affording relief and diminishing the fatality from the disease. It is to be added that a comparison of different collections of cases with reference to the rate of mortality under different methods of treatment is of little value, on account of the wide diversity as regards severity of the disease.

Certain measures which have heretofore been employed in the treatment of scarlatina are now regarded as, in general, opposed by sound reasoning and experience. This statement applies to bloodletting, active purgatives, mercurialization, blisters, and emetics. These are very rarely, if ever, indicated, and, if not indicated, must of necessity prove hurtful. From the fact that measures are not addressed to the disease per se, it follows that the expectant plan is to be pursued, and the indications are to be drawn from particular symptoms, events, and complications in individual cases.

In the majority of mild cases, hygienic treatment is alone required. In addition to free ventilation, cooling drinks, and light nourishment, the hygi enic treatment should embrace measures to maintain the functions of the skin. In view of the fact that renal disease, as a complication or sequel, is a source of danger in these cases, attention to the skin is important, however mild may be the disease. The tepid bath once or twice daily is to be recommended. If the bath be not practicable, the application of a sheet wet with tepid water or repeated sponging of the body may be employed in its stead. There is reason to believe that the more the functions of the skin are maintained by these measures, the less is the liability to an affection of the kidneys either during or after the disease. Exposure to cold is to be avoided both while the disease is in progress and in convalescence, but care in this respect should not lead to error in the way of free ventilation, or of oppressing the patient with an overplus of clothing. Vigilance or restlessness, if not relieved by the use of the bath, the wet sheet, or sponging, may indicate anodyne remedies. Constipation is to be relieved by simple enemas; other symptoms may indicate appropriate palliative remedies. For the affection of the throat the chlorate of potassa may be prescribed, internally and as a gargle.

In some cases, frequently the leading indication is derived from the intensity of the febrile movement, as denoted by the increased heat of the body and the frequency of the pulse. Insomnia, restlessness, and delirium are measurably dependent on the febrile movement, and in general the latter is a criterion of the severity and danger of the disease. To diminish the heat, and the frequency of the heart's action is an important object of treatment. This object may be most effectually accomplished by the use of water. It was in this disease that Currie was led, more than half a century ago, to employ cold affusions with a happy effect. This mode of applying water is strongly advocated by Trousseau, who states that he has employed it with highly satisfactory results in a large number of cases in private and hospital practice. It is doubtless the most efficient measure to be employed for the relief of the active delirium which sometimes occurs in this disease. The apparent boldness of the practice renders it frequently objectionable on the score of popular prejudice. Frequent sponging of the body doubtless secures, to a considerable extent, the same results; but, probably, the use of the wet sheet is, in most cases, not less efficacious than the cold affusions as practised by Currie. In employing the wet sheet as a sedative and diaphoretic measure, water is to be used at about the temperature of 70° Fahr.; the patient, stripped of all clothing, is enveloped in the sheet and closely covered with several blankets. The procedure is that practised by the hydropathists under the name of the wet pack. Usually, after remaining in the pack for about an hour, free perspiration is induced. The pack is to be re

moved when this effect occurs, the body wiped dry, and the patient placed in bed.

There is abundant testimony to the value of this measure. In a conver sation with the late John Ware many years before his death, he advocated it in strong terms, and I have repeatedly made trial of it with great apparent benefit. Quite recently it has been advocated by Dr. R. W. Mathewson, of Durham, Conn. Directly after the application, the frequency of the pulse is notably lessened, the skin becomes comparatively cool, the patient is tran quillized and obtains refreshing sleep. The measure may be repeated once or twice daily. Its effect is so agreeable that patients generally desire its repetition. There is no occasion for fears of repelling the eruption. The conditions under which it is always appropriate are increased heat, with dryness of the skin and frequency of the pulse, that is, intensity of febrile movement.

In malignant cases in which the vital powers are overwhelmed, and whenever the intensity of the disease involves a tendency to death by asthenia, the chief reliance must be on sustaining measures. Alcoholic stimulants are indicated in proportion to the frequency and feebleness of the pulse, together with general prostration. I have witnessed the same striking benefit from the free use of wine or spirits in certain cases of scarlatina as of typhus or typhoid fever. Alcoholic stimulants, however, are not to be given without discrimination, and the physician is to be guided in their use by watching their immediate apparent effects, precisely as in other essential fevers. In children, wine-whey, milk-punch, and egg-nog are eligible forms for the administration of stimulants and nourishment.

Cases of so-called scarlatina anginosa, in addition to sustaining treatment, call for measures addressed to the affection of the throat. The chlorate of potassa is now generally considered, and probably with justice, an important remedy in these cases. From one to two drachms may be given daily. The chlorine mixture is highly recommended by Watson and others. The formula for this mixture has been already given. Stimulating or caustic applications to the pharynx are of doubtful utility. The difficulty of making them in children, and the perturbation occasioned by making them forcibly, in spite of the resistance of patients, are not small objections; but, aside from these objections, it may be doubted if they produce a beneficial effect. They have been deemed important with a view of preventing the resorption of decomposed matter and the production of septicemia; but it is by no means certain that a putrid infection of the blood thus induced is ever an element of the disease. It is proper, however, to state that local applications within the pharynx are deemed useful by many, if not most, physicians. Of cauterizing applications, the hydrochloric acid is generally preferred. Alumen, capsicum, tannin, and the borate of soda, applied in solution or in powder, have been much used. Antiseptic applications, by gargling, if the patient be not too young, or made by means of a sponge if the resistance be not too violent, contribute at least to comfort. The solution of chlorinated soda may be used for this purpose, diluted with eight or ten parts of water. The permanganate of potash may also be used in the proportion of half a grain of the salt to five ounces of water. The free use of iced drinks is useful as regards the condition of the throat. The patient may be allowed to take into the mouth small pieces of ice almost ad libitum; and for young children

1 Medical Communications and Proceedings of the Connecticut Medical Society, May, 1864. The communication by Dr. Mathewson may be consulted for the details of the operation of packing. See, also, Stille's Materia Medica and Therapeutics, under head of Water, for the same details, and for the management of cold affusions.

2 Vide page 766.

a convenient plan is to confine pieces of ice in a gauze bag which may be held in the mouth, as recommended by the late Dr. Samuel Jackson, of Northumberland, Pa. Externally compresses kept wet with cold water may be applied. It has been recommended to apply ice to the sides of the neck. I have been accustomed for many years to advise the pretty free use of the tincture of iodine to the neck, especially if there be much glandular swelling. If suppurative inflammation ensue, poultices or the water dressing should be applied. Prof. W. T. Gairdner attaches more importance to the inhalation of the steam of hot water, continued from the beginning to the end of the fever, than to any other measure addressed to the throat affection. He states that in his practice this supersedes all other local applications.1

Extreme pruritus of the skin is, in some cases, a source of much annoyance, preventing sleep and increasing the constitutional disturbance. With reference especially to this symptom, some years ago a plan of treatment originated in Germany, consisting in the application of lard to the surface of the body, the rind of bacon being used for this purpose. This plan was adopted to some extent in this country. It relieves, in some cases at least, the pruritus, and diminishes the febrile excitement. Other applications, however, less disagreeable are equally efficacious. Glycerine and the rose-water ointment, recommended by Dr. J. F. Meigs, may be substituted. But a still better substitute has been successfully employed by Dr. P. M. Hastings, of Hartford, Conn., viz., glycerine and cologne-water, in the proportion of one part of the former to four or five parts of the latter.

Convulsions are generally due to uræmia, but, occurring early in young children, they may be incident to the development of the disease without denoting a renal complication. They are less frequent in children in the early part of this disease than in variola. Whether uræmic or otherwise, if they continue, the inhalation of chloroform is indicated. I have notes of two cases in which this measure was employed with immediate relief, and recovery followed. Trousseau extols compression of the carotids, in the manner already described, as highly efficacious in arresting convulsions in this disease."

Uræmic phenomena, in addition to convulsions, viz., cephalalgia, disturbance of vision, or coma, render prompt measures of treatment vastly important. Saline purgatives or elaterium are to be employed at once to eliminate urea, and diaphoresis should, if possible, be procured by the use of the warm or hot air bath or the wet sheet. Vomiting or purging should always suggest the inquiry whether they be not due to uræmia, and, if so, they are not to be arrested. Albuminuria, and especially a deficiency of urea in the urine, should lead to measures with a view of forestalling the effects of uræmia. Fomentations are to be applied over the loins, the bowels are to be kept loose with saline laxatives, and, with reference to this object, it is important to produce diaphoresis by means of the warm bath or the wet sheet.

Restlessness and vigilance, if not relieved by measures of treatment already noticed, may require anodyne remedies. The succedanea of opium are to be preferred, viz., belladonna, hyoscyamus, etc. If, however, they are not efficacious, opiates are to be given, but cautiously in young children, or if uræmia be threatened. With reference to the liability to heart-clot, Richardson advises the carbonate of ammonia, given in small doses frequently repeated. Several writers have strongly advocated this remedy as exerting a special curative influence in scarlatina.

The treatment of the sequels of scarlatina need not be here considered. The most frequent of the important sequels, viz., acute albuminuria, has 2 Vide page 618.

Clinical Medicine, Edinburgh, 1862.

been considered in a former part of this work, to which the reader is referred. In the treatment of pruritus, pericarditis, rheumatism, and chorea, are involved essentially the same principles as when these affections occur in other pathological connections. External otitis is often neglected, and is apt, therefore, to continue, and, in the end, lead to impairment of hearing. Daily cleansing the ear by the injection of tepid water and soap will usually prove sufficient to effect a cure; but, if the affection continue in spite of this simple measure, which from its very simplicity it is often difficult to enforce, mild astringent injections should be employed.

I will add a remark with reference to the prevention of renal disease as a sequel of scarlatina. The occurrence of this sequel being generally attributed to cold, it is common to confine patients within doors and sometimes even to the bed, for two or three weeks after convalescence. Regarding, however, the sequel as a remnant of scarlatina, this extreme care is unnecessary. It is sufficient to observe the same precautions with regard to exposure to cold or other morbid agencies as during convalescence from any acute affection. Gestation, out of doors, has seemed to me to be useful even when patients are suffering from albuminuria and general dropsy following scarlet fever.

It remains to notice the protective influence against scarlatina, which has been imputed to belladonna. For the conflicting statistical data bearing on the question whether minute doses of this remedy tend to render the system, for the time, insusceptible to the disease, the reader is referred to works treating of materia medica and therapeutics. In estimating the force of evidence for and against the assumed prophylactic nature of the remedy, it is to be considered that the failures to afford protection are the positive facts. A certain proportion of persons do not contract scarlet fever, however great the exposure. We have no data for determining the proportion of persons among those exposed at any particular time or place, who are thus naturally insusceptible. Of those who, under the use of belladonna, fail to contract the disease, it may be said that they might have been naturally insusceptible, whereas, all the instances in which the disease is contracted notwithstanding the use of belladonna militate against the protective power of this remedy. Giving due weight to this consideration, satisfactory proof of the prophylactic power of belladonna, requires that the number of failures shall not be large; and, judged by this rule of evidence, it is extremely doubtful if there be any ground for imputing to this remedy a prophylactic power. It is, however, to be considered that to prescribe belladonna as a prophylactic is always a harmless experiment, and is, therefore, only objec tionable on the score of supererogation. Moreover, as the popular mind has been directed to this question, the wishes of friends are often better satisfied if the remedy be prescribed. These considerations may properly influence the physician. The following are the directions for the use of the remedy: "Dissolve from one to three grains of fresh and well-prepared extract of belladonna in an ounce of cinnamon water, adding a few drops of alcohol to prevent fermentation. Of this solution may be given, two or three times a day, one drop for each year of the child's age, to be so administered for two weeks, or longer, if the danger should continue."

Stillé, op. cit.

CHAPTER VIII.

ERUPTIVE FEVERS.-Concluded.

Rubeola, or Measles-Clinical History-Causation-Diagnosis-Prognosis-TreatmentRoseola Summary of the more important of the Differential Characters of Variola, Scarlatina, Rubeola, and Roseola-Dengue.

RUBEOLA, 80-called from the red color of the eruption, called also morbilli, and commonly known as the measles, is a disease of less importance than the eruptive fevers which have been considered. It is generally a mild and often a trivial disease; but it is desirable as early as possible to discriminate it from the other eruptive fevers; it is of frequent occurrence, it is sometimes accompanied by grave complications, it is occasionally followed by serious sequels, and, in a certain proportion of cases, the disease is intrinsically severe, or even malignant. Hence, rubeola is by no means an unimportant disease.

Rubeola, like scarlatina, has no special anatomical characters exclusive of the internal and external efflorescence which is most conveniently considered as belonging among the symptoms of the disease. I shall pass, therefore, at once to the clinical history.

CLINICAL HISTORY.-The career of this disease is subdivided, like the other eruptive fevers, into the stages of invasion, eruption, and desquamation, each stage claiming separate consideration.

Stage of Invasion.-The distinctive local symptoms in this stage resemble those of a common cold, or rather an attack of influenza. There is coryza, with frequent sneezing, and an acrid muco-serous discharge from the nostrils. The eyes are irritable, reddened, and watery. Epiphora is sometimes marked, the tears excoriating the face, and there is more or less intolerance of light. Subacute laryngitis, denoted by hoarseness, frequently occurs, and the symptoms of bronchitis are generally present, the cough being dry, sonorous, and painful. Occasionally the pharynx is the seat of subacute inflammation. The bronchitis, laryngitis, and coryza are due to the efflorescence which takes place on the mucous membrane of the air-passages prior to its appearance on the skin. With these local affections, which vary much in intensity in different cases, there is associated more or less febrile movement, accompanied by irregular chilly sensations and shivering, but rarely ushered in with a distinct chill; the appetite is impaired or lost, and in some cases nausea and vomiting occur; pain in the head and limbs, with debility and lassitude, are, in general, proportionate to the amount of febrile movement. The general are often out of proportion to the local symptoms, as in cases of influenza; they are less intense than in the stage of invasion in variola and scarlatina, and in some cases are slight. Constipation exists in some cases, and in other cases there is diarrhoea. Convulsions sometimes occur in this stage, chiefly in children. In general they are not indicative of danger. Epistaxis is, in some cases, a prominent symptom. Spasm of the glottis, or false croup, is an occasional symptom in young children.

The average duration of this stage is four days. The duration is, therefore, twenty-four hours longer than in variola, and forty-eight or more hours