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.