Chapter XXXIII: Part II: , Showing Predominance of Malarial Element . . . . 617 (32)

Whether the complications or sequelæ be dangerous depends upon their character. Rheumatism has never in my practice been dangerous, nor has it materially retarded convalescence, except when it affected the heart, causing pericarditis or endocarditis, when it involves great danger. Nephritis, if it be moderate, attended by little albuminuria and serous effusion, and by the occurrence of few renal casts in the urine, commonly ends favorably under judicious treatment, as we have already stated; but severe nephritis, with abundant albuminuria and casts and serous effusions, soon gives rise to alarming symptoms, and is the cause of death in a considerable number of instances. A similar remark is applicable to the angina, which occurs in all grades of severity. If it be attended by much cellulitis, with considerable ulceration or necrosis, the state is one of danger, in consequence of the difficulty in administering sufficient nutriment, of the diminished assimilation and of the loss of strength from the prolonged inflammatory fever, the septic poisoning, and the occasional hemorrhages. Complication by pharyngeal or nasal diphtheria, now so common where diphtheria is endemic, also greatly increases the danger.

Many cases, even when their course is normal and without complications, involve danger, and some are necessarily fatal, from the direct effect of the scarlatinous blood-poisoning. Such are grave or malignant forms of the disease which the experienced eye recognizes at a glance. Death often occurs rapidly from the toxæmia. Such cases are characterized by high temperature (105° or 106°), rapid pulse, a dusky-red hue of the surface from languid capillary circulation, pungent heat, frequent vomiting, diarrhoeal stools, a dry-brown tongue, and marked nervous symptoms, such as delirium, great restlessness, or stupor. Not a few in this form of scarlet fever take eclampsia, which is apt to be severe and repeated, and to end in fatal coma.

Other inflammatory complications and sequelæ, which have been described in the preceding pages, retard convalescence and jeopardize the life of the patient, such as empyema, endocarditis, pericarditis, and pneumonia. Otitis media is seldom immediately dangerous, although it may be painful and involve serious consequences, even a fatal meningitis, as has been stated above, after months or years of otorrhoea. Anomalous cases are believed to be, as a rule, more dangerous than such as are {536} attended by an early and full efflorescence and have the usual symptoms.

TREATMENT.--PROPHYLAXIS. Since the discovery by Jenner of the prophylactic power of vaccination as regards small-pox, the attention of the profession has been frequently directed to the prevention of scarlet fever. Belladonna has been employed for this purpose by a class of practitioners who believe in the theory that an agent which produces symptoms similar to those of a disease is antagonistic to that disease, and therefore tends to prevent it, or, if it be present, to render it milder; and since this herb causes an efflorescence upon the skin and redness of the fauces, it was selected as the proper preventive and remedial agent for scarlet fever. Its use, however, for this purpose has been fruitless, and it is now nearly or quite discarded.

It is probable, from a considerable number of observations, that scarlet fever occasionally occurs in the domestic animals during epidemics of the disease in children. It is stated that Spinola observed it in the horse; that Heim saw a dog that occupied the same bed with a scarlatinous patient sicken with fever, which was followed by desquamation; that Letheby saw scarlatina in swine, and Kraus in young cattle. Prominent veterinary surgeons, as Williams of Great Britain, admit the occurrence of scarlatina in animals, and the hope has arisen that since small-pox is modified in cattle so as to afford us the vaccine virus, perhaps scarlet fever may also be modified by passing through one of the lower animals, so that a milder and less fatal form of the disease might be produced in man by inoculation from the animal. This theory, though it deserves investigation, is far from being established. It has not yet, so far as I am aware, been shown that scarlet fever is milder in any animal than in man, nor, if we admit that it is modified in the animal, is it certain that the disease could be returned to man in the modified form. In the _N.Y. Medical Record_ for March 24, 1883, some experiments are detailed by S. W. Strickler of Orange, New Jersey. He cites the experiments of Caze and Feltz, who injected scarlatinal blood under the skin of sixty-six rabbits, and of these sixty-two died within eighteen hours to fourteen days, which indicated a highly poisonous state of the blood employed, either septic or scarlatinous, and certainly no mitigation of the virulence of the scarlet fever. Strickler obtained from Williams of Edinburgh nasal mucus from a horse supposed to have scarlatina, and with it inoculated twelve children, all of whom had sores at the point of inoculation, with redness of the skin around the sores, and in some instances swelling of the adjacent lymphatic glands. It is stated that the children thus inoculated did not contract scarlet fever subsequently when they were exposed to scarlatina. Obviously, there is a serious objection to such experiments upon children, so that they may not be repeated, but a movement has been made in one of the New York medical societies looking to the appointment of a competent committee to investigate them. Some of the prominent veterinary surgeons of this city do not attach much importance to the experiments thus far made, as they are in doubt whether the virus employed was that of the genuine disease.

It is a matter of great interest and importance, and one not yet elucidated, whether or to what extent disinfectant and antiseptic remedies administered internally prevent the occurrence of the infectious maladies {537} in those who have been exposed, and aid in curing those who are sick with them. Sodium sulpho-carbolate, from which, by decomposition in the system, carbolic acid is supposed to be set free, has been used for this purpose. It is administered to adults in doses of ten to thirty grains, and to children in doses proportionate to their age. Declat has prepared a syrup of phenic (carbolic) acid as a preventive and curative agent in the infectious diseases. It is now employed by several of the New York physicians, but thus far the statistics of its use are not sufficient to determine its efficacy. It is a question whether the so-called antiseptics can, on account of their toxic properties, be used with safety in doses sufficiently large to be antidotal to the specific principle of any of the infectious maladies.

It is not my intention to recommend in this treatise any remedial agent that has not been fully tried and its efficacy determined; but from observations made by myself in nearly twenty families in which scarlet fever was prevailing, I am convinced that boracic acid (acidum boricum), an antiseptic recently introduced into our Pharmacopoeia, deserves trial as a preventive and antidote of scarlet fever as well as diphtheria. The good result in my practice from the use of this agent, which only extends over about six months, may be due to the present type of scarlet fever, but I have been surprised at the favorable progress of the cases which appeared very grave in the beginning, at the small mortality, and at the large proportion of well children exposed to scarlatinous cases that escaped infection, to whom this medicine was regularly administered. Boric (boracic) acid has been recently used by aurists with remarkable success in suppurating and granulating otitis media, and by oculists as an eye-wash. E. R. Squibbs says of it (_Ephemeris_, May, 1883): "A solution saturated at ordinary temperatures contains between 4 and 5 per cent.... It is a very bland and soothing application, whether applied in powder or solution, relieving irritation and reducing suppuration.... It has been administered internally in large doses without any disturbing effects." The preparation which I have employed is one found in the shops, with the name listerine, prepared by a Western pharmaceutical firm. It contains, according to the manufacturers, the "essential antiseptic constituents of thyme, eucalyptus, baptisia, gaultheria, and mentha arvensis," and also two grains of benzo-boracic acid in each drachm. The dose of listerine which I have employed for an adult is one teaspoonful, considerably diluted with cold water. A child of five years can take ten to fifteen drops every two to four hours. I call the attention of the profession to the use of boracic acid as an antidote to the scarlatinous poison, without sufficient experience to enable me to speak positively of its efficacy, but with the hope and expectation, from observing its apparent effects in seventeen families afflicted with scarlet fever, that it will be found a useful addition to our means of controlling this much-dreaded and fatal malady.

In the present state of our knowledge the most reliable and certain prophylaxis is the isolation of patient and nurses, and the thorough and judicious employment of disinfectants upon their persons and in the apartments. All furniture and articles not absolutely required should be removed from the sick room, and no one should be allowed to enter it except the medical attendant and nurses. Constant ventilation should be {538} insisted on by lowering the upper and raising the lower sash of the window two or three inches in mild weather. Even in stormy weather sufficient ventilation can be obtained in this way without exposing the patient to currents of air, which should be avoided.

Since the exhalations from the body, the various excretions, and the epidermic cells shed so abundantly in the desquamative period contain the scarlatinous poison, measures should be employed to disinfect them, in so far as the comfort and well-being of the patient will allow. Vessels which receive the excretions should contain carbolic acid, chloride of lime or other disinfectant, and they should be immediately emptied and cleaned after use. By the frequent application of disinfecting washes to the nostrils and fauces the secretions from these surfaces are to a great extent deprived of their contagiousness. If otorrhoea occur, boracic acid, so serviceable in its treatment, acts as a disinfectant, but in addition the ear should be syringed with warm carbolized water, one drachm of carbolic acid to the pint of water, and this should be continued during convalescence, for cases occur which show that the discharge from the ear is probably the vehicle by which the virus is communicated. Even as late as the fourth week after the disappearance of the rash children in scarlet fever experience relief from inunction of the surface, and if carbolic acid be added to the substance which is employed for this purpose, and the inunction be made twice daily over the entire surface, contamination of the air through the exfoliations and exhalations from the skin is in great part prevented. The late William Budd of Bristol, England, was in the habit of recommending inunction of the surface twice daily with sweet oil, which answered the purpose of preventing dissemination of epidermic particles through the air; and we will presently see how successful were his precautionary measures.

A convalescent child should not be allowed to mingle with other children till three or four weeks have elapsed and desquamation has ceased; and all who are liable to take the malady should be excluded from the room in which a case has occurred for a longer period, and until it has been thoroughly disinfected by burning sulphur or other methods.

The New York Board of Health enforces the following excellent regulations to prevent the spread of scarlet fever as well as other acute infectious maladies:

"Care of Patients.--The patient should be placed in a separate room, and no person except the physician, nurse, or mother allowed to enter the room or to touch the bedding or clothing used in the sick-room until they have been thoroughly disinfected.

"Infected Articles.--All clothing, bedding, or other articles not absolutely necessary for the use of the patient should be removed from the sick room. Articles used about the patients, such as sheets, pillow-cases, blankets, or clothes, must not be removed from the sick room until they have been disinfected by placing them in a tub with the following disinfecting fluid; eight ounces of sulphate of zinc, one ounce of carbolic acid, three gallons of water. They should be soaked in this fluid for at least an hour, and then placed in boiling water for washing.

"A piece of muslin one foot square should be dipped in the same solution and suspended in the sick room constantly, and the same should be done in the hallway adjoining the sick room.

{539} "All vessels used for receiving the discharges of patients should have some of the same disinfecting fluid constantly therein, and immediately after being used by the patient should be emptied and cleansed with boiling water. Water-closets and privies should also be disinfected daily with the same fluid or a solution of chloride of iron, one pound to a gallon of water, adding one or two ounces of carbolic acid.

"All straw beds should be burned.

"It is advised not to use handkerchiefs about the patients, but rather soft rags, for cleansing the nostrils and mouth, which should be immediately thereafter burned.

"The ceilings and side-walls of a sick-room after removal of the patient should be thoroughly cleaned and lime-washed, and the woodwork and floor thoroughly scrubbed with soap and water."

By such measures of prevention there can be no doubt that the number of cases of scarlet fever would be greatly reduced.

Budd for years recommended similar precautions in the families which he attended, and the following is his testimony in regard to the result: "The success of this method in my own hands has been very remarkable. For a period of nearly twenty years, during which I have employed it in a very wide field, I have never known the disease to spread beyond the sick-room in a single instance, and in very few instances within it. Time after time I have treated this fever in houses crowded from attic to basement with children and others, who have nevertheless escaped infection. The two elements in the method are separation on the one hand, and disinfection on the other."[7]

[Footnote 7: _British Medical Journal_, Jan. 9, 1869.]

HYGIENIC TREATMENT.--The room occupied by a scarlatinous patient should be commodious and sufficiently ventilated. Its temperature should be uniform at about 70° during the course of the fever. When the fever begins to abate and desquamation commences, a temperature of 72° to 75° is preferable, so that there is less danger that the surface may be chilled during unguarded moments, as at night, when the body may be accidentally uncovered, since sudden cooling of the surface at this time may cause nephritis or some other dangerous inflammation. Henoch does not believe in the theory that the nephritis is commonly produced by catching cold, but many observations show that those who are carefully protected from vicissitudes of temperature, who remain during convalescence in a warm room, and are protected by abundant clothing, more frequently escape this complication than such as are under no restraint of this kind and are carelessly exposed in times of changeable weather. Nevertheless, it is true that a certain proportion suffer from nephritis however judicious the after-treatment may be. The best hygienic management does not always prevent its occurrence. The patient should not, therefore, leave the house until four weeks after the beginning of the fever, and in inclement weather not till a longer time has elapsed. So long as desquamation is going on and the skin has not regained its normal function the patient should remain indoor, and when finally he is allowed to leave the house he should be warmly clothed.

THERAPEUTIC TREATMENT.--In order to treat scarlet fever successfully it is necessary to bear in mind that it is a self-limited disease, running for a certain time and through certain stages, and that it is not {540} abbreviated by any known treatment. Therapeutic measures can only moderate its symptoms and render it milder. The severity of the disease is indicated by its symptoms, and the symptoms are to a certain extent under our control.

MILD CASES.--A patient with a temperature under 103°, and with only a moderate angina, does not require active treatment, but, however light the disease, he should always be in bed and in a room of uniform temperature, as stated above. Instances have come to my notice in the poor families of New York in which scarlet fever was not diagnosticated, and the patients were allowed to go about the house, and even in the open air, in the eruptive stage, till some severe complication or an aggravation of the type created alarm and medical advice was sought, when it appeared that a grave and dangerous condition had, through carelessness and ignorance, resulted from a mild and favorable form of the malady. The physician, when summoned to a case however mild, should never fail to take the temperature, note the pulse, inspect the fauces, and inquire in reference to the fecal and urinary evacuations, that he may detect early any unfavorable changes which may occur.

Since in all cases angina and more or less blood-deterioration are present, the following prescription will be found useful in mild as well as severe scarlet fever:

Rx. Potass. Chlorat. drachm ii;
Tr. Ferri Chloridi fl. drachm ii;
Syrupi fl. oz. iv. M.

S. Half a teaspoonful every hour to two hours to a child of three years; a teaspoonful to a child of six years.

Small doses of this medicine frequently administered act beneficially on the surface of the throat and tend to prevent the anæmia which is so common after scarlet fever. If the medicine be given gradually diluted with only a moderate amount of water, the effect is better on the inflamed fauces. Potassium chlorate is known to be an irritant to the kidneys in large doses, causing intense hyperæmia of these organs, with bloody urine or suppression of urine. The melancholy fate of Fountaine, who died from the effects of one ounce of this medicine, is known to the profession. I have seen a similar instance in a child. But doses of one to four grains, according to the age, can be administered with safety to children, so that half a drachm to a drachm and a half are taken in twenty-four hours. A quantity much exceeding this amount involves risk. In mild cases it is not necessary to treat the throat by topical measures, the above prescription producing sufficient local effect, but camphorated oil may be used externally. I ordinarily prescribe quinine in small doses for this form of scarlatina, as in the following formula:

Rx. Quiniæ Sulphat. gr. xvi;
Ext. Glycyrrhizæ scruple ss;
Syr. Pruni Virginianæ fl. oz. ii. M.

S. One teaspoonful every fourth hour to a child of three to five years, the potassium chlorate and iron mixture being administered twice between.

The treatment of scarlatina by antiseptic remedies will be considered hereafter.

{541} The itching and dryness of the surface, which increase the discomfort of the patient in mild as well as severe scarlatina, are relieved by frequently anointing the whole body with vaseline, cold cream, or butter of cocoa. Carbolic acid is an efficient remedy for pruritus, while it is also a disinfectant. It may be used in the following formula:

Rx. Acidi Carbolici drachm i;
Vaseline oz. iv. M.

S. To be applied over the entire surface.

In New York leaf lard has long been employed as an unguent over the entire surface in scarlet fever, and patients experience benefit from it. Alcohol and water or vinegar and water are sometimes employed for the same purpose. The linen should be changed every day and the bed thoroughly aired.

ORDINARY CASES AND CASES OF SEVERE TYPE.--A safe temperature in scarlet fever may be considered at or below 103°. If it rise above this, measures designed to abstract heat are very important--more important even in many cases than the medicinal agents which are commonly used to combat this disease. Since a high temperature retards assimilation, promotes deleterious tissue-change, and causes rapid emaciation and loss of strength, measures designed to reduce it are urgently needed. "The production of heat depends chiefly on oxidation of the constituents of the body" (Billroth). Therefore fever indicates an increase of the oxidation and a molecular disintegration above the healthy standard. Hence the augmentation of urea in the urine and the progressive emaciation and loss of weight which characterize the febrile state. Fever also diminishes the secretions by which food is digested and destroys the appetite, so that repair of the waste is insufficient. Moreover, a high temperature continuing for a time tends to produce degenerative changes, albuminous and fatty, in the tissues, the more rapidly the higher the temperature, so that the functions of organs are seriously impaired. Among the most dangerous of the tissue-changes is granulo-fatty degeneration of the muscular fibres of the heart. In dogs and rabbits that have perished from a high temperature artificially produced by experimenters granular clouding of the elementary tissues has been found after death.[8] A high temperature, therefore, in itself involves danger, and if it occur in an ataxic disease like scarlet fever, and be protracted, it greatly diminishes the chances of a favorable issue.

[Footnote 8: See experiments by Mr. J. W. Legg, _Lond. Path. Soc. Trans._, vol. xxiv., and others.]

The temperature can be reduced without shock or injury to the child by the judicious use of cold water externally. The cold-water treatment is not necessary if the temperature be under 103°, though useful if judiciously employed by sponging when the temperature is at 102° or 103°; but if it rise above 103° it is required, and the more urgently the higher the temperature. The external use of cold water as an antipyretic in the febrile diseases is now almost universally recommended by physicians, but it still meets with opposition on the part of families, especially in the treatment of the exanthematic fevers, and the directions for its employment are therefore not apt to be fully carried out during the absence of the medical attendant. The old theory that the fevers require warmth and sweating has such a firm hold on the popular mind that some years longer will be required for its removal.

{542} The modes of applying cold water recommended by cautious and experienced physicians are various. Von Ziemssen recommended that the patient be immersed in water at a temperature of 90°, and cool water be gradually added till the temperature fall to 77°. In a few minutes the patient is returned to his bed, his surface dried, and he is covered by the proper bed-clothes, when his temperature will probably be found reduced two or two and a half degrees. If the patient complain of chillness or his pulse be feeble, he should be immediately removed from the bath and stimulants administered, either whiskey or brandy, for if the extremities remain cool and the capillary circulation sluggish, the effect may be injurious, since some internal inflammation may arise to complicate the fever. Under such circumstances increased alcoholic stimulation is required.

The cold pack is also effectual for reducing the temperature. The patient is placed upon a mattrass protected by oil-cloth, and is covered by a sheet wrung out of water at a temperature of 70°. This is covered by one or two blankets. In half an hour he is returned to bed, and will be found to have a temperature two or three degrees less than that before the bath. Another method is to apply the sheet wrung out of water at 90°, and then reduce the temperature by adding water at a lower degree from a sprinkler. In most cases, however, I prefer to reduce the temperature by the constant application to the head of an india-rubber bag containing ice. The bag should be about one-third filled, so that it should fit over the head like a cap. At the same time, as a potent means of abstracting heat, at least when the temperature is at or above 104°, a similar application should be made by an elongated rubber bag lying over the neck and extending from ear to ear. Cold applied over the great vessels of the neck promptly abstracts heat from the blood, while it diminishes the pharyngitis, adenitis, and cellulitis; which is an important gain. At the same time, it is proper to sponge frequently the hands and arms with cool water. If the temperature with this treatment be not sufficiently reduced, one or two thicknesses of muslin frequently wrung out of ice-water should be placed along the arms and upon either side of the face. By such local measures, which are agreeable to the patient and without any shock or perturbing effect on the system, we can reduce the temperature two or three degrees. By adding alcohol or one of the alcoholic compounds to the water the popular objection to the use of cold is overcome.

Trousseau, in the treatment of sthenic cases attended by a high temperature, was in the habit of placing the patient naked in a bath-tub and directing three or four pailsful of water to be thrown over him in a space of time varying from one quarter of a minute to one minute, after which he was returned to bed and covered by the bed-clothes without being dried. Reaction immediately occurred, often with more or less perspiration. This treatment was repeated once or twice daily, according to the gravity of the symptoms. Trousseau, alluding to this treatment, says: "I have never administered it without deriving some benefit." But the application of cold water in a manner that does not excite or frighten the patient seems preferable. Henoch, having a large experience, gives the following advice in reference to the water treatment: "If the fever continue high and the apparently malignant {543} symptoms described above develop, the head should be covered with an ice-bag, ... and the child placed in a lukewarm bath, not under 25° R. (88.25° F.). I decidedly oppose cooler baths, because in scarlatina, which presents a tendency to heart-failure, cold may produce an unexpected rapid collapse more than in any other affection. But I strongly recommend washing the entire body every three hours with a sponge dipped in cool water and vinegar."[9] In grave cases with a high temperature the application of cold should be sufficient to produce a decided reduction of heat, otherwise the full benefit from its use is not obtained. With proper stimulation and proper precautions prostration does not occur from the ice-bags to the head and neck and cool sponging of other parts, so long as the temperature does not fall below 102° or 103°. The danger alluded to by Henoch can only occur from the use of the pack or general bath, and the water treatment can be efficiently carried out and the temperature sufficiently reduced without resorting to these. Even Currie of Edinburgh, who first drew attention to the benefit from the cold-water treatment of scarlet fever in an age when the sweating treatment, and even the exclusion of cool and fresh air from the apartment, were deemed necessary, recommended cold affusion only in sthenic cases with full and strong pulse, and he mentions as a warning two cases with quick and feeble pulse and cool extremities in which death occurred immediately after the use of the water.

[Footnote 9: _Diseases of Children._]

Sodium salicylate is in some instances a useful remedy for the reduction of heat in the infectious diseases. It seems to be more decidedly antipyretic than quinine in the febrile and inflammatory diseases, though somewhat depressing to the heart's action. James Couldrey writes to the _London Lancet_ (Dec., 1882, p. 1064) that he has derived great benefit from its use in seven cases of scarlet fever. He administered it every two hours till ringing in the ears was produced, and afterward every four hours, prescribing one grain for each year in the age of the patient. It is, in my opinion, a proper remedy when the pulse is full and strong and the temperature is not sufficiently reduced by the cold-water treatment.

Aconite and veratrum viride reduce fever, but they are too depressing to be safely employed in grave scarlet fever, and their antipyretic effect is less than that of water. The use of digitalis might be suggested by the quick and feeble pulse in certain cases that are attended by high temperature, but the judgment of the profession is for the most part against its use in such cases. What Stillé and Maisch state of its employment in typhoid fever appears equally applicable to scarlet fever: "Even its advocates have not shown that it abridges the disease or lessens its mortality, while it is abundantly demonstrated to impair the digestion, reduce the strength, and even to occasion sudden death. The use of digitalis in other forms of fever is equally unsatisfactory, and justifies the judgment of Traube, that the true field of action for digitalis is not fever."

Quinine is the medicine which above all others has been heretofore most used, by almost common consent of the profession, to reduce the temperature in malignant scarlet fever, but its use for this purpose is, according to my observations, far from satisfactory. To obtain its {544} antipyretic action it must be administered in large doses, and if any of the quinine salts in ordinary use be administered by the mouth in sufficient quantity, they are apt to be vomited. To a child of five years five grains should be administered twice daily by the mouth, or ten grains of a soluble salt, as the bisulphate, may be given per rectum, dissolved in a little warm water. Administered per rectum, it is frequently not retained unless held for a time by a napkin. A considerable proportion of the malignant cases are attended by not only irritability of the stomach, already alluded to, but by diarrhoea, so that quinine, if administered at all, should be employed hypodermically. The double salt of quinia and urea answers for this purpose, as it is very soluble in water and does not produce inflammation of the connective tissue. When the antipyretic doses of quinine are discontinued, this agent may be prescribed as a tonic in the doses recommended for the treatment of mild scarlet fever.

In severe cases with frequent and rapid pulse, in which ante-mortem heart-clots are apt to occur, the ammonium carbonate is often useful. It should be dissolved in water and given in milk, in as large doses as five grains every hour or second hour to a child of five years. It aids in producing stronger contraction of the cardiac muscular fibres, and thus diminishes the danger of the formation of thrombi. Ten-drop doses of the aromatic spirits of ammonia may be employed instead of the carbonate, given in sweetened water. It is especially useful if the stomach be irritable.

In severe cases attended by considerable angina and foul and offensive secretions upon the faucial surface an antiseptic, as boracic acid in small quantity, should be added to the potash and iron mixture recommended above. If no drink be allowed for a few minutes after the dose, so as not to wash it too soon from the fauces, the antiseptic effect is more certainly produced. Those old enough should be directed to hold the medicine for a moment like a gargle in the throat before swallowing it. I employ boracic acid by preference, as in the following formula:

Rx. Acid. Boracic. drachm ss;
Potass. Chlorat. drachm ii;
Tr. Ferri Chloridi fl. drachm ii;
Glycerinæ,
Syrupi _aa._ fl. oz. i;
Aquæ fl. oz. ii. M.

S. Give one tablespoonful every two hours to a child of five years.

More minute directions will presently be given for the treatment of the pharyngitis when we speak of the complications.

Alcohol, whether administered in one of the stronger wines, as sherry, or in whisky or brandy, is a most useful remedy in scarlet fever, and is indeed indispensable in all grave cases which are attended by feeble capillary circulation and evidences of prostration. Milk is also the best vehicle for this agent. The wine-whey or milk-punch should be given every hour or second hour. In scarlet fever, as well as diphtheria, comparatively large doses are required, as a teaspoonful of the stimulant every hour or second hour for a child of five years.

During convalescence the hygienic treatment already described is important. Nutritious diet and a moderate amount of alcoholic {545} stimulants are required, while the patient is kept indoors and protected from currents of air as long as desquamation is occurring. More or less anæmia is present in most convalescent patients, so that a mild tonic containing iron will aid in restoring the health. Elixir of calisaya-bark and iron; preparations of beef, iron, and wine, or the following prescription, will be found useful under such circumstances:

Rx. Ferri et Ammon. Citrat.,
Ammon. Carbonat. _aa._ gr. xxiv;
Syrupi fl. oz. i;
Aquæ fl. oz. ii. M.

S. Dose, one or two teaspoonfuls, according to the age, every third hour.

ANTISEPTIC TREATMENT.--It is still to be determined whether or to what extent antiseptics, administered internally, antagonize and control the scarlatinous poison, and are therefore curative of scarlet fever. The most important agent of this class, carbolic acid, can only be employed in small doses, for a dose much exceeding a drop for a child, or even exceeding a fractional part of a drop for a young child, might produce poisonous symptoms. Carbolic acid is a cardiac and arterial sedative, and it appears to reduce temperature. Intra-uterine injections of carbolized water in the treatment of puerperal fever are known to reduce temperature, even when there is no septic matter in the uterus to be disinfected and washed away, as in a case related to me in which the fever proved to be due to measles. It is not improbable that the antipyretic action in patients of this class who have no septic substance within the uterus is due largely, if not mainly, to the absorption of carbolic acid from the uterine surface and its sedative action on the vascular system. Whether this agent, so highly extolled by Declat, and to which I have alluded in a preceding page, can be safely employed in doses large enough to be efficient and curative will be determined by future observations. The same remark is applicable to the sulphocarbolate of sodium, whose antiseptic action is supposed to be due, as already stated, to the liberation of carbolic acid in the system. Since boracic acid does not seem to have any deleterious action, this agent has been administered to most of my scarlatinous patients during the last year, in addition to the older and better known remedies, and with a very small percentage of deaths. What may be the result in a more severe type of the disease remains to be seen.

TREATMENT OF COMPLICATIONS AND SEQUELÆ.--Local measures designed to diminish or cure the pharyngitis are important in all but the mildest cases. They are more especially required in the anginose variety and in those not infrequent cases in which diphtheria complicates scarlatina. Formerly it was necessary, in making applications to the fauces, to employ the brush or probang for those too young to use the gargle, but hand-atomizers, as Richardson's or Delano's, which are now in common use, afford a quick and easy method for making such applications. Six or eight compressions of the bulb of a good atomizer are sufficient to cover the fauces with the spray. Those hand-atomizers in the shops which have slender metallic points are apt to prick the buccal surface and cause bleeding if the child resist and toss the head. To prevent this, I am in the habit of directing india-rubber tubing to be drawn over the point in such a way as not to obstruct its action. The following will be found useful mixtures for the atomizer: For ordinary cases, {546}

Rx. Acidi Carbolici drachm ss, vel. Acid. Boracic. drachm ii;
Potass. Chlorat. drachm ii;
Glycerinæ fl. oz. ii;
Aquæ fl. oz. vi. M.

If the surface of the throat be covered by foul secretions,

Rx. Acidi Carbolici drachm ss;
Potass. Chlorat. drachm ii;
Glycerinæ fl. oz. j;
Aquæ Calcis fl. oz. vii. M.

Or else,

Rx. Tinc. Ferri Chloridi fl. oz. ss;
Acidi Sulphurosi fl. drachm ii;
Potass. Chlorat. drachm ii;
Glycerinæ fl. oz. i;
Aquæ q. s. ad. fl. oz. vi. M.

If diphtheritic exudation complicate the scarlatinous angina, or the surface of the throat in consequence of ulceration or necrosis present an appearance like that in diphtheria when the exudation begins to soften, being foul, jagged, of a dirty brown appearance from dead matter and fetid secretions, the following should be prescribed for use in the atomizer:

Rx. Acidi Carbolici drachm i, vel. Acidi Boraci drachm iii;
Liq. Potassæ fl. drachm i;
Potass. Chlorat. drachm ii;
Glycerinæ fl. oz. ii;
Aquæ Calcis fl. oz. viii. M.

Liquor potassæ, although a very efficient solvent of pseudo-membranes, is too irritating for use in the atomizer unless largely diluted. One part to eighty, as in the above mixture, will not be found too concentrated. The following powder, used every third hour through the insufflator, is also useful in cases of diphtheritic exudation:

Rx. Acidi Salicylici drachm ii;
Bismuth. Subnitrat. oz. ii. M.

To be used every third hour. It is the favorite remedy of some of the prominent New York physicians in the local treatment of diphtheria.

The following mixture is also beneficial for local treatment when the faucial surface is foul and offensive from the exudations and secretions. It should be applied by a large camel's-hair pencil every three to six hours:

Rx. Acidi Carbolici gtt. x;
Liq. Ferri Subsulphatis fl. drachm ii;
Glycerinæ fl. oz. i. M.

In all cases of scarlatinous pharyngitis sufficiently severe to require special treatment, cool applications should be made over the neck from ear to ear, as by two thicknesses of muslin frequently squeezed out of cold water, or by the elongated india-rubber bag already recommended in our remarks relating to methods to reduce temperature.

In the first days of scarlet fever the coryza is slight, and no discharge from the nostrils occurs, so that no local treatment is required; but before the termination of the malady, in cases of ordinary gravity, a nasal discharge usually supervenes, producing more or less redness and {547} excoriating the upper lip. Moreover, in localities where diphtheria occurs, if this malady complicate scarlet fever, it is apt to affect the nostrils at the same time that the fauces are invaded. These conditions require local treatment of the nares. It should be remembered that the Schneiderian membrane is midway in sensitiveness, as it is in location, between the conjunctival and buccal surfaces, and is readily irritated by strong applications. Medicinal applications made to it must be much milder than those which the fauces tolerate. They should always be applied warm, and a teaspoonful of any mixture properly employed is sufficient for each nostril at one sitting. The applications should usually be made every two or four hours, according to the gravity of the case and the amount of discharge. The best instrument for this purpose is a small syringe of glass or brass with curved neck and bulbous tip. The child's head should be thrown back and the piston depressed rapidly, so as to thoroughly wash out the nasal cavity. The application can also be made through an atomizer with a rounded tip or a tip covered by rubber tubing. The following is a useful prescription:

Rx. Acidi Carbolici drachm ss;
Sodii Chloridi drachm ii;
Aquæ Oj.

The substitution of 2 or 3 drachms of boracic acid in place of the carbolic acid makes a nicer preparation. If the diphtheritic pseudo-membrane appear in the nares, the officinal lime-water, injected every hour or second hour, is beneficial in consequence of its solvent action on pseudo-membranes.

It is evident, from what has been stated above, that the condition of the ear should be closely observed in and after scarlet fever. If the patient have earache, considerable relief may be obtained in the commencement by dropping a few drops of laudanum and sweet oil into the ear and covering it by some hot application, either dry or moist, which will retain the heat. A light bag containing common table-salt, heated, or dry and hot chamomile flowers will also answer the purpose. Water as hot as can be well tolerated dropped into the ear or allowed to trickle from a fountain syringe, so as to fill the ear, is also very beneficial in allaying the pain. If a few drops of laudanum be added it is more useful. If the pain be not quickly relieved, a leech should be applied at the base of the tragus. O. D. Pomeroy, an experienced aurist of New York, says: "Leeching employed at the right time rarely fails to subdue the pain and inflammation. The posterior face of the tragus is ordinarily the best place for applying the leech, but it may be applied in front of the ear or behind, wherever the tenderness on pressure is greatest. In my opinion, paracentesis may frequently be rendered unnecessary by the timely use of one or two leeches applied to the meatus."

If the otitis continue, as shown by pain in the ear, of which children old enough to speak bitterly complain, and which causes those too young to speak to press their fingers into or against their ears, this inflammation should not be neglected, as it may involve serious consequences. Multitudes of children have had permanent impairment or even loss of hearing, with caries or necrosis of the walls of the middle ear and of the mastoid cells, which might have been prevented by prompt and skilful {548} management of the ear in the early stage of the inflammation. If, therefore, the otitis continue without mitigation of pain after the above measures have been employed, paracentesis of the drumhead is probably required. The following directions for performing this operation, which will be useful to country practitioners who may not be able to obtain the assistance of a specialist, are from the pen of Pomeroy: "The forehead mirror should be worn, in order to leave the hands free to operate by either artificial or day light. A good-sized speculum is introduced into the meatus. Then an ordinary broad needle, about one line in diameter, with a shank of about two inches, such as oculists use for puncturing the cornea, should be held between the thumb and fingers, lightly pressed, so as not to dull delicate tactile sensibility. The part being well under light, the most bulging portion of the membrane should be lightly and quickly punctured with a very slight amount of force. The posterior and superior portion of the membrane is most likely to bulge. The chordæ tympani nerve ordinarily lies too high up to be wounded. The ossicles are avoided by selecting a posterior portion of the membrane. After puncture the ear should be inflated by an ear-bag whose nozzle is inserted into a nostril, both nostrils being closed, so as to force the fluid from the tympanum. The puncture may need to be repeated at intervals of a day or two, provided that the pain and bulging return."

Albert H. Buck of New York, in a highly instructive paper read before the International Medical Congress in 1876, writes as follows of paracentesis of the membrana tympani in scarlatinous otitis: "In this one slight operation, which in itself is neither dangerous nor very painful, lies the power to prevent the whole train of disagreeable and dangerous symptoms." Buck relates an instructive example: The age of the patient was three years, and the earache had been complained of only about twenty-four hours. "Toward morning," says he, "I was sent for, as the pain had become constant.... An examination with the speculum and reflected light showed an oedematous and bulging membrana tympani (posterior half), the neighboring parts being very red, though as yet but little swollen. In the most prominent portion of the membrane I made an incision scarcely three millimetres (one-tenth inch) in length, and involving simply the different layers of the membrana tympani. This was almost immediately followed by a watery discharge (without the aid of inflation), which ran down over the child's cheek. At the end of three or four minutes the child had ceased crying, and in less than a quarter of an hour she was fast asleep. At first, the discharge was very abundant and mainly watery in character, but it steadily diminished in quantity and became thicker, till finally, on the fourth day, it ceased altogether. On the tenth day the most careful examination of the ear could not detect any trace of either the inflammation or the artificial opening." The ear had probably been saved from ulceration of the drum membrane, long-continued suppurative otitis, and perhaps from permanent impairment of hearing.

When an opening has been made in the membrana tympani either by incision or ulceration, it is advisable in some instances to inflate the tympanum by Politzer's method, which has been alluded to above. The nozzle of an india-rubber bag, with a flexible tube attached, is introduced into the nostril on the affected side, and both nostrils are compressed {549} against it. The patient fills his mouth with water, which he swallows at a given signal, as after the words one, two, three, spoken by the operator. During the act of swallowing, which opens the Eustachian tube, the rubber bag is forcibly compressed, which forces the air along the tube into the middle ear and facilitates the escape of the pent-up secretions in the tympanic cavity.

If the otitis have continued unchecked by treatment until the secretions within it, after days and nights of suffering, have escaped by ulceration through the drumhead, the opportunity for prompt and certain cure is passed. Still, the patient under these circumstances may quickly recover, or there may be the other alternative described above, in which the ear is badly damaged and chronic inflammation established in the walls of the tympanum, giving rise to an offensive otorrhoea. In this state of the ear internal remedies are indicated, such as surgeons employ in suppurative inflammations of bone occurring in other parts of the system. Cod-liver oil and iodide of iron are required, especially by patients of strumous diathesis, the object being to promote a more healthy state of system, so as to prevent extension of the inflammation and facilitate the healing process. Carbolized solutions, as the following, syringed warm into the ear in which otorrhoea is occurring, are useful in promoting cleanliness and increasing the comfort of the patient:

Rx. Acidi Carbolici drachm ss;
Glycerinæ fl. oz. ii;
Aquæ fl. oz. iv. M.

But recently a much more effectual curative agent for local treatment has been discovered in boracic acid, by the use of which the discharge more quickly diminishes and the condition of the ear more certainly and rapidly improves than by the use of the carbolized mixtures. When the inflammation is recent and the ear sensitive and painful, the following prescription should be used:

Rx. Acidi Boracici drachm iiss;
Morphiæ Sulphat. gr. i;
Glycerinæ,
Aquæ _aa._ fl. oz. i. M.

S. Drop one to three drops into the ear three times daily.

If the acute stage of the otitis have passed, with fever and pain, and no tenderness be present on pressure, the following prescription, which causes too much pain in the acute stage, will be found useful to check the inflammation and otorrhoea and restore a healthy state to the granulating surface:

Rx. Acidi Boracici drachm iiss;
Alcohol.
Aquæ _aa._ fl. oz. i.

S. Drop one to three drops into the ear three times daily.

The beneficial effects observed from the use of boracic acid in aural surgery have given it nearly the same position as a curative agent to diseases of the ear which atropine holds to diseases of the eye. Recently, aurists are employing finely-triturated powder of boracic acid dusted into the ear. The patient lies upon the side with the affected ear uppermost. The ear is thoroughly cleaned by syringing with tepid water, and by means of a little scoop made of stiff paper or pasteboard or the segment {550} of quill as much of the powder is introduced into the ear as would cover a five-cent silver piece. By working the ear it descends to the drumhead. I can bear witness to its efficacy in the otorrhoea of children when it is used in this manner three times daily.

The following astringent has also been employed with good results for the otorrhoea resulting from scarlet fever as well as from other causes:

Rx. Zinci Sulphatis,
Aluminis _aa._ gr. v;
Aquæ fl. oz. i. M.

A few drops of this should be dropped into the ear, or, if the ear be sensitive and painful, five drops should be added to a teaspoonful of warm water and dropped or syringed into the ear.

But in recent times aurists have discovered a remedy superior to the above in iodoform, the action of which is safe and efficient for protracted otorrhoea with granulations, and it is superseding to a great extent the agents heretofore used in the treatment of this disease. The ear should first be thoroughly cleaned by syringing with warm water and dried, and iodoform, to which a little balsam of Peru is added to cover the disagreeable odor, should be pressed down to the bottom of the auditory canal by any convenient instrument. It is anodyne, astringent, and disinfectant, and should be employed in a dry state in considerable quantity.

The sequelæ of otitis media, such as granulations sprouting out from the drumhead, some of which may be of large size and are known as polypi, may require treatment by the aurist. A polypus may sometimes be removal by the forceps or better by the snare. Polypi not large and favorably located can sometimes be cured by an astringent powder, as iodoform, sulphate of zinc, or alum, or by applying the liquid subsulphate of iron. The otitis externa produced by the irritating discharge which flows from the middle ear soon disappears when the flow ceases.

The renal affection, which, as we have seen, so often commences in the declining period of scarlet fever or during convalescence in mild as well as severe cases, is frequently more dangerous than the primary disease. It largely increases the percentage of deaths. A clear appreciation of its therapeutic requirements is important, since by judicious treatment many recover who would inevitably be sacrificed by improper measures. The family should be informed that the danger from scarlet fever does not cease with the decline of the eruption, and that the kidneys may become seriously affected by too early exposure of the patient to currents of air or sudden changes of temperature, by which cutaneous transpiration is checked. He should therefore be kept indoors in a comfortable and uniform temperature three or four weeks after the termination of the fever, until desquamation has entirely ceased and the new epiderm is sufficiently thick and firm to protect the surface. During the changeable temperature of the autumnal, winter, and spring months even longer confinement at home may be advisable.

The nephritis and consequent albuminuria antedate by some days the occurrence of dropsy, and a physician should never discharge a scarlatinous patient without one or more examinations of his urine. When his visits cease the nurse should be instructed to make the examinations by heat and nitric acid during the ensuing month, and if any evidence, however slight, appear that the kidneys are involved, he should be notified, {551} in order that appropriate treatment may be immediately commenced. Early and correct treatment of the nephritis is attended by much better results than delayed treatment, and many more patients are doubtless now saved than in former times, when little attention was given to the state of the kidneys until dropsy or other prominent symptoms appeared. I have found no mother or nurse so ignorant that she could not properly employ the test of nitric acid and heat, and, if she be solicitous for the welfare of the child, she will not hesitate to carry out the directions and immediately notify the physician if the tests employed produce the least cloudiness or turbidity of the urine.

The patient as soon as nephritis commences, as shown by the state of the urine, should be put to bed in a room of warm and equable temperature (72° to 75° F.). His diet should be liquid, consisting of milk, farinaceous food, and a moderate quantity of animal broths. He may drink liquids freely, especially water not too cool, to which spiritus ætheris nitrosi is added. If he be prostrated by the primary disease, alcoholic stimulants should be allowed.