TREATMENT OF MILD SCARLET FEVER.

789

bystander it seems to have the effect of removing the pungent heat so remarkable in most cases of scarlet fever, and of keeping the skin supple and comparatively cool, though I am not prepared to say whether it exerts any real influence on the temperature of the surface as estimated by the thermometer. It does not prevent the desquamation of the cuticle after the decline of the eruption, nor does its most diligent employment exclude the occurrence of albuminous urine; though I think it considerably lessens the amount of the former, and diminishes the risk of the latter assuming a serious character.

This immunity from bad symptoms, however, is doubtless in great measure due to the circumstance that the cases in which the inunction was employed were those which came earliest under treatment, and in which, consequently, opportunity existed for carrying out a judicious management of the disease through all its stages. I believe it promotes the patient's comfort, and lessens the risks of some of the ordinary sequelæ of the disease; but the extravagant laudations which this proceeding has received from some medical men, induce me to add that I do not consider it as anything more than a useful adjunct to appropriate treatment, and in no sense a substitute for it. During the period of development of the rash, the inunction should be practised twice a day; when the eruption is on the decline, its employment once in the twenty-four hours is generally sufficient; whilst, if the desquamation is at all abundant, the hot-air bath is of the greatest service in facilitating its completion and maintaining the activity of the skin. How slight soever the attack of scarlet fever may have been, the patient ought not to be allowed to leave his bed in less than ten days, nor his room in less than three weeks from the commencement of the attack, while the urine ought to be tested for albumen twice a day, in order that the first threatening of so serious an evil as scarlatinal dropsy may at once be met by appropriate treatment. During the whole of the stage of convalescence, or so long at least as the skin shows any trace of desquamation, even though the child is allowed to leave his bed, the inunction should be continued every morning, while the child should be placed in a warm bath every evening, and well rubbed with a soft towel on being placed in bed again. During the whole of this time the diet must be mild and unstimulating, and due attention must be paid to the state of the bowels. For some time after, much caution must be exercised in not allowing the child to go out when the air is cool, and in avoiding all errors of diet, while

790

TREATMENT OF SEVERER FORMS

it is also expedient that flannel should be worn next to the skin for a considerable period after apparent convalescence from scarlet fever. I know that these precautions may appear to you overstrained, they often do to our patients, but I can only say that every year of added experience leads me to insist upon them more and more, just as each year shows me more of the dangers of scarlatinal dropsy, and of its intractable character.

Even in severer cases of the disease, you must not be in too great a hurry to resort to active measures, for you will remember that a somewhat stormy onset is characteristic of all but the very mildest forms of scarlatina. That disturbance of the sensorium for instance, which, when the child is sufficiently old, shows itself by the early occurrence of delirium, must not lead you to have recourse hastily to depletion either general or local, in order to quiet the disorder of the brain. The results afforded by depletion in scarlet fever even when the disease occurs in the adult are by no means encouraging; and in the child the loss of blood in these circumstances is even less well borne; so that, unless the patient is robust and plethoric, the cerebral disturbance very serious, and the evidences of congestion of the brain very marked, you should content yourselves with the application of cold to the head, perhaps employing cold affusion, if the symptoms are very urgent. It is indeed many years since I employed depletion in the course of scarlet fever, though, as I have already mentioned, the abstraction of blood is frequently needed in the dropsy which constitutes its most formidable sequela. In the malignant forms of the disease there is often very considerable disturbance of the sensorium, great restlessness alternating with a state of stupor; but the frequent and feeble pulse at once forbids depletion in such cases, and points out the necessity for adopting every means to support the feeble powers of life. It is very likely that the low type which a disease such as scarlatina is almost sure to assume in the crowded dwellings of the poor, has rendered my practice in this respect somewhat different from that which might be advantageously pursued in the case of children more favourably situated. To the same circumstance it is also probably due that, in a large proportion of cases, I have found it desirable to give ammonia almost from the outset of the disease; a practice which has been recommended as universally applicable, and which (though the remedy does not deserve the indiscriminate praises that have been lavished on it) you will do well to follow, whenever the pulse presents the characters of frequency and softness

combined. The state of the throat must be carefully watched in every case of scarlet fever; and whenever there is much swelling of the tonsils, if the child be too young to gargle, a slightly acidulated lotion should be injected into the throat by means of a syringe every few hours, in order to free it from the mucus which is so apt to collect there, and to be the source of much discomfort, or the solution of chlorate of soda or of permanganate of potash largely diluted, may be used for the same purpose. If there is much deposit of lymph upon the tonsils, it is generally desirable to apply strong hydrochloric acid, mixed with honey, in the proportion of about one part of the former to six of the latter, by means of a camel's hair pencil, or a solution of twenty grains of nitrate of silver in an ounce of distilled water, once or twice at intervals of twenty-four hours; but I do not think that in scarlatinal sore throat, any more than in that of diphtheria, the frequent application of strong caustics either does as much good, or yields as much relief, as the frequent gargling or syringing the throat with milder remedies. The coryza, which is so distressing and so ill-omened a symptom in cases of severe scarlatina, is best treated by throwing a small quantity of a solution of gr. j. or gr. ij. of nitrate of silver in 3j. of distilled water, up the nostrils every four or every six hours. The glandular swellings are very difficult to relieve, though their development sometimes seems to be retarded by painting the skin over them, two or three times a day, with tincture of iodine. When considerable, they do not seem to be benefited by leeches; the employment of which is also contraindicated by the feeble state of the patient's powers; while they show very little disposition to suppurate, and consequently are not relieved by lancing; so that the constant application of a warm poultice is often all that can be done to afford ease to the patient. Children in whom the local affection is severe, or in whom the disease assumes a malignant character, require all those stimulants, and that nutritious diet which we are accustomed to give to patients in certain stages of typhus fever; though unfortunately, the best devised means will in many such cases prove ineffectual.

It may be well to add a few words in conclusion with reference to the alleged virtues of belladonna as a prophylactic against scarlatina. Hahnemann, the founder of the homoeopathic system. first introduced it into practice, being induced to try it by certain resemblances which he believed to exist between its effects and the ordinary symptoms of scarlet fever. Other practitioners, without

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PROPHYLAXIS OF SCARLATINA.

subscribing to homoeopathic opinions, have yet adopted this proceeding, and aver that infinitesimal doses of belladonna do in reality exert the marvellous protective powers which the drug was said to possess.

The evidence of its virtues, however, is in the last degree unsatisfactory. There are many recorded instances of its failure when tried on a large scale, while the strongest advocates of its use have never put its virtues to the obvious and simple test of administering the remedy to half of a given number of persons placed in similar circumstances as to age, health, and exposure to contagion, and comparing the results thus obtained. In the only instance with which I am personally acquainted where this mode of inquiry was adopted, the results, though the experiment was on too small a scale to justify a positive conclusion, seemed to show that the protective power of belladonna was absolutely null. I cannot do better than relate the experiment which was made at the Royal Military Asylum at Chelsea, by Dr. Balfour, in the words in which he was good enough to communicate it to me. Scarlet fever having broken out in the institution, Dr. Balfour determined to try the virtues of belladonna. There were,' he says, '151 boys of whom I had tolerably satisfactory evidence that they had not had scarlatina; I divided them into two sections, taking them alternately from the list, to prevent the imputation of selection. To the first section (76) I gave belladonna; to the second (75) I gave none; the result was that two in each section were attacked by the disease. The numbers are too small to justify deductions as to the prophylactic power of belladonna, but the observation is good, because it shows how apt we are to be misled by imperfect observation. Had I given the remedy to all the boys, I should probably have attributed to it the cessation of the epidemic.'*

To these remarks I need add nothing. They convey a most important lesson, but one which I fear we are all too apt to forget in the study and in the practice of medicine.

* Any one who still feels a lingering faith in the prophylactic powers of belladonna, will do well to read the very careful and candid enquiry into the evidence on both sides of the question, published by Dr. Warburton Begbie, in the British and Foreign Medico-Chirurgical Review for January, 1855.

INDEX.