BY B. F. JOSLIN, JR., M. D., NEW YORK.

Scarlatina has prevailed in this city during the past few months, and has assumed an unusually severe and fatal character. A large number of cases has occurred in the Protestant Half Orphan Asylum; the medical management of which institution has been under the able and skilful care of Dr. B. F. Bowers for thirteen years. So numerous were the cases at one time, that he requested my assistance to diminish the too heavy tax upon his time. In this way I collected the materials for the present article, founded mainly upon my own observation, but partly on his records previous to the commencement of my services The present epidemic has been far the most fatal of any which has occurred during Dr. Bowers' long period of service; the previous percentage of mortality being excessively small even for homoeopathic practice. The present mortality, although proportionately greater than the records of this institution show for any similar period under the homoeopathic practice, is not to be regarded as really great, considering the large number of cases (eighty to one hundred) of the disease which occurred. With one exception (convulsions) the deaths from Scarlatina were in cases in which dropsy ensued; of these latter cases four were fatal. At the present time I intend to confine myself to some account of those cases accompanied by dropsical symptoms. At a future time I may give a more complete account of the epidemic, but it would extend the present article beyond a suitable length to include more at this time.

A large proportion of the dropsical patients had the first stage of the disease in an exceedingly mild form, so much so that in one or two of the fatal cases they had been scarcely supposed to have had the Scarlatina at all. One (case v.) had sore-throat without eruption; another, slight eruption only (case xii.) neither of these went to bed until the appearance of the dropsical symptoms. In these, the first indication of any thing serious was edema round the eyes, followed soon by more general anasarca and other troubles. Several of the dropsical cases may appear quite slight, but our experience taught us to regard any symptom of this complication as a very important omen not to be thought lightly of.

The following quotations from West on Diseases of Children accord with our experience in this epidemic: —

“The degree of anasarca varies much in different cases, and likewise fluctuates at different periods in the same patient.”

His description of the more severe cases will be found to correspond very closely to cases two, three, four, five, six, twelve, thirteen and sixteen. He says: —

“The chief suffering, however, is referred to the chest; the respiration is labored and accelerated, and the child is frequently unable to assume the recumbent posture, and is, moreover, distressed by a frequent short hacking cough. Under these circumstances, life is sometimes prolonged for several days, though in a state of extreme suffering, remedies proving unable either to increase the action of the kidneys, or to relieve the dropsy. Death is sometimes preceded by a sudden aggravation of the signs of disorder in the respiratory organs, which assumes all the painful characteristics of edema of the lungs; and in other cases, a comatose condition comes on, such as often precedes death from Bright's disease in the adult.”

Cases six, nine, ten and thirteen were marked by a tendency to drowsiness, and cases two, three, four, five, six, seven ten, twelve and sixteen by difficult and rapid respiration.

The cases reported are in the order in which the eruption occurred.

CASE I. John Girvan, aged six.

February 16th 1860. Eruption; had cough. Puls. 30 was prescribed — On 18th and 21st, he is recorded as doing well. Puls. 30 was continued. — April 5th. While looking over the convalescents who were up and about the nursery rooms, found him with slight edema of eyelids; abdomen was swollen; pulse quite frequent; had also glandular swelling of sub-maxillary region. Apis 1 was prescribed. — 6th. The edema of eyelids was less apparent. Apis 30 was prescribed. — 7th. Says he feels well; has slight cough; pulse 140. Hep. 30. — 9th. Diarrhea; pulse 124. Ars. 30. Bowels continued somewhat relaxed for several days. Ars. 30 was continued. Since he has been well.

CASE II. Herman Stevens, aged seven.

February 25th. Face flushed; chilly; pulse weak; pain in stomach; has vomited. Acon. 30 in solution, a dose every two hours was prescribed. — 27th. Face all over red as a lobster; sore-throat; pain in stomach; head-ache; red tongue; pulse 130. Bell. 30, every four hours. — 28th. Still very red. Puls. 30, every four hours — 29. Continued Puls. 30. — No further record until March 21st. Face swollen. Sulph. 30. — March 23rd. Swelling of face, eyes and feet. Ars. 30. — 24th. Feet swollen. Ars. 30. — 25th. More swollen. Ars. 30. — 26th. Worse. Ars. 30 and Merc. 30. — 26th. Second visit, at seven, p.m.; when I first saw him, I record face much puffed; feet and legs somewhat swollen; abdomen swollen. Very great dyspnea, so that he has to sit upright to breathe. If allowed to recline says he is choking. Passed no urine from last evening till this evening while we were present, then only half a gill of dark brown color. Pulse very frequent and feeble. 1 Apis 30 and 1 Apis 0 were given, but he died at half-past eleven the same evening.

CASE III. Charles Smith, aged six.

February 29th. Fever; red eruptions; vomiting head-ache. Puls. 30. — March 1st. White dry tongue; redness continues Acon. 30. — 2nd. Puls. 30. — 16th. (Where a considerable period elapses without particular record, we may infer that the patient was doing well.) Stiff neck; glands swollen. Bell. 30 and Merc. 30. — 21st. Inflammation in front of neck to right side with deep swelling. Bell. 30. — 23rd. Opened abscess on neck. Sulph. 30. — 26tb. edema of face. Apis 30. — 27th. Seems better; pulse 92. Apis 30. — 28th. Face more swollen; no edema of feet; pulse 80, irregularly intermittent. Apis 1. — 29th. Face not so much puffed; pulse 100, regular. Apis 1. — April 2nd. Pulse 76, not quite regular. Apia 1. — 3rd. Less swelling of face; pulse 100. Apis 1. — 5th. Feels well; less swelling of face; pulse 92, not quite regular. Apis 1. — 8th. Skin hot; thirst; pulse 148; respiration good, 32; The weather Is today rainy and close, which I have no doubt has had an unfavorable influence on his case, as there is no other reason known for the change. Acon. 30 and Bell. 30.

April 9th. Feels well and appears so; pulse 96; had rapid respiration all night, but is now quite easy; last night had an evacuation in bed. Acon. and Bell. — 10th. Doing well; pulse 104. Apis 1. — 11th. Respiration good; still has some swelling of face. Apis 1. — 12th. Pulse 114; respiration 28. Apis 1 — 13th. Says he feels wells, but he does not appear quite so bright as usual; no appetite for dinner; pulse 116. Apis 1. — 14th. Appetite better; pulse 112. Apis. — 16th. Doing well; pulse 92. Apis 1. — 17th. Doing well; pulse 100. Apis 1. — 18th. Seems well. Hep. 30. Has remained well.

CASE IV. Mary Butler, aged ten and a half.

March 1st. Nausea. Verat 30. — 2nd. Eruption. Puls. 30. — Must have been slightly affected as there is no further record till the 21st, when swelling of face was observed. Sulph. 30. — 22nd. Feet swelling. Sulph 30. — 23rd. Swelling of face, eyes, and feet. Ars. 30, every four hours. — 24th Vomiting; pain in stomach; oppressed breathing; swelling of abdomen; pulse 115. Ars. 30 was continued. — 25th. No sleep all night; vomiting brown yellow bile frequently (every twenty minutes); painful efforts to pass urine with very little effect; great pain in stomach, relieved after vomiting; short panting respiration. Merc. cor. 30 every hour. Second visit — pulseless. Ars. and Carb. veg. were given bat she died at 8.25, p.m.

CASE V. Jacob Shannon, aged nine.

March 2nd. Tonsilitis. Bell 30. — -3rd. Sore-throat improving. Bell. 30. — 8th. Lame in both legs; stiff neck; sore-throat. Bell. 30.

This is the whole record of the first stage of his case, there is no doubt that the symptoms were occasioned by Scarlatina but he was so slightly affected that he never went to bed in consequence.

March 27th. Found him among the convalescents, with edematous swelling of face; tongue coated, white papilla, enlarged. Apis1. In the evening Dr. Bowers found his pulse very frequent and irregular, dropsical symptoms increased. — 28th. I record, in bed quite sick; face puffed; great edema of scrotum and of lower extremities; dulness of left chest, in region of heart; respiration normal on both sides of chest; pulse 120, regular; ascites; tongue red with brownish coat. Apis 1. — 29th. Since last evening, very severe pain in chest and abdomen; respiration labored; dropsy increased; abdomen much distended; edema of face; dulness of chest on percussion; pulse very feeble and frequent; urine scanty and pale. Hell. 0, every hour. Died on the morning of the 30th, instant.

CASE VL William White, aged six.

March 3rd. Fever; red eruption. Acon. 30. — 10th. Fever. Puls. 30.

No further record until April 2nd, during which period he was up and about the nursery; at this date he was observed to be drowsy and to hare edema under the eyes; was desquamating. Apis 30.

April 3rd. Face puffed. Apis 30. — 4th. Face more swollen; much pain in abdomen today; abdomen swollen and tympanitic; pulse 130 very small. Apis 1. — 5th. Much Less edema of face; respiration pretty good; pulse 120 and fuller; perspires. Apis 1. — 6th. Says he feels better; respiration better; pulse 119; swelling of face about the same; abdomen tympanitic. Apis 30. — 7th. Much less swelling of face; pulse 108; says he feels well.

As his improvement was uninterrupted after this date it is unnecessary to copy the daily record. April 15th. the urine was observed to have a very deep color. No change was made in the treatment till the 18th, when Hep. 30 was substituted for Apis 30. No edema remained.

His case was one which we regarded as of great danger, as it resembled very closely the preceding case which was fatal.

CAES VII Emma Leslie, aged four and a half.

March 6th. Eruption red. Puls. 30. — 8th. Puls. 30 — 22nd. Cervical glands swollen. Bell. 30. — 27th. Eruption of pale irregular blotches over chest and back; tongue thickly coated yellow; attempted to look at throat but could not succeed, the touch of the finger caused slight bleeding from throat; rather offensive smell from throat. Bell. 30. — 28th. edema of face; no dulness of chest; pulse 100. Apis 1 — 29th. Face puffed. Apis 1. — 31st. Doing well. Hep. 30. — Convalesced regularly.

CASE VIII. Jane McKee, aged eight.

March 6th. Red eruption. Puls. 30 — 12th. Stiff neck. Bell. 30. — 13th and 16th. Same record. — 18th. Pain in back, head and limbs. Puls. 30: — 19th. Groans and talks in sleep. Puls. 30. — 20th. Improving. Puls. 30. — 21st. Headache; desquamating. Bell. 30. — 24th. Bry. 30. — 31st. Swelling of abdomen and of face. Apis. 1.

April 2nd. Increased swelling. Apis. 1. — 3rd. Much less swelling of abdomen, and of feet; says she feels well; pulse 72. Apis 1. — Gradually convalesced; had about the 15th instant, an attack of dysentery lasting a few days.

In this case the swelling of abdomen and of feet was great No other remedy was used for the dropsical symptoms but Apis, and they entirely disappeared.

CASE IX. John Dakenheart, aged five and a half.

March 13th. Eruption. Puls. 30. — 31st. Yesterday had tympanitic distension of abdomen; pain in abdomen. Cham. 30 was given. Continued same. — April 2nd. Swelling of face. Apis. 1. — 3rd. Less swelling of face. Apis 1

Edema of face gradually disappeared under Apis 1, and after the 6th inst of Apis 30. He was rather drowsy most of the time. On the 15th, inst., he appeared well, and Hep. 30 was given as was our rule to all the convalescents from Scarlatina.

CASE X. Kitty Goverment, aged six and a half.

March 18th. Fever; red eruption. Bell. 30.

Her attack must have been slight, as no further record was recorded.

April 4th. I record, was up day before yesterday; edema of eyelids pulse 92. Dr. Bowers' gave her Acon. 30. last night. Apis 1. — 5th. Red erysipelatous looking eruption on cheeks and nose; edema of face; pulse 96; Apis. — 6th. edema of face. Apis 30. — 7th. Feels well pulse 76. Apis 30.

Same condition and treatment until 12th, when Hep. 30 was substituted. On the 13th the urine was of a very deep brown color, appeared almost black; pulse 96. Hep. 30 was continued till the 15th, at this date, increased swelling of face was observed; respiration was short and she was inclined to sleep; pulse 100. Apis 1.

16th. Feels well; pulse 92. Apis 30. — 17th. Was feverish and had frequent loose cough during night. Acon. 30 and Bell. 30. — 19th. Pulse 126, small; doing well. Acon. 30 and Bell. 30.

On the 21st had greenish vomiting, for which Verat. 30 was given with good effect; afterwards only Hep. 30 was given.

CASE XI. John Carrew, aged ten.

Mar. 24th. Red eruption; vomiting. Bell. 30. — 26th. Dropsy. Ars. 30. — 27th. Cheeks red and swollen; eruption of blotches on chest; no sore-throat.

Examined a specimen of urine; color normal. Albumen was precipitated copiously both by heat and Nitric acid. With the microscope found abundant epithelium and mucus; some quite large globules were seen, in which no granular structure could be distinguished. I could not detect any blood globules. Apis 1.

March 28th. Not so much swelling of face; no redness. Apis 1. — 29th. Face less puffed; feels better; slight fluctuation of abdomen; dulness of left chest; pulse 62. Apis 1. — April 2nd. Better. Apis 1.

Convalesced rapidly. On the 18th instant, had head-ache and ear-ache, which were relieved by Puls. 30, at this time his pulse was 94

CASE XII George Welsh, aged ten.

March 24th. Red eruption; vomiting. Bell. 30. Attack was very slight. Did not go to bed.

April 3rd. Was observed to have edema of right side of face. Apis 30. Was, however, apparently well until the 9th, when at three, a.m., he had profuse bleeding from nose and mouth, commenced with a short cough; this was, I have no doubt, hemoptysis. Two hours after, had another attack similar, afterward watery vomiting; abdomen tympanitic; slight edema of face. Dr. Bowers was called early in the morning and gave him Acon. 30. and Bell. 30, alternately each hour. I saw him about noon (my usual time of visiting the Asylum), his pulse was 120; he did not appear very sick. Dr. Bowers said he was, much improved since morning. He continued Acon and Bell.

On the 10th, he was in a desperate condition. Pulse so feeble and irregular as not to be counted; respiration difficult; started up wildly; put his hand to his throat; said he wanted to pull something out of it; frequent short cough (I considered him to have edema of the glottis); wanted cold water frequently, but Vomited it up, spitting out once a yard or more. Had a black frothy evacuation and vomiting of similar matter; in both instances the matter was no doubt blood. Lips bluish. Lach 30 was given, and after half an hour the lips were observed by Dr. Bowers, the nurses, and myself, to be less bluish. I counted the pulse then 140. Lach. 30 was continued.

11th. He died at two. a.m. Had bleeding from nose twice last night, half a gill each time. Respiration was stridulous.

CASE. XIII. Margaret Henry, aged eight.

March 27th. Said to have had Scarlatina, now edema of face and pain in stomach. Acon. 30. — 27th. edema of face; tongue clear. Apis 1.

April 7th. Has lameness and want of power over feet; strongly inclined to sleep; has chronic pustular eruption and abscess in axilla; pulse 120. Bell. 30. 9th. Is quite weak and cannot stand; pains in lower extremities, on moving them. Bry. 30. — 10th. Improving. Bry. 30. — 11th. Bell. 30. — 12th. Sleeps all the time, I roused her with very great difficulty. Says, she has pain at pit of stomach; tongue red; purulent discharge from eyes; pulse 80. Op. 30 — 13th. Not so sleepy; no pain; pulse 100. Op. 30. — 14th. Is bright; pulse 100. Op. 30. — 15th. Feels well; pulse 114. Op. 30. — 16th. Moaning and crying during sleep; head-ache; pulse 120 during sleep. Acon. 30 and Bell. 30. — 17th. Well; pulse 96. Acon. and Bell. — 18th. Well; pulse 88. Hep. 30. Remained well.

CASE XIV. Julia Mathews, aged ten.

March 26. Red eruption. Bell. 30. — 27th. Cheeks red and hot; pulse frequent. Bell. 30. — 28th. edema of eyelids. Apis 1. — 31st. appears well. Apis 1. April 18th. Feels well; has slight edema of face_; Apis 1. Convalesced well.

CASE..XV. Isabella Rowlandson, aged ten.

March 27th. Characteristic general eruption; sore-throat; tongue bright red, papillae very distinct; pulse 116; had had vomiting on the 23rd, Verat. was then given, now Bell. 30. — 28th. Discharge from nose; pulse 132. Hep. 30. — 29th. Throat much swollen; deglutition quite painful; pulse 132. Merc. 30. — 30th. Feels better. Merc. 30. — 31st. Throat less sore; tongue red; desquamation. Merc. 30.

April 2nd. Throat not very sore; feels better; pulse 130. Merc. 30. — 3rd. Offensive smell from mouth; ulceration on margin of right upper eyelid. Carb. veg. 30. — 4th. Improving. Carb. vog. 30. — 5th. No pain; feels well; no offensive smell from the mouth now; pulse 126. Carb. veg. — 6th. Improving; pulse 130. Carb. veg. 30. — 7th. Feels well; eye very much better, and general appearance good; pulse 140, after dinner. Carb. veg. 30. — 8th. Says, she feels well; has undoubtedly edema of upper eyelids; urine of a very deep brown or purplish color. Neither heat nor Nitric acid caused any perceptible deposit of albumen; with microscope epithelium mucus, tubes and blood globules were

The following table shows the date of the first symptoms of Scarlatina and of the first indications of Dropsy observed, and the number of days intervening between, together with the result: —

Of fifteen cases in which the time of attack of Scarlatina was known —

[* In this case the date of commencement is merely approximate, as no record was found until the appearance of dropsical symptoms, it is then stated that he had the Scarlatina three weeks before.]

Two of these cases are recorded as occurring at very short periods after the eruption-One at two and the other at three days. The first case is perhaps somewhat doubtful, and may have been the ordinary edema which occurs in the early stage of Scarlatina. The only reason to doubt this is, the fact that slight edema of face remained on the 18th of April, three weeks after it was first observed. The second occurring in three days after the appearance, is less ambiguous. Albumen was found in the urine on the same day (third), and a few days subsequently, fluctuation of abdomen was discovered and dulness of left chest observed. Several cases which appeared doubtful to us have been excluded. The case which showed evidence of dropsy sooner (ten days) than any but these two, was the most formidable, and after the symptoms were fully established the most rapidly fatal of the whole (case twelve).

I have been thus particular to note the intervening period between the eruption and the dropsy, because considerable discrepancy is found among the most respectable authorities on this point.

Watson says: — “According to the observations of Dr. Wells, the dropsical symptoms commonly show themselves on the twenty-second or twenty-third day after the commencement of the preceding fever. They have been known to begin as early as the sixteenth and as late as the twenty-fifth day.

West (Diseases of Children, p. 419,) says: — “Dropsical symptoms generally show themselves within a fortnight, or three weeks from the appearance of the rash.”

Wilson (Diseases of the Skin, p. 417,) says: — “During the period intervening between the tenth and twelfth day, and sometimes as early as the fifth or sixth day, anasarca is developed.”

He says further: — “Anasarca sometimes proceeds from anemia.” This form “may occur as early as the fourth day of the eruption.” The “urine is pale, and contains neither albumen, blood corpuscles nor epithelial cells.” This kind of “edema begins in the vicinity of the joints.”

Case eleven, which commenced in three days after eruption, does not coincide with this description of anasarca from anaemia as the edema commenced in eyelids, and as the urine was decidedly albuminous and contained epithelium.

Neither do any of the cases reported, agree in their characteristics with the above description. The urine was examined in five of the dropsical cases, and in three (eleven, twelve and sixteen) albumen was found; and in two cases (one and and fifteen) none was discovered. Heat promptly produced a flocculent precipitate in the specimens of urine which contained albumen, but the action of Nitric acid was more dilatory than is usual.

In cases eleven and twelve epithelium and mucus, and in case twelve tube casts and blood globules were found. In case sixteen, the urine was not examined by the microscope for want of time. The same reason prevented me from making a microscopical examination of the urine of case one, but in case fifteen epithelium, mucus, tubes, and globules having the ring appearance of blood globules in urine were found, notwithstanding no traces of albumen could be discovered.

Case eleven, where the urine was clear and normal, afforded the most albumen of any. The high colored smoky looking urine of some of the other cases which contained blood globules, as seen by microscope and hematosine (coloring matter of blood) as shown by tests, contained very little albumen.

This is strictly in accordance with Golding Bird's observations on “Bright's Disease.” The smoky appearance is characteristic of the presence of blood. The clear normal colored urine contains none.

I made careful examinations of the urine in two cases, not included in the present article, in both the presence of albumen was doubtful, but epithelium, tubes and mucus were found, and one deposited uric acid in beautiful lozenge crystals, united in clusters and in rhombic prisms.

I much regret that want of time prevented me from making more examinations of the urine. In regard to the presence of albumen in the urine, my experience coincides with the following extract from Wilson on Diseases of the Skin:

“Albumen is commonly, but not always found in the urine during the period of desquamation. Dropsy may even supervene without the urine becoming albuminous.

“Simon further observes, in reference to the contradictory opinions put forth with regard to the presence of albumen in the urine.”

“We have dropsical symptoms with albuminuria, dropsical symptoms without albuminuria, and albuminuria without dropsical symptoms.”

---