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Hydriatic treatment of Scarlet Fever in its Different Forms
by Charles Munde
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HYDRIATIC TREATMENT

OF

SCARLET FEVER

IN ITS DIFFERENT FORMS.

OR

HOW TO SAVE,

THROUGH A SYSTEMATIC APPLICATION OF THE WATER-CURE, MANY THOUSANDS OF LIVES AND HEALTHS, WHICH NOW ANNUALLY PERISH.



Being the Result of

TWENTY-ONE YEARS' EXPERIENCE, AND OF THE TREATMENT AND CURE OF SEVERAL HUNDRED CASES OF ERUPTIVE FEVERS.

BY

CHARLES MUNDE, M.D., Ph.D.



New-York:

WILLIAM RADDE, 300 BROADWAY.

1857.



Entered according to Act of Congress, in the year 1857, by

WILLIAM RADDE,

In the Clerk's Office of the District Court of the United States, for the Southern District of New-York.



HENRY LUDWIG, Printer, 39 Centre-street, N.-Y.



PREFACE.

In offering this pamphlet to the Public in general, and to Parents and Physicians in particular, I have no other object than that of contributing my share to the barrier which the medical profession has attempted, for more than two hundred years, to raise against the progress of the terrible disease which carries off upon an average, half a million of human beings annually. All the efforts of medical men to stop the ravages of Scarlet-Fever have hitherto proved unavailing; every remedy which was considered, for a while, a specific proved subsequently inefficient; and, notwithstanding the assertion to the contrary of a few, the Dr. Jenner who shall discover a reliable prophylactic against scarlatina, is probably not yet born. The patients die in the same proportion as they did two hundred and fifty years ago, and the physicians who have any success at all in the treatment of the terrible scourge, are those who treat for symptoms and leave the disease to Nature.

Under these circumstances, a mode of treatment which promises a decrease in the number of victims, from the experience of a quarter of a century, and a score of epidemics of different characters, cannot but be received with pleasure by the public. I have treated scarlet-fever hydriatically for twenty-one years, and out of several hundred cases never lost a patient, except one who died of typhus during an epidemy of scarlatina; and my observations, during twenty-five years, of the practice of other physicians of the same school, present a result about as favorable as my own.

My present position is such, that no self-interest, if I could have any in a question of such importance for the human race; would induce me to publish this article, as a rush of scarlet-fever patients would only tend to destroy the practice at my establishment, instead of increasing my income. My purpose, therefore, must be honest; and the zeal which I have manifested for many years in the promulgation of the Water-Cure is no longer the effect of enthusiasm, but of the observations and practice of Priessnitz's method during the best part of a man's life, and the conviction of its merits gained from facts.

I consider Hydro-therapeutics as one of the healthiest branches of the Tree of Medical Science, but not, like some others do, as the whole Tree. I do not pretend to be able to cure every thing with water; but in yielding to other medical systems what belongs to them, I earnestly claim for the Water-Cure, what belongs to it, frankly accusing for the little progress the hydriatic system has made in this country, the spirit of charlatanism and speculation on one side, and ignorance, self-conceit, self-interest and laziness on the other. According to my experience, and the result obtained by other hydriatic practitioners, eruptive fevers decidedly belong to Hydro-therapeutics, or the Water-Cure. If the result obtained by men like Currie, Bateman, Gregory, Reuss, Froelichsthal, &c., long before Priessnitz, were highly satisfactory, the important additions and the more systematic arrangement of the treatment of the inventor of the Water-Cure and myself, have made the method almost infallible in eruptive fevers, and my innermost conviction is, that all the other modes of treatment of these fevers put together will not do the tenth part of the service which may with certainty be expected from the systematic use of water as I give it in this treatise.

Owing to the reluctance of the profession to allow Hydro-therapeutics an honorable place among medical systems, I address myself more to parents than to physicians. Had I intended to write for the latter, exclusively, the important subject which I am treating, would have received another coat. However, nothing of value to the physician has been omitted, whilst much has been said, which though he does not need it, seemed to me indispensably necessary for people not initiated in the medical art.

In regard to the style and language in general, I solicit the reader's indulgence. I may appear pretentious in publishing the present pamphlet, written in a tongue which is not my own, without submitting it, previously, to the correction of an English or American pen; but this publication has been called forth by the tears of mothers mourning over the bodies of their darlings during the present winter, and too much time has been lost already in preparing it, for those whose life might have been saved, by an earlier publication, whilst I am fully aware of the imperfections of a work, which has been done during the few, often interrupted, leisure-hours left to me by the position I occupy. But whatever may be its defects, I feel convinced, that it cannot fail doing some little good; and should but one mother's tears remain unshed, I would never regret having published it. The good it will do, must depend on the favor with which it is received.

CHARLES MUNDE.

FLORENCE WATER-CURE,} NORTHAMPTON, MASS. }

March, 1857.



TABLE OF CONTENTS.

PART THE FIRST.

DESCRIPTION OF SCARLET-FEVER. PAGE

1. Definition—Scarlet-Fever or Scarlatina 13

2. Division of the process of the disease into Periods 13

3. Period of Incubation, or Hatching 13

4. Period of Eruption, or Appearing of the Rash 14

5. Period of Efflorescence, or Standing out of the Rash 15

6. Period of Desquamation, or Peeling off 16

7. Period of Convalescence 17

8. Varieties of Forms of Scarlatina 17

9. Scarlatina simplex, or simple Scarlet-Fever 17

10. Scarlatina anginosa, or Sore-Throat Scarlet-Fever 18

11. Mild Reaction (erethic) 19

12. Violent Reaction (sthenic) 19

13. Torpid Reaction (asthenic) 19

14. Scarlatina miliaris 19

15. Scarlatina sine Exanthemate 20

16. Malignant Forms of Scarlatina 20

17. Sudden Invasion of the Nervous Centres 20

18. Affection of the Brain 20

19. 20. Affection of the Cerebellum and Spine 21

21. Putrid Symptoms 21

22. Condition of the Throat, and other Internal Organs 21

23. Other bad symptoms 22

24. Destruction of the Organ of Hearing 22

25. Other Sequels, Dropsy, &c. 22

26-27. The Contagion of Scarlatina very active 23

28. Diagnosis 24

29. Diagnosis from Measles 24

30. Prognosis 25

31. Favorable symptoms 25

32. Unfavorable symptoms 26



PART THE SECOND.

TREATMENT OF SCARLET-FEVER.

33. Different Methods of other Schools 27

34. The Expletive Method 27

35. The Anti-gastric Method 28

36. Ammonium carbonicum 29

37. Chloride of Lime 30

38. Acetic Acid 30

39. Mineral Acids. Muriatic Acids—Prescriptions 30

40. Frictions with Lard 30

41. Belladonna 31

42. There is neither a Specific nor a Prophylactic to be relied on 32

43. Water-Treatment, as used by Currie, Reuss, Hesse, Schoenlein, &c. 33

44. Priessnitz's Method—The wet-sheet-Pack 34

45-47. Technicalities of the Pack and Bath 34-36

48. Action of the Pack and Bath—Rationale 36

49. 50. What effect could be expected from a warm wet-sheet? 38

51. No cutting short of the process of Scarlatina—the morbid poison must be drawn to the skin as soon as possible 40

52. Necessity of Ventilation—Means of Heating the sick-room— Relative merits of Open Fires, Stoves and Furnaces 41

53. Temperature of the sick-room 43

54. Water-drinking 44

55. Diet 44

56. Treatment of Scarlatina simplex 45

57. Treatment of Scarlatina anginosa 46

58-65. Treatment of the mild, or erethic Form of scarlatina anginosa 40-50

66. Treatment of the violent, or sthenic Form of scarlatina anginosa 50

67. Temperature of the water—double sheet—Changing sheet 51

68. 69. Length of Pack—Perspiration 52

70. Length of Bath 53

71. Caution 53

72. The wet Compress 54

73. Highly inflamed Throat—Croup 54

74. Necessity of allaying the Heat 55

75-77. The Half-bath—The Sitz- or Hip-Bath 55-56

78. Action of the sitz-bath explained 56

79. 80. Relaxation of Treatment towards the end of the third period—Continuation of Packs during and after Desquamation 57

81. Treatment of torpid Forms of scarlatina—Difference in the Treatment pointed out 58

82. Length of Pack 59

83. Cold Affusions and Rubbing 59

84. Ice-Water and Snow-Bath in malignant cases 59

85. Wine and Water, &c., if no reaction can be obtained 60

86. Ablutions and Rubbing with Iced-Water or Snow 61

87. Wet Compress 61

88. Ventilation all-important 61

89. Continuation of Packs—Convalescence 62

90. Mineral Acids, in case of severe sore Throat 62

91. Putrid Symptoms—Gargle—Solution of Chloride of Soda—Drink: Chlorate of potass—Liquor calcii chloridi 62

92. Treatment of Affections of the Nervous Centres 63

93. 94. Sitz-bath, anchor of safety 64

95.-97. Cases 65-68

98. 99. Impossibility of answering for the issue of every typhoid case 71

100. Is Water applicable in all typhoid cases? 71

101.-109. Rules for the application of water in typhoid cases 71-73

110.-112. Illustrations 73-78

PART THE THIRD.

113. Treatment of other Eruptive Fevers 80

114. Small-Pox 80

115. Varioloids, and Chicken-pocks 82

116. Measles 82

117. Urticaria, Zoster, Rubeola 83

118. Erysipelas 83

119. Erythema 83

120. 121. Additional Rules for the Treatment of Eruptive Diseases 83-84

122. Conclusive Remarks—Obstacles 84

123. Want of Water 84

124. Dripping Sheet, substitute for the Half-bath 84

125. Rubbing Sheet, substitute for the Half-bath 85

126. Where there is a will, there is a way 85

127. Prejudice of Physicians against the Water-Cure 86

128. Rebellion! 87

129.-130. Facts 87

131. More Facts! 89

132. Conclusion: Help yourselves, if your physicians will not help you! 90



PART I.

DESCRIPTION OF SCARLET-FEVER.

1. SCARLET-FEVER, OR SCARLATINA,[1]

is an eruptive fever, produced by a peculiar contagious poison, and distinguished by extreme heat, a rapid pulse, a severe affection of the mucous membranes, especially those of the mouth and throat, and by a burning scarlet eruption on the skin.

2. DIVISION OF THE PROCESS OF THE DISEASE INTO PERIODS.

Its course is commonly divided into four distinct periods, viz.: the period of incubation, the period of eruption, the period of efflorescence, and the period of desquamation; to which may be added: the period of convalescence.

3. PERIOD OF INCUBATION, OR HATCHING.

The time which passes between the reception of the contagious poison into the system and the appearance of the rash, is called the period of incubation; incubation or incubus meaning, properly, the sitting of birds on their nests, and figuratively, the hatching or concoction of the poison within the body, until prepared for its elimination. There is no certainty about the time necessary for that purpose, as the contagion, after the patient has come in contact with it, may be lurking a longer or a shorter time about his person, or in his clothes and furniture.

As in almost all eruptive fevers, so in scarlatina, the patient begins with complaining of shivering, pain in the thighs, lassitude, and rapidly augmenting debility; frequently also of headache, which, when severe, is accompanied with delirium, nausea and vomiting. The fever soon becomes very high, the pulse increasing to upwards of 120 to 130 strokes in a minute, and more; the heat is extreme, raising the natural temperature of the body from 98 to 110-112 degrees Fahrenheit, being intenser internally than on the surface of the body. The patient complains of severe pain in the throat, the organs of deglutition located there becoming inflamed, and swelling to such a degree that swallowing is extremely difficult, and even breathing is impeded. The tongue is covered with a white creamy coat, through which the points of the elongated papillae project. Gradually the white coat disappears, commencing at the end and the edges of the organ, and leaves the same in a clean, raw, inflamed state, looking much like a huge strawberry. This is called the strawberry tongue of scarlet-fever, and is one of the characteristic symptoms of that disease. There is a peculiar smell about the person of the patient, reminding one of salt fish, old cheese, or the cages of a menagerie.

4. PERIOD OF ERUPTION, OR APPEARING OF THE RASH.

Commonly, on the second day, towards evening, sometimes on the third, and only in very bad cases later, the rash begins to make its appearance, under an increase of the above symptoms, especially of the fever and delirium, and continues to come out for about twelve hours. Usually the eruption commences in the face, on the throat and chest; thence it spreads over the rest of the trunk, and finally it extends to the extremities. The minute red points, which appear at first, soon spread into large, flat, irregular patches, which again coalesce and cover the greater part, if not the whole, of the surface, being densest on the upper part of the body, particularly in front, in the face, on the neck, the inner side of the arms, the loins, and the bend of the joints. The scarlet color of the rash disappears under the pressure of the finger, but reappears immediately on the latter being removed. Sometimes the eruption takes place with a profuse warm sweat, which prognosticates a mild course and a favorable issue of the disorder. Together with the appearance of the rash, the disease develops itself also more internally: the inflammation of the mouth and throat increases; the tonsils and fauces swell to a high degree; the eyes become suffused and sensitive to the light; the mucous membranes of the nose and bronchia become also affected, the patient sneezes and coughs, and all the symptoms denote the intense struggle, in which the whole organism is engaged, to rid itself of the enemy which has taken possession of it.

5. PERIOD OF EFFLORESCENCE, OR STANDING OUT OF THE RASH.

During the first day or two of the period of efflorescence, which lasts three or four days, the above symptoms usually continue to increase. Sometimes, however, the patient is alleviated at once on the rash being formed. This alleviation always takes place when the rash comes with perspiration, and also under a proper course of water-treatment. If the rash continues to stand out steadily, the symptoms decrease on the third day; the patient becomes more quiet, the pulse slower (going down to 90 and even to 80 strokes per minute); the rash, then, gradually and steadily fades, and finally disappears altogether.—Sometimes the rash fades or disappears too early, in which cases, usually, the internal symptoms increase, the brain and spine become affected, and the situation of the patient becomes critical.

6. PERIOD OF DESQUAMATION, OR PEELING-OFF.

About the sixth or seventh day, the epidermis, or cuticle of the skin begins to peal off, commencing in those places which first became the seat of the rash, and gradually continuing all over the body. In such parts as are covered with a thin delicate cuticle (as the face, breast, &c.) the cuticle comes off in small dry scurfs; in such parts as are covered with a thicker epidermis, in large flakes. There have been instances of almost complete gloves and slippers coming away from patients' hands and feet.—The fever subsides entirely, and so does the inflammation of the throat and mouth, which become moist again. Also the epithelia, or the delicate cuticles of the mucous membranes, which have been affected by the disease, peal off and are coughed up with the tough thick mucus covering the throat, or they are evacuated with the faeces and the urine, forming a sediment in the latter.—Desquamation is usually completed in from three to five days; sometimes it requires a longer time; under hydriatic treatment it seldom lasts more than a few days. Whilst desquamation is taking place, a new cuticle forms itself, which, being exceedingly thin at first, gives the patient a redder color than usual for some time, and requires him to be cautious, in order to prevent bad consequences from exposure.—

Thus the disease makes its regular course in about ten days, and, under a course of hydriatic treatment, which not only assists the organism in throwing off the morbid poison and keeps the patient in good condition, but also protects him from the influence of the atmosphere, the patient may consider himself out of danger and leave the sick-room under proper caution, of which we shall speak hereafter.

7. THE PERIOD OF CONVALESCENCE,

under the usual drug-treatment, is, however, usually protracted to twice or thrice the duration of the disease, the patient being compelled to keep the house for five or six weeks, especially from fear of anasarca, or dropsy of the skin, frequently extending to the inner cavities of the body, and proving fatal. This dangerous complaint has been more frequently observed after mild cases of scarlet-fever than after malignant cases, probably from the fact that in mild cases the patient is more apt to expose himself, than when the danger is more obvious and all possible care is taken.—Sometimes also severe rheumatic pain, or rather neuralgia, in the joints, swelling of the glands, and other sequels prolong his sickness. I never observed a case of dropsy, or of neuralgia, after a course of water-treatment.

8. VARIETIES OF FORMS OF SCARLATINA.

The above is the description of scarlet-fever, as it most frequently occurs. But far from taking always that regular course, the constitution of the patient, the intensity of the epidemy and the virulence of the poison, the treatment and other circumstances influencing the development of the disease, cause several anomalies, from scarlatina simplex to scarlatina maligna, which too often baffles all the resources of the Medical Art.

9. SCARLATINA SIMPLEX, OR SIMPLE SCARLET-FEVER.

In the mildest form of the disease, called scarlatina simplex, or simple scarlet-fever, there is no inflammation of the throat, the fever is moderate, and the patient suffers very little. Unfortunately this form is so rare, that many experienced physicians never saw a case. Probably, it was a case belonging to this class, which was mentioned a number of years ago by one of the writers on Priessnitz's practice, when a lady with scarlet-fever joined a dancing party at Graefenberg, a case for reporting which the author[2] has been ridiculed by the opponents of the Water-Cure, but which by no means belongs to impossibilities; for scarlatina simplex having been declared by eminent physicians (not of Priessnitz's school) to be "scarcely a disease,"[3] becoming fatal only through the officiousness of the doctor,[4] and other physicians of note recommending cold rooms and open air through the whole course of the disease,[5] or at least towards the latter part of it;[6] I do not see why a patient under water-treatment should not be safer in producing perspiration by dancing than in sitting in a cold room or in walking in the open street. The fact, of course, is unusual, and I do not exactly recommend its practice, but it is not at all impossible, and ridiculing the reporter of it shows either ignorance of the disease or a bad will towards the new curative system, to which those are most opposed who know the least of it.

10. SCARLATINA ANGINOSA, OR SORE-THROAT SCARLET-FEVER.

Wherever the throat is affected, which is almost always the case, the disease is called scarlatina anginosa, or sore-throat scarlet-fever. This is the form described at the commencement of this article. There are several varieties, however, of scarlatina anginosa.

In any case, the organism, invaded by the contagious poison, will try to rid itself of its enemy. The reaction is necessarily in proportion to the violence of the miasma and to the quantity of organic power struggling against it.

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.

12. VIOLENT REACTION (STHENIC).

If both, the contagious poison and the organism, are very strong, a violent reaction will take place, and the safety of the patient will be endangered by the very violence of the struggle, by which internal organs may be more or less affected.

13. TORPID REACTION (ASTHENIC).

The more violent the contagious poison, and the weaker the organic power, the less decidedly and the less successfully will the organism combat against the poison, and the more inroad will the latter make upon the system, affecting vital organs and paralyzing the efforts of the nervous system by attacking it in its centres. In such cases of torpid reaction, the patient frequently passes at once into a typhoid state. This is what we call scarlatina maligna, or malignant scarlet-fever.

14. SCARLATINA MILIARIS

Sometimes the red patches of the rash are covered with small vesicles of the size of mustard-seed, which either dry up or discharge a watery liquid, leaving thin white scurfs, that come away with the cuticle during desquamation. Although this form, called scarlatina miliaris, being the result of exudation from the capillary vessels, shows an intensely inflamed state of the skin, its course is usually mild and its issue favorable; because the morbid poison comes readily to the surface.

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.

16. THE MALIGNANT FORMS OF SCARLET-FEVER

are caused by the character of the epidemy, but, perhaps, more frequently by the weak and sickly constitution of the patient and the external circumstances affecting it. Thus, persons of scrofulous habit, being naturally of a low organization, without much power of resistance, are much more liable to experience the destructive effects of scarlatina than those whose organism possesses sufficient energy to resist the action of the morbid poison, and to expel it before it can do any serious harm inside the body.

17. SUDDEN INVASION OF THE NERVOUS CENTRES.

Of the different forms of scarlatina maligna the most dangerous is the sudden invasion of the nervous system, particularly the brain, the cerebellum and the spine, by which the patient's life is sometimes extinguished in a few hours. In other cases the symptoms deepen more gradually, and death ensues on the third, fifth or seventh day.

18. AFFECTION OF THE BRAIN.

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 dyspnoea (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.

19. AFFECTION OF THE CEREBELLUM AND SPINE.

In affections of the cerebellum and spinal marrow, the patient complains of violent pain in the back of the head and neck, in the spine, and frequently in the whole body. These also frequently terminate with the destruction of life.

20. During all these invasions of the nervous centres there is little or no rash, and what appears is of a pale, livid hue.

21. PUTRID SYMPTOMS.

Next to those most dangerous forms—most dangerous, because the organic power (the vis medicatrix naturae), from which the restoration of health must be expected, and without which no physician can remove the slightest symptom of disease, becomes partly paralyzed from the beginning—putrid symptoms present a good deal of danger, although they give the organism and the physician more time to act.

22. CONDITION OF THE THROAT, AND OTHER INTERNAL ORGANS.

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 diarrhoea 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.

23. OTHER BAD SYMPTOMS.

These symptoms may present themselves with the rash standing out; but most frequently they occur when there is little or no eruption, or when it fades, becomes livid, or disappears altogether. A sudden disappearance of the rash, before the sixth day, commonly increases the typhoid symptoms, and must be considered a bad omen. Also the invasion of the larynx, which is happily of rare occurrence, is commonly fatal.

24. DESTRUCTION OF THE ORGAN OF HEARING.

When the glands pass into a sloughing state, the parts connected with them are frequently damaged. Thus the ulceration of the parotid gland often causes deafness, by the gangrenous matter communicating to the eustachian tube and the inner ear, where it destroys the membrane of the drum and the little bones belonging thereto, or by closing up the tube. When the discharge from the outer ear is observed, the destruction has already taken place, and it is too late to obviate the injury.

25. OTHER SEQUELS, DROPSY, &C.

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.

26. THE CONTAGION OF SCARLATINA VERY ACTIVE.

The contagion of scarlatina is very active, and adheres for a long time to the sick-room, bedding, clothes and furniture. The best means to destroy it, is plenty of air. It is difficult to say when the contagion is over, as much depends on the season of the year and the care with which the house is aired. Physicians and visitors at the sick-room are very apt to carry it about, unless they be exceedingly careful in changing their clothes and washing themselves, hair and all, before entering other rooms inhabited by persons who had not had the disorder before. It is astonishing how easily such persons are taken by it; and it even sometimes happens that such as have gone through it, take it again in after years. I am authorized by experience, that the idea as if patients under water-treatment, or even such as take a cold bath every morning, were inaccessible to the contagion, is erroneous. I have had patients under treatment for chronic diseases, who had had scarlatina several years before, and neither this nor the water-cure protected them from taking it again. With some of them, however, the throat only became affected and no desquamation took place, whilst the character of the complaint with the rest was rather mild. I have been astonished to read that in a meeting of a medical society of this country, which took place a very short time ago, some members could have raised the question whether scarlatina was really contagious. I admit that the profession in general has not made great progress in the cure of the complaint, but it does not require great study and long experience to know that scarlet-fever is contagious!

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.

28. DIAGNOSIS.

After what has been said about the symptoms of scarlatina, it cannot be difficult to distinguish it from similar eruptive diseases. However, as there is much resemblance between scarlatina and measles, at least in the milder form of the former, I shall give a few symptoms of each, to assist parents in making the distinction.

29. DIAGNOSIS FROM MEASLES.

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 laminae, whilst the latter comes off in small scales or scurfs.

30. THE PROGNOSIS,

under a well conducted course of hydriatic treatment is, in general, favorable. Much depends, however, on the season of the year (in damp and cold weather—partly owing to a lack of pure air in the sick-room—the disease is more dangerous than in summer); on the general health of the patient (not on his mere looks, for well-fed and stout children are subject to affections of the brain); on the age of the patient (adults are generally more in danger than children); on the form of the disease and the character of the fever (erethic or mild fever being the most favorable, whilst typhoid fever is the worst; a violent character of the fever is not very dangerous under hydriatic treatment, as we have plenty of means to limit its ravages without weakening the patient); on the eruption, the condition of the throat, the process of desquamation, &c.

31. FAVORABLE SYMPTOMS

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.

32. UNFAVORABLE SYMPTOMS

are: A fetid breath, with ulceration and sloughing of the throat and glands; a smarting and weakening diarrhoea; involuntary evacuations of the bowels; dizziness, deafness, coma, grinding of the teeth; retention of urine; petechiae; a rapid decline of the patient's strength; a quick, small, weak pulse; rapid breathing; twitchings, tetanus, hiccough, &c.—Closing up of the nose frequently precedes a dangerous affection of the brain. A sudden disappearance of the rash, or of the inflammation of the throat, is a bad omen. With such symptoms as these, there is usually little or no rash, and the little there is, of a pale, livid color, and the skin, in general, inactive.

FOOTNOTES:

[1] The expression scarlatina does not imply, as it is believed by many, on account of its diminutive form, a peculiar mild form of the disease: it is nothing but the Latin and scientific name for scarlet-fever.

[2] Captain Claridge.

[3] Thomas Watson, M. D. Lectures on the Principles and Practice of Physic.

[4] Sydenham.

[5] G. C. Reich, M.D. Neue Aufschluesse ueber die Natur und Heilung des Scharlachfiebers, Halle, 1810.

[6] L. Hesse, M. D. in Rust's Magazin, Vol. XXVII., H. 1 S. 109.



PART II.

TREATMENT OF SCARLET-FEVER.

DIFFERENT METHODS OF OTHER SCHOOLS.

33. Before giving the description of hydriatic treatment of scarlet-fever, I shall, for the sake of a better appreciation, glance over the different methods which have been recommended by other schools.

34. THE EXPLETIVE METHOD (blood-letting)

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.

35. THE ANTI-GASTRIC METHOD,

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.

36. THE AMMONIUM CARBONICUM,

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.

37. CHLORIDE OF LIME.

About the same opinion may be given on Chloride of Lime. As a gargle, and taken internally, the aqua-chlorina has done good service in malignant scarlatina, especially in putrid cases.

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.

39. MINERAL ACIDS (MURIATIC ACID—PRESCRIPTIONS)

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]

40. FRICTIONS WITH LARD

were used already by Caelius Aurelianus,[17] and recently re-introduced into practice, by Drs. Daene 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."

41. BELLADONNA.

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 homoeopathic 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.

42. THERE IS NEITHER A SPECIFIC NOR A PROPHYLACTIC TO BE RELIED ON.

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.

43. WATER-TREATMENT, AS USED BY CURRIE, REUSS, HESSE, SCHOENLEIN, &C.

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 Froehlichsthal,[28] and others, have treated their scarlet-patients with cold affusions. Henke, Raimann, Froehlich, Hesse,[29] Steimmig,[30] Gregory, Jr., Schoenlein, 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.:

44. PRIESSNITZ'S METHOD—THE WET-SHEET-PACK,

a remedy which, alone, is worth the whole antiphlogistic, diaphoretic, and, indeed, the whole curative apparatus of the profession, in ancient and modern times, for any kind of fevers, and especially for eruptive diseases. Nor did the physicians before Priessnitz know anything about the use of the sitz-bath for affections of the brain in torpid reaction, which in such cases, is the only anchor of safety. In short, water-treatment was, like other methods, an excellent thing for certain symptoms, but not generally and safely applicable in every case.

To appreciate the effects of the wet-sheet pack, one must have seen it used for inflammatory fever, when it acts like a charm, frequently removing all the feverish symptoms, and their cause, in a few hours.

45. TECHNICALITIES OF THE PACK AND BATH.

Let me give you its technicalities, and the rationale of its action:

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 deg.,) 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.

48. ACTION OF THE PACK AND BATH.—RATIONALE.

The action of the wet-sheet pack is thus easily accounted for:

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.

51. NO CUTTING SHORT OF THE PROCESS OF SCARLATINA—THE MORBID POISON MUST BE DRAWN TO THE SKIN AS SOON AS POSSIBLE.

Scarlet-fever is a disease, which cannot be cut short. Any attempt to stop the process of incubation, after the contagion has once been received within the body, or to prevent its being thrown out upon the surface, would destroy the patient's life: the morbid poison must be concocted, and it must come away by being drawn to the skin as soon as possible, to prevent its settling in the vital parts, and injuring them. The safest way of assisting nature in her efforts of eliminating the poison, is to open the way, which she points out herself. We know that the sooner and the more completely the eruption makes its appearance, the brighter and the more constant the rash, the less there is danger for the patient, and vice versa. Well, there is not a better remedy than the wet-sheet pack, to serve the purpose of nature, i. e., to remove the morbid poison from the inner organs, and draw it to the surface; whilst at the same time it allays the symptoms, improves the condition of the skin for the development of the rash, and relieves the patient, without depriving him of any part of that organic power so indispensable for a cure, and without which the best physician in the world becomes a mere blank. Under the process of wet-sheet packing, the heat invariably abates, the pulse becomes slower and softer, the violence of the symptoms is alleviated, the skin becomes moist, the restlessness and anxiety of the patient give way to a more quiet and comfortable condition; he perspires and falls in a refreshing sleep. Is there any other remedy, that has the same general and beneficial effect? I know of none.

52. NECESSITY OF VENTILATION—MEANS OF HEATING THE SICK-ROOM—RELATIVE MERITS OF OPEN FIRES, STOVES AND FURNACES.

Next to its intrinsic value, our method gives the patient the great advantage of enjoying pure fresh air, either in or out of bed, as it keeps the skin and the whole system in such order as to resist the effects of atmospheric influences better than under a weakening process. And every body knows, or, at least, every body ought to know, that free circulation of fresh air is one of the most important means, in contagious diseases, of preventing the malady from becoming malignant, and of lessening the intensity of the contagion. Although the times are passed, when patients in the heat of fever were almost roasted in their beds, whilst a drink of cooling water was cruelly and stupidly denied them; the temperature of the sick-room is, in general, still kept too high, and not sufficient care is taken to renew the air as frequently, I ought to say as constantly, as necessary for the benefit of the patient. Usually there is no ventilation; very seldom a window is opened, especially in the cold season, when epidemics of scarlatina are most common, and commonly the room is crowded with friends of the patient, who devour the good air, which belongs to him by right, and leave him their exhalations to breathe instead. There is nothing better able to destroy contagious poisons than oxygen and cold; and if we consider that every human being absorbs every minute a volume of air larger than the bulk of its own body, we must understand how necessary it is to keep people away from the sick-room, who are not indispensably necessary to the patient, and to provide for a constant supply of fresh air. But whatever may be the arrangement for that purpose, the patient should not be exposed to a draught. Stoves and fire-places are pretty good ventilators for drawing off the bad air from the room; if you take care not to have too much fire, and to allow a current of pure air to enter at a corresponding place, the top of a window, or a ventilator in the wall opposite the fire-place, there will always be pure air in your sick-room. The air coming from furnaces, which unfortunately have become so general, is good for nothing, especially when taken from the worst place in the house, the cellar or basement. I consider the worst kind of stoves better than the best kind of furnaces; only take care not to heat the stove too much, or to exclude the outer air, which is indispensable to supply the air drawn off by the stove for feeding the fire. The difference between a furnace and a tight stove or fire-place is this: The furnace takes the bad air from the basement or cellar, frequently made still poorer through its passing over red hot iron, which absorbs part of its oxygen, and fills the room with it. The room being filled with poor air, none of the pure air outside will enter it, because there is no vacuum. Thus the bad air introduced into the room, and the bad air created by the persons in it, will be the only supply for the lungs of the patients. But should the furnace take its air from outside the house, as it is the case with some improved kinds, there would still be no ventilation in the sick-room, except there be a fire-place beside the register of the furnace. With the stove or fire-place it is different: The stove continually draws off the lower strata, i. e. the worst part, of the air to feed the fire, whilst pure air will rush in through every crevice of the doors and windows to supply every cubic-inch of air absorbed by the stove. Thus the air in the room is constantly renewed, the bad air being carried off and good air being introduced. However, the openings through which the pure air comes in, must be large enough in proportion to allow a sufficient quantity of air to enter the room to make fully up for the air absorbed by the stove; for, if not, the air in the room will become thin and poor, and the patient will suffer from want of oxygen. An open fire, from the necessity of its burning brighter and larger to supply sufficient heat, a comparatively large part of which goes off through the chimney, will require a greater supply of air, and consequently larger ventilators or openings for the entrance of the pure air from outside the room. In very cold weather, and in cold climates in general, stoves are preferable to fire-places, the latter producing a draught, and not being able to heat a room thoroughly and equally, causing one side of the persons sitting near them to be almost roasted by the radiant heat in front, whilst their backs are kept cold by the air drawing from the openings in the doors and windows towards the fire to supply the latter. In merely cool weather, and in moderately cold climates, especially in damp places, I would prefer an open fire to a stove. In cold climates stoves are decidedly preferable, especially earthen ones, as they are used in Germany and Russia. Iron stoves must never be heated too much, as the red hot iron will spoil the air of the room, by absorbing the oxygen, as you can easily see by noticing the sparks, which form themselves outside the stove in very hot places.

53. TEMPERATURE OF THE SICK-ROOM.

The temperature of the sick-room should not be much above 65 deg. Fahrenheit; in no case should it rise above 70, whilst I do not see the necessity of keeping it below 60, as some hydriatic physicians advise.[31] The patient, in the heat of fever, will think 60 deg. high enough, and rather pleasant; and if others do not like a temperature as low as that, they may retire. The person necessary for nursing the patient may dress warmly and sit near the fire. Let the sick-room be as large as possible; or open the door and windows of a room connected with it. Towards the close of the disease, after desquamation has begun, the temperature of the room may be kept at 70 deg., as then the fever and heat have subsided and the delicate skin of the patient requires a comfortable temperature.

54. WATER-DRINKING.

As the patient should have a constant supply of pure air for his lungs, so he should also have plenty of pure cold water for his stomach, to allay his thirst and assist in diminishing the heat of fever, and in eliminating the morbid poison from his blood. Though cold, the water for drinking should not be less than 48 or 50 deg. Fahrenheit. Whenever there is ice used for cooling the water, the nurses should be very careful not to let it become colder, than the temperature just indicated, except in typhoid cases, when the stimulating effects of icy cold water and ice may prove beneficial.

55. DIET

I have little to say with regard to diet, at least to physicians. During great heat and high fever, the patient should eat little or nothing; but he should drink a good deal. Substantial food must be avoided entirely. When the fever abates, he can take more nourishment, but it should be light. Meat and soup should only be given, when desquamation has fairly begun. Stewed fruit (especially dried apples) will be very agreeable to the patient. In great heat, a glass of lemonade may be given occasionally; however, great care must be taken not to spoil the patient's taste by sweets, or to allow him all sorts of dainties, such as candies, preserves, &c., as it is the habit of weak parents, who like to gratify their darlings' momentary desires at the expense of their future welfare. In torpid cases, some beef-tea, chicken-broth, and even a little wine with water, will raise the reactive powers of the patient. During convalescence, meat may be permitted to such patients as have been accustomed to eat it, and, in general, the patients may be allowed to gradually resume their former diet (provided it were a healthy one), with some restriction in regard to quantity. In general, under water-treatment, the digestive organs continuing in a tolerably good state, and the functions in better order, we need not be quite so careful with respect to diet, as if the patient were left to himself, or treated after any other method of the drug-system. Let the food be plain, and the patient will scarcely ever eat too much. To stimulate his appetite by constantly asking him whether he would not like this or that, is sheer nonsense; and to satisfy his whims, against our better conviction, is culpable weakness.

From this general outline, I shall now pass to the treatment adapted to the different forms of scarlatina.

56. TREATMENT OF SCARLATINA SIMPLEX, OR SIMPLE SCARLET-FEVER.

Scarlatina simplex, or simple scarlet-fever (9), without inflammation of the throat, is generally so mild in its course, that it requires little or no treatment. However, I would not have parents look upon it as "scarcely a disease," as neglect and exposure may bring on bad consequences (7 and 25). If the fever and heat are very moderate, the first days an ablution of the body with cool water (say 70 deg.), twice a day, is sufficient. The patient had better be kept in bed, or, if unwilling to stay there, he should be warmly dressed and move about his room, the temperature of which, in this case, should not be below 70 deg. Fahrenheit, and the windows should be shut, as long as the patient is out of bed.

When the period of efflorescence, or standing out of the rash, is over, packs ought to be given, to extract the poison completely from the system, and to prevent any sequels, such as anasarca, &c. (25). Should the rash suddenly disappear before the fifth or sixth day, or should it linger in coming out, a long pack will bring it out and remove all danger. The packs, once begun, should be continued, once a day, during and a few days after desquamation. The patient may go out on the tenth or twelfth day warmly dressed, after his pack and bath, and walk for half an hour; sitting down or standing still to talk in the open air is not to be permitted. During, and some time after convalescence, the patient should take a cool bath, or a cold ablution every morning, immediately on rising from bed, and walk after it as soon as he is dressed. In very cold and disagreeable weather, the walk should be taken in the house; but the patient should not sit down, or stand about, before circulation and warmth are completely restored in every part of the body, especially in the feet. I cannot insist too much upon exercise being taken immediately after every bath, as, without it, the bath may do more harm than good, and dressing, with many, will take so much time, that they will take cold before getting their clothes on.

If the patient should take cold, or feel otherwise unwell, during convalescence, the packs must be resorted to again, and continued till he is quite well.

57. TREATMENT OF SCARLATINA ANGINOSA, OR SORE-THROAT SCARLET-FEVER.

In scarlatina anginosa, or sore-throat scarlet-fever, which is the most common form of the disease (1-7) we have to discriminate, whether

1) the reaction is mild, the heat of the body not being much above 100 deg. Fahr. and the pulse full, but not above 110 to 120, the pain and swelling of the throat moderate, the brain little or not affected; or

2) violent, the heat from 106 to 112, the pulse 120 to 150 beats or more, the inflammation of the throat decided and extensive, the brain very much affected; or

3) torpid, little or no heat, the pulse quick and weak, the inflammation of the throat undecided, varying, the rash appearing slowly or not at all, and what there appears of a pale, livid color, the patient more or less delirious.

58.—1. TREATMENT OF THE MILD OR ERETHIC FORM OF SCARLATINA ANGINOSA.

The mild or erethic form of scarlatina anginosa requires about the same treatment as scarlatina simplex. I would, however, for the sake of safety, advise a pack and bath per day, through the whole course of the disease, in the afternoon, when the fever begins to rise; and during the period of eruption, when all the symptoms increase, two and even three packs a day may be required. This depends on the increasing heat and fever, as well as on the condition of the throat. The greater the heat and fever, and the more troublesome the inflammation, the more packs. If the fever and pain increase some time after the pack, in which the patient may stay for an hour or two, the packing must be repeated. The length of the pack depends much on circumstances; as long as the patient feels comfortable and can be kept in it, without too much trouble, he ought to stay. In case the patient cannot be prevailed upon to stay longer than an hour, or if the fever increases soon after the pack, it may be necessary to repeat packing every three or four hours, which is the general practice of several water-physicians in Germany and England.

59. If the patient becomes restless soon after having been packed, the heat and fever increasing, as may be ascertained from the pulse at the temples and the general appearance of the face, the sheet must be changed, as directed above (46) till the patient becomes quiet and feels more comfortable. In case of repeated changing of sheet, the patient should stay in the last sheet, till he has perspired about half an hour, or longer, before he is taken out to the bath, which should be of about 70 deg., as in all the mild forms of scarlatina. The length of the bath depends on the heat, and reaction of the patient, who should be well cooled down all over, before going to bed again or dressing. He ought not to be out of bed for a long time, and only after a bath, as this will protect him from taking cold.

60. The throat should be covered with a wet compress, i. e. a piece of linen four to eightfold, according to its original thickness, dipped in cold water (60 deg.-50 deg.), well wrung out and changed as often as it grows hot. It should be well covered to exclude the air. This compress should be large enough to cover the whole of the throat and part of the chest; it should closely fit to the jaw, and reach as far up as the ear to protect the submaxillary and parotid glands located there.

61. When the period of eruption is over, there is commonly less fever, and the packs and baths may be diminished.

62. Towards the end of the period of efflorescence, when the rash declines, fades, disappears, and the skin begins to peal off, an ablution in the morning of cool water, with which some vinegar may be mixed, and a pack and bath in the afternoon, are quite sufficient, except the throat continue troublesome, when a pack should also be given in the morning. The packs, once a day, should be continued about a week after desquamation. The patient may safely leave the house in a fortnight. I have frequently had my patients out of doors in ten or twelve days, even in winter.[32]

63. This going out so early, in bad weather, is by no means part of the treatment. I mention it only to show the curative and protective power of the latter, and have not the slightest objection to others using a little more caution than I find necessary myself. It is always better, we should keep on the safe side, especially when there is no one near that has sufficient experience in the matter. I can assure my readers upon my word and honor, that though I never kept any of my scarlet-patients longer in-doors than three weeks (except a couple of malignant cases), I have never seen the slightest trouble resulting from my practice.

64. In case of some trouble resulting from early and imprudent exposure, which is about as apt to occur in the house as out of it, a pack or two will usually be sufficient to restore order again. As long as the patient moves about, warmly dressed, there is no danger of his taking cold after a pack, and provided packing be continued long enough, and the patient be forbidden to sit down or stand still in cool places, or expose himself to a draught, there is nothing to be apprehended.

65. I have no objection to homoeopathic remedies being used at the same time, nor would I consider acids, as mentioned above (39, note), to be objectionable in cases of severe sore throat; but I must caution my readers against the use of any other remedies, especially aperients, except in cases, which I shall mention hereafter (72). In a couple of cases, where I acted as consulting physician, I have observed dropsical symptoms proceeding from laxatives and the early discontinuation of the packs during convalescence. Let the bowels alone as long as you can: there is more danger in irritating them than in a little constipation. As for the rest we have injections, which will do the business without drugs, of which I confess I am no friend, especially in eruptive fevers.

66.—2. TREATMENT OF THE VIOLENT, OR STHENIC FORM OF SCARLATINA ANGINOSA.

The violent, or sthenic form of scarlatina anginosa becomes dangerous only through the excess of reaction, when the heat is extreme (upwards of 105 deg. Fahrenheit, sometimes 112 to 114), the pulse can scarcely be counted, as it hammers away full and hard in a raging manner, the throat being inflamed and swollen to suffocation, and the patient in a high state of delirium; but it need not frighten the physician or parent acquainted with the use of water. We have the means of subduing that violence without weakening the patient. It is in this form of scarlatina that the greatest mistakes are committed by physicians unacquainted with the virtues of water, and that our hydriatic method shows itself in all its glory; for where there is an abundance of heat, water cannot only be safely applied, but it is also sure to bring relief. It is in this form of the disease that the cold affusions recommended by Currie and his followers, have shown themselves so beneficial, and that the wet-sheet, used properly and perseveringly, is almost infallible.

67. TEMPERATURE OF THE WATER—DOUBLE SHEET—CHANGING SHEET.

The water for the wet-sheet pack, in this violent form, ought to be cold; in summer it should be iced down to 46-48 deg. Fahr. The sheet ought to be coarse or doubled, in order that it should retain more water, and it should not be wrung out very tight. In a thick wet-sheet the patient will be better cooled than in a thin sheet, and he will be able to stay longer in it before changing. It may be advisable, however, with very young and rather delicate persons, not to double the sheet about the feet, as they might be apt to remain cold, which would send the blood more to the head. But, although the patient will feel easier in the pack for a while, the heat and fever will soon increase again, and, in proportion as the sheet grows warmer, he will become more and more restless, and the changing of the sheet will become indispensable. When the symptoms increase again, in the second pack, the sheet is changed a second time, and so on till the patient perspires and becomes relieved for a couple of hours or longer; which usually happens in the third or fourth sheet. After the first, every following sheet is wrung out tighter and tighter, and the last one may be taken single, or doubled only at its upper end.

68. LENGTH OF PACK—PERSPIRATION.

To make quite sure of the reaction, the single sheet may be tried first, except in exceedingly violent cases, and the double sheet may be resorted to, if the single sheet prove inefficient. Or, should there be any doubt, the double sheet may be dipped in water of a higher temperature than that given above, say 55 to 60 deg.. With young and delicate children I prefer this course, especially if they be very excitable, and the shock of very cold water may be expected to be too much for their nerves. In these matters some discrimination should be used: it is always better we should keep on the safe side, and rather give a pack more than frighten the little patients out of their wits. Proceed safely, but firmly and try to obtain your object in the mildest manner possible.

69. Before perspiration comes on, there is a little more excitement for a few minutes (41), which must not induce the friends of the patient to take him out of the pack; only when it continues to increase, instead of the perspiration breaking out and relieving the patient, it will be necessary to change the sheet, another time, as in that case the organism is not fully prepared for perspiration. After the breaking out of the latter, the patient invariably feels easier, and continues so for some time. When the feverish symptoms increase, during perspiration, which can be ascertained by feeling the pulse on the temples and by the thermometer, it is time to remove the patient from the pack, to give him his bath. Half an hour's perspiration is commonly sufficient; if the patient feel easy, however, and can be prevailed upon to stay an hour, or longer, till a good thorough perspiration brings permanent relief, it will be better. It would be unwise to let the patient stay too long and get him in a state of over-excitement; but, on the other hand, parents ought to remember that very few children like to be packed, and that a patient in high fever is a bad judge of his own case. I have always found those children the best patients, who had been brought up in strict obedience to their patients' dictates, before they were sick, and this, as well as the daily habit of taking baths, and the quiet and firm behavior of the physician and friends of the patient under treatment generally remove all difficulty.

70. LENGTH OF BATH.

Although the temperature, in sthenic cases, should be a little lower than in erethic cases, it is not advisable to use the water very cold, as this would cause too strong a reaction, and consequently new excitement. The safer way is to let the temperature of the bath be between 70 and 65 deg., according to the age and constitution of the patient (the younger and more delicate the patient, the higher the temperature), and to let him stay long enough in the bath to become perfectly cool all over, which can be ascertained by placing the hand or the thermometer under the arm-pits, which usually retain the warmth longest. I understand, in advising such a temperate bath of several minutes, duration, that the patient be hot and the rash standing out full and bright on coming from the pack; or else the bath must be colder and shorter, not exceeding a minute or two.

71. CAUTION.

After the bath, the patient is rubbed dry, and either taken to his bed, or, if he feels well enough, dressed and induced to walk about the room, or placed in a snug corner (not near the fire, however), till he feels tired and wishes to go to bed. During his stay out of bed, the rash ought to be an object of constant attention for his friends; for as soon as it becomes pale, the patient ought to be sent to bed immediately and covered well, or should then the rash continue to become paler and paler, the pack should be renewed, and the patient kept in bed ever after, till desquamation is over.

72. THE WET COMPRESS.

In bed, a wet compress is put on the throat, and another on the stomach, which, beside the direct influence it has on that organ, acts as a derivative upon the throat and head, and as a diaphoretic upon the skin, assisting in allaying the fever and heat. This compress on the stomach is an excellent remedy with small children and infants in a restless, feverish condition. I often use it, even with infants scarce a week old, and always with perfect success. I wish, mothers could be made to substitute it for paregoric and the like stupefying stuff, to procure their crying infants relief and themselves rest. There is more power in the compress than any one who is not familiar with its use, can imagine. At the same time it has a very good effect on the bowels, which should be kept regular, either with the assistance of tepid injections, or, if they fail to operate, with a moderate dose of castor oil. If possible, however, avoid the irritation of the digestive apparatus through medicines, which are apt to counteract the external applications, whose object is to draw the morbid poison as early and as completely as possible to the skin.

73. HIGHLY INFLAMED THROAT—CROUP.

If the throat is in a highly inflamed condition, repeated packing is the surest means of allaying the inflammation and preventing croup. Although I have had very bad cases under my hands, I never saw a case of scarlet-croup under water-treatment. All you have to do is, to pack your patient early enough and often enough to keep the inflammation down, to keep a wet compress on his throat and chest, and, in general, treat him as I have prescribed. The condition of the throat will improve in proportion to your perseverance in packing.

74. NECESSITY OF ALLAYING THE HEAT.

The packs and baths should be continued, even when the patient cannot be prevailed upon to stay long enough in the packs to perspire. The heat of the skin and the general inflammatory condition of the whole organism must be allayed, especially, when there is much delirium. In that case, the patient ought to be kept long enough in the bath to clear off the head, and care ought to be taken, that he should never stay in the pack to become much excited.

75. THE HALF-BATH—THE SITZ- OR HIP-BATH.

Should the half-bath or shallow-bath (which are technical terms for the bath described above), not be sufficient to relieve the head, the patient must be placed in a sitz- or hip-bath of 65 deg. to 70 deg. and stay there, with his body covered by a blanket or two, till the head is easy. During and after the sitz-bath, the parts exposed to the water, as well as the lower extremities, should be rubbed repeatedly, to favor the circulation of the blood. The head should be covered with a compress, dipped in cold water and but slightly wrung out, to be changed every time it becomes warm. The time required will vary according to the condition of the patient, from half an hour to one hour and a half. There is no danger of his taking cold, provided the body be covered sufficiently. The room ought not to be too warm, as a hot room will increase the tendency of the blood to the head; 65 to 70 deg. is perfectly warm enough. I would rather have it between 60 and 65.

76. The sitz-bath may be taken in a small wash-tub, if there is no proper sitz-bath-tub at hand. It should be large enough to allow the water to come up to the navel of the patient, and to permit rubbing. Too large a tub would not allow the patient to sit in it comfortably. If there is no tub to fit, a common bathing-tub may be raised on one end, by putting a piece of wood under it, so as to keep the water all in the other end, allowing the feet of the patient to be kept out of the water. This latter practice is more convenient with very small children, with whom, however, the sitz-bath will scarcely be required, a half-bath of sufficient duration being almost always efficient. It is not advisable for persons little acquainted with the use of water as a curative, to let the patient stay very long in the sitz-bath, it being safer to pack the patient again, and to repeat the sitz-bath after the pack, if his delirium is not removed, or not lessened in half an hour or three-quarters of an hour. This alternating with the pack and sitz-bath should be repeated, till the head becomes clear.

77. In excessive heat and continuous delirium, a half-bath may be given, also, every time the packing sheet is changed. The rule is that we ought not to yield, but the symptoms must; and they will, if the treatment is persevered in. Only go at it with courage and confidence. There is nothing to be apprehended from the treatment: where there is too much heat, there is no danger of a lack of reaction, and consequently no occasion for fears that the rash might be "driven in." A physician afraid of using water freely in violent cases of scarlet-fever, would resemble a fireman afraid of using his engine, for fear of spoiling the house on fire.

78. ACTION OF THE SITZ-BATH EXPLAINED.

The sitz-bath acts in a direct manner upon the abdominal organs and the spine, and through the latter on the brain. Indirectly, it helps in removing the inflammatory and congestive symptoms in the throat and head, by cooling the blood, which circulates through the parts immersed in the water, and by doing so cools also the upper parts of the body, equalizes the temperature, and diminishes the volume of the mass of the blood, thus making its circulation easier, whilst it has no tendency to impede the action of the skin. Besides, the abstraction of electricity, by the sitz-bath, should be taken in account of its action. After the sitz-bath, the reaction takes place in those parts which were immersed in the water, thereby making the relief of the upper parts more lasting.

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