Chapter VI: Part II: Treatment of Scarlet-Fever (1)

DIFFERENT METHODS OF OTHER SCHOOLS.

33. Before giving the description of hydriatic treatment of scarlet-fever, I shall, for the sake of a better appreciation, glance over the different methods which have been recommended by other schools.

34. THE EXPLETIVE METHOD (_blood-letting_)

has been advocated by some of the best authorities, and there cannot be a doubt but that it must have rendered good service in cases of violent reaction, or else men like de Haen, Wendt, Willan, Morton, Alcock, Dewees, Dawson, Dewar, Hammond, &c., would not have pronounced themselves in favor of it. However it requires nice discrimination and a great deal of experience, as in any case where it does no good it is apt to do a great deal of harm, by weakening the patient and thus depriving him of that power which he so much needs in struggling against the enemy invading his system. Besides, the expletive method has found many antagonists of weight: Simon, Williams, Tweedie, Allison and others have shown the danger of a general and indiscriminate use of it. Williams,[7] in his comparison of the epidemics of scarlatina from 1763 to 1834, has come to the conclusion that the possibility of a cure in cases of blood-letting, compared with the cases where the patients have not been bled, is like 1:4; i. e. four patients have died after blood-letting, when only one died without bleeding. "Experience has equally shown, says Dr. Allison, that the expectation entertained by Dr. Armstrong[8] and others, that by early depletion the congestive or malignant form of the disease may be made to assume the more healthy form of inflammation and fever, is hardly ever realized; and in many cases, although the pulse has been full and the eruption florid in the beginning, _blood-letting (even local blood-letting) has been followed by a rapid change of the fever to a typhoid type, and manifestly aggravated the danger_."--My own experience would prompt me to declare myself against blood-letting in general, even if I had not a sufficient quantity of water at hand to manage the violent or irregular reaction of a case. Blood-letting, in any case of eruptive fever, and with few exceptions in almost every other case, appears to me like pulling down the house to extinguish the fire. A little experience in hydriatics, a few buckets of water, with a couple of linen sheets and blankets, will answer all the indications and remove the danger without sending the patient from Scylla into Charybdis.

35. THE ANTI-GASTRIC METHOD,

consisting in the free use of emetics or purgatives, has been recommended by some eminent practitioners. Withering,[9] Tissot, Kennedy and others are in favor of the former, and find fault with the latter, whilst Hamilton,[10] Willard, Abernethy, Gregory, &c., prefer purgatives, and some, of course, look upon calomel as the anchor of safety, which they recommend in quantities of from five to ten grains per hour.[11] The friends of one part of the anti-gastric method make war upon the other: Withering finding purgatives entirely out of place and Sandwith, Fothergill and others having seen nothing but harm done by them, whilst Wendt,[12] Berndt,[13] Heyfelder and others caution their readers against emetics. The anti-gastric method has been of some service in epidemics and individual cases, when the character of the disease was decidedly gastric and bilious. To use emetics or purgatives indiscriminately would do much more harm than good; as, for instance, during a congestive condition of the brain, the former, and with inflammatory symptoms of the bowels, the latter, would be almost sure to sacrifice the patient to the method.

36. THE AMMONIUM CARBONICUM,

recommended by Peart,[14] has been considered by many as a specific capable of neutralizing the scarlatinous poison, whilst others have used it only as a powerful tonic in torpid cases. Experience has shown that it is not a specific, and that its use as a tonic, requiring a great deal of care and discrimination, is a good deal more dangerous than the mode of treatment I am going to recommend in cases where tonics are required.

37. CHLORIDE OF LIME.

About the same opinion may be given on _Chloride of Lime_. As a gargle, and taken internally, the aqua-chlorina has done good service in malignant scarlatina, especially in putrid cases.

38. ACETIC ACID.

Brown[15] recommends diluted _Acetic Acid_ as a specific against all forms of scarlatina. Experience, however, has not supported his confidence in the infallibility of his remedy.

39. MINERAL ACIDS (MURIATIC ACID--PRESCRIPTIONS)

have also been used with good effect in some epidemics. _Muriatic acid_ I have frequently used myself for inflammation of the throat, in connection with hydriatic treatment, and it has almost always contributed to relieve the symptoms materially.[16]

40. FRICTIONS WITH LARD

were used already by Caelius Aurelianus,[17] and recently re-introduced into practice, by Drs. Daene and Schneemann,[18] in Germany, and by Dr. Lindsley,[19] in America. Even hydriatic physicians[20] have tried them with some success. However, notwithstanding the strong recommendations of the remedy on the part of the above named practitioners and others, the efficacity of it as a general remedy for scarlet-fever has not been confirmed. On the contrary, Berend[21] and Hauner[22] found that it did not prevent desquamation, as it had been asserted, and even Richter restricts his commendations to the vague assertion "that it seemed to him as if the cases when he used the lard were made milder than they would have been without it."

41. BELLADONNA.

The remedy which has attracted and still attracts in a very high degree the attention of physicians and parents, is _Belladonna_. This remedy was first introduced as a specific and prophylactic by Hahnemann, and soon recommended not only by his own disciples, but by some of the best names of the "regular" school.[23] But soon after, as many physicians of standing declared themselves adversaries to Hahnemann's discovery,[24] and whatever may be the merits of belladonna as a specific and prophylactic in some quarters, it is certain that it never answered the expectation raised by its promulgators in others. As far as my own experience extends, I have seen very little or no effect from it. I have restricted myself, it is true, to homoeopathic doses, being afraid of the bad consequences of larger quantities in children; but from what I have seen in my own practice and that of some other physicians with whom I was familiar, I cannot but advise my readers not _to rely_ either on the prophylactic or the curative power of belladonna, when a safer and more reliable remedy is offered to them. A remedy may be excellent in certain cases and certain epidemics, and many an honest and well-meaning physician may be deceived into the belief that he has a general remedy in hand, whilst others, or himself, on future occasions discover that he has allowed himself to be taken in. Had not belladonna and aconite proved beneficial in many cases, they would scarcely have acquired their reputation, but with all due respect for Father Hahnemann and his system, I must deny belladonna to be a general, safe and reliable remedy in the prevention and cure of scarlet-fever.

42. THERE IS NEITHER A SPECIFIC NOR A PROPHYLACTIC TO BE RELIED ON.

All these different methods and remedies, and many others, have been and are still used with more or less effect. But where there are three physicians to recommend one of them, there will always be four to contradict them. They may all do some good in certain epidemics or individual cases; they may relieve symptoms; they may save the life of many a patient who would have died without them (although many a patient who died, might have lived also, had he been under a more judicious treatment, or--under no treatment at all.) But none is reliable in general; none contains a specific to neutralize the morbid poison; none is a reliable prophylactic, such as vaccina for small-pox; and if single physicians, or whole classes of physicians, assert to the contrary, the fault must lie somewhere, either in their excess of faith in certain authorities, which induces them to throw their own pia desideria into the scales, or in a want of cool, impartial observation continued for a sufficient length of time to wear out sanguine expectations. _The fact is that there neither exists a reliable prophylactic, nor has a safe specific been found as yet; that all is guess-and-piece work; and that people are taken by scarlet-fever and die of it about the same as before those vaunted methods and remedies were discovered._ I wish to impress my readers with this fact--the proofs of which they can easily find in the mortality lists of the papers--to make them understand that by giving up for the hydriatic method any of the modes and remedies, which have been in use hitherto, they do not run a risk of losing anything.

43. WATER-TREATMENT, AS USED BY CURRIE, REUSS, HESSE, SCHOENLEIN, &C.

Beside the above modes of treatment _cold_ and _tepid Water_ has been extensively used and recommended by reliable authorities. Currie,[25] Pierce, Gregory, Bateman, von Wedekind, Kolbany,[26] Torrence, Reuss,[27] von Froehlichsthal,[28] and others, have treated their scarlet-patients with _cold affusions_. Henke, Raimann, Froehlich, Hesse,[29] Steimmig,[30] Gregory, Jr., Schoenlein, Fuchs, and others, have not ventured beyond _cool_ and _tepid ablutions_. The former, although the general result has been very satisfactory, have proved dangerous in some cases; and the latter, though safer in general, have not been efficient in many others. The use of water, though safer than other remedies, has never become general, _owing to the unsystematic, unsafe, or inefficient forms of its application_.

Fear and prejudice--fed by the great mass of physicians, who generally take too much care of their reputation to expose it in the use of a remedy the effects of which are so easily understood by every one--have also been obstacles to its promulgation; and the exaggerations of some of its advocates in modern times, bearing for a great part the characteristics of charlatanism, have scared many who might have become converts to Priessnitz's method, to whose genius and good luck we are indebted for the most important, most harmless, and at the same time the most efficient and most reliable discovery, viz.:

44. PRIESSNITZ'S METHOD--THE WET-SHEET-PACK,

a remedy which, alone, is worth the whole antiphlogistic, diaphoretic, and, indeed, the whole curative apparatus of the profession, in ancient and modern times, for any kind of fevers, and especially for eruptive diseases. Nor did the physicians before Priessnitz know anything about the use of the _sitz-bath_ for affections of the brain in torpid reaction, which in such cases, is the only anchor of safety. In short, water-treatment was, like other methods, an excellent thing for certain symptoms, but not generally and safely applicable in every case.

To appreciate the effects of the wet-sheet pack, one must have seen it used for inflammatory fever, when it acts like a charm, frequently removing all the feverish symptoms, and their cause, in a few hours.

45. TECHNICALITIES OF THE PACK AND BATH.

Let me give you its technicalities, and the rationale of its action:

A linen sheet, (linen is a better conductor than cotton,) large enough to wrap the whole person of the patient in it (not too large, however; if there is no sheet of proper size, it should be doubled at the upper end) is dipped in water of a temperature answering to the degree of heat and fever, say between fifty and seventy degrees Fahrenheit, and more or less tightly wrung out. The higher the temperature of the body, and the quicker and fuller the pulse, the lower the temperature of the water, and the wetter the sheet. This wet sheet is spread upon a blanket previously placed on the mattress of the bed on which the packing is to take place. The patient, wholly undressed, is laid upon it, stretched out in all his length, and his arms close to his thighs, and quickly wrapped up in the sheet, head and all, with the exception of the face; the blanket is thrown over the sheet, first on the packer's side, folded down about the head and shoulders, so as to make it stick tight to all parts of the body, especially the neck and feet, tucked under the shoulders, side of the trunk, leg and foot; then the opposite side of the blanket is folded and tucked under in the same manner, till the blanket and sheet cover the whole body _smoothly_ and _tightly_. Then comes a feather-bed, or a comforter doubled up, and packed on and around the patient, so that no heat can escape, or air enter in any part of the pack, if the head be very hot, it may be left out of the pack, or the sheet may be doubled around it, or a cold wet compress, not too much wrung out, be placed on the forehead, and as far back on the top of the head as practicable, which compress must be changed from time to time, to keep it cool. Thus the patient remains.

46. The first impression of the cold wet sheet is disagreeable; but no sooner does the blanket cover the sheet, than the chill passes away, and usually before the packing is completed, the patient begins to feel more comfortable, and very soon the symptoms of the fever diminish. The pulse becomes softer, slower, the breathing easier, the head cooler, the general irritation is allayed, and frequently the patient shows some inclination to sleep. When the fever and heat are very high, the sheet must be changed on growing hot, as then it would cause the symptoms to increase again, instead of continuing to relieve them. The best way to effect this changing of the sheet is to prepare another blanket and sheet on another bed, to unpack the patient and carry him to the new pack, where the process described above is repeated. Sometimes it is necessary to change again; but seldom more than three sheets are required to produce a perspiration, and relieve the patient for several hours, or--according to the case--permanently. The changing of the sheet may become necessary in fifteen, twenty, twenty-five, thirty or forty minutes, according to the degree of fever and heat. In every new sheet the patient can stay longer; in the last sheet he becomes more quiet than before, usually falls asleep, and awakes in a profuse perspiration, which carries off the alarming symptoms.

47. A few minutes before the perspiration breaks out, the patient becomes slightly irritated, which irritation is removed by the appearance of the sweat. I mention this circumstance, to prevent his being taken out just before the perspiration is started. When he becomes restless _during perspiration_, he is taken from his pack and placed in a bathing-tub partly filled with cool or tepid water, (usually of about 70 deg.,) which has been prepared in the meanwhile; there he is washed down from head to foot, water from the bath being constantly thrown over him until he becomes cool. Then he is wrapped in a dry sheet, gently rubbed dry, and either taken back to his bed, or dressed and allowed to walk about the room. When the fever and heat rise again, the same process is repeated.

48. ACTION OF THE PACK AND BATH.--RATIONALE.

The action of the wet-sheet pack is thus easily accounted for:

According to a well-known physical law, any cold body, whether dead or alive, placed in close contact with a warm body, will abstract from the latter as much heat as necessary to equalize the temperature of both. The transfer of caloric will begin at the place at which the two bodies are nearest to each other. The wet sheet, which touches the patient's body all over the surface, abstracts heat from the latter, till the temperature of the sheet becomes equal to that of the body. In proportion as the surface of the body yields heat to the sheet, the parts next to the surface impart heat to the latter, and so forth, till the whole body becomes cooler, whilst the sheet becomes warmer. As the heat imparted to the sheet cannot escape from it, the sheet being closely wrapt up in the blanket and bed, the current of caloric once established towards every part of the surface of the body will still continue; after the temperature of the sheet and the body has become equal, there will be an accumulation of heat around the body, frequently of a higher degree than the body itself. To explain this phenomenon, we ought to consider that we have not to do with _two dead_ bodies, but with _one dead_ and _one living_ body, which constantly creates heat, thus continuously supplying the heat escaping from it to the sheet, and keeping up the current of caloric _and electricity_ established towards the surface. There cannot be a doubt that the abstraction of electricity from the feverish organism contributes in a great measure to the relief of the excited nerves of the patient, as well as to the excess of temperature observed around the body in the wet-sheet pack (after the patient has been in it for some time); and that, in general, electricity deserves a closer investigation in the morbid phenomena of the human body than it has found to this day.

49. WHAT EFFECT COULD BE EXPECTED FROM A WARM WET-SHEET?

The first impression of the wet-sheet is, as I stated before, a _disagreeable_ one. If it were _agreeable_--as a warm sheet, for instance, would be, which has been occasionally tried, of course without doing any good--_it would not produce a reaction at all, and consequently there would be no relief for, and finally no cure of the patient effected by it_. But the impression of the cold sheet, being powerful, is transferred at once from the peripherical nerves, which receive the shock, to the nervous centres (the spine, the cerebellum and the brain), and, in fact, to the whole nervous system, and the reaction is almost immediate; the vascular system, participating in it, sends the blood from the larger vessels and the vital parts, to the capillaries of the skin; and when, through repeated applications of the sheet, the system is relieved and harmony restored, in a sufficient degree, in and among the different parts of the organism, to enable them to resume their partly impeded functions, a profuse perspiration brings the struggle to a close, by removing the morbid matter which caused the fever, whereupon the skin is refreshed and strengthened, and the whole body cooled and protected by a cool bath from obnoxious atmospheric influences.

50. I am not aware that a better rationale can be given of the action of other remedies. Any physician can understand that its effect must be at once powerful and safe, and that there is no risk in the wet-sheet pack of the reaction not taking place, as it may be the case in severer applications of cold water, without the pack. One objection I have often heard, viz.: that the process is very troublesome. But what does trouble signify, when the life and health of a fellow-being is at stake?--It is true, the physician is frequently compelled to render the services of a bath-attendant, and stay with the patient much longer than in the usual practice; but he gets through sooner, and, if not the patient and his friends, his own conscience will pay him for his exertions and sacrifice of time.

There is little trouble with small children, who make a fuss only, and become refractory, when the parents, grandmammas and aunts set the example. When all remain quiet, and treat the whole proceeding as a matter of necessity, children usually submit to it very patiently, and soon become quiet, should they be excited at the beginning. The fewer words are said, and the quicker and firmer the physician performs the whole process, the less there is trouble. After having been taught how to do it, the parents or friends of the patient will be able to take the most troublesome part of the business off the physician's hands, who, of course, has more necessary things to do, during an epidemic, than to pack his patients and attend to them in all their baths himself.

Only with spoiled children I have had trouble, and more with them that spoiled them. The best course, then, is to retain only one person for assistance, and to send the rest away till all is over. There are people, who _will_ be unreasonable; of course, it is no use to attempt reasoning with them. I remember the grandmother of a little patient, with whom the pack acted like a miracle, removing a severe inflammatory fever in two hours and a half, telling me "she would rather see the child die, than have her packed again," although she acknowledged the pack to have been the means of her speedy recovery. It is true there was some trouble with the child, but only because the whole family were assembled in the sick-room to excite the child through their unseasonable lamentations and expressions of sympathy about the "dreadful" treatment to which she was going to be submitted. Grandmother would not have objected to a pound of calomel!--But we shall speak about objections and difficulties in a more proper place.

51. NO CUTTING SHORT OF THE PROCESS OF SCARLATINA--THE MORBID POISON MUST BE DRAWN TO THE SKIN AS SOON AS POSSIBLE.

Scarlet-fever is a disease, which cannot be cut short. Any attempt to stop the process of incubation, after the contagion has once been received within the body, or to prevent its being thrown out upon the surface, would destroy the patient's life: the morbid poison must be concocted, and it _must come away by being drawn to the skin as soon as possible_, to prevent its settling in the vital parts, and injuring them. The safest way of assisting nature in her efforts of eliminating the poison, is to open the way, which she points out herself. We know that the sooner and the more completely the eruption makes its appearance, the brighter and the more constant the rash, the less there is danger for the patient, and _vice versa_. Well, there is not a better remedy than the wet-sheet pack, to serve the purpose of nature, i. e., to remove the morbid poison from the inner organs, and draw it to the surface; whilst at the same time it allays the symptoms, improves the condition of the skin for the development of the rash, and relieves the patient, without depriving him of any part of that organic power so indispensable for a cure, and without which the best physician in the world becomes a mere blank. Under the process of wet-sheet packing, the heat invariably abates, the pulse becomes slower and softer, the violence of the symptoms is alleviated, the skin becomes moist, the restlessness and anxiety of the patient give way to a more quiet and comfortable condition; he perspires and falls in a refreshing sleep. Is there any other remedy, that has the same general and beneficial effect? I know of none.

52. NECESSITY OF VENTILATION--MEANS OF HEATING THE SICK-ROOM--RELATIVE MERITS OF OPEN FIRES, STOVES AND FURNACES.

Next to its intrinsic value, our method gives the patient the great advantage of enjoying _pure fresh air_, either in or out of bed, as it keeps the skin and the whole system in such order as to resist the effects of atmospheric influences better than under a weakening process. And every body knows, or, at least, every body ought to know, that free circulation of fresh air is one of the most important means, in contagious diseases, of preventing the malady from becoming malignant, and of lessening the intensity of the contagion. Although the times are passed, when patients in the heat of fever were almost roasted in their beds, whilst a drink of cooling water was cruelly and stupidly denied them; the temperature of the sick-room is, in general, still kept too high, and not sufficient care is taken to renew the air as frequently, I ought to say as constantly, as necessary for the benefit of the patient. Usually there is no ventilation; very seldom a window is opened, especially in the cold season, when epidemics of scarlatina are most common, and commonly the room is crowded with friends of the patient, who devour the good air, which belongs to him by right, and leave him their exhalations to breathe instead. There is nothing better able to destroy contagious poisons than oxygen and cold; and if we consider that every human being absorbs every minute a volume of air larger than the bulk of its own body, we must understand how necessary it is to keep people away from the sick-room, who are not indispensably necessary to the patient, and to provide for a constant supply of fresh air. But whatever may be the arrangement for that purpose, the patient should not be exposed to a draught. Stoves and fire-places are pretty good ventilators for drawing off the bad air from the room; if you take care not to have too much fire, and to allow a current of pure air to enter at a corresponding place, the top of a window, or a ventilator in the wall opposite the fire-place, there will always be pure air in your sick-room. The air coming from furnaces, which unfortunately have become so general, is good for nothing, especially when taken from the worst place in the house, the cellar or basement. I consider the worst kind of stoves better than the best kind of furnaces; only take care not to heat the stove too much, or to exclude the outer air, which is indispensable to supply the air drawn off by the stove for feeding the fire. The difference between a furnace and a tight stove or fire-place is this: The furnace takes the bad air from the basement or cellar, frequently made still poorer through its passing over red hot iron, which absorbs part of its oxygen, and fills the room with it. The room being filled with poor air, none of the pure air outside will enter it, because there is no vacuum. Thus the bad air introduced into the room, and the bad air created by the persons in it, will be the only supply for the lungs of the patients. But should the furnace take its air from outside the house, as it is the case with some improved kinds, there would still be no ventilation in the sick-room, except there be a fire-place beside the register of the furnace. With the stove or fire-place it is different: The stove continually draws off the lower strata, i. e. the worst part, of the air to feed the fire, whilst pure air will rush in through every crevice of the doors and windows to supply every cubic-inch of air absorbed by the stove. Thus the air in the room is constantly renewed, the bad air being carried off and good air being introduced. However, the openings through which the pure air comes in, must be large enough in proportion to allow a sufficient quantity of air to enter the room to make fully up for the air absorbed by the stove; for, if not, the air in the room will become thin and poor, and the patient will suffer from want of oxygen. An open fire, from the necessity of its burning brighter and larger to supply sufficient heat, a comparatively large part of which goes off through the chimney, will require a greater supply of air, and consequently larger ventilators or openings for the entrance of the pure air from outside the room. In very cold weather, and in cold climates in general, stoves are preferable to fire-places, the latter producing a draught, and not being able to heat a room thoroughly and equally, causing one side of the persons sitting near them to be almost roasted by the radiant heat in front, whilst their backs are kept cold by the air drawing from the openings in the doors and windows towards the fire to supply the latter. In merely cool weather, and in moderately cold climates, especially in damp places, I would prefer an open fire to a stove. In cold climates stoves are decidedly preferable, especially earthen ones, as they are used in Germany and Russia. Iron stoves must never be heated too much, as the red hot iron will spoil the air of the room, by absorbing the oxygen, as you can easily see by noticing the sparks, which form themselves outside the stove in very hot places.

53. TEMPERATURE OF THE SICK-ROOM.

The _temperature of the sick-room_ should not be much above 65 deg. Fahrenheit; in no case should it rise above 70, whilst I do not see the necessity of keeping it below 60, as some hydriatic physicians advise.[31] The patient, in the heat of fever, will think 60 deg. high enough, and rather pleasant; and if others do not like a temperature as low as that, they may retire. The person necessary for nursing the patient may dress warmly and sit near the fire. Let the sick-room be as large as possible; or open the door and windows of a room connected with it. Towards the close of the disease, after desquamation has begun, the temperature of the room may be kept at 70 deg., as then the fever and heat have subsided and the delicate skin of the patient requires a comfortable temperature.

54. WATER-DRINKING.

As the patient should have a constant supply of pure air for his lungs, so he should also have _plenty of pure cold water_ for his stomach, to allay his thirst and assist in diminishing the heat of fever, and in eliminating the morbid poison from his blood. Though cold, the water for drinking should not be less than 48 or 50 deg. Fahrenheit. Whenever there is ice used for cooling the water, the nurses should be very careful not to let it become colder, than the temperature just indicated, except in typhoid cases, when the stimulating effects of icy cold water and ice may prove beneficial.

55. DIET

I have little to say with regard to _diet_, at least to physicians. During great heat and high fever, the patient should eat little or nothing; but he should drink a good deal. Substantial food must be avoided entirely. When the fever abates, he can take more nourishment, but it should be light. Meat and soup should only be given, when desquamation has fairly begun. Stewed fruit (especially dried apples) will be very agreeable to the patient. In great heat, a glass of lemonade may be given occasionally; however, great care must be taken not to spoil the patient's taste by sweets, or to allow him all sorts of dainties, such as candies, preserves, &c., as it is the habit of weak parents, who like to gratify their darlings' momentary desires at the expense of their future welfare. In torpid cases, some beef-tea, chicken-broth, and even a little wine with water, will raise the reactive powers of the patient. During convalescence, meat may be permitted to such patients as have been accustomed to eat it, and, in general, the patients may be allowed to gradually resume their former diet (provided it were a healthy one), with some restriction in regard to quantity. In general, under water-treatment, the digestive organs continuing in a tolerably good state, and the functions in better order, we need not be quite so careful with respect to diet, as if the patient were left to himself, or treated after any other method of the drug-system. Let the food be plain, and the patient will scarcely ever eat too much. To stimulate his appetite by constantly asking him whether he would not like this or that, is sheer nonsense; and to satisfy his whims, against our better conviction, is culpable weakness.

From this general outline, I shall now pass to the treatment adapted to the different forms of scarlatina.

56. TREATMENT OF SCARLATINA SIMPLEX, OR SIMPLE SCARLET-FEVER.

_Scarlatina simplex_, or _simple scarlet-fever_ (9), without inflammation of the throat, is generally so mild in its course, that it requires little or no treatment. However, I would not have parents look upon it as "scarcely a disease," as neglect and exposure may bring on bad consequences (7 and 25). If the fever and heat are very moderate, the first days an ablution of the body with cool water (say 70 deg.), twice a day, is sufficient. The patient had better be kept in bed, or, if unwilling to stay there, he should be warmly dressed and move about his room, the temperature of which, in this case, should not be below 70 deg. Fahrenheit, and the windows should be shut, as long as the patient is out of bed.

When the period of efflorescence, or standing out of the rash, is over, packs ought to be given, to extract the poison completely from the system, and to prevent any sequels, such as anasarca, &c. (25). Should the rash suddenly disappear before the fifth or sixth day, or should it linger in coming out, a long pack will bring it out and remove all danger. The packs, once begun, should be continued, once a day, during and a few days after desquamation. The patient may go out on the tenth or twelfth day warmly dressed, after his pack and bath, and walk for half an hour; sitting down or standing still to talk in the open air is not to be permitted. During, and some time after convalescence, the patient should take a cool bath, or a cold ablution every morning, immediately on rising from bed, and walk after it as soon as he is dressed. In very cold and disagreeable weather, the walk should be taken in the house; but the patient should not sit down, or stand about, before circulation and warmth are completely restored in every part of the body, especially in the feet. I cannot insist too much upon exercise being taken immediately after every bath, as, without it, the bath may do more harm than good, and dressing, with many, will take so much time, that they will take cold before getting their clothes on.

If the patient should take cold, or feel otherwise unwell, during convalescence, the packs must be resorted to again, and continued till he is quite well.

57. TREATMENT OF SCARLATINA ANGINOSA, OR SORE-THROAT SCARLET-FEVER.

In _scarlatina anginosa_, or _sore-throat scarlet-fever_, which is the most common form of the disease (1-7) we have to discriminate, whether

1) the _reaction is mild_, the heat of the body not being much above 100 deg. Fahr. and the pulse full, but not above 110 to 120, the pain and swelling of the throat moderate, the brain little or not affected; or

2) _violent_, the heat from 106 to 112, the pulse 120 to 150 beats or more, the inflammation of the throat decided and extensive, the brain very much affected; or

3) _torpid_, little or no heat, the pulse quick and weak, the inflammation of the throat undecided, varying, the rash appearing slowly or not at all, and what there appears of a pale, livid color, the patient more or less delirious.

58.--1. TREATMENT OF THE MILD OR ERETHIC FORM OF SCARLATINA ANGINOSA.

The _mild_ or _erethic form_ of scarlatina anginosa requires about the same treatment as scarlatina simplex. I would, however, for the sake of safety, advise a pack and bath per day, through the whole course of the disease, in the afternoon, when the fever begins to rise; and during the period of eruption, when all the symptoms increase, two and even three packs a day may be required. This depends on the increasing heat and fever, as well as on the condition of the throat. The greater the heat and fever, and the more troublesome the inflammation, the more packs. If the fever and pain increase some time after the pack, in which the patient may stay for an hour or two, the packing must be repeated. The length of the pack depends much on circumstances; as long as the patient feels comfortable and can be kept in it, without too much trouble, he ought to stay. In case the patient cannot be prevailed upon to stay longer than an hour, or if the fever increases soon after the pack, it may be necessary to repeat packing every three or four hours, which is the general practice of several water-physicians in Germany and England.

59. If the patient becomes restless soon after having been packed, the heat and fever increasing, as may be ascertained from the pulse at the temples and the general appearance of the face, the sheet must be changed, as directed above (46) till the patient becomes quiet and feels more comfortable. In case of repeated changing of sheet, the patient should stay in the last sheet, till he has perspired about half an hour, or longer, before he is taken out to the bath, which should be of about 70 deg., as in all the mild forms of scarlatina. The length of the bath depends on the heat, and reaction of the patient, who should be well cooled down all over, before going to bed again or dressing. He ought not to be out of bed for a long time, and only after a bath, as this will protect him from taking cold.

60. The throat should be covered with a wet compress, i. e. a piece of linen four to eightfold, according to its original thickness, dipped in cold water (60 deg.-50 deg.), well wrung out and changed as often as it grows hot. It should be well covered to exclude the air. This compress should be large enough to cover the whole of the throat and part of the chest; it should closely fit to the jaw, and reach as far up as the ear to protect the submaxillary and parotid glands located there.

61. When the period of eruption is over, there is commonly less fever, and the packs and baths may be diminished.

62. Towards the end of the period of efflorescence, when the rash declines, fades, disappears, and the skin begins to peal off, an ablution in the morning of cool water, with which some vinegar _may_ be mixed, and a pack and bath in the afternoon, are quite sufficient, except the throat continue troublesome, when a pack should also be given in the morning. The packs, once a day, should be continued about a week after desquamation. The patient may safely leave the house in a fortnight. I have frequently had my patients out of doors in ten or twelve days, even in winter.[32]

63. This going out so early, in bad weather, is by no means part of the treatment. I mention it only to show the curative and protective power of the latter, and have not the slightest objection to others using a little more caution than I find necessary myself. It is always better, we should keep on the safe side, especially when there is no one near that has sufficient experience in the matter. I can assure my readers upon my word and honor, that though I never kept any of my scarlet-patients longer in-doors than three weeks (except a couple of malignant cases), I have never seen the slightest trouble resulting from my practice.

64. In case of some trouble resulting from early and imprudent exposure, which is about as apt to occur in the house as out of it, a pack or two will usually be sufficient to restore order again. As long as the patient moves about, warmly dressed, there is no danger of his taking cold after a pack, and provided packing be continued long enough, and the patient be forbidden to sit down or stand still in cool places, or expose himself to a draught, there is nothing to be apprehended.

65. I have no objection to homoeopathic remedies being used at the same time, nor would I consider acids, as mentioned above (39, note), to be objectionable in cases of severe sore throat; but I must caution my readers against the use of any other remedies, especially aperients, except in cases, which I shall mention hereafter (72). In a couple of cases, where I acted as consulting physician, I have observed dropsical symptoms proceeding from laxatives and the early discontinuation of the packs during convalescence. Let the bowels alone as long as you can: there is more danger in irritating them than in a little constipation. As for the rest we have injections, which will do the business without drugs, of which I confess I am no friend, especially in eruptive fevers.

66.--2. TREATMENT OF THE VIOLENT, OR STHENIC FORM OF SCARLATINA ANGINOSA.

The _violent_, or _sthenic form_ of scarlatina anginosa becomes dangerous only through the excess of reaction, when the heat is extreme (upwards of 105 deg. Fahrenheit, sometimes 112 to 114), the pulse can scarcely be counted, as it hammers away full and hard in a raging manner, the throat being inflamed and swollen to suffocation, and the patient in a high state of delirium; but it need not frighten the physician or parent acquainted with the use of water. We have the means of subduing that violence without weakening the patient. It is in this form of scarlatina that the greatest mistakes are committed by physicians unacquainted with the virtues of water, and that our hydriatic method shows itself in all its glory; for where there is an abundance of heat, water cannot only be safely applied, but it is also sure to bring relief. It is in this form of the disease that the cold affusions recommended by Currie and his followers, have shown themselves so beneficial, and that the wet-sheet, used properly and perseveringly, is almost infallible.

67. TEMPERATURE OF THE WATER--DOUBLE SHEET--CHANGING SHEET.

The water for the wet-sheet pack, in this violent form, ought to be cold; in summer it should be iced down to 46-48 deg. Fahr. The sheet ought to be coarse or doubled, in order that it should retain more water, and it should not be wrung out very tight. In a thick wet-sheet the patient will be better cooled than in a thin sheet, and he will be able to stay longer in it before changing. It may be advisable, however, with very young and rather delicate persons, not to double the sheet about the feet, as they might be apt to remain cold, which would send the blood more to the head. But, although the patient will feel easier in the pack for a while, the heat and fever will soon increase again, and, in proportion as the sheet grows warmer, he will become more and more restless, and the changing of the sheet will become indispensable. When the symptoms increase again, in the second pack, the sheet is changed a second time, and so on till the patient perspires and becomes relieved for a couple of hours or longer; which usually happens in the third or fourth sheet. After the first, every following sheet is wrung out tighter and tighter, and the last one may be taken single, or doubled only at its upper end.

68. LENGTH OF PACK--PERSPIRATION.

To make quite sure of the reaction, the single sheet may be tried first, except in exceedingly violent cases, and the double sheet may be resorted to, if the single sheet prove inefficient. Or, should there be any doubt, the double sheet may be dipped in water of a higher temperature than that given above, say 55 to 60 deg.. With young and delicate children I prefer this course, especially if they be very excitable, and the shock of very cold water may be expected to be too much for their nerves. In these matters some discrimination should be used: it is always better we should keep on the safe side, and rather give a pack more than frighten the little patients out of their wits. Proceed safely, but firmly and try to obtain your object in the mildest manner possible.

69. Before perspiration comes on, there is a little more excitement for a few minutes (41), which must not induce the friends of the patient to take him out of the pack; only when it continues to increase, instead of the perspiration breaking out and relieving the patient, it will be necessary to change the sheet, another time, as in that case the organism is not fully prepared for perspiration. After the breaking out of the latter, the patient invariably feels easier, and continues so for some time. When the feverish symptoms increase, during perspiration, which can be ascertained by feeling the pulse on the temples and by the thermometer, it is time to remove the patient from the pack, to give him his bath. Half an hour's perspiration is commonly sufficient; if the patient feel easy, however, and can be prevailed upon to stay an hour, or longer, till a good thorough perspiration brings permanent relief, it will be better. It would be unwise to let the patient stay too long and get him in a state of over-excitement; but, on the other hand, parents ought to remember that very few children _like_ to be packed, and that a patient in high fever is a bad judge of his own case. I have always found those children the best patients, who had been brought up in strict obedience to their patients' dictates, before they were sick, and this, as well as the daily habit of taking baths, and the quiet and firm behavior of the physician and friends of the patient under treatment generally remove all difficulty.

70. LENGTH OF BATH.

Although the temperature, in sthenic cases, should be a little lower than in erethic cases, it is not advisable to use the water very cold, as this would cause too strong a reaction, and consequently new excitement. The safer way is to let the temperature of the bath be between 70 and 65 deg., according to the age and constitution of the patient (the younger and more delicate the patient, the higher the temperature), and to let him stay long enough in the bath to become perfectly cool all over, which can be ascertained by placing the hand or the thermometer under the arm-pits, which usually retain the warmth longest. I understand, in advising such a temperate bath of several minutes, duration, that the patient be hot and the rash standing out full and bright on coming from the pack; or else the bath must be colder and shorter, not exceeding a minute or two.

71. CAUTION.

After the bath, the patient is rubbed dry, and either taken to his bed, or, if he feels well enough, dressed and induced to walk about the room, or placed in a snug corner (not near the fire, however), till he feels tired and wishes to go to bed. During his stay out of bed, the rash ought to be an object of constant attention for his friends; for as soon as it becomes pale, the patient ought to be sent to bed immediately and covered well, or should then the rash continue to become paler and paler, the pack should be renewed, and the patient kept in bed ever after, till desquamation is over.

72. THE WET COMPRESS.

In bed, a wet compress is put on the throat, and another on the stomach, which, beside the direct influence it has on that organ, acts as a derivative upon the throat and head, and as a diaphoretic upon the skin, assisting in allaying the fever and heat. This compress on the stomach is an excellent remedy with small children and infants in a restless, feverish condition. I often use it, even with infants scarce a week old, and always with perfect success. I wish, mothers could be made to substitute it for paregoric and the like stupefying stuff, to procure their crying infants relief and themselves rest. There is more power in the compress than any one who is not familiar with its use, can imagine. At the same time it has a very good effect on the bowels, which should be kept regular, either with the assistance of tepid injections, or, if they fail to operate, with a moderate dose of castor oil. If possible, however, avoid the irritation of the digestive apparatus through medicines, which are apt to counteract the external applications, whose object is to draw the morbid poison as early and as completely as possible to the skin.

73. HIGHLY INFLAMED THROAT--CROUP.

If the _throat_ is in a highly inflamed condition, repeated packing is the surest means of allaying the inflammation and preventing _croup_. Although I have had very bad cases under my hands, I never saw a case of scarlet-croup under water-treatment. All you have to do is, to pack your patient early enough and often enough to keep the inflammation down, to keep a wet compress on his throat and chest, and, in general, treat him as I have prescribed. The condition of the throat will improve in proportion to your perseverance in packing.

74. NECESSITY OF ALLAYING THE HEAT.

The packs and baths should be continued, even when the patient cannot be prevailed upon to stay long enough in the packs to perspire. The heat of the skin and the general inflammatory condition of the whole organism _must_ be allayed, especially, when there is much _delirium_. In that case, the patient ought to be kept long enough in the bath to clear off the head, and care ought to be taken, that he should never stay in the pack to become much excited.

75. THE HALF-BATH--THE SITZ- OR HIP-BATH.

Should the half-bath or shallow-bath (which are technical terms for the bath described above), not be sufficient to relieve the head, the patient must be placed in a _sitz-_ or _hip-bath_ of 65 deg. to 70 deg. and stay there, with his body covered by a blanket or two, till the head is easy. During and after the sitz-bath, the parts exposed to the water, as well as the lower extremities, should be rubbed repeatedly, to favor the circulation of the blood. The head should be covered with a compress, dipped in cold water and but slightly wrung out, to be changed every time it becomes warm. The time required will vary according to the condition of the patient, from half an hour to one hour and a half. There is no danger of his taking cold, provided the body be covered sufficiently. The room ought not to be too warm, as a hot room will increase the tendency of the blood to the head; 65 to 70 deg. is perfectly warm enough. I would rather have it between 60 and 65.

76. The _sitz-bath_ may be taken in a small wash-tub, if there is no proper sitz-bath-tub at hand. It should be large enough to allow the water to come up to the navel of the patient, and to permit rubbing. Too large a tub would not allow the patient to sit in it comfortably. If there is no tub to fit, a common bathing-tub may be raised on one end, by putting a piece of wood under it, so as to keep the water all in the other end, allowing the feet of the patient to be kept out of the water. This latter practice is more convenient with very small children, with whom, however, the sitz-bath will scarcely be required, a half-bath of sufficient duration being almost always efficient. It is not advisable for persons little acquainted with the use of water as a curative, to let the patient stay very long in the sitz-bath, it being safer to pack the patient again, and to repeat the sitz-bath after the pack, if his delirium is not removed, or not lessened in half an hour or three-quarters of an hour. This alternating with the pack and sitz-bath should be repeated, till the head becomes clear.

77. In excessive heat and continuous delirium, a half-bath may be given, also, every time the packing sheet is changed. The rule is that _we_ ought not to yield, but the _symptoms must_; and they will, if the treatment is persevered in. Only go at it with courage and confidence. There is nothing to be apprehended from the treatment: where there is too much heat, there is no danger of a lack of reaction, and consequently no occasion for fears that the rash might be "driven in." A physician afraid of using water freely in violent cases of scarlet-fever, would resemble a fireman afraid of using his engine, for fear of spoiling the house on fire.

78. ACTION OF THE SITZ-BATH EXPLAINED.