an excellent purpose. Should the fault lie in a debilitated state of the system, from excessive loss of blood, a typhous tendency, or other cause, it may be necessary to administer warm wine-whey, and the preparations of ether or ammonia internally, while sinapisms, stimulating frictions, and artificial heat are diligently applied externally. When irritation exists in one of the interior organs, a sinapism or blister over the organ will be advisable. The convulsions whieh occur in children, in the early stage, often require nothing more than hot pediluvia, or the warm bath, and sinapisms to the limbs; and, indeed, often subside spontaneously without injury; but, when they are persistent, often repeated, or followed by stupor, in addition to the . remedies just mentioned, blood may be taken from the arm or the temples, cold applied to the head, and a dose of calomel given internally. An emetic dose of ipecacuanha sometimes proves very useful. Discrimination, however, is necessary; and the practitioner should endeavour to ascertain, whether the affection may not arise from some source of irritation extraneous to the brain, as the bowels for example, or the gums in dentition. In such cases, the remedies should be directed to the real seat of disorder. In all cases of this kind, bleeding should be employed with a proper caution. In the advanced stages of the disease, when convulsions occur, it is oftener probably from nervous irritation than cerebral congestion or inflammation; and the nervous stimulants, as assafetida, camphor, musk, and sometimes even opium, are more efficient than depletion; but the practitioner must be guided by the - symptoms. Diarrhoea, if moderate, should not be disturbed; but, if profuse, painful or obstinate, it should be checked by means addressed to the existing pathological state of the bowels. (See Enteritis and Diarrhoea.) Malignant measles must be treated like other typhous diseases, by tonics and stimulants, a judicious use of laxatives, and, when attended with inflammation, by very cautious local depletion, blisters, and calomel with opium. The diet, in ordinary measles, should be strictly antiphlogistic throughout the disease. During the existence of considerable fever, it should be chiefly in the liquid form. In cases attended with debility, it may be necessary to have recourse to milk and animal broths. During convalescence, care should be taken to guard the patient against the cold; and in winter he should not be allowed to leave the house until desquamation has been for several days entirely completed, and the catarrhal symptoms have disappeared. Friction with fat bacon over the whole surface of the body, as recommended by Dr. Schneeman in the treatment of scarlet fever, has been employed also in measles, with much supposed advantage, by Dr. John Evans. (St. Louis Med. and Surg. Journ., ix. 276, from Charleston Med. Journ.) Attempts have been made to prevent measles by inducing a mild form of the disease by means of inoculation. An instance is quoted by MM. Guersant and Blache, (Dict. de Méd., xxvii., p. 684,) in which the operation is said to have been performed in eleven hundred and twenty-two cases, with liquid taken from the patches, or with a tear of the patient, and failed only in seven out of every hundred. The resulting disease was mild, and in no case fatal. On the seventh day the fever appeared, on the ninth or tenth the eruption, on the fourteenth the desquamation; and on the seventeenth the patient was quite well. Ordinarily measles are so mild as scarcely to call for this mode of protection; but in malignant epidemics of the disease, it might be tried, under circumstances of great exposure. Article XI. SCARLET FEVER, or SCARLATINA. This is a contagious febrile disease, characterized by inflammation of the fauces, and a scarlet rash appearing usually on the second day, and ending in desquamation about the sixth or seventh day. Scarlet fever was long confounded with measles, and, even when distinctly described, appears, from the names employed, to have been considered merely. as a variety of that disease. Ingrassias is said to have been the first to allude to it as a peculiar affection, in a work published in 1556. It was afterwards noticed by Coyttar of Poictiers, in France, and by Morton in England; but Dr. Withering has the credit, among British physicians, of being the first who clearly and fully pointed out the differences between the two diseases, and established the claims of scarlatina to its present rank. Most authors describe three varieties of scarlet fever, the simple, the anginose, and the malignant, and each of them so precisely, that the student might very readily be led into the error of supposing them to be equally distinct in nature. But the fact is, that, though cases are not unfrequently observed in which the characters of each variety are tolerably well marked, yet it very often happens that they are blended together, so that it would be quite impossible to determine to which of them a particular case might belong. The disease is essentially the same in all its varieties, and produced by the same cause; and there is no better reason for distributing it into different sections than for treating in the same manner most other febrile diseases. I shall, therefore, first describe it generally, and afterwards refer to its modifications. Symptoms, Course, &c.-Either with or without the ordinary preliminaries. of languor, weariness, rigors, and pains in the back and limbs, the fever sets in with a frequent pulse, hot dry skin, flushed face, furred tongue, anorexia, thirst, and great muscular weakness. Sometimes there are nausea and vomiting; sometimes also more or less headache, or other symptoms of nervous disorder, such as restlessness, morbid vigilance, delirium, stupor, coma, or convulsions. In relation to the severity of its symptoms, the fever is of every possible grade, from a mildness scarcely amounting to disease, up to the highest point of violence and danger. Along with the fever, sometimes beginning with it, and sometimes a little after it, there is almost always more or less irritation or inflammation of the fauces, which, upon being examined, appear red and not unfrequently swollen. The same colour is diffused over the interior of the mouth; and the tongue, though coated with a white, or yellowish-white fur, exhibits projecting red papillæ upon its surface, and is red at the tip and edges. The rash makes its appearance, in most instances, upon the second day of the fever, often, however, earlier or later, and sometimes at the very commencement, so far as can be determined from the statements of the patient or his friends. It occurs usually first upon the neck, face, and breast, whence it gradually spreads over the trunk and extremities, occupying about twentyfour hours in its diffusion. Sometimes its course is the reverse of that stated. In the beginning, it is in minute red points, which rapidly coalesce in broad patches, and in the course of a few hours generally form a continuous scarlet blush over large portions of the surface. But great diversity exists, in different cases, both in the amount and arrangement of the eruption. Some times it is very scanty, presenting only a few scattered points here and there, or some patches of moderate extent; but much more frequently, it covers, in a greater or less degree, the whole body; being either uniformly diffused over the surface, or exhibiting this uniformity in certain parts, while in others it is punctuated or in patches. The redness is usually diffused equably over the face and neck, and appears with great intensity in the flexures of the joints, as in the groins, armpits, and bend of the knees and elbows. In certain cases, in the midst of the general blush, points of a deeper redness are observable. The colour has been compared to that of a boiled lobster; but it is usually, I think, of a darker hue. It disappears under pressure, and returns when the pressure is removed. Whatever increases the general excitement has a tendency to deepen it. Hence, the colour is most intense during the exacerbations of the fever, and is increased when the patient cries, or is otherwise agitated. The reddened surface is smooth to the finger; the rash being in no degree perceptibly elevated. Sometimes, however, it has a rough feel like that of goose-flesh in certain parts of the body, as the limbs and anterior portion of the trunk, in consequence of the enlargement of the papillæ. The skin itself is often slightly swollen, especially in the face, hands, and feet; and the hands are rendered somewhat stiff in their movements. Along with the characteristic rash, may not unfrequently be observed, upon the neck, in the armpit, at the bend of the elbow, &c., a crop of small miliary vesicles, which make their appearance at different stages of the eruption. Minute pimples and pustules sometimes also mingle with it during its decline. The cutaneous affection is attended with a sense of burning, itching, or other irritation, which is sometimes very annoying to the patient, and interferes with sleep. The fever does not abate upon the appearance of the rash, but continues with various degrees of violence, throughout its whole progress. The pulse is usually very frequent, much more so than in febrile diseases generally of the same degree of violence. It is often 120 or 130 in the minute, and sometimes still more frequent. Occasionally it has considerable force, but this is not its predominant character. The skin is dry and burning hot, and the temperature, as indicated by the thermometer, is not unfrequently 105° or 106 of Fahrenheit, and is asserted to have reached 112°. The highest point, however, observed in the experiments of Andral, and those more recently made by M. Roger, was 41° Cent., equivalent very nearly to 106° F. (Dict. de Méd., xviii. 155.) The fever often has exacerbations towards evening; and is occasionally attended with restlessness or delirium, and sometimes with comatose symptoms. The bowels are generally constipated; but sometimes diarrhoea occurs in the advanced stage. Occasionally also, there is irritability of stomach; but this is not a very frequent symptom. The affection of the throat, in some cases, never exceeds that already noticed as occurring even before the appearance of the eruption. But very often it becomes the most prominent and distressing symptom, being attended with swelling within and without, painful deglutition, and sometimes impeded respiration. This feature of the disease will be more particularly noticed, in the description of the anginose variety. The disease attains its height usually from the fifth to the ninth day, when, in favourable cases, all the symptoms begin to decline. The rash fades, the miliary vesicles if present dry up, the heat of skin diminishes, the pulse becomes slower and fuller, the throat affection abates, and the tongue, if it has not previously thrown off its fur, does so now, often, however, remaining for some time reddish, glossy, and with prominent papillæ. Sometimes the amendment is accompanied with a profuse perspiration, or a diarrhoea, which may be regarded as critical; but they are very often wanting. Desquamation generally begins with the decline of the eruption. Sometimes it is furfuraceous, but frequently the cuticle separates in small scales; and, when it is thick, as upon the palms of the hands and soles of the feet, it occasionally comes away in large flakes. I have known the whole cuticle of the palm and fingers to separate, so as to form a complete mould of the inside of the hand. The process of desquamation is often attended with a very troublesome itching and irritation, and sometimes with much tenderness of the skin. It is usually completed by the end of the second week, though sometimes delayed longer, in consequence of a succession of exfoliations. At this time, if no untoward complication has occurred, the patient may be considered as well, though not yet exempt from liability to unpleasant and even dangerous disease. In many cases of scarlatina, albumen may be detected in the urine a few days after the commencement of desquamation; and, when examined with the microscope, it is found in these cases to be attended invariably, according to Dr. Begbie, with a considerable amount of epithelium of the uriniferous tubules, or other portions of the urinary passages. Of twentyone cases examined by Dr. Begbie, albumen was detected in all. The quantity was small, and it continued to appear but a few days. (Ed. Month. Journ. of Med. Sci., Jan. 1849, p. 443, and Oct. 1852, p. 323.) But the course of the complaint is often much less favourable. From the beginning to the close, it is not free from danger. Death sometimes takes place in the first stage, even before reaction, from the overwhelming force of the shock upon the nervous system; and, at any subsequent period, the patient is liable to the same result from coma or other violent cerebral affection, which often leaves no organic trace behind it. Inflammation occasionally attacks some vital part, especially one of the serous membranes, with fatal effect. Disease of the stomach and bowels sometimes carries off the patient; and instances have occurred in which affections of the larynx have been the cause of death. The patient may also sink from debility consequent upon the malignant character of the affection, the occurrence of gangrene of the throat, or the exhausting purulent discharges incident to local affections, which are apt to remain after the proper disease has gone. Having given this general view of the complaint, I will now invite the attention of the reader to its prominent varieties. 1. Scarlatina Simplex.-This is distinguished by the absence of the throat affection. There are only the fever and the rash. Such is the definition of scarlatina simplex; but the fact is, that complete exemption from inflammation of the fauces is very rare; and a moderate degree of it would not be considered as excluding the case from the present category. Redness and some degree of soreness in the fauces are scarcely less common than the eruption itself. The simple variety of scarlet fever is often very mild. In some cases the patient is not even confined to bed. The first sign of disease which attracts attention is occasionally a scarlet blush upon the face and neck, which is attended with a slight febrile movement, and declines upon the fifth day, or sooner. But in other cases it is much more severe. There is a universal diffusion of the rash, which is of an intense redness, the heat of skin and frequency of pulse are extreme, and not unfrequently a slight delirium occurs, especially during the exacerbations of the fever at night. But, unless from some intercurrent inflammation, or concealed malignant tendency, or dangerous sequela, there is little risk of life. 2. Scarlatina Anginosa.-In this variety the affection of the fauces is prominent. Stiffness of the jaws, soreness of throat, and pain in swallowing are often experienced at the commencement of the attack. The eruption is usually somewhat later in making its appearance than in the simple variety, sometimes occurring on the third instead of the second day. It is also, as a general rule, less copious and less diffused. Sometimes it is confined to a particular part, as the hand and forearm. I have seen it in distinct points, very sparsely scattered over the trunk. Not unfrequently it is in patches, with intervening portions of the skin of the natural colour. But very many instances also occur, in which the rash is nearly or quite general, and as intense and uniform as in the simple. Occasionally, after partially breaking out, it disappears, perhaps to return again after a longer or shorter interval; and this process is sometimes repeated more than once. The fever is ordinarily more severe than in scarlatina simplex, with a more frequent pulse, and a greater tendency to delirium or stupor. The inflammation of the fauces advances with the progress of the disease; and not unfrequently the eyes are red and irritated, though not usually watery, as in measles. The patient sometimes sneezes, has a dry cough, and a guttural voice; and hemorrhage sometimes occurs from the nostrils. Upon examination of the fauces, the tonsils, uvula, and soft palate are observed to be swollen and of a deep-red colour; and patches of a concrete exudation, resembling false membrane, are generally seen upon the surface of the tonsils at an early period. These patches are of a dirty white, yellowish, or ash colour, and are sometimes very extensive, covering the surface of the fauces, and spreading into the pharynx as far as it can be seen. They are usually soft, so that they may not unfrequently be scraped off with an instrument. Formerly, they were thought to be the surfaces of ulcers, or gangrenous portions of the mucous membrane; but, when removed, they leave the surface for the most part merely reddened, and without organic change. Sometimes, however, they really do cover ulcerated or eroded surfaces, which may even be gangrenous. Occasionally they extend into the larynx, producing the symptoms of pseudo-membranous croup; but this event is very rare. They often impart a very offensive odour to the breath. Along with this interior disease, there is almost always more or less swelling of the external parts, in the region of the parotid and submaxillary glands; and sometimes the tumefaction is very great. It has been supposed that the parotid is the seat of the inflammation; and this may sometimes be the case; but more frequently it is in the neighbouring cellular tissue, or the lymphatic glands. The external swelling is hard and painful, and sometimes prevents the patient from opening his mouth so far as to permit an inspection of the fauces. Deglutition is difficult and painful; and, when attempts are made to swallow liquids, they occasionally return through the nostrils. Sometimes the internal parts are so much swollen as to interfere with respiration. The patient is very much troubled with a viscid mucus, secreted in the fauces, which he cannot well swallow, and finds it difficult to discharge from the mouth. The lips are often cracked, invested here and there with crusts, and painful when parted. Not unfrequently the mucous membrane of the nostrils partakes of the disease; the nasal passages are closed by the consequent swelling, and the crusts which form upon their surface; and the patient is compelled to breathe exclusively through the mouth, producing dryness of the tongue and lips. At a more advanced stage, a yellow and exceedingly offensive liquid is occasionally discharged from the nostrils, which is sometimes very acrid, and excoriates the orifices. A similar secretion from the fauces is swallowed, and probably conduces to the production of the irritation of stomach and diarrhoea, which are occasional features of the disease towards its close. The discharges from the bowels are also sometimes acrid, |