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 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 Fahr. The sheet ought to be coa.r.s.e 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. 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, according to the age and const.i.tution 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 diaph.o.r.etic upon the skin, a.s.sisting 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 subst.i.tute 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 a.s.sistance 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 to 70 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 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 ma.s.s 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.

79. RELAXATION OF TREATMENT TOWARDS THE END OF THE THIRD PERIOD--CONTINUATION OF PACKS DURING AND AFTER DESQUAMATION.

When the patient is through the first part of the period of efflorescence the symptoms decrease, and he will be easier. Under the treatment prescribed, the time when the excitement is highest, is much abridged, and usually the treatment can be relaxed in less than twenty-four hours. When the patient is easier, the treatment may be given as in the milder form of scarlatina anginosa, with due regard to the state of the throat. In proportion as the heat abates, the packs should not be repeated so often, the sheet not changed; the patient should stay longer in the packs, and the baths should be shorter. The sitz-bath would then be out of season. The packing should be repeated whenever the symptoms increase again; but even if they should not, one pack and bath a day are necessary.

80. During and after desquamation, the treatment should be continued as indicated in milder cases, except the throat continue troublesome, when more packs should be used. If the throat is well, the patient may leave his room by the sixteenth day, under the precautions given above.

81.--3. TREATMENT OF TORPID FORMS OF SCARLATINA--DIFFERENCE IN THE TREATMENT POINTED OUT.

When the _reaction_ is _torpid_, the pulse small, weak, quick, the skin dry, the rash slow to appear, and when it appears in small, pale, livid spots, instead of bright scarlet patches (16-25); the treatment ought to be calculated to produce a short, but powerful, stimulus upon the surface of the body, after which a long pack should a.s.sist the organism in producing a slow, continuous and increasing reaction. If in violent reaction a repet.i.tion of short packs and long cooling baths is indicated,--in torpid reaction, cold and short tonic baths or affusions and long packs are required, in proportion to the degree of the reactive power of the patient. Therefore the packing sheet should be very cold, but thin and well wrung out, so as to make a strong, but transitory, impression, soon overcome by the reaction it calls forth, upon which all our success depends. The patient stays in the pack till he becomes quite warm and tired. Perspiration is seldom produced; if it is, it may be considered a favorable symptom. I have had patients stay in the pack for four, five, six and seven hours, and almost always, when I took them out, their skin was covered with eruption. The only phenomenon, which should induce the physician to relieve the patient of the pack before he becomes perfectly warm, is increased delirium, which in torpid reaction, indicates a tendency to a typhoid character of the disease, when the warm and moist atmosphere of the long pack would be more favorable to the disease than to the patient, by weakening the nerves still more. In that case, a long half-or sitz-bath is required, the former, under constant rubbing, from 15 to 20 minutes, the latter from 30 to 40 minutes; the temperature of either from 65 to 70.

82. LENGTH OF PACK.

Usually it is time for the patient to come out from his pack, when the pulse becomes fuller and stronger, the face begins to flush and the head to be affected. Frequently he sleeps till awakened by the increasing heat. A drink of cold water will quiet him for a while, which may be administered by means of a gla.s.s tube (julep-tube), in order not to disarrange the pack by lifting him up. As long as the head is not affected, there is no danger of his staying too long. The longer he can stay, the surer the eruption will appear.

83. COLD AFFUSIONS AND RUBBING.

After the pack, the patient is placed in an empty bathing or wash-tub, and cold water (of 65-60 Fahr., only with very young and delicate children a little higher, with adults rather lower) is thrown over him in quick succession by means of a dipper, whilst he is well rubbed all over his body, especially the extremities. Not too much water should be poured over the head; however, the head should be always wetted first.

This process should not last longer than a minute or two, except the patient continue very warm during it, in which case it should be prolonged, as the perfect cooling of the body is necessary to prevent the fever from coming on soon after and the patient continuing weak.

After the bath, he should be rubbed dry, first with the bare hands of the attendants, and then with a dry sheet, and put to bed again, or, if he feel inclined to stay up, dressed warmly and be induced to walk about as long as he can.

84. ICE-WATER AND SNOW-BATH IN MALIGNANT CASES.

If no rash appear during the first pack, which will scarcely fail, the proceeding should be repeated, and the patient stay longer in the pack than the first time. In very bad cases, when the patient fails at once under the action of the poison (malignant scarlet-fever) iced water or snow may be resorted too. I know several instances of patients, having been given up by their physicians, reviving again under the influence of a snow-bath, which produced a healthy reaction, when nothing else was of avail. I have never had occasion myself to resort to such extremes, cold water having always answered my purposes; but I would not hesitate a minute to use snow and ice in a case where I could think it useful and necessary. Such proceedings _look_ cruel; but it _is_ decidedly more cruel to let the patient's life be destroyed from want of timely a.s.sistance. I distinctly remember a case, which occurred in Ca.s.sel, when the physician objected to "tormenting the poor boy," and wanted the father to "let him die in peace." But the father,[33] who had some knowledge of, and a great deal of confidence in hydriatics, put the little patient, a boy of 8 or 9 years, into a bathing-tub filled for the greater part with snow, covered him over with the cold material, and left him there till he became conscious; then he was rubbed all over, placed in a dry pack (without a sheet), and left to perspire, which ensued and brought out the rash. The patient was out of danger in four hours' time, and Dr. S., on calling again in the evening, was quite astounded at seeing him alive, out of bed, and covered with a tolerably bright eruption.

85. WINE AND WATER, IF NO REACTION CAN BE OBTAINED.