Observations on scarlatina

40 Dr. Fitzpatrick's Observations on Scarlatina.

powers of vegetation are not inert even in the secretions of the human body.

We will now take leave of our subject until, in some future essay, we shalI give minuter details on the form atad compo- sition o[" tubercle, and its numerous and possible evolutions.

ART. I I . - -Observat ions on Scarlatina. By THOMAS I~'ITZ - l'.~ralcK, M . D . , Licentiate of the King and Queen's Col- lege of Physicians, and formerly Physician to the Dublin General Dispensary.

[Read at the Dublin Obstetrical Society.]

T~IE records of mediclne demonstrate, that scarlatina has exhibited the greatest variety in its character and symptoms during its prevalence at different periods as an epidemic, at one time, from the mildness of its form, scarcely deserving the attention of tile physician, at another, remarkable for its virulence and fatal consequences, thus fully supporting the quaint observation of Darwin, that scarlatina differs from a fleabite to the plague. It is not my intention, on the present occasion, to offer any observation on the history of this disease, it is sufficient to remark, that the best authorities agree in file opinion, that however varied in type and symptoms, the one species of disease was described by Sydenham, Morton, Huxham, and Fothergill, and was identical in its pathology with the scarlatina of our day, which, from the time when it was accurately described by Withering, to the present period, has exhibited in different years the greatest variety in its constitution, thereby forming the character of the prevailing epidemic. The common division of scarlatina into three forms, although useful in in- struction to the student, and frequently borne out in practice, is yet not sufficiently marked to obtain the implicit acquiescence or'the practitioner, who sees, that in many instances tile line of demarcation is obliterated ; the first form gradually assuming the character of the second, and ultimately degenerating into

Dr. Fitzpatrlck's Observations on Scarlat ina. 41

that termed malignant, however, sufficient cause exists to induce an adherence to this division, but at present I shall con- fine my remark to scarlatina anginosa, and scarlatina maligna, particularly in relation to the character they have presented of late years in this city. The student who examines the works of authors who have treated on fl~is disease, will be surprized to find, that although no great difference is observable in the detail of its symptoms, yet, the greatest variety in the recommen- dation of remedies is remarkable. He will find one advocating cordials and tonics ; another, diffusible stimuli ; a third, acids ; a fourth, purgatives; a fit'th, bleeding and active depletion, and a sixth in favour of cold effusion ; but minute investigation will demonstrate, that the proposers of the three first plans of treatment, recommend that due attention should be paid to the approach of inflammatory symptoms, while the advocates of the three latter are cautious in the promulgation of their doctrines, and advise particular observation to be directed to the accom- panying fi~ver ; thus, Dr. Armstrong, in recommending bleeding and strong purgatives, says, that these powerful proceedings must be confined to the stage of excitement, and within the first thirty hours of that stage.

We can only reconcile the difference in the treatment of the same disease, of course, supported by the experience ofeach author, by supposing, that its constitution, and particularly the type of fever, varied with the adoption of remedies, presenting as its predominant feature, either the pure inflammatory or typhoid character, or a participation of both. Were scarlatina simply an inflammatory disease, the treatment of it would be ottended with little difficulty ; did it even from its ingress in- dicate the character of a purely typhoid fever, we might, by proper care, hope for a favourable termination ; but the com- bination of these two phenomena, accompanied with the fact, of a specific poison being the primary cause, renders medical treatment doubtfid in some cases, hopeless in others. In too many instances the physician is, as it were, placed between two

vow.. xxl. NO. 61. G

42 Dr. Fitzpatrick's Observations on Scarhttina.

enemies. No sooner does he combat one, than, by that very act, he gives power to the other, and in this unequal contest, a peculiar gift of prophecy is not required to foresee the re- suit. In such a disease as epidemical scarlatina, a true judgment of the peculiarities of the fever, which it may present, can only be formed by observation of the effects of remedies ; but it must be ever borne in mind, that even in epidemics, in which, in a great number of instances, the train of symptoms is similar, as well as the effects of remedies, occasional cases may present themselves, exhibiting a marked difference in their character- istics, probably dependent on the constitution of the individual. I here particularly allude to the development of the inflammatory form of the disease, perhaps in one of a family, the remaining members presenting the characters of a low or typhoid fever, and vice versh.

The specification of the symptoms of scarlatina would be on the present occasion a work of supererogation, and even a division of the forms, which of late years it has presented, in the order of tile succession of symptoms, would far exceed the intended limits of this communication. It is not to be won- dered at, that variety in the onset and progress of scarlatina should be observed when we reflect on tile numerous morbid lesions which may be developed in its course, implicating indiscriminateIy the most important serous and mucous mem- branes of the body, and creating irritation or inflammation in the neighbouring glands and cellular tissue. Dr. Graves, in his admirable account of the epidemic in 1834, describes three forms which it assumed. The first characterized, not merely by sore throat and headach, but by such violent congestion of the brain as occasioned convulsions and coma on the first or second day, and generally proved f/~tal. The second form was ushered in by severe pyrexia, incessant vomiting, and purging, unaccompanied by epigastric or abdominal tenderness, and evidently depending on morbid action in the brain. The pulse was excessively rapid, sometimes irregular ; headach was complained of, accompanied by restlessness, anxiety, and delirium ;

Dr. Fitzpatrick's Observations on Scarlatina. 43

the fauces were inflamed, a continuous efflorescence was observed over the body, and tile surface of the tongue affected with exanthematous redness, becoming afterwards dry, foul, and parched ; as the disease advanced, delirium increased ; jac- titation and subsultus were developed, insensibility followed, and in some cases convulsions preceded the fatal termination.

The third form was marked by the mildness of the symptoms in ttle early stage, the soreness of the throat being slight, and tile eruption normal, matters appearing to go on most favourably till the eighth or ninth day, when a return of fever was noticed ; the nostrils became irritated, and sore throat was complained of; the skin became hot, accompanied with great prostration of strength ; a painful tumefaction commenced in the region of the parotid and sub-maxillary glands, eventually surrounding tile throat like a collar. In the meantime, the nostrils poured out a viscid secretion in considerable quantity, increasing to such a degree as to render them impervious to the air in breathing ; the internal fauces and mouth exhibited a similar secretion, causing difficulty in swallowing; tile ac- companying fever displayed the worst form of typhus, and death closed the scene, being preceded by a state of restlessness, during which it was impossible to decide whether the patient was still sensible. Accurate as is the description of these variations of disease given by Dr. Graves,* it does not include all the forms as witnessed during the late epidemic. In some cases, the predominant symptoms depended on the morbid action having extended from tile throat to the epiglottis and larynx. In others, the swelling of the external fauces was

one of the earliest symptoms, followed by the acrid discharge from the nose and mouth, and the patient died on the third or fourth day, without local symptoms sufficiently marked to war- rant the prognosis era rapidly fi~tal termination. Iam indebted

* Dr . Graves did not profess to give a detai led account of the epidemic ;

he confined his observations to the most remarkable forms of the disease which

came under his notice.

44 Dr. Fitzpatrick's Observations on Scarlatina,

to my friend Dr. Lees, for notes of three cases of this class~ which came under his observation in the South Union Work- house. In all, tile disease commenced with tile swelling of tile external fauces, the tonsils and throat being but slightly affected, no symptom of (edema of the glottis existed, the children gradually fell into a state of stupor, and all died within fi~'e days from the period of attack in each case. The most accurate post mortem examination afforded no evidence to explain the cause of death in those cases. In a third, but rarer class, the disease assmned tile character of scarlatina maligna, but without the efflorescence, tile marked features consisting in inflammation, ulceration, and sloughing of the throat. It has been well remarked by Dr. Tweedie, that in the various forms of scarlatina, the treatment to be adopted must have reference to each individual case, as well as to the prevailing type of the fever ; indeed, the general principle which ought to guide us, is to reduce local inflammation at the least possible ex- pense of the patient's strength ; but tile reduction of inflammatory action, which has approached its acmd, does not constitute the cure of the malady. In two cases, in which my at- tendance was requested on the seventh day of the illness, presenting inflammation and ulceration of the fauces, with great external tumet~action of the throat. I succeeded by appropriate treatment in relieving these prominent symptoms; de- glutitlon became easy, and the throat assumed the natural aspect ; ibr two days, a visible improvement in the patient's general state was apparent ; then came a fresh accession of fever, accompanied with a slighter degree of glandular tame- faction than previously existed, but with marked evidence of great derangement of the nervous system ; one died of typhoid on the seventeenth day, the other case terminated on the twenty- first day, presenting a miserable spectacle of gangrene in different parts of the body. With reference to the treatment of scarlatina, I shall only briefly allude to two points of practice in the early stage of the complaint, namely, the use of cathartics, and the admission of cold air to the surface of the body, as I


believe that the doctrines of Sydenham and Hamilton, in relation to general fever, are frequently too heroically earried into effect, and tend to the subsequent aggravation of the disease.

Let us take the following exumple: A child is attacked with fever and sore throat ; scarlatina is apprehended ; the child is purged on the first day ; on the second, the feverish symptoms are not alleviated, and the throat is probably worse, the body being covered with the eruption. The child is leeched, purged again, and tartar emetic solution is then administered ; the little patient is first in some degree exhausted by the application of leeches ; during this state the action of the purgative com- mences ; the ehild is carelessly taken out of bed~ not to answer the call of nature, but of medicine, and is exposed during its operation to the cold air. The tartar emetic is now given, and nausea and vomiting are added to the ante-febrile agents. Still the fever is not subdued; the pulse continues rapid, but

weak; tile eruption begins to disappear, the child, from being restless, becomes remarkably quiet, and a train of formidable symptoms follows. Having witnessed such results, I have adopted a different mode of praetlee ; I place the patient, if possible, in a large and airy room, directing, after the appearance of the eruption, that the surface of the body should be carefully at all times covered by the bed-clothes, regulating their quantity by the temperature of the atmosphere, but taking care that an equal temperature is always maintained, moderating the heat and uneasiness in the skin by frequent tepid sponging, and administering aperients only sufficient to keep up the re- gular action of the bowels ; by this mode of proceeding (being of course prepared to meet inflammation which might arise), I feel assured, that severe forms of the disease terminated favourably, which, under a more decidedly antiphlogistle treatment, would have assumed dangerous appearances. Let me not be understood as advocating the old heating and stimulant plan of treatment, nor deprecating depletion, when circumstances demand it; but such circumstances generally prove the exeep-


tion, not tile rule. In proof of this assertion, [ may observe, that Dr. Williams, in his work on Morbid Poisons, mentions, that in 241 cases, treated at the London Foundling and Fever Hospitals by bleeding and active depletion, the deaths were one in six, while in 555 cases treated by aperients and mineral acids, the deaths were one in twenty-two. We have, however, un- fortunately too well established evidence, that in some cases of this malady, all modes of treatment are unavailing; too many instances have occurred of whole families being carried off, not- withstanding the unceasing efforts of the most experienced practitioners. It is to such cases occurring in families that I wish to direct the attention of the Society.

In the consideration of this subject, the first question which suggests itself, is, what is the best mode of proceeding, relative to the remaining children in a family, where one is attacked with a malignant form of scarlatina ? Are we justified in recommending their removal from home? It is strange, that although most medical authorities are against this proceeding, the feelings of the public are still prejudiced in its favour. In the year 1803, a very sensible work was published by Dr. Black- burne, exhibiting the injurious results of this practice, particularly in disseminating infection. I might bring forward some cases which came under my own observation, proving its fallacy ; but the two following are quite sufficient evidence against its adoption. On the evening of Saturday the l l th of June, 1836, my friend Dr. Callan was sent for, to see a child aged eight years, who was attacked with convulsions, being the first symptom of scarlatina maligns, which ultimately proved fatal. On the following morning the other children of the family, four in number, were removed from the house. Three were sent to different parts of the city, and one to the country. Within the period from the 15th of June, to the 14th of July, all those children were attacked by the disease, and died, although every remedy which the most eminent advice could suggest was adopted. In the second instance, a


gentleman residing in the country had a family o f f our children; on an evening during last Summer, one of them was attacked with fever and sore throat; the following morning her father found her covered with an eruption, and dreading scarlatina, he instantly removed the other children ; he sent one to a house in the neighbourhood, and two under the care of a servant to Dublin ; within a week the child in the country was sent home labouring under the disease. The father allowed the remaining two children to continue in Dublin for nine weeks, and then supposing all danger of infection had passed away, they were brought home on a Wednesday. On the following Saturday evening, the malady presented itself in one of them, next day in the other, and in three days afterwards the servant became affected. The further investigation of this subject would more fully prove the truth of the position, that children have as fair a chance of escape from the disease, if left at home, all communication with the sick room being cut off, as they have by removal ; in fact, some will resist tile contagion, though fully exposed to its influence, while the most trifling, and perhaps unnoticed communication, will produce the malady in others; besides, it is questionable, that the first child attacked may not, during the latent period of the disease, infect individuals.

Although it is difficult to overcome popular prejudices, yet, I feel confident, that were these facts better understood, the system of removal, which affords no positive protectiofi, and tends to the dissemination of disease, would be discontinued ; and I may fnrther add, that even in the existing feeling of the public mind, could we offer the choice, when scarlatina ap- pears in a family, of total escape to the remaining members, or subjection to a mild form of the disease, the latter would be preferred as in a great degree securing a ftlture immunity. But it may be asked, do we possess the means of arresting the progress of scarlatina in families, or of modifying its form? both powers have been ascribed by some German physicians to

48 Dr. Fitzpatriek's Observations on Scarlat ina.

belladonna; not having tested the value of this drug in such cases, I feel diffidence in cleciding against its utility ; however, the very minute doses, in which it has been administered, must render us sceptical as to its possessing this virtue, and may even lead some to agree with Dr. James Johnson, in ranking it among the fooleries of Homoeopathy. Even admitting that belladonna possesses anti-scarlatinous properties, it should be administered in appropriate doses, and tile continued exhibition of so powerful an agent to children, is not free from hazard. Being therefore prejudiced against its use, I adopted other means, not as prophylactic, but with the hope of modifying the character of the disease, which will be best explained btea brief narration of the following cases. In the latter end.,of May, I attended a child iu a severe form of scarlatina anginosa, wt~ich terminated favourably ; at the period of the child's con- valescence, her aunt who had been the constant attendant during her illness, was one evening seized with rigors, prostration of strength, headach, and sore throat. Supposing she had caught cold in the discharge of duties as a nursetender to her niece, she bathed her feet and retired to bed at an early hour, having previously taken some purgative medicine; she passed a restless night, suffering from severe headach, nausea, and a most distressingTeeling of fulness, with a burning sensation and soreness in her throat ; her stomach sickened, and in the course of the night she threw off a large quantity of bilious fluid. I visited her early the next day, and found her complaining of severe headach, and great soreness ofthe throat; the whole face and neck presented a dark red colour, but without any efflorescence; the conjunctiva was injected, and the submaxillary glands tumid and painful to the touch ; the skin was remarkably hot and dry ; pulse 120. On examination, the tonsils and pharynx presented a dark-red colour, with some tumefaction, and were partly covered with a viscid mucous secretion, patches of coagulahle lymph being here and there observable. The vomiting had ceased, and the bowels were


tree. I may here observe that this lady was about the middle period of life, of rather a delicate constitution, and peculiarly susceptible to the influence of mercury, a circumstance which at the moment escaped my recollection. I directed twelve leeches to be applied to the throat, and ordered a pill containing two grains of calomel, and a grain and a half of James' powder, to be taken every four hours ; a pouhiee to be applied round the throat after the removal of the leeches, and warm barley water to be used occasionally as a gargle. I visited my patient the following morning, and was agreeably surprised on entering the room, to find her smiling, when she exclaimed tt: T had cured her throat, but that her teeth were loose, and hel gums sore ; on approaching the bed, I perceived the mercurial foetor, and examination proved that she was fully under the influence of the medicine. She stated, that tile head- acb was considerably alleviated, and the uneasy sensation in the throat completely removed; the appearance of this part was much improved; it had lost the dark-reddish hue and the exudation of lymph was considerably diminished ; the fever was also alleviated : she had taken four of the pills. I directed a rhubarb draught to be taken immediately, and during the day she got minute doses of tartar emetic solution, and a gargle containing borax was used occasionally. It is unnecessary to detail the further history of this case; from this period, matters went on favourably, and in about eight days she was convalescent, no efflorescence having appeared on the skin. On the 18th of June, I was requested to see a child about five years' old, labouring under scarlatina; on paying my visit, I found a remarkably fine boy lying in a comatose state, with an acrid discharge from the nostrils ; great tumefaction of the fauces, and a partial livid eruption on the surface. I ascertained that he had been ill only three days, previous to which time he enjoyed the most perfect health. Before I saw him, the throat had been leeched, and other remedies adopted, but without the slightest effect in mitigating the disease. I had no

VOL. xxl. No. 61. n


hesitation in pronouncing tile case as hopeless; a prognosis which was verified, as the child died in the course of the night. After leaving the patient~ and while passing through another room, the child's mother, who exhibited the deepest distress of mind, pointing to two other children, exclaimed, that they would be also lost, and in an imploring manner asked, could nothing be done to save them from the disease ? This question influenced me to make inquiry as to the number ofthe family; I ascertained that it consisted o['the man and his wife, and three children, including the one in scarlatina, and that they occupied two rooms. I examined the children, one a boy aged seven, the other a girl about three years' old; both appeared in excellent health, and did not exhibit the slightest trace of the scrofulous diathesis ; on the contrary, they were robust, well formed, and healthy looking children. Chiefly with the object of allaying the mother's anxiety for the time, I ordered for each a powder consisting of mercury with chalk, and rhubarb. I confess, this poor woman's question humiliated me. I saw one child irretrievably lost, and two others probably on the verge of destruction, and yet, what means could I suggest to avert the impending danger ? Was I to wait until the malady exhibited itself', and then probably find remedies ineffectual? These important questions engaged my attention. I was not aware &any remedy having been suggested under such circumstances, with the exception of belladonna, and in this I had no confidence, particularly as I considered it highly probable, that, from the necessary exposure to contagion, the children were, at the time, under the influence of the miasma. The extraordinary effect of rapid mercurial action, in modifying the character of the disease, as exhibited in the case of the lady already already alluded to, influenced me in concluding, that the exhibition of mercury in daily alterative doses, prior to the esta- blishment of the febrile stage, would place the children in the most favourable position for the production of the full effect of this remedy, at a very early period of the disease, should the character of the inflammatory symptoms require such a proceed-


ing. From the high repute which the mineral acids possess in the treatment of scarlatina, I also determined on giving muriatie acid, having, besides, in view its tonic effect. I considered, that by cautious observation of the ei~bcts of the mercury, and by taking care that it was not given to such an extent as to produce its usual marked effects on the system, no possible injury could accrue to the child if he escaped scarlatina ; while if it became developed he would not be in a more unfavourable state for the resistance of its influence. On the contrary, it might reasonably be supposed, that even if the efIbct of the remedies was merely the promotion of the natural functions of the alimentary canal ; such a result would be more beneficial than otherwise ; but another important consequence might tbllow, namely, the production of an altered condition of the individual's constitution, which would modify the character of the disease, it being remarkable, that the most apparently strong natural constitution~ so far from offering due resistance to scarlatina, serves rather as an indication of its probable severity. My observation leads to the conclusion, that children of a delicate and even scrofulous constitution, frequently present the disease in a milder form, and certainly the most extraordinary recoveries from the greatest danger that I witnessed, occurred in individuals of this class. Influenced by these considerations, I visited the children on the following day (June 19th), and ordered a mixture containing dilute muriatic acid, syrup, mucil. of gmn arabic and water, the dose being so regulated, that the eldest child took five drops of the acid three times a day, and the younger one a proportionate dose. I also directed three grains of blue pill for the boy, and half that quantity for his sister to be taken at bed-hour, and advised that they should be allowed to take their usual exercise, and that their diet should be light and nutritious.

June 20th. The children took the medicine yesterday ; no visible effect was produced, they appear quite well. I ordered that each should be placed in an artificial salt water bath for five minntes previous to going to bed. The medicines to be continued.

52 Dr. Fitzpatrick's Observations on Scarlat ina.

June 21st. The boy looks paler to-day, but makes no complaint; he slept well, and took his breakfast with an appetite. On examining his tongue, the papillae seem rather elevated, and a very slight hyperemia is observable over the internal fauces ; the other child is in the same state as yesterday.

22rd, After my visit yesterday, tile boy exhibited appearances of lassitude, and was chilly ; he got some sleep in tile early part of the night, but afterwards became hot and restless, and complained of headach and sore throat. 1 saw him at nine A. M. The report is, the fever is rather severe; the palate, tonsils, and uvula, red and swollen. He complains of difficulty of deglutition and of nausea; pulse 120 ; skin hot and dry; the submaxillary glands are slightly enlarged; tongue white and moist ; bowels confined since yesterday. I ordered a powder containing a grain of calomel and a grain of James' powder, to be given every four hours, three leeches to be applied to tile neck below each ear, and a gargle of barley water and honey to be used occasionally.

23rd. He vomited the first, but retained the subsequent powders; the bowels were acted on yesterday evening ; he had some sleep in the night, and feels better to-day; a normal eruption is observed on the surface; the throat presents the appearance of slight superficial ulceration, but is neither so red nor swollen as yesterday ; the general uneasiness is less; the pulse l l0 . I directed the throat to be touched by means of a camel's hair brush, with a linctus consisting of solution of chloride of lime and honey ; a purgative injection to be administered, and the face, neck, chest, and extremities to be sponged twice a day with warm vinegar and water. The following mixture was taken :

1~ Aquae Acet. Ammon. 5 ij. Syrup. Aurant. 5ij. Liq. Antim. Tart. 5ij. Aquae Ros~e ~ iiiss.

M. Smnat Coch. amp. tertia qufique hora.


The further progress of this ease presented no peculiarity : no bad symptoms occurred, and the child eventually recovered.

The younger child was attacked on the morning of the 23rd ; the symptoms bore a resemblance to those of her brother, but in a milder degree ; the treatment was consequently less ener- getic, leeches not being required. In neither ease was it necessary to continue tile calomel after the first twenty-four hours, nor was there any evidence of its having affected the system. In the consideration of the result of treatment in the foregoing eases, it may be questioned, whether they might not have proved as favourable without any preparatory treatment, it being occasionally observed, that variations in the character of the disease occur in its progress through families. While we are ignorant of tile cause of such variations, it is quite idle to attempt the solution of this question. Although it is admitted, that they are occasionally observed, yet, medical authorities of great eminence are opposed to their general probability. Dr. Willan states, " tha t when scarlatina spread widely, it exhibited, in the different persons aiTeeted, every variety and gradation of appearance, from the slightest to the most malignant form of the disease, yet, during its diffusion through some large families and schools, he had seen it uniformly retain the series of symptoms which occurred in the first patient with nearly the same degree of fe~er."

Dr. Graves also observes, " tha t when one member of a family died, there was always much reason to fear for the others when attacked."

One of the greatest obstacles against ttle adoption of the course I pursued, is, the repugnance which must be felt against submitting a child in apparent good health to, medical treatment; but when it is recollected, that this proceeding is only recommended, where the first case occurring in a family has presented a severe or malignant form of the disease, and that its adoption is not likely to be productive &injury, I cannot think there exists any valid objection against its application. But it


may be inquired, for what period are the remedies to be continued ? I have before remarked, that the operation of the mercury should be carefully watched, and that it ought not to be continued so as to affect the mouth, or produce ptyallsm ; in fact, much must depend on the judgment of the practitioner, in determining on the time for commencing its administration, and the period of its continuance. On general principles I would say, that the latter should not exceed six days, supposing no perceptible influence was produced, nor had scarlatina exhibited itself, and then a longer interval might be allowed to pass between each dose, thus gaining time, and yet, not completely laying aside the medicine. An average taken from various sources leads to the conclusion, that the specific contagion of scarlatina has a latent period from four to seven days. I shall select one instance, furnished to me by a friend. A gentleman residing in this city had a family of three remarkably healthy children; on the 16th of June, 1841, one of them, a boy aged three years, was attacked with scarlatina ; on the 18th the disease presented a malignant form, and he died on the 22nd. His sister, aged eleven, was seized with the malady on tile 23rd, and died on the 2Sth ; and the remaining child became ill on the 25th, and died on the ~gth. Now, admitting for a moment the efficacy of any plan of preparatory treatment, it is plain, that in cases exactly similar to those, the third day of the first child's illness, when its malignancy was evident, should be the period of commencing the remedies ; thus, giving in one instance, five, and in the second, seven days, for their operation previous to the febrile stage. It may be recollected, that in one of the children whom I treated, I observed, several hours before the febrile stage, an elevation of the papillae of the tongue, and hyperemla of the fauces ; such evidence was valuable, as being of recent origin, and unaccompanied by gastro-intestinal derangement. I find, in a paper published by Dr. Sims, in the Memoirs of the Medical Society of London, the following observations which bear on this point :


" The irritation of the throat will be found to commence very early, if it be minutely inspected, for though no complaint is usually made of uneasiness in the throat previous to the febrile symptoms, yet, ifit be closely examined, the velum pendulum palati will be found redder than natural, and sometimes the uvula will appear to be a little inflamed, the pulse being at this time not more than slightly disturbed or flurried, rather than feverish." It is almost unnecessary to remark, that the development of such symptoms would, in a case where doubt might exist as to the approach of the disease, decide the pro- priety of pursuing the course of treatment.

In approaching the inquiry as to the efficacy of tiffs mode of treatment, I feel, that in determining on this point, more extended observation is required, and being satisfied that the opportunities afforded to one individual would not suffice to test its value, I preferred bringing this communication in a crude form under the notice of the Obstetrical Society. I do not ad- vocate the doctrine that mercury is a specific in scarlatina, for tile simple reason, that I have witnessed cases in which ptyalism was established, eventually proving fatal, but it was at an advanced period of the disease, when the patients became mercu- rialized, and even then, a temporary improvement was produced, followed, however, by an aggravated fatal termination. I have before remarked, that one object I had in view in administering mercury in alterative doses previous to the febrile stage, was to placethe patient in that position whereby, if the character of the inflammation demanded it, I could with greater probability produce a rapid mercurial effect, with tlle hope of arresting the inj~ammatory action in its progress, an object which, under or- dinary circumstances, can scarcely be produced, if the febrile stage hasexisted for any lengthened period, because this state of the system bears an analogy to bad typhoid feve5 in presenting the greatest difficulty of bringing the constitution under the influence of mercury ; indeed, the attempt to induce mercurial action in scarlatina after the febrile stage has been thlly de-


veloped, and the local inflammation has arrived at a degree of intensity, is rather injurious than beneficial. I shall not stop here to inquire whether the first link in the chain of morbid action is connected with the great nervous eentres, or the mucous membrane, but I feel satisfied, that the early arrest of inflammation in the mucous membrane is most desirable; and we have positive evidence that such an effect can be produced by creating a sudden new impression on the part, even though the irritated or inflammatory state may arise from a specific poison ; this difference being applicable to scarlatina, that mere local treatment fails, unless accompanied by remedies which produce an effect on the general constitution. At all events, apart from the ad- vocacy of any peculiar plan of treatment, I am fully persuaded of the value of Doctor Armstrong's opinion : he says, " i t should be repeated again and again, that most of the rudiments of danger in fevers are laid in the first stage of oppression, and if we can alleviate the symptoms of that stage, we thereby usually insure a most favourable issue." The investigation of the proper mode and time of administering mercury in different diseases has engaged the attention of Dr. O'Beirne and other eminent observers in this city, and is a subject full of interest.

The principle has been established, that in diseases in which mercury was previously considered injurious, an early stage exists, in which it is of the most marked utility, that stage passed, its exhibition is attended with doubtful efficacy, ifnot positive injury. Is this doctrine applicable to scarlatina ? In concluding this communication, I feel, that, even should future experience prove the efficacy of the plan of treatment I propose, circumstances must tend to limit the field of its utility, among which may be enumerated, first, an aggravated variation of the disease occurring in a family ; and secondly, the rapidity with which one child may be attacked after another ; still it should be recollected that these are exceptions to the general rule, and acknowledging, as we must, that the means hitherto adopted to counteract this dreadful malady have, in too many

Dr. Hocken on the Actions of the Orbicularis Palpebrarum. 57

instances, proved unavailing, it becomes an imperative duty to endeavour to remove that opprobrium which this epidemic has affixed to the science of medicine.

AnT. I i I . - - Observations on the separate and combined ./lctions of the Orbicularis Palpebrarum. By EDWAm) ttOCK~, M.D. , M. R. C. S . L

DI~FEaENT observers, at different periods, in the extensive field of physiology, have taken different views regarding the action of the orbicularis palpebrarum, as also of the other muscles of the eye and its appendages : one party assert its strictly voluntary action, and again, another as loudly claim for it the title of a sphincter. The author will endeavour to show that its single and combined actions are peculiar, and that it may or may not be linked by unity of effort with other muscles or sets of muscles, according to the condition of the lids and the state of the feelings or emotions. Every muscle in the body possesses its proper antagonist, which it either controls, modifies, or limits in its sphere and manner of action ; in the instance before us, the levator palpebrm holds this relation to the orbicularis. These two muscles possess an alternate and peculiar action: the relaxation of one is invariably, during health, followed by the contraction Of the other ; which seems to be voluntary, or nearly so, as we are always conscious of the act. I will now mention the exceptions. There is a medimn at which thelids are uninfluenced by other muscles, in which they hold a relation to each other occasioned by the mere influence of gravity ; in this state, the upper lids fall over the globe in its upper two- thirds, covering the front of the cornea, and hiding the iris, so that nothing but the eonjunctiva, and subjacent tunica albuginea, " the white of the eye," are visible, constituting the lower third. The opportunities of seeing this absence &contraction in either muscle are comparatively few ; some people during sleep thus expose their eyes, but this is rare. When, however, the

V O L . XXI. NO. ( J l . I

Observations on scarlatina

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