or four days from the occurrence of the symptoms of general depres sion. Its final stage is almost invariably attended with petechiæ, oozing of dark-colored blood from the mouth or nostrils, and discharges of the same kind from the bowels or bladder. A few hours previous to dissolution, there is often a transient glow over the body, a dark flushing of the face, great difficulty of respiration, accelerated pulse, and partial or general perspiration. The excitement, however, quickly subsides, the extremities become cold, the face of a cadaverous hue, and where the skin is pale, it has often the smooth waxen appearance of a corpse. Under such circumstances, life seldom lingers long. The prominent symptoms of both the varieties of scarlatina just described, are evidently dependent upon a lesion of the nervous system giving rise to extensive engorgements of the central organs, and of the large venous trunks. The abortive efforts at reaction, in the one case producing a degree of irregular and transient excitement, while in the other the organic functions of the brain and nervous system appear to be so completely paralyzed, that the patient sinks from a comparatively rapid extinction of all the vital functions which are unable to react, from the want of sufficient nerve power.

In the irregular congestive form, the oppression of important organs, is seldom to such an extent as to occasion any immediate danger; still, these organs, from the irregular determinations of blood which take place during the stage of imperfect reaction, are predisposed to serious lesions. The brain, the lungs, and abdominal organs are those which most commonly suffer, presenting, after death, either an injected state of their vessels, or the indications of subacute inflammation. In the regular congestive variety, after death, the brain, lungs, and liver, as well as the heart, and the large vessels in its vicinity, are found to be extensively engorged with dark-colored grumous blood, without any vestige of inflammatory action.

In congestive scarlatina, it is only in the early period of the case that we can expect any decided benefit from medical treatment. Called to a child that has been recently attacked, we should direct him to be at once immersed in a warm bath, and his body, at the same time, to be briskly rubbed with the hand or a flannel cloth. On coming out of the bath, he should be carefully wrapped in a blanket, and have sinapisms applied to the extremities, and over the epigastrium. In violent cases, if a warm bath cannot be immediately prepared, no time should be lost in waiting for it; but friction of the surface with a warm flannel cloth, impregnated with any warm, stimulating liquor, as vinegar, common spirits, cologne water, bay rum, &c., should be instantly employed; while bottles or bladders filled with warm water, are applied to the lower extremities. A full dose of calomel should be administered without delay, and followed, in a few hours, by an infusion of senna with the addition of sulphate of magnesia, or the compound powder of jalap. If these be tardy in their operation, some active purgative enema should be resorted to.

During the first day or two, it is important to repeat the bath, at least twice in the twenty-four hours; in severe cases, its action may be augmented by the addition of salt, or a small quantity of powdered.

mustard. Subsequently, the warm bath should be used daily, until symptoms of recovery ensue.

Calomel would appear to be the purgative best adapted to most cases of this form of scarlatina. It unloads the liver of its undue amount of blood; excites the mucous membrane of the intestines to a more healthy secretion; and seems to produce, throughout, a more equable and healthy action of the capillary system. The calomel should be administered at first in full doses, and followed by such cathartics as will insure its full action upon the bowels. As soon as the pulse becomes more free and full, the skin of a moderate and equable warmth, and the discharges from the bowels of a more healthy appearance, the calomel may be omitted, and castor oil, magnesia, and rhubarb, or any other mild laxative substituted. Calcined magnesia, saturated with lemon juice, is said by Armstrong to be, under the circumstances referred to, a very excellent purgative. Turpentine, combined with castor oil, is the one we have generally employed, and it has appeared to us to act beneficially, independently of its purgative properties.

Until convalescence is fully established, it is proper that a free and regular condition of the bowels should be maintained, without, however, endangering the occurrence of excessive purgation; a neglect of this precaution may cause a recurrence of all the more serious symptoms.

Every case of congestive scarlatina should be closely watched, and if symptoms ensue indicative of considerable oppression of the brain, lungs, or other important organ, the cautious abstraction of a small quantity of blood, by leeches or cups, from the neighborhood of the affected part, will, in general, produce great relief, and often insure a permanent, moderate, and general reaction. Much judgment will be demanded in the employment of bloodletting in these cases; its effects upon the pulse should be carefully watched, and if the slightest appearance of sinking occurs, the bleeding should be immediately suspended. The best time for the operation is immediately after the patient comes out of the bath, or it may be performed whilst he remains in the bath. The amount taken away should, under all circumstances, be moderate, even though a repetition of the bleeding be rendered

necessary.

During the flow of blood, the skin should be well rubbed with a coarse cloth or flesh-brush dipped in warm vinegar, in which a quantity of salt has been dissolved. The finger should be kept constantly upon the pulse, and if this become more full, free, and regular, the bleeding may be continued; if, on the contrary, it becomes weaker, or seems disposed to sink, the bleeding should be immediately arrested; though, subsequently, it may be again proper to try its effects, with the same precautions. It is all-important, however, that the bleeding be not carried too far, even when the pulse rises under the flow of blood, otherwise a dangerous state of collapse may be induced. Above all, the slightest approach to syncope should be avoided.

Bloodletting, it must be recollected, is proper only in the early period of the attack, unless violent reaction, as is sometimes the case,

should occur; the treatment should then be precisely the same as in any acute form of disease.

Bleeding, more especially by cups, in the immediate vicinity of the affected organ, in numerous cases, constitutes, unquestionably, a most important remedy in congestive scarlet fever. Upon the cautious and judicious employment of it the safety of the patient will often mainly depend. Hence, while it should be unhesitatingly resorted to whenever the brain or lungs exhibit symptoms of serious oppression, it must, at the same time, be recollected that it is not a remedy equally applicable to every case, and that in none can it be employed with the same freedom as in diseases of a purely inflammatory character. The great object of the practitioner should be, to relieve, as quickly as possible, the brain from its undue load of blood; by so doing, he will increase the nervous energies of the other organs, and enable them the better to relieve themselves of the oppression under which they labor. Sinapisms upon the extremities, and friction to the surface generally, being at the same time resorted to.

In violent attacks, after the warm bath, friction of the surface, and the cautious abstraction of blood, the administration of a large stimulating enema will often produce prompt relief, by unloading the lower portion of the intestinal canal, and diminishing the irritability of the stomach. The ordinary domestic enema, with the addition of turpentine, may be employed.

In conjunction with the remedies already recited, some gentle diaphoretic will often be found beneficial; the liquor acetatis ammoniæ, or a combination of camphor, ipecacuanha, and hydrochloride of ammonia,' may be employed. In some instances a weak infusion of serpentaria, or small and repeated doses of the carbonate of ammonia, will be found to produce a gentle and universal diaphoresis, which contributes materially to the relief of the overloaded organs, and, in this manner, to occasion a gentle and permanent reaction.

In scarlatina maligna, Dr. Peart recommends the carbonate of ammonia, in doses of five or six grains every second or third hour, as somewhat of a specific.

The patient may be allowed to partake of any warm, diluent drink, as thin gruel, panada, chicken water, or the like; when given immediately upon his removal from the bath, it tends to promote reaction. The same kind of drink may be continued at regular intervals throughout the disease. When, however, the skin remains cool, and reaction is with difficulty established, it will be proper to allow small and repeated portions of warm wine whey, or warm wine and water; but the moment that reaction ensues, every species of diffusible stimuli should be immediately discontinued, and warm diluent drinks substituted.

When a state of collapse begins to manifest itself, it will be necessary, in most cases, to administer moderate portions of some diffusible stimulant, as warm wine whey, or a little Madeira wine diluted with

milk, or brandy with milk. It is probable, also, that the infusion of serpentaria, and small doses of the carbonate of ammonia, will, in such cases, prove beneficial. Under the circumstances referred to, direct stimulants will often be demanded to support the patient's strength; it must, however, be recollected that a too early resort to their use, or their administration in too large quantities, or at too short intervals, is to be cautiously avoided. Close attention and much judgment will be demanded properly to time their use, and graduate the proper extent to which they should be carried.

When, by an energetic and well-directed treatment, a general, free, and moderate reaction has been brought about, the stage of collapse will be slight and of short duration, and require no difference in its management from that occurring in the inflammatory form of scarlatina. The utmost care should be taken to guard against exposure to cold or damp, to avoid every species of stimulating food or drink, and to preserve the bowels in a free regular condition. By a neglect of these precautions, dropsical effusion-of more frequent occurrence after the congestive than after the other varieties of the disease-will very generally be produced, or the occurrence of a subacute inflam mation, particularly of the brain or alimentary canal, of long continuance, and difficult to manage, will be endangered.

We have had a full opportunity, in the course of several severe epidemics, to test the value of the practice above recommended, and have no hesitation in saying, that, when judiciously carried into execution, it is calculated to disarm the disease of its malignancy, and to prevent the necessity, in the advanced period of the attack, of a resort to "powerful cordials, tonics, and antiseptics," to remove "the putrid symptoms which then show themselves." The "bold and indiscrimi nate use of the lancet " we should certainly strongly object to; but of the beneficial effects of a cautious employment of bloodletting, in the manner and under the circumstances directed, we speak from actual and repeated observation; it is unquestionably, in a large number of cases, the only "restorative and tonic" upon which any confidence can be placed.

The discredit into which bloodletting has fallen, in the treatment of all the forms of scarlet fever, has, we suspect, arisen altogether from the want of due attention to the circumstances under which it is alone proper. It is a remedy of great efficacy, for good or for evil. If used at random, and without a careful discrimination of the circumstances of each case, the reprobation that has been thrown upon it by Currie, will most assuredly be justified; it may then prove, in many instances, "a fatal practice." If, on the other hand, it is employed at the proper time, and in sufficient quantity, it will prove, as Dewar has very cor rectly remarked, a means of cure, safe and successful, far beyond any other with which we are acquainted.

Before quitting the subject of scarlatina, it will be proper to say a few words in relation to some of its most common sequelae. One of the most frequent is anasarca, either local or general. Effusion may also take place in the brain and the serous cavities generally, and this, occasionally, after the mildest cases; usually, however, it occurs only

after an attack of the more violent forms of the disease.

The effusion

is, in a large number of instances, the result of exposure to cold and damp, or of an injudicious administration of stimulants and restoratives, during the period of convalescence. It may, however, occasionally occur, according to Reil, as a strictly, complemental affection. In the generality of cases, it is attended with little danger, being readily removed by an appropriate treatment.

The dropsical effusion is occasionally accompanied with a quick, frequent, tense, and sometimes full pulse; a hot and dry skin, costive bowels, and scanty, high-colored urine. Under these circumstances, the good effects of bloodletting are attested by numerous writers. Combinations of calomel, nitrate of potassa, and digitalis,' will be found often to remove the effused fluid with great rapidity. Calomel, alone, in large doses, five or ten grains daily, is strongly recommended by Richter and Kreisig. As a drink, a weak solution of the bitartrate of potassa will be among the best we can give. In some cases, benefit will be derived from the following mixture.2

'R.-Calomel. gr. xij.

Nitrat. potassæ, 3j.

Digitalis, gr. iv.-M. f. ch.
No. xij.

One to be given for a dose, every two,
three, or four hours.

2R.--Aquæ, 3vj.

Sulph. magnesiæ, 3iv.

Spir. æth. nitr. Ziv.

Nitrat. potassæ, 3ij.

Tart. antimonii, gr. j.-M.

Dose, a teaspoonful every three hours.

The daily use of the tepid bath, followed by friction of the surface, will always be advantageous. Perfect quietude should be enjoined, in a dry, freely ventilated apartment, and every precaution taken against exposure to cold or damp. The mildest farinaceous diet alone. should be allowed.

When the effusion occurs in connection with a relaxed and debilitated condition of the system, bleeding will be improper. If the bowels are confined, they should be freely evacuated by calomel, followed by some gentle aperient. As diuretics, the squill, spirits of turpentine, and tincture of cantharides, have been highly recommended in these cases. The sulphate of quinia, the proto-carbonate and the tincture of the sesquichloride of iron, will often be found decidedly advantageous. Dr. Hamburger (Prague Vierteljahrschr., 1861) administered quinia in forty-seven cases of scarlatinal dropsy; in forty-four, improvement very speedily took place. The febrile symptoms of the subacute stage diminished, the secretion of urine increased, with greater clearness of the secretion; exuded matters were reabsorbed, abscesses were resolved, and there was a return of appetite and strength. The urine may continue albuminous for a time, but without interfering with the progress of convalescence. The dose of quinia given by Dr. Hamburger was from one and a half to two grains, twice a day for a child.

Mauthner (Journ. f. Kinderkrankheiten, 1841) objects to the use of diuretics in cases attended with bloody and albuminous urine. He depends entirely upon a well-regulated diet for the cure of the dropsy. Under an exclusive milk diet he has seen a copious secretion of urine free from albumen established, followed speedily by the removal of the dropsy. When this does not occur, he administers urea or the