Mr. Burke on Scarlatina, with Ulcerated Throat. 3t

no evil consequences can follow, there remaining, allowing for the coil, an adequate portion of the cord free. The cord should in all cases be drawn down a little, to relieve the stress upon it, and to loosen the part round the neck ; but, except in a very few cases, more will not be necessary. I may add, that this was all that was attempted in the cases I have recorded.

ART. IV,--Scarlatina, with Ulcerated Throat, and Inflam- mation of the Arachnoid Membrane. By TIMOTHY Bt~RKE, Licentiate Apothecary.

THIs complication I had an opportunity of observing on an extensive scale, during the last and present autumn, it being epidemic.

From the infant to the adult, none were exempt. Tile worst cases, and the most fi'equent, were those of children from two to ten years of age. I have very seldom observed the adult to be attacked in the malignant manner that the children were.

The peculiar characters which marked this epidemic were the following. For the sake of clearness, I shall divide it into three stages.

1. The Premonitory. 2. The Eruptive, with a blush of redness on the fauces. 3. The Sinking, with ulceration, sloughing of the fauces, and

c o m a .

The first stage I seldom witnessed. It generally lasts about two days. The child becomes irritable ; refuses food ; and has alternate attacks of heat and cold: in the night the skin is hotter than usual ; the little patient restless and thirsty. Oh looking into the throat at this early period~ a slight blush might be observed occupying the fauces.

The second stage.--Towards the evening of the second day the redness of the skin becomes apparent: it generally commences on the chest and face, and soon spreads universally,

32 Mr. Burke on Scarlatina, with Ulcerated Throat:

giving the skin the well-known appearance of a boiled lobster- shell. At this period the fever becomes aggravated, the eyes

f iery, heat of skin intense, pulse 120, hard and wiry ; tongue elongated, red at the tip and edges, papillae erect ; great thirst, h6adaeh, intolerance of light, and raving, follow ; the little patient avoids the stimuli of light and sound ; all the secretions are arrested ; the urine is red and scanty. On looking into the throat, a bright redness appears occupying the entire of the fauces ; the tonsils are red, and so enlarged as almost to meet. This erisypelatous redness will sometimes be found to have spread upwards along the Schneiderian membrane, and downwards along the mucous lining of the oesophagus and air passage, giving rise to peculiar symptoms, according as those parts be- come affected.

Third stage. If the former stage be not arrested after two or three days, we will find the last fully set in. The fever be- comes lessened ; the face pallid, pulse rapid, and hardly to be felt ; and tile eruption disappears ; the patient lies in a half comatose state, occasionally uttering a low moan: on being roused, the child for a moment regains its natural appearance, but soon sinks again into dosing : the vessels of the eye appear injected, but of a duller eolour than that observed in the former stage : a scum begins to cloud the vision ; betimes there will be purging; an acid irritating humour distils from file nostrils; when the little patient attempts to swallow, it seems to be in danger of choking, and whatever is given returns through the nostrils. On looking into the mouth, the soft palate ap- Pears of an ash colour, covered with tenacious mucus : the ton- sils enlarged, but have lost the intense red hue, which charac- terised the former stage, and on close examination, large ul- cers will be found in their body, their bases of an ash colour, their edges ragged, with tenacious mucus and lymph adhering to the back of the pharynx. When in this state, the patient hardly ever recovers ; it becomes more and more comatose, and death soon closes the scene.

Mr. Burke on Scarlatina, with Ulcerated Throat. 33

Treatment requires to be prompt and bold ; its success mainly depends upon the stage it is employed in. In the first stage I have succeeded in arresting the throat affection, by brushing the pharynx with a solution of nitrate o[" silver, a scru- ple to the ounce, and administering calomel and James's powder.

In the second stage, if the child be strong, and the fever violent, the neck must be repeatedly leeched, until the blush on the fauces be found of a less intense hue, and paler aspect; calomel, and James's powder used : cold ablution employed ; and water, for which the child is very anxious, should be freely given. If the head appears much engaged, it must at once be shaved, leeches applied, and cold sponging continually used. In adults, it will be usefill to steam the throat with the vapour of vinegar : when the intense inflammation has somewhat sub- sided, a strong solution &the nitrate of silver must be applied to file ulcers which are now making their appearance. If this treat- ment be successful, the pulse will be found to have diminished in frequency and hardness &character ; the intense heat of the skin will become lessened ; the child more lively ; drink can be taken without pain ; and the little patient gradually re- covers. Great care still should be taken of the ulcers, never flailing to touch them, until they appear clean.

In the third stage three indications for treatment present themselves. 1st. To change the character of the ulcers by some powerful caustic. 2nd. To relieve the congestion of the brain, which now puts on a most alarming character. 3rd. To sup- port the fast fhiling vital powers.

The first is to be carried into execution by applying nitric acid, by means of a camel hair brush to the diseased parts: this should be repeated until the well known red line os de- marcation is observed bounding the slough.

The second will be best obtained by shaving the head~ using cold lotions, and leeching the temples and back of the ears; blisters should then be applied to the vertex, temples, and back of the neck, never leaving them on for more than

voL. XL NO. 31. 1~

34 Mr. Burke on Scarlatina, with ulcerated Throat.

from two to four hours ; sinaplsms to the calves of file legs ; and calomel administered, if it can be got down. I f these means be successful, the eye appears less dull ; the child will get more natural sleep, and when spoken to, will answer cor- rectly ; and the vacant, stupid expression will be exchanged for the happy smile, which cheers the medical attendant, and re- wards his labours.

Third indication. This will be best effected by administering wine and quinine, cautiously watching the effects: if they appear to excite irritation, their use must be at once suspended, and recourse had to other appropriate means.

I t is only in the fllird stage that blisters will be useful. In the second they add to the inflammation, and often do irrepara- ble injury, not only increasing the inflammation of the throat, but the blistered surface will often become gangrenous, and strip the neck to the most frightful extent. I have seen the fascia and vessels laid bare, and the child sink~ from the effects of an untimely application of a blister, when the disease itself had sub- sided : even in the third stage they will often fail. I seldom applied them to the anterior of the neck : the nape is the place where I have found them of most service. I f the child be pallid and sunk, they can hardly excite the least irritation ; the vesicle will be colourless, and when broken, the denuded surface will be perfectly pale and unirritated : this is a fatal sign, as it shews the powers of life to be at the lowest ebb. There is a happy medium, when the vascular excitement is much lessened, yet not so much so as when a blister is applied ; no redness or irritation will follow. Here counter-irritants will be exceedingly useful : the period requires to be carefully watched : the pulse will be found to have become less frequent : the heat and general fever mitigated. Yet on looking into the throat, the redness still continues, but not of so intense a hue.

I f success crowns our labours in this dreadful stage, the little patient has a long and lingering convalescence to wade through, which too often terminates badly. Tile consequences most to be dreaded are inflammation under the parotid, with

Mr. Burke on Scarlatina, with Ulcerated Throat. 35

formation of matter under the fascia of the neck ; dropsy, or wasting diarrhoea ; and deafness.

The first affection generally commences two or three days after all the severe symptoms have subsided, with pain in the ear, then a lump becomes evident in the neck, this enlarges, inflames, and requires, after a short time, to be freely opened ; it continues to discharge for a long time, and often sinks the patient irrecoverably; or gangrenous erysipelas takes place, and denudes the neck to a great extent.

The second affection, dropsy, does not set in till about a week after seeming convalescence ; generally commencing in the face and abdomen, and afterwards engaging the extremities ; its sudden origin, evidently shews it to depend upon some wrong actions of the vessels of the skin, which have been morbidly excited during the scarlatina. Some say that it depends upon a want of due exhalation on account of the newly formed cutis ; others advocate the more rational opinion, that it depends upon an inflammatory state of the vessels, not so intense as when file scarlatina prevailed. The latter opinion seems borne out in practice, as we observe the disease will give way it" we employ mild antiphlogistic means ; moderate general bleeding, if the patient will bear it, hydragogue cathartics, as pul. jalap, comp., warm hath, and low diet ; after the disease has subsided, tonics, nutritive diet, and country air will be found most beneficial. I should remark that great danger exists while the affection remains; for betimes it will suddenly disappear externally; and metastasis take place to some important internal organ, which too often terminates fatally.

The third consequence, diarrhvea, I have not so frequently met with. Some cases of scarlatina set in with well marked symptoms of an inflammatory affection of the gastro-enteric membrane, and in these I have observed that the throat and head generally were free from any complication ; the tenderness of the belly from the commencement,with vomiting and purging, formed the chief characteristics : this tenderness was so excessive that I could only compare it to peritonitis, except that you had

36 Mr. Burke on Scarlatina, with Ulcerated Throat.

none of the tympanitic state of the abdomen which marks that disease; this affection was best treated with local depletion, mild anodynes, absorbent medicine, bland diet, opiate injec- tions, and after it had subsided by general tonics, &e.

CASES ILLUSTRATIVE.

During last autumn, I was called to see a child of nine years

of age; my patient presented all the characters of the com- mencement of the third stage, I applied the nitrld acid to the dis- eased parts separated, and were thrown up after two days; each

day I applied the acid twice : the little fellow's convalescence was tedious , abscesses occurred in the region of the neck, which I freely opened ; these suppurated for a fortnight, and be got gra-

dually well without any other bad symptom. The day I first saw this boy, I had the mortification ofseelng a youngercbild perish ; he had been ill Ibr some days previous to my visit, and was treated in the usual manner, with leeches, gargles, &c., but soon fell a victim ; before the boy, nine years of age, got well, another of the family took the complaint, and it travelled through them all--the mother and four in family ; two were

grown up, about eighteen to twenty; the youngest was five

years old ; with all there was hardly any premonitory symptom, and except in the youngest no appearance of eruption. The first examination of the throat shewed the intense redness, and ash-coloured ulcer, with enlarged and dropsical uvula : to each I applied the n~tric acid at once without any delay, and had the happiness ofnotlosing a single patient; none were followed with any bad sequelm except my first patient, and even with this lad

I do not think that any turnout would have occurred had I seen

him earlier ; for the longer disease is allowed to linger in the

throat the more danger that it will have spread and engaged the cellular membrane of the neck: each case did not last more than four days, and each presented all the bad symptoms which

usually characterize the worst prognosis. During this period, and prior to the above case, I happened to be called to attend a fine boy, attacked with this malignant affection ; I applied

every thing I considered would be of benefit, leeching, cold

Mr. Burke on Scarlatina, with Ulcerated Throat. 37

lotion, solution of nitrate of silver &c., but was not aware of tile good results of the application of the acid, which I did not use till a late period of tile affection. I saw him die in con- vulsions after a week's illness; the ash-coloured slough had spread along the entire palate, and had completely destroyed file Schneiderian membrane.

During the present season I have been busily engaged in treating this disease. The first case was a boy, aged ten ; he was attacked most fiercely. After about two days premonitory fever, tim eruption appeared universal, tile skin so hot that the hand could scarcely be retained upon it, the carotid beating most violently ; eyes red ; face scarlet ; intolerance of light and sound; pulse 120, and hard; tongue red and fiery; no purg- ing nor vomiting ; throat universally red ; tonsils enlarged, with tile uvula so tumified that it threatened suffocation ; the end ot' the uvula and both tonsils were covered with the ash slough. l saw no time was to be lost. At different periods, for two days, forty leeches were applied : and cold ablutions: little medicine could be given: the nitric acid was diligently used. During the evening of the second day he was to all appearance next to death. He lay exhausted with the loss of blood ; the eyes dull and suffused ; muttering delirium ; unable to swallow the smallest particle ; tenacious mucus, with unseparated slough clogging the throat : respiration performed with a violent eflbl't, creating what the vulgar call the rattle, and which too often is tile forerunner of dissolution. With all these bad symptoms I determined not to give up: having first inspected the tilroat, and made up my mind that file nitric acid had done its duty, I then had the head shaved, running blisters applied, and sinapisms to the legs and feet. During tile night I had his throat washed from time to time witii a large brush, dipped in a decoction of bark, and muriatic acid. I remained three hours (from nine to twelve) putting into practice what I have mentioned, and few, except those who have acted the operator as well as the physician, can imagine fire difficulty and trouble experienced in performing the llecessary duties.

38 Mr. Burke on Scarlatina, with Ulcerated Throat.

My visit in the morning repaid aU the trouble of the labo- rious night ; the boy answered me correctly, the eye had again become intelligent, the pulse had fallento ninety. The skin was now moderately cool, and he was able to tell me that during the night he felt something like a piece of flesh separate from his throat, which being unable to spit up he swallowed: on exam- ining the throat evidently a piece of slough had disappeared ; a red line marked its termination ; and the erysipelatous blush much subsided. From this period he went on well ; the decoction of bark was still applied till all the slough came away ; bowels were opened by enema and oil, and after the lapse of four days I had the pleasure of- seeing him in a fair way of recovery. Anxiously looking out for any sequelae, I ob- served, after five or six days, that he complained of pain in the ear ; this was soon followed by tumefaction in the angle of the jaw ; a little opening medicine, with stupes, terminated this usually troublesome affection. In about two days more a swel- ling appeared in his face : this rapidly spread itself over thebody; the urine became diminished, and of a red colour, with the remainder of the symptoms which characterize dropsy. I then directed any animal food he was getting to be discontinued, and ordered compound powder of jalap in small doses, with cream of tartar water for drink : tiffs had the desired effect ; the urine was increasing in quantity, and the swelling diminishing ; when it suddenly disappeared ; he immediately complained of pain in the head ; he shivered violently; re-action soon took place ; and when I saw him, he had all the symptoms of commencing araehnitis. I instantly directed leeches to the temples, with an active aperient of calomel and jalap, followed by the senna mixture ; this at once gave relief ; sleep soon followed ; and after the lapse of some hours he awoke free from any bad symp- tom. Months elapsed before fire convalescence could be pro- nounced perfect; and even still his squalid countenance and excavated tonsils bear evidence of the severity of the disease, from which he so fortunately recovered.