gangrenous sloughs or ulcers; extension of the pseudo-membranous exudation into the larynx; the occurrence of severe intercurrent inflammation of the vital organs; gangrene of the extremities, or of the sacrum and hips where pressed upon; and great prostration, as indicated by a very feeble pulse, cold skin, and involuntary discharges.

The absence of the above symptoms, and a gradual subsidence of the disease, are favourable signs; but, as before stated, they cannot be relied on, in consequence of the changes to which the disease is liable; so that a guarded prognosis in scarlet fever is almost always prudent.

Treatment. In the vast majority of cases, scarlet fever would end favourably without treatment. Hence the reputation acquired by homoeopathy in this disease. When the symptoms are very mild, it is advisable to do little more than to keep the bowels open, to administer cooling drinks, to regulate the diet, and to see that the apartment is well ventilated, and of comfortable temperature.

A gentle emetic at the outset of the disease is generally thought, and I believe justly, to have a happy effect in modifying its future course. This remedy should, therefore, be administered in every case, when seen at that stage; for, though it may possibly not be necessary, yet it can do no harm, and it is impossible to foresee what is to be the character of the case. Ipecacuanha may be used, or a mixture of this with tartar emetic.

In all cases, except those of great mildness, it will be proper, in children, to follow the emetic with a purgative dose of calomel, which, if it do not operate thoroughly in six or seven hours, should in its turn be followed by castor oil, magnesia, or one of the saline laxatives. Afterwards, the bowels should be kept open, if necessary, by cathartics, which should be accommodated to the circumstances of the case; those of a depletory character, such as sulphate of magnesia, being given if there is much excitement with considerable energy of system; the Seidlitz powder, when there are nausea and vomiting; magnesia, when there is evident acidity of the primæ viæ; castor oil, when there is abdominal pain; and rhubarb when the system is too feeble to admit of watery purgation. In the incidental diarrhoea, advantage will sometimes accrue from castor oil combined with laudanum; as the bowels are thus cleansed of the offensive secretions which are swallowed, while they are rendered less sensible of the irritant impression. Great care, however, must be taken not to purge to exhaustion.

Is bleeding proper in scarlet fever? Some strenuously advocate the affirmative of this question, and recommend the remedy in almost all violent cases, in the early stage. Some consider it hazardous under any circumstances. In relation to depletion in this disease, it should always be borne in mind that the tendency of the system is usually to an asthenic state; that the cause is probably in general depressing in its nature, though capable of rousing the energies of the system, in many cases, to an active resistance. It should also be remembered that the influence of the cause is, in certain epidemics, much less depressing than in others; so that, while bleeding may be employed with impunity in one, it may be very dangerous in another. The inference from these considerations is, that bleeding should be used with much caution and reserve, and only when there is an obvious indication; as when symptoms of inflammation of one of the vital organs exist, and threaten great danger. For the mere inflammation of the fauces, it is seldom requisite. Indeed, it has in general little influence upon that affection, especially when accompanied with pseudo-membranous exudation. In no instance, even of decided inflammation, should it be resorted to when the pulse is feeble, and other signs indicate a malignant tendency. In all doubtful cases, it is best

to have recourse to local depletion by leeches or cups. Should experience show that the disease, in any particular epidemic, is of a more than usually sthenic character, the remedy may be used with less reserve; should malignancy be the predominant character, it should scarcely be used at all. I have seldom found it advisable to bleed in any case; and do not remember the instance, in which it appeared to me that I had occasion to repent my absti nence. "Dr. R. Williams, who has bestowed great attention on this point, has drawn up a table of different epidemics which have prevailed from 1763 to 1834; and adds, that the conclusion which inevitably follows is, 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 patient not to have been bled." (Dr. Burrows, in Tweedie's Syst. of Pract. Med.) Whenever bleeding is resorted to, it is a good rule to place the patient in a sitting posture; as the failure of the pulse, in this position, will sooner give warning to arrest the flow of blood, than in the horizontal.

In cases of severe serous inflammation accompanying the disease, leeching or cupping may generally be employed with advantage. Leeching is also recommended when there is much external swelling about the jaws; but care must be taken, before it is used, that there is sufficient strength of pulse to bear the loss. Great external swelling sometimes exists, when it is of the utmost importance to husband the resources of the system. In the convul. sions of the early stage, it will often be proper to apply leeches to the temples, or behind the ears.

In all cases in which the skin is universally hot and dry, and the patient experiences no sensation of chilliness, the external application of cold water is highly useful. It relieves the pungent heat of the surface, quiets restlessness, reduces the frequency of the pulse, and adds greatly to the comfort of the patient. I have generally preferred sponging; some recommend affusion. In doubtful cases, warm water may be substituted for cold.

When the fever is well developed, a course of internal refrigerant treatment should be adopted. The patient should be allowed to drink cold water frequently though moderately, and to hold ice in his mouth if he desire it.* Small doses may be given every hour or two, during the day, of the neutral mixture, solution of acetate of ammonia, citrate of ammonia, or muriate of ammonia, to which, when the stomach is quite retentive, and the general condition of system is not asthenic, minute doses of tartar emetic may be added. When the stomach is irritable, the effervescing draught should be

* Dr. Samuel Jackson, of Philadelphia, formerly of Northumberland, has given to the public highly interesting statements of his success, in the treatment of anginose cases of scarlatina, by means of ice kept constantly in the mouth and swallowed as it dissolved, and of chloride of soda as a local application to the fauces. The ice is to be used in small lumps, or, in the cases of infants not old enough to guard against swallowing the pieces undissolved, inclosed in a gauze bag. When the fever is very high, small quantities of the ice may be swallowed in the form of fine powder. In very young infants, ice-cold water may be injected into the throat, and powdered ice may be swallowed, if there is much fever. To be successful, this practice must be maintained incessantly, night and day, until the inflammation has evidently yielded. The solution of chloride of soda is applied when the disease in the fauces becomes gangrenous. These simple remedies were found exceedingly efficient by Dr. Jackson, and by several other practitioners who had been induced to employ them upon his recom mendation. They were not, however, used by him to the exclusion of other measures, such as bleeding, emetics, cathartics, antimonials, cold water to the head, warm water to the feet, &c., when circumstances seemed to call for them; but the ice appears to have been the one most relied on in the anginose cases. (See Am. Journ. of Med. Sci., xii. 261 and 550; and xxii. 45; also Eberle's Practice of Medicine, edited by Dr. George M Clellan, i. 478.)

preferred. Nervous symptoms may be counteracted by the addition to the diaphoretics just mentioned of sweet spirit of nitre, Hoffmann's anodyne, or camphor water. Should a sour smell, as often happens, exhale from the patient, he should take bicarbonate of soda or of potassa, three or four times daily. I have found great apparent advantage, in cases attended with a very frequent pulse, from the use of tincture of digitalis, which, to an adult, may be given in doses of from five to ten drops every four hours.

When the urine is very scanty, and especially if a tendency to delirium or coma should be observed, mild diuretics may be resorted to with hope of benefit, such as sweet spirit of nitre, acetate of potassa, bitartrate of potassa, wine of colchicum root, &c.

But the practitioner should always be on the watch for symptoms of debility, and be prepared to counteract them. In some instances, they attend the case from the commencement, in others come on during its course. They are such as occur in the typhous state of fever. Whenever they are seen, no hesitation should exist in resorting to tonics or stimulants. Sulphate of quinia dissolved in one of the dilute mineral acids, or the compound infusion of Peruvian bark, is admirably adapted to many of these cases. But, when the debility is considerable, it is necessary to use stronger stimulants, such as capsicum, carbonate of ammonia, oil of turpentine, and wine diluted with water, or in the form of wine-whey. The Germans prescribe the flowers of arnica. When nervous symptoms are superadded, musk, assafetida, camphor, or valerian may be employed. Animal broths or jellies should also be given, especially in the advanced stages, and when the blood is depraved. Swelling of the throat, or even comatose or delirious symptoms, should not deter from the use of the above measures, when the signs of debility are evident.

Should the eruption come forth sparingly, or retrocede, and at the same time threatening symptoms appear, efforts should be made to invite it to the surface by the hot bath, and the more active rubefacients. Urtication by means of the nettle has also been recommended.

Solution of chlorine, and chlorate of potassa, have been recommended in the treatment of scarlatina. The aqua chlorinii of the Dublin Pharmacopoeia may be given in the dose of a fluidrachm for an adult, and ten drops for a child two years old, three or four times a day. It may be given largely diluted, in one of the aromatic waters, and sweetened. Dr. Watson speaks very favourably of a solution of chlorate of potassa, in the proportion of a drachm to the pint, as a drink; of which from a pint to a pint and a half may be used during the day. I have had no experience with either of the above remedies; but nitromuriatic acid, which contains free chlorine, is sometimes useful in the atonic forms of the complaint.

Local Remedies.-These are important. In slight affection of the throat, it is sufficient to employ demulcent, acidulous, slightly astringent, or saline gargles; such as infusion of flaxseed or slippery elm, water acidulated with sulphuric or muriatic acid or vinegar, compound infusion of red roses, weak solutions of alum, nitre, or common salt, &c. When pseudo-membranous or gangrenous patches are observed in the fauces, and the colour of the mucous membrane is dark red, infusion of capsicum, or the powdered red pepper itself diffused in water or vinegar and water, is an excellent application. (See U. S. Dispensatory.) It certainly exercises a peculiar and very happy influence over this low species of inflammation. Very often the patient finds it soothing to the throat, even though burning to the mouth, in which the same condition of the membrane does not exist. The remedy is, I think, too much undervalued by recent writers. In children who cannot gargle, I apply it by means of a large camel's-hair pencil, or some equivalent instrument,

loaded with the powder mixed up with water, and turned about in the fauces. I have also used with advantage a strong solution of sulphate of zinc, containing fifteen or twenty grains in a fluidounce of water, as an application to the patches; and the nitrate of silver is also an excellent remedy, especially when the patches threaten to invade the larynx. Applied in solution, varying in strength from a scruple to a drachm to the fluid ounce of water, and repeated daily or twice a day, the latter preparation is now much employed, and by some practitioners is thought very favourably to modify the course of the disease when early resorted to. Dr. Eberle speaks favourably of a strong infusion of the root of the common wild indigo (Baptisia tinctoria) in putrid sore-throat. The offensive odour which proceeds from the throat, in some of these cases, may be corrected by gargles or washes of solutions of creasote, chloride of soda, and chloride of lime, or by diluted pyroligneous acid, which act also favourably upon the diseased surface.

Leeches may sometimes, as already stated, be used externally when there is considerable strength of pulse; and some also recommended blisters. I have employed these frequently, but not with much apparent advantage. In the asthenic cases the blistered surface is liable to slough. Rubefacient applications to the throat, such as the liniment of ammonia, tincture of capsicum, or oil of turpentine diluted with olive oil, may be used. Among the best external applications is a large emollient poultice.

During convalescence, it is important to guard against exposure to cold air, to keep the bowels regularly open, and, if the patient remain feeble with a want of appetite, to invigorate the stomach and system by the mineral acids, quinia, or the simple bitters.

The rules of diet applicable to other kinds of fever should be observed in this; and it is unnecessary to repeat them.

The sequelae of the disease often require attention. When the external parts about the neck suppurate, emollient poultices should be applied, and the patient's strength supported by tonics and nutritious food. Red oxide of mercury mixed with almond oil has been recommended in the otirrhoea which is apt to follow the disease.

The diarrhoea and inflammatory affections which set in must be treated as if these affections were original, reference being had to the debilitated state of the system. But it is proper to observe that, when they occur after a mild attack of the disease, depletion is often very well borne; the depressing influence of the poison having been removed. The brain must be especially watched, and, if symptoms of stupor supervene, blood should generally be taken from the arm. For the treatment of dropsy consequent upon scarlet fever, the reader is referred to the subject of dropsy.

Other modes of treating scarlatina have been employed, with great asserted success. Dr. John Gardner has treated thirty cases, some of which were of alarming violence, by means of belladonna, without the loss of a patient. He gives from half a grain to a grain of the extract, every three, four, or six hours, according to its effects, with no other medicine except an occasional dose of castor oil. (Braithwaite's Retrospect, xxiii. 28.) Inunction of the surface is highly recommended by Dr. Schneeman, of Hanover, and the practice has been successfully repeated by others. The whole surface of the body, with the exception of the face and scalp, is rubbed with a piece of fat bacon every morning and evening. (See Am. Journ. of Med. Sci., N. S., xx. 503.) Among the new modes of treatment is also the external application of hot water, recommended by Dr. Bully, of the Berkshire Hospital. For the mode of employing it, the reader is referred to Braithwaite's Retrospect (xx. 30), and to the Medical Times (August 29, 1849). In malignant cases,

brewers' yeast has proved highly useful in the hands of Dr. G. B. Smith, of Baltimore. He gives the yeast mixed with an equal bulk of water, and sweetened with brown sugar, in the dose of a tablespoonful every two hours. (Boston Med. & Surg. Journ., xlvi. 9.) Dr. H. L. Byrd, of Savannah, Geo., has recently met with great success from the use of the tincture of chloride of iron, given in a moderate dose every four hours or less frequently. (Charleston Med. Journ. & Rev., ix. 165.)

Preventive Treatment.-It is peculiarly important to guard children against scarlatina; as the older they grow, the less liable they are to be attacked. Hence, they should be kept separate as far as possible from every source of infection; and free ventilation of the sick chamber should be employed, in order to dilute and dissipate the poison. Different prophylactic medicines have been recommended; among which belladonna enjoys perhaps the confidence of the greatest number of practitioners. Its use for this purpose was introduced by Hahnemann, on the ground that it produces effects analogous to those of scarlatina. I confess, though I have used belladonna much, I have never seen from it anything resembling scarlatina. But whatever may have been the origin of the practice, its value must be determined by experi ence. The weight of testimony is, I think, decidedly against its possession of any prophylactic virtues. It is used in very small doses. Three grains of the extract are dissolved in a fluidounce of distilled water, and three drops of the solution given, twice a day, to a child under one year, to be increased one drop for every additional year. Another prophylactic is said to have been employed with great effect by several physicians of Groningen. It consists, for children from two to four years old, of a sixteenth or eighth of a grain of calomel, and the same quantity of the golden sulphur of antimony, with a little sugar or magnesia, given from once to four times daily. (Dict. de Méd.) Dr. John Webster, of London, strongly recommends, as a means, conjointly with isolation, of preventing the spread of scarlatina, the frequent sponging of the patient with warm vinegar. He believes, as the result of much observation, that with this precaution the disease will very seldom be communicated. (Ed. Month. Journ. of Med. Sci., Dec. 1849, p. 1295.) I have had no experience with either of the above prophylactics.

Article XII.

ERYSIPELAS.

Syn.-Saint Anthony's Fire.-Rose.-Ignis Sacer.

The term erysipelas was derived from the ancients, to whom the disease was known. It is a constitutional affection, characterized by a peculiar, spreading, circumscribed inflammation of the skin, with fever beginning a little before, simultaneously with, or a little after the local disease.

SYMPTOMS, COURSE, &c.-Languor, general uneasiness, aching or soreness in the limbs and joints, chilliness, or rigors alternating with flushes of heat, are succeeded by a frequent pulse, hot skin, a furred tongue, anorexia, thirst, sometimes nausea and vomiting, headache, restlessness, muscular weakness, and not unfrequently soreness of throat, or swelling of the lymphatic glands, in the vicinity of the part which is to be the seat of the cutaneous inflammation, as of the neck in erysipelas of the face, and of the axilla or groin in that of the extremities.

On the second or third day of the fever, though sometimes earlier and sometimes later, and occasionally as the first observable phenomenon, there