Part 84

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.