The efforts of a physician to prevent the spread of a contagious disease is usually a thankless task, and not always can we carry out in detail the methods advocated in this paper, but the nearer we can approach it, the more certain will be our success.

Treatment. In no disease of childhood is it more important to treat the patient and not the disease than in scarlet fever. In a disease which presents itself in such varied types, and which has so many complications that every case must be a law unto itself. Since Sydenham in the seventeenth century gave us the first clear description of scarlet fever until the present time, many drugs have been offered as specifics, but all have proved valueless, and a clearer conception of the disease has taught us that it has a self-limited course which cannot be modified by any known treatment. Our efforts are to modify its symptoms, shorten its course and prevent its complications.

I shall endeavor not to trespass on the subject which is to follow, but a discussion of scarlet fever would be incomplete without considering those complications of the throat, ear and kidneys, which occur with such frequency as to become a part of the clinical history of most cases.

Acknowledging that our treatment is purely symptomatic, I shall not consider the disease in its various stages, but discuss the therapeutic measures applicable to the symptoms.

Fever. For the reduction of the temperature the use of cold water supersedes all other measures in efficiency. Mild cases with a temperature below 102.5 require no treatment, but sponging with water at a temperature of 86 will do much to allay restlessness and produce a feeling of comfort. A temperature of 104 or over is always an indication of active measures and either the cool bath, or cold pack will be found useful. I prefer the cold pack, as it is less troublesome to apply and more certain in its effect. The patient is wrapped in a sheet which has been dipped in water at a temperature of 75 or 80 degrees and placed in bed with light woolen blankets. The nurse should place a hot water bottle at the patient's feet, as the extremities are apt to become chilled. An ice bag or cold cloths are applied to the head. The patient should remain in the pack from fifteen to twenty minutes, cold water being sprinkled on the enveloping sheet at frequent intervals, with gentle rubbing of the body as long as the pack is continued. The pack not only reduces temperature, but in cases characterized by the tardy appearance of the eruption, it will be found the quickest means of developing the full rash. There is one other measure for using cold water for the reduction of temperature which is not as commonly used as its merits would warrant. I refer to the high colon injection of ice water. In malignant cases with very high temperature this procedure will be found very efficient. The water must be as cold as would be used for drinking purposes, and must be injected high into the colon by means of a long rubber tube. This is one of the quickest and surest way of reducing tempera

ture.

I do not believe the cold tar derivatives should be used for their antipyretic effect, but small repeated doses of phenacetine will be found useful

for their sedative action. Where there is great restlessness, sodii bromid, either alone or in combination with phenacetine has proved useful. Plenty of cold water should be allowed, and older children may hold pieces of cracked ice in the mouth.

Vomiting, so common in the beginning of scarlet fever, seldom persists after the first few hours, and, like convulsions, has a very different interpretation during the period of invasion, than when it occurs at a later date. Bismuth, or small repeated doses of calomel, about one-tenth grain, given every hour, until the bowels move freely, is usually all that is required. The diet should be curtailed in amount, or discontinued altogether, as long as this symptom lasts. Convulsions occurring at a late period of the disease are usually uremic. At the beginning they are usually due to the high temperature and toxic action of the scarlatina infection. They are best controlled by the use of bromides, which must be given in comparatively large doses, or by chloral hydrate which is best given per os, dissolved in milk, and by those measures already described for reducing the temperature. It is well in the beginning of every case of scarlet fever to secure a free evacuation of the bowels at once, and by so doing we remove a possible source of irritation, which frequently acts as a causative factor in producing convulsions.

That the heart is especially affected by the scarlatina infection is shown by the fact that the pulse is always rapid in proportion to the temperature, and in all severe cases measures to sustain it are called for. This is especially true in cases complicated with suppuration of the glands of the neck, otitis media and gangrenous processes of the throat.

An irregular rapid pulse with feeble first sound is always an indicator for stimulation, no matter what the period of the disease. Alcoholic stim ulants, digitalis, stropthanthus, ether, camphor and ammonia are most useful. The quantity to be given is governed only by their effect. Alcohol is best given in the form of brandy or whiskey, diluted with hot or cold. water. Digitalis I prefer to give as the fluid extract, in 1 m. doses to a child of five years, repeated every three or four hours. Strychnine is best given hypodermically to of a grain and camphor, which is one of the best cardiac tonics, is also given hypodermically in doses of 1⁄4 to 1⁄2 gr. to a child of five years.

The throat in mild cases will require little or no treatment. Ice held in the mouth will relieve the heat and dryness, while the external application of camphorated oil, and warm compresses are useful. In those cases characterized by an intense angina, pseudo or true diphtheria, with marked cervical adenitis, we have one of the serious complications to deal with. Topical applications to the throat are useful if they can be used without a great resistance on the part of the patient, but when every application means a struggle, their frequent repetition should not be practiced. To give a list of drugs for local treatment of the throat would include nearly every astringent and local sedative in the pharmacopeia. Every physician has his favorite remedies, and as cleansing of the throat of its secretions is our object, there is little choice. Personally I have found hydrogen peroxide, carbolic acid and boråcic acid useful. The first I use as a swab for

the throat, and spray in the nose. Carbolic acid is used as a spray in combination with tannic acid, glycerine and water, and boracic acid as a gargle or swab.

The adenitis is best controlled by the use of the ice bag or cold pack. Suppuration is less likely to occur than when heat is used, while pain and tenderness is relieved equally as well.

When suppuration seems imminent, warm antiseptic compresses should be used and free incisions made, with irrigation as soon as pus becomes localized. Enlarged glands which show little tendency to change may often be resolved by the use of an ointment containing ichthyol, mercury and belladonna.

The diphtheritic processes in the throat of the scarlet fever patient calls for an accurate differential diagnosis before the line of treatment to be followed is decided upon. The exudate occurring during the height of the scarlet fever process is usually of streptococcic origin, while at a later period it is more often true diphtheria due to Klebs-Loefler bacillus. In the former instance those measures already described for the treatment of the angina will be found useful, while in the latter antitoxin is our main reliance. Without the aid of the microscope the differential diagnosis is often difficult, sometimes impossible, and the old adage. "When in doubt, play trumps," is most applicable.

When the diphtheritic membrane involves the larynx the use of the calomel fumigation is often of marked benefit. Ten to fifteen grains of calomel should be burned under an improvised tent or canopy, and repeated every two, three or four hours, as the condition may warrant. Intubation is of course indicated.

When stenosis is not relieved by these measures, after a careful differential diagnosis, and the use of antitoxin early in the case of true diphtheria, or the other measures, if the membrane is a pseudo-diphtheria, are usually all that will be required.

Complications of the ear are troublesome and should receive prompt attention. We seldom have a simple catarrhal inflammation, but an inflection of the tympanic cavity due to streptococcus. As soon as an otitis is suspected or complained of, a careful examination should be made. The ear speculum with strong reflected light should be used, and if there is no bulging of the drum, we may try palliative measures. A blister or leech may be applied in front of the tragus, or hot water instilled into the external meatus and hot dry external applications used. Warm oils, melted vaseline or irritants, such as chloroform or carbolic acid, should not be poured into the ear.

If these measures are not successful in controlling pain and checking the inflammation, there is but one rational treatment; that is, paracentesis of the tympanum with drainage. This is a very simple operation. The point of incision should be that portion of the drum which is most bulging, and the opening must be an incision, not a mere puncture. Carry the incision well downward to the floor of the meatus. A free flow of pus follows with immediate relief of symptoms. Cleansing with a boracic acid or bichlorid solution is all the after-treatment required in simple cases.

Until recently I had a dread of this simple procedure, but after performing it and noting its excellent results, I should not hesitate to do it in every case not relieved by more simple measures.

Treatment of the post-scarlatina nephritis is that of an acute nephritis occurring independently of this disease, and to enter into a detailed treat ment is to involve us in a discussion of acute nephritis in general.

During the height of the scarlet process, the urine in perhaps the majority of all but the mildest eases, will show traces of albumen, blood corpuscles and a few casts, but this involvement of the kidneys is not productive of special symptoms, and other than warning us of the presence of renal irritation, may be ignored.

The serious kidney lesions occur after the substance of the active fever process. It may follow the mildest as well as the more severe cases, and may prove a more serious condition than was the primary disease.

The prophylaxis of this complication should receive careful attention. Every convalescent case should be warned against exposure in cold and damp, and the diet should be light and largely non-nitrogenous. Water should be used freely, the bowels kept loose with frequent warm baths to promote activity of the skin. These measures, no matter how carefully adhered to, are often of no avail, and the frequency with which nephritis occurs in spite of a most careful regime has lead many observers to place but little confidence in preventive measures.

With the first symptoms of kidney involvement the patient should be confined to bed, an absolute milk diet instituted, with free evacuation of the bowels induced preferably by a concentrated saline.

The urine may be increased and rendered less irritating by the use of the alkaline or small doses of acetate or citrate of potash may be given. In mild cases this is all the treatment required.

Cases characterized with marked dropsy, scanty urine and uremic symptoms require more active measures. Counter irritation over the kidney s maintained by the use of mustard or dry cups followed by poultices, depletion by the production of copious water stools best induced by the Rochelle or Epsom salt, diaphoreses from the use of hot wet pack, and the administration of the milder diuretics such as acetate and citrate of potash, infusion of digitalis and especially diuretin, will be indicated.

Pilocarpin is recommended for its diaphoretic action, but it is a marked depressant and should not be used as a routine treatment. Recently its use as an inunction into the skin (5 cent. grain pilocarpine to 100 grain ol. olivea) has been favorably commended.

Uremic convulsions will be best controlled by the hypodermic use of morphia and the rectal administration of chloral and bromides and in cases with full bounding pulse venesection should be tried. From two to six ounces of blood may be taken, according to the urgency of the symptoms (Holt). The rectal injection of normal salt solution is also useful in inducing a free flow of urine and aiding the elimination of toxic substances.

Convalescence requires iron, bitters and above all a gradual return to the customary habits and diet of the patient.

TH

The Symptoms and Diagnosis of Scarlatina.

BY HENRY GARNSEY OHLS, M. D.,

ODELL, ILLINOIS.

Read before the Livingston County Medical Society.

HE symptoms of scarlet fever vary with the severity of the infection and also with the age and general condition of the system of the patient. Thus some epidemics are severe, the mortality being as high as 40 per cent, while the average is only from 12 to 14 per cent. In two recent epidemics in the New York Infant Asylum 29 patients under 1 year old. had a mortality of 55 per cent; 37 between 1 and 2 years, 22 per cent; 28 between 2 and 3 years, 7 per cent; and 23 over 3 years, no deaths. It may be safely assumed that the mortality varied in direct proportion to the severity of the symptoms and the complications.

Invasion. The attack is usually ushered in by vomiting, chills, a rapid rise of temperature and sore throat. The vomiting is in some cases repeated several times, it is often projectile and without nausea. The tempera

ture in severe cases rises to 10.4 or 105 F.; in mild cases it may not rise above 101°. The pulse is very rapid, even out of proportion to the fever. The face is flushed and the eyes brilliant. The child may not com. plain of sore throat, but upon examination the fauces are generally found congested and the hard palate is often covered with small red points. A membranous deposit is often seen covering the tonsils and fauces more or less, but it is not usually seen before the 3d or 4th day of the fever. The tongue, except at the edges, is nearly covered with a thick white or yellowish coat through which the enlarged papillæ project, red and prominent. After a few days the coating is cast off and the whole tongue becomes very red and the papillæ remain prominent for 6 or 8 days. In severe cases the tongue is very dry and brown. Diarrhea is not uncommon, especially in summer. The nervous system is more or less disturbed; in young children and infants convulsions may be the first sign of the infection. Later the nervous symptoms, such as delirium and general prostration, depend upon the height of the fever and complications, such as nephritis. Blood count shows marked leucocytosis during the height of the eruption.

Eruption. The eruption generally appears in from 12 to 36 hours after the first symptoms of the invasion; exceptionally as late as the 3d or 4th day. In 75 per cent the rash lasts from 3 to 7 days; in 5 per cent, 2 days or less; in 15 per cent from 8 to 11 days. In a very small number it lasts over 11 days and in exceptional cases the rash disappears and recurs. The typical rash begins in the form of minute red points on the upper part of the breast and neck, rapidly spreading until the surface involved is a bright even red color. The body, face and limbs may be entirely covered within a few hours, or the rash may extend slowly, only covering the surface after 2 or 3 days, or it may be limited to certain areas throughout its course. Variations in the rash are frequent and puzzling. It may be so faint as to escape observation in mild cases; or the rapid disappearance of a bright