions, and 
 inflammation of the membranes of the heart, may be dependent 
 on this interruption of the functions of the skin. Certain it 
 is, that all these sequels are observed to follow more fre- 
 quently those cases in which the affection of the skin has been 
 most decided. Some authors make a contrary assertion ; but 
 my own observation is very positive on this point. Thus in 
 
SCARLET FEVER. 81 
 
 the malignant and irregular forms of the disease, in which 
 the eruption is often slight and transient, the mortality is 
 greatest in the first week, or results from the injury done to 
 the brain or nervous system, by the direct onset of the dis- 
 ease. While in those mild cases of the simple form in which 
 there is abundant efflorescence, with high febrile reaction, 
 death, if it occur at all, is found to be most frequent during 
 the period in which this desquamative process is being accom- 
 plished, and is the result of dropsical effusion, or some of the 
 other secondary affections, as those of the heart or brain. 
 When the rash has been very vivid, and the heat and dryness 
 of the skin correspondingly great, the destruction of the epi- 
 dermis is most decided; and most writers agree in testimony, 
 that in such cases, there is more reason to apprehend the oc- 
 currence of sequelce ; while in those cases in which the rash does 
 not appear, is but slight, or recedes soon after its appearance, 
 the functions of the skin being less disturbed, the convalescence 
 is less frequently interrupted by the occurrence of dropsical 
 effusions, or of inflammation of the membranes of the heart, 
 which prove the most fertile sources of danger after the first 
 stage of the disease has been safely passed through. We must 
 also bear in mind the fact that the disease of the skin is more 
 strongly marked in the simple and anginose than in the ma- 
 lignant or irregular forms, and all writers coincide in the de- 
 claration that the sequelae are more usual in the mild and re- 
 gular, than in the severe and irregular cases. 
 
 It must not be concealed, however, that both Dr. Graves 
 of Dublin and Dr. Copland, mention having met with what 
 they term "latent cases," in which the dropsy has been the 
 first indication of the impression of the scarlet fever miasm, 
 the previous stages having passed unobserved; and, upon this 
 fact, as well as others, Dr. Copland rests his opinion that 
 the primary influence of the original cause of scarlet fever is 
 developed largely on the kidneys themselves. 
 
 The importance of the skin, and the influence upon the 
 
82 AN ESSAY ON 
 
 whole economy of the mode in which its functions are per- 
 formed, cannot, however, be too strongly insisted on. We all 
 are conscious of the effect on our own sensations arising from 
 the arrest of those functions, by whatever cause it may be pro- 
 duced ; and we know that every feeling of discomfort is only 
 an indication of a deviation from health. This, however, does 
 not make so strong an impression on our minds as the facts 
 which are proven by observation on the results of the healthy 
 action ; when, for example, we estimate the influence on the 
 circulating fluids which must be produced by the twenty-eight 
 miles of "perspiratory tubing," with its seven millions of 
 pores opening through the epidermis, discharging daily two 
 ounces of excrementitious matter, and not less than thirty 
 ounces of watery vapour, we can better appreciate the effects 
 which must result from the entire interruption of this excre- 
 tion, produced by the drying of the cuticle though which those 
 pores are transmitted : nor must we forget that this excretory 
 process is not the only one which is going on through cuta- 
 neous agency. Physiology teaches us how large is the amount 
 of influence on the blood, subsidiary to that of the lungs, ex- 
 erted by the direct imbibition of oxygen through the skin. 
 Now if we bear in mind the activity of the vital processes, and 
 that no one of them is needless, but each absolutely essential 
 to the other, and to the integrity of the whole organization ; 
 and then remember that by the destruction of the cuticle not 
 only the depurative action is arrested, but an obstruction 
 placed on one channel, by which the vitalizing influence of 
 oxygen is introduced, we shall be better prepared to appre- 
 ciate the condition of the blood in scarlet fever, and the con- 
 sequent danger to the patient, from the interruption of the 
 functions of the skin. It is, moreover, a fact well established 
 by the observation of surgeons, that in burns and scalds, the 
 danger is proportioned less to the depth of the injury and the 
 intensity and duration of the heat applied, than to the extent 
 
SCARLET FEVER. 83 
 
 of surface involved, thus affording additional evidence of the 
 importance to the system of the cutaneous function. Nor 
 must we overlook the fatal results which have been produced 
 on animals of a lower grade, by coating the skin with some 
 impermeable material. Now in this disease the whole surface 
 is affected, and more decidedly than in any other of the ex- 
 anthemata, except confluent small pox. In rubeola there are 
 patches of healthy skin; in erysipelas the extent of surface 
 involved at one time is much smaller, and neither of these 
 diseases leaves the dead cuticle to impede the normal action 
 of the new. It may in some instances be compared to the 
 varnish applied to the surface in the experiments of the phy- 
 siologist. The student will not, therefore, be surprised that 
 when treating of the inferences as to the final result, to be 
 drawn from the symptoms of the disease, we expressed a cau- 
 tion against the common error, of supposing that the freeness 
 and extent of the cutaneous affection was a favourable sign ; 
 and will understand why we thus draw attention to the des- 
 quamatory process ; and place it first among the sequels of 
 the disease ; and will also be the better able to comprehend 
 why the mortality is often greater in the secondary than the 
 primary stages. So decidedly is this the case, that common 
 observation has taught it. When on one occasion I assured 
 an intelligent mother of a large family, several of the children 
 having been attacked simultaneously, that the crisis of the 
 disease was passed, she replied: " Well, then, this is the period 
 
 of danger; Mr. , who lost several children with it, 
 
 told me that they all died just as the doctor told him they 
 were getting well." 
 
 This, then, is the period in which the anxieties of the phy- 
 sician should be especially active, and his care most vigilant; 
 and the danger to the patient is closely connected with, though 
 not wholly dependent upon, the interruption to the healthy 
 action of the cutaneous emunctories. The process of casting 
 
84 AN ESSAY ON 
 
 off the cuticle, which we observe, and to which this term des- 
 quamation is applied, is not itself a diseased process. It is 
 the result of the previous disease and the natural course by 
 which an impediment to the normal action of the system is 
 removed. Commencing in favourable cases from the time at 
 which the cuticle is destroyed, in others it is postponed, some- 
 times even for a fortnight, from the 14th to the 20th day; and 
 this third week is the period during which the greatest num- 
 ber of cases of dropsical effusion occur. The peril is always 
 proportioned to the tardiness with which it is accomplished; 
 and until it is completed, the patients are depressed by the 
 poisoned condition of the blood, and liable to the sudden de- 
 velopment of cerebral disease or inflammation in some organ 
 essential to life. 
 
 But the external cuticle is not the only organ for exhala- 
 tion the action of which is, in a similar manner, suspended or 
 destroyed by the disease. Every one is aware from observa- 
 tion on his own person, and it is important to apply this 
 observation to its relation to disease, that wherever any 
 influence from without arrests the cutaneous transpiration, 
 a corresponding increase is found in the watery constituent 
 of the secretion from the kidneys. This is the cause of 
 the increased secretion of those organs under the influence 
 of fear, and cold externally applied; both giving rise to the 
 contraction of the capillaries of the skin, and thus arresting 
 the cutaneous transpiration. This is not the case, however, 
 in diseases where the same cause certainly operates equally 
 on both kidneys and skin, and produces a similar result in 
 each. Hence we find, that though the amount of urine 
 has been but little diminished during the four or five first 
 days of scarlet fever, it is either wholly arrested or becomes 
 very scant about the same time that the functions of the 
 skin are most impeded. Thus proving beyond controversy 
 that the same cause which interrupts the action of the skin is 
 
SCARLET FEVER. 85 
 
 operating to produce a similar arrest of the normal functions 
 of the kidneys. The same is true in other febrile diseases, in 
 most of which, we find the excretions through the skin and 
 kidneys are not antagonistic as in health, but are either sup- 
 pressed or increased in freeness under the influence of some 
 common cause. The occurrence simultaneously of increased 
 discharges from both organs is noted as marking the crisis of 
 febrile diseases. Now it is not at all a forced idea that the 
 same diseased action may be established in the Malpighian 
 bodies and epithelium of the uriniferous tubules, as is observed 
 on the external tegument; and it is well known that the flow 
 of urine is always much diminished about the time at which 
 the process of desquamation is at its height, and epithelial 
 scales are found at this juncture abundantly in the urine. 
 The facts observed, therefore, confirm the suspicion which 
 might be entertained from reasoning only, that there is such 
 a connexion between the diseased condition of the skin and 
 kidneys, in their influence upon the other sequelae of scarlet 
 fever, as justifies the relation which I have ventured to sug- 
 gest before; and indicate the latter organs as equally inte- 
 rested with the skin in the production of some of the results 
 which will claim our attention immediately. The diseased 
 condition of the kidneys is not dependent on the interrup- 
 tion of the functions of the skin : both organs are simulta- 
 neously affected by one common agency. In this opinion I 
 find myself supported by the highly important authority of 
 Dr. Copland, who says: "I cannot hesitate to state my con- 
 viction, that in many cases which terminate fatally at an early 
 period of the disease, whether the eruption be abundant or 
 scanty, or altogether suppressed, this issue is in great measure 
 owing to the early implication of the kidneys having been 
 overlooked, for I have remarked in many instances, as re- 
 spects both the symptoms during life and the appearance of 
 the kidneys after death, suflacient evidence to convince me 
 
86 AN ESSAY ON 
 
 that these organs are remarkably congested, and their secreting 
 and tubular surfaces are the seats of a similar vascular injec- 
 tion or efflorescence to that existing in the vascular rete of 
 the skin, and that this efflorescence on the surfaces of the uri- 
 niferous tubes, &c, and the associated swelling and conges- 
 tion of these organs during the early stages of the malady, 
 either impede, or interrupt, or altogether suppress the func- 
 tion of the urinary excretion, and thereby occasion an accu- 
 mulation of excrementitial and contaminating materials in the 
 blood ; and, consecutively an increase of the poisonous action 
 of the infected blood upon the nervous system, and on vital 
 organs and parts, thereby producing further complications." 
 
 "In this early period of the disease, the interrupted functions 
 of the kidneys, produced in the manner now stated, has the 
 effect not merely of preventing the discharge by these emunc- 
 tories of the usual excremental matters in the blood, but also 
 of arresting the evacuation of those morbid materials evolved 
 in the blood from the action of the infectious miasm upon the 
 nervous and vascular system. The obstruction of the kidneys 
 arising, as just explained, during the early stage of the dis- 
 ease, produces a more immediate, and a more intense or acute 
 effect than the obstruction so frequently caused subsequently 
 and during, or after the process of desquamation by the ac- 
 cumulation and infarction of the epithelium scales thrown off 
 from the uriniferous tubes. The obstruction of the uriniferous 
 tubes, caused by the accumulation in them during this latter 
 period of epithelium scales, is entirely the result of a species 
 of desquamation, as respects those tubes, consequent upon the 
 vascular action, congestion and tumefaction, of which they 
 with other parts of the kidney are the seat in the eruptive or 
 early stage, and which in this stage frequently becomes, as 
 just stated, the source of the most acute and fatal complica- 
 tions. The obstruction of the kidneys in the early stage, 
 arising, as now shown, is often more complete and rapid in its 
 
SCARLET FEVER. 87 
 
 accession, than that which follows in its last stage as a pro- 
 cess of desquamation ; and hence the consequences are gene- 
 rally not so severe, nor so fatal in this last stage, especially 
 when due precautions are used during the period of desqua- 
 mation." 
 
 Some cases reported by Dr. Graves, of Dublin, give strong 
 support to the opinion here advanced, that the kidneys par- 
 take of the diseased action in scarlet fever from the beginning 
 of the attack. In these instances there were desquamation and 
 anasarca in members of families in which scarlet fever was 
 prevailing, though there had been none of the primary symp- 
 toms of the disease in some cases, and no eruption in others. 
 Certain it is, that dropsical effusions occur in a very large pro- 
 portion of cases of regular scarlet fever, frequently in despite 
 of all precautions, always if care be not taken to prevent ex- 
 posure to atmospheric vicissitudes or errors of diet. The 
 more regular the course of the case, the more vivid and abun- 
 dant the eruption, the more certainly may this desquamation 
 as well internal as external be expected, and its consequences, 
 dropsical effusion, be looked for. There are, however, cases 
 in which there has been no eruption whatever, the scarlatinous 
 nature of which is proven by subsequent anasarca. 
 
 The external cellular tissue affords the most common seat 
 for the serous effusion. It may take place, however, into any 
 or all the cavities of the body from the ventricles of the brain 
 or pericardial sac, the pleural sac, or the cellular structure of 
 the lung, to the tunica vaginalis testis. The internal effusions 
 are almost always preceded by that of the external cellular 
 tissue, especially of the face. 
 
 The actual effusion of fluid is generally preceded, a longer 
 or shorter time, sometimes only four or five hours, in other 
 cases, for a day or two, by feelings of languor and drowsiness, 
 and loss of appetite ; and not unfrequently by nausea and vomit- 
 ing, coated tongue, and great heat and dryness of the skin: the 
 
j, u i ,. i . i. ,, e and oorded, with i return of the fcequeney, l! 
 (i, ,i i, ; ,.i mb ided. En everj c > e that bat po ed under mj 
 there bai been appre ""' - 1 mm, "> pwwdtaj tl 
 , -tin .... i i. ...1 the end of the Br it free* to the begin 
 , n:i . ,,i the third, I • the period at whioh the i ympl >m • ii «' 
 m , frequently developed, Bj Par the lar pet number of 
 al R bout the end of the leeond week, Though no 
 natural of precaution oan wholly remove the liability to tl 
 i U n ,, || i, v ii.. meani anoommon to Rnd it brought about bj 
 Improper expo are to atmo pheric viei >itud >me error 
 
 1U ,i. ( ( , And '1 bai been luppoied bj many that it ii to the 
 i (Vl ,,r oara ui theae point!, reiulting from the Idee that the 
 i . been to i mild to require it, we maj aaeribe the 
 greater prop irtionate fcequenoj of dropej after the mildest 
 
 krletfevei Theee irregulai 
 :l , ( ,„,■», !s , . the diaturbto ■ which derange the n 
 
 . M1> :llll i thui overcome the power of re- 
 ;,-,•, which would otherwiie bave been sufficient to oarrj 
 iho I , i\i v through the period of dieturbanoe oonee 
 
 quent en the primary imprei lion of the oau( e of 
 
 y ft e present will probably be ai appropriate s plac 
 th.a m:iv offer to exhibit the importance of enfi 
 
 . lu i to tl are and the indul 
 
 f ft ppet| \ j difficult to make those 
 
 who bave not purchased their own experience bj a iev( re lee 
 ion, tui : N .«« ire of it i 
 
 lu tlu . j \ % l v l for late at night, by the late 
 
 P, i Vu , v . the family of an officer of the tfavy, in 
 
 which Bve of the children had been under the care of an infirm 
 superannuated physician, with mild scarlet fever, He bad 
 a tiuMu In the morning, pronounced them well, and bad 
 tc their being allowed the free range ot the 
 nouw and tl e aeual diet of the family, When I reached the 
 house, twoof the children were already dead from convulsions, 
 
SCARLET FEVER. 
 
 and the others were saved with difficulty, having fever followed 
 by anasarca, depending, in all probability, on inflammation of 
 the kidneys, the result of the exposure of the day and very 
 improper indulgence in food. No examination of the bodies 
 was permitted. Dr. Chapman describes similar results as 
 having occurred under his own observation. 
 
 In another instance I was attending a child from South 
 Carolina at lodgings here, which was carried happily through a 
 mild attack, with but little treatment except of a palliative 
 character. An older daughter of about eighteen was taken 
 sick after I had ceased my attendance on the first case. The 
 symptoms were so benign, and the treatment I had adopted 
 had been apparently so inert, that the parents were induced 
 to believe the disease was but little to be dreaded, and re- 
 quired no care whatever. They, therefore, did not seek me- 
 dical advice in the second case, and permitted her to pursue her 
 usual habits, as regards diet and exposure; at the end of a 
 fortnight I was sent for to prescribe for general anasarca, for 
 which they were at a loss to account. "Warned by these and 
 similar instances in which the most serious consequences have 
 followed the want of proper care in cases which Mere in the 
 primary stages of a very benign character, some of which I 
 shall refer to when treating of other sequela:, I am always 
 earnest in my endeavours to impress on the parents of scar- 
 let fever patients, the great importance of care on these points, 
 until the entire process of desquamation has been completed; 
 and this care is more especially important, at the very junc- 
 ture when it is least likely to be exercised; just at the close 
 of the process ; when the condition of the blood, produced as well 
 by the original impression of the cause of the disease upon the 
 organic nerves and through them upon the blood, as by the 
 arrest of the secretion from the skin and kidneys, is at its 
 worst point, and the new cuticle most tender and liable to the 
 impression of cold air. The effusion is generally first observed 
 7 
 
90 AN ESSAY ON 
 
 about the face and hands. The complexion suddenly assumes 
 a less healthy hue, resembling that of anasmia, the eyelids are 
 observed to be somewhat puffy, and upon attempting to flex the 
 fingers they are found to be stiffened. The trunk and upper 
 parts of the lower limbs next assume the appearance of disease, 
 and on feeling these parts they are sensibly harder to the 
 touch than natural, and there is often some complaint of ten- 
 derness on pressure, which, moreover, does not at this period 
 leave the indentation found commonly in anasarca. All these 
 circumstances agree in the indication that though the condition 
 of the kidneys is undoubtedly abnormal, and the lesion of those 
 organs may be regarded very properly as the principal cause 
 of the dropsical effusion, the skin itself is also in fault, and 
 that the disease is not one of mere infiltration, caused by some 
 affection of the viscera, or destruction of the crasis of the 
 blood. It is upon this fact that MM. Rilliet and Barthez 
 found their conviction that there is an inflammation of the 
 subcutaneous lymphatic layer in all cases of scarlet fever, and 
 that the dropsy and albuminuria are dependent on a special 
 alteration of the blood, resulting from this cause. They at- 
 tach some importance to the influence of exposure to cold, es- 
 pecially when conjoined to moisture; but refer to the many 
 cases in which anasarca occurs in despite of the most careful 
 precautions as proof that this is not the only cause. There is no 
 practitioner of enlarged observation who has not met with such 
 cases, while undoubtedly there are many patients, who, during 
 convalescence from scarlet fever, are much exposed to vicissi- 
 tudes of temperature and errors of diet, who yet escape. There 
 are certain epidemics in which this tendency is much greater 
 than in others. MM. Rilliet and Barthez also assert, on the 
 authority of M. Noivot, that in about one third of the cases of 
 dropsy there is no albuminuria, and they quote Dr. Phillip, 
 a German author, as asserting that in more than sixty cases 
 of anasarca following scarlet fever, no trace of albumen could 
 
SCARLET FEVER. 91 
 
 be found in the urine. The suddenness with which this swell- 
 ing follows exposure, also confirms the same view, as I have 
 known it to be manifested almost immediately on the return 
 from a drive, or exposure at the door or window, or other simi- 
 lar imprudence. The bowels are generally costive at this time ; 
 and even though the secretion of urine may not before have 
 been so much diminished as to arrest attention, it will now be 
 found, on inquiry, that it is very scanty, high-coloured, and 
 turbid. A critical examination of this fluid under these cir- 
 cumstances proves it to contain blood, and albumen, and to be 
 very acid. At one time this was thought to indicate the ex- 
 istence of the incipient stage of that peculiar condition of the 
 kidney found in cases of what is known as Bright's disease. 
 This is, however, an error. The presence of albumen in the 
 urine as indicated by the deposit of that substance coagulated 
 by heat or nitric acid, is often dependent on simple inflamma- 
 tion or, perhaps, congestion only, of those organs; and this is 
 undoubtedly the case in the instances under consideration. 
 In Bright's disease the quantity of the urine is increased, its 
 specific gravity diminished, its colour light : in all these respects 
 presenting a marked contrast with the condition of the secre- 
 tion in the dropsy following scarlet fever. The examination, 
 moreover, of the bodies of those who have died of scarlet fever, 
 as reported by MM. Rilliet and Barthez, proves that no such 
 disorganization as that known to produce Bright's disease ex- 
 ists. It is true these authors do not indicate how many of 
 their fatal cases had progressed to the period in which dropsy 
 is developed, but they say that "in no case were the kidneys 
 enlarged or pallid, though sometimes red or congested." 
 There is no disease in which we stand more in need of ac- 
 curate, well digested observations of post-mortem examina- 
 tions. This results from the fact that the mortality generally 
 occurs in private practice, where the distress of parents and 
 friends prohibits the physician from proposing anything which 
 would aggravate their sorrow. 
 
92 AN ESSAY ON 
 
 The strumous diathesis has a powerful influence in promoting 
 the development of the sequelse now under consideration, and 
 renders them much more grave when they do occur. It is 
 always marked by a diminution of the power of resistance, 
 and greater susceptibility to the chronic forms of organic dis- 
 ease. In children in whom it prevails, the kidneys, like the 
 throat, are liable to chronic inflammation or congestion after 
 scarlet fever, and the disease is less amenable to treatment. 
 I have known the most abundant secretion of limpid urine in 
 such instances without any diminution of the effusion or feb- 
 rile disturbance, and one such case terminated in death from 
 convulsions in the fourth week. 
 
 Anasarca is the form in which the dropsical effusion most 
 generally presents itself. If it were the only one, the previous 
 diseased condition of the cutaneous capillaries, and the gene- 
 rally acknowledged dependence of the disease on the impres- 
 sion of cold on the surface, would justify the belief which has 
 been expressed by some authors that "it arises from increased 
 action in the sanguiferous system."* Next to the cellular 
 tissue beneath the skin in liability to this effusion, I should 
 place the pleural sac or the pulmonary tissue; and after this, 
 in order of frequency, the ventricles of the brain and the peri- 
 cardium; and I have no doubt that sudden death is caused in 
 many cases by these latter lesions. An instance of this oc- 
 curred in my own practice. An infant had been carried out 
 by its nurse, apparently in perfect health. It was brought 
 home in a state of collapse, and died in a few hours without 
 reaction. Within a few days another child in the same fa- 
 mily sickened with scarlet fever, and had a mild anginose at- 
 tack with an abundant eruption. It passed through the first 
 week safely, and was apparently convalescent, when an anx- 
 ious grandmother, confident that it stood in need of more 
 nourishment than I had allowed to be given, fed it largely with 
 *Tweedie, Cyclop. Pract. Med. 
 
SCARLET FEVER. 93 
 
 cakes, ice cream, and animal food. At the end of forty-eight 
 hours of this injudicious treatment, the child was seized with 
 general anasarca, dry cough, and dyspnoea to such a degree 
 as prevented the child from lying down. Death speedily 
 ensued. Post-mortem examination of the body exhibited 
 pulmonary oedema, and effusion into the pleura and pericar- 
 dium. Dr. Hamilton reports three similar cases among the 
 boys of a school in England, in which death took place within 
 thirty-six hours, the symptoms indicating effusion in the ven- 
 tricles of the brain, and the cavities of the thorax and abdo- 
 men, as well as in the cellular tissue generally. 
 
 Cerebral effusion is certainly the most formidable of the 
 sequelae of scarlet fever, though happily less frequent than the 
 anasarca. It is indicated by the occurrence of stupor, or vio- 
 lent headache and vomiting. The pulse is slow, one or both 
 pupils dilated. Vision is impaired, or even lost entirely, and 
 there may be strabismus, or even general convulsions, or pa- 
 ralysis. The countenance is at the same time bloated ; often 
 excessively so. 
 
 Such cases are by no means to be regarded as beyond the 
 reach of medical treatment; nor, urgent and alarming as are 
 the symptoms, do these indicate any lesion which can impair 
 the power of the intellect. I meet frequently a gentleman 
 now actively engaged in the pursuits of commerce, whom I 
 attended when about the age of puberty during an attack of 
 scarlet fever of a mild anginose form. He was the only child 
 of anxious and careful parents, so that my directions as to 
 treatment were implicitly followed. At the end of the second 
 week his face became puffy, and upon examination I found 
 the urine scanty in quantity, and high-coloured. The swell- 
 ing extended to the entire cellular tissue, and there was an 
 almost total suppression of urine. I placed him upon a rigid 
 diet, and directed the use of nitrate of potash and a gentle 
 purgative. No diuretic action was produced ; and while the 
 
94 AN ESSAY ON 
 
 external swelling constantly increased, he gradually became 
 dull and finally comatose, with dilated pupils, strabismus, and 
 convulsions. I bled him largely, added calomel to the nitrate 
 of potash, and gave in addition the infusion of digitalis in 
 full doses. Under the influence of this treatment the convul- 
 sions were arrested, the secretory action of the kidneys was 
 restored, the effusion both internal and external was absorbed, 
 and the patient was perfectly restored. MM. Rilliet and Bar- 
 thez, speaking of this condition, remark: "Differing in this 
 from the other cerebral affections of childhood, which so often 
 leave as a consequence some disorder of the locomotive organs, 
 the sensitive functions, or of the intellect, albuminuric encepha- 
 lopathy leaves, to those who recover, the undisturbed possession 
 of their sensorial, motive, and intellectual faculties. The 
 most remarkable instance that could be adduced is that of 
 De Candolle, so well known for the delicacy of his mind, and 
 his profound scientific acquirements. In childhood he suffered 
 from an attack of encephalopathy, following the dropsy of 
 scarlet fever. Treated by Odier for hydrocephalus, he often 
 referred to his recovery as a remarkable case, hydrocephalus 
 being then thought incurable. The perfection of the cure 
 was proven by the high rank he attained as a naturalist." 
 
 Only one such case has proved fatal under my notice. It 
 was that of a leucophlegmatic girl about twelve years old. 
 Her parents had both died of strumous diseases, and an older 
 brother of scarlet fever about a fortnight before she was at- 
 tacked. I was called to see her on the third day of her dis- 
 ease, in consultation with a highly intelligent and experienced 
 physician. I found her covered with a vivid scarlet eruption, 
 which occurred in patches of a uniform hue, with very irre- 
 gular margins. It was blotched about the body and neck as 
 though a sponge saturated with some scarlet dye had been 
 suddenly pressed upon it. There was some cough, much sore 
 throat, with swelling as well external as internal, and a free 
 
SCARLET FEVER/ 95 
 
 discharge from the nostrils. The attending physician had ex- 
 pressed his opinion that the case was one of rubeola. Even 
 though the previous occurrence of a fatal case of scarlet fever 
 in the family had been wanting, there was more resemblance 
 to that disease in the course of the fever and the character of 
 the eruption, than to rubeola ; while the cough was evidently de- 
 pendent rather on the irritation of the fauces, than on any affec- 
 tion of the bronchial mucous membrane. The discharge from 
 the nostrils was also characteristic of the disease of the posterior 
 nares which attends scarlet fever: not the thin mucus of ru- 
 beola, but a sero-purulent curdy acrid fluid. The child was put 
 upon the use of chlorate of potash in solution, and passed 
 safely through the primary stages of the disease. The angi- 
 nose symptoms and congestion disappeared, and the pulse lost 
 its frequency. The secretion of urine was maintained through- 
 out in a sufficient abundance. There was, however, much 
 puffiness of the face, a very unhealthy pallid complexion, 
 headache, dilated pupils and sluggishness of intellect, with 
 anorexia, and, occasionally, slight nausea. Circumstances led 
 to my withdrawal from the care of the case, though not with- 
 out the expression of my conviction that there was still immi- 
 nent danger of a fatal result. The family physician also 
 ceased to visit her daily. The abundant flow of watery urine 
 was supposed to indicate a restoration of the healthy action 
 of the kidneys, and that the remaining symptoms of disease 
 would gradually yield. At the end of about a week I was 
 suddenly recalled to find her in violent convulsions, with an 
 excessively bloated countenance, dilated pupils, strabismus, 
 and tumid neck. Leeching, calomel, enemata, stimulating pe- 
 diluvia, all failed to produce the slightest diminution of the coma, 
 or relaxation of the muscles, till death brought release. No 
 examination was allowed. I learned that the quantity of urine 
 had continued to be excessive, of a pale colour, and without 
 any deposit on cooling; while, no albumen was detected by 
 
96 AN ESSAY ON 
 
 the test resorted to. A doughy, pallid, puffed face is always, 
 as in this case, to be considered an indication of danger, even 
 though the quantity of urine is large. Nor must it be forgot- 
 ten that it is quite as important that the urine should be charged 
 with the saline constituents, as that its quantity should be abun- 
 dant. A mere leakage of watery fluid does not restore the 
 blood to its normal condition; and till this is effected, the pa- 
 tient is still liable to serious complications. 
 
 This formidable affection occurs generally, as in the in- 
 stances now recorded, after the anasarca has existed some 
 time, though sometimes it is developed at an earlier period. I 
 have often met with cases in which the same condition was 
 ushered in most unexpectedly by violent headache, with vomit- 
 ing, temporary amaurosis and strabismus ; and I am always 
 alarmed when these symptoms occur during the third or fourth 
 week of convalescence from scarlet fever. 
 
 The pathology of this affection is somewhat obscure. By 
 some, the condition of the brain and nervous system is 
 ascribed to the poisonous influence of the urea, which the 
 diseased kidneys fail to eliminate from the blood. By some, 
 meningitis is thought to be always present; and by others, 
 mere passive effusion of serum into the meshes of the pia 
 mater, the ventricles of the brain, and in the substance itself 
 of that organ, is supposed to exist. The coma and convul- 
 sions, which are the prominent symptoms, are common to all 
 these. The reports of the results of post-mortem examina- 
 tions prove that different lesions are found. MM. Billiet and 
 Barthez " ascribe the cerebral symptoms neither to a phleg- 
 masia nor to a neurosis; but regard them as the consequence 
 of hydrocephalus, taking that term in its widest acceptation : 
 that is, as including not only effusion into the ventricles of 
 the brain and within or beneath the arachnoid membrane, but 
 also oedema of the cerebral substance." The nature of the 
 symptoms and the course they follow, differ as widely from 
 
SCARLET FEVER. 97 
 
 those of inflammation as from the mere neuroses. They are 
 less permanent than the former, and less transient than the 
 latter. The most formidable in appearance yield to treatment 
 •with a certainty and promptitude we could not look for if 
 dependent on actual inflammation or the changes in structure 
 consequent upon that action ; and they are more fixed than 
 they would be if dependent on merely nervous disturbance. 
 Dr. Copland has found more decided organic change: he says, 
 "The membranes and even the substance of the brain present 
 increased vascularity, with some serous effusion between the 
 membranes, especially at the base of the brain and in the 
 ventricles particularly, in those cases in which the urine has 
 been very scanty or suppressed." 
 
 Dr. Tripe, in illustrating the causes of mortality in this dis- 
 ease, gives us an abstract from the Report of the Registrar 
 General of England and Wales, and from this source derives 
 the information that of 128 cases of death during the stage of 
 effusion after scarlet fever, in which the symptoms were noted 
 in the report of the medical attendant, and the appearances 
 found on dissection added, " affections of the brain and spinal 
 cord " were recorded as the causes of death in 14. Of this 
 number, " meningitis " is specified in 6 cases, and " passive ef- 
 fusion into the cerebral cavity " in 7 cases. Thirty-seven other 
 cases of the 128 are reported as having died from "unemic 
 poisoning," as manifested by convulsions alone, or coma with 
 convulsions, in 27. Coma alone, 5. Tetanic convulsions, 1. 
 Epileptic convulsions, 1. And two cases are reported with 
 "complete suppression of urine, with coma and convulsions." 
 Dr. Tripe remarks : " Though coma and convulsions are pro- 
 minent symptoms of uraemia, yet in making post-mortem 
 examinations we rarely detect any morbid alterations. Some- 
 times, when the symptoms come on gradually, we meet with 
 indications of slight inflammatory disease; yet in the majority 
 of cases the quantity of fluid in the ventricles and arachnoid 
 cavity is but little, if at all, above that of health. In my 
 
98 AN ESSAY ON 
 
 own cases I did not detect any morbid products ; and Frerichs 
 makes a similar statement, having never met with more than 
 a slightly increased amount of fluid, the largest quantity not 
 exceeding an ounce." The presence of even this quantity of 
 fluid at any point within the cranium is certainly a sufficient 
 cause of serious cerebral disturbance, whether it be the result 
 of active inflammation or mere passive effusion. 
 
 Still another class of pathologists is disposed to attribute 
 the whole train of symptoms to the mere toxic effect of the 
 urea retained in the blood, as in the latter stages of Bright's 
 disease. By others this view is opposed, however, on the 
 ground that in the case now under consideration there is not 
 the slow and gradual increase of stupor which marks the 
 accumulation of the poisonous principle in the former: the 
 invasion is violent and sudden, nor is there any correspondence 
 between the amount of urea found in the blood and the vio- 
 lence of the attack. Large quantities, moreover, of urea 
 have been injected into the veins of animals, not only without 
 causing coma or convulsions, but, what is more striking, with 
 the effect of producing diuresis. With MM. Rilliet and Bar- 
 thez, I am disposed to attribute the symptoms to the combined 
 influence of a poisoned state of the blood — partly due to the 
 primary cause of scarlet fever, partly to the impaired action 
 of the skin, and still more to the interruption of the function 
 of the kidneys caused by the congestion and perhaps inflam- 
 mation of those organs — and serous effusion within the cra- 
 nium ; nor am I at present disposed to attribute the effusion 
 to active inflammation of the encephalon. The cases which 
 have fallen under my notice have occurred chiefly among those 
 patients who were beyond the stage of childhood in which 
 meningitis is most commonly developed; and instead of the 
 contracted pupil, frequent pulse, grinding of the teeth, con- 
 stant vomiting and constipated bowels of that disease, we find 
 a slow pulse, dilated pupil, coma and convulsions, with great 
 
SCARLET FEVER. 99 
 
 distress in respiration. The vomiting which occurs is violent, 
 but of short duration. 
 
 The recent interesting experiments of Dr. Hammond of the 
 U. S. Navy, made to determine the question as to the mode in 
 which urea acts on the system when injected into the veins, 
 are highly important, proving as they do beyond a question 
 the toxic effects of this matter when retained, and the power 
 of the kidneys in its elimination from the blood. Where these 
 organs were left undisturbed, a large quantity of urea was 
 received and promptly discharged, with a comparatively slight 
 disturbance of the normal functions. When the kidneys were 
 extirpated before the urea was introduced, the animals soon 
 manifested the stupor and convulsions of ursemia, and died. 
 We thus find confirmation of the view which attributes the 
 most important influence to the morbid state of the kidneys 
 themselves. 
 
 The returns of the fatal cases of scarlet fever to the Regis- 
 trar General of England and Wales, for the year 1848, have 
 been carefully examined by Dr. Tripe ; and from an analysis 
 of his own cases added to this more extended report, he has 
 reached the conclusion that the fourteenth day is the period 
 at which the dropsical effusion most commonly appears : the 
 extremes being the first day, of which two cases are reported, 
 and the ninth week, in which one occurred. Nine per cent, of 
 the attacks were in the first week, 38 per cent, in the second, 
 34 per cent, in the third, 11 per cent, in the fourth, and 4 per 
 cent, in the fifth week. 
 
 There is another most formidable consequence of scarlet 
 fever which has occasionally fallen under my notice. In 
 speaking of the length of the incubative period, I alluded to 
 the case of the family of a gentleman about to travel to Europe, 
 in which that term was prolonged much beyond the usual time. 
 When the family was on the eve of starting, the youngest 
 child, about four years old, complained of tenderness of the 
 
100 AN ESSAY ON 
 
 spinal muscles of the neck and dorsum. Supposing it to be 
 only rheumatism, and unwilling to interrupt important and 
 long arranged plans of duty, as well as pleasure, they were 
 allowed to sail. On reaching Germany, the child who still 
 complained of his back, was left under the care of a faithful 
 nurse, with near relatives during the summer months ; and in 
 the autumn was brought home. So soon as I saw him I de- 
 tected caries of the vertebra, which has run its regular course, 
 causing great deformity, and will result in death. Another 
 case of an analogous character, though happily with a very 
 different result, has occurred more recently under my notice. 
 The child, a fine healthy boy about eight years old, had a 
 common attack of regular anginose scarlet fever. Under the 
 discriminating care of my judicious friend, Dr. Rumsey, it 
 went through its course without any peculiar violence, and 
 with nothing to indicate the anomalous symptoms subsequently 
 manifested. About the end of six weeks, after convalescence 
 had been fairly established, without having been subjected to 
 any exposure or irregularity of diet, he began to complain of 
 stiffness of the neck, with extreme tenderness of the muscles. 
 His head was drawn permanently toward the left shoulder, 
 and there was a decided tumefaction of the occipital region on 
 the same side. The tenderness was so great as to preclude 
 the possibility of any minute examination: he shrank with 
 terror from the slightest touch, though a cheerful-tempered 
 and courageous boy. There was no febrile reaction, nor dis- 
 turbance of any of the functions of the organs of assimila- 
 tion or secretion. Under the impression that it was a case of 
 mere muscular rheumatism, frictions were applied, at first of 
 a narcotic and afterward of a stimulating character. This 
 treatment produced no relief. The rigidity of the muscles 
 became greater, and the exaltation of sensibility more intense. 
 The slightest movement was productive of great suffering, and 
 ultimately even the jar of the floor was distressing to him. 
 
SCARLET FEVER. 101 
 
 He kept one hand constantly applied to his head in order to 
 guard it against motion, and it was with great difficulty he 
 could make any change of posture. Leeches and blisters were 
 applied to the nape of the neck. At the end of a fortnight 
 he lost the muscular power of the left hand and arm, though 
 there was no diminution of the sensibility. The paralysis 
 gradually extended itself, first to the leg of the same side, and 
 finally involved all the extremities. It was total. He suf- 
 fered much from the strain upon the muscles of the neck when 
 lying down, and preferred an inclined chair, on -which he 
 rested, unable to move any of his muscles except those about 
 the face and mouth. Occasionally he was thrown forward 
 with his forehead supported against the bed, and his limbs 
 hanging as powerless as those of a rag doll. Still there was 
 no loss of sensation of any part. There was very great tume- 
 faction of the nape of the neck, and the sensibility there 
 was so excessive that the mere approach of a finger gave him 
 great distress, and the change of the dressing applied to the 
 blistered surface, even when these were of the most soothing 
 character, occasioned intense suffering. Under the impression 
 that this condition was dependent on inflammation of the 
 sheath of the spinal cord, with plastic effusion causing pres- 
 sure at the roots of the nerves, the external irritation was 
 long continued by means at first of blisters, and then by 
 iodine ointment, while calomel in small doses and subsequently 
 iodide of potash were administered internally. There was, 
 however, no mitigation of the symptoms, while his general 
 health was rapidly sinking under the treatment. Dr. Pepper 
 was now called to our assistance, and during a fortnight the 
 same treatment was pursued. At the end of that period, the 
 length of time which had elapsed, the active antiphlogistic 
 treatment which had been pursued, and the entire absence of 
 febrile disturbance, appeared to indicate a change of plan, and 
 we made trial of the effects of strychnia, but with no benefit. 
 
102 AN ESSAY ON 
 
 The limbs were all absolutely powerless ; the swelling of the 
 occipital region and the exaltation of sensibility were as great 
 as ever, though the part was no longer irritated by local ap- 
 plications. The spring was far advanced, and the period 
 approaching at which he could enjoy the benefit of a change 
 to his father's country seat; and though not without serious 
 apprehension that the disease had involved the bodies of the 
 vertebras of the neck, it was decided to abandon the use of 
 all those remedies which caused pain by their application, or 
 exhausted still more his vital force, which was manifestly 
 yielding. He was therefore placed upon the use of cod-liver 
 oil, which was continued many weeks. He was taken to the 
 country, and daily drawn about the grounds on a mattress 
 placed on wheels ; and during the heat of the summer he was 
 carried to the sea-side. The result has been most happy. He 
 has entirely recovered his locomotive powers, and is in robust 
 health, though there is still the fixed contraction of the mus- 
 cles of the left side of the neck, projection of the spinous 
 processes, and undue sensibility of the occipital region. In 
 the " Clinical Lectures" of Dr. Graves of Dublin, as re-pub- 
 lished here by Dr. W. W. Gerhard, may be found a letter 
 from Mr. Ferral of Dublin, in which he narrates the history 
 of four analogous cases of what he designates as "a peculiar 
 affection of the neck, which (he) had not before seen in con- 
 nexion with Scarlatina," three of which recovered perfectly, 
 and one with a wry neck. In none of these cases, however, 
 was there the paralysis which presented so marked a fea- 
 ture in this case. Dr. Ferral says: "I can offer no better 
 explanation of the occurrence of this affection during the 
 progress of scarlatina, than by supposing that the inflamma- 
 tion of the fauces and back of the pharynx was propagated 
 to the covering of the spine, and thence more or less deeply 
 to the adjoining parts." Dr. Copland also reports having 
 met with similar instances. He says: " They are observed 
 chiefly in the most malignant cases; and even in more rare 
 
SCARLET FEVER. 103 
 
 instances of this kind which recover, the morbid action has 
 extended posteriorly to the tissues and parts between the 
 pharynx and bodies of the cervical vertebras, until these lat- 
 ter and the intervertebral substances and ligaments have be- 
 come implicated, and dangerous if not fatal sequela have 
 followed the pharyngeal complication. This lesion is met 
 with, not only as a complication, but also as a sequela of 
 scarlet fever. In either form, in the latter especially, it is 
 often attended by spasm, contraction, or painful distortion of 
 the head or neck, and in this state the lesion has often been 
 viewed as merely consisting of irritation, or of simple " crick 
 in the neck," or of rheumatism from cold, and been overlooked 
 until it has advanced to disease of the intervertebral sub- 
 stance, to destruction of the ligamentous or cartilaginous 
 structure, and even to caries of the bones of the base of the 
 skull, or of one or more of the cervical vertebrae, with thick- 
 ening of the ligaments and of the theca of the canal, and 
 complete or incomplete, partial or general paralysis. Of this 
 sequela I have seen several instances, and two of complete 
 recovery, with much shortening and stiffness of the neck from 
 destruction of one or two of the cervical vertebrae, and ossific 
 adhesion of those adjoining." Such would undoubtedly have 
 been the result of the case I have narrated, had the treatment 
 been less energetic and appropriate. 
 
 Endo-cardial inflammation is another of the sequelae of 
 scarlet fever of a most formidable character, which you will 
 find mentioned by most authors. The suddenness and violence 
 which mark its character and the period at which it most 
 commonly occurs, are all illustrated by the following instance 
 which occurred in my practice many years since. This was 
 in the case of a lad of twelve years old. Scarlet fever in its 
 mildest form had passed through a family of six children, of 
 which he was the oldest and last taken. The most rigid at- 
 tention to diet, and the greatest care to avoid exposure, had 
 
104 AN ESSAY ON 
 
 been practised; my attendance had been prolonged to six 
 weeks, and as convalescence was fairly established, I had 
 called in the evening to take my leave, and sat till a late 
 hour. In parting I expressed my gratification at the result, 
 for there is certainly great cause for thankfulness when this 
 disease assumes a form so benign as to pass through a family 
 of that size, and leave the circle unbroken. The reply of the 
 mother, was the expression of her fear that the peril was not 
 yet entirely passed. The hearty laugh of the one that had 
 last been sick, which was just then heard from the nursery, 
 might have induced me to ridicule such apprehensions, had I 
 not known the treacherous character of the disease. Scarcely 
 three hours had elapsed when I was summoned to see him with 
 great dyspnoea, tossing about the bed, unable to lie down, with 
 a small tense pulse and hot skin. Bleeding, leeching, blister- 
 ing, calomel, digitalis and colchicum, aided by the most anx- 
 ious and affectionate nursing and rigid abstinence, carried 
 him through this attack, but left him with an hypertrophied 
 condition of the left ventricle, and disease of the valves, from 
 which he has, however, since recovered, and is now a well de- 
 veloped young man, actively engaged as a civil engineer. 
 
 Rheumatic pains, with fever, are of very frequent occurrence 
 during the convalescence from this disease. It is often, though 
 not always, the result of premature exposure, and like the 
 dropsical effusion, is more likely to occur in mild than grave 
 cases. A fine healthy child was spending the summer months 
 in the country where scarlet fever had never before prevailed. 
 He had an eruption with febrile symptoms, but of so mild a 
 character that the physician in attendance remarked, he 
 might have had scarlet fever, but that there was not sufficient 
 disturbance of the child's health to correspond with the amount 
 of eruption, and his ideas of the disease. The little fellow 
 was allowed to pursue his usual out door amusements without 
 interruption. At the end of a week he complained that his 
 
SCARLET FEVER. 105 
 
 "legs were too long for him," that he was "tired," became 
 feverish and languid, refused food, lost the power of using his 
 lower extremities, and died. This was an extreme case; 
 more generally some time during the second week, there is a 
 return of the fever, the pulse becoming quick and corded, and 
 the skin hot and dry; the child complains of pain in the legs, 
 and cries when any attempt is made to move it. This state 
 continues two or three days, and then yields to proper treat- 
 ment. Often there is swelling and redness of the joints as in 
 common articular rheumatism ; while the febrile reaction and 
 violence of pain are equal to the most formidable cases of the 
 idiopathic disease. 
 
 Some authors speak of purulent deposits in the joints. This 
 is a result which has never fallen under my notice. 
 
 Diarrhoea, when it occurs, is to be ascribed to the irritation 
 of the putrid colluvies swallowed from the ulcers in the throat, 
 rather than to any direct influence of the cause of the disease 
 on the mucous membrane of the alimentary canal. Dr. South- 
 wood Smith, and MM. Rilliet and Barthez, affirm however, 
 that ulceration of the glands of Peyer is a frequent lesion in 
 fatal cases : and peritonitis sometimes proves fatal even under 
 the most judicious treatment. 
 
 "We are now prepared to enter upon the consideration of the 
 treatment of this disease. Though it is undoubtedly true, that 
 but few diseases are amenable to the influence of purely spe- 
 cific remedies, it is not the less certain, that general principles 
 of treatment must be regulated in their application to each 
 disease, by close observation of the peculiar character and 
 tendencies which mark its own history. No habit can be 
 more pernicious to the physician, and less beneficial to the 
 patient, than that so often adopted by superficial thinkers 
 and indolent practitioners, of omitting the consideration of 
 the causes which produce, and circumstances which influence, 
 the progress of any form of disease; and filling the memory 
 
106 AN ESSAY ON 
 
 •with modes of treatment and specific remedies which may be 
 employed empirically, without endeavouring to understand 
 the principles which should determine their adoption, and re- 
 gulate their application. There is no disease "which more 
 fully illustrates this common truth than that now under con- 
 sideration. It is only from a careful study of its general his- 
 tory, as well as minute observation of the course of symptoms 
 in individual cases, that any suitable idea of treatment can be 
 deduced; and the liability, which the history of the disease has 
 exhibited, to frequent change in type, from simple and sthenic, 
 to irregular and malignant, demanding a corresponding change 
 in the mode of treatment, renders the success of the practi- 
 tioner equally dependent upon the soundness of. his general 
 principles and the accuracy of his particular observation. 
 
 Preserving ever certain distinctive peculiarities which prove 
 its identity, yet yielding continually to the influence of those 
 extraneous impressions which govern its development at par- 
 ticular periods, scarlet fever is a disease in which the treat- 
 ment must be regulated by one leading principle, while it is 
 varied, not only by temporary or local demands, but often in 
 accordance with individual peculiarities. This view of the 
 case has been too little regarded by those writers on the sub- 
 ject whose works are generally consulted by medical students. 
 During some epidemics assuming a sthenic character, in others 
 marked by a strong typhoid tendency; in some, complicated 
 with severe local lesions, while in others, there is but little 
 tendency to any particular organ or structure ; in some cases, 
 pursuing a course as regular as the progression of the hours ; 
 while in others, it only touches at certain points on the con- 
 fines of the disease, and assumes every conceivable variety of 
 irregularity, it must be at once evident that no single remedy 
 or simple plan of treatment could be set forth as appropriate 
 to scarlet fever in all its varied phases and different stages. 
 
 There is, however, one idea which should be ever present to 
 
SCARLET FEVER. 107 
 
 the mind, as the regulating principle by which every plan of 
 treatment must be conducted, and which shall place decided 
 limits to the extent to which any course may be followed. 
 Whatever peculiarities may mark the epidemic character, or 
 vary the individual case, scarlet fever, in all its varieties, is a 
 disease which has a specific origin, a fixed course, and a cer- 
 tain termination. 
 
 There are some diseases in which every hour of continued 
 pain or disordered function, is a reproach to the skill of the 
 physician ; since they are subject to properly applied remedies, 
 and may, by them, be at once subdued. Scarlet Fever, on the 
 contrary, is one, the duration of which is fixed and may not be 
 curtailed; and often its tendencies to local destruction may be 
 only moderated, not wholly averted. This fact should never 
 be lost sight of in the treatment of this and other kindred dis- 
 eases ; since he who should attempt to cut short the duration of 
 scarlet fever, would find that it could be done only at the ex- 
 pense of the life of the subject. Even in guarding against local 
 injuries, the same fact should be borne in mind ; as these are a 
 part of the result of the specific cause, operating on individual 
 organs as well as upon the general system ; and in a large 
 majority of cases, they have a natural tendency to abatement 
 with the decline of the primary symptoms of the disease upon 
 which they depend. It was in all probability the observation 
 of these facts which led Sydenham to express his celebrated 
 caution against over anxiety and too vigorous effort: — " Cum 
 e contra si plus negotii segris facessamus, vel lectulis conti" 
 nenter incarcerando, vel cardiacis aliisque remediis superva- 
 caneis nimis docte et (ut vulgo videtur) secundum artem supra 
 moduin ingestis, morbus statim intenditur, et reger non raro 
 nulla alia de causa, quam nimia diligentia Medici ad plures 
 migrat." By the same knowledge we are supplied with power 
 to meet the empty claim of superior success in treatment, put 
 forth with so much vain-glorious boasting by modern empirics. 
 
108 AN ESSAY ON 
 
 While some cases have a fatal tendency so strong that no 
 skill may avert it, by far the larger proportion of simple and 
 anginose cases need little more than the avoidance of imper- 
 tinent interference, and the guarding against injurious im- 
 pressions from without, and they will cure themselves. Let 
 me not be supposed to advocate an indolent indifference, or to 
 assume that no treatment is necessary. There is no disease 
 which demands more watchful care, none is more influenced 
 by skilful scientific practice. I would only assert my convic- 
 tion that medical science has other remedies than drugs ; and 
 caution the inexperienced practitioner against the unscientific 
 resort to empirical perturbative treatment, which is certainly 
 more to be dreaded than the morbid impressions of the dis- 
 ease itself. These general principles are applicable to all 
 the various forms assumed by this disease, and must be ever 
 kept in mind during the consideration of the various plans of 
 treatment and specific remedies which will be passed in re- 
 view. 
 
 In order to render it more easy to embrace the views it is 
 intended to present, the same division of the disease will be 
 adopted as was resorted to when describing it. Commencing 
 with the mildest form as affording the type of its character 
 and treatment, we shall be better able afterward to proceed 
 to the consideration of the graver cases. 
 
 In the simple form of scarlet fever, where there is merely 
 some slight impression on the nervous system with vascular 
 excitement, disturbance of the digestive functions, the erup- 
 tion on the skin and redness of the mucous membrane, without 
 swelling of the throat, nothing more is needed than a mild 
 laxative, followed by a gentle refrigerant and diaphoretic 
 treatment, with the avoidance of fatigue and exposure and the 
 adoption of a careful diet, not only during the four days of 
 febrile action, but until the desquamation is complete. A 
 dose of good calcined magnesia, adapted to the age and other 
 
SCARLET FEVER. 109 
 
 peculiarities of the patient, should be given on the first day of 
 the disease. Lemonade, if the taste of the patient desire it, 
 may be used freely as drink, and it may be prepared either 
 "with simple boiling water, or with barley or rice water ; and 
 in either case may be rendered more grateful by the addition 
 of ice. In the case of infants and young children, ice water 
 or gum water is more acceptable than either. As a diapho- 
 retic, the common neutral mixture, prepared with the natural 
 lemon-juice and carbonate of potash, and not with the citric 
 acid of the chemist, is very useful. The addition to this mix- 
 ture of a small quantity of the spirit of nitrous ether is of ser- 
 vice, as it not only increases the tendency to moisture of the 
 surface, but also promotes the secretion of urine, which it is 
 important to attend to ; the kidneys partaking of the morbid 
 impression and suffering a disturbance of their functions in 
 these simple cases, as frequently as in those more formidable 
 ones, in which the force of the disease falls upon the throat. 
 The addition to the neutral mixture of a small quantity of the 
 syrup of orange made with the rind of the fruit, renders it 
 much more acceptable to the patient, whether infant or adult. 
 It may also be added with equal, if not greater propriety, to 
 the solution of carb. of soda or the liq. ammonia acetatis, 
 where these are preferred to the neutral mixture. The urine 
 having been found to be more acid in this disease than in 
 health, the use of an alkali was therefore suggested. To 
 meet this indication, the carb. of soda has been much employed, 
 and very many cases have passed through my hands to my 
 entire satisfaction, in which no remedy was resorted to beyond 
 the weak solution of this salt with the addition of sweet spirits 
 of nitre. I am in the habit of directing the solution of a tea- 
 spoonful of the soda in a tumblerful of water, to which one tea- 
 spoonful of sweet spirits of nitre is added, and give from one 
 teaspoonful to a dessert-spoonful every hour or two, according 
 to the age of the patient. In these milder cases, the appetite 
 
110 AN ESSAY ON 
 
 is often but little impaired, and it is therefore important to 
 guard against impropriety in indulgence. I am much in the 
 habit of directing for children the cake known in this city as 
 " lady finger " or Naples' biscuit, which contains nothing but 
 wheat flour with a little sugar and egg, baked in thin slices, so 
 that it is dry and does not become sodden when chewed; or 
 a thin slice of stale bread toasted quickly; or the biscuit 
 known as "dried rusk," or a sweet, well made, soda biscuit; 
 with milk diluted with boiling water sweetened, for the morn- 
 ing and evening meal. Where the fever is very slight, milk- 
 toast without butter may be permitted. It is better that the 
 midday meal should be of the same character if it can be ac- 
 complished; and no animal matter, either solid or in the shape 
 of broth or soup, should, on any account, be allowed during 
 the first four days, even where the febrile symptoms abate 
 thus early. Where grapes and oranges are accessible, they 
 may be freely used ; care being taken that the skins and pulp 
 are not swallowed. The indulgence of the child in these harm- 
 less articles will much abate the desire for other food. 
 
 Where the case is more severe and the nervous system more 
 deeply implicated, and we have to contend with muscular 
 twitching, or trembling, or delirium, the greatest possible 
 benefit will be derived from cutaneous ablutions, to be em- 
 ployed conjointly with the treatment first indicated. No 
 slight diversity of opinion with respect to this practice has 
 been expressed by medical writers and practitioners. Under 
 the erroneous impression that the morbid matter present in 
 the fluids was to be eliminated by the skin, some have ob- 
 jected to the application of water to the surface, on the 
 ground of its tendency to resist this action; whilst others 
 have feared to resort to it lest it should diminish the cutaneous 
 activity, and produce a transfer of the disease to the nervous 
 centres. Both these views are founded on false notions of 
 the pathology of the disease, and experience has fully proved the 
 
SCARLET FEVER. Ill 
 
 apprehensions they suggest are without foundation. Equally 
 great has been the difference of opinion as to the mode 
 of application of the water. In this case as in all others, 
 the object proposed and the circumstances of the individual 
 patient must be kept in view. In the large majority of in- 
 stances, the object to be attained is merely the abstraction of 
 heat from the surface, and the consequent diminution of ner- 
 vous excitement. This may be effected with the greatest com- 
 fort to the patient and the least inconvenience to the attend- 
 ants, by simply sponging with water. It will allay the heat, 
 soothe the tormenting itching of the surface, and reduce the 
 frequency of the pulse. The temperature of the fluid should 
 be adapted to the sensations of the patient. There are great 
 constitutional peculiarities as regards the influence of tem- 
 perature on the surface. While some persons in health enjoy 
 a high temperature, and find all their functions performed 
 with most comfort during the warm season, others are then 
 languid and oppressed, and long for the return of the cold 
 weather. In the use of baths, a like diversity is found. The 
 languor and depression which in one person will follow the 
 resort to cold bathing, will in another result in equal degree 
 from the employment of the warm bath. Now these same 
 constitutional peculiarities are carried into the hours of sick- 
 ness. Tepid sponging may always be employed with benefit 
 where the skin is hot and dry, the pulse quick and strong, 
 and the patient restless. Affusion of water at a temperature 
 not less than 96° or 98° of Fahrenheit, will in most similar 
 cases be very beneficial, and especially in those patients where 
 there is great restlessness and delirium. It allays nervous 
 irritability, and is often followed by refreshing sleep. Cur- 
 rie, of Liverpool, a physician of great eminence of the lat- 
 ter part of the last century, has advocated in very strong 
 terms, the use of cold affusions in this disease as well as in 
 typhus fever, and he has been followed in this recommenda- 
 
112 AN ESSAY ON 
 
 tion by other writers. The preponderance of testimony is, 
 however, against it, and it appears to me to be founded on 
 imperfect views of the operation of cold. We are all familiar 
 with the fact, that its primary impression is sedative. This 
 cannot, however, be long maintained without producing serious 
 depression of the vital force. When it is interrupted before 
 this exhaustion is brought about, the result is increased action 
 of the general circulation, and also of the capillaries of the 
 part to which it has been applied. Both these conditions are 
 injurious in scarlet fever: and at the best the cases reported 
 by Dr. Currie prove only that no mischief resulted, since the 
 most he claims is the final abatement of the fever on the fourth 
 day. Dr. Chapman believes the cold affusion to be especially 
 adapted to those cases in which the nervous system is most 
 deeply involved, and he asserts that he has derived from the 
 application of cold water to the surface, more positive benefit 
 than from any other remedial measure he has employed. 
 There is one set of cases to which it is beyond doubt peculiarly 
 appropriate. I allude to those in which there is violent delirium? 
 with great heat of skin, very rapid pulse, and extreme restless- 
 ness, and not unfrequently convulsions, or at the least, violent 
 muscular twitching. Bleeding, whether local or general, is in 
 such cases very often followed by fatal results. But a cold 
 douche to the head, maintaining the impression by cloths wrung 
 out of iced water, while the whole surface is freely sponged 
 with that fluid at the temperature of the chamber, or but little 
 below it, will do more to procure tranquillity and reduce the 
 nervous excitement, than any other plan that can be adopted. 
 Much important testimony to the value of this treatment 
 variously modified, might be adduced. By Dr. J. Forsyth 
 Meigs the employment of affusion of water at 96°, containing 
 a small quantity of vinegar, is mentioned with approbation. 
 I have long resorted to baths from 96° to 100°, to which 
 whiskey has been added as a means of tranquillizing young 
 
SCARLET FEVER. 113 
 
 children and inducing sleep. The temperature of the surface 
 in this disease is much exalted above the natural standard of 
 health. When, then, we resort to the application of water 
 which feels warm to the hand of the person who uses it, it is 
 yet so far below the temperature of the patient that it ab- 
 stracts heat from the surface, and hence it is that apparently 
 tepid sponging is followed by nearly the same results as those 
 ascribed to more positive cold, and the shock being less, it is 
 not so liable to be followed by pernicious reaction. It dimi- 
 nishes the capillary excitement, and maintains a more healthy 
 condition of the cutaneous functions; the interruption to 
 which exerts so baneful an influence on the subsequent course 
 of the disease. The influence of these results on the disease 
 appears sufficiently great to account for the benefit conferred, 
 without adopting the suggestion of Dr. Chapman, that " while 
 mitigating undue excitement by its sedative agency, it also 
 proves more directly the corrective of the effects of the spe- 
 cific virus causing the disease;" to which I refer only for the 
 purpose of exhibiting how high is the estimate he places on 
 this mode of treatment. Dr. Condie is equally decided in 
 the expression of his confidence in it; and Dr. Bell, in his 
 work on baths, asserts " there is no other remedy which unites 
 to any thing like the same extent, efficacy with safety, and 
 immediate pleasurable results, as the cold bath." 
 
 "When we bear in mind the importance of the functions of 
 the skin, and the great influence the interruption of them 
 must have upon the condition of the circulating fluids, and the 
 nervous centres, it will not be supposed that undue prominence 
 is given to this remedial agency. More recently, similar views 
 have led to the adoption of a practice, which, though highly 
 lauded by some of my professional friends, who have employed 
 it, when first presented to the mind has no very strong claims 
 to regard. I allude to the employment of inunctions, origi- 
 nally suggested by a German author in the offensive shape of 
 
114 AN ESSAY ON 
 
 rubbing with the skin of fat bacon. It is rendered less dis- 
 gusting when modified, as by a recent English writer, who 
 commends it as equally applicable to all febrile diseases, and 
 resorts to an ointment composed of equal parts of suet and 
 lard, which is to be rubbed into the dry skin by vigorous fric- 
 tion. A somewhat similar practice has long been commended 
 by my valued friend, Prof. H. L. Hodge, who employs a lini- 
 ment composed of olive oil and spirits ammonia, in varying 
 proportions according to the coldness of surface or feebleness 
 of circulation in the capillaries. Dr. Hodge does not confine 
 this treatment to scarlet fever, but resorts to it in all cases of 
 febrile disease in childhood when accompanied by a harsh dry 
 skin. Whatever benefit may accrue from this practice in the 
 primary stages, can be ascribed only to the soothing influence 
 of the unctuous application to the skin, which acts here as in 
 erysipelas, in which it certainly allays the local irritation, and 
 thus by the removal of one important cause of excitement, may 
 tend to the subduing of the febrile action. How far it may be 
 applicable to the latter stages of the disease, and to those cases 
 in which the sedative influence of cold would be pernicious, I 
 am not prepared to express an opinion : though analogy affords 
 many examples, which might, perhaps, induce some to think fa- 
 vourably of the practice as modified by Mr. Taylor, and to give 
 it a trial, not only in scarlet fever, but in other febrile dis- 
 eases, with a dry, husky condition of the skin. Nothing can 
 be conceived less likely to promote the restoration of the pa- 
 tient than the German practice as reported in Banking's Ab- 
 stract. Not only is the material used for anointing the skin, 
 offensive in itself, but directions are given that the clothing 
 should not be changed, " as a clean shirt takes up more of the 
 fatty matter than one already saturated. The rubbing in is 
 to be kept up twice a day for three weeks, and once a day 
 during the fourth. The patient is, after this, to be washed 
 daily with soap and cold water, and then only is the warm 
 
SCARLET FEVER. 115 
 
 hip bath to be commenced." It would require the utmost con- 
 fidence of success, to reconcile an American mother to such 
 treatment, or to induce an American physician to make his 
 daily visits to a chamber so foul. Whatever benefit might 
 accrue from the softening of the cuticle, would be more than 
 balanced by the loathsome effluvia. Nor does the length of 
 time during which the application is to be made, convey an 
 impression at all favourable to the remedial influence of this 
 mode of treatment. I have heard, however, of families in 
 which it has been carried out literally in all its original dis- 
 gusting uncleanliness. 
 
 It will thus be seen that in the management of the simple 
 form of scarlet fever, I am inclined to adopt a very simple 
 treatment, even in those cases in which some symptoms of a 
 very formidable character present themselves. Emetics re- 
 commended by some, may be harmless if employed in the very 
 onset of the disease, when the spontaneous vomiting by which 
 it is often ushered in, would appear to afford a natural indi- 
 cation for their use. If the stomach is known to be loaded 
 with some improper food, or if the spontaneous efforts at 
 vomiting are unsuccessful, a small dose of ipecacuanha may 
 be given to aid in the expulsion of the undigested remains 
 of the last meal. I have never found it necessary to resort 
 to vomiting except in those cases which are ushered in by con- 
 vulsions as the primary symptom, and which in their onset 
 cannot be known to be scarlet fever, unless some direct com- 
 munication with the disease, or its presence in the family, 
 should give occasion for suspicion. In either case, the ob- 
 ject to be accomplished by the emetic is very simple. 
 
 When treating of the cause of the disease, I referred to the 
 fact that it is often developed by some agent independent of 
 the specific influence to which it owes its essential character. 
 Whatever disturbs the healthy balance of the system, may 
 thus prove the exciting cause of an attack of scarlet fever, 
 
116 AN ESSAY ON 
 
 and among children nothing more frequently acts thus, than 
 improprieties in diet, whether in quantity or quality. Diges- 
 tion is suspended for the time, either from having been taxed 
 beyond its normal power, or from the depressing influence of 
 the scarlet fever miasm. In either case the presence of the 
 ingestse in the stomach becomes a source of irritation, which 
 greatly aggravates the danger of the patient, often causing 
 convulsion. The more promptly this offending matter can be 
 discharged the better; and a dose of ipecacuanha, propor- 
 tioned to the age of the patient, should be given the moment 
 the power of deglutition is restored. The body should be im- 
 mersed in warm water, while a cold cloth is applied to the 
 head, or cold water poured upon it from a slight elevation. 
 This will almost always suspend the spasmodic action suffi- 
 ciently long to permit the swallowing of the ipecacuanha 
 which acts as a simple evacuant. Such cases generally occur 
 in early childhood or infancy. 
 
 Purging, beyond the mere evacuation of the bowels, as sug- 
 gested, by magnesia, is positively injurious, and the use of 
 calomel in this disease is, I think, so deleterious, except in 
 cases hereafter to be noticed, that if I were in doubt as re- 
 gards a case, whether it were scarlet fever or not, I should 
 think the doubt sufficient cause for withholding the use of that 
 remedy, so great is the depressing influence it exerts in its 
 primary impression. There is, in fact, no indication to be 
 met by the use of purgatives ; certainly none demanding the 
 resort to mercurials. Neither the symptoms nor the results of 
 examination of the bodies of the dead, afford any reason to 
 suspect the presence of those disorders of the viscera, either 
 functional or organic, to the relief of which this remedy is so 
 well adapted. The depressing influence of calomel, and the 
 irritation of the mucous membrane by the other cathartic re- 
 medies are both injurious. 
 
 Bleeding is better endured in the simple form of the disease 
 
SCARLET FEVER. 117 
 
 than in any other. But when the case is not violent it is un- 
 necessary, and if it assume a deeper grade of severity, my per- 
 sonal experience is very decidedly unfavourable to its employ- 
 ment. Dr. Graves, of Dublin, expresses himself strongly to 
 the same effect. He delineates very ably the state of medical 
 opinion and its influence on the practice of that city, at the 
 period at which his clinical lectures were delivered. The pic- 
 ture is the precise counterpart of what I myself witnessed in 
 this city in the years 1829 and 1830. He describes the cases 
 in which depletion was resorted to, and records the fatal results. 
 The cases which are attended by convulsions and high cerebral 
 excitement with very rapid pulse, are those in which, if in any, 
 blood-letting may be supposed appropriate. Dr. Graves says, 
 " This form of the disease where the pulse, without becoming 
 strong, at once became extremely rapid, bore Y. S. badly, and 
 required great caution even in the application of leeches; the 
 nervous symptoms only appeared accelerated by the system of 
 depletion, although the heat of the skin suggested its employ- 
 ment. The derangement of the brain and nerves in this form, 
 depends on something more than the violence of the circulation, 
 and originates in something altogether different from mere 
 cerebral inflammation or congestion. What that something 
 was, I cannot even conjecture, but it was probably the result 
 of an intense poisoning of the system by the animal poisoning 
 of the scarlet fever miasm." I have never seen any good re- 
 sult from it even in those cases in which the nervous symp- 
 toms were most severe, and the vascular excitement the most 
 intense, and I have, alas too frequently ! had occasion to 
 mourn over its fatal influence. The impression of cold will, 
 in these cases, be always sufficiently sedative to allay the ner- 
 vous excitement; and neither analogy nor direct examination 
 of the results on the bodies of those who die, affords any rea- 
 son to suspect the existence of cerebral inflammation in them. 
 In almost every instance in which I have resorted to depie- 
 
118 AN ESSAY ON 
 
 tion, either local or general, in cases of scarlet fever in the 
 primary stages of the disease, no matter how vigorous the pa- 
 tient, or violent the symptoms, the case has had a fatal ter- 
 mination; and in no cases has its evil influences been more 
 manifest than in those in which convulsions or violent delirium, 
 accompanied by sudden shrieks and grinding of the teeth, as 
 in meningitis, would appear to have presented the strongest 
 possible reason for a resort to it. In one recent case of a lad 
 of thirteen years, in whom the delirium was violent, amount- 
 ing to maniacal fury, with great muscular force, and strong 
 as well as rapid pulse, four ounces of blood were taken by 
 leeches, after which he was treated with mild diaphoretics and 
 morphia with the happiest result. 
 
 One case which occurred in what might be properly termed 
 the transition stage of my views of the treatment of this dis- 
 ease, will illustrate, at the same time, the character of a se- 
 vere attack of simple scarlet fever and the treatment I think 
 most appropriate. The subject was a healthy boy, five years 
 old. He had retired to bed in his usual health. About clay- 
 light I was called to see him with convulsions. I found him 
 wholly insensible, with violent spasmodic action of the muscles of 
 the whole body as well as of the extremities, pupils contracted, 
 pulse frequent, and skin hot. Though it was impossible to 
 arouse his attention, yet the least disturbance, as in moving 
 him, or administering an enema, produced increased convul- 
 sions followed by long continued muscular tremor. On in- 
 quiring into the history of the attack, I was informed he had 
 been waked up by a sense of sick stomach, and the convulsions 
 had occurred whilst he was in the act of vomiting. Portions 
 of an apple eaten on the previous day were ejected just as he 
 had swallowed it, imperfectly masticated. Supposing the case 
 to be one entirely dependent on indigestion, so frequent among 
 young children, I adopted the treatment appropriate to its re- 
 lief. A stimulating injection was promptly administered, and 
 
SCARLET FEVER. 119 
 
 the child removed to a warm bath ; and so soon as it could be 
 procured, a dose of calomel and ipecacuanha was given during 
 an interval between the convulsions, while mustard cataplasms 
 were applied to the extremities and epigastrium, for the pur- 
 pose of revulsion. At the end of two hours he vomited again, 
 throwing off an additional quantity of undigested apple ; soon 
 after which he recovered his consciousness, so far only as to 
 protrude his tongue when solicited to do so. He neither 
 spoke nor manifested consciousness in any other manner. He 
 continued through the day to start much, and manifested no 
 knowledge of the action of the bowels produced by a dose of 
 magnesia given soon after the operation of the emetic. As 
 the convulsions did not return, and the pupils recovered their 
 natural condition, I determined to rely on the counter-irrita- 
 tion of a blister, which was applied to the nape of the neck, 
 and cool cloths kept constantly on the forehead, and to wait 
 for the full effect of the purgative. The pulse continued very 
 rapid throughout the day, though the skin presented no indi- 
 cation of any rash. The following morning I found him with 
 a vivid eruption on the face and neck, conjunctiva injected, 
 eyes upturned, and pupils contracted, pulse very rapid. The 
 tendons of the wrist twitched incessantly under the finger ; 
 he started frequently, as though about to spring off the bed, 
 and grated his teeth with much violence. It was impossible 
 to arouse him ; and his pulse was still as frequent as on the 
 previous day. There could be no hesitation in recognising 
 scarlet fever, even if the tongue had not assumed the peculiar 
 appearance which is so common in that disease. There was, 
 however, no evidence of angina, except some little shrinking 
 on passing the finger beneath the angle of the jaw. The ce- 
 rebral symptoms were certainly urgent, and appeared to de- 
 mand the most energetic treatment. In any other disease 
 than scarlet fever, I should not have hesitated to resort to 
 free depletion. Sad experience of the fatal results of bleed- 
 
120 AN ESSAY ON 
 
 ing, whether local or general, in several cases, in which the 
 convulsions and delirium had been even more violent than 
 this, which had then recently passed through my hands to a 
 fatal termination, had led me to determine never again to em- 
 ploy depletion in such cases. I explained to the father my 
 views of the case, told him the result of my observation, as- 
 sured him of my readiness to meet any other physician of ex- 
 perience and good judgment in consultation on the case, or 
 even, if he desired it, to yield the treatment to another; that 
 if I employed any depletion, it must be to the smallest possible 
 extent. Twelve American leeches were applied to the temples, 
 by which but about one ounce and a half of blood was ab- 
 stracted — and the case was then committed to a mere expec- 
 tant treatment. The rash was fully developed. There was 
 no affection of the throat, beyond that which was indicated 
 by the tenderness on pressure. The coma gradually subsided 
 from hour to hour, till, on the fifth day, the symptoms all dis- 
 appeared, and convalescence was fairly established. The fa- 
 vourable result of this case afforded me much encouragement. 
 While in every such instance in which active depletion had been 
 employed by me for the relief of the cerebral symptoms, death 
 had ensued; here was a propitious result, though the amount 
 of blood drawn was too small to be entitled to any part of the 
 credit of the case. I was thus confirmed in the opinion, that 
 the cerebral symptoms were purely nervous, and had no con- 
 nexion with inflammation, or even vascular congestion, and that 
 the proper indication was merely to allay nervous irritation, and 
 to avoid every agent which should prostrate the vital energies. 
 I accordingly from that time adopted a treatment having this 
 object in view, in all similar cases, and have no hesitation in 
 expressing myself entirely satisfied with the result. I place 
 an entirely different estimate on the value of depletion in the 
 treatment of the sequelse of this disease. 
 
 I should now not employ even the calomel which was added 
 
SCARLET FEVER. 121 
 
 to the ipecacuanha in this case under the impression that it 
 was wholly dependent on gastric disturbance, — but should rely 
 on the simple evacuants, to get rid of the ingestoe ; following 
 them by the tepid bath or affusion, and the use of simple 
 drinks, with entire rest. The whole train of morbid pheno- 
 mena disappeared as the case approached the period at which 
 scarlet fever terminates. I saw it first before daylight on the 
 morning of Tuesday, and on Saturday convalescence was 
 fairly established. To sum up the treatment of simple scar- 
 let fever, I should adopt and recommend that of Dr. Arm- 
 strong : — " Open the bowels {not purge) every day with some 
 mild aperient, (if spontaneously opened, there is no need of 
 medicine.) Keep the patient at rest, between cool clean 
 sheets, or on a bed, or on a mattress with light clothing, and 
 in a temperature from 56° to 60° F. Sponge the surface 
 with tepid water twice or three times a day, while it is hotter 
 than natural. Admit plenty of fresh air, allow a bland diet, 
 and in two or three days the patient will be well." Above 
 all, do not allow the dread of the name scarlet fever to induce 
 the adoption of a treatment which shall be more injurious 
 than the disease itself. 
 
 While the general character of the simple form of scarlet 
 fever is sthenic, and, as I have remarked when describing the 
 treatment appropriate to it, will bear depletion better than 
 the other varieties, though rarely or never demanding it, the 
 anginose form, which is that in which it most commonly pre- 
 vails., is not so uniform in this respect. In different epidemics, 
 and sometimes between different families or individuals during 
 the same epidemic, it presents every grade of action, from 
 one of acute inflammatory fever, till it is merged, by imper- 
 ceptible shades, into the low or malignant form. Hence arises 
 the great variety in the modes of treatment recommended by 
 different authors, and the great difference in the mortality in 
 different years ; or in the same year at different places. This 
 9 
 
122 AN ESSAY ON 
 
 difference in mortality cannot always be ascribed to different 
 modes of treatment, though this does undoubtedly exert a 
 powerful influence. In the London Fever Hospital it varied, 
 in the course of eleven consecutive years, from one fatal case 
 in every six, to one in forty ; and an equally great variation 
 will mark the practice of most medical men, not only in the 
 course of years, but even during the same year, in different 
 parts of the same town or district of country, and in different 
 families. It is of the utmost importance, in estimating the 
 value of any given plan of treatment, to bear ever in mind 
 the variations in the stationary constitution of diseases, origi- 
 nally noticed by Sydenham, and confirmed by the report of 
 all careful observers since his day. There is no fact better 
 established in medical science, and none the influence of which 
 on modes of treatment is more decided. The transition 
 from a sthenic to an asthenic constitution of disease is not, 
 generally, sudden, but gradual. Occasionally we have the 
 outbreak of a violent typhous epidemic, with no perceptible 
 change in atmospheric conditions to herald its approach; 
 but, as the general rule, there is a gradual though perceptible 
 change in the prevalent type of all diseases, which will not 
 escape the notice of the close observer. Dr. Copland re- 
 marks with reference to this point: "During the stationary 
 epidemic constitution from about 1810 to 1820 or 1825, blood- 
 letting, even in this disease, especially in its more inflamma- 
 tory types, was much better tolerated than subsequently, and 
 some writers considered their recommendation of it as suffi- 
 cient to constitute it the chief remedy in all circumstances 
 and for all time, denouncing those who had preceded them for 
 advising different means, although more appropriate for the 
 types of the disease for which those means were employed. 
 More recently, and since late writers have ascertained that 
 blood-letting should be more cautiously employed even in the 
 most inflammatory type, cupping on the nape of the neck, or 
 
SCARLET FEVER. 123 
 
 leeching behind the ear, has been advised for the more sthenic 
 anginose form of the malady, and often practised by myself 
 for many years." "In the more sthenic diathesis or inflam- 
 matory type, if generally adopted, blood-letting is a destruc- 
 tive practice, unless in rare epidemic visitations, "when the 
 prevailing epidemic constitution admits of the practice, with 
 such limitations and cautions as the nature of the disease and 
 the peculiarities of the case suggest." The observation of 
 these facts has caused me to be very cautious in the expres- 
 sion of condemnation of any particular mode of practice. 
 The candid remark of the judicious and upright Dr. Fothergill 
 may be borne in mind with great advantage: " In some cases 
 the disease appears to be of so mild a nature, and so benign, 
 as to require but little assistance from art; persons even re- 
 cover from it under the disadvantages of unskilful and injuri- 
 ous management; whilst in others the progress of the symp- 
 toms is so rapid, and the tendency to corruption so strong, 
 that nothing seems able to oppose it." It is not, therefore, 
 just, always to estimate the advantage of a plan of treatment 
 by the recovery of a limited number of patients. It may 
 merely indicate that the power of nature for self-preservation 
 is sufficiently strong to resist the combined injurious influences 
 of the disease and the treatment. I desire to make this re- 
 mark with entire candour, and that it should be applied with 
 equal fairness to the treatment I myself suggest, as to that 
 often strongly recommended by others; while, at the same 
 time, I may safely assert that it is not without personal expe- 
 rience of the effect of other plans that I have adopted my 
 own. 
 
 The same general remark as to the limited duration of the 
 original disease, the importance of which I endeavoured to 
 impress when the simple form was under consideration, is 
 equally applicable to this. It is here of far greater import- 
 ance, however, to keep it ever in mind, and to allow it to 
 
124 AN ESSAY ON 
 
 modify the treatment. The greater urgency of the symptoms 
 appears to demand a proportionate increase of the energy of 
 treatment; the local lesions are frequently so severe from 
 the very onset, as to require anxious care; and the influence 
 they exert in prolonging the fever by their irritation after the 
 primary disease has subsided, is well calculated to render the 
 treatment obscure, and the result doubtful. Few minds are 
 so well balanced as to be able to resist the influence of these 
 circumstances, or capable of such nice discrimination as will 
 enable them to arrange the symptoms and adopt the treatment 
 without improper bias. Not only does the severity of the 
 local lesions, in many cases, incite to the adoption of a treat- 
 ment needlessly energetic, but the appearance of active inflam- 
 mation, the redness, heat, swelling and pain of the local lesions, 
 and the fear of the result of these local inflammations, is often 
 so great, as to overwhelm the judgment. I have known not a 
 few lives sacrificed to the anxiety to avert anticipated evils, 
 and to cure a condition which art can only relieve, while na- 
 ture herself is working out the cure, in the regular course of 
 events. Nor have I any wish to screen myself from the cen- 
 sure of being a participant in such results. The remembrance 
 of too many cases in which I have had reason to regret a too 
 energetic treatment, whether depletory or stimulating, urges 
 me thus earnestly to press opinions which have been formed 
 at the expense of much personal observation. 
 
 The occurrence of a local lesion giving rise to the anginose 
 variety of scarlet fever, does not of itself involve any change 
 in the general principles of treatment already laid down. In 
 its slightest degree the angina manifests itself by a little ten- 
 derness about the angle of the jaw, with some enlargement of 
 the lymphatic glands. If the condition of the fauces is ex- 
 amined, the membrane lining the arches and covering the 
 tonsils and uvula, will be found more intensely red, and some- 
 times oedematous. From this condition the severity of the 
 
SCARLET FEVER. 125 
 
 local affection gradually increases, till it assumes the various 
 appearances formerly described. 
 
 The only change in the treatment demanded by this local 
 affection, when there is no tendency to sloughing of the in- 
 flamed organs, nor general disposition to prostration of the 
 vital force, is attention to those agents which will afford pre- 
 sent relief from the discomfort it occasions. The external 
 swelling and tenderness will yield to the soothing influence of 
 warmth and moisture. When properly applied, this is always 
 grateful ; but when done in a slovenly or careless manner, is 
 exceedingly offensive. A flannel cloth wrung out of hot water, 
 and applied with moderate firmness, and of several folds 
 thickness, and then covered with a layer of oiled silk, and 
 that enveloped in a nice napkin, will retain the necessary de- 
 gree of warmth and moisture a long time. It is lighter than 
 the poultices commonly resorted to, and is free from the smell 
 which renders them offensive, and does not leave the dried 
 deposit which forms around the edges of the cataplasms. 
 Next to this in adaptation is a thin layer of Indian mush, 
 thoroughly boiled till it forms an adhesive mass, and applied 
 in a thin flannel envelope, taking the same precautions to 
 avoid evaporation. Better than either is a portion of the 
 article known as spongio-piline, made of wool and sponge, 
 wrought into a thick felt-like texture, and coated on one side 
 with gutta-percha, cut into such a shape as fits the neck, 
 soaked with warm water moderately and bound lightly around 
 the throat. This forms a very convenient and comfortable 
 epithem; a little rose water or Cologne water, sprinkled on 
 the wrappings or mingled with the hot water in which it is 
 soaked, covers any unpleasant odour. Dr. Sutton of Aurora, 
 Illinois, in an exceedingly able and interesting paper published 
 in the Medico- Chirurgical Review of Philadelphia, for Novem- 
 ber, 1857, ascribes great advantage to the use of a portion of 
 fat salt bacon adapted to the size and shape of the part, and 
 
126 AN ESSAY ON 
 
 bandaged around the neck. He applies it at an early period 
 of the anginose and malignant cases. Some think these are 
 matters which may be left to the attention of the nurse ; but 
 not only the reputation of the physician will be increased by 
 his ability to give minute directions about apparently trifling 
 matters, but, what is of vastly greater consequence, not only 
 the present comfort of the patients will be promoted, but these 
 little things influence, in a great degree, the ultimate result. To 
 no portion of human experience is the line of the satirist more 
 applicable, than to that which comes under the notice of the 
 medical adviser: 
 
 " Let school-bred pride dissemble all it can, 
 These little tilings are great to little man." 
 
 Great not only in relation to comfort, but to results. 
 
 But while warmth and moisture externally applied are thus 
 important, the internal condition requires an opposite treat- 
 ment. There is nothing so effectually soothes the internal 
 irritation, and averts the probable results of the excited action 
 of the capillaries of the mucous membrane, as the free use of 
 ice. In the same manner as the sponging or ablution of the 
 surface, it acts not only in the relief of the local inflamma- 
 tion, but also on the general nervous system. The natural 
 instinct of the patient calls for such treatment, and its appro- 
 priateness will commend it to every one ready to throw off the 
 trammels of authority. I had long employed it to great ad- 
 vantage before I was aware that it had been used by any other 
 person, but am happy to be able to fortify my testimony to its 
 usefulness, by the report of Dr. S. Jackson of Northumber- 
 land, which is given in the North American Medical and Sur- 
 gical Journal. Dr. Jackson deserves, I believe, the credit of 
 first drawing the attention of the profession to its use, through 
 the agency of the press. I direct the ice to be divided into 
 small fragments, such as can be easily held in the mouth 
 while dissolving. When thus prepared, wrapped well in flan- 
 
SCARLET FEVER. 127 
 
 nel and placed in a bowl at the bedside, so as to be easily 
 accessible, the patient may use it as freely as is agreeable. 
 When old enough to perform the act of gargling, iced water 
 is the best article for that purpose, or tepid water with vinegar 
 and honey. In a large majority of cases I have found this 
 local treatment, joined to the same general course previously 
 recommended, of mild diaphoretic and alterative liquids, lead 
 to the entire subsidence of the local symptoms simultaneously 
 with the decline of the primary fever. 
 
 "Would that I could promise so happy a result in every case, 
 even where the primary symptoms are least threatening. It 
 occasionally happens that ulceration of some part of the 
 mucous membrane occurs, either in the posterior nares or the 
 fauces, and gives rise to a profuse secretion of viscid mucus, 
 or a discharge of an acrid fluid, which spreads the destruction 
 over adjacent parts; and, as I have mentioned already, even 
 excoriates the skin when it is allowed to rest upon it. It is 
 almost equally important to relieve both of these conditions. 
 The latter secretion, by spreading the ulcerative process, adds 
 to and prolongs the irritative fever, while the former very 
 materially increases the risk of a fatal termination by the se- 
 rious impediment to free respiration which it interposes. The 
 vital powers already prostrated by the depressing agency of 
 the miasm which produces the disease, the blood poisoned by 
 its deleterious influence and the arrest and perversion of the 
 secretions, the life of the patient may depend on the freedom 
 with which air is drawn into the lungs. The nervous force 
 diminished and the muscular power abated, we have only to 
 obstruct the air passages through which the life-giving oxy- 
 gen is admitted, to cut off the only avenue for hope. How 
 often have I seen a poor child lie with the nostrils — the na- 
 tural breathing channel — entirely obstructed: the mouth un- 
 naturally open to supply a supplementary avenue for air: yet 
 tossing and struggling in instinctive efforts for fresh air to 
 
128 AN ESSAY ON 
 
 vivify the blood; while the injected conjunctiva, the up-turned 
 eye, and the livid hue, all told how vain was the effort. Though 
 When our patients have reached this point in the downward 
 course, little hope can cheer our efforts, even then they should 
 not be abandoned, as relief to suffering is within our reach, 
 even though death may finally conquer. Emetics of sulphate 
 of zinc and ipecacuanha, or of salt and mustard, are advised 
 by some authors in order to evacuate the throat and fauces, 
 and to produce a revulsive action. My own experience does 
 not enable me to endorse the recommendation. The vital 
 forces are too much exhausted to be thus rallied, and the lo- 
 cal lesion too firmly rooted to be thus removed. Gargling is 
 then wholly useless; the seat of the diseased action is beyond 
 its reach, and the barbarous substitute of swabbing is but little 
 more effective, with all the pain it gives to the patient and 
 trouble to the operator. The syringe affords a most effectual 
 and very easily applied remedy. When no other was accessi- 
 ble, I have employed a common gill pewter pipe; but the neat 
 syringe with a long ivory tube, now used for cleansing the ear, 
 is admirably adapted for this service. Water, alone does not 
 sufficiently deterge the mucous membrane. A little nice soap ? 
 which has no volatile oil in it, may be diffused in the water, 
 in those cases where the irritation of the mucous membrane 
 gives rise to a viscid tenacious secretion; or if this is not ef- 
 fectual in changing the action, a very weak solution of sul- 
 phate of copper or zinc. Either of these agents coagulates 
 the mucus and facilitates its removal at the same time that it 
 acts kindly on the diseased membrane. In those cases in 
 which the secretion is thin and acrid, I have found simple 
 lime water the best detergent. An infusion of rose leaves 
 forms a peculiarly elegant wash, where we require only 
 cleansing of the parts, or in cases where there is much ulcera- 
 tion with febrile action. Claret wine diluted with water may be 
 employed. This may be used as a drink also in asthenic cases 
 
SCARLET FEVER. 129 
 
 "with great advantage. Any of these substances may be thrown 
 into the nostril, care being taken to have the head elevated 
 at the time, and the person of the child inclined forward, while 
 the direction given to the syringe should be such as will cause 
 the fluid to pass toward the posterior nares, and not toward 
 the cells and sinuses. When the throat is much swollen, the 
 fluid thrown into one nostril will often return through the 
 other, thus effectually cleansing both; carrying before it large 
 quantities of coagulated mucus and affording instant relief; 
 in other cases it will be rejected through the mouth. The 
 greatest trouble it causes is some little retching or sneezing, 
 either of which is advantageous to the patient. I have often 
 saved life by this simple resort, and commend it to notice as 
 of great practical value. Washes thus thrown into the nostril 
 are applied to the pharynx and tonsils more effectually than by 
 swabs through the mouth. When these are employed, they 
 should always be large soft camel's hair brushes, short and 
 thick, and not long and inflexible. The solution of sulphate of 
 copper or zinc should not be employed during the first five 
 days of the disease. They then only increase the irritation 
 and aggravate the suffering of the patient, as well as promote 
 the ulceration they are so adapted to cure in the later stage. 
 Purging as a curative agent is needless, though it is impor- 
 tant in this form as in the simple, to secure a regular action 
 of the bowels, which may be readily effected either by small 
 quantities of calcined magnesia or the use of the neutral mix- 
 ture. We meet with some cases in which there is a tendency 
 to diarrhoea, caused by the irritation of the acrid secretions 
 swallowed by the child. These are most effectually treated 
 by the magnesia in very small doses, which absorbs the acid 
 and carries off the cause of irritation. It should be followed 
 by suitable doses of Dover's powder or laudanum. 
 
 After the bowels have been moderately evacuated by the 
 magnesia, or where it is preferred, a small dose of castor oil 
 
130 AN ESSAY ON 
 
 as in the simple form, we may resort to the usual diapho- 
 retic remedies as advised when describing the treatment of 
 that form of the disease. The solution of the chlorate of pot- 
 ash is especially well adapted to this form. The citrate of 
 potash may be given in the state of effervescence to those pa- 
 tients who are old enough to swallow it promptly, before the car- 
 bonic acid gas has escaped, and as there suggested the spiritus 
 etheris nitrosi could be added. I have found great benefit 
 from the practice of securing some tranquil rest by the care- 
 ful administration of small doses of morphia in these diapho- 
 retic solutions in the latter part of the day or evening. I do 
 not combine them with the entire quantity of the mixture, but 
 direct the addition of doses of suitable amount as the state of 
 the patient requires or permits. A slight anodyne combined 
 with a diaphoretic draught, will compose a restless child, 
 sooth the delirious disturbance, and secure tranquil sleep, and 
 thus economize the strength and promote the recovery of the 
 patient. I know of no point in the treatment which is more 
 important than this. 
 
 But whilst I thus recommend, as the result of my own obser- 
 vations, in a field by no means limited, a treatment so simple, 
 and by some, thought inert, when brought into contest with 
 a disease of so formidable character, there are not wanting 
 many authors, and those, too, of the very highest authority 
 injmedical science, who urge a very different plan. General 
 bleeding is not without its advocates, as well among our own 
 medical authors as those of Europe. Even those writers, how- 
 ever, who most recommend its employment, do not hesitate to 
 admit that there are epidemics to which it is inappropriate. 
 Cerebral complications have been thought especially to de- 
 mand it; on that point I have already delivered my opinion. 
 I have never known a patient to recover from the anginose 
 form of scarlet fever when I employed the lancet. The rapidi- 
 ty of the circulation, the heat of the surface, and the buffy 
 
SCARLET FEVER. 131 
 
 coat on the blood, which have been adduced as indications for 
 bleeding or justification of its use, have all been proved by 
 more accurate observation to be susceptible of a different con- 
 struction. I do not mean to assert that it is not possible for 
 the disease to assume a character which may demand such 
 treatment. I know it to be capable of changes so extreme, 
 that I can easily believe such may have been its character 
 without my having met with the cases. 
 
 But even many of those authors who coincide with me in the 
 abandonment of general bleeding, still urge the necessity of the 
 topical abstraction of blood by cups or leeches. This practice 
 is, I think, open to still greater reprehension than the other. 
 Not only is it subject to the same objection on account of its 
 depressing influence, but there is superadded the liability to 
 ulceration of the bites of the leeches or the gashes of the sca- 
 rificator, which give rise to tedious sores, and often leave un- 
 sightly scars, even if the vigour of the patient be sufficient to 
 carry him through the combined injurious influences of the 
 disease and the treatment. While modern observation has 
 cast a shade of doubt on the necessity for blood-letting in 
 even the pure phlegmasia, it has brought still greater dis- 
 credit on the resort to it in the mixed cases of local inflam- 
 mation with specific fever. Even quinsy, which is more 
 closely allied by its topical lesions to anginose scarlet fever 
 than any other disease, is rarely, if ever, arrested in its pro- 
 gress by either general or topical blood-letting. While, 
 therefore, there is much to discountenance the resort to these 
 measures, there is, on the other hand, little to invite to their 
 use. 
 
 The employment of emetics has been highly commended by 
 many authors, as the first effort in the treatment of the angi- 
 nose form of the disease, and their use may be vindicated 
 more easily than that of bleeding. The shock given to the 
 nervous system is by some thought to promote the regular 
 development of the disease. This is at least a questionable 
 
132 AN ESSAY ON 
 
 assertion. I believe the only mode in which they can act ad- 
 vantageously, is by the discharge of the contents of the 
 stomach, which might, if retained, become a source of irrita- 
 tion, and by the production of that determination to the sur- 
 face which accompanies the act of vomiting. Antimonial 
 emetics are wholly unsuited. Ipecacuanha is the best article 
 that can be employed for the purpose; and next to it I rank 
 the powdered alum, so highly and justly recommended by Dr. 
 Meigs in croup. This would exert a beneficial influence on 
 the fauces and pharynx, as well when rejected as when swal- 
 lowed. Dr. Sutton recommends strongly salt and mustard, 
 and Dr. Copland the addition of capsicum to whatever agent 
 is employed. 
 
 Purging, when persisted in beyond the free evacuation of 
 the bowels, is not only uncalled for, but pernicious. It cannot 
 remove the specific irritation of the mucous membrane of the 
 alimentary canal, and adds another to that already existing. 
 Even Dr. Hamilton, while he lauds highly the advantages of a 
 free purge in the beginning, admits that it is not required 
 subsequently. The recovery of patients after vomiting or 
 purging, cannot be adduced as evidence of the benefit of the 
 practice, for reasons already assigned; and when there are 
 any signs of irritation of the mucous membrane, purging is 
 decidedly injurious. Dr. Fothergill, speaking of the treatment 
 of the disease, says: " Bleeding was prejudicial," but with 
 that caution which gives the more weight to his authority, 
 adds, " in general, some admit of it at the first attack, but 
 later it never fails to aggravate the symptoms, and in some 
 cases it appears to have produced fatal consequences. Nor 
 has purging," he continues, "been observed to be more bene- 
 ficial, and nitrous cooling medicines produce the like effect." 
 Gentle emetics, if administered early, he commends highly, 
 declaring that they often cure the disease, even when the 
 symptoms are most threatening. 
 
 It not unfrequently happens that about the fifth day from 
 
SCARLET FEVER. 133 
 
 the first invasion of the disease, as the primary fever subsides, 
 the pulse loses its frequency, the skin becomes cool and moist, 
 and the patient languid. A moderate use of quinine in such 
 circumstances is highly important. Great care is requisite 
 not to push it too far, either in quantity or the length of 
 time. A few days bring us to the period which is especially 
 liable to inflammatory sequelae. A return of the frequency 
 of the pulse, and an increase of the languor, will mark the 
 occurrence of this condition, and should cause an immediate 
 suspension of the tonic treatment, and great care about 
 the diet. This is especially necessary, as it is impossible to 
 foresee in which of the organs liable to the secondary affec- 
 tions the mischief may develop itself; and the attacks are 
 so formidable, that it is important to guard against the very 
 beginning of the evil. A cerebral or cardiac inflammation 
 would be materially aggravated by the influence of the quinia. 
 The condition of the urine is an important means of de- 
 termining how far it may be proper to pursue the tonic treat- 
 ment. While that secretion continues abundant and clear, 
 and the skin cool and perspirable, there can be no risk. I 
 was indebted to my honoured friend, the late distinguished 
 Professor Chapman, for this suggestion. There is, however, 
 nothing novel in the resort to the use of cinchona in malignant 
 scarlet fever. It is as old as our knowledge of the remedy 
 itself. A recent author, Mr. Hood, of London, has claimed 
 for the quinia a specific influence in counteracting the cause 
 of the disease itself, and gives to it the most important posi- 
 tion in the treatment. This, I am confident, is an erroneous 
 idea; and, if admitted, would lead to a dangerous practice. 
 But though I cannot subscribe to the assertion made by Mr. 
 Hood, that "quinine is the antidote to the specific poison of 
 scarlet fever," I can with confidence recommend it when used 
 as I have suggested above as the best agent we possess to 
 restore tone to the exhausted nervous system, and thus restore 
 the blood to its normal condition and prevent the local dis- 
 
134 AN ESSA7 ON 
 
 organization which would otherwise occur in the throat and 
 kidneys. It should be given in full doses, at intervals of two 
 or four hours. The interruption of the secretion from either 
 of these eliminating organs, or the deep colour or turbidity of 
 the urine, would at once indicate the propriety of suspending 
 the quinine. 
 
 It is at this period that we frequently meet with that very 
 formidable complication, inflammation of the larynx, pro- 
 ducing croup. Even in this complication no benefit will result 
 from depletion, or any other depressing agent. Dependent 
 on the extension of the specific inflammation from the fauces, it 
 must be relieved by local treatment alone. Emetics of alum, 
 zinc, or ipecacuanha are the most valuable of our remedies, 
 and may be repeated as often as the urgency of the symptoms 
 requires; care being taken at the same time to afford proper 
 support, by suitable nourishment and even stimulants. One 
 of the happiest results I ever achieved, was in the recovery 
 of a child of about two years of age, in whose case the disease 
 was ushered in by convulsions, which yielded to tepid baths, 
 with cold affusions to the head. The disease then ran its re- 
 gular course, accompanied with much sloughing of the fauces 
 and uvula, and leaving an exceedingly red ulcer. This I 
 treated with the injections recommended above, and was flat- 
 tering myself with the expectation of a speedy recovery, when 
 the harsh clangor of a croupy cough sounded like the knell of 
 hope. I procured at once a stick of nitrate of silver, securely 
 fastened in a quill, and, depressing the tongue, thrust it deep 
 into the fauces, with the design of extending the application 
 to the very verge of the glottis itself. A sudden struggle of 
 the child broke off the caustic in the quill, and, to my inde- 
 scribable horror, one gulp carried it into the stomach. To fail 
 in one's efforts to cure is disheartening enough, — to feel that 
 those efforts, however well meant, have rendered death certain 
 is like being dragged at the chariot wheel to swell the tri- 
 
SCARLET FEVER. 185 
 
 umph. Determined not to yield without an effort, and saying 
 nothing of the accident, I called for the salt cellar, which was 
 promptly handed me, and compelled the child to take large and 
 repeated draughts of a strong solution of salt. This of course 
 produced free emesis, at the same time that it rendered insolu- 
 ble and inert the poisonous mass thus undesignedly passed 
 into the stomach. "Whether the result may be ascribed to the 
 action of the caustic, or that of the saline application to the 
 local disease, or, what is more probable, to the oft repeated 
 vomiting, I am not prepared positively to assert. I am dis- 
 posed to divide the credit between the two latter influences, 
 providentially though unintentionally applied. Certain it is 
 that most unexpectedly the child recovered. 
 
 But the most judiciously planned treatment, though faith- 
 fully carried out, will not ensure a successful result, even in 
 those cases which do not manifest any very unfavourable 
 symptoms at the beginning. The impeded deglutition, the la- 
 boured respiration, the swollen lymphatics, the oedema of the 
 neck, occurring about the end of the first week, or even sooner, 
 all speak of a condition full of danger, while a hard, quick pulse 
 which generally accompanies this condition, would appear to 
 demand local depletion for the relief of the local disease. We 
 must not allow ourselves to be beguiled even now by this simu- 
 lation of inflammatory action. The corded pulse tells of irri- 
 tative action, but not of one which can be removed by deple- 
 tion, either local or general. Neither would the resort to 
 blisters be a whit more beneficial. Dependent on the disease 
 of the mucous membrane, it will only yield as that subsides. 
 Happy indeed were it for the patient if it were certain then 
 to disappear. Too often the inflammation results not only 
 in effusion into the cellular tissue, but also in suppuration, 
 either in that tissue or in some of the glands, leaving one of 
 the results of which we shall speak when we come to treat 
 of the sequels. This acute glandular enlargement and effu- 
 
136 AN ESSAY ON 
 
 sion will yield more kindly to the continuation of poultices 
 and injections than to any other plan. Iodine and the iodide 
 of potassium have been employed both locally and internally, 
 but I believe without any well attested advantage. 
 
 The diet of the patient in anginose scarlet fever should 
 also claim the attention of the physician. During the earlier 
 stage, the remarks made on the simple form are equally appli- 
 cable here. Water ices, iced cream or chocolate ice, subacid 
 fruits and whey, either frozen or dissolved, are excellent, if 
 used with moderation. When the farinaceous food is accep- 
 table, which it often is not, any of the usual preparations of 
 arrow root, rice flour and tapioca may be employed. Milk and 
 water and stale bread may be used sparingly. As the primary 
 fever subsides, animal broths, and bread and milk are well 
 adapted ; still keeping in view the fact that quantity is quite as 
 important as quality. 
 
 The treatment of those cases in which the eruption appears 
 imperfectly developed from the first, or in which, after having 
 been well marked, it recedes, or where the force of the attack 
 falls upon the throat, from the very beginning, causing great tu- 
 mefaction and difficulty of deglutition, must be very energetic. 
 In all these cases, this condition evidently results from the 
 overwhelming influence of the poison upon the nervous system. 
 Whether convulsions, or restlessness, or stupor, complicate the 
 case, or mere languor and exhaustion, all are but varying phases 
 of one condition, and that, a condition which is to be removed 
 by appropriate stimulation ; and it is in these cases that the 
 capsicum is productive of the happiest results. It was, I con- 
 fess, with great reluctance, I was first prevailed on to resort to 
 a remedy apparently so little appropriate to the treatment of a 
 disease in which the rapid circulation and heated surface 
 seemed rather to call for remedies which should produce a re- 
 frigerant impression; and to force a harsh irritating liquid 
 into a throat already inflamed, was, I thought, little short of 
 
SCARLET FEVER. 137 
 
 a refinement of cruelty. The entire failure of the cooling 
 treatment in such cases, led me to test the opposite course, and 
 I can recommend it with entire confidence. Weak animal 
 broths, freely charged with capsicum, may be given with great 
 safety, even to the youngest infants in this condition; and 
 though it may not — indeed it rarely does — so rouse the ener- 
 gies of the system as to cause the full development of the erup- 
 tive features of the disease, it will so far excite the vital 
 forces as to carry the patient safely through the regular period. 
 Should there be much local disease of the throat, it will re- 
 ceive great benefit from the passage of the capsicum over it. 
 I have often administered the simple infusion when the stomach 
 rejected the broths, or when I desired to maintain a more con- 
 stant local impression. The common formula of a teaspoonful 
 of powdered capsicum, the same quantity of common table salt, 
 a large spoonful of vinegar, and a half-pint of boiling water, is 
 an exceedingly good one. Of this, a teaspoonful may be given 
 every hour or two to a child of five years old and upwards, 
 followed by a small portion of broth, or even wine-whey. 
 Brandy and quinine have not the same beneficial influence in 
 these cases that they exert over those we shall consider here- 
 after. They oppress the nervous centres instead of relieving 
 the load. "Where there is great restlessness I have derived ad- 
 vantage from moderate doses of morphia, given in the liquor 
 acetatis ammonire, or, which is more often tolerated, from small 
 doses of the Dover's powder. Wine-whey having more ten- 
 dency to promote the determination to the skin, than quinine 
 and brandy, may be given with safety, even in cases where these 
 too would be inappropriate. The resort to hot and stimulating 
 baths, irritating frictions, and the revulsive treatment generally, 
 which would naturally suggest itself, has never been followed by 
 any advantage, so far as I have had opportunity for obser- 
 vation; and the internal use of carbonate of ammonia has also 
 disappointed my expectation. 
 10 
 
138 AN ESSAY ON 
 
 Under the plan of treatment thus indicated, I have found 
 the cases in which the eruption was irregular, defective, or 
 even entirely absent, yield quite as large a percentage of re- 
 covery as those which are accompanied with the most intense 
 degree of cutaneous inflammation. It is worthy of remark 
 that such cases are less liable to be followed by dropsical in- 
 filtration of the cellular tissue, though the convalescence is 
 more tedious and imperfect. 
 
 Dr. Copland, on the contrary, is disposed to look to the kid- 
 neys as the organs on which the force of the disease falls in 
 these cases, and directs attention to the removal of this "con- 
 gestion or affection as a primary intention of cure, and when- 
 ever the state of the constitutional power does not admit of 
 vascular depletion," advises "dry cupping on the loins, and 
 an epithem applied on flannel or spongio-piline to the same 
 parts, composed of: — 
 
 Liniment. Terebinth., gij. 
 Linim. Camph. Comp., 5j. 
 01. Olivge, jiij. 
 01. Cajeputt, 3J. 
 
 The flannel to be covered with oiled silk. This is, I doubt 
 not, an excellent practice. 
 
 While, as we have seen, death occasionally defies our best 
 directed efforts, and terminates the course of even simple scar- 
 let fever, either as the result of some unexpected local inflam- 
 mation, or, more often, of one of the sequels of the disease ; 
 and with greater, though still varying frequency, occurs in all 
 stages of the anginose variety — the malignant form more 
 often sets at defiance the utmost energy of treatment, even 
 when directed by the most consummate skill. The melancholy 
 picture of its ravages in the earlier period of the settlement 
 of this country, as drawn by Dr. Kearsley, has been already 
 exhibited ; and similar vestiges of its progress have been left in 
 all parts of Europe, as well as in every age, of the diseases of 
 which we possess any history sufficiently accurate to enable 
 us to distinguish them clearly. The very term malignant, 
 
SCARLET FEVER. 139 
 
 conveys, even to the unprofessional ear, the idea of great dan- 
 ger, and in the language of medicine is meant to express a 
 great tendency to the prostration of the vital forces. The 
 knowledge of the lethal character of this form of the disease, 
 should, however, lead to no despondency, but rather stimulate 
 to more determined effort to rescue the patient, and increase 
 the triumph of medical science. There are many other dis- 
 eases which partake more or less, at different times, of this 
 tendency to prostration. Between them and malignant Scar- 
 let Fever, there is however this very important point of dif- 
 ference: that in this the local lesions are very severe, and 
 often in themselves sufficient to cause death, even though the 
 vital energy were not impaired by the peculiar character of 
 the case. 
 
 A theory which taught that in this, as in the kindred forms 
 of fever characterized by the same tendency to rapid decline 
 of vital power, there was a previous stage of excitement, of 
 greater or less intensity; upon which the subsequent depres- 
 sion depended, not as a mere sequence, but as the effect upon 
 a cause, was at one time generally received; and exerted a 
 most deleterious influence on the interests of medical science. 
 Discarded now by most authorities from its position in con- 
 nexion with other fevers, it still exhibits some lingering traces 
 of its influence in a few of even the more modern writers on 
 this disease. Those who adopted this view, recommended in 
 strong terms the prompt resort to an antiphlogistic treatment 
 of the early stage, under the impression of the fallacious hope 
 that by such measures they would diminish the primary re- 
 action, and thus avert the consequent depression ; and there 
 are not wanting authors of even a recent date, who still teach 
 this erroneous doctrine ; and strongly recommend the prompt 
 resort to bleeding, vomiting, and purging. When called early 
 to these cases, they do not hesitate to direct an antimonial 
 emetic, followed by an active mercurial purgative, nor do they 
 shrink from a prompt and decided bleeding if these fail. They 
 
140 AN ESSAY ON 
 
 assert that " this treatment, if adopted at the onset of the 
 symptoms, will, generally, not only moderate the fever, but 
 shorten the duration and violence of the disease." In the 
 clinical lectures of Dr. Graves, of Dublin, he describes vividly 
 the influence of this theory on his own mind: the certainty 
 with which he attributed the mortality of the disease in other 
 hands to a neglect of proper evacuants : and the zeal with 
 which he himself brought it to bear on his own practice ; and 
 candidly admits the result to have caused him to abandon the 
 theory and change his treatment. 
 
 Nor is this view and the practice founded on it, confined to 
 European physicians. One of our own writers on the diseases 
 of children, Dr. Condie, has adopted them to their full extent, 
 and claims for his practice a degree of success which would 
 justify the positive terms in which he commends his views. 
 " In a table of two hundred and sixty-eight cases, occurring 
 during different epidemics of considerable extent and severity, 
 and treated on the plan laid down by me," (into which bleed- 
 ing, calomel in full doses, and castor oil with spirits of tur- 
 pentine, as purgatives, enter,) "two hundred and twenty-three 
 recoveries, and forty-five deaths are enumerated." Dr. Con- 
 die asserts of the treatment he recommends, that "when judi- 
 ciously carried into execution, it is calculated to disarm the 
 disease of its ' malignancy ' and to prevent the necessity for 
 a resort to powerful cordials, tonics and antiseptics, in the ad- 
 vanced period of the attack, and to remove the putrid symptoms 
 when they show themselves." " The bold and indiscriminate 
 use of the lancet," Dr. Condie "strongly objects to; but of 
 the good effects a cautious use of blood-letting in the manner 
 and under the circumstances directed, is calculated to produce," 
 he says, " I speak from actual observation." " It is," adds Dr. 
 C., " unquestionably, in a large number of cases, the only * re- 
 storative and tonic ' upon which any confidence can be placed." 
 In thus quoting the testimony of Dr. Condie, I have designed 
 
SCARLET FEVER. 141 
 
 to furnish the strongest statements that can be offered in fa- 
 vour of the antiphlogistic treatment. 
 
 I need not repeat what I have already said when treating 
 of the other forms of this disease, that, believing the pri- 
 mary influence of the cause to be depressing, I cannot adopt 
 a view which assigns to its first impression a sthenic charac- 
 ter. If bleeding, and antimonials, and purgatives are inap- 
 propriate to the simple anginose form, much less are they re- 
 quired in that now under consideration ; and Dr. R. Williams, 
 after a careful investigation of the history of the epidemics 
 which have prevailed from 1763 to 1834, asserts, with regard 
 to scarlet fever in general, " that the chances of recovery are 
 diminished by the practice of bleeding, in the ratio of nearly 
 four to one, as compared with the chances supposing the pa- 
 tient not to have been bled." 
 
 With this expression, my own observation is concident, and 
 my views are sustained by not a few authorities of deserved 
 repute. Dr. Fothergill, than whom a more accurate, careful 
 observer, or more honest writer, cannot be found, when he 
 sums up his views of the practice and treatment of this dis- 
 ease, of which it is evident he saw the malignant form, asserts, 
 " that a cordial, alexipharmic, warm regimen has been found 
 by experience to be of the most use in such cases," and con- 
 demns as injurious, " bleeding, purging, and antiphlogistics 
 liberally employed." He says: "In some of the first cases 
 I met with, the quickness of the pulse, the degree of heat, the 
 apparent inflammatory redness of the eyes and face, and pain 
 in the head, sometimes urged me to order bleeding, especially 
 if there were any marks of plethora; but in these cases it did 
 not appear to have any advantageous effects; so that notwith- 
 standing the vehemency of the symptoms above mentioned, 
 it seems proper in general to omit this evacuation." 
 
 Dr. Kearsley, speaking of the disease as it appeared in 
 Philadelphia in 1746, says: — "The pulse was generally full 
 
142 AN ESSAY ON 
 
 and quick, yet attended with some remissions and even sink- 
 ings, but it most commonly kept up those deceiving strokes 
 which sometimes but very improperly indicate the use of the 
 lancet." .... "Although most of the symptoms in 
 the beginning of this disease, as well as the fulness of the 
 pulse, appeared to point out to us the necessity of bleeding, 
 yet, should we have complied with the indication, it would 
 have proved a fatal error." That this opinion was the result 
 of observation is proved by the remark, that " the blood which 
 has been drawn away in these cases has been often observed 
 to have a tenacious glue upon the surface, and yet, neverthe- 
 less, it has been found underneath to be broken, loose and 
 divided in its texture, and has also thereon very evident marks 
 of a putrid gore which must and does increase by bleeding." 
 " One blood-letting may make a difference of a change from 
 a texture that, with proper management, would have carried 
 a patient through the sickness with safety, to no texture at 
 all, but a total dissolution of all animal fluids, which must in 
 course terminate in death. Of such vast consequence is this 
 one article of bleeding, that it has been my choice to give 
 this caution against it in the strongest terms." Dr. Burrows 
 in an interesting article on this disease, in the Library of 
 Practical Medicine, remarks of the malignant form, that, " it 
 quickly indicates its formidable nature by the sudden de- 
 pression of the vital powers. If blood-letting from the arm 
 be a remedy of doubtful propriety in the two former varieties, 
 it is here hazardous in the extreme." Dr. Chapman says: — 
 " The abstraction of blood appears to be required by the 
 loaded state of the organs, and contra-indicated by the de- 
 pression of the vital energies. My own conviction is, that it 
 should not be hazarded, unless reaction is pretty firmly es- 
 tablished, the circulation in some force, and the skin warm, and 
 even then is to be resorted to with extreme circumspection." 
 And with regard to the general applicability of blood-letting 
 
SCARLET FEVER. 143 
 
 as a remedy in any form of scarlet fever he says: — "It is 
 true that the loss of blood has no direct curative tendency in 
 the disease, it only abating action, without changing or sub- 
 verting it; and is usually not well borne to any extent. It 
 is not safe to detract it with the same freedom as in more 
 purely phlegmasial affections, or perhaps, to the amount that 
 the existing indications in the case would seem to demand. 
 Collapse, frightful and sometimes even fatal, I have repeatedly 
 seen to result from an abuse of the practice, and it is always 
 hazardous in an advanced stage of the disease." 
 
 Dr. J. Forsyth Meigs, in his able work on the diseases of 
 children, after producing the testimony of many distinguished 
 writers on this disease to the doubtful tendency of a resort to 
 blood-letting, says: — " On the whole, it is clear, I think, that 
 the weight of evidence is against blood-letting to any con- 
 siderable extent, in grave cases. If used at all, it is only to 
 be used in the earliest period, and even then with great cau- 
 tion. My own opinion, derived from personal experience, is 
 as follows: — I believe that I have seen general depletion use- 
 ful in several cases of the regular form, in which there was a 
 tendency to the grave form, shown by the presence of exces- 
 sive reaction, and still more by great jactitation and irrita- 
 bility, alternating with drowsiness and delirium. But in those 
 sudden attacks of the disease, in which it assumes from the 
 very start the terrible symptoms which threaten extreme dan- 
 ger to the patient, in which we find the child within a few 
 hours of the onset, delirious or comatose, or labouring under 
 convulsions, convulsive movements or contractions, in which 
 the eruption is imperfect or scanty, or copious and of a deep 
 livid tint ; in which in other words there are either strongly 
 marked ataxic or adynamic symptoms, general blood-letting 
 has never seemed to me at all advantageous, and I have se- 
 veral times feared that it had been injurious. As to leeches, 
 I have never known them to be really useful but in one case, 
 
144 AN ESSAY ON 
 
 and in that they were used sparingly, and after an interval 
 of two days. In all other cases they appeared to be without 
 any effect." 
 
 The local abstraction of blood from the neck in these cases, 
 cannot be too strongly condemned. It can no more arrest 
 the progress of the inflammation of the fauces, than it can 
 that of an external part tending to gangrene. The bites of 
 the leeches do not heal, but continue to permit the leakage 
 of a thin bloody serum, till they take on a low T grade of in- 
 flammation themselves, which results either in sphacelus, or 
 spreading ulcers. This remark is equally applicable to the 
 use of blisters, which almost always, either slough or ulcerate, 
 and have not unfrequently proved the cause of death even 
 after the sufferer had struggled through the disease for the 
 relief of which they were employed. 
 
 I might swell largely the list of authors who have either 
 condemned depletion entirely, or expressed their doubt of its 
 fitness to the treatment, and proposed its employment with 
 caution ; but I have adduced testimony enough to prove that 
 observation places depletion among the remedies of doubtful 
 value, to say the least of it, and thus confirms the view, de- 
 rived from reasoning on the nature of the disease, its origin 
 and course, which I have endeavoured to present. 
 
 But, though blood-letting, antimonial emetics, and anti- 
 phlogistic treatment, are all, for the same reason, excluded from 
 our list of remedies in the malignant more decidedly than in 
 the other forms of scarlet fever, a simple emetic of ipecacuanha, 
 or of infusion of Eupatorium perfoliatum, the thoroughwort or 
 bone-set, of our own meadows, may be given in the commence- 
 ment of a case of this malignant form with decided advantage. 
 Where the prostration is great, capsicum should be added. It 
 evacuates the primge viae, and produces a strong determina- 
 tion towards the surface, without leaving any secondary de- 
 pression of the vital forces or exhaustion, such as follows the 
 use of antimonials. 
 
SCARLET FEVER. 145 
 
 The action of the emetic having been accomplished, attention 
 should at once be given to the support of the vital power, 
 which will be found flagging from the very commencement in 
 many cases, and to the arrest of the local lesions in the fauces 
 and pharynx. The capsicum is here an agent of great value, 
 acting at once to the fulfilment of both indications. We are 
 indebted to the West India practitioners for the introduction 
 of this remedy to our notice in this disease. It is not only to 
 its local impression on the throat that its beneficial influence 
 is to be ascribed. It excites the depressed forces of the di- 
 gestive organs, gives greater power to the functions of as- 
 similation, and thus supports life by a secondary influence, 
 even if it be not a direct nervous stimulant. Though the first 
 sensation produced in the throat is one of increased heat, this 
 soon passes away, and is followed by a sense of relief from 
 the tension and soreness which aggravate, so materially, the 
 sufferings of the patient. 
 
 I have conducted many cases to a favourable conclusion by 
 these remedies alone, giving the capsicum in the manner sug- 
 gested, when treating of the form of the disease last under 
 notice, and supporting the strength of the patient by animal 
 broth and wine whey. 
 
 Purgatives have been recommended in this as in other forms 
 of the disease, even by those who condemn other antiphlogistic 
 treatment; especially calomel, either in combination with those 
 articles usually united with it to secure its prompt action, or 
 followed by castor oil and spirits of turpentine. The object 
 proposed by this treatment, is to promote a free secretion from 
 the viscera, and, as is supposed, remove a load which is thought 
 to oppress the vital energy. The reasoning is, I think, erro- 
 neous, and the practice founded on it pernicious. The con- 
 gested condition of the vascular system, and the suspension 
 of secretory action, are dependent on the diminution of the 
 vital forces, and not the cause of that depression ; and it were 
 
146 AN ESSAY ON 
 
 as contrary to common reason to bleed a porter struggling to 
 support a load beyond his power, as to resort to any remedy 
 which diminishes vital force in the malignant form of scarlet 
 fever. Since the completion of this essay, while the MS. was 
 still in the hands of the publisher, I have met with one in- 
 stance in which the life of a child was saved by the use of 
 calomel, which I feel bound to report. I was called to see 
 the family in which one child had died from scarlet fever of 
 the malignant type, and another of about two years old was 
 just seized. Jt lay insensible, tossing and rolling about the 
 bed with up-turned eyes, making unceasing efforts to vomit, 
 and utterly unable to retain on its stomach any thing which 
 was administered. The skin was pale, the heat of the surface 
 great, the pulse extremely rapid; warm baths, stimulating 
 pediluvia, cataplasms of mustard to the surface all failed to 
 afford any mitigation of the symptoms. On examination of 
 the abdomen, I found extreme tenderness of the epigastric 
 region and evident congestion of the liver. The child was 
 rapidly sinking under the oppression caused by this state. 
 I suggested the employment of calomel in doses of a half grain 
 every hour, to be dusted upon the tongue and washed down 
 with a little sweetened water. Six grains were thus given 
 with the happiest result; the vomiting and jactitation subsided, 
 the pulse became more full, the consciousness of the child was 
 restored, and the case pursued a normal course. Dr. Copland 
 advises calomel as a purgative in those cases in which the 
 sthenic diathesis is exhibited in the commencement, and Dr. 
 Douglass appears to have resorted to it with a view to its spe- 
 cific or alterative influence. 
 
 However much diversity of opinion may prevail as regards 
 the employment of antiphlogistics and purgatives at the com- 
 mencement, there is great uniformity in advising the resort to 
 a cordial treatment so soon as these have produced their effect; 
 if the case assume the asthenic form, the chlorate of potash as 
 
SCARLET FEVER. 147 
 
 an alterative, is much more appropriate than either the ci- 
 trate of that salt, or the acetate of ammonia, and should be 
 given at short intervals steadily. The ol. terebinth, may be 
 alternated with it suspended in a sweetened mucilage of gum 
 acacia. An infusion of cinchona and capsicum, containing 
 carb. of soda, may be resorted to ; or serpentaria may be used 
 instead of the cinchona; and when decided stimulation is de- 
 manded, the tinct. cinchona compos: may be added in doses 
 appropriate to the age of the patient. 
 
 My mode of treating the severe malignant form, may be 
 illustrated by the record of my experience in one family. It 
 was that of a widow who had been compelled to leave her chil- 
 dren without protection, while she returned to England to se- 
 cure a bequest. The oldest was a girl of about fifteen years. She 
 and two others were seized, simultaneously, with scarlet fever. 
 I found her lying, insensible, on the bed; the whole surface of 
 a mulberry hue, the pulse too frequent to be counted : there was 
 perfect stupor and extreme jactitation ; the throat swollen so as 
 entirely to prevent deglutition ; the fauces covered with ash- 
 coloured deposit; a fetid ichor distilling from the nostrils; the 
 eyes injected and upturned. The two other cases presented 
 the usual marks of the severe anginose form. I at once se- 
 cured the services of a judicious nurse, and in order to call 
 out the utmost exertion of care and effort, told her, that 
 though severe, the worst case was not hopeless, and that I 
 was so conscious that the best medical advice would be useless 
 without the aid of good nursing, that I was willing she should 
 have all the credit of her recovery if it were accomplished. I 
 furnished her with a syringe, and introduced a stomach tube 
 through the nostrils. Wine whey, beef broth, highly seasoned 
 with capsicum and quinine, were thus injected into the stomach 
 at stated intervals, while the solution of sulphate of copper, and 
 compound capsicum infusion were employed as local applica- 
 tions to the throat, by means of a syringe. Convulsions oc- 
 
148 AN ESSAY ON 
 
 curred within a few hours ; three days she lay in the condition 
 described, the only evidence of consciousness afforded, being 
 found in the resistance she opposed to treatment. On the fourth 
 day the jactitation diminished, and there was a manifest abate- 
 ment of the stupor, and much to my gratification, she re- 
 covered ; without any sequels being developed. The other 
 cases were treated in the simple manner described when 
 speaking of the anginose form, and with an equally happy 
 result. 
 
 The application of cold to the surface, and the use of ice 
 internally, has been advocated by some authors even in this 
 form of the disease. I need hardly say that the sedative im- 
 pression of cold, is as much to be avoided as that of any other 
 agent; but where the skin is hot and dry and the eruption is 
 very abundant, great benefit results from the tepid sponging; 
 and the addition of a small quantity of vinegar or whiskey to 
 the water is advantageous. Several authors speak of fatal 
 collapse following the injudicious resort to external cold. 
 
 Even Dr. Currie himself, to whom we owe the introduction 
 of this treatment, did not consider it appropriate here. The 
 cases to which he refers as " purpurata," are those which I in- 
 clude under the head of malignant, and to such, Dr. C. says, 
 " the cold effusion is scarcely applicable, and tepid effusion 
 makes little impression. In my experience, indeed, all reme- 
 dies have been equally unsuccessful. It outstrips in rapidity, 
 and it equals in fatality the purple confluent small-pox, to 
 which it may be compared." The internal use of ice in these 
 cases is too often forbidden by the stupor and delirium. 
 Where these do not prevent, it may be resorted to with the 
 same advantage as in the common anginose form. The in- 
 ternal use of a weak solution of the chloride of soda has been 
 strongly recommended by Dr. Jackson of Northumberland, 
 who reports many cases in his own practice, and that of his 
 friends, which recovered under the use of this remedy and 
 ice. 
 
SCARLET FEVER. 149 
 
 No attempt should be made to separate the sloughs or de- 
 tach the deposits from the mucous membrane of the throat, 
 either by mechanical means or by harshly stimulating washes. 
 Fatal hemorrhage is sometimes brought about by this rude in- 
 terference, or the tendency to gangrene aggravated by it. 
 
 Many practitioners are in the habit of resorting to the 
 use of common yeast in large doses, in those cases where the 
 throat is gangrenous. This practice was adopted from the 
 surgical use of the same article in external gangrene, and the 
 result is said to be highly satisfactory. 
 
 Carbonate of ammonia has been highly commended by some 
 authors in this form of disease. One insuperable obstacle to 
 its use, is found in the difficulty of deglutition. Even in those 
 forms of low fever which are free from angina, the pungent 
 character of the remedy makes it difficult of administration, 
 and where there is much swelling or ulceration, it would be 
 impossible that it could be swallowed, especially by a child. 
 
 The capsicum produces all the benefit which could be hoped 
 from the ammonia, and with less effort in swallowing. 01. 
 terebinth, is an excellent stimulant, especially where there is 
 tympanitis. If it purge, it should be guarded by the addition 
 of properly graduated doses of laudanum. When combined with 
 mucilage of gum Arabic and syrup flavoured with aniseed, it 
 can be given to very young children without difficulty. 
 Dr. Copland recommends highly the external application of 
 the ol. terebinth, combined with spirits camphor and olive oil, 
 especially to the loins and abdomen. 
 
 Musk, too, and camphor, have their advocates in those 
 cases where the nervous symptoms predominate. I do not 
 believe they possess any special virtues which entitle them to 
 favour, and prefer depending on a few tried and proved friends 
 to the resort to many other articles of questionable powers. 
 The rational indications are met by those I have recommended, 
 and on them we may safely rely. 
 
150 AN ESSAY ON 
 
 In those irregular cases which I have described, it is im- 
 possible to direct any uniform plan of treatment. There is 
 no specific for scarlet fever, even in its regularly developed 
 forms. I have endeavoured to indicate the symptoms, and to 
 deduce from them a treatment based on the known rules which 
 regulate the human economy in health and disease. Where 
 these laws cease to exert a control, the physician must be 
 guided by his own discretion in each case as it presents itself. 
 
 Warm, stimulating, spirituous baths, or vapour baths, may 
 be employed to invite the diseased action to the skin, and thus 
 to liberate the central nervous system from the load by which 
 it is oppressed; and where there is much tendency to collapse, 
 warm wine whey or brandy may be given internally. 
 
 In those cases where the skin is hot and dry and yet de- 
 void of eruption, and where there is great restlessness, I have 
 used the Dover's powder with advantage. Capsicum, too, in 
 some cases of this kind, has appeared to confer benefits which 
 might be supposed almost to entitle it to the character of a 
 specific; and should never be omitted. 
 
 Free ventilation is of the utmost importance in all the forms 
 of this disease ; but in the malignant form its value is beyond 
 estimation. Nor is there, during the progress of the primary 
 fever, any danger from the influence even of cool draughts, so 
 much dreaded by parents and nurses. 
 
 I am fully aware that many condemn the views I have here 
 presented, and that it is not uncommon to find the advocates 
 of the antiphlogistic treatment attributing the mortality of 
 this disease to the stimulating treatment I have thus recom- 
 mended. Improperly employed, it is certainly pernicious. It 
 should never be resorted to except where the feeble pulse, lan- 
 guid circulation, livid or violet colour of the eruption, and 
 sloughing throat, give unmistakeable evidence of the failure 
 of vital power. The resort to the treatment appropriate to 
 this state from an apprehension of its approach, is, indeed, 
 
SCARLET FEVER. 151 
 
 likely to induce it. It is even more to be deprecated than 
 the opposite extreme. Where bleeding, the application of 
 cold, or the exhausting treatment, has reduced the patient, 
 there is still room for hope that reaction may be produced by 
 the resort to the proper remedies. But where the nervous 
 energy has been exhausted by the addition of artificial stimu- 
 lation to the febrile excitement, a state of prostration from 
 over-excitement is induced for which we have no remedy. 
 "While, therefore, I desire to caution against the resort to those 
 measures which directly exhaust the vital power, I would enter 
 an equally strong protest against the premature employment 
 of stimulating remedies. If, as in the case I have described, 
 the malignant symptoms are present from the first, adopt im- 
 mediately the stimulation necessary to counteract their ten- 
 dency; but do not let the fear of its future occurrence induce 
 the premature resort to them as a preventive. This, like 
 bleeding beforehand to avoid inflammation, will only precipi- 
 tate or make more certain the result which is dreaded. These 
 remarks are especially applicable to the use of quinine. The 
 wine whey is transient in its influence, the capsicum gives rise 
 to no febrile reaction, but the quinine produces a more per- 
 manent impression upon the nervous system, and has a stronger 
 tendency to excite local inflammation. Properly applied, it is 
 the sheet anchor of our hope : the very power which renders 
 it so, causes it when misused to be most pernicious. It should 
 be given, when required, in full doses at long intervals, leaving 
 the stomach free to receive the animal broth, wine whey, or 
 brandy. These latter are most conveniently given in arrow- 
 root or some of the usual farinaceous articles of diet. 
 
 Before passing to the consideration of the sequelce of the 
 disease, and the proper treatment of them, some notice must 
 be bestowed on the question how far it is possible to remove 
 the susceptibility to the impression of scarlet fever. It is now 
 many years since it was announced that the administration of 
 
152 AN ESSAY ON 
 
 small doses of belladonna to those who were exposed to the 
 influence of this cause, whether epidemic or contagious, pro- 
 duced an almost entire immunity. The source from which the 
 suggestion came, though entirely destitute of authority, was 
 less calculated to excite suspicion than the reasoning by which 
 the assertion of its power was supported. 
 
 In order that no injustice may be done even to Hahnemann 
 himself, I shall introduce his own statement of the circum- 
 stances which led to the adoption of this prophylactic treat- 
 ment, as derived from an English translation of his work, 
 quoted in the British and Foreign Medico-Chirurgical Review 
 for January, 1855: " The mother of a large family, at the 
 commencement of July, 1799, when the scarlet fever was most 
 prevalent and fatal, had got a new counterpane made up by a 
 sempstress who (without the knowledge of the former) had in 
 her chamber a boy just recovering of scarlet fever. The first 
 mentioned woman, on receiving it, examined it and smelt it in 
 order to ascertain if it might not have a bad smell which 
 would render it necessary to hang it in the open air ; but as 
 she could detect nothing of the sort, she laid it beside her on 
 the pillow of the sofa, on which some hours later she lay down 
 for her afternoon's nap. She had unconsciously, in this way 
 only, (for the family had no other near or remote connexion 
 with scarlet fever patients.) imbibed the miasm. A week sub- 
 sequently, she suddenly fell ill of a bad quinsy, with the cha- 
 racteristic shooting pains in the throat, which could only be 
 subdued after four days of threatening symptoms. Several 
 days thereafter, her daughter, ten years of age, infected most 
 probably by the morbific exhalations of the mother, or by the 
 emanations from the counterpane, was attacked in the evening 
 by severe pressive pain in the abdomen, with biting itching on 
 the body and head, and rigour over the head and arms, and 
 with paralytic stiffness of the joints. She slept very restlessly 
 during the night, with frightful dreams, and perspiration all 
 
SCARLET FEVER. 153 
 
 over the body excepting the head. I found her in the morn- 
 ing with pressive headache, dimness of vision, slimy tongue, 
 some ptyalism, the submaxillary glands hard, swollen, and 
 painful to the touch, shooting pains in the throat on swallow- 
 ing and at others. She had not the slightest thirst, her pulse 
 was quick and small, breathing hurried, and anxious; though 
 she was very pale, she was hot to the touch, yet complained 
 of horripilation over the face and hairy scalp. She sat 
 leaning somewhat forward, in order to avoid the shooting in 
 the abdomen, which she felt most acutely when stretching or 
 bending back the body ; she complained of a paralytic stiff- 
 ness of the limbs, with an air of the most dejected pusillani- 
 mity, and shunned all conversation. i She felt,' she said, 'as 
 if she could only speak in a whisper.' Her look was dull and 
 yet staring, the eyelids inordinately wide open, the face pale, 
 the features sunk. 
 
 Now I knew only too well that the ordinary favourite re- 
 medies, as in many other cases so also in scarlatina, in the 
 most favourable cases, leave everything unchanged : and there- 
 fore I resolved, in this case of scarlet fever just in the act of 
 breaking out, not to act as usual in reference to individual 
 symptoms, but, if possible, (in accordance with my new syn- 
 thetical principle,) to obtain a remedy whose peculiar mode of 
 action was calculated to produce in the healthy body most of 
 the morbid symptoms which I observed combined in this dis- 
 ease. My memory and my written collection of the peculiar 
 effects of some medicines, furnished me with no remedy so 
 capable of producing a counterpart of the symptoms here 
 present, as belladonna. It alone could fulfil most of the in- 
 dications of this disease, seeing that in its primary action it 
 has, according to my observations, a tendency to excite even 
 in healthy persons great dejection, "pusillanimity, dull, staring 
 (stupid) look, with incredulously opened eye-lids, obscuration 
 of vision, coldness and paleness of the face, want of thirst, 
 11 
 
154 AN ESSAY ON 
 
 excessively small rapid pulse, paralytic immobility of the 
 limbs, obstructed swallowing, with shooting pains in the paro- 
 tid gland, pressive headache, constrictive pains in the abdo- 
 men, wliicli became intolerable in every other position of the 
 body besides bending forward, rigor and heat of certain parts 
 to the exclusion of others — e. g., of the head alone, of the 
 hands alone, &c. If, thought I, this was a case of approach- 
 ing scarlet fever, as I considered was most probable, the sub- 
 sequent effects peculiar to this plant — its power to produce 
 synochus, with erysipelatous spots on the skin, sopor, swollen, 
 hot face, &c, — could not fail to be exceedingly appropriate to 
 the symptoms of fully developed scarlatina. I therefore gave 
 this girl — ten years of age, who was already affected with the 
 first symptoms of scarlet fever — a dose of the medicine, 
 (4 3 2^0 00 P art °f a g ra i n of the extract, which, according to 
 my subsequent experience, is rather too large a dose.) She 
 remained quietly seated all day, without lying down ; the heat 
 of her body became but little observable; she drank but little; 
 none of her other symptoms increased that day, and no new 
 ones occurred. She slept pretty quietly during the night, and 
 the following morning — twenty hours after taking the medi- 
 cine — most of the symptoms had disappeared without any 
 crisis: the sore throat alone persisted, but with diminished 
 severity, until evening, when it, too, went off. The following 
 day, she was lively, ate and played again, and complained of 
 nothing. I now gave her another dose, and she remained 
 perfectly well, whilst two other children of the family fell ill 
 of bad scarlet fever without my knowledge, whom I could 
 only treat according to my general plan detailed above. I 
 gave my convalescent a smaller dose of belladonna every 
 three or four days, and she remained in perfect health. I 
 now earnestly desired to be able, if possible, to preserve the 
 other five children of the family free from infection. Their 
 removal was impossible, and would have been too late. 1 
 
SCARLET FEVER. 155 
 
 reasoned thus: A remedy that is capable of quickly checking 
 a disease in its onset, must be its best preventive; and the 
 following occurrence strengthened me in the correctness of 
 this conclusion. Some weeks previously, three children of 
 another family lay ill with a very bad scarlet fever; the eldest 
 daughter alone, who up to that period had been taking bella- 
 donna internally for an external affection on the joints of her 
 fingers, to my great astonishment did not catch the fever, 
 although during the prevalence of other epidemics she had 
 been the first to take them." 
 
 " This circumstance completely confirmed my idea. I now 
 hesitated not to administer to the other five children of this 
 numerous family this divine remedy, as a preventive, in very 
 small doses; and as the peculiar action of this plant does not 
 last above three days, I repeated the dose every seventy-two 
 hours, and they all remained perfectly well, without the slight- 
 est symptom throughout the entire epidemic, and amidst the 
 most virulent scarlatina emanations from their sisters who lay 
 ill with the disease. In the meantime, I was called to attend 
 another family, where the eldest son was ill with scarlet fever. 
 I found him in the height of the fever, and with the eruption 
 on the chest and arms. He was seriously ill, and the time 
 was consequently past to give him the specific prophylactic 
 treatment. But I wished to keep the other three children 
 free from this malignant disease. One of them was nine 
 months, another was two years, and the third four years of 
 age. The parents did what I ordered: gave each of the 
 children the requisite quantity of belladonna every three days, 
 and had the happiness to preserve these three children free 
 from the pestilential disease, free from all its symptoms, 
 although they had unrestricted intercourse with their sick 
 brother." 
 
 More inconsequential reasoning could not be presented; 
 and certainly there is nothing in the description of the case 
 
156 AN ESSAY ON 
 
 just narrated, to convey any idea of its relation to scarlet 
 fever. Nor, if the power of production of similar symptoms is 
 to be the test of the adaptation of a medicine to act either as 
 remedy or preventive, are the "symptoms" of belladonna in 
 the least degree suggestive of its applicability to scarlet fever 
 as it generally prevails. The absurdity of the dose, and the 
 interval at which it is repeated, are not wanted to show the 
 absolutely baseless foundation on which the claims of bella- 
 donna rest in either case. 
 
 Various other articles have been at different times commend- 
 ed by different authors, as capable of affording a similar ex- 
 emption — such as small doses of rhubarb, given daily. There 
 is one insuperable objection to them all. The advocates of the 
 use of preventives, whether Homoeopathic or others, refer to the 
 preventive influence of vaccination as though the cases were 
 parallel, or illustrative of each other. There is no affinity 
 between them. In the one case, the susceptibility of the sys- 
 tem to a specific miasm producing a disease to which as a ge- 
 neral rule the system is liable but once, is saturated or ex- 
 hausted by the introduction into the system of the specific 
 miasm either in its integrity, as in inoculation, or in a modified 
 form, as in vaccination, in which case the disease has been 
 satisfactorily proven to be variola, modified by passing through 
 the system of the cow. 
 
 Now, not even a disciple of Hahnemann can venture to as- 
 sume this identity for the active principle of belladonna and the 
 scarlet fever miasm ; and until this can be proven, no reason- 
 ing can be brought from the one to bear on the other. 
 
 There is another important subject for consideration before 
 adopting the preventive treatment, even granting that observa. 
 tion had proved its power, though the observation had its origin 
 in false reasoning. Hahnemann claims three days as the dura- 
 tion of the belladonna influence. Children cannot be kept 
 permanently under this influence until they pass the period of 
 
SCARLET FEVER. 157 
 
 greatest susceptibility. Nor are parents always aware of the 
 moment of exposure, so as to meet the poison by the antidote. 
 An illustration of the questionable character of the testimony 
 on which the prophylactic virtues of belladonna are supported, 
 the necessary uncertainty which attends it, as well as of the 
 point which it is here attempted to enforce, occurred in the 
 practice of my son, Dr. J. Cheston Morris. A sudden death 
 by malignant scarlet fever occurred in a lodging house, in which 
 several families, with many children, boarded together. The 
 medical attendant of one of those families gave belladonna. 
 The father of four children, who were under the care of my 
 son, applied to him with great solicitude for his opinion of the 
 propriety of adopting the same measure. At my suggestion, 
 it was not employed. No second case of scarlet fever occurred 
 in the entire household. The only approach to it was an at- 
 tack of sore throat and fever without eruption, which confined 
 to his bed three days the father of the family under my son's 
 care. Had this family joined the other families in the house 
 in the use of the belladonna, it would have furnished a case as 
 satisfactory as any that have been reported in favour of the 
 treatment. About four weeks after this, the family alluded to 
 removed to another residence ; and six weeks after the re- 
 moval, the children were all seriously ill with scarlet fever of 
 the most violent type, from which they happily recovered. 
 Another experience of my son may be quoted here also, as 
 bearing on the same point. (See American Journal of the 
 Medical Sciences, for April, 1857: Experiments made to de- 
 termine the protective power of Belladonna in Scarlatina. 
 By J. Cheston Morris, M. D.) The experiment was conducted 
 in an asylum for children, containing at the time 49 inmates 
 between four years and twelve years old, males and females. 
 The apartments were large and airy, and the sick were promptly 
 and entirely separated from the well. Six of the children were 
 attacked, within a few hours, by scarlet fever of a malignant 
 
158 AN ESSAY ON 
 
 type, leaving 43 as subjects of the experiment. Of this num- 
 ber, fourteen were supposed to have had the disease previously, 
 on the testimony of their parents at the time of their admission. 
 This testimony was discarded as questionable, however, and 
 the whole number were divided, without regard to this point, 
 into two bodies, one of 24, to whom no belladonna was given, 
 and another of 19, who took daily one drop for each year of 
 the child's age, of a solution of the Extract made by adding 
 grs. iii., to water 3iv., alcohol f£i. The quantity of the ex- 
 tract in each drop, therefore, was equal to about ? Jq part of 
 a grain, and one drop for each year of the child's age, was 
 given daily — by no means a Homoeopathic dose, as in the older 
 children it amounted to a pretty full dose. As the result, it 
 proved that of the 24 who took no belladonna, 18 had the 
 disease with great severity; and of the 19 who did take it, 11 
 were affected with equal violence. The epidemic was one of 
 great malignity, and complicated by the simultaneous presence 
 of whooping cough and measles. The rubeola appeared 
 as the primary symptoms of the scarlet fever abated in 
 each case, ran the regular course cotemporaneously with the 
 sequelae of the scarlet fever, and added pneumonia to them. 
 Though the percentage is slightly in favour of the belladonna 
 treatment, if we look on it in that point of view, the absolute 
 failure to protect, in so many cases, is sufficient to destroy our 
 confidence in its powers, and to lead us to attribute the ex- 
 emption of those who did escape, to some other cause. 
 
 In the British and Foreign Medico-Chirurgical .Review for 
 January, 1855, already quoted, may be found an analysis of 
 the testimony both for and against the belladonna treatment. 
 Among the latter is that of Lehman, a German practitioner. 
 He gives the following, among other observations: A boy 
 five years of age, an only son, contracted scarlet fever 
 after having taken belladonna uninterruptedly during several 
 months. The fever assumed a cerebral character, and on the 
 fourth day the little patient died. In a family of four chil- 
 
SCARLET FEVER. 159 
 
 dren, the eldest (who was five years old) became affected with 
 scarlet fever. The remaining three were immediately put on 
 the use of the belladonna. On the twenty-first day of the 
 employment of the drug, two of the three were attacked by 
 the disease in a more violent form than the first case. 
 
 Dr. West, of London, reports having given it a trial similar 
 to that of Dr. J. Cheston Morris already referred to, but on a 
 larger scale. He had 151 boys under notice, of whom he had 
 reason to believe none had experienced a previous attack. He 
 gave the belladonna to 75, and withheld it from an equal 
 number. There were two seizures of each class. 
 
 Dr. Sims reports that rhubarb, taken in such doses as will 
 produce one loose stool per cliem, was found by him to be the 
 best preventive. " He did not see one, who used this, confined 
 afterward to bed, though several commenced the practice after 
 they had been infected." Dr. Lee, (see Copland's Diet.) 
 says : " Where a person has been exposed, I have reason to 
 believe that the liberal use of spirits of nitre, with magnesia, 
 or spirits of mindereri, will prove successful in preventing a 
 severe attack, and in some instances in arresting it altogether. 
 The depurating organs should all be kept active if we seek 
 to avoid a severe attack." 
 
 MM. Rilliet and Barthez give us the report of Gumpert, 
 who employed belladonna in more than twenty families with 
 entire success. Berndt found that of one hundred and 
 twenty-four children to whom it was administered during ex- 
 posure, only fourteen took the disease ; and Hillenkamp had 
 still better results, only five having sickened out of one hun- 
 dred and twenty who took the belladonna. Our own medical 
 journals contain reports of the same favourable character. 
 Dr. Condie, however, asserts that, having tried it in repeated 
 instances, he never found it to produce the slightest effect in 
 mitigating the character or preventing the occurrence of 
 scarlet fever; and Dr. Sutton, in the paper already quoted^ 
 
160 AN ESSAY ON 
 
 says: " Belladonna was given as a prophylactic; but, seeing 
 children attacked with the disease while taking the medicine, 
 I lost all confidence in it, and perhaps discontinued it before 
 I had given the medicine a fair trial." 
 
 The only field for a crucial experiment is some large insti- 
 tution for orphans or destitute children, where it can be tried, 
 while all other means of prevention are avoided. Larger num- 
 bers than can be found in private families, and more careful 
 observation are necessary to settle this point. Though the 
 reasoning of Hahnemann in support of his prophylactic is simply 
 absurd, it is quite possible that the influence on the nerves of 
 organic life, of a slight narcotic, may so preoccupy them that 
 they shall not yield to the impression of the epidemic or con- 
 tagious principle. If it be proven to have this effect in scarlet 
 fever, it should be equally available in the case of other dis- 
 eases which are diffused by the same agency. Professor Chap- 
 man long since drew attention to the effect of the occupation 
 of the stomach by food, in preserving those who are exposed 
 to miasmatic impressions. It would be impossible to keep the 
 stomach always filled with food ; but the nervous system may 
 be kept constantly affected by the narcotic, and, if given in 
 quantities sufficiently minute, without inconvenience. I have 
 never tested the effect myself, not having had an opportunity 
 which was sufficiently guarded from sources of uncertainty. 
 Though I have thus entered at large into the question on ac- 
 count of the positive assertions of the advocates of prophy- 
 lactic treatment, and have endeavoured to exhibit the manner 
 in which, if at all useful, it operates, I have no faith in the 
 prophylactic power of this, or any other agent. The mode 
 of exhibition recommended, is to suspend three grains of the 
 extract of belladonna in one ounce of water; of this, two or 
 three drops are to be given twice a day, to a child under 
 twelve months old, adding one drop for each additional year 
 of age. 
 
SCARLET FEVER. 161 
 
 "We now come to the consideration of the treatment of those 
 diseased conditions which are commonly recognised as the 
 sequelse of scarlet fever, though they may perhaps in many 
 cases be considered, with greater propriety, a mere continu- 
 ance of the diseased action caused by the specific poison. 
 
 I have already described them, and spoken of them as sus- 
 ceptible of division into two classes. Those which appear to 
 be the mere continuation of the local lesions developed during 
 the progress of the disease itself, ulceration of the throat, en- 
 largement of the cervical glands, with infiltration of the cellu- 
 lar tissue of the adjacent parts, abscesses about the neck, and 
 inflammation of the ear, were grouped together as the first 
 class: while the inflammation of the endocardium, or of the 
 kidneys, and the dropsical effusion and rheumatic fever, were 
 arranged as the second; and an attempt was made to exhibit 
 the connexion of the dropsical effusion with the interruption 
 of the functions of the emunctories of the skin and kidneys. 
 This division was not adopted without design, and has refe- 
 rence to the treatment appropriate to the several groups. 
 
 The ulceration of the throat requires no change in the treat- 
 ment which has already been suggested as appropriate to the 
 anginose symptoms during the primary stage. The lime 
 water, solution of chloride of soda, sulphate of copper or nitrate 
 of silver, may be injected as detergent and stimulating appli- 
 cations for the cure of the internal affections, should they not 
 subside spontaneously with the decline of the fever: while 
 fomentations are still applied to the external swelling. Fric- 
 tion with a pommade of iodide of potassium combined with 
 the officinal camphor liniment, or dissolved in glycerine, may 
 be used advantageously in promoting the absorption of the 
 effusion and the reduction of the enlarged glands. If suppu- 
 ration occur, the abscesses should be discharged so soon as the 
 matter approaches near enough to the surface to permit the 
 safe resort to the lancet. 
 
162 AN ESSAY ON 
 
 The affections of the ear which complicate scarlet fever in 
 its progress, or are developed as sequelae, should always re- 
 ceive prompt attention, as they not unfrequently result in the 
 entire destruction of the diseased organ. There may he otitis, 
 or acute inflammation of the inner ear, or mere otorrhoea. The 
 least important cases are those in which the inflammation com- 
 mences in the meatus auditorius externus. This may occur at 
 any time during the progress of the disease, hut most commonly 
 commences about the fourth or fifth day. If the patient be a 
 young child, it will be found more drowsy than usual, and 
 when awake, more fretful; and if old enough to express the 
 seat of distress, it will indicate one or both ears. In some 
 cases, however, there is little or no pain, and the first intima- 
 tion of any local lesion will be derived from the stain of the 
 cap or pillow-case, by a glairy, purulent discharge, which ex- 
 coriates the concha as it flows over it, and occasions a vesicu- 
 lar eruption wherever it touches the skin. Whether the ac- 
 cumulation of this matter in the ear produce an extension of 
 the disease to the tympanum, or the membrana tympani itself 
 take on the inflammatory action, it not unfrequently happens 
 that even those cases which are attended by little or no suffering 
 in the beginning, become very serious in their progress, and 
 result, finally, in the destruction of the membrana tympani 
 and discharge of the ossicula. 
 
 During the first few days, the external meatus should be 
 kept perfectly cleansed by the injection of simple warm water 
 with a little pure Castile soap dissolved in it; after which, if 
 the discharge still continue and become fetid, the weak so- 
 lution of chloride of soda or sulphate of copper may be em- 
 ployed. 
 
 The injection of the ear should never be intrusted to the 
 mother or nurse. Ignorant of the structure of the parts, they 
 are either restrained from the effectual use of the remedy by 
 apprehension of doing mischief, or employ an undue force, 
 
SCARLET FEVER. 163 
 
 and injure the inflamed membrane. Where the ulcerative 
 process has destroyed the membrana tympani especially, 
 great care is requisite not to throw the fluid so far into the 
 cavity that it shall lodge there and become a source of addi- 
 tional irritation. 
 
 Even the cases which originate externally, sometimes result 
 in the entire destruction of the ear; but when the inflamma- 
 tion is extended from the fauces through the Eustachian tube 
 to the internal ear, the pain at the time of invasion is much 
 more severe, and the consequences are much more serious. 
 In the case of infants or young children, this internal affec- 
 tion is first manifested by sudden shrieks, like those of me- 
 ningitis, accompanied by grinding of the teeth and violent fe- 
 brile excitement; these symptoms may continue many days 
 before any discharge from the external ear affords positive 
 evidence of the site of the inflammation. 
 
 This extension of the inflammation from the fauces to the in- 
 ner ear, may occur at any period ; either during the progress of 
 the scarlet fever, or after the primary symptoms have declined. 
 In either case, it demands prompt and energetic treatment; 
 and unless the prostration of the vital forces is so extreme as 
 to render the recovery of the patient hopeless, leeclies should 
 be applied to the mastoid process, followed by a blister. No 
 apprehension of sloughing or ulceration should be allowed to 
 interfere in these cases. The introduction of warm olive oil 
 and laudanum into the external meatus may be resorted to 
 for the temporary relief of the suffering, simultaneously with 
 these applications; and morphia may be applied afterward to 
 the blistered surface, in doses appropriate to the age of the 
 patient. 
 
 These are the cases which result, of necessity, in the de- 
 struction of the organ, and lay the foundation for necrosis of 
 the petrous portion of the temporal bone, and occasionally 
 produce inflammation of the dura mater and death. It is 
 
164 AN ESSAY ON 
 
 not at all uncommon for the matter to find its way into the 
 mastoid cells, and to give rise to abscesses behind the ear, 
 which discharge externally; and leave openings, through 
 which pus, contaminated by the dead bone, is discharged 
 during a series of years; making the patient an object of dis- 
 gust and pity by the excessive fetor. I have known both 
 ears thus destroyed, reducing the child to the condition of a 
 mute. Where the disease assumes this chronic form, cod liver 
 oil is a most valuable resort, and should be administered per- 
 severingly. 
 
 Croup, when it occurs as a complication during the first week 
 of the disease, should be treated by emetics of ipecacuanha, 
 alum or sulphate of zinc. Should it be developed during the 
 convalescence, the disease of the larynx will partake of the cha- 
 racter of that of the adjacent parts, and if that be one of active 
 inflammation, V. S. or leeching may be safely resorted to; the 
 quantity of blood drawn being regulated by the degree of re- 
 action which is present. In taking leave of the primary stage 
 of the disease, and the local affections associated with, or imme- 
 diately dependent upon it, we encounter an entirely new con- 
 dition of the system, one of active inflammation. Should the 
 croupy cough and difficulty of breathing continue, the child 
 should be put at once on the use of iodide of potash, given in 
 large doses, freely diluted in some simple vehicle, such as gum 
 syrup and syrup: zingiberis, in equal proportions. 
 
 It is admitted by all writers on this subject, that the ma- 
 lignant form of scarlet fever is less likely than the simple 
 and anginose to be followed by those sequelae which I have 
 grouped together as the second class. Though in the former, 
 the powers of the system may be so far exhausted that it is 
 long in recovering its healthy tone, and the convalescence 
 may be protracted to many weeks, and rendered more tedious 
 by the condition of the throat or ears, there appears to be 
 little or no tendency to the secondary inflammations or drop- 
 
SCARLET FEVER. 165 
 
 sical effusions which so frequently follow even the mildest 
 cases of the latter. "When they do occur, these sequelae of the 
 second class are always of an inflammatory character, and 
 in severe cases affecting vital organs, the safety of the patient 
 depends upon the promptitude and vigour with which deple- 
 tion is practised. They most frequently exhibit themselves 
 between the tenth and twentieth day from the development 
 of the primary symptoms, and are all of them ushered in 
 by loss of appetite, languor, and in cases of children, fretful- 
 ness. They are often excited by errors in diet or exposures 
 to vicissitude of temperature, though they do certainly occur 
 without any such exciting cause, with sufficient frequency to 
 justify the belief that they are, in reality, dependent on the 
 original influence of the miasm which gives rise to the dis- 
 ease, of which they might, perhaps, be considered the latter 
 stage, rather than a sequela. They are all accompanied or 
 ushered in by a dry, heated condition of the skin; a sus- 
 pension or great diminution of the secretion from the kid- 
 neys ; a tense and rapid pulse. 
 
 The endocardial inflammation, though not the most common, 
 is one of the most formidable of these sequelae, and may be 
 recognised by the extreme rapidity of the pulse, the disposi- 
 tion to sigh, and especially by the pain in the region of the 
 heart, and soreness upon pressure. I have already indicated 
 the plan of treatment which I think adapted to this case, when 
 I alluded to it in the description of the disease. A decided 
 and immediate impression should be produced by free vene- 
 section; a full dose of calomel should be given, followed by 
 oil or citrate of magnesia; a blister should be applied over 
 the region of the heart; the diet should be restricted to bar- 
 ley or rice water ; the most positive quiet should be maintained, 
 and if the febrile reaction be not subdued by these means, and 
 the strength of the patient admit it, leeches or cups should be 
 applied between the lower angle of the scapula of the left side 
 
166 AN ESSAY ON 
 
 and the vertebrae, or over the region of the heart on the front 
 of the thorax. Calomel and nitrate of potash should be 
 given in small doses frequently repeated, and digitalis added 
 in the form of infusion. Having by these means arrested the 
 progress of the case, the patient must be kept in a state of 
 perfect tranquillity of mind and body, and on the most rigid 
 diet, till all symptoms of active inflammation are subdued. 
 
 In the case of an adult who had an attack of scarlet fever, 
 so slight in its primary stages that she was not obliged to sus- 
 pend the performance of her duties as the nurse of the child 
 whose mother's case has been referred to, (see page 58,) the en- 
 docardial inflammation was very severe. Bleeding, cupping 
 and blistering were all employed to the full extent to which it 
 was proper to push them, and mercury to the production of se- 
 vere ptyalism. Aconite in moderate doses was then resorted 
 to and proved most useful, subduing the action of the heart 
 and tranquillizing the nervous excitability. Under this treat- 
 ment she perfectly recovered. 
 
 The dropsical effusion and the inflammation of the kidneys 
 may be spoken of under one head, since they are at least in- 
 timately associated, and demand the same treatment, even if 
 the former do not generally depend on the latter as the prox- 
 imate cause, which I believe to be the true pathology of such 
 cases. Where the affection is slight and the febrile reaction mild, 
 a dose of calomel followed by a saline cathartic will often suf- 
 fice to subdue the inflammation and arrest the progress of the 
 effusion. Should the skin continue dry and husky, the tongue 
 coated, the pulse quick and corded, great advantage may be 
 expected from the use of the solution of acetate of potash or 
 the effervescing draught with sweet spirits of nitre; and these 
 failing to give relief, the nitrate of potash with the addition 
 of small doses of calomel may be resorted to. If the fever be 
 high and constant, bleeding will be not only well borne, but 
 absolutely requisite. The blood drawn under these circum- 
 
SCARLET FEVER. 167 
 
 stances is always much cupped, and covered with a dense huffy 
 coat, and the relief which follows the abstraction of it is very 
 great; I have known the most urgent symptoms yield imme- 
 diately. 
 
 Where there is any hesitation about the propriety of re- 
 sorting to general depletion, cups should be applied to the 
 loins, especially in those cases where the presence of blood in 
 the urine without high arterial excitement indicates the ex- 
 istence of congestion of the kidneys. Indeed, I have found 
 the abstraction of a small quantity of blood by cups applied 
 to the lumbar region, as near as possible to the kidneys, a 
 most satisfactory remedy in the febrile anasarca following 
 scarlet fever. I have formerly in cases where there was 
 great febrile disturbance, administered nitrate of potash 
 and other diuretics during many consecutive days, without 
 any benefit, and the resort to stimulating diuretics is still 
 more pernicious. An active purging by calomel followed by 
 castor oil or tartrate of potash and soda, has sometimes sup- 
 plied the place of the cupping where it has been impossible to 
 induce the parents or friends to consent to this measure. The 
 first indication of improvement will be found in the restora- 
 tion of the healthy action of the kidneys. Should this not 
 take place very shortly, digitalis should be given. 
 
 The best form for exhibiting this remedy with reference to 
 its diuretic effect is, certainly, the infusion, made according 
 to the prescription of Withering, except that sweet spirits of 
 nitre may be substituted with great advantage for the tinct. 
 cinnamomi. The proper formula for the preparation of this 
 infusion, is that given in the Dispensatory of Drs. Wood and 
 Bache. The dose must of course be proportioned to the age 
 of the patient. If there be much fever, and the urine be very 
 scant and high-coloured, with deposit of brown flocculent 
 matter, there can be no room to doubt the presence of active 
 congestion or inflammation of the kidney, which will be best 
 
168 AN ESSAY ON 
 
 met by the application of leeches or cups to the loins. I have 
 found the perseverance in nitre and diuretic remedies in these 
 cases without first removing the local inflammation by local 
 blood-letting, to aggravate the sufferings of the patient with- 
 out producing any increase of the secretion. 
 
 Since the publication of the first edition of this work, Dr. 
 Copland's Dictionary of Practical Medicine has reached the 
 subject of scarlet fever. It is with no little satisfaction I find 
 him dwelling with great earnestness on the same pathological 
 view of the importance of the influence of the scarlet fever 
 miasm on the kidneys. He says, "The prevention of the 
 affection of the kidneys upon which the most frequent of the 
 secondary diseases or sequelae of scarlet fever chiefly depend, 
 should be a principal object in the treatment of this malady. 
 During desquamation, and early or advanced convalescence — 
 for a month at least after the disappearance of the eruption — 
 the patient's diet and regimen should be strictly prescribed, 
 however mild the disease may have been." There is great 
 reason to adopt the view inculcated by Dr. C, that the ten- 
 dency of the miasm producing scarlet fever is to the pro- 
 duction of congestions and inflammation of the kidneys, just 
 as it is to the analogous affection of the fauces and throat. 
 In this view of the case, the affection of the kidneys and the 
 dropsical effusion would be transferred to the class of sequelae 
 we have just had under consideration. The following note 
 of a case in which I was consulted, was furnished me during 
 the passage of this sheet through the press. 
 
 " Hartford, April 18th, 1858. 
 
 " My Dear Sir: — At Mr. 's request, I send you the 
 
 important points of the disease under which your little grand- 
 son is labouring. 
 
 " I shall give you such data as will enable your family phy- 
 sician to give you as correct an idea of his situation without 
 seeing him; and should be most happy to receive any sugges- 
 
SCARLET FEVER. 169 
 
 tions from him, (either directly or through you,) which may 
 occur to him. 
 
 " He came to his bed with a mild attack of scarlet fever, 
 about the 12th of March. There was no sore throat or other 
 complication during the course of the eruption. 
 
 " The second week, there was a mild anasarca of the upper 
 half of the body, without constitutional disturbance. This 
 gradually gave way, and he slowly but on the whole satisfac- 
 torily improved, until the 10th of the present month, w T hen he 
 appeared to have taken a sudden cold. 
 
 " For a day or two he had considerable fever, rapid pulse, 
 troublesome cough, with short, hurried respiration. The se- 
 cond day, his face was quite fully bloated, and the urine pre- 
 sented a dark appearance — evidently blood which had been 
 retained in the kidneys or bladder some little time. Quantity 
 at first scanty. 
 
 " April 12th. The above symptoms existing, with dulness 
 in the lower third of the left pleura. Inclined to sleep. 
 Bowels constipated. Ordered digitalis and iodide of potassa, 
 alternated with protiod. mercury. 
 
 " April 12>th. Had an uncomfortable night from coughing ; 
 otherwise, would have slept. Not as much fever. Bowels 
 moved. Urine increased in quantity, and much the same ap- 
 pearance. Could not obtain a specimen to test. Medicine 
 continued. 
 
 " April lAth. A much better night. Urine freer, and 
 bowels open. Obtained about six ounces of urine. In the 
 bottom of the vessel is quite a quantity (say 5 i) of fresh blood. 
 Nitric acid added to two ounces turns the entire quantity 
 white, and the precipitated albumen reaches about half way 
 to the surface. Heat gives me, upon the surface, a quantity 
 about equal to the white of one egg to — say — four ounces of 
 urine. Under the microscope I find abundant blood discs, 
 with epithelium and pus globules. No uriniferous casts. 
 12 
 
170 AN ESSAY ON 
 
 Ordered tincture of iron, alternated with the digitalis and 
 hydriodate of potassa. Generous but plain diet. 
 
 " April 15th. Is considerably improved in general appear- 
 ance. Pulse slower, soft and regular. Less dulness over the 
 lungs. Coughs but very little. The same general appearance 
 of urine as seen in the vessel. Albumen slightly diminished. 
 Blood and pus the same. 
 
 "April 16th. Patient is dressed, and says he feels well. 
 Appetite good. Anasarca entirely gone. Dulness of left 
 side nearly gone. Urine the same. 
 
 "April 11th. Appears quite well, except pale and weak. 
 Albumen diminished nearly one half. Other characteristics 
 the same. 
 
 " April 18th. Same as yesterday. Albumen a little less. 
 Medicine continued." 
 
 The child recovered. 
 
 But of all the manifestations of disease which mark the pro- 
 gress of scarlet fever, none are so much to be dreaded as the 
 cerebral affections which occur at the period now under con- 
 sideration. By some authors we are taught that meningitis 
 is suddenly developed; and proves fatal either by giving rise 
 to serous effusion, or by terminating in the secretion of pus, or 
 lymph. I have never met with' cases in which I had reason 
 to suspect the results last mentioned. The serous effusion is 
 comparatively of frequent occurrence, and is sometimes poured 
 out so rapidly as to produce convulsions and death, before the 
 proper means for relief can be applied. In other instances 
 the effusion takes place more gradually, but with an equally 
 fatal tendency. 
 
 Some years since, I was attending a young gentleman of 
 about fifteen years of age, who was apparently convalescent 
 from a severe attack of simple scarlet fever. He was an only 
 son, and the object of intense anxiety to his parents. My 
 directions about diet and exposure were carried out with great 
 
SCARLET FEVER. 171 
 
 care ; and yet the fever, and suspension of secretion from the 
 skin and kidneys, supervened at the end of the second week. 
 I at once resorted to purgatives and nitrate of potash. On the 
 third day I was summoned to see him lying entirely comatose, 
 with slow pulse, dilated pupils and cool skin. There was no 
 metastasis of the effusion to the brain, for his whole body was 
 cedematous. Recognising at once the urgency of the case, I 
 tied up his arm and bled him largely, and then put him on 
 the use of small doses of calomel and nitrate of potash, with 
 the infusion of digitalis. At the end of forty-eight hours the 
 kidneys resumed their natural action, and in less than a week 
 the whole train of symptoms had disappeared. These cere- 
 bral symptoms depend on the effusion of fluid into the ventri- 
 cles or at the base of the brain, rather than on any vascular 
 congestion, or inflammation of the membranes, and are con- 
 sequent upon the same causes as those which give rise to the 
 anasarca; the bleeding acts by curing the condition of the 
 kidneys, upon which the whole series of symptoms depends, 
 as well as by withdrawing a portion of the blood, rendered 
 unhealthy by the retention in it of matters which should have 
 been eliminated by the skin and kidneys. 
 
 Among the most formidable of the sequelae is the effusion 
 of serum into the cavity of the pleura, or the parenchyma of 
 the lungs, giving rise to the most distressing orthopnoea. De- 
 pending on the same cause as the cerebral cases just noticed, 
 it requires the same treatment, which should be pursued with 
 the same degree of energy. 
 
 I have never seen a case of dropsical effusion following 
 scarlet fever, which was not materially aggravated by the 
 early resort to tonic or stimulating remedies. "When the ef- 
 fusion, whether general or local, has been absorbed and dis- 
 charged through the kidneys, but not till it has entirely disap- 
 peared, it will be proper to administer some mild tonic; small 
 doses of quinine in the first instance, followed by some of the 
 
172 AN ESSAY ON 
 
 preparations of iron, especially the lactate or tartrate, with 
 fresh air and a good diet. It must not, however, be forgot- 
 ten, that the convalescence from these attacks is slow. It is 
 even possible that many months may elapse before the pa- 
 tient is restored to a condition of entire health. 
 
 The Rheumatic Fever I have always found yield promptly to 
 properly graduated doses of Dover's powder. Should the 
 pulse be tense and quick, and the suffering prolonged, bleed- 
 ing would be appropriate in this case also. 
 
 Diarrhoea depends upon the irritation produced by the 
 acrid matter swallowed from the throat, and is most likely to 
 occur after very severe anginose or malignant cases. It is 
 quite possible that ulceration of the mucous membranes may 
 be thus induced, keeping up this unpleasant disease a long time, 
 and retarding the restoration of the strength of the patient. 
 Opiates and mild absorbent remedies are the agents upon which 
 we must rely in such cases, and we shall generally find the dis- 
 ease yield to them. I have, however, known the irritation 
 transmitted from the ulcerated membrane to the mesenteric 
 glands, and the patient has died, worn out by profuse discharges 
 and hectic fever, after weeks of suffering. 
 
 There are other instances in which a condition of the blood 
 like that which is found in some cases of typhoid fever, is pro- 
 duced; either as the result of the original miasm, causing the 
 disease, or the consequence of the febrile action itself, or of 
 the influence of a diseased constitution of the individual pa- 
 tient. There is hectic fever, with profuse sweating attending 
 on the state of sleep; and a degree of nervous irritability 
 which is scarcely tolerable, either by the patient or attendants. 
 Such cases generally recover and require a treatment con- 
 ducted upon simple, rational, principles. The blood is vitiated 
 and impoverished by the action of a poison and the interrup- 
 tion of the normal process of assimilation and excretion. No 
 remedies can be supposed capable of producing a prompt 
 
SCARLET FEVER. 17o 
 
 chancre and restoration of these functions, much less of that 
 healthy condition of the organism which is the result of this 
 normal action. Iodide of potash, or a solution of citrate of 
 iron and extract of cinchona in sherry wine, during the inter- 
 missions, and the solutions of the salts of potash during the 
 febrile paroxysms, are the drugs most appropriate ; so soon as 
 circumstances will permit, the influence of fresh air will be 
 found highly beneficial. 
 
 A wholesome diet is especially important, and yet the fas- 
 tidiousness of the irritable convalescent stomach often taxes 
 to the utmost the inventive powers of the physician and at- 
 tendants to provide articles which shall be acceptable and not 
 injurious. Some degree of acquaintance with the science of 
 cookery and familiarity with the mode of preparation of food, 
 will, in such cases, be of great value to the physician. The 
 cutting censure of common medical dietetics uttered by Dr. 
 Chapman nearly half a century since, is perhaps less appli- 
 cable to the diet list of doctors now than then, yet is still not 
 without an edge. " You condemn your patients to eat what 
 your own stomach revolts at." 
 
 This acquaintance with culinary science and art is as impor- 
 tant to the treatment of the convalescence from Scarlet Fe- 
 ver, as is the knowledge of its pathology to the administra- 
 tion of remedial measures during the primary stages; and it 
 should never be forgotten that the apparatus of the good phy- 
 sician is not limited to the contents of the shop of the phar- 
 maceutist, but embraces within its legitimate scope, the air, 
 the sunshine, the fruits and flowers of the earth; all things 
 pleasant to the eye, grateful to the ear, acceptable to the 
 palate, and capable of assimilation by the stomach and its 
 collatitious organs. 
 
APPENDIX. 
 
 THE 
 
 PRACTICAL HISTORY 
 
 OP 
 
 A NEW EPIDEMICAL ERUPTIVE MILIARY FEVER, 
 WITH AN ANGINA ULCUSCULOSA, 
 
 PREVAILED IN BOSTON, NEW ENGLAND, 
 
 IN THE YEARS 1735 and 1736. 
 
 BY WILLIAM DOUGLASS, M. D. 
 
 BOSTON, N. E. 
 
 PRINTED AND SOLD BY THOMAS FLEET, AT THE SIGN OF THE HEART AND 
 CROWN, IN CORNHILL, 1736. 
 
TO 
 
 w> ms^i^c m««fij w siwfw, 
 
 Gentlemen, — This piece of Medical History does naturally ad- 
 dress itself to you, considering that I have the pleasure of being one 
 of your number, that you have been fellow labourers in the manage- 
 ment of this distemper, and therefore competent judges of this per- 
 formance, and . that where difficult or extraordinary cases have oc- 
 curred in any of your private practice, I was favoured to visit the 
 patients in order to make a minute clinical inquiry; in short, with- 
 out your assistance this piece would have been less perfect, and not 
 so well vouched. 
 
 As this distemper continues to spread and prevail in several towns 
 of this and the neighbouring Provinces, I thought it might prove 
 a piece of humanity and benevolence, if after many months' diligent 
 observations made in most of the varieties which occur in this illness, 
 I did endeavour to reduce them to some easy distinct Historical and 
 Practical Method. 
 
 The vanity of appearing as an author or writer was no inducement, 
 because we all know that in a plantation life neither Jwnour nor 
 credit are to be acquired by loriting. It is not published by way of 
 a quack bill to procure patients and their money, as has been the 
 practice of some, void of modesty and truth ; because the distemper 
 is almost over in Boston, and while it prevailed here I could not well 
 have attended more patients than what I had from time to time un- 
 der my care, and make with attention the proper observations at the 
 same time. 
 
 A secondary reason for my writing is, to induce some gentlemen 
 of the profession in our other provinces and colonies, where this dis- 
 temper does or may prevail, to give some account of its appearance 
 with them; in order to discover what influence, progress of time, 
 varieties of climate and soil may have in the phenomena of this dis- 
 ease. 
 
 This method of taking things originally, that is, from the life, if 
 pursued, (but by abler hands,) in the Epidemical Distempers which 
 may from time to time happen amongst us, may be of considerable 
 advantage in physic. 
 
178 APPENDIX. 
 
 A speculation that is a novelle might have been composed sooner, 
 but not a real history : for as amongst naturalists, many repeated ob- 
 servations and experiments are requisite to form established truths 
 or conclusions; so it ought certainly to be in the practice of medicine, 
 where no affair of speculation or curiosity, but the life and death of 
 a fellow citizen is the object of our inquiry. 
 
 Yours, &c, William Douglass. 
 
 THE PRACTICAL HISTORY OF A NEW EPIDEMICAL 
 MILIARY FEVER WITH AX ANGINA 
 
 ULCUSCULOSA. 
 
 This distemper did emerge 20th May, 1735, in Kingston Town- 
 ship, 50 miles eastward from Boston ; it was no foreign importation, 
 Kingston being an inland place, of no trade or considerable commu- 
 nication. 
 
 The first seized was a child who died in three days' illness; about 
 a week thereafter in another family at four miles' distance, three chil- 
 dren were seized successively, and died also the third day ; it con- 
 tinues spreading gradually in that township, seizing here and there 
 particular families with that degree of violence, that of the first cir- 
 citer forty decumbents, none recovered as we were informed. 
 
 It was vulgarly called the throat illness, or a plague in the throat, 
 and alarmed the provinces of New England very much : some died of 
 a sudden or acute necrosis; but most of them by a symptomatic 
 affection of the fauces or neck; that is by sphacelations or corrosive 
 ulcerations in the fauces, or by an infiltration and tumefaction in the 
 chops and forepart of the neck, so turgid, as to bring all upon a level 
 between the chin and sternum, occasioning a strangulation of the 
 patient in a very short time. 
 
 After a few weeks it spread into the neighbouring townships, but 
 with more mildness. The first appearance that we can recollect of 
 it in Boston, was 20th August on a child of Captain Stanny's at the 
 North End; having white specks in the throat, and a cutaneous ef- 
 florescence; a few more in the same neighbourhood were seized in like 
 manner, about the same time. 
 
 Towards the end of September it appeared in several parts of the 
 town, with a complaint of soreness in the throat, tonsils swelled and 
 specks, uvula relaxed, slight fever, flush in the face, and an erysipe- 
 
TRACT OF DR. DOUGLASS. 179 
 
 las-like efflorescence on the neck, chest, and extremities; but being 
 of no fatal or bad consequence, nothing more than a common cold 
 was suspected. 
 
 Our first alarm was from a young man, How, set. 20, in the begin- 
 ning of October. His history runs thus : he was lately arrived from 
 Exeter to the eastward; where his brother died of this illness; his 
 symptoms were great prostrations of strength, a speck in one of the 
 tonsils, colliquative sweats, pulse not high, and full, but low, hard, 
 stringy, unequal, and more frequent than natural, deglutition good 
 to the last, no sphacelation in the throat, no eruption ; from a rash, 
 inconsiderate opinion of forcibly quelling the malignity, he was thrice 
 let blood, had some emetics and cathartics administered, and by pro- 
 fuse evacuations was gradually reduced, so as to die of a gentle decay 
 of natural strength, the sixth day of illness. 
 
 Beginning of November it spread considerably in Boston, espe- 
 cially among children, with more violent symptoms, and several died 
 of it in various periods ; it seemed to be at the height, as to numbers 
 ailing, and quantity of deaths, the second week of March ; that week 
 there were twenty-four burials, whereas communibus annis in that 
 season there were only nine or ten per week. 
 
 It is generally in so considerable a degree more favourable in Bos- 
 ton, than in the townships where it first prevailed, that many can 
 scarce be persuaded of its being the same distemper. 
 
 It is nevertheless essentially the same, there is no symptom, even 
 the most malignant, that has appeared in New Hampshire, but what 
 the like has occurred in Boston : perhaps Boston's dry healthy air, 
 good feeding, constitutions less psoric, and the better management 
 of the sick, favoured us; the reasons for its proving more mortal in 
 the other towns, may be, the country woodland and fresh water damps, 
 (the sheep in fenny lands are most susceptible of, and suffer most by 
 the rot,) their coarse food, salt pork diet, psoric constitutions, (which 
 is one of the principal endemial distemperatures in New England,) 
 bad lodgings, and that mischievous practice of using this distemper 
 with profuse evacuations, whereby the laudable and salutary cuticu- 
 lar eruption has been so perverted as to be noticeable only in a few, 
 and in these it was called a scarlet fever, the great prostration of 
 strength essential to this distemper is so much increased, as to render 
 nature an undermatch for the assaults of this illness, and its conse- 
 quences. 
 
 In fact, to the eastward in some country towns, at certain times, 
 have died one in three of the sick, in others, one in four, in scarce 
 any fewer than one in six, whereas in Boston not above one in thirty- 
 five, have died. 
 
180 APPENDIX. 
 
 As in most epidemical, acute illnesses, especially eruptive fevers, 
 (witness the small pox,) so in this, are very many varieties or de- 
 grees, from the most gentle and benign, to the most malignant. 
 Symptoms did vary chiefly from something inscrutable in the consti- 
 tutions of families and persons; the scrofulous and psoric were the 
 most susceptible of it, and did suffer most by it; the regimen had a 
 considerable influence; hence some who might have survived the na- 
 tural symptoms, did succumb by profuse V. S., and other evacuations? 
 one of the most essential symptoms of this distemper, (as before 
 hinted,) being great prostration of strength. In so great variety it 
 is not possible to give any concise scholastic description, which may 
 comprehend all. We shall therefore, as a standard, first describe 
 the most frequent sort, as it appeared in good constitutions. 
 
 A previous listlessness and languishing countenance for a day or 
 two, or some other prasnuncia as e. g. wet nurses losing their milk. 
 The first attack is somewhat of a chill or shivering; soon after fol- 
 lows headache or some other versatile spasmodic pains, as pain in the 
 back, joints, sides, &c; a vomiting, or nausea, or in some constitu- 
 tions which are not easily provoked to vomit, only a certain uneasi- 
 ness or sickness at stomach; at the same time the uvula but chiefly 
 the tonsils were tumefied, inflamed and painful, with some white 
 specks; then follows a flush in the face, and some miliary eruptions 
 there, with a benign mild fever, the same efflorescence soon after ap- 
 pears on the neck, chest, and extremities; the third or fourth day, 
 eruption is at the height, and well defined with fair intervals; the 
 flushing goes off gradually, with a general itching; and in a day or 
 two more the cuticle scales or peels off, especially in the extremities : 
 at the same time the cream-coloured sloughs or specks in the fauces 
 become loose and cast off, and tumefactions thereto do subside. 
 
 The tongue from the beginning is furred as in a mercurial ptya- 
 lism, urine highly coloured; blood by V. S., more florid than natu- 
 ral. In the whole course of the distemper a very great prostration 
 of strength, and faintness upon recovery, nervous pains and weakness 
 in the joints, particularly in the neck, wrists, and ankles; universal 
 tenderness to the touch ; a tickling guttural cough, some short hectic 
 flushings, and loss of embonpoint. 
 
 As in the measles there is a peculiar smell, so in our distemper the 
 effluvia from the patient have a proper smell; in children as if trou- 
 bled with worms, in grown persons the rancid smell of foul bed linen : 
 the alvine excrement is of a dark cast and \erj fetid. 
 
 This standard kind when left to nature, with a warm soft regimen, 
 had generally an easy and salutary course in six or seven days, but 
 
TRACT OF DR. DOUGLASS. 181 
 
 when by a hot cordial method, or on the other extreme, by being too 
 much exposed to the cold, or by officious profuse evacuations nature 
 was disturbed in her work; the distemper was protracted, or some 
 consequential ails from an imperfect defecation ensued. 
 
 Where nature required any assistance, the principal intentions 
 were with regard to the cuticular eruption and the ulcuscula in the 
 throat. Any affection of the throat does frequently produce a natu- 
 ral ptyalisni ; mercurials used with discretion are a kind of specific 
 in such like ulcers and ulcuscula, and in fact here they moistened 
 the throat and mouth, stopped the spreading of the ulcuscula, and 
 promoted the casting off of the sloughs; and as an accessory advan- 
 tage, (the patients being mostly children,) destroyed worms; amongst 
 all its preparations calomel answered best, the gentle vomiting or few 
 stools that it occasioned in some, did not confound the natural course 
 of the distemper : turbith proves generally too strong a revulsion, and 
 the eruption is thereby too much diverted; this distemper did not 
 well bear any other evacuations but mercurials. 
 
 Any detergent gargle, with an addition of the tincture of myrrh 
 and aloes, was of good use, especially for the ulcuscula, and did pro- 
 mote the discharge of a ropy phlegm lodged in the fauces. As to 
 the cuticular efflorescence, it was not a scarlet suffusion, but a mili- 
 ary palpable eruption, or in lieu thereof, in some constitutions a con- 
 tinued gentle breathing sweat; and in a very few who have naturally 
 a liberior transitus by the pores than is usual, no sensible cuticular 
 excretion; in all, the morbid effluvia discovered themselves by their 
 peculiar smell. These were with good effect solicited by snake root 
 tea, or, (as in some persons,) where this did occasion an ardour or 
 burning heat, instead of breathing mellow sweat, spts. cornu cervi, 
 or any other volatile spirit in small herb teas answered well. Blis- 
 ters and suppedanea, in the beginning where symptoms were not vio- 
 lent, occasioned a protracted eruption; in some immediately upon 
 their application, the eruptions vanished or became less vivid. 
 
 When the eruption began to decline, a few loose stools were very 
 refreshing, the patient being up, and having recovered a competent 
 degree of strength, is to be purged once or twice, to carry off any fe- 
 culency that may have remained in the blood and juices. For a 
 more distinct conception of the varieties in this distemper, they may 
 be reduced to three classes. 
 
 1st. Those who die the first, second, or third clay, of illness, by 
 an irremediable necrosis of the ceconomy: in such the seizure is ge- 
 nerally sudden, a sinking pain in the stomach, an extreme prostra- 
 tion of strength, a titubating low pulse, in some a stupor, in others a 
 
182 APPENDIX. 
 
 delirium, in some children convulsions, and all of them generally die 
 dozie; they are attended with some colliquation, as continued vomit- 
 ing, purging, profuse sweats, bloatedness of the habit, an infiltration 
 like that of the mumps, vulgarly so called, one or more of these. In 
 general the texture of their blood and juices is much destroyed and 
 rendered an incoherent puddle of corruption; in fact immediately 
 upon (sometimes before) their exit, they have an intolerable fetor. 
 In this class V. S. and other evacuations did accelerate death. 
 
 2d. Those where the distemper has its common or ordinary course; 
 here the sixth or seventh day seems to be critical, and the symptoms of 
 death or recovery do generally then begin to manifest themselves. 
 Some by peculiarity of constitution, and from improper administra- 
 tions do die or have an incipient recovery sooner; others for the like 
 reasons or some particular accidents (e. g. if about the time of regu- 
 lar menstruation, the complicated fact occasions worse symptoms, 
 and of longer continuance) have this period protracted, and in such 
 (where death is inevitable,) the symptoms of death may continue a 
 day or two longer, that is, the patient may die the eighth or ninth 
 day, all who continue ill after that period, belong to the third class 
 that is, of consequential ails. 
 
 The symptoms of bad omen in this class are very great prostrations 
 of strength, dejection, and despondency of mind, titubating low pulse, 
 incessant vomitings, purgings or sweats, tonsils much inflamed, en- 
 dangering strangulation, the specks in the fauces of a brownish or 
 leaden colour, or ragged and jagged, a continued jactantia in some, 
 in others a stupor, refusal of assumenda even of diluting common 
 drinks, a dry parched skin, eruptions appearing and disappearing al- 
 ternately, eruptions universal of a dark reddish cast continuing crude 
 many days, (because in this, as in all eruptive fevers, the darker or 
 more livid the efflorescence the more malignant,) where the miliary 
 pustles are large, distinct and pale like a crystalline small pox; where 
 strong cordials and alexipharmics have been used, the face, eyelids, 
 arms, hands, legs, feet swell, and are of a dark red complexion, as in 
 the most malignant small pox; in children, if the velum palati be 
 much affected, with an ichorous discharge by the nose; where many 
 mucous linings are expectorated, resembling the cuticle raised by 
 vesications; when pus was brought up, where no sloughs or exulce- 
 rations could be seen in the fauces; where without any difficulty in 
 swallowing, this affection has reached down the bronchia unto the 
 lungs, with the symptoms of a New England quinsey, and was erro- 
 neously deemed such; the deeper in the thorax the complaint, the 
 greater the danger : in some young children with scarce any appear- 
 
TRACT OF DR. DOUGLASS. 183 
 
 ance in the throat, spreading ulcers did form behind the ears in the 
 place where infants have a natural issue or running. 
 
 In some the tongue did throw off a slough or exuvia retaining the 
 impressions of the papilla^ being a mucus inspissated, and of the same 
 nature with those mucous linings expectorated from the bronchia or 
 oesophagus. Some have had impostumations in the fauces, with a 
 fatal strangulation, while others have escaped by the discharge of 
 ichorous curdly matter. Some, especially of the adult female kind, 
 have had hysterical or nervous suffocations ; but of no bad conse- 
 quence, unless officiously and ignorantly treated with Y. S. and other 
 evacuations. 
 
 The fever is seldom too high, sometimes it is too low for a thorough 
 laudable eruption. If the fever is too high, if the patient is pletho- 
 ric or accustomed to Y. S. ; take away some blood but with discre- 
 tion; if the tonsils are much inflamed with great pain and difficulty 
 in swallowing, use Y. S. in the jugulars, epispastics ad nucham, en- 
 courage the eruption, or its succedaneum a breathing sweat; a pro- 
 fuse fudor is equally to be avoided as a continued diarrhoea, either of 
 them confound the distemper in its natural course. 
 
 In case of colliquations give ol. cinnamomi, decoct, alb., elixir 
 vitriol, torrified rhubarb and the like. As to the specks or sloughs 
 in the fauces, (they cast off in course in the benign kind,) mercurials 
 inwardly, and the gargles before mentioned topically, are useful; the 
 practice in some country places of separating them forcibly by spa- 
 tulas is hurtful, because the irritation occasioned thereby induces a 
 further flux upon the part, and the sloughs form again worse con- 
 ditioned than before. Where the brain is affected as in vigilias jac- 
 tantia, delirium, coma, stupor, &c, glysters, vesicatories, and snppe- 
 danea are to be used. 
 
 Where faintness or great prostration of strength, give toasted bread 
 soaked in some generous wine and water, or volatile spirits in their 
 common drinks; bezoars, testacea, and the like, are of no use: the 
 shop cordial juleps and mixtures are only sugared drams. To enu- 
 merate all the other accidental symptoms which do happen here, in 
 common with other acute diseases would be trifline. 
 
 3d. Consequential ails, which may be enumerated as in the follow- 
 ing articles. 
 
 1st. The natural effects of an intense corrosive scorbutic-like col- 
 liquation of the blood and juices, anasarcous swelling or bloatedness 
 of the face, in some to that degree as to shut up their eyes; the same 
 oedematous swellings in the extremities; in a few an infiltration in 
 the scrotum, in some petechias, purple spots, scorbutic-like sugilla- 
 
184 APPENDIX. 
 
 tions upon the least scratcli or bruise ; hemorrhages of all sorts, by 
 the nose, from the lungs in expectoration, by stool, by urine, proflu- 
 viums in women, tempore non debito; these are dismal phenomena 
 in the state of any acute fever, e. g. small pox, and scarce any recover; 
 but in our distemper being only short temporary consequential ails, 
 scarce any of them proved mortal, but gave way to a soft milk diet, 
 in some to cortex Peru v., or elixir vitriol in others; a girl, set. 14, 
 with hemorrhages of several sorts, with purple spots and scorbutic- 
 like sugillations, recovered, notwithstanding of a very loose regimen. 
 N. B. These were not to be attributed to the mercurial administra- 
 tions, because they equally happened to those who had taken no mer- 
 cury. 2d. When the defecation has not been complete, from want 
 of natural strength, or from catching cold, or from undue evacuations : 
 the reliquie were thrown off by urtications, by vesications in several 
 parts of the body, by serpiginous eruptions, chiefly in the face, by 
 purulent pustules, by boils, by swellings and impostumations in the 
 groin, armpits, and other parts of the body. The most frequent con- 
 sequential ail of this kind is, when from cold received, the glands 
 and cellulary tegument called the panicula adiposa in the forepart of 
 the neck, becomes infiltrated and obstructed; if not soon resolved by 
 the continued fotus of warm woollens, and hot animating applications; 
 the induration increases and spreads every way, so as to suffocate 
 some, in others they sphacelate and become ulcers mortal or of difficult 
 cure: thus a few have died with us in Boston, but many in the 
 country. 
 
 By catching cold likewise, the tonsils have afterwards inflamed, 
 and come to suppuration. In a young woman the tonsils and uvula 
 being much ulcerated, did unite and coalesce into one mass and re- 
 main so; this might have been prevented by frequent gargling. 
 
 While these indurations are only in the form of kernels, as they 
 are vulgarly called, woollen mufflers, empl. de ranis cum mercurio, 
 and the like, with gentle cathartics, soon resolve them; cataplasms 
 in this case have done much mischief; because as soon as they be- 
 come cold, they act as a chilling damp upon the part, and destroy 
 its vitality. When they arrive to the state of putrid flaccid ulcera- 
 tions, digestives and soft fomentations intenerate the part, and occa- 
 sion the ulcer to spread ; spirituous animating desiccative dressings 
 have done better. Exposing the part to the cold, either in state of 
 tumefaction only, or in the subsequent exulcerations aggravates the ail. 
 
 3d. From the violence which the nerves have suffered in this ill- 
 ness : even where the symptoms were apparently mild, they all com- 
 plain of great faintness and universal weakness, particularly in the 
 
TRACT OF DR. DOUGLASS. 185 
 
 joints. Some women have hysteric affections, in a few upon recovery 
 imbecility of mind or silliness, in some stammering or loss of speech, 
 for a few days, some have had short fits of melancholy, some were 
 seized with epileptic fits, but not so as to become habitual. All these 
 disorders soon vanished, as the patient recovered his strength in 
 course of time, and by the help of a restorative cordial regimen and 
 diet. 
 
 4th. Other consequential ails, in common with other fevers, par- 
 ticularly where the strength of nature has been much impaired by 
 the distemper itself, or by immoderate evacuations, the patient is left 
 in a languishing weakness. Where the eruption has been impeded 
 by being exposed to the cold, or by unseasonable V. 8. or cathartics; 
 the patient falls into hectical wastings, fatal to some in a very short 
 time. All who underwent immoderate evacuations, were a long time 
 in recovering their strength. 
 
 Scholia, or some general remarks upon the whole. 
 
 1st. This seems to be a new kind of epidemical disease, it is not 
 the same with the aphthae which have at times prevailed in Holland, 
 as described by Forestus, and mentioned by Boerhaave in his colleges. 
 Tournefort says there is a distemper not uncommon in the Levant, 
 viz. : a carbuncle or plague sore in the bottom of the throat, it car- 
 ries off children in a few days, but does not affect grown people, as 
 does ours. Captain Morton, of late Plymouth Colony, who wrote 
 many years ago his New England Memorial, says that in 1650 a dis- 
 ease in the mouth and throat prevailed, which proved mortal to many 
 in a short time ; but he does not describe it, and mentions nothing 
 of a fever. In Boston November 1719, a slight miliary fever chiefly 
 with children, but was over in two or three days, unless by catching 
 cold it continued appearing and disappearing alternately for some 
 days longer; there was no complaint of the throat, and no deaths en- 
 sued. It is not the same with the sore throats which are observed 
 from time to time, in some of our country towns, especially in the 
 winter season; these are endemial and constitutional, being tume- 
 factions and ulcerations with fluxion in the fauces and neck; pro- 
 ceeding from an intense scrofulous, scorbutic, or psoric habit, (in 
 such subjects vesications by cantharides did putrifie,) without any 
 eruptive fever, or tendency that way, so that of those who have died 
 in Boston, not above one in seven died of any throat ail, but of this 
 fever. It is however observable that the scrofulous and psoric, are 
 most susceptible of this distemper, and suffer more remarkably. 
 
 2d. This epidemical distemper is no creature of the seasons, it 
 having prevailed from May 1735, when it first emerged, the whole 
 13 
 
186 APPENDIX. 
 
 year or all the seasons round. It is no produce of peculiar climates 
 and soils, because it hath made its appearance in various places, from 
 Pemaquoid in 44 N. lat. to Carolina southward, and as we are lately 
 informed, it is in our West India Islands. It is remarkable that in 
 damp places, as near large ponds, fresh water rivers, woodlands, and 
 the like, it has done the greatest execution, as does the rot amongst 
 sheep in fenny lands. 
 
 It is not personally infecting after the rate of the plague, small 
 pox, &c, where every person is susceptible, excepting a very few 
 anomalous constitutions, children are the most obnoxious to any in- 
 fection; but with us several children in the family where the dis- 
 temper appeared, have escaped; it is true where it happens in a fa- 
 mily, it frequently seizes several, as in the case with our country pe- 
 ripneumonic fevers, and our autumnal remitting slow fevers, which 
 cannot be said to be contagious. 
 
 The distance in time of infection to be supposed received from a 
 sick person, to the time of the distempers appearing in the supposed 
 infected, could never, with any reasonable allowance of latitude, be 
 reduced to any rule, as in small pox, measles, &c. We have anato- 
 mically inspected persons who died of it with so intense a fetor from 
 the violence of the disease, that some practitioners could not conti- 
 nue in the room; but without being infected ourselves or carrying it 
 into families. Many children without reserve, frequent the houses 
 and chambers of the sick, and escape. It does therefore proceed 
 from some undiscovered quality of the air, affecting only peculiar 
 constitutions of persons and families: notwithstanding its being ge- 
 nerally favourable, it proves fatal to certain families; many families 
 for this reason have buried all or most of their children, e. g., Boyn- 
 ton of Newbury Falls, lost his eight children. At Hampton Falls, in 
 five families 27 persons died. 
 
 3d. This is a very anomalous illness. Some complain a day or two 
 before they are confined, some are seized as it were instantaneously, 
 it is generally most severe with these last. In some a soreness of 
 the throat and darting pain there, reaching the ears, is previous to 
 all other symptoms; in others the common symptoms of a fever ap- 
 pear, before any inflammation or specks are perceivable in the fauces, 
 some have a sore throat without any perceivable eruption, only a 
 gentle breathing continued sweat, or an increased insensible perspi- 
 ration with the peculiar smell of the morbid effluvia. 
 
 Some (but very few) have the cuticular eruptions without any 
 sloughs in the throat, only the tonsils, uvula, and velum palati, tu- 
 mefied and inflamed; and in a few a purulent discharge from some 
 
TRACT OF DR. DOUGLASS. 187 
 
 parts deeper than the fauces, that is lower than the sight can reach, 
 these are not without danger, many of those who died early of a ne- 
 crosis, had no tumefaction, inflammation, or specks in the throat. 
 The time of eruption is very uncertain; in a few it precedes the sore- 
 ness of the throat, in a few it goes pari passu with the affection of 
 the fauces ; but generally it is (not much) later than the first com- 
 plaints of the throat : in a young woman it was later by fourteen days. 
 
 In ruddy complexions the efflorescence is very discernible; it is 
 not so distinctly perceivable in brunettes, Indians, and negroes; un- 
 less the miliary eruptions have a considerable relief as in some, they 
 generally scale and peel notwithstanding. Sometimes it appears only 
 in the cheeks, sometimes only a few clusters in the extremities, some- 
 times the suffusion was scarce miliary, and vanished insensibly, by 
 becoming gradually paler without scaliug. "Where the miliary erup- 
 tions were considerable, the extremities peel in scraps or strips like 
 exuvia; in one or two, the nails of the fingers and toes did cast off. 
 The period or continuance of eruption is sometimes prolonged by 
 weakness of nature, by undue evacuations, or by the patients being 
 exposed to the cold. 
 
 4th. In some who were slightly affected, their illness was of a much 
 shorter continuance, than is described in the standard kind. Most of 
 those who died of the physician, died of immediate evacuations. As to 
 the deaths, only a few were occasioned immediately by any distempera- 
 ture of the throat; they were generally the effect of the fever, either by 
 an immediate necrosis at first seizure or by the ordinary fatality of 
 fevers, or by consequential ails. In Boston at a medium of the last 
 eight healthy years", (1723, 1724, 1725, 1726, 1727, 1728, 1732, 
 1733,) in the months of October, November, December, January, 
 February, March, April, to 18th May, died 382, is 114 extra deaths, 
 and may be reasonably charged to this illness, it being, otherwise, a 
 healthy time; of these 114, about 71 cases came to my knowledge, 
 whereof in the first period 35 died, in the second period, 28, and of 
 consequential ails 8; of these 71, only about 10 can be said to have 
 died of sore throats. Of these 71, only 9 were upwards of 14 set. 
 According to the nearest estimate I can make, in round numbers, 
 about 1 in 35 have died, that is about 4000 persons in Boston, have 
 had this distemper, which is about one-fourth part of the inhabitants. 
 . 5th. The summer of 1735 was unusually wet and chilly, with many 
 easterly winds, in the summer and autumn it prevailed and was very 
 mortal in several country towns. In Boston it began in autumn, but 
 did not prevail until winter, which was not rigid with hard frosts as 
 
188 APPENDIX. 
 
 is usual, but with a very disagreeable chill in the air, especially in 
 the month of March last, in which month was our greatest mortality. 
 
 6th. Most malignant distempers affect to throw off their malignancy 
 by some emunctory. The despumation of this acrid inquination of 
 the juices in our distemper, that is, its natural crisis, seems to be by 
 the patent and salutary emunctories of the fauces and skin. In cor- 
 rosive taints, e. g. venereal and others, a mercurial ptyalism and fu- 
 dorisic decoction of the woods, answer best : this gave us the hint of 
 promoting the tendency of nature in our illness, by mercurials and 
 gentle breathing sweats a bed; which with good management seldom 
 failed, excepting where the necrosis was irremediable from the be- 
 ginning. 
 
 Some affection of the throat seems to attend most kinds of erup- 
 tive fevers. In the small pox, (even where the pustules and other 
 symptoms were in the smallest degree,) they all complain of a sore- 
 ness of the throat, but without ulcerating. In the measles there is 
 a hoarseness, and soreness of the throat, in ours besides the soreness, 
 tumefaction, and inflammation in the fauces; there are specks or 
 sloughs of a mellow white or cream colour, like those on the inside 
 of the cheeks in a mercurial ptyalism; the scrofulous, and venereal 
 ulcers in the throat are yellow; aphthse are more of the nature of 
 phlyctense; many of our patients complain of a copperish taste or 
 peppery smart in the throat, as they express it. 
 
 7th. As in all other distempers so in this there do sometimes hap- 
 pen violent symptoms, merely from the regimen and medicine used; 
 which on that account are not of that bad consequence, as if they 
 had proceeded from the distemper in its natural course, e.g. in some 
 constitutions a turbith bolus operates with violence, so as to occasion 
 shiverings, torsions of the bowels and spasms, as if the patient were 
 moribund : calomel even in very small doses seizeth the mouth of 
 some to a very considerable degree of inconveniency. 
 
 8th. We did not observe any genuine second seizures : it is true, 
 being winter season, many common sore throats, that is relaxations 
 of the uvula and inflammations of the tonsils, have passed with the 
 less observing practitioners, for the genuine epidemic and were used 
 accordingly; such have afterwards had this illness, and was errone- 
 ously called a second seizure. N. B. Our epidemic is attended with 
 no cough, unless when complicated with a cold or some old habitual 
 tussis : upon recovery it leaves frequently a small catarrhous colli- 
 quation or cough, but of short continuance. 
 
 In some after being well, upon catching cold the tonsils have been 
 inflamed even to suppuration ; in others the uvula and velum palati 
 
TRACT OF DR. DOUGLASS. 189 
 
 infiltrated and some phlyctenas or common aphthoe, have appeared, 
 such have also by some been deemed as second seizures, and used 
 as such. 
 
 After a long contiuuance of cold chilly weather, there set in sud- 
 denly warm weather, hot as mid summer. May 25th, 26th, &c, se- 
 veral children, who formerly had this eruptive fever, had an efflo- 
 rescence or miliary eruption by the heat, as is not unusual with chil- 
 dren in hot weather, this was by mistake of some practitioners, and 
 others, called a second seizure. 
 
 9th. No conditions of mankind were exempted (in our epidemical 
 autumnal dysentery, A. D., 1734, the negroes escaped.) Europeans, 
 West India Islanders, Indians, and Negroes, of all ages, were sub- 
 ject equally to it, but, as in most epidemical diseases, it affected chil- 
 dren and the younger persons more generally. 
 
 10th. This is a real history of the distemper as it appeared in Bos- 
 ton, New Eugland, taken clinically, taken from the life, and not 
 copied; there is no stroke or clause, but what I can vouch by real 
 not imaginary cases; it is founded only upon observations, or pheno- 
 mena, that is, upon the symptoms that appeared in the course of the 
 epidemical disease; it must therefore be of permanent truth. 
 
INDEX 
 
 Ablutions of skin, 110. 
 
 Abscesses in neck, 18; treatment of, 
 
 161. 
 Aconite, 166. 
 Affusion, 111. 
 Age, influence of, 56. 
 Albuminuria, 90. 
 Ammonia, Carb., 149. 
 Anasarca, 66, 92. 
 Anatomy morbid, of scarlet fever, 68, 
 
 69. 
 Anginose form, 10, 15,18; treatment 
 
 in, 121. 
 Anodynes, 129, 150. 
 
 Belladonna, prophylactic use of, 152, 
 
 157. 
 Bleeding in scarlet fever, 116, 118, 
 
 130, 139, 142, 167. 
 Blisters, not appropriate, 18. 
 Blood, condition of after death, 68. 
 Brain, affections of, 96. 
 Brain, condition of in fatal cases, 67. 
 Brain, condition of in malignant form, 
 
 20. 
 Bright's disease, 91. 
 
 Calomel, beneficial effects of, 146, 165, 
 
 166. 
 Capsicum, use of, 136, 144, 145, 149, 
 
 150. 
 Cause of scarlet fever, 34. 
 Cerebral Effusion, 93, 96, 170. 
 Cold to surface, 111, 148. 
 Colden Cadwallader, history by, 57. 
 Complications, 33, 70. 
 Constitution stationarv, of epidemics, 
 
 122. 
 Contagion, 34. 
 Convulsions attendant on first stage, 
 
 14. 
 Convulsions, treatment of, 118. 
 Copland on Fomites, 37. 
 Coryza, 19. 
 Croup, 33, 79, 134 ; treatment of, 164. 
 
 Death, causes and periods of, 69. 
 Delirium, 65, 70. 
 
 Delirium attendant on simple form, 14. 
 
 Desquamation, 15, 80. 
 
 Diaguosis, 71. 
 
 Diarrhoea, 105, 172. 
 
 Diet, 110, 136, 173. 
 
 Digestive organs, state of, 13. 
 
 Digitalis, employment of in effusion, 
 
 167. 
 Discharge from ear, 15. 
 Divisions of. 10. 
 
 Douglass, of Boston, notice by, 52. 
 Duration of primary fever, 33. 
 
 Ear, diseases of, 78, 162. 
 
 Effusion, cerebral, 93; pulmonary, 92. 
 
 Effusion, seat of, 87; period of, 87; 
 
 description of, 90, 171. 
 Elliotson, views on contagion, 37. 
 Emerson, tables of, 39. 
 Emetics, use of, 115, 131, 134, 139, 
 
 144. 
 Endemic character, 39. 
 Endocardial inflammation, 103, 165. 
 Epidemic influence, 35, 39, 41. 
 Eruption, description of, 11. 
 
 " Irregularity of appearance 
 
 in anginose form. 15. 
 Eustachian tube, affection of, 71. 
 
 Fauces, state of in malignant form, 20. 
 Fever of irritation, 32. 
 Fomites, influence of, 36, 37. 
 Fothergill's description of malignant 
 
 form, 21. 
 Fothergill, views of treatment, 132, 
 
 141. 
 
 Glands of neck, swelling of, 18, 80. 
 Good, J. Mason, 36. 
 Gregory, Dr. George, 28, 45. 
 
 Hahnemann on Belladonna, 152, 156. 
 Hammond, experiments of, 99. 
 Heart, Affection of, 71. 
 Heat of skin, excessive, 12. 
 Hectic fever, 172. 
 
 Hildebrand, case of communication 
 by, 37. 
 
192 
 
 INDEX. 
 
 History of, earliest, 49. 
 
 " " in America, 57. 
 
 Hosack, -views on contagion, 37. 
 House of Refuge, cases at, 43. 
 
 Ice, employment of, 126, 148. 
 
 Imperfect development, treatment in, 
 136. 
 
 Incubation, period of, 17. 
 
 Inoculation, useless, 39. 
 
 Interval between primary and se- 
 condary stages, 32. 
 
 Inunctions, 113. 
 
 Irregular cases, division of, 10, 150. 
 " description and cases of, 27. 
 
 Kearsley, Dr. John, tract by, 54, 141. 
 Kidneys, affections of, 81, 84, 85, 86. 
 Kidneys, state of in commencement, 
 
 13. 
 Kidneys, treatment of disease of, 138, 
 
 166, 168. • 
 
 Laryngitis, 70, 134. 
 
 Latent cases, 32, 81. 
 
 Leeches injurious, 18. 
 
 Liability to, 59. 
 
 Local affections, treatment of, 124. 
 
 Malignant form, 10; description of, 
 19; treatment of, 138, 147. 
 
 Measles concurrent with scarlet fever, 
 75. 
 
 Meningitis, 33. 
 
 Mortality, rate of, and period of, 62 ; 
 proportion of, 64. 
 
 Negroes liable to, 58. 
 Nitrate of silver, 134. 
 
 Odour, peculiar, 16. 
 
 Otitis attendant on simple form, 15. 
 
 Otitis in anginose form, 17. 
 
 Percival, case of communication by 
 fomites, 36. 
 
 Peyer and Brunner glands affected, 
 105. 
 
 Philadelphia, first notice of disease, 54. 
 
 Pleural sac, effusion into, 92 ; cases of, 
 171. 
 
 Pneumonia, 71. 
 
 Pregnancy and puerperal state, influ- 
 ence of, 63. 
 
 Prognosis, indefinite, 62 ; unfavour- 
 able, 65 ; favourable, 66. 
 
 Propagation, modes of, 46. 
 
 Prophylactic treatment, 151, 156, 159. 
 
 Pulmonary tissue,effusion into, 92,171. 
 
 Pulse, frequency of, pathognomonic, 
 
 11. 
 Purgatives, use of, 116, 129, 132, 139, 
 
 145. 
 
 Quinine, use of, 151, 156, 159. 
 
 Rapid course characteristic of, 10. 
 
 Rheumatism, 70, 104, 172. 
 
 Rilliet and Barthez, 45. 
 
 Rubeola, may be confounded with, 19. 
 
 Rush, Dr. B., description of disease, 24. 
 
 Scarlatina faucium, 35. 
 
 Seasons, influence of, 41. 
 
 Second attacks, 60. 
 
 Secondary results, 19. 
 
 Seneca, description of plague by, 49. 
 
 Sequelae, 74, 77, 151; treatment of, 
 
 161, 164. 
 Serous effusion, 87. 
 Sex, influence of, 55. 
 Simple scarlet fever, 11. 
 Simulative cases, 42. 
 Skin, condition of, 13, 83. 
 Spinal disease, case of, 102. 
 Sponging in scarlet fever, 111. 
 Sporadic cases occur, 39. 
 Stages of disease, 18. 
 Stimulating treatment, remarks on, 
 
 150. 
 Strumous diathesis, 92. 
 Sudamina, present, 12. 
 Suddenness of attack, 11. 
 Sutton, Dr., essay on scarlet fever, 30. 
 Sydenham, 10, 14, 20. 
 
 Temperature of weather, influence of, 
 41. 
 
 Termination, days of, 32. 
 
 Throat in simple form, 12; in angi- 
 nose, 15, malignant, 20. 
 
 Tongue, appearance of, 12, 13. 
 
 Treacherous character of, 10. 
 
 Treatment, 106 ; of simple form, 108 ; 
 anginose form, 121; malignant, 138. 
 
 Ulceration of mucous membrane, 19, 
 33, 70; of throat, 161. 
 
 Urea, retention of, 98, 99. 
 
 Urine, state of, as affording prognos- 
 tic signs, 66, 91, 95, 133. 
 
 Vertebrae, diseases of, 68, 100. 
 Vomiting, 14. 
 
 Washes for throat, 128. 
 
 Yeast, use of, 149. 
 
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 JUVENILE PUBLICATIONS, 
 Will be forwarded Free of Expense upon application. 
 
 LINDSAY & BLAKISTON, 
 
 PUBLISHERS AND BOOKSELLERS, 
 
 No. 25 South Sixth Street, above Chesnut. 
 
 PHILADELPHIA. 
 
LINDSAY & BLAKISTON'S PUBLICATIONS. 
 
 This -useful little annual, now issued for the sixth time, has received each year a steadily increasing patronag 
 Physicians once using it find it so invaluable, that it would he an absolute loss of both time and money to do witho 
 it. Each year the publishers endeavor, by some improvement that will meet the wants of the profession general! 
 to make it more acceptable to them, and they trust the present issue will not be found wanting in this respect. 
 
 Being convinced, by the numerous testimonials of it. received from all quarters, that the number of copies sold shou 
 only be limited by the number of the profession in active practice throughout the United States, the publishers w 
 continue their efforts to improve it, and they trust that those gentlemen who have tested its merits and usefuln< 
 will commend it to such of their friends who have not. 
 
 LINDSAY AND BLAKISTON'S 
 
 PHYSICIAN'S VISITING LIST, DIAEI 
 
 AND 
 
 DAY-BOOK FOR 1859. 
 
 (NOW BEADY.) 
 
 Containing a Visiting List for Every Day in the Year, Memoranda-Page for Each Mont 
 Pages for Obstetric Engagements, for Vaccination Engagements, and for Accom 
 asked for and delivered. 
 
 It is an invaluable Pocket-Companion for every Physician — compact, easily carried in the pocket; methodical 
 arrangement, and so useful, that the Physician once using it will never afterwards be without it. 
 
 " It will Cost the Physician Fifty or Seventy-five Cents : it rvill Save him as many Dollars. 
 
 (Sent by mail, postage paid, at the following prices:) 
 
 Price, prepared for 25 patients weekly, Plain, 50 Cts. 
 
 25 " " Tucks, 75 Cts. 
 
 " « 50 " " Plain, 75 Cts. 
 
 " « 50 " " Tucks, $1.00. 
 
 Messrs. Lindsay and Blakiston have laid the profession under 
 f'^ut obligations for one of the greatest conveniences ever.fur- 
 d.siied them. Here is a little pocket-book, half an inch tinck, 
 six by three in dimensions, which will hold all memoranda of 
 visits paid and to be paid for each day ot each month during the 
 the year — of obstetrical engagements, things wanted and lent, 
 the addresses of patients and nurses, bills and accounts asked 
 for, &c. <kc. With it in one's pocket, everybody's bill can be 
 made out in a few minutes. It is the most complete thing we 
 ever saw, and every practitioner would secure one if he could 
 see it.— Stethoscopist. 
 
 This pocket-companion for medical men has proved itself so 
 useful and convenient, that it is likely to become a permanent 
 annual, and will be everywhere preferred by the profession 
 when once its merits are tested by use. It serves all the pur- 
 poses of a day-book, cash-book, and remembrancer, and may be 
 conveniently carried in the breast-pocket. No physician who 
 has ever had the advantage of so useful a pocket-companion, 
 can, we ate satisfied, afford to be without it.— Examiner. 
 
 This is an exceedingly useful work : one which, for conve- 
 nience and time-saving, should be in the hands of every physi- 
 cian. — N. Y. Journal of Medicine. 
 
 To many this will save ten times its price during the year for 
 <Vhich it is intended. — Western Journal. 
 
 This is an indispensable convenience to the physician having 
 any extent of practice, and needs only to be examined to be 
 purchased.— East Tennessee Record. 
 
 This is the most complete professional work of the kind we 
 have seen. It is a little volume, which the physician can easily 
 carry m his pocket, yet furnishing a perfect record of all his en- 
 gagements, past and future.— American Medical Journal. 
 
 We cannot conceive of a more useful little manual to a pi 
 sician, to save both time and trouble : it should be in the pi 
 session of every one in the profession. — Express. 
 
 It is almost indispensable to persons like ourselves, who 
 constantly forgetting where we have promised to be at so 
 particular hour, the name of the person who borrowed a bo 
 or the professional visits made in a day. There are lea 
 labelled at the top, giving appropriate places for memoranda 
 every kind, and other conveniences which an every-day pra 
 tioner would prize exceedingly. — Boston Med. <f- Surg. Jour? 
 
 This is one of the neatest, most convenient, and best cal 
 lated pocket-companions we know of. In it the physician '< 
 store the business of one whole year, and yet have it always 
 hand. It contains an almanac, lists for patients for eVery'da 
 the year, memoranda of obstetrical and vaccinating enga 
 ments, of things wanted and lent, addresses of patients, accou 
 asked for — indeed, there is nothing that one wishes, but he ! 
 find in this little book. We are certain of the thanks of th 
 of our readers who may be induced by our recommendation 
 send their orders to Lindsay & Blakiston. — Nelson's North.Lan 
 
 This pocket-memorandum has been published for the spei 
 use of physicians who require to keep a journal or diary of e 
 day's works, wants, and requirements. It is constructed w 
 much labor and ingenuity, arid has become a sine qua 
 among the medical faculty on the other side of the Iak< 
 Toronto Daibj Patriot. 
 
 This beautiful little convenience is before us. The wor 
 now so popular, so necessary, and so generally known, th; 
 is unnecessary to do more than announce its appearance. Vv 
 us it is a "rademecum," a universal remembrancer. We wr 
 sooner think of practising without a pocket-case than witl 
 this pocket-book— Ohio Medical and Surgical Journal. 
 
 FOR SALE IN NEW YORK BY S. S. & W. WOOD, No. 389 BROADWAY ; WILEY 
 HALSTED, No. 351 BROADWAY; STRINGER & TOWNSEND, No. 222 BROADWAY. 
 IN BOSTON BY TICKNOR & FIELDS ; A. WILLIAMS & CO. ; REDDING & CO. ; A 
 BURNHAM & BROTHERS.— IN BALTIMORE BY CUSHINGS & BAILEY ; J. S. WATEK 
 ARMSTRONG & BERRY; AND HENRY TAYLOR. —AND BY ALL THE PRINCIP 
 BOOKSELLERS THROUGHOUT THE UNITED STATES AND CANADA. 
 
LINDSAY & BLAKISTON'S PUBLICATIONS. 
 CAZEATTS TEXT-BOOK OF MIDWIFERY 
 
 A NEW TRANSLATION 
 From a New and Greatly Enlarged French Edition. 
 
 WITH MANY NEW ILLUSTRATIONS. 
 
 A THEORETICAL AND PRACTICAL TREATISE ON MIDWIFERY; including 
 the Diseases of Pregnancy and Parturition. By P. Cazeau, Member of the Imperial 
 
 Academy of Medicine, Adjunct Professor in the Faculty of Medicine of Paris, &e. &c. 
 A New Translation from the Fifth French Edition, by W. R. Bullock, M. D. With 
 Lithographic and Numerous other Illustrations on Wood. 
 
 In one large royal octavo volume. Price, $4. 
 
 The great value cf this work has been sufficiently attested by its adoption as a TExt-Boox by the Eoyal Council of 
 Public Instruction in France, and the very favorable opinion expressed of it by many members of the medical pro- 
 fession in the United States, as well as by its very rapid sale both in this country and in France, where it has already 
 reached a fifth edition — the thorough revision which it has received from its author, and the numerous additions 
 made, rendered a new translation necessary; this has been done by a gentleman who, during a recent visit to Paris, 
 became a student of Mons. Cazeau, and thus becoming familiar with his views and opinions, was peculiarly fitted to 
 accomplish the task assigned to him in an acceptable manner. 
 
 " When an author, who may be a stranger, presents himself 
 before the profession in the attitude of a teacher, a proper re- 
 spect for our readers requires us to inform them something; of 
 the character and standing: of the writer. P. Cazeau, the author 
 y( the above treatise, was, for a number of years, physician- 
 accoucheur to one of the largest, lying-in hospitals of Paris, where 
 he enjoyed the amplest opportunities for ascertaining the value 
 of the doctrines put forth by obstetrical writers; and where all 
 mere speculation was made to give way to the severe test of 
 truth and experiment. Monsieur C. was, besides, a long time 
 cfo'fde clhiiqi'A to Professor Dubois, and a pupil of the distin- 
 guished Moreau. Besides, he has been a lecturer, for the last 
 eight or ten years, on midwifery, in the schools of Paris, in the 
 capacity of adjunct professor. We think we have said enough 
 to satisfy the reader that our author is not a quack, but a stu- 
 dent, and a practical physician. The plates are well executed, 
 and will assist the reader materially in understanding the text." 
 
 "We cannot do less than commend his book to the careful 
 perusal of the student and practitioner ; assuring both that they 
 will be amply rewarded for a careful study of the work."— Xew 
 Orleans Med. and Surg Journal, May. 1850. 
 
 "In the multitudinous collection of works devoted to the pro- 
 
 pagation of human beings, and to the details of parturition, none, 
 in our estimation, bears any comparison to the work of Cazeau, 
 in its entire perfectness ; and if we were called upon to rely 
 alone on one work on aceouchments, our choice would fall upon 
 the book before us. without any kind of hesitation."— West. 
 Journal of Med. and Surgery. 
 
 " Written expressly for the use of students of medicine, and 
 those of midwifery especially, its teachings are plain and explicit 
 presenting a condensed summary of the leading principles esta- 
 blished by the masters of the obstetric art, and such clear, prac- 
 tical directions for the management of the pregnant, parturient 
 and puerperal states, as have been sanctioned by the most au- 
 thoritative practitioners, and confirmed by the author's own 
 experience. Collecting his materials from the writings of the 
 entire body of antecedent writers, carefully testing their cor- 
 rectness and value by his own daily experience, and rejecting all 
 such as were falsified by the numerous cases brought under his 
 own immediate observation, he has formed out of them a body 
 of doctrine, and a system of practical rules, which he illustrates 
 and enforces in the clearest and most simple manner possible." 
 —Medical Examitier. 
 
 MEIGS'S VELPEAU'S ILLUSTRATED MIDWIFERY. 
 
 FOURTH AMERICAN EDITION. 
 
 {Tins work has been recommended and used as a Text-Book in the University of Pennsyl- 
 vania, the Jefferson Medical, and other large Schools in the United States.) 
 
 A COMPLETE TREATISE ON MIDWIFERY; or, The Theory and Practice of Toko- 
 logy, including the Diseases of Pregnancv and Labour, and the Puerperal State. 
 Translated from the French, by Charles D. Meigs, M. D., Professor of Midwifery in 
 Jefferson Medical College. Fourth American, from the Last French, Edition. By 
 W. Byrd Page, M. D., Lecturer on Obstetrics in the Philadelphia Medical Institute, 
 Member of the College of Physicians, &c. With numerous beautifully executed Illus- 
 trations. One volume, royal octavo. Price, $3.50. 
 
 " The elaborate Treatise on Midwifery by Velpeau is well known, and its translation by Dr. Meigs has long enjoyed a great 
 Transatlantic reputation. The present edition by Dr. W. B Page is very well executed: the type is very good, and the 
 plates exceedingly well engraved. The whole work is a valuable contribution to the history and practice of Tokology, alike 
 suitable to the student and the practitioner.'*— Land. Mai. Times. 
 
 GOOCH'S 
 
 PRACTICAL 
 Robert Goc 
 
 Surgeons, London 
 
 PRACTICAL MIDWIFERY.- (New Edition.) 
 
 MIDWIFERY; including the Diseases of Females and Infants. By 
 Gooch, M. D. Edited by George Skinner, Member of the Royal College of 
 A New Edition. One volume, octavo, sheep. Price, $1.50. 
 
LINDSAY & BLAKISTON'S PUBLICATIONS. 
 
 The rapidity with which two large editions of this work hare been sold is a fair demonstration of the value placed 
 apon it by the profession, whilst the large practice and great experience of the author in this peculiar branch of 
 medicine, unite to give it a value certainly not inferior to any other book upon the subject. 
 
 MEIGS OH" CHILDREN. 
 
 Third Edition Just Ready. 
 
 A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. A New and 
 Enlarged Edition. By J. Forsyth Meigs, M. D., Lecturer on the Practice of Medicine 
 in the Philadelphia Medical Association, Fellow of the College of Physicians of Phila- 
 delphia, Member of the Academy of Natural Sciences, and of the American Philoso- 
 phical Society. In one volume, octavo. Price, $3.50. 
 
 Dr. Meigs has enhanced the value of the new edition of his 
 Work by an Introductory Essay on the Clinical Examination of 
 Children; by the re-arrangement and re-writing of the articles 
 on Croup, Bronchitis, and Pneumonia; by a discussion of the 
 value of Tracheotomy in Croup; by the insertion of an article 
 on Atelectasis, or Imperfect Expansion of the Lungs ; by a revi- 
 sion and partial re-writing of the article on Scarlet Fever, and 
 by the addition of ,Tiore than a hundred pages of new matter 
 on Diseases of the Skin. — N. W. Med. $ Surg. Journal. 
 
 We have gone over those parts of the work which have ap- 
 peared to us to be of most interest to ou readers, and cannot 
 but express the satisfaction which its pei usal has afforded us. 
 No pains appear to have been spared to obtain the most recent 
 information in regard to the important subjects of which it 
 treats, and we feel confident that it will meet the approbation 
 of the profession. — American Medical Journal. 
 
 This very much enlarged edition is a decided improvement of 
 this excellent work. The style is free from pedantry and affec- 
 tation, while the descriptions of disease are accurately drawn, 
 and the treatment, for the most part, remarkably judicious. It 
 forms one of the most complete works on the Diseases of Chil- 
 dren that has appeared. — Ohio Medical and Surgical Journal. 
 
 The well-earned reputation of Dr. Meigs, as authority in any- 
 thing he might say in relation to the diseases of children, will 
 insure a demand for any work emanating from his pen on this 
 important subject.— Western Lancet. 
 
 Dr. Meigs deserves professional confidence by his learning aRf' 
 ability, and especially by the ample opportunities he has had foi 
 acquiring practical knowledge in the school of experience. Hi' 
 publishers have done themselves credit by the style of excellent j 
 in which they have sent forth this edition from their press.— 
 New York Medical Gazette. 
 
 We have great pleasure in bearing testimony to its high me- 
 rits, and especially to the improvements introduced into tha 
 present edition. There is certainly, now, no work in the lan- 
 guage in which the leading diseases of children are more agree- 
 ably, clearly, and faithfully delineated.— Medical Examiner. 
 
 We feel proud when we examine this work. It is an evidence 
 that, however valuable foreign productions may be for refer- 
 ence, we do not need to go abroad for elaborate treatises on 
 medicine. Let our publishers and our profession hold out suffi- 
 cient encouragement to native talent and authorship, and soon 
 American ideas in American books will be more eagerly sought 
 for on the other side of the Atlantic than they have been, while 
 we will depend less upon foreign talent and observation. . . . 
 We bespeak for Dr. Meigs' book what it richly deserves — awn's 
 circulation.— N. J. Medical and Surgical Reporter, August, 1853. 
 
 Because Dr. Meigs' book is up with the times in pathology; 
 because it is accurate and practical in its classification of facts 
 and deductions, we like it; and we like it still more, because 
 it speaks to us in that plain and simple language which we cab 
 readily understand. — Western Medico- Chirurgical Journal. 
 
 TILT'S FEMALE HYGIEHE. 
 
 ELEMENTS OF HEALTH, AND PRINCIPLES OF FEMALE HYGIENE. By F. J. 
 Tilt, M.D., Senior Physician to the Farrington General Dispensary and Lying-in 
 Charity, and the Padington Free Dispensary for Diseases of Women and Children, 
 Author of a Work on the Diseases of Menstruation, &c. In one volume. Price, $1.2$. 
 
 As Dr. Tilt justly remarks, the application of hygiene to women is still in arrears ; and we know no one better qualified to supply 
 this acknowledged deficiency than our author. His works on kindred subjects, and the valuable papers which he is constantly 
 contributing to the periodical literature of his country, have rendered his name high authority in this branch of his profession. . 
 He divides life into the septennial epochs so long adopted by philosophers and medical men, discussing, under the different ages 
 the physical and moral relations, diseases, &c, peculiar to each. The chapter devoted to the age from fourteen to twenty-one 
 years contains much valuable advice respecting the menstrual function during that period. Tables showing the value of life at 
 each of the different periods of life, are appended in their proper places; and the work also contains other statistics of value and 
 interest. Indeed, the whole work has been prepared with great care, and contains a large amount of valuable information, 
 which professional men may consult with profit. The mechanical execution of the work is highly creditable to the enterprising 
 house by which it is published.— N. Y. Medical Times. 
 
 BULL OH CEILDEEI. 
 
 THE MATERNAL MANAGEMENT OF CHILDREN IN HEALTH AND DISEASE. 
 A New and Improved Edition. By Thomas Bull, M. D., Member of the Royal College 
 of Physicians. In one volume, duodecimo. Price, $1.00. 
 
 We are pleased to see a second edition of this very sensible treatise. Were it generally circulated among mothers, and could 
 they be induced to study with care, and carry out in practice, the excellent precepts inculcated by the author in reference to 
 the management, during health and disease, of their offspring, much good would result. Even if nothing more were effected by 
 the sound, practical teachings of the author, than the banishment from the nursery of the numerous errors and prejudices m 
 regard to the physical and dietetic management of" infants and children which there still prevail, the work would prove a blessing 
 to every family, and save its youthful members from much temporary discomfort, the effects of which are too often experienced 
 throughout every portion of their future lives. Even the second part of the work, devoted to the proper management of childreE 
 in disease, is well calculated to diminish domestic quackery, and to warn the mother to seek, in the incipient stages of the several 
 diseases incident to this period of life, competent medical advice. The author, in his remarks in regard to these diseases, while 
 he communicates much that it is important parents should be familiar with, has very skilfully avoided the dangerous error of lead- 
 ing them into the belief that, without the aid of a skilful physician, the maladies of infants and children can be nrooerlv ari 
 safely managed.— American Medical Journal. 
 
LINDSAY & BLAKISTON'S PUBLICATIONS. 
 HEADLAND'S ACTION OF MEDICINES. 
 
 SECOXD AMERICAN, 
 
 From the Second Revised and Enlarged London Edition. 
 
 HIE ACTION OF MEDICINES IN THE SYSTEM, or, The Mod- m which Thera- 
 peutic Agents introduced into the Stomach produce th^ir peculiar Effect on the Animal 
 Economy Being the Prize Essay to which tin Medical Society of London awarded 
 the Fothergillian Gold Medal for 1852. By Frederick William Headland, M. D., 
 B. A., F. L. S. Second American edition, in one volume. Price, $1.75. 
 
 This work has received the most unqualified approbation of the Medical Press, both in this country and in Europe, 
 
 nounced by them to be the most original and practically useful work that has been published for many years. 
 
 It is truly a great scientific work in a small compass, and deserTes to be the hand-book of every lover of the profes- 
 
 give the same opinion regarding it, that Dr. Rush did concerning the works of Sydenham, "It should be 
 
 uept where it would he convenient to lay one's hands upon it." It gives the only scientific and satisfactory view of 
 
 the action of medicine; and this is not in the way of idle speculation, but by demonstration and experiments, and 
 
 inferences almost as indisputable as demonstrations. That part of the medical horizon where rested the densest 
 
 clouds is now the most luminous, aud made so through the agency of this work. No physician should b* 
 
 without it. 
 
 We can speak of this work is unqualified terms o" ... yrooa- 
 tion. The author has brought to his task a soum 
 extensive knowledge of the literature of his sm ■<:„.., perfect 
 acquaintance with the principles of modern sci* c . and a large 
 number of original observations. — AtheiKBUV 
 
 He lias treated his very difficult subject .. «. novel and highly 
 scientific manner.— Dublin Medical Press. 
 
 It is a full and clear exposition .ji 'he doctrines which have 
 now began to prevail in regard to the manner in wi... 
 cines produce their physiological and therapeutical effects. It 
 is well aud carefully written, and deserves to be carefully 
 studied.— Jim Journal qf Pharmacy. 
 
 We recommend the work as replete with information: the 
 practitioner cannot fail to obtain from it many valuable hints. — 
 • cal Journal 
 
 We unite most cordially with our contemporaries in com- 
 mending if. to our professional brethren. —Buffalo Medical 
 Journal. 
 
 Actuated by a desire for truth, each paje bears the impress 
 of candor and impartiality.— Charleston Med. Journal. 
 
 We congratulate Mr. Headland as the author of this work : it 
 shows the writer to be a thinker — a man of some observation 
 and a good deal of reflection, and one who has willingly devoted 
 time and talent to the praiseworthy object of endeavoring to 
 throw some light into one of the dark coiners of medical 
 science — Edin. Monthly Journal. 
 
 Mr. Headland has put the present views of therapeutics in a 
 clear light ; anu. by n:s own experiments and observations, has 
 removed some of the many deep obscurities which have so long 
 surrounded tue subject. — Lancet. 
 
 This book displays in every page the evidence of extensive 
 knowledge and of sound reasoning; and it will be useful alike 
 to those who i ag their studies, and to those 
 
 who are engaged in the active pursuits of professional life. — 
 
 A text-hook of the action of medicines. It is a well-timed 
 publication.— Association Journal 
 
 In our opinion, it is the ablest, the most philosophical and 
 ratisfac ory treatise on the action of medicines that has ever 
 Oeeu issued. — St. Louis M. c£ S. Journal. 
 
 PEBEIRA'S PRESCHIPTIO N-BOOK. 
 
 Second American from the Twelfth London Edition. 
 
 THE PHYSICIAN'S POCKET PRESCRIPTION -BOOK; containing Lists of Terms, 
 Phrases, Contractions, and Abbreviations, used in Prescriptions, with Explanatory 
 Notes. Also, the Grammatical Constructions of Prescriptions, &c. ; to which is added 
 a Key, containing the Prescriptions in an unabbreviated Form, with a Literal Translation, 
 intended for the use of Medical and Pharmaceutical Students. By Jonathan Periera, 
 M. D., F. R. S.. &c. Price, 03 cts. in cloth; 75 cts. in Tucks with pocket. 
 
 We know of few wonts .is<-v, to be more acceptable to the student of medicine and surgery, or to the practitioner, than this 
 tittle volume.— Boston Meeacal and Surgical Journal. 
 
 WYTHE S' DOSE AND SYMPTOM-BOOK. 
 
 Second Edition, Revised and Improved. 
 
 THE PHYSICIAN'S POCKET DOSE AND SYMPTOM - BOOK ; containing the Doses 
 and Uses of all the Principal Articles of the Materia Medica and Chief Officinal Prepa- 
 rations ; also, Tables of Weights and Measures, Rules to Proportion the Doses of Medi- 
 cines, Common Abbreviations Used in Writing Prescriptions, Table of Poisons and 
 Antidotes, Dietetic Preparations, Table of Symptomatology, and Outlines of General 
 Pathology and Therapeutics. By Joseph H. "Wythes, M. D., Author of "The Micro- 
 cope," " Curiosities of the Microscope," &c. &c. Price, 63 cts. in cloth ; 75 cts. in Tucks 
 with pocket. 
 This is one of those convenient little pocket remembrancers, designed more particularly to meet the practical wants of the 
 student of medicine, and calculated also to prove useful to the country practitioner, the aim of the compiler having been to render 
 it rather suggestive than complete. An alphabetical list of medicines is given, with medicinal and English names, and in most 
 ctM,es, uie mode of preparation. The therapeutic effect is then given, followed by the diseases in which each medicine lias beeu 
 used, and the mode of employing it, with the dose and principal incompatible substances. There is then a table of poisons 
 and antidotes, and a chapter on dietetic preparations ; also, an outline of General Pathology and Therapeutics, aad a table of 
 Symptomatology.— Journal of Pharmacy. 
 
LINDSAY & BLAKISTON'S PUBLICATIONS. 
 
 PAGET'S 8U&GICAL PATHOLOGY, ILLTJST&ATED. 
 
 LECTURES ON SURGICAL PATHOLOGY, delivered at the Royal College of Surgeons 
 of England. By James Paget, F. R. S. Lately Professor of Anatomy and Surgery to 
 the College ; Assistant Surgeon and Lecturer in Physiology at St. Bartholomew's Hos- 
 pital, &c. &c. Illustrated by 116 beautifully-executed Engravings on wood. In one 
 volume, octavo. Price, $3.50. 
 
 Dr. Paget's Lectures will form one of the standard works of 
 English Medicine, and will become a landmark when the flood 
 of progress has concealed from view less lofty and stable pro- 
 ductions. The style is so easy, the illustrations are so apposite 
 and so graphic, and the expression of facts so pointed, that it 
 is impossible not ro see that Mr. Paget possesses, in an unusual 
 <*egree, not only the art of observation, but the still more un- 
 common one of exposition. 
 
 It is equally distinguished by the two great qualities of range 
 and clearness ol thought. — Brit, and For. Medico- Chirl Review. 
 
 The Lectures of Mr. Paget contain a large amount of valuable 
 information, and they deserve to be studied with the utmost 
 Mention by all who wish to obtain just ideas on the intimate 
 „ature of the morbid changes to which the human body is liable. 
 It is a work that cannot fail to be at once necessary and service- 
 able to the physician as well as the surgeon. — Edinburgh Medical 
 and Surgical Journal. 
 
 Mr. Paget's work, in a scientific and practical point of view 
 is by far the most fimsued treatise with which we are ae. 
 quainted. —Medical Times. 
 
 It is the contribution of an original mind, representing ths 
 result of many years of profound research, careful study, large* 
 practical experience, and wiJdly-extended reading. The book 
 is eminently instructive. — Dublin Quarterly Journal. 
 
 The amount of practical research and varied learning exhi- 
 bited in these volumes are really remarkable. We are delighted 
 with the laborious and accurate observation, the lucid descrip- 
 tion, the powers of comparison and generalization, and the phi- 
 losophical deduction which every page exhibits, as well as with 
 the elegant simplicity of style and the lofty tone of the whole. 
 We think we do not err in saying that, since the publication of 
 Mr. Hunter's works, no contribution has been made in the Eng- 
 lish language of so much value, in Surgical Pathology, as this 
 of Mr. Paget.— London Lancet. 
 
 STOKES ON THE HE A BT- (New Edition). 
 THE DISEASES OF THE HEART AND THE AORTA. By William Stokes, Regius 
 Professor of Physic in the University of Dublin ; author of the Treatment and Diagnosis 
 of the Diseases of the Chest, &c. &c. A New Edition. In one volume, octavo. Price, $3.00. 
 
 In the course of the last thirty years the name of Dr. William 
 Stokes has gained an extraordinary celebrity. Of the many 
 ardent cultivators of medical science who have labored in that 
 interval to shed lustre on our native land, few have equalled, 
 and certainly none surpassed, the author of the treatise before 
 us. His reputation has sprung from the commanding fact that 
 originality of thought, vigor of reasoning, and utility in purpose 
 have invariably formed the combined characteristic of his me- 
 moirs. This book will, of course, be extensively read. Every 
 one who has studied the author's previous works will be doubt- 
 less a-uxious to see his latest production, and we can very well 
 anticipate some important changes in the cultivation of the 
 practice of medicine, which must result from such a general 
 perusal.— Dublin Quarterly Journal. 
 
 The physician who has felt at the bedside the difficulty of 
 diagnosis and treatment will best appreciate its value, and will 
 be prepared to rerder homage to the thoroughly practical cha- 
 racter which stamps its every page. It is eminently practical 
 in its character, and yet it is no mere register of facts, strung 
 together in unmeaning sequence, or to accommodate some arbi- 
 trary system. In the true spirit of inductive philosophy, the 
 author lias taken a higher range; with him facts are but the 
 mstmments which he uses in high philosophic generalizations. — 
 Edinburg Med. and Surg. Journal. 
 
 A treatise like this, replete with facts, observations, and im- 
 portant opinions upon a subject which has occupied the most 
 acute and practised minds in the profession, can hardly need 
 the imperfect indication of its value which we have given, but 
 which we nevertheless hope will induce many to consult it 
 who may desire a reliable guide in the study of the Diseases of 
 the Heart and Aorta. — Am. Medical Journal. 
 
 As embodying the experience of a great clinical investigator, 
 this work is largely entitled to the confidence of all engaged m 
 practice ; and there are few indeed who may not consult it with 
 profit and advantage in the doubts and difficulties that almost 
 every important case presents.— London Med. Times and Gazette. 
 
 It embodies the results of clinical observations continued 
 almost unremittingly for upwards of a quarter of a century. 
 
 We most heartily commend the work to the perusal of our 
 readers.— Medical Examiner. 
 
 Embracing every symptom and description calculated to throw 
 light upon the condition ->r Uiose essential organs, it seems 
 almost impossible that farther advances can be made in this 
 direction. Here is a minuteness and clearness which puts away 
 much of the doubt attending heart affections, and enables the 
 practitioner to determine at once the course to be pursued. It 
 would be a hopeless undertaking to particularise the abounding 
 excellencies of this invaluable work. We feel that the world- 
 wide reputation of the author is quite sufficient to give character 
 and currency to any production on medicine that bears ins 
 name,— Boston Med. and Surg. Journal. 
 
 Everything from the pen of Dr. Stokes naturally arrests our 
 attention. His fame has long been European. His skill as an 
 auscultator has added celebrity to the Dublin School of Medi- 
 cine. The long and close study with which he has applied 
 himself to the investigation of the particular objects treated of 
 in the volume named at the head of this article, at once secures 
 for him the attention of his professional brethren. " The 
 work," he tells us, " embodies the results of my clinical expe- 
 rience, continued almost unremittingly for upwards of a quarter 
 of a century."— London Monthly Journal, of Medical Science. 
 
 AN ENGLISH AND GERMAN CLINICAL PHRASE - BOOK 
 
 Containing the usual questions and answers employed in examining and prescribing for 
 patients, questions in asking for and buying medicines, &c. ; with an English-German 
 and German-English Pronouncing Lexicon of all the words occurring in the phrases, 
 with the chief technical terms of medical writers and apothecaries, Grammatical 
 Appendix, Table of Idioms, &c. Designed to aid Physicians and Surgeons in Hos 
 pitals, Aims-Houses, and Private Practice ; also, Druggists and Pharmaceutists in Dis- 
 pensing their Prescriptions. By Montgomery Johns, M. D. Price, in half roan, 
 $1.25 ; in tucks, with pocket, $1.50. 
 This little work is one of much labor ; it has been prepared with great care; it is, in fact, a Manual of the German 
 Language, specially adapted to the wants of Physicians, and will be found of great value to those practising in dis. 
 tricts of country where large numbers of Germans are settled, or in Hospitals, Aims-Houses, or other public institu- 
 tions where those speaking the German Language only are so often found. 
 
LINDSAY & BLAKISTON'S PUBLICATIONS. 
 
 TODD ON THE NERVOUS SYSTEM. 
 
 CLINICAL LECTURES ON PARALYSIS, DISEASE OF THE BRAIN, AND OTHER 
 AFFECTIONS OF THE NERVOUS SYSTEM. By Robert Bentlet Todd, M.D., 
 F. R. S., Physician to King's College Hospital. Price, $1.50. 
 
 We fee! that we should be wanting: in our duty, did we not 
 declare that these Lectures, in their fidelity of description, 
 soandness of doctrine, and practical value, have seldom been 
 equalled, and never surpassed. — Dublin Quarterly Journal. 
 
 They contain matter of ftie utmost theoretical and practical 
 val-ue, and we know of few books which will so well repay the 
 perusal of any medical man engaged in the earnest and careful 
 exercise of his profession.— Edinburg Monthly Journal. 
 
 Like all Dr. Todd's writings, this work is exceedingly easy 
 reading, and replete with just such information as the scientific 
 practitioner requires. The subjects are discussed in a tho- 
 roughly practical manner.— London Medical Times. 
 
 Every practitioner of medicine should make himself master 
 at the present series of Lectures, which will render him more 
 
 capable to understand and treat a formidable class of diseases 
 of every-day occurrence. — Association Medical Journal. 
 
 These Lectures cannot but be very acceptable to the profes- 
 sion, as conveying-, in a practical manner, the views of their dis- 
 tinguished author on the principal points in the pathology ol 
 Nervous Affections. — Brit, and Foreign Medico- Chirurg. Review 
 
 We have derived both pleasure and instruction from the pe- 
 rusal of these Lectures, and we cannot recommend them too 
 strongly to the attention of our readers.— Dublin Medical Press. 
 
 The manner in which Dr. Todd's work is written, will, we 
 hope, have the effect of making our readers study it with that 
 care and attention of which it is eminently deserving.— Glasgow 
 Medical Journal. 
 
 THOMPSON ON CONSUMPTION. 
 
 CLINICAL LECTURES ON PULMONARY CONSUMPTION. By Theophilus Thomp- 
 son, M. D., F. R. S. Fellow of the Royal college of Physicians, London, &c. &c. With 
 Illustrations. In one volume, octavo. Price, $1.25. 
 
 We desire also to express our admiration of the earnest and 
 intelligent spirit which has evidently presided over this work ; 
 the condensation of style, the clearness of conception anil ex- 
 pression, the abundance of materia! for thought which distin- 
 guish this volume from the crowd of ephemeral productions 
 which load our table. No one can doubt that it is the work of 
 a man who has seen and heard for himself, and who, by means 
 of labors conducted in a scientific spirit, and under favorable 
 circumstances, lias earned the right to submit his conclusions to 
 the public, with somewhat more of authority than we should be 
 lisposed to allow to the majority of medical authors.— Edin- 
 wgh Med. and Surg. Journal. 
 
 The volume abounds in useful and instructive matter.— Dublin 
 iledical Press. 
 
 It is refreshing to find a man like Dr. Thompson employing 
 nmself in enlightening the profession hv strictly clihicnl obser- 
 vation, the fruit of extensive opportunity, and ample expe- 
 «nce.— N. Y. Medical Gazette. 
 
 Here will be found a clear exr 
 their complications.— the details \ 
 ceptionable Diagnosis, from which 
 and sound data for the treatrnenl 
 which, as a whole, constitute Phth 
 Lectures at the length commensui 
 
 of the symptoms and 
 n to establish an unex- 
 illy flows the Prognosis 
 e many complications 
 l T e cannot notice these 
 th their great import- 
 ance and high value. Thev form one of the most, practical and 
 useful works on the same subject now before the profession — 
 Lancet. 
 
 Tiie work is an important addition to our present knowledge 
 of the indications and treatment of pulmonary diseases. — Ame- 
 rican Medical Monthly. 
 
 As physician to a large hospital devoted especially to this singl» 
 disease, the author has had ample opportunities to study Con- 
 sumption in all its phases, and he seems diligently to have im 
 proved the advantages he thus possessed.— N.Y. Journal of Med 
 
 They give evidence of long and careful bedside observation 
 ar»d are tminently practical. American Journal of Insanity. 
 
 BE. SKODA'S GEEAT WORK. 
 
 AUSCULTATION AND PERCUSSION. By Josefh Skoda, Translated from tla 
 Fourth German Edition, by W. 0. Markham, M. D., Assistant Physician to St. Mary a 
 Hospital. In one volume, 12mo. Price, $1.00. 
 
 We must content ourselves by recommending it strongly to 
 the attention of our readers, assuring them that they will find 
 m it. many valuable suggestions.— Edinburgh Medical and Surg. 
 Journal. 
 
 The physicii.M will find Dr. Skoda's book exceedingly valuable, 
 %nd full of practical details, as well as original views.— S. Med. 
 and Surg. Journal. 
 
 A work of such original thought is worthy to receive the 
 national franchise. We feel assured that it deserves the high 
 position that it has won for itsell abroad, and it requires only to 
 he known t<< -'tain in this country.— Dublin Quarterly. 
 
 Since the £,«at work of " Ltennec" we have had none to 
 equal it. Every page contains practic; 1 remark? of the highest 
 interest. It will take a high place in slaiMtaiH ried'ial litera- 
 ture.— Dublin Med. Press.. 
 
 We know Skoda to be an excellent guide, and can confidents? 
 recommend it.— American Lancet. 
 
 We urge its careful perusal, both from th« high position an£ 
 authority of the author, and the intrinsic merit of his investi- 
 gations.— N. Y. Journal of Medicine. 
 
 As a work replete with original thought and close observation, 
 Skoda's treatise stands only next in importance to the great 
 work of Lsennec.— Medical Examiner. 
 
 It is the fruit of careful study and of long continued and ac.ow' 
 rate observation.— JN. Y. Med. Times. 
 
 In originality of thought, closeness of reasoning, condensation 
 of style, and clearness of conception and expression, it is infinite! r 
 suDerior to the many ephemeral productions which load our ta 
 li'ia — W. Journal oj Med. and Suif/cry. 
 
LINDSAY & BLAKISTON'S PUBLICATIONS. 
 
 The demand for this useful and very popular work, by Prof. Mendenhall, has already exhausted four editions. 
 The present one, now just issued, is, in all the departments of medicine, fully brought up to the present time, and 
 will be found, upon examination, deserving of the patronage so freely given to former editions. 
 
 THE FIFTH EDITION, REVISED AND ENLARGED, 
 
 OF 
 
 MENDENHALL' S MEDICAL STUDENT'S YADE MECUM. 
 
 A COMPENDIUM OF 
 
 ANATOMY, 
 
 PHYSIOLOGY, 
 
 CHEMISTRY, 
 
 THE PRACTICE OF MEDICINE, 
 
 SURGERY, 
 
 OBSTETRICS, 
 
 DISEASES OF THE SKIN, 
 
 MATERIA MEDICA, 
 
 PHARMACY, 
 
 POISONS, &c Ac. 
 
 BY GEORGE MENDENHALL, M. D., 
 
 Lecturer on Obstetrics in the Miami Medical College of Cincinnati, Member of the 
 
 American Medical Association, &c. &c. 
 
 WITH OVER 200 ILLUSTRATIONS. 
 
 One volume, 12m o. Price, $2. 
 
 "This work is of the same character of Neill and Smith's 
 Compendium, and is of established reputation. Its accom- 
 plished author, Dr. Mendenhall, enriches each successive edi- 
 tion with the improvements in all the departments of medical 
 science." 
 
 "The present edition is still more entitled to favorable con- 
 sideration, from the fact that it has been carefully revised, en- 
 larged, and illustrated with numerous well-executed wood- 
 cuts." — Western Journal of Med. and Surgery. 
 
 " The work by Dr. Mendenhall has already secured favor, as 
 evidenced by the speedy exhaustion of the previous editions. 
 The present edition has been carefully revised and improved, 
 and about one hundred and fifty pages of new matter added. 
 
 It is, therefore, still more deserving of approbation and success, 
 which it will doubtless receive."— Buffalo Medical Journal. 
 
 " We recommend this book to all students, who may need 
 such a compendium, as one of the very best in print."— Stctho- 
 scu]jist. 
 
 " This volume puts the student in possession of a condensed 
 medical library. Its accuracy is a strong recommendation, 
 while the portability of a volume containing the whole circle 
 of medical science, is a matter that will have weight with those 
 for whose service the book was originally designed. The work 
 is offered, too. extremely cheap, and will be found a valuable 
 assistant even to a well-informed practitioner of any branch ot 
 medicine."— .Boston Medical and Surgical Journal. 
 
 RAND'S MEDICAL CHEMISTRY. 
 
 AN OUTLINE OF MEDICAL CHEMISTRY, for the Use of Students. By B. Howard 
 Rand, M. D., Professor of Chemistry in the Philadelphia College of Medicine, &c, &c. 
 One volume,- 12mo. Price, $1. 
 
 BIDDLE'S MATERIA MEDICA. 
 
 A REVIEW OF MATERIA MEDICA, for the Use of Students. By John B. Biddle, 
 M. D., late Professor of Materia Meclica in the Franklin Medical College, Fellow of the 
 College of Physicians, &c. In one volume, duodecimo. Price, $1. 
 
 This is an admirable summary of Materia Medica, and to the student will prove a very useful handbook. Valuable as are the 
 "J nited States' Dispensatory and Pereira's Materia Medica, they are far too voluminous to be used profitably as text-books. Dr. 
 Biddle's Review is just such a manual as the student wants, to recall the chief points to which he has attained. — Western Jour- 
 nal of Medicine and Surgery. 
 
 REESE'S AMERICAN MEDICAL FORMULARY. 
 
 THE AMERICAN MEDICAL FORMULARY, based upon the United States and British 
 Pharmacopoeias ; including also numerous Standard Formulae, derived from American 
 and European Authorities, together with the Medical Properties and Uses of Medicines; 
 Poisons, their Antidotes, Tests, &c. Designed for the Medical and Pharmaceutical Stu- 
 dent. By John J. Reese, M. D., Professor of Medical Chemistry in the Philadelphia 
 Medical College, &c. &c. In one volume. Price, $1.50. 
 
 The title page of this volume is an ample index to its contents. The author has arranged it for easy reference, in alphabetical 
 form, and has given preference throughout the volume to the various medicinal substances and pharmaceutical preparations 
 recognised by our own national Pharmacopoeia, and has striven to make it truly American. 
 
 JAMESON OH CHOLERA. 
 
 EPIDEMIC CHOLERA, embracing its Causes, History, Local Preferences, Non-Conta- 
 giousness, Symptomatology and Pathology, with complete Dissections and Vivi-sections. 
 Also, Observations showing a Choleraic Constitution of the Atmosphere, Views of its 
 Treatment, &c. &c. By Horatio G. Jameson, M. D., &c, of Baltimore. In one volume, 
 octavo. Price, $2. 
 
LINDSAY & BLAKISTON'S PUBLICATIONS. 
 
 WALTON ON TEE EYE, BY LITTELI. 
 
 " It is full of sound practical views." — Dr. Mackenzie, Author of a Practical Treatise on the 
 
 Diseases of the Eye. 
 
 OPERATIVE OPHTHALMIC SURGERY. By Hayxes Walton, F.R.C.S., Surgeon t 
 the Central London Ophthalmic Hospital, and Assistant Surgeon to St. Mary's Hospital. 
 With 1G9 Illustrations. Edited by S. Littell, M.D., Surgeon to the Wills Hospital for 
 the Diseases of the Eye, Fellow of the College of Physicians, &c. &c. In one volume, 
 octavo. Price, $3.00. 
 
 It is eminently a practical work, evincing: in its author great 
 research, a thorough knowledge of his subject, and an accurate 
 and most observing mind. — Dublin Quarterly Journal. 
 
 We look upon it as one of the most finished and comprehen- 
 sive works which has of late years emanated from the medical 
 press. It must have cost Mr. Walton much labor, but he lias 
 already been rewarded, for it stamps his character at once as a 
 sound and experienced ophthalmic surgeon. — Land. Med. Times. 
 
 It shows the rapid advances which ar2 being made in this de- 
 partment cf the medical art.— Brit, and For. Medico-Chirurgical 
 Review. 
 
 It is entitled to oui unqualified commendation. — Southern 
 Medical and Surgical Journal. 
 
 We heartily recommend it to the attention of the profession - 
 Virginia Medical and Surgical Journal. 
 
 Dr. Walton's work bears evidence of great research and e~ 
 tensive opportunities for observation.— A'ew York Medical Tune 
 
 This work throughout bears evidence of an intimate acquaint 
 ance with the principles of general pathology, and of the sound 
 common sense which characterises the British school of oph- 
 thalmic medicine — Am. Journal of Medical Sac/ice. 
 
 LITTELL'S MANUAL OF THE DISEASES OF THE EYE. 
 
 \ TREATISE ON OPHTHALMOLOGY. By S. Littell, M.D., Surgeon to Wills' Hos- 
 pital, Fellow of the College of Physicians of Philadelphia, &c. &c. In one volume, 
 12mo. Price, §1.25. 
 
 Our limits will not allow us to notice the work of Dr. Littell in detail ; but after an attentive perusal of the volume, we con- 
 fidently recommend it to the senior as well as junior members of I he Profession It is replete with information ; yet so terse in 
 style, and compressed in bulk, as at once to entice and repay perusal. The descriptions are short but compiehensive, while the 
 treatment is characterized by great prudence. He has introduced almost all that is valuable, and every thing absolutely necessary 
 to the student, within the compass of two hundred and fifty small p;iges ; and we would deliberately recommend our young friend* 
 to read this work before encountering the voluminous treatises of Lawrence, Travers, Mackenzie, Middlemore, &w ~Eritish ant 
 Foreign Medical Review. 
 
 PROF. SIMPSON'S HQMCEQPATHY. 
 
 HOMCEOPATHY, ITS TENETS AND TENDENCIES; THEORETICAL, THEOLO 
 GICAL, AND THERAPEUTICAL. By James Y. Simpson, M.D., F.R.S., Professor 
 of Midwifery in the University of Edinburgh, &c. &c. From the third Edinburgh 
 
 Edition. In one volume, octavo. Price, §1.25. 
 
 It contains the most philosophical exposure of Homceopathy 
 lu the English, or indeed any other, language, and is consequently 
 best adapted for furnishing materials to combat the specious 
 reasonings occasionally put forward by its professors or its dupes. 
 —Dublin Quarterly Journal. 
 
 Dr. Simpson's treatise is a most starching, philosophical, and 
 truthful expose of the Hahnemann fallacies, and cannot fail to 
 prove- eminently serviceable in eradicating the evils of that 
 system, so far as the credulity' of the age can be cured of a deep- 
 rooted blight. — The Western Lancet. 
 
 Physicians in our country, who have not had access to Hahne- 
 mann's writings, will do well to procure Prof. Simpson's work. 
 
 Hut it i< especially desirable to have the book placed in the hantas 
 of such non-professional persons as may be inclined to look favor- 
 ably on this nonsensical system. By keeping a copy for this 
 purpose, ear-h practitioner will exert more influence in his 
 neigborhood than by personal controversies, m which lie maybe 
 regarded as an interested witness by those who do not know how- 
 to distinguish between the love of truth and the love of lucie.— 
 Southern Medical and Surgical Journal. 
 
 V e assure our readers that they could not procure a more 
 piquant book, one abounding more in curious facts and instruct- 
 ive details, relating in any way to medicine, than it is. Let it be 
 read, and ;is incontrovertible facts be given to the people- 
 Western Journal of Medicine and Surgery 
 
 PROF. HENDERSON'S EEPLY TO PEOF. SIMPSON. 
 
 HOMCEOPATHY FAIRLY REPRESENTED. By William Henderson, M.D., Professor 
 of General Pathology in the University of Edinburgh. In one volume, octavo. 
 Price, $1.25. 
 
 A reprint from the second Edinburgh edition of the most acute 
 *nd interesting defence of Homoeopathy that we have had occa- 
 sion to notice. Dr. IIender>on is Professor of General 1 
 in the Unn inburgh.and the attack upon Homoeopathy 
 
 to which he. replies, and which is also .reprinted in this country 
 by Messrs. Lindsay & Blakiston, was written by the Professor of 
 Obstetrics in the same institution, Dr Simpson. The controversy 
 is spirited, sarcastic, caustic; and both the works of Professors 
 Henderson and Simpson are well worth reading.— Commercial 
 Advsrtiser. 
 
 Dr. Henderson's work is by no means deficient in ability, vigor, 
 and a certain degree of success. It is as good, and certainly as 
 ingenious, a defence as that side of the question will permit. It 
 is a work of rare ingenuity and skill, making the worse appeal 
 the better cause— Boston Atlas. 
 
 Those who wish to see what a man ot talent, and a cleve 
 writer, can say in defence of such a subject as homoeopathy, as a 
 system of cure of disease, and what apology its extravagances 
 and absurdities admit of, will peruse this work of Dr. Henderson 
 with interest.— New York Medial Times. 
 
LINDSAY & BLAKISTON'S PUBLICATIONS. 
 
 BEASLEY'S DRUGGISTS' RECEIPT-BOOK. 
 
 The Third Edition now Ready. 
 
 "WITH UPWARDS OF 
 
 200 NEW FORMS, RECEIPTS, AND PROCESSES; 
 
 Containing Numerous Recipes for Patent and Proprietary Medicines, Druggists' Nos- 
 trums, &c, &c, Factitious Mineral Waters, and Powders for Preparing them. Also, 
 Numerous Recipes for Perfumery, Cosmetics, Beverages, Dietetic Articles, and Condi- 
 ments, Trade Chemicals, Miscellaneous Compounds, used in the Arts, Domestic Eco- 
 nomy, &c. ; with many other Useful Tables and Memoranda. Also, a Copious Vete- 
 rinary Formula and Materia Medica, &c. By Henry Beasley. Third (Improved) 
 Edition. In one volume. Prise, $1.50. 
 
 Little more than two years have elapsed since the publication 
 of the first edition of this work : the call for a second edition 
 shows that it has been generally well appreciated. The arrange- 
 ment ofttie multitude of recipes given, is such that any one can 
 be readily found Although called a Druggist's Reeeipt-Book, it 
 will be found highly useful to professional men.— N. Y.M. Times. 
 
 The "General Receipt-Book" is an extensive appendix to the 
 "Formulary." No Pharmaceutist who possesses the formei 
 should be withouc the latter, for the two form a complete 
 counter-companion.— A nnual of Pfujrmacy. 
 
 Druggists will find this an invaluable manual. It is a most 
 thorough and carefully prepared work.— Evening Bulletin. 
 
 BEASLEY'S FORMULARY. — (New Edition:) 
 
 A COMPANION TO THE "DRUGGISTS' RECEIPT -BOOK." 
 
 THE MEDICAL FORMULARY; comprising Standard and Approved Formulae for the 
 Preparations and Compounds employed in Medical Practice. By Henry Beasley. 
 Second American, from the Sixth London, Edition. In one volume. Price, $1.50. 
 
 The fact that Mr. Beasley's Formulary has reached a sixth 
 edition, is a sufficient proof of the estimation in which it is 
 held by the medical and pharmaceutical public. It is. in fact, a 
 very comprehensive work, containing a great mass of informa- 
 tion in a very small compass. The arrangement is alphabetical, 
 as being most convenient. It contains selections from the Ame- 
 rican, French, German, and other foreign Pharmacopoeias, in 
 addition to the Formulae from the three British ones. The 
 work, however, is so well known, that it is unnecessary to do 
 more than announce the present edition, and to state that the 
 ioses of the various medicines have now been added.— Medical 
 Times and Gazette. 
 
 It is sufficient for us to mention the republication of this 
 work, which has gained for itself a high character for utility, 
 accuracy, and comprehensiveness of information. . . . We can 
 
 only now point to the success of former editions as the best 
 testimony in favor of the author's care and discrimination.— 
 British and Foreign Medico-Ckirurgical Review. 
 
 The book furnishes us elegant Formulas of all the New Re- 
 medies recently introduced into our Materia Medica, and gives, 
 in numerous instances, concise methods of preparing many medi- 
 cines entirely overlooked in larger and more extensive works on 
 the subject. For reference, amid the hasie and toil of an active 
 practice, we would commend Mr. Beasley's Formulary; and we 
 feel satisfied that every dispensing Pharmaceutist will keep the 
 work on his counter, as soon as he becomes acquainted with 
 its merits. It occupies a middle ground between the United 
 States Dispensatory and our works on Materia Medica; and for 
 ceriain purposes, it will be found superior to both. — New Orteam 
 Medical and Surgical Journal. 
 
 BEASLEY'S PRE S C RIPTIO N-B OK, 
 
 THE BOOK OF PRESCRIPTIONS: containing Two Thousand, Nine Hundred Pre- 
 scriptions, collected from the Practice of the most Eminent Physicians and Surgeons. 
 
 By Henry Beasley, Author of " The Medical Formulary, 
 Book," &c. &c. In one volume, duodecimo. Price, $1.50. 
 
 The Druggists' Receipt- 
 
 The editor, carefully selecting from the mass of materials at 
 nis disposal, has compiled a volume, sufficiently comprehensive, 
 and yet sufficiently portable, in which both physician and drug- 
 gist, presenber and compounder, may find, under the head of 
 each remedy, the manner in which that remedy may be most 
 effectively administered, or combined with other medicines in 
 the treatment of various diseases. The alphabetical arrange- 
 ment adopted renders this easy; and the value of the volume is 
 still further enhanced by the short account given of each medi- 
 cine, and the lists of doses of its several preparations. This is 
 really a most useful and important publication, and, from the 
 great aid which it is capable of affording in prescribing, it should 
 fee in the possession of every medical practitioner. Amongst 
 other advantages is, that, by giving the prescriptions of some 
 
 of the most able and successful practitioners of the day, it fcjfords 
 an insight into the methods of treatment pursued by them, and 
 of the remedies which they chiefly employed in the treatment oi 
 different diseases. The volume is small, and its cost trifling — 
 Lancet. 
 
 Mr. Beasley has brought to his aid, in the preparation of this 
 work, the skill and ability in selection, which he has previously 
 displayed in his ''Medical Formulary" and his " Druggists' Re- 
 ceipt-Book." We warmly commend it to our readers."— Dublin 
 Quarterly Journal. 
 
 The book is one of real value to practical men: it contains 
 numerous formulae, embracing almost all possible combinations 
 
 in prescribing. — Medico- Chiruryical Review. 
 
 BRAHSTOH'S HAND-BOOK OF PRACTICAL RECEIPTS 
 
 FOR 
 
 EVEKY-DAY USE. 
 
 A Manual for the Chemist, Druggist, Medical Practitioner, &c. &c. Comprising the Offici 
 nal Medicines, their Uses, and Modes of Preparation, and Formulae for Trade Preparations, 
 Mineral Waters, Powders, Beverages, Dietetic Articles, Perfumery, &c. ; with a Glos- 
 sary of Medical and Chemical Terms, and a copious Index. By Thomas F. Branstos. 
 From the Second Revised and Enlarged Edition. In one volume, 12mo. Price, $1 
 
LINDSAY & BLAKISTON'S PUBLICATIONS. 
 
 THE FAMILY, SHIP, 
 
 AND 
 
 MEDICINE CHEST COMPANION, 
 
 A COMPENDIUM OF 
 DOMESTIC MEDICINE, SURGERY, AND MATERIA MEDIC A, wUh Directions for 
 Diet, and Management of the Sick-Room ; Plain Rules for the Administration of Medi- 
 cines, their Properties and Doses ; General Rules for Bathing, and for the Treatment 
 of Fractures and Dislocations; an Account of the Asiatic and Spasmodic Cholera, and 
 its Proper Mode of Treatment in the absence of Professional assistance, &c. &c. By 
 Francis Gurnet Smith, M. D., Professor of the Institutes of Medicine in the Medical 
 Department of the Pennsylvania College, &c. &c. 
 
 A New Edition, in one volume, octavo. Price, $3. 
 
 MORRIS ON SCARLET FEVER. 
 
 A New and Enlarged Edition. 
 
 LECTURES ON SCARLET FEVER. By Caspar Morris, M. D., late Lecturer on Prac- 
 tical Medicine in the Philadelphia Medical Institute, Fellow of the College of Physi- 
 cions, &c. &c. In preparation. 
 
 CRAIGIE'S ANATOMY. 
 
 GENERAL AND PATHOLOGICAL ANATOMY. Presenting a full view of the present 
 state of knowledge in these branches of science. By David Craigie, M.D., F.R.S., 
 Fellow of the Royal College of Physicians, author of "Elements of the Practice of 
 Physic/' &c. &c^ The Second Edition, Revised and Improved. One volume, royal 
 octavo. Price, $3.00. 
 
 This work forms probably the most comprehensive one on the subject extant; the first edition passed rapidly out of print, an<] 
 the author, in preparing the present, has made many additions and improvements, communicating information in a prenise' aim 
 methodical manner, the leading points of each division hems placed before the reader in a clear and concise, though sufficiently 
 comprehensive style, the whole forming a volume which may be read with pleasure and profit both by the non-professional man 
 of science and by the practical anatomist.— London Lancet. 
 
 HENLE'S PATHOLOGY. 
 
 A TREATISE ON GENERAL PATHOLOGY. By Dr. J. FIenle, Professor of Anatomj 
 and Physiology in Heidelberg College. Translated from the German, by Henry C 
 Preston, A.M., M.D. In one volume, octavo. Price, $2.00. 
 
 Prof. Henle'a eminent character as a distinguished medical teacher, and as the best modern pathological authoi 
 »s too well known among German Students to need more than the announcement of his name and\is work to 
 insure an enthusiastic and grateful reception in the medical literature of any country or language. 
 
 HASTINGS' MINOR SURGERY. 
 
 THE PRACTICE OF SURGERY. Including Bandaging, the Application of Dressing, &c. 
 By John Hastings, M.D., late Lecturer on Operative Surgery, Surgical Anatomy,' &c. 
 With 145 Illustrations. In one volume. Price, $1.50. 
 
 In it the student will find the principles of Surgery detailed in a simple and concise manner; and while there are. 
 of course, many things omitted that will he found in larger treatises, he will find sufficient of really practical and 
 valuable information on the subject of surgical diseases, minor and operative surgery, to render him competent to 
 manage cases that ordinarily come into the is.nds of the general practitioner. The portion devoted to operative sur- 
 gery is written with great clearness and simplicity; every thing being made as plain as possible to the comprehension 
 of the student. The wood-cuts with which it is illustrated are correct and accurate delineations, and add no little to 
 its value. 
 
 MURPHY'S CHEMISTRY. 
 
 A REVIEW OF CHEMISTRY FOR STUDENTS. Adapted to the Courses as Taught in 
 the Principal Medical Schools in the United States. By John G. Murphy, M.D. In 
 sne volume. Price, $1.00. 
 
 This is fi n exceedingly well-arranged and convenient Manual. It gives the most important facts and principles of Chemistry, 
 m a clear and very concise manner so as to subserve most admirably the object for which it was designed.— Aortft Western 
 tiedical and Sura?cal Journal, 
 
T,INJDSAY & JBLAKISTON'S PUBLICATIONS. 
 
 REESE'S ANALYSIS OF PHYSIOLOGY. 
 
 Being a Condensed View of the most important Facts and Doctrines, designed especially 
 for the Use of Students. By John J. Reese, M.D., Professor of Medical Chemistry 
 and Pharmacy in the Pennsylvania Medical College, Physician to Wills' Hospital, &e. 
 Second Edition, enlarged. In one volume. Price, $1.50. 
 
 Its general accuracy and clearness of outline, cannot fail to render this analysis a useful manual to the student of medicine, for 
 whose benefit, more especially, it was prepared ; whether as an introduction to the more extended treatises and monographs upon 
 the several subjects of which it. treats, or as a guide to him in a review of his progress in this department of natural philosophy: 
 or, finally, as a convenient text-book to a course of lectures.— American Medical Journal. 
 
 FLINT ON FEVEES. 
 
 CLINICAL REPORTS ON CONTINUED FEVER. Based on an Analysis of One Hun- 
 dred and Sixty-four Cases, with Remarks on the Management of Continued Fever, the 
 identity of Typhus and Typhoid Fever, Relapsing Fever, Diagnosis, &c. &c. By Austin 
 Flint, M. D. Professor of the Theory and Practice of Medicine in the University of 
 Louisville, &c. &c. In one volume, octavo. Price $2.00. 
 
 FORDYCE 01 FEVERS. 
 
 THE HISTORY AND TREATMENT OF FEVERS. In Five Dissertations. By George 
 Fordyce, M.D., F.R.S. A new American Edition. One volume, octavo. Price, $1.50 
 
 The publishers have done an acceptable service to the profes- 
 sion in republishing them — Philadelphia Medical Examiner. 
 
 Fordyce has not been excelled by any writer before or since 
 las day.— Buffalo Medical Journal. 
 
 The dissertations which compose the work of Dr. Fordyce oa 
 Fever, are, of all his writings, those which in an especial man- 
 ner have established his reputation for sound medical views*. — 
 Southern Journal of Medicine and Pharmacy. 
 
 HASTINGS ON YELLOW FEYER. 
 
 LECTURES ON YELLOW FEVER. Its Causes, Pathology, and Treatment. By John 
 Hastings, M. D., U. S. N. Price, 50 cents. 
 
 This volume contains the results of twelve hundred cases treated hy the author during its prevalence in the 
 Gulf of Mexico, on board the United States' Fleet. 
 
 FLAGG ON ETHER AND CHLOROFORM. 
 
 Their Employment in Surgery, Dentistry, Midwifery, Therapeutics, &c. By J. F. B. Flagg, 
 M.D., Surgeon Dentist. In one volume, 12mo. Price, 75 cents. 
 
 This volume contains a full history of the employment of anassthetic agents, their composition and modes of application, so ar 
 to fulfi the various objects for which they are designed. It treats the subject in a candid manner, and contains a large amour* 
 of information of great value. Every person using this class of agents should read it.— Western Lancet. 
 
 MACKINTOSH'S PRINCIPLES OF PATHOLOGY AND PRACTICE OF 
 
 MEDICINE. 
 
 By John Mackintosh, M.D., &c. Fourth American, from the last London, Edition 
 With Notes and Additions, by Samuel George Morton, M.D., &c. In one volume 
 octavo. Price, $3.00. 
 
 COXE'S WRITINGS OF HIPPOCRATES AND GALEN. 
 
 Epitomised and Rendered into English, by John Redman Coxe, M.D., formerly Professoi 
 in the University of Pennsylvania, &c. In one handsome volume, octavo. Price, $2.00. 
 
 COMFORT'S THOMSONIAN PRACTICE OF MEDICINE. 
 
 Adapted as well to the Use of Families as to that of the Practitioner. With Practical 
 Directions for administering Thomsonian Medicines, including the various methods 
 of administering Vapour Baths, Emetics, &c, and a Materia Medica adapted to tha 
 Work. By J. W. Comfort, M.D. In one volume, octavo. Price, $3.00. 
 
LINDSAY <fc BLAKISTON'S PUBLIGA'llONS. 
 
 HARRIS'S DENTAL SURGERY.— (Sixth Edition.) 
 
 THE PRINCIPLES AND PRACTICE OF DENTAL SURGERY. Sixth Edition, with 
 236 Illustrations. By Chapix A. Harris, M.D., D.D. S., Professor of the Principles 
 and Practice of Dental Surgery in the Baltimore College of Dental Surgery; Member 
 of the American Medical Association, &c. &c. One volume, royal octavo. Price, $4.00 
 
 We have read this excellent work with much satisfaction, and 
 we are only giving the author the credit he most honorably de- 
 serves, when we say, that the views and opinions put forth in 
 the present treatise merit the attention of ever)' Surgeon Dentist 
 who wishes not only to be a skilful operator in his department 
 of practice, but also a scientific practitioner.— London Medical 
 Times. 
 
 Although this work is written especially for the instruction of 
 Dentists, it is well worthy the attention of the general Surgeon, 
 The seventh part, on diseases and defects of the palatial organs, 
 would well repay perusal by all medical men. We doubt not 
 that this work will long retain its position, now generally 
 acceded to it, as the standard of modern dentistry.— Denial In- 
 telligencer. 
 
 The continued demand for this work is perhaps its best eulc- 
 gium ; as a practical work adapted to the wants of the Professioo 
 it is the best work extant.— Dental Register of the West. 
 
 This work has run rapidly through five editions, indicating its 
 popularity with the profession, and proving, at the same time, 
 the improvement and upward tendency of dentistry in the 
 country. The book contains ample evidence of faithful and able 
 authorship. Indeed, for fulness, variety, usefulness, and effect- 
 ive array, the author may jus f ly claim the highest praise from 
 the students and practitioners of the profession. We most cor- 
 dially testify our approbation of the work.— American Medical 
 Journal. 
 
 This book has been the labor of a good part of the professional 
 life of Dr. Hams, and, from a small practical treatise, as it ap- 
 peared in the first edition, has now become the most complete 
 aria valuable system of Dental Surgery which has ever been 
 published. Dr. Harris has sought to keep up with the advances 
 made in the science and art of Dentistry, and to embody every- 
 thing new in his different editions as they have appeared. The 
 present edition is in many respects superior to any former one. — 
 Dental Recorder. 
 
 HARRIS'S DICTIONARY OF DENTAL SURGERY. 
 
 . A New Edition with 8000 New Words. 
 
 A DICTIONARY OF MEDICAL TERMINOLOGY, DENTAL SURGERY, AND THE 
 COLLATERAL SCIENCES. By Chapin A. Harris, M.D., D.D.S., &c. &c. In one 
 
 volume, royal octavo. Price, $4.5*0. 
 
 It contains all the requisites of a first class Medical Dictionary, 
 as well as a full and much needed supply of reliable information 
 relative to Dental Surgery: to the student.it is indispensable, 
 and certainly no practising Dentist should be without it.— Dental 
 Recorder. 
 
 It is a valuable book, and one that cannot be dispensed with 
 <ii any dental library.— Dental News Letter. 
 
 The title-page of this work explains its character; and the 
 demand for a second edition shows that it has been found useful. 
 
 It is intended, more especially, mr those who practice Dental 
 Surgery, than for the general practitioners of Medicine: but 
 may be consulted advantageously by all. The multiplication cf 
 works upon Dentistry, their extensive sale, and the liberal 
 patronage of the several schools of Dental Sursery. constitute 
 an American peculiarity to which no one has so much contri- 
 buted as Professor Harris, who, by his zeal and ability, has 
 placed his profession upon higher grounds in the United States 
 than it enjoys in any other country.— Southern Medical ana 
 Surgical Journal 
 
 FOX AND HARRIS ON THE HUMAN TEETH. 
 
 A New and Improved Edition.— Price, only $3.00. 
 
 Their Natural History and Structure, the Treatment of the Diseases to which they are 
 Subject, the Mode of Inserting Artificial Teeth, &c. &c. By Joseph Fox, Surgeon "Den- 
 tist, Lecturer at Guy's Hospital, &c; and Chapin A. Harris, M.D., D.D.S?, &c. In 
 one volume, royal octavo, with 250 Illustrations. Price, $3.00. 
 
 The known character of this work, together with the reputa- 
 tion of the American Editor, renders it unnecessary for us to say 
 anything in its favor, except that the engravings are executed n>. 
 the best manner, and the paper and type correspond ; and though 
 far superior to, it is sold at about one-third the price of the 
 English edition. — Dental Intelligencer. 
 
 Its intrinsic scientific worth, the number and beauty of the 
 engravings, and the paper and typography, altogether entitle it 
 to ranK among the first, if not the very foremost, of the many 
 works issued of late years on the anatomy and diseases of the 
 teeth, and their curative treatment —Bulletin of Medical 
 Science. 
 
 Considering the vast amount of practical information it con- 
 tnins. the judicious arrangement of its subjects, and last, though 
 not least, the great number of valuable engravings, many of 
 which are not to he met with elsewhere, it is a work which we 
 think every dental student, and especially practitioner, should 
 possess. The plates alone are worth the price of the book.— 
 American Journal of Denial Science. 
 
 The present edition comes forth with the advantages of a care- 
 ful revision, and the sanction of a distinguished teacher and 
 practitioner of the dental art. That these additions are judicious, 
 we need no better guarantee than the known competency of the 
 editor. — Philadelphia Medical Examiner. 
 
 ARTHUR'S TREATISE ON THE DISEASES OF THE TEETH. 
 
 Including a Description of their Structure and Modes of Treatment, and the usual mode 
 of Inserting Artificial Teeth, &c. &c. By Kobert Arthur, D. D. S., &c. Price, 50 cts 
 
LINDSAY & BLAKISTON'S PUBLICATIONS. 
 
 HANDY'S TEXT-BOOK OF ANATOMY, 
 
 Price Reduced to $3.00. 
 
 AND GUIDE TO DISSECTIONS. For the use of Students of Medicine and Dental 
 Surgery. By Washington R. Handy, M.D., Professor of Anatomy and Physiology in 
 the Baltimore College of Dental Surgery; late Professor of Anatomy and Operative 
 Surgery in the Washington University, Baltimore, &c. &o. With three hundred and 
 and twelve Illustrative Figures, engraved on wood. In one handsome volume, royal 
 octavo. Price, $3.00. 
 
 This is a work much needed, particularly by Dental Students. 
 It has been arranged with special reference to the Anatomical 
 studies of the Dental Student. The anatomy of the head, and 
 the nerves, glands, &c, which are often implicated in dental 
 disease, have been treated at full, and in such a manner as to 
 meet the wants of our students. The teeth are treated as of 
 some consequence in the general organization; and we are glad 
 to see such a work published, and heartily command it to the 
 Profession.— Dental Register. 
 
 We heartily commend it to both the Medical and Dental 
 Profession, as a thorough, faithful, and Physiological Treatise 
 on Anatomy.— American Journal of Dental Science. 
 
 Dr. Handy is well known as a popular Professor of the Balti- 
 more College of Dental Surgery, and as a zealous student of 
 anatomy. He has prepared the present work with a view of 
 inducing students of Dentistry to acquire more of anatomy than 
 a mere knowledge of the teeth. It is an accurate and well 
 written work.— Virginia Med. and Surg. Journal. 
 
 BOND'S DENTAL MEDICINE. -(Second Edition.) 
 
 A Practical Treatise on Dental Medicine ; being a Compendium of Medical Science, as 
 connected with the study of Dental Surgery. By Thomas E. Bond, M.D., Professor of 
 Special Pathology and Therapeutics in the Baltimore College of Dental Surgery. In 
 one volume, octavo. Price, $2.50. 
 
 We have spoken, or intended to speak, heartily in praise of 
 Dr. Bond's work. It has unmistakeable evidence of thorough 
 medical science in its subject matter, and of a capital authorship 
 m its style and treatment. — American Medical Journal. 
 
 Professor Bond's work is deservedly popular with the Dental 
 profession, and has already reached its second edition in less 
 than two years. It is an excellent book, both as regards manner 
 and matter. — Southern Medical and Surgical Journal. 
 
 This volume, of humble pretensions, is really one of the best 
 on Dental science which has for a long time issued from the 
 press. It will amply repay the physician and surgeon for the 
 time bestowed in a careful perusal of its contents. It supplies a 
 place in medical literature which has been felt to be a want, 
 and then fore we commend it to the favorable attention of our 
 readers.— N. Y. Jour, of Medicine, Jan. 1853. 
 
 PIGGOTT'S DENTAL CHEMISTRY AND METALLURGY. 
 
 Containing Physiological Chemistry, as applied to Dentistry; the Minerals used in 
 making Artificial Teeth, and their constituent parts; the Action of Five upon them; 
 the Mode of Treating them in the Furnace ; the Metallic Oxides used in Coloring them; 
 the various Metals used in filling in Plate Work, &c, with their Alloys, Fusing Points, 
 Metallurgic Management, &c. By A. Snowden Piggott, M.D., Professor of Practical 
 and Analytical Chemistry, &c. &c. In one volume, octavo. Price, $3.00. 
 
 J; at once guides the operative Dentist in the details of his 
 every -clay work, and teaches the student the principles directly 
 involved in the philosophy of his profession.— American Journal 
 of Medical Science. 
 
 We think the work is one which should be in the hands of 
 every Dentist. Much labor and research has been spent on it, 
 and an immense amount of useful information combined and 
 given in a very desirable form to the profession.— Dental Register. 
 
 It fills a vacancy in the Dental library, and meets a pressing 
 want of the profession. The author gives ample proof of the 
 sufficiency of his resources, and exhibits great skill in their em- 
 
 ployment for the special use intended. For practical purposes 
 it has the character of a manual and operative directory; and 
 for instruction in the scientific relations of his theme, it could 
 scarcely be more judiciously and profitably executed. It is nei- 
 ther encumbered with, nor deficient in, chemical science. It at 
 once guides the operative dentist in the details of his every-day 
 work, and teaches the student the principles directly involved in 
 the philosophy of his profession. The work, it. will be seen by 
 this brief synopsis, is a full one, well and methodically arranged. 
 It appears to us to be as well treated as it is planned, and we 
 are satisfied it will contribute to the commendable effort which 
 the profession is now making to liberalize and elevate its study 
 and practice. — Dental News Letter. 
 
 THE AMERICAN JOURNAL 0E DENTAL SCIENCE. 
 
 (The Oldest Established Dental Journal published in the English Language.) 
 
 PUBLISHED QUARTERLY: THE YEAR COMMENCING IN JANUARY. The Con 
 
 tents of the Journal are : 
 
 ORIGINAL COMMUNICATIONS, -upon Subjects of Im- 
 portance, from Members of the Dental Profession in this 
 Country and in Europe. 
 
 REVIEWS OF NEW BOOKS. 
 
 SELECTIONS, from Foreign and Domestic JournalS- 
 A QUARTERLY SUMMARY OF DKNTAL NEWS; an 
 EDITORIAL ARTICLES, upon Subjects of Interest to 
 the Profession. 
 
 Every effort is made to give value and variety to its contents, and the articles are frequenV y illustrated by well- 
 executed Engravings. Edited by ChaPIS A. Harris, M.D., D.D.S.. and A. Snowden Piggott, M.D., assisted by pro- 
 minent Members of the Profession in this country and in Europe. 
 
 TERMS OF SUBSCRIPTION, FIVE DOLLARS PER ANNUM. 
 SUBSCRIBERS remitting in advance will receive the Journal Postage Free. 
 
LINDSAY & BLAKISTON'S PUBLICATIONS. 
 
 AN IMPORTANT WORK FOR 
 
 DRUGGISTS, CHEMISTS, AHD MANUFACTURERS. 
 
 A NEW AND GREATLY ENLARGED EDITION, 
 "With over 500 Illustrations. 
 
 CHEMICAL AND PHARMACEUTICAL MANIPULATIONS. 
 
 A MANUAL OF THE 
 
 CHEMICAL AND CHEMICO-MECHANICAL OPERATIONS OF THE LABORATORY. 
 
 By Campbell Morfit, Professor of Analytic and Applied Chemistry in the University 
 of Maryland, assisted by Clarence Morfit, Assistant Melter and Refiner in the United 
 States Assay Office. 
 
 One volume, royal octavo. Price, $4. 
 
 The Publishers, in issuing a new edition of this work, have found it necessary, in order to bring it up with the 
 present state of science, to enrich it with much additional matter, and many new illustrations, and thus to mate- 
 rially increase its size. The author has given, in a familiar but clear stj'le, the details of all the manipulations of 
 the laboratory, including many improvements that have been made since the previous edition was issued. It is 
 beautifully illustrated by numerous well-executed engravings, and will be found, they trust, superior to any work 
 of the kind that has been issued from the American Press. 
 
 " To realize for chemistry its true character of a science — to 
 render it ' a system il lust rated and proved by experiment,' there 
 is an indispensable need of proficiency in those manual of opera- 
 tions of the laboratory, by means of which chemical changes 
 are induced, observed, and estimated. This accomplishment in 
 manipulation — tins expertnessin handling and adjusting imple- 
 ments, it is true, depends upon time and practice; but, although 
 the student may not become an adept in the art solely from 
 written instructions, yet much may be thus taught which will 
 lighten his labors, and smooth the way to the acquisition of 
 6k ill and accuracy. 
 
 "Such is the object of the present work; and it has been 
 made to comprise practical lessons upon the mechanical and 
 chemico-mechanical business of the chemist, in reference both 
 to the exact detail of analytic research, and the more extended 
 processes of pharmaceutical science. Explanatory drawings of 
 important forms of apparatus, too, have been profusely em- 
 ployed to give greater intelligibility to the text; and while the 
 authors have drawn largely from their own personal experience, 
 they have not neglected to make available all the useful infor- 
 mation that was to be derived from other sources. 
 
 '• In this second and enlarged edition, there are many im- 
 
 provements upon the original work. The old matter has been 
 emended, and niuch that is novel and invaluable added ; so 
 that in its present form it embraces full and fresh teachings, 
 adapted to the requirements of the uninitiated, as well as the 
 more advanced student."— Preface. 
 
 "The arrangement of the whole is such, that every student 
 will be able to go through the work without a guide to lead 
 him, provided the necessary apparatus are at his command. 
 But. even without them, a careful study of the book will give 
 the attentive student a very useful insight in all the manipula- 
 tions of the pharmaceutical chemist, an'd thousands, no doubt, 
 who are prevented from attending the schools of pharmacy and 
 chemistry, will gladly avail themselves of the only means left 
 them for self-improvement. The amount of perseverance and 
 industry displayed in the setting up of this work is truly aston- 
 ishing, and the clearness of expression in every sentence, and 
 the accurateness of the 500 illustrations are above praise. 
 ' Morfifs .Manipulations' ranges iu utility immediately after the 
 U. S. Dispensatory. 
 
 " The external appearance of the book is worthy of the firm 
 from which it emanated."— Cliemical Gazette. 
 
 NOAD AND MORFIT'S CHEMICAL ANALYSIS, 
 
 QUALITATIVE AND QUANTITATIVE. By Henry M. Noad, Lecturer on Chemistry 
 at St. George's Hospital, &c. And Campbell Morfit, Practical and Analytical Chem- 
 ist. With Illustrations. One Volume, 8vo. Price, $1.50. 
 
 "To those who desire a competent guide and accurate chemical investigator, none better than Mr. Noad's book can be found; 
 all the important processes of Rose, Presenilis, Leibig, and Mulder, in Analytical Chemistry, are embodied in the work ; and tJ 
 the student who can hardly be supposed to have access to the original authorities.it is of great value. The American Edition 
 has been posted up so as to embrace the newest methods of Analysis. The gentleman who performed this task is admirably 
 qualified for it. and has already acquired a high reputation as a chemist, by the publication of an Encyclopaedia of the Science 
 and a work on Chemical and Pharmaceutical Manipulations." — Literary World. 
 
 MANURES. 
 
 THEIR COMPOSITION, PREPARATION, AND ACTION UPON SOILS, WITH 
 THE QUANTITIES TO BE APPLIED. Being a Field Companion for the Farmer, 
 from the French of standard authorities. By Campbell Morfit, Practical and Ana- 
 lytical Chemist, One volume, cloth. Price, 25 cts. 
 
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 THE HALF-YEARLY ABSTRACT OF THE MEDICAL SCIENCES; being a Prac- 
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 a Series of Critical Reports on the Progress of Medicine and the Collateral Sciences. 
 Edited by W. H. Ranking, M. D., and C. B. Radcliffe, M. D. 
 
 This work contains a vast amount of information, in a concentrated form, for a merely nominal price. It embraces, 
 
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 cal and Surgical Journal. 
 
 This is a publication on a somewhat different plan from 
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 cially in containing- condensed Reports on the various branches 
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 Medical and Surgical Journal. 
 
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 Journal. 
 
 It gives, in the compass of a few pages, the quintessence of 
 all the improvements in Medicine and Surgery.— Ohio Medical 
 and Surgical Journal. 
 
 No practitioner should neglect to supply himself with so valu- 
 able a source of information.— Illinois and Indiana Medical 
 and Surgical Journal. 
 
 We recommend " Ranking" to all who do not take it. It will 
 furnish all the best papers from all the best journals. — Ameri- 
 can Journal of Dental Science. 
 
 The design is well conceirel a.id ably carried out. There is 
 no other source whence sue.ti i variety and amount of choice 
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