that during the acute stage the urea is also increased, the water reduced, and the chlorine reduced; conditions almost identical with those which occur in pneumonia.*

That the amount of urine should be decreased in the early stages of scarlatina is, at first glance, remarkable, but is easily understood when another comparison is instituted, as between this disorder and pneumonia, or other diseases of the same class. For in them all, contrary to the general view, there is an excessive exudation from the skin. The position of this question was admirably put by Dr. Snow in his paper on the circulation in the capillaries. (Vide the Medical Gazette for 1842-3, volume 1, pp. 810-16.) In this paper, after quoting the experiments of MM. Breschet and Becquerel, which prove that the application of an impermeable gauze to the whole surface of the body of an animal stops transpiration and causes a gradual decrease of temperature, Snow proved that the same effects could be produced locally in his own person; since, by clothing his arm in an impermeable covering, he brought down the temperature in a marked degree. Moving from this fact to its opposite, Snow deduced with great acuteness, and with his natural precision he afterwards proved the deduction, that whenever the skin is hot and dry, during febrile states, the dryness is not an indication of suppressed, but of rapid excretion, due to the excessive emanation of caloric, and immediate evaporation.

* See Parkes, On the Urine, p. 263.

But if this view be applicable to all disorders of the inflammatory type, so is it most applicable in scarlet fever, where, with an universally heated state of skin, there are constant thirst, gratified largely by copious drinks, a decreased excretion of urine, and withal a decreasing weight of the body. With these general, there are, moreover, in scarlet fever local indications of the true inflammatory state. The bare fact that acute rheumatic arthritis is an occasional concomitant, is alone sufficient to prove the pathological position of the disease; for rheumatic inflammation could not coexist with anything less than an inflammatory diathesis: but more frequent examples of local inflammatory changes also mark definitely the same fact. Of these local inflammations the throataffection comes first; next, I think, enlargement and suppuration of glands situated superficially. In one case, of which I have the notes before me, this glandular inflammation, commencing in the parotid and involving the whole side of the neck in what looked like an erysipelatous suppuration, did such destruction that the motor nerves of the face were destroyed, and the cheek was left permanently paralysed. Following after these results, purulent deposits in joints occur, perhaps, next in sequence; and after these, inflammatory products in the internal organs, especially in the lungs and spleen. I do not include in these indications of inflammatory conditions the kidneydisorder which is so common a sequela, because I am inclined to consider this rather as a mechanical derangement than an inflammatory result; but even

this point is one which remains sub judice, for exfoliation of epithelium is virtually little different from an inflammatory exudation.

Lastly, the mode of death during scarlet fever in the acute stage is essentially, in so far as my experience goes, the same as in all the true inflammatory affections. In this stage the blood, when drawn, is cupped or buffed; the blood-corpuscles show that well known attraction for each other which causes them rapidly to run together, and sink en masse to the lower part of the fluid; and the fibrine exhibits its tendency to slow and clear separation. And as out of the body the tendency is to a deposition of the fibrine, so in it the same tendency, commencing on the right side of the heart, leads to rapid death from arrest of the circulation. Even mild cases of scarlet fever sometimes rapidly, and without assignable reason to those who are unacquainted with the symptoms of fibrinous deposit, end fatally from this cause alone. I have written so fully in another volume on these forms of death, that I will not trouble the reader with the repetition of an old history in a new place.

THE POISON OF SCARLET FEVER IN RELATION TO ITS PROPAGATION AND ITS MODE OF ACTION.

The poison of scarlet fever, specific in its nature, is the most subtle of all the zymotic poisons. It travels on material objects with infinite ease, and may be laid up in material objects for any period; yet, left to itself, it seems incapable of transit to any considerable distance, the air alone not wafting it more than a few feet, if so far.

The poison, though minutely distributed, is almost certainly solid in respect to its own material property. If it were volatile, gaseous, it would be more dangerous than it is to those who surround patients suffering from the disease, and would rapidly lose all its dangers on distribution upon articles of clothing and the like. Being solid, however, it traverses over a limited area about the patient, but fixes on surrounding objects capable of receiving it, and abides by them until destroyed by heat or other disinfectant. Adhering in this manner to transmissible substances, the poison is carried in the most mysterious manner into the bodies of the susceptible. I know, for instance, of a well authenticated case in which the disease was conveyed into the family of a medical man by the mere transmission of a letter from the house of a friend many miles distant, in which one of the inmates was suffering from the disorder. The infected letter was unhappily seized by the child of the medical man, and was conveyed by her to her mamma. Both were susceptible, both contracted the disease, and both died of it.

For the same reason the poison can be laid up in the homes of infected families in the most singular way. During my early career, I assisted a practitioner at Saffron Walden in Essex for a considerable period. In our union district we had an outbreak of scarlet fever. At a short distance from one of our villages there was situated on a slight eminence a small clump of labourers' cottages, with the thatch peering down on the beds of the sleepers. A man and his wife lived

in one of these cottages, with four as lovely children as England ever owned. Not those immortal Angles whom Pope Gregory recognised as angels in the slavemart of Rome were more worthy of our country. But the poison of scarlet fever entered this poor man's door, and at once struck down one of the flock. I had no time allowed me for the practice of any special remedy; but it seemed to me that I had saved the remaining children by obtaining their removal to the care of a grandparent, who lived at a village a few miles away. Some weeks elapsed, when one of these was allowed to return home. Within twenty-four hours it was seized with the disorder, and died with equal rapidity to the first. We were doubly cautious in respect to the return of the other children. Every inch of wall in the cottage was cleansed and lime-washed; every article of clothing and linen was washed, or, if bad, destroyed. Floors were thoroughly scoured, and so long a period as four months was allowed to elapse before of the living children were brought home. Then one child was allowed to return, a boy nine years of age. He reached his father's cottage early in the morning: he seemed dull the next day; and at midnight in the succeeding twelve hours I was sent for, to find him also the subject of scarlet fever. The disease again assumed the malignant type, and this child died, despite all that could be done. I recommended after this event that the cottage should be newly roofed; but I am unable to say whether any such precaution was taken, for soon afterwards I left the

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