letting. It is seldom that this is called for in the case of young children, but in adults of full habit of body it is sometimes indispensable. An apprehension has often been entertained of the debilitating effects of this practice in scarlet fever, which, however, may in most cases be safely disregarded. Headache, general oppression, with a full and flushed countenance, are the symptoms which most urgently call for its adoption. These should be relieved even at the risk of depressing the powers of life, for a continuance of them leads inevitably to evils at least as great. When from the low or typhoid character of the epidemic, or other sufficient cause, general bloodletting may be thought unadvisable, leeches may be applied to the temples; and they are often productive of great relief. They may also be applied with advantage to the throat, when the swelling of the tonsils is very great. Their employment in this disease requires more than ordinary caution, for in consequence of the excited state of the cuticular circulation, they often bleed very profusely. The application of lunar caustic is the readiest and most effectual means of checking the hæmorrhage thus occasioned. When the eye or the ear becomes seriously implicated, blood should be taken from the temples by cupping to the extent of six or eight ounces.

Cold affusion.-Experience has proved, that in the cold affusion we possess another means of controlling this state of disease, which, though not equally effectual, is free from the risk which sometimes attends bloodletting. We are indebted to Dr. Currie, of Liverpool, for this improvement in practice. The great heat of skin renders the free affusion of cold water grateful to the patient. The disorder prevails chiefly among children, in whom it can be applied with facility. In common cases of scarlatina there is not that degree of febrile weakness which the fatigue of a cold affusion would augment. There is no tendency to affection of the chest, as in measles, which the application of cold to the surface might aggravate. An ulcerated state of the throat forms no objection to its use. On the contrary, the cold affusion frequently checks this symptom in the most remarkable manner. The repetition of the remedy at intervals, proportioned to the urgency of the symptoms, is indispensable; it may be safely applied whenever the skin is hot and dry. It cools the skin, abates thirst, diminishes the frequency of the pulse, relieves the headache, and the languor,

and disposes to sleep. Cold or tepid spunging may be substituted in cases where the cold affusion is inadmissible.

Evacuants.-Emetics have been strongly recommended throughout the whole course of scarlet fever; but they are not advisable, except at the very onset of the disease. Moderate purging is greatly to be preferred, and yet a prejudice against it was long entertained, probably in consequence of observing the danger of supervening diarrhoea. In the common forms of scarlatina, where high inflammatory action prevails in the throat, with a dry and burning skin, active purgatives frequently repeated, containing calomel and jalap, are quite indispensable.

Gargles of infusum rosæ are useful at an early stage to wash away the vitiated mucus; when the sloughs are separating, barley water is preferable. In severe cases a blister may be applied to the throat. In all cases it is desirable to cut the hair close; but when the determination of blood to the head is great, the head should be shaved, and kept cool by vinegar and water, or the common evaporating lotion, containing a due proportion of spirits of wine. Saline draughts are of little value in scarlet fever. The mineral acids are more serviceable, and may be given in the following form:

R Acidi muriatici, 3j.

Syrupi limonum, ss.

Aquæ fontane, zvijss. Misce.

Sumat partem sextam quarta quaque hora.

Tonics. In the malignant form of scarlet fever, treatment of any kind is of course less efficacious; but several of the measures already recommended may be had recourse to with a prospect of success. An emetic at the commencement of the disease has often proved of great service, and in some cases appears to have completely broken its force. Stimulant gargles, as of port wine, or of decoction of bark with tincture of myrrh, are of considerable use. The bowels should be cleared by gentle doses of castor oil, but severe purging is dangerous. Tonics and cordials afford here the best prospect of success. Draughts with camphor, serpentaria, and ether, may be given at first every four hours; but as the disease advances, it becomes necessary to support the patient with decoction of bark and acids, port wine, opium, and aromatics. In the severe

M

epidemic which prevailed in the West Indies in 1787,* capsicum taken internally, and employed as a gargle, proved very serviceable.

The convalescence from this disease is always very tedious, and may sometimes be shortened by a judicious administration of bitters and cordials. At the same time it should be observed, that an excited and feverish state of the system frequently accompanies the process of desquamation, requiring the long continued use of medicines that will encourage the action of the kidneys and bowels. For this purpose a saline diuretic, with tincture of digitalis, is to be given two or three times daily, and a senna draught every morning.

SCARLATINAL DROPSY.

I have delayed to this period the description of a very remarkable phenomenon in the history of scarlet fever;-namely, the dropsy, which frequently succeeds it. It generally takes the form of anasarca, but ascites has also been noticed. It as often succeeds the mildest as the severest cases. It occurs, on an average, upon the twenty-second day from the decline of the eruption, seldom earlier than the sixteenth, or later than the twenty-fifth. Dr. Tweedie relates a singular case where the dropsy did not appear till five weeks after desquamation had begun. It is preceded for several days by languor, costiveness, and sickness. These symptoms frequently continue, accompanying a quickened pulse. The urine is scanty, and often coagulates on heating. This species of dropsy sometimes proves dangerous from the occurrence of coma, but more commonly from thoracic symptoms indicating effusion in the chest.

In speculating on the nature of this affection, Dr. Wells decidedly inclines to the idea of its being inflammatory, and in this he is supported by the opinions of later pathologists. He argues, that it is not owing to debility, for it often attacks those who are strong, and passes by those who are weak; its occurrence is confined to a particular period, though great weakness may exist before and after; and lastly, it is often attended with a white tongue and a bounding pulse. In such cases the

Vide Medical Communications, vol. ii. page 363.

† The reader will find a classical paper on this subject, from the pen of the late Dr. Wells, in the Transactions of a Society for the Improvement of Med. and Chir. Knowledge, vol. iii. page 167.

occurrence of dropsy probably depends upon the continuance of that highly excited state of the cutaneous capillaries which earlier in the disease occasions desquamation of the cuticle; but it must be admitted that its precise causes have never been clearly explained. The common method of treating this form of dropsy is by purging, squills, and digitalis, and it is for the most part successful. Many cases have lately been published, pointing out the efficacy of bleeding from the arm, where the symptoms are more urgent. I have met with several instances, however, which appeared to indicate the propriety of bleeding and purging, but which resisted both, and ultimately yielded to bark and aromatic confection. From this we may presume that the theory which ascribes the dropsy to loss of power or tone in the exhalants, has, in some cases at least, a foundation in

nature.

CHAP. VII.

THE MINOR EXANTHEMATA.

Herpes. Urticaria, or Nettle-rash. Lichen, acute and chronic. Roscola. Erythema. Miliaria. Framboesia, or the Yaws. Its Symptoms and Progress. Peculiarities of its Contagion. Principles of its Treatment.

In the present chapter I purpose to treat of those lesser febrile eruptions, which do not, under any circumstances, go to the extent of affecting life, and are chiefly interesting with reference to diagnosis. They are, Herpes, Urticaria, Lichen, Roseola, Erythema, Miliaria, and Framboesia.

I. HERPES.

Of all the lighter varieties of cutaneous eruption complicated with fever, herpes is that which is most distinctly entitled to the character of an exanthema. The term herpes is appropriated to a vesicular disease, preceded by febrile languor, and other marks of constitutional disturbance, often very severe. The vesicles pass through a regular course of increase, maturation, and decline, terminating, in most cases, in about a fortnight or three weeks. Herpetic vesicles are distinguished by

their occurring in distinct but irregular clusters, appearing in quick succession, being set near together, and upon an inflamed base, which extends some way beyond the margin of each cluster. The most frequent form of the disease is the herpes zoster, or shingles, in which the eruption appears on the abdomen, but is observed also in some cases on the extremities, or breast.

Young persons, from fifteen to twenty-five years of age, are commonly the subjects of this disease. Very little is known regarding its causes. Anxiety of mind, change of climate, and irregularities in the mode of living, are the remote causes to which it is in general attributable. It is most frequent in summer and autumn, and seems in some cases to arise from exposure to cold after violent exercise. It is always slight, seldom confining the patient to the house, or occasioning any debility. Its course cannot be shortened by internal medicine, and it does not require any external applications. In hot countries, herpetic ringworms (herpes circinatus) often prove both tedious and severe, but in this country they follow the usual progress. An herpetic state of the lips (termed herpes labialis) occasionally appears as an idiopathic affection, originating from cold and fatigue. It is then preceded for two or three days by nausea, lassitude, languor, and sometimes severe feverish symptoms. The same affection is frequently symptomatic of some internal disorder. The common purgative draught, repeated as circumstances may require, seems to comprise every thing that is really necessary in regard to the treatment of herpes. The decoction of bark is certainly useful in the severer cases, and may be given in combination with the liquor ammonia acetatis, if the secretions of the kidney are scanty.

II. URTICARIA.

There are several kinds of eruption attended with fever, which have occasionally been mistaken for measles and scarlatina. They are all very trifling diseases, but they deserve some attention on the score of diagnosis. One of these is the febrile urticaria, or nettle-rash, a rare disease, of which a very scanty notice will suffice. It sometimes shows itself without warning; at other times it is preceded by feverish symptoms, vomiting, and pain in the bowels, which last for twenty-four hours. The eruption appears in the form of white elevations of the cuticle, similar to those produced by the stinging of