SOME ACCOUNT OF THE EPIDEMIC OF SCARLATINA, WHICH PREVAILED IN DUBLIN, FROM 1834 TO 1842 INCLUSIVE, WITH OBSERVATIONS. By Henry Kennedy, M.B.

For the last eight years scarlet fever has prevailed in Dublin to a great extent, and with symptoms of very considerable severity. Dr. Kennedy, who has had extensive opportunities of observing the epidemic, considers that it may be classed under the head of "scarlatina maligna;" not that every case put on the malignant form, but on account of the high proportion of deaths to the numbers attacked.

Pathological Appearances.-Dr. Kennedy divides the disease into two formsfirst, the simply malignant; second, the complicated malignant.

In the first of these, the appearances on the surface of the body varied a good deal. In the greater number of cases, however, there were large dark petechiæ, or vibices, especially about the clavicles and groins. On cutting into these, little if anything was found to account for the mark so apparent on the surface; no extravasation was detected in any instance. In the head, chest, and abdomen, it may be stated generally that nothing but congestion, varying in degree in different cases, was found. The state of the throat in this form of disease was quite of secondary importance; during life it was often not complained of at all, after death some ulceration, of the upper part of the tonsils in particular, was found, unattended with any swelling.

The second form of the disease, to which Dr. Kennedy gives the name of "complicated malignant," owed its severity, in part, to the upper portion of the throat and its neighbourhood becoming engaged. In general the swelling of the neck occupied both sides; this swelling was often immense, encircling the neck like a cravat, and sometimes spreading down to the clavicles; in one case it engaged the pectoral muscles, rendering them as hard as a board. This tumefaction subsided considerably after death; on cutting into it in an early stage, effusion of serum, with a turgid vascular state of the lymphatic glands, was all that was found; at a later stage, pus of an unhealthy character was discovered, either infiltrated through the textures, or collected into a distinct abscess or abscesses. If the inflammation pursued the course of common abscess, the case usually did well: frequently, however, sloughing of the parts took place, proceeding with great rapidity, in some instances causing death by hæmorrhage from the coats of the large vessels becoming involved.

Sometimes the inflammation, after spreading down the neck, invaded the sterno-clavicular articulation, giving rise to abscess in the joint,* or destruction of the cartilages.

Another form of swelling of the neck, to which the author directs attention, was caused by the effusion of nothing but lymph; this was rapid in its progress, at least to a certain point, for when the swelling had reached its height, it seemed at once to become stationary, in fact it rarely went on to form abscess. The hardness in these cases was excessive.

With regard to the condition of the internal fauces, two affections more particularly came under Dr. Kennedy's notice, viz. diphtherite, and oedema of the glottis. Both of these were accompanied by ulcerations, varying in extent and number-thus there was very constantly one in the upper part of either tonsil, with irregular edges, and of considerable depth. Ulcers were also found about the chordæ vocales.

Sequelae. In some cases, when the patient was to a certain degree convalescent, it was found that the child's neck had become crooked, and that when any attempt was made to bring the head straight, it caused severe pain referred to No. LXXVIII. Нн

the upper part of the neck, and commonly to one side. This may have arisen, in some instances, from the inflammation of the throat spreading to the neighbouring textures, so as to engage those of the spine, and sometimes in this way cause caries in other cases it occurred where there had been swellings of the neck, with the effusion of lymph, this effusion taking place about the small muscles of the nape of the neck, and sometimes in the upper portion of the trapezius; it was attended with some pain on pressure, and was very difficult to remove. In a third set of cases it arose from a spastic state of the muscles on one side of the neck, more particularly engaging the sterno-mastoid, and appeared to be caused by the patient lying in one position in bed for a considerable period.

Another sequela of the disease consisted in the inflammation spreading into the Eustachian tube, and so reaching the internal ear, causing abscess and exfoliation of the small bones. At other times, an abscess formed in the parotid region, and burst into the ear.

Purulent effusion into the joints was another and most formidable sequela of this epidemic. Sometimes only one of the large joints was attacked, at other times three or four were found to be full of pus. The synovial membrane was commonly healthy, though at times it was found intensely injected and coated with lymph. The same remark may be made of ulceration of the cartilages. In some very severe cases, the epiphyses separated from the shafts of the long bones. The internal organs were not affected in these cases.

The milder forms of the disease were frequently complicated by internal lesions. Of these the attacks of the chest were the most frequent and most serious. Dropsical effusions were also often present. In these cases, as a general rule, the kidneys were quite healthy, whether the urine was or was not albuminous. In other cases again, great congestion of these organs existed, sometimes to so marked an extent, that it appeared to have enlarged the kidney. In three instances, one of the stages of Bright's disease was very well marked; the kidneys were a good deal larger than natural, and their texture soft; and when the fibrous coat was taken off, the surface was distinctly mottled as if from the deposition of lymph.

Symptoms. The invasion of the disease was generally sudden, the symptoms being commonly referred to the stomach. The stage of collapse rapidly fol lowed, marked by its usual symptoms; there was seldom any distinct rigor, it was more of a creeping or shuddering, and often existed with a warmer state of the surface. The average duration of this stage of collapse was from two to five hours, when reaction set in, and the more prominent symptoms of the disease made their appearance. Sore-throat was constantly met with, varying from simple redness to the most extensive sloughing. Chronic enlargement of the tonsils, and an unnatural redness of the throat, remained for an indefinite time in some cases. The tongue very frequently did not present the usual appearance said to be so characteristic of scarlatina. The pulse was usually much quickened; during the stage of collapse, it was weak and indistinct; but in from eight to twelve hours it had again developed itself, and was to be found ranging close to 120. From this period it steadily declined in strength, till about the fourth day, when (supposing the patient did well) it again began to improve in tone and vigour, and its frequency became lessened. In those instances where the disease was more like a plague than scarlatina, that is where there was little if any reaction, it at times happened that no pulse could be felt at the wrist for several hours before death. The eruption varied considerably in its intensity; in its most severe form, it was in one continuous sheet over the whole surface. In other cases, it presented itself in great patches of a very bright colour, as large as one's hand would cover, but which were entirely separate one from the other. In both these cases spots of purpura occasionally appeared sub

sequent to the general eruption. If the eruption appeared in the following manner, the disease was sure to prove of a very severe form. "A case would occur in which the eruption of the common character had come fully out; it might or might not be favourable, but on the following day an additional crop would make its appearance; this was usually of a brighter colour, and much better defined than the first and what was curious about it was, that this last eruption might disappear again, leaving the skin only covered with the first."

In many instances nothing but large dark petechiae were visible about the clavicles and inguinal regions, often running down the inner side of the lower limbs. Sometimes there was merely lividity of the hands, feet, and depending portions of the trunk. In many cases, where there was very little eruption, the skin of the hands, particularly where the nails join it, assumed a very peculiar red and shining aspect, without any swelling. These were all very severe cases. As a general rule, the fever presented either the irritative or the typhoid form; very rarely indeed was it of the sthenic inflammatory type.

Treatment. The line of treatment on which Dr. Kennedy placed most reliance, and which he used in the majority of instances, was as follows:-stimulant emetics-warm baths-tepid or cold sponging-cold affusion to head-internal stimulants-diluents-free application of nitrate of silver to the throat, followed by soothing treatment-occasionally the internal administration of opium. "Such, modified by the peculiarities of each individual case, was the plan of treatment adopted, and the one which, under analogous circumstances again, I would certainly have recourse to."

Numerous cases are detailed; and the volume closes with an appendix, containing an account of an epidemic of scarlatina which prevailed in the County of Armagh during the year 1842, communicated by Dr. Lynn, of the Market-hill Dispensary.

CONTRIBUTIONS TO THE MATERIA MEDICA. By Fr. Simon.

I. CHEMICAL CAUTIONS IN THE WRITING OF PRESCRIPTIONS. It is a prerogative of modern times, for which, according to some, we are indebted to homoeopathy, that the writing of prescriptions is no longer conducted in that complex and confused manner, where for every symptom a remedy stood on paper, and where possibly one, two, or more remedies became ineffective by reason of mutual decomposition, or else exercised an entirely different effect from that intended; but now medicines are ordered in a form as little complex as possible, or even in a simple form altogether. Still, notwithstanding this essential improvement in the writing of prescriptions, it sometimes occurs, that the physician, deficient altogether in a knowledge of chemistry, unfortunately selects the few remedies he employs in such a manner, that they chemically destroy each other, and act either not at all, or in a different manner from what he expected.

Independently of the inconvenience hence resulting both to the patient and the cure in general, but which may be soon discovered and again rectified by a prudent physician well versed in the practice of such cases, we must now consider another inconvenience of a far more serious import. The recipe is in a certain way the only written document, which the physician gives to the apothe cary and to the public at large with respect to his conduct and mode of treatment. The apothecary soon sees the faults committed against the laws of cheInical affinity, and the public must observe them, when the medicine obtained, whether mixture, solution, &c. exhibits entirely different properties from what the physician assigned it. Now, though the apothecary is sometimes so com

plaisant as to take the blame to himself, this however does not always happen, and the physician necessarily loses in character.

The study of chemistry, considered from this point of view, is urgently necessary to the physician for daily use; but it embraces a field far too extensive to be acquired with anything like facility. Hence it occurred to us, that some general rules may prove not unacceptable, which may serve as a clue to enable practitioners to shun those gross chemical blunders in the writing of prescrip

tions.

1. SUBSTANCES MUST NOT BE PRESCRIBED IN SOLUTION WHICH ARE INSOLUBLE.

A. The Aqueous Solution.

As the aqueous solution is the most usual, the most frequent errors are comImitted in this instance. It is known that water dissolves the so-called soluble salts, extracts, gum, sugar and soaps, not resins, oils, fats, balsams, camphor, nor sulphur, phosphorus, iodine, calomel, &c.

With respect to the salts, or saline combinations, it is necessary to exhibit some which are insoluble or nearly so, though they are still prescribed in the form of solution; we must, however, impart to them solubility by means of other salts which are soluble; in cases of this kind errors are not infrequently committed.

The following substances are insoluble, or nearly so:

Magnesiæ carbonas and m. usta-ferri prussias, et f. phosphas.-pulvis antim. compos.-antimonii sulphuretum auratum,-antim. sulphuretum rubrum,— zinci carbonas, zinci cyanidum, and some other metallic cyanides-to these, also, may be added the pure vegetable alkalies, quinine, cinchonine, salicine, and the sulphate of quinine, so often prescribed in solution; which is dissolved in pure water in extremely small quantity, but readily in water slightly acidified with sulphuric acid.

Of the combinations of iodine and bromine, those of iron are readily solublethe same may be said of the iodide of zinc-iodide of gold is insoluble-the perbromide and protobromide of mercury are very difficult of solution-the periodide and iodide of mercury are insoluble.

With respect to the solution of extracts, it should be observed, that this is perfect in but few cases; partly because the extracts become changed, and a part is rendered insoluble by its combination with oxygen, partly because they contain resinous combinations, especially if they have been prepared by means of alcohol; in these cases the solution is turbid, being partly of a brownish, and partly of a greenish colour.

B. The Alcoholic Solution.

Alcohol chiefly dissolves resins, ethereal oils, balsams, soaps, camphor, and iodine. Of the salts, alcohol dissolves more especially the combinations of chlorine soluble in water, or bichloride of mercury, the chloride of gold, chloride of iron, &c.—the acetates and lactates, the carbonates, sulphates, and phosphates are not at all soluble in alcohol. Alcohol dissolves but a very small quantity of sulphur and phosphorus.

The alcoholic solution of resins, ethereal oils, balsams, camphor, and iodine are thrown down on the addition of water. The salts not soluble in alcohol, gums, also, several extracts, are thrown down from their aqueous solution, by adding alcohol.

c. The Ethereal Solution.

Sulphuric ether dissolves fat, ethereal oils, camphor, phosphorus, and some

combinations of chlorine, as chloride of iron, chloride of gold, and chloride of mercury.

D. The Oily Solution.

The ethereal oils combine with fluid and solid fats; they dissolve camphor, sulphur and phosphorus, the Dippel oil in great quantity; they are soluble in alcohol. The fatty oils mix with the ethereal oils; they also dissolve camphor, sulphur, and phosphorus; in æther they are readily soluble, in alcohol but slightly so.

When a substance is given in solution, the most indifferent solvent must be employed, lest, when a full dose is to be administered, the action of the solvent should predominate.

2. NO SUBSTANCES SHOULD BE PRESCRIBED TOGETHER, WHICH

MUTUALLY DECOMPOSE EACH OTHER.

This is a principle which may easily be defended, but it is one which must find a stumbling-block raised by usage. But why do we not endeavour to remove this block by the aid of science, a block, too, not set up by justice, but by mere custom? Were there no re-action in science, we should make no advance, and use and authority, however badly grounded, would become laws. We do not mean to say any thing here against the black and red wash, nor against Goulard's mixture, and several other preparations of that kind. These are useful preparations in the cases where they are indicated. We here intend to guard our readers against those unchemical formula where the intention, as well as the character, of the practitioner simultaneously suffer.

The following general rules may probably serve many a practitioner as a clue, wherein it is to be remarked, that in reference to the medicine which is to be prescribed, and that which is to be avoided, a reciprocal relation always naturally exists.

When salts of baryta, of lead and of lime are ordered, sulphates and free sulphuric acid are to be avoided, as the sulphuric acid yields white precipitates, difficult of solution with salts of baryta, of lead and of lime.

When salts of silver and salts of lead are prescribed, the hydrochlorates and free hydrochloric acid are to be avoided as the chloride of silver is insoluble, and the chloride of lead is difficult of solution.

:

When metallic salts are prescribed, care must be taken to avoid :a. Combinations of sulphur, especially those that are soluble, as sulphuret of potassium, or of ammonium, as the insoluble black or yellow, or reddish-coloured metallic sulphurets are precipitated. Even when both the metallic salt as also the sulphur-combination are insoluble, their combination should be avoided. Insoluble sulphur-combinations with such as are soluble, may be prescribed together.

b. Soluble carbonates, more especially carbonate of soda, carbonate of potash, as they form insoluble metallic carbonates; this is more especially to be remarked in the salts of iron, lead, copper, zinc, antimony and mercury.

c. The free alkalies and free earths, more especially the aqua ammoniæ causticæ, and the aqua calcis, are to be reckoned here: on mixing the metallic salts with these substances, the metallic oxides are generally thrown down in the state of hydrate. It is necessary to keep this in view when ordering substances for external use; as in ordering corrosive sublimate, calomel, acetate of lead, &c. &c.

d. Extracts, and especially those containing yellow colouring matter, (extr. of cascarilla, bark, rhatany, &c.)

All the metallic salts yield with the extracts, which, with few exceptions, contain a certain quantity of yellow colouring matter, insoluble, flocculent, dark-brown or black precipitates. These are particularly marked in the salts