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.