11. MILD REACTION (ERETHIC).

If the poison is not virulent, and the body of the patient in a favorable condition, the reaction is mild, and the poison is eliminated without any violent efforts on the part of the organism. This is the case in scarlatina simplex, and in mild forms of scarlatina anginosa.

15. SCARLATINA SINE EXANTHEMATE.

There are also mild cases of scarlet-fever, when little or no rash appears, and the throat is very little affected. These are the result of a particularly mild character of the epidemy, together with a peculiar condition of the skin, the desquamation of which shows that the poison went to the surface without producing the usual state of inflammation, or the rash peculiar to the disease. This form, called scarlatina sine exanthemate, is extremely rare.

When the brain is affected, the patient suddenly complains of violent headache, vomits repeatedly, loses his eye-sight, has furious delirium, or coma (a state of sleep from which it is difficult to rouse the patient); his pupils dilate; the pulse becomes small, intermits; sometimes the skin becomes cold; there is dyspnœa (difficulty of breathing), fainting, paralysis, convulsions, and finally death; or, sometimes, the paroxysm passes suddenly by with bleeding from the nose or with a profuse perspiration.

The condition of the throat requires the most constant attention. From a highly inflamed state, it often passes into a foul and sloughy condition; the breath of the patient becomes extremely fetid; the nostrils, the parotid and submaxillary glands swell enormously, so that swallowing and breathing become very difficult. There is an acrid discharge from the nose; the gangrenous matter affects the alimentary canal, causing pain in the stomach, the bowels, the kidneys and the bladder; a smarting diarrhœa with excoriation of the anus, and inflammatory symptoms of the vulva. Also the bronchia, lungs, pleura and pericardium become affected, as sneezing, cough (the so-called scarlet-cough) and the pain across the chest and in the region of the heart indicate.

Beside the ulceration of glands and deafness, some of the sequels of scarlatina are white swelling of one or more of the joints, usually the knee, chronic inflammation of the eyes and eyelids, and partial paralysis. These chiefly occur in scrofulous subjects. Dropsy, which I have mentioned before, is one of the sequels that frequently prove fatal.

27. The form of the disorder in one patient does not imply the necessity of another who caught it from him having it in the same form. A person can take the contagion from one who dies of malignant scarlet-fever and have it in the mildest form, and vice versa. The character of the disease depends very much on the constitution, as I have said above. However, if the epidemy in general is of a malignant character (which may again depend, partly at least, on the constitution of the atmosphere), it will prove so in many individuals who are taken with it, and the precautions ought to be so much the more careful on that account.

In scarlatina the heat is much greater, and the pulse is much quicker than in measles.—In scarlatina the throat is inflamed, usually the brain affected, and the patient smells like salt-fish, old cheese or the cages of a menagerie; in measles, the eyes are affected, inflamed, and incapable of bearing the light; the organs of respiration likewise (thence coryza, sneezing, hoarseness, cough); the perspiration smells like the feathers of geese freshly plucked.—In scarlatina the period of incubation is a day less than in measles; namely, in scarlatina the rash appears on the second day after the first symptoms, in measles on the third.—The scarlet-rash consists of large, irregular, flat patches, which cover large spaces with a uniform scarlet-red, being brightest in those parts which are usually covered by the garments of the patient; in measles the spots are small, roundish or half-moon-like, with little grains upon them, and usually of a darker color; the measle-rash is thickest in such parts as are exposed to the air.—In scarlatina the symptoms of fever and the affection of the mucous membranes continue two days after the eruption has begun to make its appearance; in measles the eruption diminishes those symptoms at once.—The scarlet-rash stands out a day or two less than the measle-rash, and comes off in laminæ, whilst the latter comes off in small scales or scurfs.

are the following: Absence of internal inflammation; a bright florid rash; a regular, steady appearance, standing out, and disappearance of the latter; a regular and complete pealing off of the cuticle; a decrease of the pulse after the eruption of the rash; an easy and regular respiration; a natural expression of the features; a moist skin.

PART II.

TREATMENT OF SCARLET-FEVER.

has been advocated by some of the best authorities, and there cannot be a doubt but that it must have rendered good service in cases of violent reaction, or else men like de Haen, Wendt, Willan, Morton, Alcock, Dewees, Dawson, Dewar, Hammond, &c., would not have pronounced themselves in favor of it. However it requires nice discrimination and a great deal of experience, as in any case where it does no good it is apt to do a great deal of harm, by weakening the patient and thus depriving him of that power which he so much needs in struggling against the enemy invading his system. Besides, the expletive method has found many antagonists of weight: Simon, Williams, Tweedie, Allison and others have shown the danger of a general and indiscriminate use of it. Williams,[7] in his comparison of the epidemics of scarlatina from 1763 to 1834, has come to the conclusion that the possibility of a cure in cases of blood-letting, compared with the cases where the patients have not been bled, is like 1:4; i. e. four patients have died after blood-letting, when only one died without bleeding. "Experience has equally shown, says Dr. Allison, that the expectation entertained by Dr. Armstrong[8] and others, that by early depletion the congestive or malignant form of the disease may be made to assume the more healthy form of inflammation and fever, is hardly ever realized; and in many cases, although the pulse has been full and the eruption florid in the beginning, blood-letting (even local blood-letting) has been followed by a rapid change of the fever to a typhoid type, and manifestly aggravated the danger."—My own experience would prompt me to declare myself against blood-letting in general, even if I had not a sufficient quantity of water at hand to manage the violent or irregular reaction of a case. Blood-letting, in any case of eruptive fever, and with few exceptions in almost every other case, appears to me like pulling down the house to extinguish the fire. A little experience in hydriatics, a few buckets of water, with a couple of linen sheets and blankets, will answer all the indications and remove the danger without sending the patient from Scylla into Charybdis.

consisting in the free use of emetics or purgatives, has been recommended by some eminent practitioners. Withering,[9] Tissot, Kennedy and others are in favor of the former, and find fault with the latter, whilst Hamilton,[10] Willard, Abernethy, Gregory, &c., prefer purgatives, and some, of course, look upon calomel as the anchor of safety, which they recommend in quantities of from five to ten grains per hour.[11] The friends of one part of the anti-gastric method make war upon the other: Withering finding purgatives entirely out of place and Sandwith, Fothergill and others having seen nothing but harm done by them, whilst Wendt,[12] Berndt,[13] Heyfelder and others caution their readers against emetics. The anti-gastric method has been of some service in epidemics and individual cases, when the character of the disease was decidedly gastric and bilious. To use emetics or purgatives indiscriminately would do much more harm than good; as, for instance, during a congestive condition of the brain, the former, and with inflammatory symptoms of the bowels, the latter, would be almost sure to sacrifice the patient to the method.

recommended by Peart,[14] has been considered by many as a specific capable of neutralizing the scarlatinous poison, whilst others have used it only as a powerful tonic in torpid cases. Experience has shown that it is not a specific, and that its use as a tonic, requiring a great deal of care and discrimination, is a good deal more dangerous than the mode of treatment I am going to recommend in cases where tonics are required.

38. ACETIC ACID.

Brown[15] recommends diluted Acetic Acid as a specific against all forms of scarlatina. Experience, however, has not supported his confidence in the infallibility of his remedy.

have also been used with good effect in some epidemics. Muriatic acid I have frequently used myself for inflammation of the throat, in connection with hydriatic treatment, and it has almost always contributed to relieve the symptoms materially.[16]

were used already by Cælius Aurelianus,[17] and recently re-introduced into practice, by Drs. Dæne and Schneemann,[18] in Germany, and by Dr. Lindsley,[19] in America. Even hydriatic physicians[20] have tried them with some success. However, notwithstanding the strong recommendations of the remedy on the part of the above named practitioners and others, the efficacity of it as a general remedy for scarlet-fever has not been confirmed. On the contrary, Berend[21] and Hauner[22] found that it did not prevent desquamation, as it had been asserted, and even Richter restricts his commendations to the vague assertion "that it seemed to him as if the cases when he used the lard were made milder than they would have been without it."

The remedy which has attracted and still attracts in a very high degree the attention of physicians and parents, is Belladonna. This remedy was first introduced as a specific and prophylactic by Hahnemann, and soon recommended not only by his own disciples, but by some of the best names of the "regular" school.[23] But soon after, as many physicians of standing declared themselves adversaries to Hahnemann's discovery,[24] and whatever may be the merits of belladonna as a specific and prophylactic in some quarters, it is certain that it never answered the expectation raised by its promulgators in others. As far as my own experience extends, I have seen very little or no effect from it. I have restricted myself, it is true, to homœopathic doses, being afraid of the bad consequences of larger quantities in children; but from what I have seen in my own practice and that of some other physicians with whom I was familiar, I cannot but advise my readers not to rely either on the prophylactic or the curative power of belladonna, when a safer and more reliable remedy is offered to them. A remedy may be excellent in certain cases and certain epidemics, and many an honest and well-meaning physician may be deceived into the belief that he has a general remedy in hand, whilst others, or himself, on future occasions discover that he has allowed himself to be taken in. Had not belladonna and aconite proved beneficial in many cases, they would scarcely have acquired their reputation, but with all due respect for Father Hahnemann and his system, I must deny belladonna to be a general, safe and reliable remedy in the prevention and cure of scarlet-fever.

All these different methods and remedies, and many others, have been and are still used with more or less effect. But where there are three physicians to recommend one of them, there will always be four to contradict them. They may all do some good in certain epidemics or individual cases; they may relieve symptoms; they may save the life of many a patient who would have died without them (although many a patient who died, might have lived also, had he been under a more judicious treatment, or—under no treatment at all.) But none is reliable in general; none contains a specific to neutralize the morbid poison; none is a reliable prophylactic, such as vaccina for small-pox; and if single physicians, or whole classes of physicians, assert to the contrary, the fault must lie somewhere, either in their excess of faith in certain authorities, which induces them to throw their own pia desideria into the scales, or in a want of cool, impartial observation continued for a sufficient length of time to wear out sanguine expectations. The fact is that there neither exists a reliable prophylactic, nor has a safe specific been found as yet; that all is guess-and-piece work; and that people are taken by scarlet-fever and die of it about the same as before those vaunted methods and remedies were discovered. I wish to impress my readers with this fact—the proofs of which they can easily find in the mortality lists of the papers—to make them understand that by giving up for the hydriatic method any of the modes and remedies, which have been in use hitherto, they do not run a risk of losing anything.

Beside the above modes of treatment cold and tepid Water has been extensively used and recommended by reliable authorities. Currie,[25] Pierce, Gregory, Bateman, von Wedekind, Kolbany,[26] Torrence, Reuss,[27] von Fröhlichsthal,[28] and others, have treated their scarlet-patients with cold affusions. Henke, Raimann, Fröhlich, Hesse,[29] Steimmig,[30] Gregory, Jr., Schœnlein, Fuchs, and others, have not ventured beyond cool and tepid ablutions. The former, although the general result has been very satisfactory, have proved dangerous in some cases; and the latter, though safer in general, have not been efficient in many others. The use of water, though safer than other remedies, has never become general, owing to the unsystematic, unsafe, or inefficient forms of its application.

Fear and prejudice—fed by the great mass of physicians, who generally take too much care of their reputation to expose it in the use of a remedy the effects of which are so easily understood by every one—have also been obstacles to its promulgation; and the exaggerations of some of its advocates in modern times, bearing for a great part the characteristics of charlatanism, have scared many who might have become converts to Priessnitz's method, to whose genius and good luck we are indebted for the most important, most harmless, and at the same time the most efficient and most reliable discovery, viz.:

A linen sheet, (linen is a better conductor than cotton,) large enough to wrap the whole person of the patient in it (not too large, however; if there is no sheet of proper size, it should be doubled at the upper end) is dipped in water of a temperature answering to the degree of heat and fever, say between fifty and seventy degrees Fahrenheit, and more or less tightly wrung out. The higher the temperature of the body, and the quicker and fuller the pulse, the lower the temperature of the water, and the wetter the sheet. This wet sheet is spread upon a blanket previously placed on the mattress of the bed on which the packing is to take place. The patient, wholly undressed, is laid upon it, stretched out in all his length, and his arms close to his thighs, and quickly wrapped up in the sheet, head and all, with the exception of the face; the blanket is thrown over the sheet, first on the packer's side, folded down about the head and shoulders, so as to make it stick tight to all parts of the body, especially the neck and feet, tucked under the shoulders, side of the trunk, leg and foot; then the opposite side of the blanket is folded and tucked under in the same manner, till the blanket and sheet cover the whole body smoothly and tightly. Then comes a feather-bed, or a comforter doubled up, and packed on and around the patient, so that no heat can escape, or air enter in any part of the pack, if the head be very hot, it may be left out of the pack, or the sheet may be doubled around it, or a cold wet compress, not too much wrung out, be placed on the forehead, and as far back on the top of the head as practicable, which compress must be changed from time to time, to keep it cool. Thus the patient remains.

46. The first impression of the cold wet sheet is disagreeable; but no sooner does the blanket cover the sheet, than the chill passes away, and usually before the packing is completed, the patient begins to feel more comfortable, and very soon the symptoms of the fever diminish. The pulse becomes softer, slower, the breathing easier, the head cooler, the general irritation is allayed, and frequently the patient shows some inclination to sleep. When the fever and heat are very high, the sheet must be changed on growing hot, as then it would cause the symptoms to increase again, instead of continuing to relieve them. The best way to effect this changing of the sheet is to prepare another blanket and sheet on another bed, to unpack the patient and carry him to the new pack, where the process described above is repeated. Sometimes it is necessary to change again; but seldom more than three sheets are required to produce a perspiration, and relieve the patient for several hours, or—according to the case—permanently. The changing of the sheet may become necessary in fifteen, twenty, twenty-five, thirty or forty minutes, according to the degree of fever and heat. In every new sheet the patient can stay longer; in the last sheet he becomes more quiet than before, usually falls asleep, and awakes in a profuse perspiration, which carries off the alarming symptoms.

47. A few minutes before the perspiration breaks out, the patient becomes slightly irritated, which irritation is removed by the appearance of the sweat. I mention this circumstance, to prevent his being taken out just before the perspiration is started. When he becomes restless during perspiration, he is taken from his pack and placed in a bathing-tub partly filled with cool or tepid water, (usually of about 70°,) which has been prepared in the meanwhile; there he is washed down from head to foot, water from the bath being constantly thrown over him until he becomes cool. Then he is wrapped in a dry sheet, gently rubbed dry, and either taken back to his bed, or dressed and allowed to walk about the room. When the fever and heat rise again, the same process is repeated.

According to a well-known physical law, any cold body, whether dead or alive, placed in close contact with a warm body, will abstract from the latter as much heat as necessary to equalize the temperature of both. The transfer of caloric will begin at the place at which the two bodies are nearest to each other. The wet sheet, which touches the patient's body all over the surface, abstracts heat from the latter, till the temperature of the sheet becomes equal to that of the body. In proportion as the surface of the body yields heat to the sheet, the parts next to the surface impart heat to the latter, and so forth, till the whole body becomes cooler, whilst the sheet becomes warmer. As the heat imparted to the sheet cannot escape from it, the sheet being closely wrapt up in the blanket and bed, the current of caloric once established towards every part of the surface of the body will still continue; after the temperature of the sheet and the body has become equal, there will be an accumulation of heat around the body, frequently of a higher degree than the body itself. To explain this phenomenon, we ought to consider that we have not to do with two dead bodies, but with one dead and one living body, which constantly creates heat, thus continuously supplying the heat escaping from it to the sheet, and keeping up the current of caloric and electricity established towards the surface. There cannot be a doubt that the abstraction of electricity from the feverish organism contributes in a great measure to the relief of the excited nerves of the patient, as well as to the excess of temperature observed around the body in the wet-sheet pack (after the patient has been in it for some time); and that, in general, electricity deserves a closer investigation in the morbid phenomena of the human body than it has found to this day.

49. WHAT EFFECT COULD BE EXPECTED FROM A WARM WET-SHEET?

The first impression of the wet-sheet is, as I stated before, a disagreeable one. If it were agreeable—as a warm sheet, for instance, would be, which has been occasionally tried, of course without doing any good—it would not produce a reaction at all, and consequently there would be no relief for, and finally no cure of the patient effected by it. But the impression of the cold sheet, being powerful, is transferred at once from the peripherical nerves, which receive the shock, to the nervous centres (the spine, the cerebellum and the brain), and, in fact, to the whole nervous system, and the reaction is almost immediate; the vascular system, participating in it, sends the blood from the larger vessels and the vital parts, to the capillaries of the skin; and when, through repeated applications of the sheet, the system is relieved and harmony restored, in a sufficient degree, in and among the different parts of the organism, to enable them to resume their partly impeded functions, a profuse perspiration brings the struggle to a close, by removing the morbid matter which caused the fever, whereupon the skin is refreshed and strengthened, and the whole body cooled and protected by a cool bath from obnoxious atmospheric influences.

50. I am not aware that a better rationale can be given of the action of other remedies. Any physician can understand that its effect must be at once powerful and safe, and that there is no risk in the wet-sheet pack of the reaction not taking place, as it may be the case in severer applications of cold water, without the pack. One objection I have often heard, viz.: that the process is very troublesome. But what does trouble signify, when the life and health of a fellow-being is at stake?—It is true, the physician is frequently compelled to render the services of a bath-attendant, and stay with the patient much longer than in the usual practice; but he gets through sooner, and, if not the patient and his friends, his own conscience will pay him for his exertions and sacrifice of time.

There is little trouble with small children, who make a fuss only, and become refractory, when the parents, grandmammas and aunts set the example. When all remain quiet, and treat the whole proceeding as a matter of necessity, children usually submit to it very patiently, and soon become quiet, should they be excited at the beginning. The fewer words are said, and the quicker and firmer the physician performs the whole process, the less there is trouble. After having been taught how to do it, the parents or friends of the patient will be able to take the most troublesome part of the business off the physician's hands, who, of course, has more necessary things to do, during an epidemic, than to pack his patients and attend to them in all their baths himself.

Only with spoiled children I have had trouble, and more with them that spoiled them. The best course, then, is to retain only one person for assistance, and to send the rest away till all is over. There are people, who will be unreasonable; of course, it is no use to attempt reasoning with them. I remember the grandmother of a little patient, with whom the pack acted like a miracle, removing a severe inflammatory fever in two hours and a half, telling me "she would rather see the child die, than have her packed again," although she acknowledged the pack to have been the means of her speedy recovery. It is true there was some trouble with the child, but only because the whole family were assembled in the sick-room to excite the child through their unseasonable lamentations and expressions of sympathy about the "dreadful" treatment to which she was going to be submitted. Grandmother would not have objected to a pound of calomel!—But we shall speak about objections and difficulties in a more proper place.