declining period of scarlet fever or during convalescence in mild as
well as severe cases, is frequently more dangerous than the primary
disease. It largely increases the percentage of deaths. A clear
appreciation of its therapeutic requirements is important, since by
judicious treatment many recover who would inevitably be sacrificed by
improper measures. The family should be informed that the danger from
scarlet fever does not cease with the decline of the eruption, and
that the kidneys may become seriously affected by too early exposure
of the patient to currents of air or sudden changes of temperature, by
which cutaneous transpiration is checked. He should therefore be kept
indoors in a comfortable and uniform temperature three or four weeks
after the termination of the fever, until desquamation has entirely
ceased and the new epiderm is sufficiently thick and firm to protect
the surface. During the changeable temperature of the autumnal,
winter, and spring months even longer confinement at home may be
advisable.
The nephritis and consequent albuminuria antedate by some days the
occurrence of dropsy, and a physician should never discharge a
scarlatinous patient without one or more examinations of his urine.
When his visits cease the nurse should be instructed to make the
examinations by heat and nitric acid during the ensuing month, and if
any evidence, however slight, appear that the kidneys are involved, he
should be notified, {551} in order that appropriate treatment may be
immediately commenced. Early and correct treatment of the nephritis is
attended by much better results than delayed treatment, and many more
patients are doubtless now saved than in former times, when little
attention was given to the state of the kidneys until dropsy or other
prominent symptoms appeared. I have found no mother or nurse so
ignorant that she could not properly employ the test of nitric acid
and heat, and, if she be solicitous for the welfare of the child, she
will not hesitate to carry out the directions and immediately notify
the physician if the tests employed produce the least cloudiness or
turbidity of the urine.
The patient as soon as nephritis commences, as shown by the state of
the urine, should be put to bed in a room of warm and equable
temperature (72° to 75° F.). His diet should be liquid, consisting of
milk, farinaceous food, and a moderate quantity of animal broths. He
may drink liquids freely, especially water not too cool, to which
spiritus ætheris nitrosi is added. If he be prostrated by the primary
disease, alcoholic stimulants should be allowed.
The indications are to relieve the hyperæmic kidneys by diaphoresis
and purgation. To produce the former the patient should be immersed in
a warm bath at about the temperature of the body (98° to 100°), in
which, if he be quiet and comfortable, he should remain from fifteen
to twenty minutes, but if restless and frightened by the water a less
time, after which he should be placed in a warm bed and well covered
by blankets. If perspiration result, the bath has been useful, and it
may be employed in grave cases two or three times daily. If
perspiration do not result, it may be produced by surrounding the body
either by hot dry or moist air. Hot dry air may be produced by burning
alcohol in a thin layer upon a plate under a chair upon which the
patient sits while he is surrounded by a blanket, or he may be covered
in bed and the hot air introduced under the bed-clothes. In New York a
convenient apparatus is used for this purpose, consisting of a small
sheet-iron pipe enclosed in a small box of the same material. The box
is in the form of a trunk, with a handle for convenience in carrying,
and the lower end of the pipe, which extends nearly to the floor,
contains an alcohol lamp. Hot moist air may be produced by placing
against the patient bottles of hot water surrounded by towels wrung
out of water. The steam arising from them and enveloping the body and
limbs produces a prompt sudorific effect. There is in use in this
city, in the treatment of these and similar cases requiring
diaphoresis, a convenient apparatus for generating steam. It consists
of a cylinder pierced with holes for the admission of air and
containing a spirit lamp, over which is a pan or pail holding a little
water. The patient, nearly naked, is placed in a chair with the
apparatus underneath, and is covered by a blanket, so that the steam
surrounds the body. This gives rise to free perspiration, which
continues after the patient is placed in bed. This treatment should be
repeated one or more times daily, according to the gravity of the
case.
The sudorific effect of the treatment by external warmth described
above should be aided by employing diaphoretics. Those which have been
most used are the acetates of ammonium and potassium, the bitartrate
and citrate of potassium, and spiritus ætheris nitrosi. If employed
when the surface is cool, they act rather as diuretics than
diaphoretics. {552} These agents, being simple in their action and
without deleterious effects, may be given frequently and in large
proportionate doses for the age.
But lately a diaphoretic which far surpasses these in efficiency has
been discovered in pilocarpine, the active principle of jaborandi.
Being soluble in water and tasteless, it is easily administered, and
is retained when, on account of the uræmic poisoning present in
scarlatinous nephritis, the stomach is irritable and other medicines,
as digitalis, are rejected. Ether may be employed with it, or the
amount of alcoholic stimulant may be increased at the time of its
exhibition in order to guard against any depressing effect. To a child
of two years one-fortieth to one-twentieth of a grain may be given
every six hours by the mouth. It may also be employed hypodermically,
as one-twentieth of a grain to a child of five years. It has both a
diaphoretic and diuretic action, while it stimulates both the salivary
and mucous secretions. According to one observer, an adult when fully
under the influence of pilocarpine secretes from one pint to one quart
of saliva within two hours, and Leyden reports a case of diphtheritic
nephritis in which the quantity of urine rose from half a pint to five
pints daily. But its most prompt and certain action is upon the
sweat-glands. Hirschfelder speaks of its beneficial action in
relieving various forms of dropsy, and adds: "In one morbid condition
of the kidney, however, jaborandi is the remedy par excellence, and
that is the acute parenchymatous nephritis which frequently follows
scarlatina.... This disease heals spontaneously if the danger that
threatens life from reduction of the urine and from the effusions of
fluid into the cavities of the body be averted. In this disease
jaborandi works wonders." I have also found it an invaluable agent
when the older remedies failed and death seemed imminent. The
following cases, in which the beneficial action of this agent was
apparent, occurred in my practice:
_Case 8._--G----, male, aged five years and six months, sickened with
scarlet fever on June 2, 1882. It began with vomiting, and was
attended by a degree of febrile movement which indicated an attack of
rather more than the average gravity. The fauces at one time exhibited
a slight exudation like that of diphtheria. In the declining stage of
the malady rheumatic pain and tenderness occurred in the wrist and
finger-joints, but not in those of the lower extremities. The case,
however, progressed favorably, and during the convalescence my
attendance ceased. On June 24th my attention was again called to the
child, when the urine was found to be scanty and very albuminous.
External measures, such as are described in the foregoing pages, were
employed, and the infusion of digitalis with potassium acetate ordered
to be given every three hours, but this medicine was for the most part
vomited. The bowels were kept open by jalap and the potassium
bitartrate. The urine, however, continued scanty, and on June 28th
severe convulsions occurred. At this time the quantity of urine was
only fl. oz. ij in twenty-four hours. The pulse in the convulsions was
quick and feeble, the skin very hot, and the axillary temperature
103°. The eclampsia continued one hour, and were controlled by large
and repeated doses of bromide of potassium, aided by clysters of five
grains of hydrate of chloral in water. Muriate of pilocarpine was now
directed to be given in doses of one-thirty-second of a grain every
three hours, dissolved in cold water. This agent was not vomited, and
it must have been given by the parents in their fright and {553}
anxiety in larger or more frequent doses than were directed, for on
July 1st the bottle containing one grain was empty. Free diaphoresis
resulted from the pilocarpine, and the quantity of urine was
increased. The mother stated that the child had taken only two doses,
or one-sixteenth of a grain, of pilocarpine when the diuretic effect
was apparent and free diaphoresis also occurred. She also stated
subsequently that the quantity of urine was larger when the
pilocarpine was administered every third hour than when given at a
longer interval. A flaxseed poultice on which mustard was dusted was
also applied over the kidneys. On June 29th the pulse was 96,
temperature 100.5°; occasional convulsive attacks occurred, which were
readily controlled by enemata of hydrate of chloral. On June 30th the
symptoms were all better; no more attacks of eclampsia had occurred,
and the urine was more abundant and less albuminous. The mother
remarked that the new medicine (pilocarpine) had settled the stomach
and increased the urine. The patient continued to improve, and on July
4th the record states: "Now takes the pilocarpine, gr. 1/32, every six
hours; passes urine freely since yesterday; has not vomited since he
began to take the pilocarpine; pulse 106, axillary temperature 99°; is
playful and takes milk freely, nearly three quarts in twenty-four
hours, with some farinaceous food. Digitalis with potassium acetate is
also given in occasional doses." July 6th, pulse 92, temperature 99°;
perspires much, and urine nearly normal in quantity and character.
_Case 9._--Mary S----, aged five years, on Dec. 22, 1882, presented
the symptoms of severe nephritis. Her brother had scarlet fever two
weeks previously, and she had sore throat at about the same time, but
without efflorescence; pulse 98, temperature 98.5°; her urine highly
albuminous, and reduced to fl. oz. iv in twenty-four hours; bowels
constipated. Ordered a single dose of
Rx. Hydrarg. Chlor. Mitis gr. iii;
Resin. Podophylli gr. 1/6. M.
The muriate of pilocarpine was also ordered, gr. 1/20, but the patient
vomited soon after taking it. Another dose was retained, and was
followed by considerable perspiration. Dec. 23d, had one stool from
the powder of yesterday. Has taken five doses of pilocarpine, but
vomited after three of them. The last dose was administered at 10
P.M., and the mother says she "sweat fearfully" during the night. The
patient was kept warm in bed; stimulating poultices of mustard and
flaxseed, one to sixteen, were constantly in use over the kidneys, and
the pilocarpine was administered three or four times a day. The record
for Dec. 26 states: "Took the pilocarpine four times since yesterday
morning, and each dose is followed by perspiration lasting from one to
one and a half hours; quantity of urine, from fl. oz. vj to fl. oz.
viij daily; vomited twice yesterday, not to-day; pulse 104,
temperature 97.75°; complains of frontal headache; bowels regular; has
considerable salivation. The patient is warm in bed, and the flaxseed
and mustard poultice over the kidneys is continued." Dec. 28th,
specific gravity of urine 1019; urine still quite albuminous, and
containing blood-corpuscles and granular casts, also crystals of
oxalate of lime. Dec. 30th, takes gr. 1/20 pilocarpine twice daily,
and occasional doses of infusion of digitalis; urine more abundant;
its specific gravity 1014, slightly albuminous, and containing {554}
very few granular casts and blood-corpuscles; has lost its smoky
appearance; reaction alkaline; perspiration slight; patient
convalescent.
In another instance, a child of five years, from three to four weeks
after scarlet fever was noticed to have anasarca of the face and
extremities, with scanty and albuminous urine. One-thirty-second of a
grain of muriate of pilocarpine was administered every six hours
without the desired sudorific effect. It was then administered every
four hours, with an increase of perspiration and urination, so that
the nephritic symptoms were relieved and the patient apparently out of
danger within three or four days.
In a fourth patient, a girl of three years, having scarlatinous
nephritis, with symptoms very similar to those in the last case, the
administration of one-twentieth grain doses of pilocarpine in
conjunction with the hot-air bath, was followed by increased
perspiration and urination, and progressive and rather rapid
convalescence. This child had been taking bichloride of mercury in
one-fiftieth grain doses, prescribed by a homoeopathic physician,
without appreciable benefit. It had been for the most part vomited.
Given, as in the above cases, in moderate doses and with sufficient
interval, pilocarpine has never in my practice had any deleterious
effect, and I regard it as a very important addition to the remedies
for the relief of scarlatinous nephritis. It is apparently the most
useful and important diaphoretic for this disease which we possess.
Cathartics, especially those of a hydragogue nature, are also very
beneficial. Their action is more certain than that of most
diaphoretics and diuretics, and their employment is imperatively
required in severe or dangerous cases in which it is necessary to
remove as soon as possible the serum or urea which endangers life.
Young children or those with delicate stomach, and those much
enfeebled by the primary disease, may take magnesia, either the
citrate or the calcined. A good cathartic for ordinary cases is a
mixture of jalap and potassium bitartrate, the pulvis jalapæ
compositus, consisting of one part of jalap and two of cream of
tartar. Ten grains of the mixture may be given to a child of five
years, and repeated according to circumstances. Its effect is
increased by dissolving a teaspoonful of potassium bitartrate in a
gobletful of water, and allowing the patient to drink from it. The
following is a good cathartic in some instances, especially if the
stomach be irritable, so that the more bulky and nauseating cathartics
are rejected. Care should be taken to obtain a good article, as some
of the podophyllin of the shops is not reliable:
Rx. Resinæ Podophylli gr. j;
Sacchari scruple j. M.
Ft. in chart. No. v.-x.
S. Give one powder, and repeat according to circumstances.
In the treatment of one of the cases reported above it will be
recollected that the mild chloride of mercury mite was given with the
podophyllin, with a good result.
After the use of laxative agents the kidneys, being less congested on
account of the diversion that has occurred, often begin to excrete
urine more freely. But if the patient be anæmic or enfeebled and the
symptoms are not urgent, it is frequently better to avoid active
catharsis, which {555} more or less reduces the strength, and employ
remedies of a sustaining character, as in the following case, which
occurred in my practice: A little boy, pallid and scrofulous, began to
have anasarca after scarlet fever, chiefly in the scrotum, accompanied
by a moderate degree of ascites. The urine, which was passed in nearly
the normal quantity, contained albumen, but not in large amount. This
patient gradually and fully recovered, with no treatment except the
use of an oil-silk jacket over the kidneys and abdomen to promote
diaphoresis, and the use of iron. Such a patient, treated by the
powerful eliminatives which we employ for the more urgent and robust
cases, would probably have been injured rather than benefited. No
treatment can therefore be recommended in a treatise on scarlatinous
nephritis which will be strictly applicable for all cases. Variations
are demanded according to the state of the patient and the form and
gravity of the disease.
Diuretics which do not stimulate the kidneys are proper at an early as
well as late period of the renal malady, and digitalis is the one
usually prescribed. I do not hesitate to order it from the first day
in combination with the acetate of potassium. One teaspoonful of the
infusion may be given every third hour to a child of five years. The
following formula is for one of this age in good general condition:
Rx. Potass. Acetatis oz. ss;
Infus. Digitalis fl. oz. vi. M.
The following formulæ are recommended by Meigs and Pepper:
Rx. Potass. Bitart. drachm i;
Spt. Junip. Comp. fl. drachm ii;
Spt. Æther. Nitros. fl. drachm i;
Tr. Digitalis, minim xv;
Syrupi fl. drachm v;
Aquæ fl oz. ii. M.
Dose one teaspoonful every two hours to a child of two to four years.
Rx. Potass. Acetat. drachm i;
Tr. Digitalis fl. drachm ss;
Syr. Scillæ, fl. drachm i-ii;
Syr. Zingib. fl. drachm v;
Aquæ q. s. ad fl. oz. iii. M.
Dose, a teaspoonful every two or three hours to children two or three
years old.
Local treatment is important. L. Thomas, Romberg, and others recommend
the application of leeches, three or more, over the kidneys. Thomas
says: "In many cases the abstraction of blood causes immediate and
permanent relief; the fever and the pain in the region of the kidneys
cease, the secretion of urine becomes augmented, the albuminuria
lessens from day to day, and the moderate degree of dropsy that has
been developed disappears." It is only in the more robust children,
who have been but little reduced by the primary disease, that leeching
is, in my opinion, admissible. In the majority of cases instead of
depletion a poultice slightly irritating, so as to cause redness of
the skin, should be applied over the kidneys, or for older children,
not likely to be frightened by the process, the dry cups may be
applied daily. In subacute cases, not attended by any alarming
symptoms, sufficient redness may be produced by one of the irritating
plasters which the shops contain, constantly worn.
{556} Eclampsia, described in the preceding pages, is produced, as we
have seen, during the course of scarlet fever by the irritating effect
of the scarlatinous poison upon the nervous centres, but, occurring
after the decline of scarlet fever, it is ordinarily produced by the
retained urea. The same remedies are required to control the
convulsive movements as when they occur under other circumstances. The
bromide of potassium should be immediately administered in large and
frequent doses whenever eclamptic symptoms arise. During eclampsia a
child of three years should take five grains of this agent every five
to ten minutes till the attack ceases, and then at longer intervals.
The hydrate of chloral is a more powerful agent, and if the eclampsia
be not quickly controlled, I commonly employ it per rectum, dissolved
in one or two teaspoonfuls of water. For a child of three to five
years five grains should be thrown into the rectum by a small glass or
gutta-percha syringe, and retained by pressure. Properly administered
and retained, it rarely fails to control the eclampsia within ten or
fifteen minutes. Subsequently, occasional doses of the bromide should
be given to prevent the occurrence of eclampsia while the measures
described above are being employed to relieve the uræmic condition.
Rheumatism, endocarditis, and pericarditis, arising as complications
or sequelæ, require the treatment which is appropriate when they occur
under other circumstances, but the remedies should not be depressing,
as the system is already enfeebled by the primary disease. The
rheumatism, if mild, usually abates in a few days without medication,
and the affected joints require only some soothing lotion and support
by a bandage. The following liniment may be applied upon muslin and
covered by cotton wadding:
Rx. Acid. Carbolici fl. drachm i;
Tinc. Belladonna fl. oz. i;
Ol. Camphorati fl. oz. ii;
If the rheumatism be severe and affect several joints, the sodium
salicylate should be prescribed, as in the idiopathic disease, with an
occasional opiate to procure rest.
Endocarditis and pericarditis require rest in the horizontal position,
avoidance of all excitement, the use of the tincture or infusion of
digitalis or of the fluid extract of convalaria to procure a slow and
steady action of the heart. Three drops of the tincture of digitalis
or five minims of the fluid extract of convalaria may be given every
four hours to a child of five years. The same external measures should
be employed as in acute pleuritis. I prefer the application of a thin
poultice of flaxseed containing one-sixteenth part of mustard and
covered with oiled silk. The cardiac inflammations, as well as
rheumatism, require opiates in sufficient doses to procure rest and
sleep.
Pleuritis, which we have stated is apt to be suppurative, demands the
same treatment as the idiopathic disease when it occurs in cachectic
patients.
{557}
RUBEOLA.[1]
BY W. A. HARDAWAY, M.D.
[Footnote 1: In the preparation of this article the writer has
consulted the following works: Thomas, in _Ziemssen's Cyclop. Pract.
Med._, vol. ii., N.Y., 1875, Am. edit.; Bohn, in _Gerhardt's Handbuch
der Kinderkrankh._, Zweiter Band, Tübingen, 1877; Squire, in Quain's
_Dict. Med._, N.Y., 1883; Ringer, in Reynolds's _System Med._, vol.
i., Phila., 1879; Meigs and Pepper, _Dis. of Children_, Phila., 1882;
J. Lewis Smith, _Dis. of Children_, Phila., 1882; Hebra, _Dis. of
Skin_, London. 1866; Vogel, _Dis. of Children_, N.Y., 1871; Niemeyer,
_Handbook of Pract. Med._, N.Y., 1869; Trousseau, _Clinical Med._,
Phila., 1871. Other references will be found in the foot-notes to the
text.]
SYNONYMS.--Rubeola, Morbilli, Measles, Masern, Flecken, Rougeole.
DEFINITION.--Measles is an acute infectious disease involving the skin
and mucous membranes, characterized by successive stages and a
maculo-papular eruption, which terminates in a fine branny
desquamation. In normal cases it runs a definite course, which from
the date of invasion to the end of desquamation occupies about
fourteen days. It is highly contagious, and occurs, as a rule, but
once in the same person.
HISTORY.--The word rubeola is probably of Spanish origin and was
formerly written rubiola or rubiolo. The designation morbilli is the
diminutive of the Italian il morbo, the plague. Although it is
doubtful, as claimed by Willan, that the Greek and Roman physicians
were acquainted with measles, there is no question that Rhazes was one
of the first to describe the affection correctly. Rubeola is said to
have been distinguished from variola by the Arabians in the twelfth
century; but, nevertheless, as late as the middle of the seventeenth
century we find Sennertus discussing the question "why the disease in
some constitutions assumed the form of small-pox, and in others that
of measles;" and in a posthumous work of Diemerbroeck, published in
1687, it is asserted that small-pox and measles are only different
degrees of the same affection.[2] According to Mayr, the merit of
having shown measles to be a distinct malady from scarlatina must be
ascribed to Forestus and Sydenham. It is not clear, however, that the
two diseases were accurately differentiated till the close of the last
century, and notably by Withering in 1792.
[Footnote 2: _Cyclop. Pract. Med._, London, 1834, p. 625.]