Monday, October 24, 2016

Scarlet Fever

From the The family medical guide: ©1871 a description and treatment for the disease.

This is another very infectious fever, causing an eruption on the skin, and ulcers in the throat.
Some wish to limit the term scarlatina to the severe forms of the disease, but as this and scarlet fever are generally considered synonymous, we shall take them as being so.

This disease, like measles, occurs generally only once during life, but there are exceptions to this rule, and it is noticed that second attacks are mild.

The poison of scarlatina is exceedingly virulent, and it is impossible to say at what stage it may cease to be contagious. An instance occurred in the circle of my own acquaintance, in which the trunk of a medical student who died in Edinburgh, which contained part of his dress that had never been worn by him during his fever, communicated scarlatina to a family in Ireland, although the clothes were freely exposed to the open air before they were worn, and might be supposed to have been purified by the sea voyage.

A high temperature, I believe, is the only certain means of destroying the contagion that lurks in apparel of any kind, especially of the woollen fabric. It should be steamed in an oven heated to 220° Fahr. for two hours, and this does not singe or injure the material.

Scarlatina appears in three forms: the first, or mildest, affecting the skin with slight rash, and merely a blush on the fauces, or throat; the second, more severe, affecting the skin, and with slight ulcers in the throat; and the third, called malignant, in which the throat is deeply ulcerated.

The most suddenly fatal cases under my care were those in which the disease commenced with inflammation of the membranes of the brain, and violent delirium, in which the dose of the poison seemed to be so great that the constitution was overpowered, and could not rally.

The first symptoms of the disease are a sensation of chilliness, amounting in some cases to a rigor or shivering, accompanied with nausea, irritability of temper, and depression of spirits.

The eruption on the forehead and face appears earlier than in measles—about the second day ; and it is distinguished from measles by being less florid in colour.

In scarlet fever, also, the eyes are not weak, nor have we the hoarse cough as in measles, while the throat is always more or less affected, the tonsils being generally ulcerated at an early period.

Treatment.—In the treatment of this and every other fever, the first thing to be done is to put the patient to bed, for the reasons given in the article on measles. And as the cuticle exfoliates very largely in this fever, the patient should remain in bed until the cuticle is tolerably restored, which will be two weeks after the eruption disappears from the surface.
Those who are exposed to changes of temperature earlier than that are always subject to anasarca (dropsy of the cellular membrane), or else to fatal dropsy of the chest.

Most of the unfavourable recoveries in my practice were from cases so mild that parents could not be persuaded to confine their children to bed a sufficient length of time to allow the cuticle to grow again, or the poison of the fever to be perfectly eliminated from the constitution. And to the same cause, together with the use of solid animal food before the stomach is in a fit state to receive it, may be attributed the relapses and bad consequences resulting from fevers.

In mild attacks, having given half a grain of podophylline with ten grains of Epsom salts, to carry off the bile, the bowels should be regulated afterwards with two grains of aloes and ten of salts given in treacle, at night, when required. The patient should be confiued to bed in a well-aired room, with covering sufficient to retain warmth ; and get toast-, barley-, or rice-water, or rennet whey, with five grains of nitre, and half a teaspoonful of the acetate of ammonia, in such drink, every three hours, alternately, if the patient be below ten years; and ten grains of nitre, and one teaspoonful of the acetate of ammonia, every three hours, alternately, if above ten years of age.

In severe cases, when the throat is ulcerated, in addition to the nitre and ammonia, the carbonate of which is preferable, being given in two- to five-grain doses, sufficiently diluted, the ulcers in the throat should be brushed with a solution of nitrate of silver, ten grains to the ounce of water, applied by a large camel's-hair pencil night and morning; and if the salivary glands below the jaw become enlarged and painful, they should be covered with a plaster of iodideof-lead ointment (two drachms of the iodide to the ounce of rendered suet), spread on soft leather, and supported by a narrow ribbon or tape over the head.
Toast-, barley-, or rice-water, or rennet whey, is sufficient muris-hment for the first three or four days; but after that the patient requires to be supported with chicken broth, beef- or mutton-tea, given once or twice a day, the former drink being continued, together with the nitre and ammonia, which latter acts as an antidote to the poison of scarlatina.

When the throat is much affected the fever is always higher, and determination to the brain is apt to supervene. As soon as heat of head or delirium indicates this, the hair should at once be shaved off entirely. Any attempt to retain it is futile, as it must fall after the fever, and its presence imperils life.

After being shaved the head should be elevated a little, and kept constantly cool by rags wet with cold water often renewed, or by ice in a bladder or oiled silk. The feet should be carefully attended to, and kept warm by a footpan of hot water rolled in flannel; and care must be taken that the bladder and bowels be emptied at proper intervals—the bladder every six hours, and the bowels once in twenty-four hours. Sponging the patient frequently with tepid water is very serviceable.

In the malignant form, when the throat is deeply ulcerated, and of a livid hue, with little appearance of eruption on the skin, the solution of the nitrate of silver should be stronger (thirty grains to the ounce of water), to be applied by a camel's-hair brush to the throat, night and morning; and before applying the caustic the discharge on the ulcers and throat should be carefully cleaned off by a piece of sponge or soft rag.

In severe cases, when the brain suffers, some apply leeches, others take blood from the arm, and a few blister. From two to six leeches applied behind or below the ears, on each side, relieve the head symptoms, and are serviceable ; but the lancet and blisters I would dissuade, having never been convinced of their benefit.

The prostration of strength in this form of the disease is always alarming, and should be counteracted by nourishing drinks or fluid food, as beef-tea, mutton-tea, chicken well bruised and boiled in vacuo, in a bottle without water and well corked; and Liebig's essence of meat. One of these should be given every three hours; with five grains of the carbonate of ammonia for an adult, and two grains for a child.

Stimulants, as wine and brandy, are preferred by many; but they are fur inferior to the ammonia, which has a specific effect in counteracting the poison of this fever.

The amount of poison in the system seems, however, so great in many cases that it must prove fatal in despite of remedies; and none but the best constitutions can recover from the malignant form of this fever, which often destroys life on the third or fourth day.

The longer the patient holds out after that, our hopes of recovery increase; and after the ninth day we may calculate on convalescence.

The consequences of this fever are always to be dreaded, and too much care cannot be taken.

The inflammation often extends from the throat to the ear by the internal passage behind the tonsils, and causes inflammation of the drum of the ear, which is destroyed, and with it the power of hearing.

An ichorous discharge from the nostrils also irritates the upper lip, and the eyelids suffer from discharge from the eyes, while the lips and mucous membrane of the mouth are often excoriated. To improve these a saturated solution of borax (as much as water will dissolve) applied by a camel's-hair brush to the excoriated parts, and injected into the ear by a small syringe, is efficient.

Tonics in some form are always necessary for patients recovering from scarlatina. For children, the solution of the perchloride of iron (five drops in a wineglassful of sugar and water), after breakfast and dinner, generally suits well; and ten or twenty drops would be the dose for adults with whom quinine disagrees. But for the latter quinine is preferable unless it gives headache, which is seldom produced by half-grain doses, thrice a day after food.

The food should be light and easily digested, commencing with roast pullet or white fish; then the lean of good beef or mutton, with stale bread or a mealy potato ; care being taken not to overload the stomach, than which nothing is more certain to retard recovery.

As sopn as the cuticle is restored, and the patient has got new boots and gloves (for the old scarf-skin is frequently cast off like a slipper or old glove), if the weather be fine and the strength sufficient, to drive out in the open air is salutary; but an attempt to walk must not be made too hastily.

A shower bath, tepid at first and cooled down gradually, is the best means of preparing the patient for exposure to the open air and for change, which is very desirable ; the sea coast being preferable, if the season be suitable. But sea-bathing should not be commenced sooner than a month after the eruption disappears. Up to that period the shower bath or sponging, followed by friction, is much safer, and equally beneficial.

Some never recover perfectly after a severe attack of any fever; while others, formerly delicate, become stout, and seem to get a new constitution; their nervous irritability, which formerly made them too susceptible of both internal and external impressions, being reduced by the poison of the fever.

To prevent the spreading of this virulent fever is very important, and should be studiously attended to.
Because belladonna, when taken into the stomach, produces, by sympathy, a rash on the skin, Hahnemann, the homoeopathist, on his principle of like curing like, proclaimed belladonna a prophylactic for this fever, or a medicine which, if taken by persons exposed to the disease, would render them proof against its contagion.

After many trials of this remedy, and much attention to its effects when given by others, I am obliged to say that I place no confidence in it for this purpose. Indeed it seems equally consistent to imagine that diseased fish or bad mushrooms, which, when eaten, produce a rash on the skin, should be a preventive for this fever.

Free ventilation in the sick apartment, perfect attention to cleanliness, and care not to inhale the breath or vapour from the patient, are the surest means of escaping contagion.

The use of Condy's Disinfecting Fluid is also highly commendable, as it destroys unpleasant perfumes arising from perspiration or otherwise ; but it should not be allowed to supersede attention to cleanliness, which must include not only frequent changes of linen, but also the immediate removal of the patient's dejections and urine, which are always offensive, and, no doubt, calculated to spread the contagion.

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