ON
SCARLATINA,
LETTER  ADDRESSED  TO  HIS  SON
WILLIAM INGALLS,  M.  D
        M. M. S. Soc, etc.
SECOND EDITION
WITH AN APPE
             BOSTON:
B.  H. GREENE, 138 WASHINGTON STREET
               1839. 

   Entered according to Act of Congress, in the year 1839,
             By  William   Inoalls,
in  the  Clerk's  Office  of the  District  Court of  Massachusetts
Manning  and  Fisher, Printers, 8 Congress  Street. 
LETTER.
      To  WILLIAM   INGALLS,   Jr.,  M.D.

                                    Princeton, Dec. 19, 1836.
Mr  Dear Doctor,
     It may not be unacceptable to you to receive a narrative of
three cases of Scarlatina,* which have recently occurred in our
family.   Alice, John, and a child of one of our domestics, were
attacked  on three successive Thursdays.
                           Your affectionate father,
                                  WILLIAM INGALLS.
          ANGINA SINE EFFLORESCENTIA.j

  Your sister Alice,  aged eight years, was seized in the morn-
ing,  October  27th,  1836.   The  disease was  ushered in by
cephalalgia;  anorexia;  soreness  of the  throat;  diarrhoea;
nausea ;  great prostration  of strength ; fever.   The  relax and
nausea continuing through  the  greater part  of the day, in the
evening an emetic [R. vini ipecacuanhae, § ss.]  was  adminis-
tered, which had  the  effect of  evacuating the digestive  canal
thoroughly ;  the  medicine continuing  to operate during the
night.
   October 28th.   Cephalalgia, nausea and diarrhoea had ceased;
deglutition painful ;  [on inspection an erythematic  blush was
conspicuous on the right and posterior part of the roof of the
mouth, extending over the region of the tonsil of the same side;]
* See Appendix. Note A.                   t Note C. 
4
 debility ; fever ;  anorexia ; thirst ;  cough ; itching ;  subsultus
 tendinum.   For the inflammation of the fauces, were  prescrib-
 ed five drops of spiritus ammoniae,  with as much tepid water as
 would  render  the  mixture slightly pungent;  repeated in  the
 course of the day; a tea  spoonful  at  a time, of  a solution of
 supercarbonas  potassae, to  be  given   and  swallowed slowly,
 to serve as a lotion to the inflamed or ulcerated throat.   Fully
 convinced  gargling tends  to produce such  irritation and  agita-
 tion, in the  organs concerned  in deglutition,  as greatly to in-
 crease inflammatory affections  of the fauces, I have for a long
 time discontinued its use.*
   In severe cases,  the inhalation of steam is exceedingly bene-
 ficial.  For this purpose,  let a bowl filled with the infusion of
 anthemis  nobilis and acidum acetosum, in  equal  parts,  made
 hot; when, by means  of a funnel made of  paper,  inverted
 and  applied  over  the  surface, and  adjusted to the  brim of the
 vessel,  the  vapor arising from the compound, of such a temper-
 ature as may be thought advisable,  can  be directed very effec-
 tually to the  part  inflamed.   It requires very little  dexterity
 and  care to render the process for general use equal, if not pre-
 ferable, to Mudge's Inhaler, f
   With regard to  diet,  the patient had so great  aversion to gru-
 els,  and indeed to almost every kind of  food, she was  indulged
 in her desire for water,  which was  given her tepid, sometimes
 with, but generally without  being  sugared;  tea,  allowed night
 and morning with sugar  and a small quantity of cream, of which
 she  usually, from  choice, drank sparingly; the  tea and tepid
 water constituted the only  articles of nourishment,  till she  be-
 came convalescent.
   Oct.  29th.  Pain  in  deglutition  relieved; debility;  cough;
 anorexia;  thirst; itching  troublesome;  heat of the surface great;
subsultus  tendinum ; startings ; jactitation ;  sleeplessness ;  no
erubescence;  a papular  eruption  beneath the cuticle distinctly
felt;  the papula;  seemed more  solid and resisting,  and the epi-
dermis more  dense and rigid  than  usual; in scratching, white
furrows, as if made on the surface overspread with mealy des-
quamation,  became  perceptible;  this  appearance,  the  papula;
* Note B.
t Note N. 
D
and  the  supposed  thickened  state of the epidermis, were the
only indications of  the cutaneous membrane being in an altered
condition.   To these phenomena my attention was attracted by
the patient herself.*
   With the view of eliciting erubescence, almost always a con-
comitant of scarlatina, and moderating the violence of the symp-
toms, her  hands were  immersed  twice in warm water, and a
gentle emetic  given with the  same intention:  these remedies,
however, were unavailing.
   To appease  the  cough,  a  few  drops  of the camphorated
tincture  of opium  were given, which, perhaps, owing to the
smallness of the doses, were  attended with little or no  benefit.
Opium and its  preparations possess, undoubtedly, the faculty of
communicating  preternatural  activity and force to the vascular
system;  exciting and increasing animal heat;  and irritating and
inflaming the skin.   Hence,  in exanthemata, the utility  of opi-
ates is, at  least, questionable.  From your sister's repugnance
to mucilaginous drinks and expectorants,  they  were reluctantly
omitted.   The recumbent posture, the mastication  and  the
swallowing of  refined sugar, were the only curative  means em-
ployed to mitigate the cough.
   Oct. 30th.   All  the symptoms enumerated as existing on the
29th were exasperated;  the subsultus tendinum, startings, jacti-
tations, itching and  superficial  heat  were carried to a formidable
height,  and  excited  the most alarming apprehensions  of the
issue; the  itching  was  so  intolerable  as  to require incessant
"rubbing  with the hand," to obtain  momentary  relief from
this troublesome symptom; the superficial heat was also insuf-
ferable;  every  attempt  to keep  the patient covered with bed-
clothes was repulsed; and, on  account of extreme suffering from
heat, we were  induced to comply with her earnest solicitation of
being clad as thinly  as possible.  To obviate any injurious effects
from exposure to the impression of cold, the temperature of the
room was preserved at as higfi elevation as possible.  There was
still no  cutaneous  erubescence,  but the color of  the  mucous
membrane of the lips and mouth was a very deep red.   Magne-
sia calcinata and vinum tartratis antimonii in small doses ;  these
* Note C. 
c
 articles, together with  the internal use, as mentioned, of tepid
 water,  exposure to air comparatively cool,* frictions to various
 parts of the surface to allay in some measure the irritation from
 excessive  itching, were the only remedies employed.  The
 disease bad now arrived at its acme.
   Oct. 3\st.   After the most intense distress for twenty-four
 hours, notwithstanding  the cough grew worse, a  profuse ptya-
 lism supervened, and extreme prostration of strength continued,
 an abatement of the lesion of innervation, though scarcely per-
 ceptible, afforded some slight ground of encouragement that the
 crisis might prove favorable.   [The physic procured two of-
 fensive discharges.]
   *Yov.  1st.   Last night the itching had remitted so  much as,
 at times, to allow her to take  some  imperfect repose ;  cough
 harassing ;   ptyalism  profuse ;   prostration of strength great ;
 ichorous defluxion from the head excoriating the portion of the
 pituitary membrane of the anterior nostrils and  upper lip.  For
 the excoriation,  cold cream was applied ;  for  the ptyalism,
 divided doses of magnesia calcinata.   After much persuasion a
 few table spoonfuls of cracker gruel were taken.
   Nov. 2d.  With the  exception of cough, ptyalism and de-
 bility,  the  prospect of  returning health  was  flattering ;  the
 patient began to take nourishment more freely.
   Nov. 3d.  From  this period convalescence was slowly but
 regularly progressive ; the symptoms daily  becoming milder,
 till health was ultimately  re-established.
   Desquamation, especially in the hands  and feet, took place,
 and the loss of  a finger nail consecutive to a  cutaneous whitlow
which surrounded it;  the epithelium of the  mucous  membrane
of the lips was detached in shreds and not in scales.f
   The ptyalism began  to decline in about six  days;  to me, in
this case, the cause  of  the complaint is  unknown.   Cases  of
idiopathic ptyalism have occasionally come under  my care from
the commencement of my practice ; some having  all  the char-

  * In Princeton, it is colder than it is in the same latitude on the seaboard
and it was with difficulty we  could elevate the temperature of the room  to
such a degree as the case seemed to require.
  t Note D. 
7
acters of a mercurial salivation.   This circumstance has led me
to conjecture it may have been the result of mercury adminis-
tered at a former period,  and having lain dormant, until some
change in the system have had the effect  of bringing into action
its properties of ulcerating the gums and mucous membrane of
the cheeks and tongue, and consequently increasing the secre-
tion of saliva.   On this subject, however,  I  have formed no
definite opinion.
   In this case  of  your sister, and also in that  of  your brother,
an account of which follows it, I would remark, the ptyalism was
not attended with the swelling and ulceration of the tongue and
gums, nor the offensive foetor peculiar to mercurial salivation.
   The cough and excoriations, which lasted three weeks, were
the last affections which  disappeared.   For the  cough, which
was very severe, laxatives were the most efficacious remedy ;
other medicines serving only as  palliatives.  The excoriations,
as mentioned above, were treated with cold cream, the object
of which was to sheath the parts from the acrimony of the de-
fluxion from the nasal  fossae.  Before the cough  ceased, the
ichorous humor, alluded to above, was converted into a profuse
excretion of a mild mucous.
   There appears to be a solecism in saying scarlatina can exist
without efflorescence ;  but that  your sister has had  the exan-
them, known by this appellation, and that it will be a preserva-
tion against a future attack, there can be  no reasonable doubt.*
               SCARLATINA ANGINOSA.

  November 3d.   John, six years of age in January next, was
taken with Scarlatina Anginosa in the  evening ;  complain-
ed of nausea ; cephalalgia ; soreness of the throat ; took some
warm water sweetened with sugar baker's treacle, but soon re-
jected it without any amelioration of the symptoms ;  an emetic
[R. vini ipecacuanha; 5 ij] was given, which had a favorable
* Note C. 
s
operation ;  besides evacuating the contents of the  stomach, it
was followed by^ several dejections.
  Nov. Alh.  . Passed a tolerable night; soreness of the throat;
cephalalgia  ;  cough ; anorexia ; fever ; on the parts of the body
covered with clothes  an eruption, which,  in the course of  the
day, spread over the whole cutaneous surface ; in the night  de-
lirium supervened.   [His diet consisted of sugar baker's trea-
cle  partially candied ; and  treacle  and tepid water, till he  be-
came convalescent.   Refined sugar was  prescribed  for  the
cough ;  but  he  objected  to  it  because  it "scratched  his
throat."]
  I remained in the room almost the whole time during the sick-
ness of  your brother.   In the course of the night, viz. of  the
4th, there was observed an expression of  uneasiness of which
it is difficult to give a distinct idea.   Besides the throbbing of
the  carotid arteries, which is very obvious in  scarlatina angi-
nosa, and by some is deemed to be a very prominent symptom ;
the  irregularity of inspirations and expirations ;  the rapid con-
tractions and relaxations of the muscles of the larynx, and con-
sequently the  correspondingly rapid  descent  and ascent of  this
organ ;  the muscles attached  to the os hyoides and the  anterior
portion  of the os maxillare inferius ; also, the muscles on which
the  diversified motions of the face, eyelids, eyeballs, and the short
muscles of the head depend, being also strongly agitated, caused
a disordered action in the  neck and  throat,  and gave a cast to
the  countenance,  indicating there  existed no ordinary irritation
in the system.
  That the actions of the muscles concerned in deglutition are
associated with those just enumerated, is confirmed by anatomy
and physiology;  so that the tumultuary motions of the muscles of
the  pharynx, proceeding from the inflamed and thickened state of
the  mucous membrane of  this organ, produce,  by abortive ef-
forts in  swallowing, consentaneous actions in those belonging to
the  larynx, os hyoides,  the anterior part of the  lower jaw, the
lips, eyelids  and  eyeballs.    Hence, by the disturbed  state of
these organs, we have a clue to direct us to the  seat of the  dis-
ease.  These phenomena,  to which may be added a very limit-
ed rolling  motion of the body from side to side, together with 
9
an inarticulate,  feeble and  querulous  utterance,  expressive of
disquietness and  exhaustion, made  me  apprehensive.a change
which might prove fatal was about to take place.  In this emer-
gency the hands of the  patient, who was growing worse every
moment, were immersed in warm water ; the application of this
remedy, and a draught of warm water sweetened, had the effect
of removing these formidable symptoms, and  afterwards those
symptoms alone belonging to severe cases remained to be en-
countered.
   The  only explanation of the cause of the above catalogue of
symptoms is, it was the consequence of a very peculiar or pel-
licular  inflammation in  the mucous  membrane of the pharynx,
which may terminate in  the production of a membraniform exu-
dation or pellicle.   With  regard to this peculiar  membraniform
excretion, or pellicle, it not only may line  the pharynx, which,
in this  disease,  is its  appropriate seat,  but it may  spread out
every way,  either upon the  surface of  the schneiderian mem-
brane,  the  mucous membrane of  the eustachian tube, oesopha-
gus  or  larynx.*    The symptoms, of course,  are modified
according to the function of the organ to which the  preternatu-
ral membrane may be attached.

   Acidum  Hydrochloricum.  For membranous  excretions
of the  mucous  membrane of the pharynx and  fauces, this acid
is recommended  in the form of a gargle.   It  is a very active,
and, no  doubt, for the  removal of pellicular exudation, a very
efficacious remedy.   I  formerly employed  it  according  to the
ensuing formulae :—
             R.  acidi hydrochlorici gutt.   XL.
                 aq.     .....§ vii.
                 mel......5 !•
                 misce, fiat gargarisma,
for inflammations and  ulcerations of the throat.
   With a table-spoonful of the above compound, I directed the
throat to be gargled four times a day.   Sometimes the applica-
tion was attended with  the  best  effect, at other times it pro-

       * In this event, symptoms resembling those of croup occur.
                 2 
10
duced too great irritation.   Not  being  able  with certainty to
apportion it so as to relieve the disordered  state of the throat,
and, convinced the acid was hurtful to the enamel of the  teeth,
I discontinued its use.
   But I have long been in the habit of applying the hydrochlo-
ric acid  in its concentrated state  to  ulcerations of the  throat.
To effect this object, a narrow strip  of sheet lint or  linen is
taken and wound two or three times around  the end of a probe,
quill, or the handle of a metallic pen,  so  that the  strip may pro-
ject beyond it ;  to be secured in the  way it may be most con-
venient.   After  covering  the  point,  instead of tying the strip,
a few casts may  be made upwards, until  it can be grasped with
the fingers ;  then moistening the end with  hydrochloric acid,
and pressing down the tongue with a  spatula or the handle of  a
spoon, it can with  ease be applied to the  disordered  part or
parts.   This  temporary swab,  which resembles the  one used
by nurses particularly for  the  cancrum oris, is proposed ; be-
cause every time the ulcer is to be retouched, the strip should
be renewed.*
   The acid should not be applied but once a day, and  should
be succeeded  by soothing  remedies.
   This course will very soon  make a beneficial change in the
ulcers.
   When circumstances are such as to make it proper to  adopt
either  method, it must be left  with you  to  select the one you
prefer.
   Nov. 5th.   Cephalalgia had ceased ; anorexia  ; cough more
severe ;  debility ;  fever ;  the  efflorescence  of a  deep  scarlet
color ; the whole  surface  was so exceedingly sore, change of
posture was nearly insupportable.  Owing probably to  immer-
sion  in warm water, the hands were not only exquisitely tender,
he being unable  to bear the weight of the bed  clothes, but en-
tirely impotent;  and continued so,  till  after  the  disease had
turned ;  sleeplessness ; delirium through the night ; none dur-
ing the day.
   Nov. 6th.   Cough ; anorexia; thirst ;  debility ; fever ; ten-
derness of the surface and hands ; efflorescence of a very deep

                         * Note E. 
11
or dark  red ;  disease at its  height;  sleeplessness ;  delirium
through the night ;  none during the day.
   Nov. 7th.   Anorexia ;  cough ;  fever ;  soreness of the sur-
face and hands  ; ptyalism ; restlessness ; itching ; in the course
of the day imagined the brightness of the efflorescence had in a
very inconsiderable degree diminished on the face, neck and on
the  anterior region of the  thorax,  affording a slight ground for
the  presumption,  the disease had begun  to "turn;" delirium
during the night ; none during the day.
   Nov. 8th.   With  the exception of cough ; ptyalism ;  itch-
ing ;  derluxion of ichorous matter from the  head, excoriating
the nostrils,  upper  lips  and  corners of  the mouth, his symp-
toms were milder ;  the eruption in  the face, neck and breast, as
far down as the epigastric region, had in some considerable de-
gree  faded ; patient  evidently stronger ; but still languid and
irritable, and continued so  for several days, till by the operation
of a  portion of physic the alvine excretions, unquestionably the
cause of this state of the system, were removed.
   From this time his restoration to  health was  daily progres-
sive.  The cough and excoriations were the last affections that
disappeared.   For the cough,  laxatives were the most effica-
cious remedy: the  other  medicines serving  merely as pallia-
tives.   The excoriated  parts were anointed with cold  cream,
for the  purpose of  obtunding the acrimonious discharge  from
the nostrils, and with relief.
                SCARLATINA  BENIGNA.

  Nov. \0th.   Sarah Jane, daughter of one of our domestics,
3 years of age, was seized with Scarlatina Benigna in the even-
ing ; superficial heat great ; restlessness.
  Nov.  Uth.   Cephalalgia ; thirst ;  fever ;  cough ;  soreness
of the  throat; eruption extending over  the  whole cutaneous
surface ; an emetic ; [R. vini Ipecacuhanae 5 i-]  a portion of
castor  oil ; both operated favorably ;  a small dose of antimony 
\2
daily ; regimen anti-phlogistic ; the  eruption turned  on  the
fourth day.
   The child was confined to her bed but two days, whereas it
was from six to eight days before Alice  and John were able to
sit up for  even a short time ; and  such  was the  prostration cf
strength when  they shewed  a disposition to get  up, it became
necessary  to lift them  out of bed, and hold them in the lap.  In
the three  cases, the usual precursory symptoms were of very
short continuance.   The recovery  of the two first was gradual;
and it was several weeks after the  eruption  disappeared before
their health was reinstated.   In  the child, the manifestations of
debility were very slight.   All  three of the patients had been
vaccinated ; Alice and Sarah had had the varicella ; John had
never been exposed to the varicellous  infection, but had  re-
cently labored  under the disease.   I shall hereafter give you an
account of the  case.  The three  have had the whooping cough.
                       SEQUELS.

   Defluxion from the head, accompanied with cough; excoria-
 tions of the anterior nostrils, upper lip, and  corners  of the
 mouth; great tenderness of the feet,  occasioned by the absence
 of the cuticle  which had  exfoliated in  flakes,  were the only
 complaints consecutive to scarlatina  under which your brother
 and sister labored; and while  these  affections continued, their
 sufferings were by no means inconsiderable.   The cough being
 altogether adventitious, and  not by any means necessarily con-
 nected with the exanthem of which we are treating, aggravated
 the sufferings of the patients.  There are, however, other se-
 quelae, to which it may not be uninteresting or uninstructive to
 advert.  •

   Sloughing of  a  Portion of the Velum  Palati and
 Uvula.   It has been my habit, as soon as a patient has so far
recovered, as,  in my  opinion,  not to require my services any 
13
farther, to discontinue my visits; and, in this way, many seque-
la; may have  taken  place  without  my  knowledge.  This was
particularly the case with  a gentleman whose family I  have at-
tended a great many years.   In  the  course of conversation he
informed me I had attended him with the "canker rash,"  the
term made use of in this city, and is synonymous with  scarlati-
na; and it was in consequence of the sore throat that he  had lost
the natural intonations of his voice.  His articulation is  nasal,
harsh, and unpleasant.*
   [Since writing the above, I have seen the patient last refer-
red to, and was told by him he had the  distemper in the month
of June, 1801;  and that he "turned black" at the time.]

   Deafness.  In some  instances the inflammation pervades
the eustachian tube, as well as the nasal fossae, producing tem-
porary deafness.  In some instances it  is so violent as to de-
stroy the membrana tympani and the periosteum covering the
flooring of the  tympanum, causing permanent  deafness; and a
perpetual discharge of  pus, either  through  the meatus audito-
rius outwards, or  through the eustachian  tube into the fauces.
 Sometimes  the organs of hearing are destroyed on one side only.
One of my patients was permanently deaf in both ears.
   [It was by accident,  and not until some  years after the re-
 covery of this patient,  that I knew he had  been deaf;  having
 met his mother, she requested me to examine his ears, which I
 did, and found he was permanently deaf in both.   He was young
 at the time of the  disease, and in consequence of  the  deafness
 became dumb, and afterwards an inmate of the Asylum for the
 Deaf and Dumb, at Hartford.]
   The destruction of the membrana tympani,  and the denuda-
 tion of the petrous or rocky flooring of the tympanum, may be
 easily ascertained by striking against it with a probe.

   Phlegmonous  Tumors.  During the prevalence of epidem-
 ics, instances of phlegmonous tumors, originating in the cellular
 tissue  surrounding the  parotid,  submaxillary  and sublingual
* See note F. 
14
glands, have happened in my practice ; though considerable ap-
prehensions with regard  to the event  had been entertained, their
termination, except in one instance, has been favorable.

   Treatment.   Having found discutient embrocations imped-
ed rather than promoted resolution, they were relinquished alto-
gether;  that fomentations and emollient cataplasms applied early
to the phlegmon tended  to augment  its bulk and to retard sup-
puration, they were deferred till fluctuation became distinctly
perceptible, when their  application generally proved innocuous;
and that, no advantage  having  been derived from keeping the
affected parts warm by bandages, but, on the contrary,  believ-
ing them to  be injurious, directions were given to leave them
uncovered, till the  signs of maturation became evident.   The
only  precaution necessary to be observed, was to guard against
cold  by keeping the patient in a warm room.
   These tumors, perhaps, modified by the action of the virus pe-
culiar to scarlatina,  occasionally  make their appearance simulta-
neously with the onset of the disease, but they are more gene-
rally the consequence of irritation caused by the soreness of the
throat.  They are subject to the usual terminations of inflamma-
tion; resolution, suppuration  and gangrene.   They sometimes
disappear  by spontaneous resolution, perhaps never by the in-
fluence of medicaments alone; suppuration, as mentioned above,
not being promoted,  but retarded by the  remedies usually em-
ployed in the treatment of phlegmonous inflammation, its forma-
tion  has  been  commonly left to nature;  cases  terminating in
gangrene have never come under my cognizance.

   The opening of the abscess.   Where  a  phlegmon  has
suppurated, and in a fit state to be lanced, the opening must be
made with great caution, as it is formed in the vicinity of glands
furnished with large blood-vessels, which are liable to be injured
by puncture, or ruptured when the pus is evacuated for want of
due support.  In either case a fatal haemorrhage may ensue.   In
the early part of my practice, this accident happened to the pa-
tient of an  eminent and experienced practitioner, in opening  an
abscess in  the region of the submaxillary gland: it is probable
the facial artery was wounded. 
15
  Frequency of Phlegmon.   In some epidemics phlegmons
occur  more  frequently than in others.   In the epidemic that
prevailed previously to my retiring to the country in '34, I met
with but  one; though,  in  many  respects, its characters  were
equivocal, still it may be considered as consecutive to scarlatina.

  Case  which  proved  fatal.   In  a child two  years  of
age, of  a  lymphatic temperament,  a tumor supposed to be
phlegmonous, originating under the right  angle of the lower jaw,
grew to a great size.  [The child was taken care of through the
eruptive  stage by the nurse,  a very  intelligent  person: my at-
tendance was requested on account of the swelling, which, when
I first  saw it, was of very considerable magnitude, and continued
to increase till its dimensions  became enormous.]   The tumor
was  of a conical form, and eventually extended across the  neck,
and  reached  as far as the top of the  sternum.   At this stage it
communicated to the touch rather the elastic resistance of flesh,
than the hardness of phlegmon.   There were no signs  of  its
substance falling into suppuration  except at  the apex, where a
very small  quantity of pus  was  ultimately  secreted,  and dis-
charged without relief or diminution  of  bulk.   The rest of the
tumor  was a solid mass;  and  undoubtedly owed its size to the
hypertrophied state of one or  more tissues.
   The base of this enormous  tumor  ultimately  compressed the
pharynx and  upper end of  the oesophagus, so as wholly to ob-
struct  the passage of the ingesta to the stomach; and it was ne-
cesssary to keep the patient in a sitting posture to prevent the
total interruption of inspiration,  which would  otherwise  have
taken  place instantly, in consequence of the pressure of the tu-
mor on the larynx and trachea.

   Treatment,  As the  strength of the child was very much
reduced by the disease  and low diet, a restorative course was
resorted to with  partial effect; the symptoms become less vio-
lent and the growth of the tumor was in some  measure check-
ed; but these flattering appearances were of short duration; nei-
ther was abstinence from external applications recommended in a
former paragraph, nor the remedies  made use of for promoting 
16
 suppuration  in  tumors reputed to be  phlegmonous, in this in-
 stance  too hastily prescribed from  the  vain  hope they might
 produce  maturation,  attended with  better success.   Indeed,
 had it  been in the power of remedies  to  have converted the
 whole substance  of the  tumor into  pus, the quantity to have
 been discharged  would  have  been so immense, and the irrita-
 tion from  exposure of the internal  surface of so large an im-
 posthume to the action of the  air,  so great, as  to  exhaust the
 strength of the child, and terminate its  existence.
   Notwithstanding the tumour was  of so refractory a nature as
 probably to resist the salutary action of every known remedial
 course, yet it would have been in accordance with my  view of
 correct practice  to have abstained from  topical applications,
 and trusted to the effect of an elevated and uniform temperature
 of  the apartment,  along with very gentle friction with the hand
 and olive  oil, from five to fifteen minutes three times a day,  and
 a light nutritious diet.   In this process,  particular care should
 be  taken  not to  occasion the slightest irritation.   It  was not
 long before the base of the tumor began to  press upon the pha-
 rynx,  and so entirely close the passage to  the  stomach, as to
 preclude  the possibility of swallowing  a  particle of  solid or
 liquid food.  The child lived so long after it was incapable of
 taking the necessaries of life, it is probable  it died of inanition
 and not of nervous irritation.

  Dropsy.  Collections  of water were seldom so considerable
 as to require particular medical aid.   The slight infiltration that
 supervened after severe cases, disappeared as the patient recov-
 ered strength.  My injunctions not to  allow my patients to be
 exposed to atmospheric vicissitudes, not only during the course
 of the disease, but while they were  in a  state of  convalescence
 were  imperative ;  and their  observance may  have been  the
 means of preventing the invasion of this sequela.*

  Rheumatism,  Erysipelas, Roseola.   These  are  se-
quelae to  Scarlatina, of which  I have no  practical knowledge.
 But in  an  interesting discourse  on  Self-Limited Diseases

                          * Note G. 
17
by Jacob Bigelow, Professor of Materia Medica in Harvard
University :  delivered before the Massachusetts Medical So-
ciety, under  note E, page  352, are the following  passages:
"Rheumatic affections are among the most common."   "Ery-
sipelas and  Roseola are  among  the appearances which I have
seen to supervene upon this uncertain disease."
           OBSERVATIONS  ON VARIOUS REMEDIES.

  Venesection.  In  the  treatment of Scarlatina, I am de-
cidedly opposed  to the detraction of blood  by the  lancet or
leeches.    In severe cases  it is a very hazardous practice.    In
the inflammatory  stage  of the  disease,  the concomitant fever
must be of a very high  grade  to render it necessary to employ
these modes of depletion,  and then  it should  be  resorted to
with great reserve and  at  the very onset of  the distemper, or
not at all.   In the whole course of my practice in Scarlatina,
I have never employed blood-letting, either  general or local ;
and I do not recollect  a single instance in which  I  have had
reason to regret the omission.   It may be proper  to state my
practice has been chiefly within the  city of Boston.  As the
situation of a place, and of course, its climate and soil, the cus-
toms and  manners of the inhabitants,  may  have  great influence
in varying the type of acute diseases ;  a difference in  the mode
of treatment may not  only be proper,  but required.
   These remarks appertain to cases of great hazard.   In those
of a milder nature, inappropriate remedies  often acquire a sup-
posititious reputation, because  the constitution is  able to sup-
port their  operation,  and  the deteriorating  effects of the dis-
ease.*

   Tartras Antimonii.   Soon after I engaged  in practice,
Scarlatina became epidemic.   At this period I adopted the
anti-phlogistic  plan  of treatment, commencing with  a watery
        * Note H.
3 
18
solution of tartrate of antimony, by which the  stomach and in-
testines were evacuated thoroughly ; but its tendency to pro-
duce hypercatharsis,  and thereby exhaust the vital powers, has
induced me to  abandon its use as  an evacuant;  but whenever
its operation happened to  be gentle, its  effect  was productive
of much advantage by promoting the secretions.  An emetic ol
ipecacuanha is to be preferred."

   Sub Murias Hydrargyri.  I  have employed this article,
not so much with  the expectation  of deriving  advantage  from
its specific action, as its being serviceable as a laxative, alterant
and promoter of the  secretions.  But it was soon found when
the sub-muriate of quicksilver was  given in a glutinous vehicle,
it  adhered to the  mucous membrane of the  fauces for some
time ;  and in  this way  had considerable efficacy, as  a topical
remedy, in reducing inflammation of the throat ; this advantage,
however, was  more  than  counterbalanced by the  irritation  it
induced.

   Emetico Cathartica.  Doses of tartrate of antimony and
sub-muriate of  quicksilver in various proportions  have  been ad-
ministered in this disease, and it has been thought by some with
advantage.   The symptoms of acute diseases are  aggravated by
the retention of the contents of the  digestive  tube, which are
liable to become acrid, and consequently a source of irritation :
under siich circumstances laxatives  are indispensable ;  but dras-
tic cathartics are to be avoided, as they irritate the inner mem-
brane of the alimentary canal, depress  the vital  powers,  and
disturb the regular  course  of the exanthem.

   Laxativa.  Infusion of senna sweetened with manna, cas-
tor oil,  rhubarb and  calcined magnesia, in sufficient  doses to
operate, are all the medicines of this description required  ; and
will answer  the purpose of keeping the bowels soluble in more
severe cases.f

   Cinchona.  Acidum  Sulphuricum  Dilutum.   During
* Note I.
t Note K. 
19
the two first epidemics that prevailed  after I began to practice,
many of the older  practitioners relied  on the tonic power of
these remedies,  probably with the view of  counteracting  the
supposed tendency of this distemper to  putrefaction.  But at
present, so far as the  practice  of physicians of this city has
come under my cognizance, these medicines  are disused.

   Anthemis   Nobilis.    Aristolochia  Serpentaria.
Crocus Sativus.   A warm infusion of these articles was for-
merly much in use ;  their virtues, however,  in  Scarlatina are
not to be depended upon.   I mention these articles because, at
the present time,  they may be considered  as domestic medi-
cines.   The people  generally believe a warm infusion, particu-
larly  of the two latter, is essential in the cure of eruptive dis-
eases.

   Sub Tonica.   When strengthening medicine is indicated, I
rely on the sub-tonic power of chalk mixture.*

   Solutio  Supercarbonatis  Sod*:.  The  formula  is  as
 follows :
               R. supercarbonatis sodae    5 n-
                   aquae.....5 viii.
                   M.
   To a tea-spoonful of  this solution  add a wine glass of warm
 water ; of this take a wine  glass full every  three  hours ; it is
 not to be drunk at once, but by the tea-spoonful at a time every
 few minutes, and swallowed slowly till  the whole be consumed.
 At the expiration of every three hours  the process is to be re-
 peated.   [See page 4th.]

    Supercarbonas Potass.e.   A  half drachm of this article
 dissolved in  a pint of balm tea,  for common drink, is a very
 good substitute  for the  dilute  solution  of the supercarbonate of
 soda.   Mucilaginous and farinacious drinks  are of great advan-
 tage in soothing the  irritation in  the fauces,  as well as affording
 a suitable diet.
* Note K. 
20
   Gargarisma.  There is a variety of gargles recommended,
which appear to be more the result of caprice than judgment.
   Those who prefer acids, may use the dilute sulphuric acid in
sage tea, in the  proportion of five drops of the  acid to a wine
glass of the tea, to be given according to circumstances.

   Capsicum Annutjm,  "is a warm, powerful stimulant, pro-
moting digestion, and obviating flatulency.  Its abuse, however,
produces visceral obstructions and an inflammatory  disposition
in the system."   "In the West  Indies  it has  been employed
both externally and internally in the sore throat."*  I  have never
employed it in Scarlatina.f

   Vesicatoria.  For the cure  of Scarlatina, vesicatories are
inapplicable.   The sensibility of the skin, and the irritability of
the muscular  system,  heightened  by the  inflamed state of  the
cutaneous organ, render topical stimulants of doubtful efficacy.
The virus stimulates  the whole system, and imparts a morbid
activity to the  circulatory organs ;  vesication  also operating in
a similar manner gives additional strength to the deleterious ten-
dency of the former  ; and by the co-operation of  these agents,
cases not of a remarkably high grade are often rendered despe-
rate.   In  children,  the sensibility of  the  integuments, and  the
irritability of  the  muscular fibre, are  more  exalted than  in
adults.   In the former, blisters induce even in other  complaints
a state  of the system, which disposes the denuded parts to de-
generate into gangrene ;  I therefore  refrain  from  their use,
unless  in cases where they may be imperatively demanded; then
I restrict their dimensions within a very narrow compass.   But
in Scarlatina,  the  skin being  already in a diseased  state, they
act with augmented force, and cause so great excitement, as to
place the  disease beyond  the control of  remedies  ; and in a
great majority of cases produce  mortification  and  death.   In
proportion as  individuals advance in age, the irritability of  the
cutaneous membrane  will  become  hebetated,  and  the danger
from vesication will be correspondingly diminished.
   The object of blistering is to interrupt the progress of mor-

     * Hooper's Medical Dictionary. By Samuel Akerly, New-York.
                          t Note B. 
21
bid actions.   This is accomplished with  more  certainty by a
comparatively small blister, than one of extensive dimensions ;
as the  latter, by  producing inordinate  irritation, exasperates,
rather than alleviates, the disordered state of the system.

   Treatment.  All that  is required after the epispastic has
performed its office, is to dress it twice a day with a pledget of
sheet lint spread with cerate made of wax and olive oil, or with
what is sold in  the shops under the appellation of cold cream.
But provided the ulcer should  become vitiated, or cankerous,
or its surface dotted with white spots formed by membraniform
exudation  accompanied  with  irritative  fever,  I direct it to be
washed with warm milk  and water, and then  to apply a curd of
alum and white  of eggs  spread  on sheet lint or linen rags, and
to repeat it as often as it becomes dry ; and prescribe such in-
ternal remedies  as the exigence  of the case may require.  When
the blister is attacked simply with inflammation, emollient  cata-
plasms  will be very appropriate.  In  the Scarlatina I never
applied but  one blister,  and  that caused  so much  suffering, I
resolved, unless  under  very  peculiar  circumstances, not to
apply another.*

   Embrocation.  Embrocating the fore part of  the neck as
far back as  the ears with  cold vinegar and water was formerly
much practised  for the  purpose of reducing inflammation, but
without success.  The united action of cold from the mixture,,
and  from that generated  by evaporation, which must necessarily
arise from the wet surface,  suppressed the reaction which is es-
sential  in  preventing the  inflamed  and ulcerated parts of the
throat from ending in gangrene,  and the fatal consequences re-
sulting  from this termination of the guttural affection.   With re-
gard to  topical  applications to  the neck in general, conceiving
them to be not only unnecessary, but often injurious, I have dis-
carded  them  altogether.

   Cold Water.  The success attending the affusion of cold
water in the  hands of Dr.  Currie and  Dr. Gregory in  Scar-
* Note L. 
22
latina, has attracted the favorable regard of the medical profes-
sion in Great Britain ; it will  also be seen in the sequel, per-
haps  unfortunately, the  practice materially modified has been
adopted  by physicians in  this  country without observing  the
precautions  recommended  by the above distinguished writers.
Of this method of cure I have had no experience.
   I  have been  conversant, however, with  the  effects of cold
communicated  through the medium of water from the time I,
with other boys, went  into  water to  learn to swim.  When we
followed the injunctions of our parents  and schoolmasters, "to
go,"  as the  phrase was, "in swimming but once a day, and not
stay in  too  long," we used to  "come out" refreshed  and in-
vigorated;  but  when  we  transgressed,  .and "went  in" from
three to  six times a day, or tarried in  a great while, especially
if we were at the time  unusually warm,  or the water very cold,
or the wind  east,  or in dog days, we suffered  from lassitude,
sensation of cold and  depression of spirits, which, with  com-
paratively few  exceptions, the  elasticity of our  constitutions
soon  overcame.   There were, indeed,  some expert swimmers
who, remaining a long  time in the water when it was cold, be-
came, as it was  supposed,  chilled  and  cramped, and, notwith-
standing  their  exertions to reach  the  shore,  were  drowned.
Thus, in sea bathing,  care must be taken  not  only of not re-
maining in the water too  long and going in  too often, but due
regard must be paid to the  temperature of the body, the air and
water, to prevent this grateful  and salutary exercise from be-
coming  immediately hazardous to life,  or eventually hurtful to
the constitution.
   Since  I  have  been in  practice, I  have  witnessed  several
cases of a very long continued, or perhaps continent, fever, in-
duced by going into the water too frequently, and staying in  too
long.   In these instances,  the surface  was  uniformly and pre-
ternaturally  cool;  pulse  very  small, easily compressible, and
not very frequent; loss of  appetite ;  prostration of strength
considerable ;  functions of  the sensorium slightly disturbed and
their  activity impaired ; an idiotic cast of countenance ; these
symptoms continued a long time before reaction took place, or
witho'ut giving  any evidence of exacerbations or remissions. ' 
23
   Ireatment.   Attention to first passages ;  clothing warm ;
farinaceous gruels ; stimulating and nervine medicines in small
doses. .
   Again, when  I  commenced practice, the cold and  shower
bath, which had been very extensively employed in the  cure of
disease, and  acquired a high reputation,  began  to fall compara-
tively into disuse.   At that time they were resorted to merely
as a source of luxurious gratification, or  from an indefinite idea
of there being some  recondite virtue in  the process beneficial
to health ; and,  therefore, their indiscriminate  use might be in-
dulged without regard  to consequences.
   Moreover, several  years  after I commenced practice, Dr.
Currie's treatise on the use and  advantage of  cold  affusions in
the  treatment of  typhus  made its  appearance.   His practice
was adopted generally by the physicians  of this  city ; and in
the typhus, when  the  heat was much elevated, with great ben-
efit ; but in  fevers symptomatic  of acute inflammation of  the
various portions of  the mucous  membrane, which have been
prevalent since the year 1815,  (a very few cases of typhus
having  appeared  since that period)  this  remedy  is  of  very
doubtful efficacy,  (unless the fauces and pharynx may be con-
sidered the seat of  Scarlatina.)   In chronic inflammations the.
application of cold through  the medium of water to the region
of the part  affected will  sometimes  be  attended with a benefi-
cial result.
   Among the variety of means  for curing diseases, there is
none requiring more judgment and  discretion  in its application
than the cold bath.    The shock it gives to the system, either
by immersion or showering, may so  derange its functions as to
produce a formidable  and protracted train  of symptoms, or ren-
 der it  perpetually enervated,  or,  unless  reaction come to  its
rescue,  overpower  it  altogether.   Reaction is the grand pre-
 ventive of the mischievous effects of cold however transmitted,
 either through the medium of water, or  air, or  ice.   This prin-
ciple is as active  in vigorous,  as it is feeble in debilitated con-
 stitutions.   Hence  by the  former the  shock  may not only be
 endured  with impunity,  but  produce  a  salutary excitement;
while to the latter it might be attended with imminent hazard. 
24
   General  directions  are  not  safe guides to the uninformed.
 To produce a salutary result in their application  to  particular
 cases, much skill and experience are required.   A number oi
 years since, there was issued from  the press an ephemeral pro-
 duction, which had an extensive circulation,  and which, by ex-
 tolling the  virtues  of cold and warm  bathing in  preserving
 health, and curing various  diseases, had the influence of  indu-
 cing large numbers to  resort to establishments erected for the
 purpose  of  accommodating those  who were desirous of  using
 them as a remedy, or enjoying them as a luxury.    As in all
 popular remedies, so in bathing, if the consequences  of its inju-
 dicious use  are  not  immediately  perceived, there  is often a
 foundation laid for some of the most obstinate and  intractable
 diseases.   It is, then, of the utmost  importance  to  those who
 wish to have  recourse  to  the  bath,  either for refreshment or
 health, to be satisfied, from the advice of persons who have
 made the subject their study,  their system is in a fit condition
 to sustain its effects without injury-.

   Case.   Permit me here to relate  (to me) a singular case of
 the combination or complication of affections  referable to  the
 indiscreet use of the cold bath.
   I was  desired to visit a young  gentleman,  twenty years of
 age, who, in consequence of indulging in bathing to excess, was
 attacked with dipsosis, limosis and diabetes insipidus.    By some
 the two former are  considered  as  merely symptoms of the  lat-
 ter; but, in  this case, not knowing which had the predominance,
 I  have  preferred  to  consider  them  as  a complication.  The
quantity of  water and food consumed, and the amount of fluid
 discharged,  it was impossible to ascertain.  Three faithful  and
 capable nurses  were in constant attendance, and their time was
 so occupied  in  contributing to the patient's wants, they could
not, with  any approximation to accuracy, keep an  account of
the quantity of fluid swallowed  or evacuated.  The young gen-
tleman's demand for water, food and  the urinal were incessant
and accompanied with such an  expression of distress as I have
rarely met with in any sickness.  A pailful of water was placed
by his  bed-side, to afford  a  ready supply,  for the purpose of 
25
giving a momentary relief to a most insatiable and urgent thirst.
The urine  was voided  in  such immense quantities,  as  to  re-
quire buckets to receive it,  and convey it away;  beside, when-
ever the night cabinet was used,  there was  a copious discharge
of fluid  per anum.   Provisions, also, were kept in  readiness,
with the view of complying promptly with his frequent demand
for food, to which he was urged by an unappeasable hunger.
   For some time previous  to the attack, contrary to his natural
disposition, he was  peevish; dogmatical;  impatient of contra-
diction;  took an antipathy  to  individuals for whom before  he
entertained  a great partiality; would not listen to any argument
or reasoning, that contravened his own views of his case.
   There was also a  turgescence of the whole surface, which ap-
peared to be owing  to the  effusion of serosity in the areola of
the_cellular membrane.

   Cause.    The cause was the  too free use of the cold bath.
There is in the system a faculty of generating heat, which is de-
pendent on the function of no particular organ,  but resides in
every  particle of the living body,  solid or fluid.   That each
particle has an independent existence  and  the  power of gene-
rating  heat, not only receives  confirmation from the  circum-
stance,  when from any cause it be  deprived  of vitality,  and, of
course, its calorific energy,  it becomes effete, and can no longer
maintain its relation  with the rest of the system;  but also, from
many of the  phenomena of inflammation and its terminations.
Though each particle may possess  this property  independently,
still  all  the  particles of which  the  body is  composed,  by their
joint operation or consent, or, in other words, acting in concert,
are contributory to the production of animal  heat and its preser-
vation at the usual temperature.   The heat  would become ex-
cessive and destructive, were there not a countervailing provis-
ion, the cutaneous  and pulmonary  transpiration,  by which an
equ'ation of temperature is maintained.  The motions of the par-
ticles are perpetual and vibratory;  and the  sensation  of cold is
the  result  of their approximation,  and  heat of their expansion.
If either their approximation or expansion be carried to an ex-
treme, death is inevitable.
                 4 
20
  According to the state of the system and the mode of appli-
cation,  cold  may prove salutary  or  deleterious.   Reaction  is
very readily excited by cold, and  this principle in sound consti-
tutions is capable of resisting the injurious effects of  water  at
its lowest temperature along time: the casualties of a sea-faring
life  afford many instances in corroboration of  this position.   In
constitutions that are slender, or disabled  from sickness, in con-
sequence of  the  great diminution of the force of reaction, the
greatest precautions must be observed  in the  use of this agent,
as its sudden application might extinguish life  instantly.   But
the  vigorous, though they may sustain the action  of sudden and
transient immersion in water  of the  lowest temperature, may,
notwithstanding, continue in it so long as to  overcome the pre-
servative power  of reaction,  and produce  disease;  as  in the
case, the history  of which we have just given.

  Treatment.   When I was called  upon  to visit the young
gentleman, the  flow  of urine,  attended with the unremitting
distress alluded  to above, was  so profuse as to wet the bed
through, and  run  in a stream on the floor.
  To produce a  change in  the  morbid actions upon which the
infiltration, thirst, hunger, and immoderate  flow of  urine de-
pended, recourse was  had  to the stimulating  properties of  opi-
um.  Accordingly, the tincture  of opium  was  prescribed  in
small doses and  at  short intervals at first, and then  increased
till  it took  effect, when a longer interval between the doses was
allowed to  intervene;  ten drops was  the minimum, and forty the
maximum number.  An infusion of senna, in limited and repeat-
ed  quantities, was ordered  to keep the bowels  open.    On the
third day the violence  of the complicated  and morbid actions,
which were the cause of so much  distress and suffering, were in
some measure  moderated; and from  this time  yielded by de-
grees to diet and regimen; and, finally, the recovery  of the pa-
tient was perfect.

   Cold.  Cold water may be applied by immersion; affusion;
showering; sponging;  aspersion;  sea-bathing; a column of wa-
ter issuing from a pump, or poured from a tea-kettle;   snow, or 
27
ice,  or ice water;  compresses or bandages,  wet with  a solu-
tion of salt in  water ; or a mixture of vinegar or dilute alcohol
and water.  However interesting it might be to take a practical
survey of the effects of cold by these means,  we must omit the
attempt, as it would be a digression from the  original design of
this  letter;  we shall, therefore, limit ourselves to the examina-
tion  of the utility of cold in Scarlatina.
   The superiority  of the  affusion of cold water  in  Scarlatina
over every other therapeutic agent,  is by no means established.
Dr.  Currie  and  Dr. Gregory acknowledge  the  principal  aim
was  to diminish the redundant heat,  in their opinion one of the
most prominent and the most  dangerous symptoms in  scarlet
fever;  and by the bold application of cold,  had the gratification
of finding the animal temperature much reduced, and the accom-
panying irritation allayed, without any disastrous result.   These
gentlemen exhibited great judgment and caution in their proce-
dure.   To render  affusion effective,  they esteemed it essential
that  it  be employed at  an early stage of the  malady, when the
heat of the body is ardent, the  circulatory organs in a state of
high action,  and the surface efflorescent and pruriginous.   In
this excited condition of the system, the patient is to be  set up-
right, and water poured suddenly on the head;  and afterwards the
hair  and skin dried with a linen cloth.   Dr. Currie used water
by gallons, while Dr. Gregory, with equal efficacy, and  far less
danger, employed only from two to four quarts.    The remedial
power of this agent is to be ascribed, not so much to the quan-
tity of  cold water  and its continuance  or  repetition, as to its
instantaneous and forcible  impression.
   The sudden  abstraction of heat, and the sensation of cold,
may be  imputed to the shock occasioned  by the affusion; the
effect  of which  is, by contracting  the  particles  of  which the
body is composed,  to diminish  the  power  of generating heat.
After a short suspension of heat,  it returns with  increased in-
tensity,  when  the  temperature  may be again reduced  in the
same way.  Dr. Gregory,  in the case of his  second patient,
grew more bold, and soused him repeatedly into  the water,—a
practice by no means to be imitated.
   Because a remedy does not prove destructive,  or even if it 
2a
relieve some symptoms, it is not sufficient evidence of its claim
to a preference over other curative agents.   Beside, the treat-
ment that can  be borne in safety in mild  cases, in severe may
prove fatal.   In cases where there is no  settled  plan of cure,
palliatives may be no doubt of eminent service; and, therefore,
whatever practice may alleviate a distressing symptom  should
by no means be condemned.
  It is stated  particularly by  Dr. Gregory, affusion alone  is
sufficient to cure Scarlatina ;  but, if we peruse with attention,
the  report of the cases in which he relied on the agency  of cold
alone,  in every instance  we  shall find  nausea,  vomiting  and
diarrhoea supervened  spontaneously.    The great  influence of
vomiting and  purging, when these evacuations are procured by
art, in lowering high inflammatory action, has long since been
acknowledged, and  the propriety of administering them for  that
purpose settled. Hence, in the cases in which cold affusion has
the credit of the cure, the efforts of nature  to  relieve itself by
these means may have contributed in  no inconsiderable degree
to conduct the disease to a favorable issue.
  In the summer of 1833, at the bottom of Pinckney street,  I
attended the niece of Mrs.-----,  eleven  years of age, who  had
the Scarlatina Anginosa of the highest grade.

  Treatment.   An emetic  ; laxatives ; solution of supercar-
bonate of soda in  water ; the  wine  of tartrate  of  antimony ;
strict anti-phlogistic regimen ; temperature as low as the weath-
er would admit, 70° Farenheit.   The medicines were  appor-
tioned  according to the age and constitution of the patient,  and
administered as the  circumstances of the case seemed to require.
The fever lasted eight days, when it abated, and her health was
gradually restored.  In this case is shown the  prejudice physi-
cians have to encounter.   After I had visited the child  several
days, her aunt, who took care of her, told me, quite incidental-
ly, she had been giving her for drink a warm infusion of chamo-
mile flowers and snakeroot in equal parts, on  the presumption
it was  essential to "keep the rash out."   I forbid its continu-
ance, but I do not  believe my injunctions  were regarded   as
there was little or no remission of fever as  is usual,  nor subsi- 
29
dence of the general tumidity of the surface, a symptom in se-
vere cases, till the eighth day.
  While visiting her niece, her aunt inquired of me with regard
to bathing the child in cold water, remarking some of the neigh-
bors advised her to try this remedy, as they were employing it
for their children ;  and made this additional remark, they were
continually bathing  them with ice water.   1 replied,  this  mode
of treatment may be very proper, but as  I have never practised
it, I preferred not to adopt it, being very well satisfied with the
course I had usually pursued.  One of the children subjected
to this process was in Charles street,  another was in  a  house
immediately opposite to  the residence of the little girl I attend-
ed.   They both died.   In these cases, the precautions of Dr.
Currie and Dr. Gregory, though requisite to be observed, were
disregarded ;  and, no doubt, the continued, instead of the tran-
sient, application of cold, ultimately rendered the organism,  on
which reaction depends, inert.*  My patient recovered.
   SCARLATINA  MALIGNA,  VEL  ANGINA  GAN-
                       GRENOSA.

My Dear Doctor,
              After your brother and sister recovered, revolv-
ing in my mind the varieties of Scarlatina, I have thought prop-
er to give you two cases of disease of the throat ;  and also to
request you to collect from Mrs. D. what information it  may
be in your power, of the cases of her children, who died at her
residence in Cambridge.
              Your affectionate father,
                                    WILLIAM INGALLS.
  In your answer, the account given by Mrs. D.  is at variance
with the report announced at the time in the newspapers,  and
* Note M. 
30
 with my recollection of the statement made at the same time
 by those who  were acquainted  with the family.   In a para-
 graph cut from a newspaper is contained the following obituary
 notice.    "In  Cambridge, on Friday night,  Helen,  aged  5
 years,  daughter of Ezra  Davis, being the third  which  this
 afflicted family has been deprived of in the short space of four
 days."
   Thinking it possible cases of this description might  come
 under my care, this intelligence  made a  strong  impression on
 my mind ;  and I was so sensitive on the subject, I  examined
 every affection of the throat with great attention, until its nature
 were  ascertained.
   The  apparent discrepancy between the above notice and  the
 account given by Mrs. D.  will be seen by the following extract
 from your answer.
   "In regard to Mrs. D's  children,  who died  in 1814 of 'pu-
trid sore throat,'  I gathered  the  following rather  imperfect
 account.
   "There were four ;  two were twins ; all died in one month,
and the  disease was upon them only five and seven  days.   It
began with nausea, shuddering and  coldness ; very soon  came
on a pain in the throat, which increased rapidly ; great difficulty
in deglutition now arrived,  so that the little  sufferers  exhibited
more  than common dread when one  approached with food or
medicine, setting their teeth, and struggling violently in their
opposition to its reception.
   "The oldest had no eruption ; one of the twins had a scarlet
eruption most evident about the neck and upper part of the
body ; the others had no eruption.    The rise and progress of
the eruption not remembered.
   "The tepid bath was made use of; and a decoction of hem-
lock bark as a gargle.   As  soon as  seized,  each patient was
pronounced incurable."
   In the above cases  eruption took place in but one ; in this
efflorescence constituted by no means  a prominent symptom.
These facts  tend to give countenance to the opinion  of Dr.
Good in rosalia paristhmitis,  or scarlatina  anginosa.   "The
determination, instead of being to the skin, is deflected to  the
throat." 
31
  After the death of Mrs.  D's  children,  many  cases  of sore
throat came under my care, two of which were very severe.

  Case  First.   In the first, the appearance of the fauces en-
grossed my whole attention.   The color of about two thirds of
the velum pendulum palati extending to  its free  margin,  and
comprehending the uvula,  was black ;  the rest of the velum
palati and the posterior portion of the palatine membrane, to a
considerable extent, were of a dark red.  At this time, there
was to be seen no line of demarkation.

   Treatment.  Being fully sensible, great advantage is often
derived from vomiting in topical inflammation, more particularly
when situated in the throat, I prescribed an emetic of [R.  pul-
vis ipecacuanha; 5 ss ;] to remove the irritation  from  retention
of faeces,  a  warm infusion of rheum palmatum ; for  the  inflam-
mation of the throat, steam,* and a lotion of sulphuric acid and
sage tea, as mentioned above ; to stop the progress of gangrene,
already commenced in the soft palate, a table spoonful, every
three hours, of a decoction made secundum artem of the follow-
ing recipe :
              R.  corticis  cinchonae rubrae
                     "    aristolochae serpentariae aa 5 ji-
                           misce et contunde.

   Diet.   Farinaceous decoctions.
   This course had  the effect  of  intercepting the  progress  of
mortification.  The mortified  part that sloughed off, compre-
hended so much of the soft palate as to render enunciation ever
after  nasal, harsh and indistinct.  Of the therapeutic  agents,
steaming the throat  was obviously  most efficacious in subduing
the inflammation, and promoting the separation  of the  sphace-
lated  part.    With  the exception  of the loss of a portion  of
the velum palati and uvula, his recovery was  perfect.

   Case Second.  A lad, about six years of age, was attacked
* Note N. 
32
 with severe inflammation of the throat ; I visited him at an earlier
 period than the first.   The inflammation was  erythematic, but
 the redness was not of so deep a  hue  as in  the former  case.
 The febrile symptoms were more acute,  and the signs of irrita-
 tion more marked.   His strength,  like the other lad's, was very
 much prostrated.

   Treatment.   With the exception of the  administration  of
 the wine of antimony in small but repeated  doses, and the omis-
 sion of the astringent and stimulating decoction, a similar course
 was pursued  in this case as in the first.
   While the lad was in a state  of  convalescence,  the  mother,
 anxious to  take a house  in another  part of the city,  desired my
 opinion on the propriety of removing him.
   On account of the danger of his  going abroad so soon  after
 the violent inflammation with which he had been afflicted,  and
 particularly from its  situation, exposure to cold air would almost
 inevitably produce a relapse, I  was opposed to his removal.
   In a short  time after,  the mother desired  me to visit  her  son
 again in the house  to  which she had removed.   I found the lad
 in a deplorable condition ;  respiration restricted ; face flushed ;
 pulse rapid and small; utterance imperfect.  In attempting to
 articulate, the emission of sound was scarcely audible.   The
 only approximation to sound  was  a noise made  by the lips,
 exactly as is  made when a person is endeavoring to light a to-
 bacco pipe.   The importance  of the symptom  will justify the
 introduction of so homely a figure, as it is strictly pathognomo-
 nic of a diseased state of the parts immediately concerned in the
 formation of sound, and the consequent cessation of the  vibra-
 tory motion of the vocal chords.
   The lad  had been indisposed a  few days :  his  mother  was
 apprised of his danger, and that the issue would, by all ordina-
ry means, be  fatal.   Laryngotomy was proposed and acceded to.
 While  I was  gone  for instruments and such assistants as were
necessary,  the affection  had so far  depressed the vital  powers
that on my arrival with the  design of performing the  operation
the patient  was in the article of death.*
* Note 0. 
33
  Post mortem examination.  A pustule, as predicted [the
prediction was founded on the nature  and severity  of the in-
flammation in the first attack, and want of resonance when at-
tempting to speak in the second] was found situated partly  in
the sinus laryngis and partly on the inferior vocal chord  of the
left side, about the bigness of a pea.  It had the appearance of
being about to suppurate ; and the mucous membrane in its vi-
cinity was inflamed and thickened.
                      VARICELLA.
  The last of February,  1837, John broke out with the chick-
en pox.   The premonitory symptoms were lassitude  and ce-
phalalgia,  which soon after were followed by an eruption in va-
rious parts of the body ;  behind the ear, there was  discovered
a pock, which filled and  burst on the fourth  day ;  the  fluid  it
contained was limpid till the fourth, when it became somewhat
opaque ;  on  the fifth the contents of the pustule or vesicle had
disappeared.
   On  the face there were several  small vesicles,  which, not-
withstanding their diminutive size, left pits  ; on the breast they
were lare;e, shallow, and  of short duration ;  on  the  posterior
region of the thorax, among others,  there  were three of large
size, upon which were formed scabs, two of which  remained
about  four weeks, when  they fell off, leaving  pits  which  pene-
trated through the superficial tissues deep into the  cutis vera.
 The pox ["properly pocks"]  (I  should prefer the word pock
 and to make use of it as a noun of multitude) with  the  excep-
 tion of the desquamation of the scabs on the posterior  region of
 the thorax, passed through the  several  stages about the same
 time with the vesicle behind the ear.  Anorexia ; cephalalgia ,
 propensity to lie a-bed ;  incited action of the vascular  system ;
 continued three days.
    So far as  we know, John's disease was sporadic
    Thi case has been given in detail, as there are in Europe
 emin   t  practitioners, who contend  the varicella and variola are
 eminent  p                            m Boston fui.nlshes ir-
 XV^"e/s,;kinS *. reliance, d. chicken
 is never  converted into the'small pox.
                    5 
34
  To prevent the  spreading of  the  variolous contagion, two
measures  were  adopted ; first,  inoculation  was  prohibited ;
second, for the accommodation of families liable to suffer from
the  casual small pox by  strangers or infectious  clothing,  a hos-
pital was provided at a distance from the  town, to which at the
public  expense, persons attacked  with this loathsome malady
might  be removed,  and  where infectious  articles  might  be
cleansed ; as either circumstance might become  the  cause  ol
the  general prevalence of the disease.
  Restrictive measures  were adopted, because, prior to vacci-
nation,  an alarm that "the small pox is  in Boston," deterred
the  people of the country from bringing in their  produce, thus
having the effect of raising the  price  of provisions,  and ren-
dering them  scarce ;  and likewise interrupting  the  trade  be-
tween town  and country, and diverting it to some other market.
  When  the state of  the  atmosphere  was favorable  to the
propagation  of the small pox, so  many  cases occurred as  to
cause a general alarm of the inhabitants, the majority  of  whom
were not protected, the regulations were suspended, and per-
mission given for a general inoculation.   John Warren, M. D.,
late Professor  of Anatomy  and  Surgery  in  Harvard  Uni-
versity, said, notwithstanding  all the means taken to prevent its
introduction, it became  indispensible to  permit  the  disease to
go  through the town once in about fifteen years.
  During the time the town was exempt from the influence of
the  variolous contagion,  varicella frequently prevailed as an
epidemic, and very few arrived at the age of puberty  without
having received the disease ;  and  in no  instance did the vari-
cella and variola prove  to be either identic  or convertible dis-
 eases.   There were, however, cases where the commencement
 and progress of the  disease so  closely represented  the symp-
 toms of small pox, as to require great  acumen and sagacity in
 determining the nature of  the  exanthem.    Hence,  it  became
 incumbent on every physician to  exercise his  powers of dis-
 cernment and  discrimination to discover  the  nature   of  the
 eruption  under which a patient  might  have labored.   A  mis-
 take in diagnosis would have  been attended with  a  loss of
 reputation and  standing in  the  profession, which, to have re-
 gained, might have  required  a  long and continued success in
 practice. 
APPENDIX.
  In a practical treatise on the management and diseases of children,
by Richardson T. Evanson, M. D., Professor of Medicine, and Hen-
ry Munsel, M. D., Professor of Midwifery, in the Royal College of
Surgeons in Ireland, printed at Philadelphia, in the Select Library,
1838, there is contained an article on  Scarlatina, from which I shall
make copious extracts.
  The  whole treatise is a production of much ability and great expe-
rience ; and it affords me peculiar satisfaction to find my views,  in so
many particulars, in accordance with theirs.  The first edition, in a
letter to my son, was published in 1837—the year previous to the ap-
pearance of the above article on Scarlatina.
   Symptoms  of  Simple Scarlatina.   "These  are, at first, the or-
 dinary  symptoms of fever, viz.—lassitude, shivering, succeeded by
 heat, thirst, quick pulse, and occasionally nausea, head-ache,  or even
 delirium.  These vary much in degree in different cases, from  the
 slightest  disturbance  of the constitution to severe  fever.   About the
 second day, the eruption  appears in  the form  of red spots-first,
 upon the face and  neck, and subsequently these coalesce and spread
 over the trunk and extremities.  On the third day, the eruption is at
 its height: and there appears in the form of a continuous bright redness
 upon the extremities, and of large irregular patches  upon  the trunk
 of the body "  "It may, however, be  occasionally intermingled with
 mi iary vesicles, or papula,, especially  when the patient has been sub-
 Te ted  to a stimulating treatment or regimen.  The erupt.cn also may
 be seen »pon the hide of  the mouth and throat winch assumes a
 briahtBcaSet color: the tongue, if clean,  exhibits  the same  hue  or
 tie,,apul« appear through the coating of fur, and their redness as
  vel a   hat of the tip, affords a strong contrast to ,ts white or yellow-
 well a* mat         '         h  occurrence  of the  eruption in the
 ish colour,  dependent upon                      ^ fifth    ^
 fauces, there is a ways more^     -«               ^ ^ ^
 eruption usually begins ; to^e and ,     J^ ^ ^         ^




    .The foregoing is a ^^^^"^^
  which Sydenhani terms but rtnan-o        ^ ^      ^ .f
  lhat admirable Phy«cmn  sHates              ^ ^ ^^  ^
  the invasion be n» its ounnat                  se       ted t0 us.
  be materially aggravated, anC  i  aanaeio 
36
By some, such an  aggravation  of character has  been considered to
constitute  a distinct variety, which  they  have described under  the
name of Scarlatina Anginosa ; but the distinction  is unnecessary,  the
difference  being rather in degree than in kind, and the  slighter  char-
acter of the symptoms being convertible  into a severer,  merely by
mismanagement, or  peculiarity of constitution.  The symptoms of
sore  throat, to which the term anginosa refers, is common, in a great-
er or less degree, to all forms of Scarlatina.  The principles of treat-
ment, also, must be the same ; and there should be no difference,  ex-
cept  in the degree to which we  may  find it necessary to  work  them
out.   We conceive, in short, that less confusion will  be created,  and
a right understanding of the treatment facilitated, by considering, as
identical in nature, and only different in  degree, all  cases  of the  dis-
ease  which possess inflammatory or sthenic characters, thereby includ-
ing under one head,  the  Scarlatina  Simplex and Anginosa  of most
writers, and Dr. Armstrong's inflammatory variety  of the Scarlatina
Maligna."
  "All the symptoms, then, which we have described, may exist in ag-
gravated degree."
  "In many cases of the Scarlatina Maligna the symptoms are, at first,
similar to  those already described."  "As the disease proceeds, they
are aggravated."
                               B.
  "Gargles can seldom be used  with children ;  and with them, as  Dr.
Armstrong justly remarks, mild emetics will be the best gargles, clear-
ing the throat, and removing the viscid secretion, which often furnish-
es a  serious obstacle to respiration.  [Instead of emetics,  the clearing
the throat by feeding the child with sage tea, acidulated with a min-
eral  acid, or water rendered slightly pungent with ammoniated alco-
hol,  may furnish a pretty good substitute.]  When gargles can be  em-
ployed, and a stimulating one is required,  an excellent one will be,  a
mixture of five ounces of infusion of roses, an ounce of honey, and  a
drachm of tincture of capsicum."
                               C.
  "Scarlatina of the Throat, or  (Scarlatina faucium.—Dr.
Tweedie.)  It is, in fact, an appearance of the eruption in the  mouth
and throat, without any efflorescence upon the surface of the  body.
It is  often  attended with a good deal  of fever,  and may be followed
by desquamation of the cuticle.   It also appears capable of communi-
cating an  infection  which will  produce  other forms of the disease."
"Dr. Armstrong also  relates cases in which children, and even adults
some time after exposure, now and then die suddenly, from the opera-
tion  of the contagion, without any appearance of efflorescence or sore
throat.  They are attacked with convulsions, or with  the symptoms
of apoplexy, and frequently sink into insensibility and death  in a  few
hours." 
37
                                D.
  tc When the fever is violent, the desquamation is occasionally  very
remarkable, the whole cuticle peeling off the hand  or foot, in the form
of a glove or sock."
                                E.
  "Local treatment should attract  particular  attention in bad  cases
of Scarlatina, the local disease sometimes perpetuating a destructive
reaction in the  system.  When the case is met early,  the dusky red,
erysipulous inflammation existing in the fauces, without ulceration or
sloughing, we would recommend the free application of a strong solu-
tion of nitrate of silver (ten grains  to the ounce) to all the parts con-
cerned.   It can be best applied by means of a  piece of lint,  sewed to
the finger of a glove, which latter is to be placed upon the forefinger
of the operator."
                                F.
   "When sloughing or ulceration have set in, we have found the best
applications to  be the mel  Egyptianum, or a linetus of five grains of
sulphate of copper and an half an ounce of honey. If gargles can be
used, the capsicum gargle, already  mentioned, may be prescribed."
                                G.
   "As sequela? of Scarlatina, we frequently have dropsy, either in the
cellular membrane, or in the cavities ; also, abscesses in various situa-
tions ; opthalmia ; suppuration from the ears  ; and various forms of
scrofula."
                                H.
   "The weight of authority  is  against the  general   employment of
bleeding ; and ever, by  its patrons, it is recommended to be practised
very cautiously.   When visceral  inflammation  sets  in during  the
course of scarlatina, and when we  have the good  fortune to discover
it early,  bleeding is certainly required, as in ordinary  fever,  under
similar circumstances ;  but it is only as a matter of necessity that we
must have recourse to it; for we believe that it is likely to  prove in-
iurious, so far as  the  fever itself is concerned, delaying us  regular
j                             .        i-------„----im   If we are
course, and increasing the tendency to dangerous sequela.
obliged to take blood, in consequence of inflammation of any organ,
the quantity must be altogether left to the judgment of the practition-
er.  Enough should be taken to control the inflammatory tendency-
but, if possible, not one drop more."
  "For the sake of the audi alteram partem,* we  give the following

q°« Wesladly take this  opportunity of  asserting, from  considerable
experience,  that  copious blood-letting is the  best remedy m severe
c!ses of Sari,  anginosa ; and that the greater the tendency to mabg-
Tancy is, the more boldly it must be employed.  This change m the

                   * The Editor of the Select Library. 
38
 treatment of scarl. malignahas naturally followed that of its congener
 typhus.—Ed. Medical and Surgical Journal, Vol. xix. p. 448."
   " Coleridge has likened the experience  of most men to the stern-
 lights of a ship, which illuminate her by-gone track :  in this case, we
 fear the light was carried to the mast-head,  and illuminated  regions
 above the cognizance of the reviewer."*
   " The acute stage of the Scarlatina maligna is extremely short, and
 often scarcely appreciable."   " It is important to recollect this in the
 treatment, as it is only in the short stage of excitement that any meas-
 ures of depletion are warrantable."*   "Fothergill, who was the first ac-
 curate describer of the disease in this country, utterly discountenanced
 bleeding,  purging, and nitrous medicines."*  "Huxham was decidedly
 opposed to bleeding, in the truly malignant forms; although, carried to
 a small extent, he thought it might be useful when the disease had more
 of a sthenic  character.  Currie styled bleeding and purging fatal  prac-
 tice."*  "Dr. Armstrong advocated bleeding.  He also supposed that
 calomel had a special effect in equalizing the circulation, and  accord-
 ingly he prescribed it in very large doses.   These two measures, with
 active purging and the saline warm bath, constituted his plan of treat-
 ment. Those, however, who read his essay carefully, will easily per-
 ceive that he was not free from misgivings as to his practice, and it  is
 equally obvious,  that he considered  the mere circumstance of  the dis-
 ease being severe and violent, as a sufficient sanction for the use of se-
 vere and violent remedies.  Such a notion, though popular  and com-
 mon, is altogether inconsistent with an enlarged view of  diseases, and
justifies the  apologue  of D'Alembert:—'The physician  being,  then,
 truly a blind man, armed with a club, who,  as chance may direct the
 weight of his blows, will be certain of annihilating either nature or the
 disease.' "*
                                I.
   " In simple Scarlatina  a gentle emetic is almost always  of ser-
 vice, by checking the fever and relaxing the skin, and also by  cleans-
 ing the throat of viscid mucus.  Its action  will be advantageously fol-
 lowed by a  purgative."   " In the scarlatina  maligna, our  first step
 would be  the administration of an emetic.   Where the patient is much
excited, and no irritation of the bowels prevent, we prefer the tartariz-
 ed antimony; when there is much feebleness, we usually employ ipe-
 cacuanha; and this drug often operates advantageously on children
 by freeing their bowels, after its emetic action has been accomplished.
 With respect to actual aperients, we think  they are often required and
 beneficial."  "They should, however, be of a mild kind."*  "This to-
 gether with  the application of leeches, is the utmost extent to which we
 can ouiselves conscientiously go in recommending depletory  measures
 in scarlatina maligna;  but kir. is right to state that some experimental
 practitioners hope for benefit from a small blood-lettin^, if it  can be
 performed at the  very onset."
* The Editor of the Select Library. 
39
                                K.
  " There is often considerable debility at the close of the disease, and
convalescence ls not unfrequently tedious, obliging us to have recourse
to tome medicines as mineral acids and quinine; "but mildlv nu^t™
food wdl commonly be sufficient  for the purpose; and any "thing in the
way of stimulants, as wine, fcc. should be given with very great cau-
tion, as, in the weakened state of the system, they are extremely likely
to excite dangerous local inflammations."
  " If a patient be fortunate enough to become convalescent from the
scarlatina maligna, the greatest  delicacy of  management is required,
in order to prevent local congestions, or other dangerous sequela, from
occurring.  While sufficient mild nourishment is given,  a carefully an-
tiphlogistic regimen must be observed,  every thing  heating or stimu-
lating being avoided, and gentle  laxatives, so as to prevent any accu-
mulations in the bowels."  '
                                L.
  " The application of blisters in this disease, at least  to children, is,
we conceive, contra-indicated, by the tendency to gangrene which ex-
ists,  and which is likely to  be communicated  to the blistered surface."
" In children living in crowded  apartments, we have  witnessed the
mdst marked change in the condition of the  throat to be immediately
produced by free exposure to air; and  in every possible  case we would
recommend the  practice to  be  adopted."   " When  applied  to the
chest, throat, &.c. leeches have led to fatal  results, by a continuance
of hemorrhage;"  their bites  may also  become gangrenous: hence it
will  be judicious to abstain entirely from their use.
                                M.
  " Currie strongly advocated the  affusion with cold water, in inflam-
matory scarlatina;  and when the patient is strong and plethoric, with
a hot  skin,  the weather being also warm—when, in short, there is no
likelihood of the want of reaction,—this measure  will be attended with
the best results.  We can commonly, however, substitute for it spong-
ing with cold or  tepid  water and vinegar;  and this in every case is
safe, bringing down the heat, and affording much comfort.   Tepid af-
fusion and  the warm  bath have also been  highly spoken  of, in the
treatment  of scarlatina;  but we have, ourselves,  more  experience
of the benefits derivable from sponging."  " When  the cuticle is des-
quamating at the close of the disease, the tepid  bath  will be found
useful  and very comfortable to the patient.  At this period exposure
to cold must be guarded against,  and the child not let into the open air
without additional clothing."   "Currie condemned his own remedy of
affusion with cold water in malignant scarlatina."
                                N.
  "If we can  get the patient to inhale the  steam of hot  water and
vinegar, it will often afford much relief." 
40
                                o.
  " Dr. Currie relates a case of his own daughter, in whom death was
occasioned by ulceration of the glottis, symptoms resembling those of
croup attending."

                        Recapitulation.
  With regard to the treatment of scarlatina,  reliance is to  be placed
chiefly on an emetic,* followed,  if necessary, by a  laxative; in  the
course of the disease, mild aperients are to be  administered, if requir-
ed; for the soreness of the throat, acid and alkaline preparations are
to be so used as to answer the purpose of a lotion, as a substitute for
gargles; due ventilation, and  the  preservation of a moderate and uni-
form temperature, to be graduated according to the  habits of the pa-
tients, are to be observed.
  In this disease, as a general rule, blisters, blood-letting, and calomel
should be avoided, as their employment, in a great majority of cases,
would prove highly deleterious.f
                        ADDENDUM.

  Since I have put my edition of 1837 into  the hands of printers for
republication, I have read, in the Boston Medical & Surgical Journal,
a dissertation on Scarlatina, by Professor Cross, taken from the last
No. of the Transylvanian Journal,  from which  I shall  make a few
extracts.  The Editor of the  Boston Journal has restricted  himself
exclusively to the remarks of Professor Cross, on the  employment  of
emetics in this disease.
  The Professor remarks, lc an emetic should be exhibited on the first
indication of the existence of Scarlatina,  and it  should be  repeated,
according to circumstances, throughout the whole course of the dis-
ease."  With regard to giving an emetic at the commencement of the
disease,  his  reasons  for selecting ipecacuanha in  preference  to
tartar emetic, in my opinion are conclusive.  But the repetition  of
emetics "throughout the whole course of the disease," is a practice that
should not be adopted without mature deliberation.    This  mode  of
treatment is very seldom required ;  it may, perhaps, be admissible  to
administer a gentle emetic, when there is an accumulation of mucus
in the throat, threatening suffocation, as mentioned by Professor Muih
sel.  After the operation of an emetic at the onset of the disease  par-
ticular attention should be paid to the guttural affection, and all causes
of irritation avoided or removed.
  In a self "limited disease," or, in other words^one that runs a certain
course, all uncalled for interference  should be sedulously avoided.
  The remarks, however, of Professor Cross are worthy of attentive
perusal by every practitioner of medicine.
* Note I.
t Note B. 
 
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