Advice to a Mother on the Management of Her Children · Chapter 27On Disease, Etc. (3)
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222. Do you believe in "Hybrid" Scarlet Fever—that is to say, in a cross between Scarlet Fever and Measles?
I never in my life saw a case of "hybrid" scarlet fever—nor do I believe in it. Scarlet fever and measles are both blood poisons, each one being perfectly separate and distinct from the other. "Hybrid" Scarlet fever is, in my opinion, an utter impossibility. In olden times, when the symptoms of diseases were not so well and carefully distinguished as now, scarlet fever and measles were constantly confounded one with the other, and was frequently said to be "hybrid"—a cross between measles and scarlet fever—to the patient's great detriment and danger, the two diseases being as distinct and separate as their treatment-and management ought to be.
223. What is the treatment of Scarlet Fever? [Footnote: On the 4th of March 1856, I had the honour to read a Paper on the Treatment of Scarlet Fever before the members of Queens College Medico-Chirugical Society, Birmingham—which Paper was afterwards published in the Association Journal (March 15 1856) and in Braithwaite's Retrospect of Medicine (January—June, 1856) and in Rankings Half Yearly Abstract of the Medical Sciences (July—December, 1856), besides in other publications. Moreover the Paper was translated into German, and published in Canstatts Jahresbericht, iv 456, 1859]
What to do—Pray pay attention to my rules, and carry out my directions to the letter—I can then promise, that if the scarlet fever be neither malignant nor complicated with diphtheria, the plan I am about to advise will, with God's blessing, be usually successful.
What is the first thing to be done? Send the child to bed, throw open the windows, be it winter or summer, and have a thorough ventilation, for the bedroom must be kept cool, I may say cold. Do not be afraid of fresh air, for fresh air, for the first few days, is essential to recovery. Fresh air, and plenty of it, in scarlet fever, is the best doctor a child can have let these words be written legibly on your mind. [Footnote: In the Times of Sept 4, 1863, is the following copied from the Bridgewater Mercury—
GROSS SUPERSTITION—In one of the streets of Taunton, there resides a man and his wife who have the care of a child This child was attacked with scarlatina, and to all appearance death was inevitable. A jury of matrons was as it were empanelled, and to prevent the child 'dying hard' all the doors in the house all the drawers, all the boxes all the cupboards were thrown wide open, the keys taken out and the body of the child placed under a beam, whereby a sure, certain, and easy passage into eternity could be secured. Watchers held their vigils throughout the weary night, and in the morning the child, to the surprise of all, did not die, and is now gradually recovering.
These old women—this jury of matrons—stumbled on the right remedy, "all the doors in the house….were thrown vide open," and thus they thoroughly ventilated the apartment. What was the consequence? The child who, just before the opening of the doors, had all the appearances "that death was inevitable," as soon as fresh air was let in showed symptoms of recovery, "and in the morning the child, to the surprise of all, did not die, and is now gradually recovering." There is nothing wonderful—there is nothing surprising to my mind—in all this. Ventilation—thorough ventilation—is the grand remedy for scarlatina! Oh, that there were in scarlet fever cases a good many such old women's—such a "jury of matrons'"—remedies! We should not then be horrified, as we now are, at the fearful records of death, which the Returns of the Registrar General disclose!]
If the weather be either intensely cold, or very damp, there is no objection to a small fire in the grate provided there be, at the same time, air—an abundance of fresh air—admitted into the room.
Take down the curtains of the bed, remove the valances. If it be summer time, let the child be only covered with a sheet. If it be winter time, in addition to the sheet, he should have one blanket over him.
Now for the throat—The best external application is a barm and oatmeal poultice How ought it to be made, and how applied? Put half a tea-cupful of barm into a saucepan, put it on the fire to boil; as soon as it boils, take it off the fire, and stir oatmeal into it, until it be of the consistence of a nice soft poultice; then place it on a rag, and apply it to the throat, carefully fasten it on with a bandage, two or three turns of the bandage going round the throat, and two or three over the crown of the head, so as nicely to apply the poultice where it is wanted—that is to say, to cover the tonsils. Tack the bandage: do not pin it. Let the poultice be changed three times a day. The best medicine is the Acidulated Infusion of Roses, sweetened with syrup:—
Take of—Dilated Sulphuric Acid, half a drachm; Simple Syrup, one ounce and a half; Acid Infusion of Roses, four ounces and a half:
To make a Mixture. A table-spoonful to be taken every four hours.
It is grateful and refreshing, it is pleasant to take, it abates fever and thirst, it cleanses the throat and tongue of mucus, and is peculiarly efficacious in scarlet fever; as soon as the fever is abated it gives an appetite. My belief is that the sulphuric acid in the mixture is a specific in scarlet fever, as much as quinine is in ague, and sulphur in itch. I have reason to say so, for, in numerous cases I have seen its immense value.
Now, with regard to food.—If the child be at the breast, keep him entirely to it. If he be weaned, and under two years old, give him milk and water, and cold water to drink. If he be older, give him toast and water, and plain water from the pump, as much as he chooses; let it be quite cold—the colder the better. Weak black tea, or thin gruel, may be given, but not caring, unless he be an infant at the breast, if he take nothing but cold water. If the child be two years old and upwards, roasted apples with sugar, and grapes, will be very refreshing, and will tend to cleanse both the mouth and the throat Avoid broths and stimulants.
When the appetite returns, you may consider the patient to be safe. The diet ought now to be gradually improved. Bread and butter, milk and water, and arrowroot made with equal parts of new milk and water, should for the first two or three days be given. Then a light batter or rice pudding may be added, and in a few days, either a little chicken or a mutton chop.
The essential remedies, then, in scarlet fever, are, for the first few days—(1) plenty of fresh air and ventilation, (2) plenty of cold water to drink, (3) barm poultices to the throat, and (4) the Acidulated Infusion of Roses Mixture as a medicine.
Now, then, comes very important advice. After the first few days, probably five or six, sometimes as early as the fourth day—watch carefully and warily, and note the time, the skin will suddenly become cool, the child will say that he feels chilly; then is the time you must now change your tactics—instantly close the windows and put extra clothing, a blanket or two, on his bed. A flannel nightgown should, until the dead skin have peeled off, be now worn next to the skin, when the flannel nightgown should be discontinued. The patient ought ever after to wear, in the day time, a flannel waistcoat. [Footnote: On the importance—the vital importance—of the wearing of flannel next to the skin, see "Flannel Waistcoats."] His drinks must now be given with the chill off; he ought to have a warm cup of tea, and gradually his diet should, as I have previously advised, be improved.
There is one important caution I wish to impress upon you,—do not give opening medicine during the time the eruption is out. In all probability the bowels will be opened: if so, all well and good; but do not, on any account, for the first ten days, use artificial means to open them. It is my firm conviction that the administration of purgatives in scarlet fever is a fruitful source of dropsy, of disease, and death. When we take into consideration the sympathy there is between the skin and the mucous membrane, I think that we should pause before giving irritating medicines, such as purgatives. The irritation of aperients on the mucous membrane may cause the poison of the skin disease (for scarlet fever is a blood-poison) to be driven internally to the kidneys, to the throat, to the pericardium (bag of the heart), or to the brain. You may say, Do you not purge if the bowels be not open for a week? I say emphatically, No!
I consider my great success in the treatment of scarlet fever to be partly owing to my avoidance of aperients during the first ten days of the child's illness.
If the bowels, after the ten days, be not properly opened, a dose or two of syrup of senna should be given: that is to say, one or two tea-spoonfuls should be administered early in the morning, and should, if the first dose does not operate, be repeated in four hours.
In a subsequent Conversation, I shall strongly urge you not to allow your child, when convalescent, to leave the house under at least a month from the commencement of the illness; I, therefore, beg to refer you to that Conversation, and hope that you will give it your best and earnest consideration! During the last twenty years I have never had dropsy from scarlet fever, and I attribute it entirely to the plan I have just recommended, and in not allowing my patients to leave the house under the month—until, in fact, the skin that had peeled off has been renewed.
Let me now sum up the plan I adopt, and which I beg leave to designate as—Pye Chavasse's Fresh Air Treatment of Scarlet Fever:—
1. Thorough ventilation, a cool room, and scant clothes on the bed, for the first five or six days.
2. A change of temperature of the skin to be carefully regarded. As soon as the skin is cool, closing the windows, and putting additional clothing on the bed.
3. The Acidulated Infusion of Hoses with Syrup is the medicine for scarlet fever.
4. Purgatives to be religiously avoided for the first ten days at least, and even afterwards, unless there be absolute necessity.
5. Leeches, blisters, emetics, cold and tepid spongings, and painting the tonsils with caustic, inadmissible in scarlet fever.
6. A strict antiphlogistic (low) diet for the first few days, during which time cold water to be given ad libitum.
7. The patient not to leave the house in the summer under the month; in the winter, under six weeks.
What NOT to do.—Do not, then, apply either leeches or blisters to the throat; do not paint the tonsils with caustic; do not give aperients; do not, on any account, give either calomel or emetic tartar; do not, for the first few days of the illness, be afraid of cold air to the skin, and of cold water as a beverage; do not, emphatically let me say, do not let the child leave the house for at least a month from the commencement of the illness.
My firm conviction is, that purgatives, emetics, and blisters, by depressing the patient, sometimes cause ordinary scarlet fever to degenerate into malignant scarlet fever.
I am aware that some of our first authorities advocate a different plan to mine. They recommend purgatives, which I may say, in scarlet fever, are my dread and abhorrence. They advise cold and tepid spongings—a plan which I think dangerous, as it will probably drive the disease internally. Blisters, too, have been prescribed; these I consider weakening, injurious, and barbarous, and likely still more to inflame the already inflamed skin. They recommend leeches to the throat, which I am convinced, by depressing the patient, will lessen the chance of his battling against the disease, and will increase the ulceration of the tonsils. Again, the patient has not too much blood; the blood is only poisoned. I look upon scarlet fever as a specific poison of the blood, and one which will be eliminated from the system, not by bleeding, not by purgatives, not by emetics but by a constant supply of fresh and cool air, by the acid treatment, by cold water as a beverage, and for the first few days by a strict antiphlogistic (low) diet. Sydenham says that scarlet fever is oftentimes "fatal through the officiousness of the doctor." I conscientiously believe that a truer remark was never made; and that, under a different system to the usual one adopted, scarlet fever would not be so much dreaded. [Footnote: If any of my medical brethren should do me the honour to read these pages, let me entreat them to try my plan of treating scarlet fever, as my success has been great. I have given full and minute particulars, in order that they and mothers (if mothers cannot obtain medical advice) may give my plan a fair and impartial trial. My only stipulations are that they must begin with my treatment, and not mix any other with it, and carry out my plan to the very letter. I then, with God's blessing, provided the cases be neither malignant nor complicated with diphtheria, shall not fear the result. If any of my confreres have tried my plan of treatment of scarlet fever—and I have reason to know that many have—I should feel grateful to them if they would favour me with their opinion as to its efficacy. Address—"Pye Chavasse, 214 Hagley Road, Birmingham."]
Dr Budd, of Bristol, recommends, in the British Medical Journal, that the body, including the scalp, of a scarlet fever patient, should, after about the fourth day, be anointed, every night and morning, with camphorated oil; this anointing to be continued until the patient is able to take a warm bath and use disinfectant soap: this application will not only be very agreeable to the patient's feelings, as there is usually great irritation and itching of the skin, but it will, likewise, be an important means of preventing the dead skin, which is highly infectious, and which comes off partly in flakes and partly floats about the air as dust, from infecting other persons. The plan is an excellent one, and cannot be too strongly recommended.
If the case be a combination of scarlet fever and of diphtheria, as it unfortunately now frequently is, let it be treated as a case of diphtheria.
224. I have heard of a case of Scarlet Fever, where the child, before the eruption showed itself, was suddenly struck prostrate, cold, and almost pulseless: what, in such a case, are the symptoms, and what immediate treatment do you advise?
There is an exceptional case of scarlet fever, which now and then occurs, and which requires exceptional and prompt treatment, or death will quickly ensue. We will suppose a case: one of the number, where nearly all the other children of a family are labouring under scarlet fever, is quite well, when suddenly—in a few hours, or even, in some cases, in an hour—utter prostration sets in, he is very cold, and is almost pulseless, and is nearly insensible—comatose.
Having sent instantly for a judicious medical man, apply, until he arrives, hot bottles, hot bricks, hot bags of salt to the patient's feet and legs and back, wrap him in hot blankets, close the window, and give him hot brandy and water—a tablespoonful of brandy to half a tumblerful of hot water—give it him by teaspoonfuls, continuously—to keep him alive; when he is warm and restored to consciousness, the eruption will probably show itself, and he will become hot and feverish; then your tactics must, at once, be changed, and my Fresh Air Treatment, and the rest of the plan I have before advised must in all its integrity, be carried out.
We sometimes hear of a child, before the eruption comes out and within twenty-four hours of the attack, dying of scarlet fever. When such be the case it is probably owing to low vitality of the system—to utter prostration—he is struck down, as though for death, and if the plan be not adopted of, for a few hours, keeping him alive by heat, and by stimulants, until, indeed, the eruption comes out, he will never rally again, but will die from scarlet fever poisoning and from utter exhaustion. These cases are comparatively rare, but they do, from time to time, occur, and, when they do, they demand exceptional and prompt and energetic means to save them from ending in almost immediate and certain death. "To be forewarned is to be forearmed." [Footnote: I have been reminded of this exceptional case of scarlet fever by a most intelligent and valued patient of mine, who had a child afflicted as above described, and whose child was saved from almost certain death, by a somewhat similar plan of treatment as advised in the text.]
225. How soon ought a child to be allowed to leave the house after an attack of Scarlet Fever?
He must not be allowed to go out for at least a month from the commencement of the attack, in the summer, and six weeks in the winter; and not even then without the express permission of a medical man. It might be said that this is an unreasonable recommendation: but when it is considered that the whole of the skin generally desquamates, or peels off, and consequently leaves the surface of the body exposed to cold, which cold flies to the kidneys, producing a peculiar and serious disease in them, ending in dropsy, this warning will not be deemed unreasonable.
Scarlet fever dropsy, which is really a formidable disease, generally arises from, the carelessness, the ignorance, and the thoughtlessness of parents in allowing a child to leave the house before the new skin be properly formed and hardened. Prevention is always better than cure.
Thus far with regard to the danger to the child himself. Now, if you please, let me show you the risk of contagion that you inflict upon families, in allowing your child to mix with others before a month at least has elapsed. Bear in mind, a case is quite as contagious, if not more so, while the skin is peeling off, as it was before. Thus, in ten days or a fortnight, there is as much risk of contagion as at the beginning of the disease, and when the fever is at its height. At the conclusion of the month, the old skin has generally all peeled off, and the new skin has taken its place; consequently there will then be less fear of contagion to others. But the contagion of scarlet fever is so subtle and so uncertain in its duration, that it is impossible to fix the exact time when it ceases.
Let me most earnestly implore you to ponder well on the above important facts. If these remarks should be the means of saving only one child from death, or from broken health, my labour will not have been in vain.
226. What means do you advise to purify a house, clothes, and furniture, from the contagion of Scarlet Fever?
Let every room in the house, together with its contents, and clothing and dresses that cannot be washed, be well fumigated with sulphur—taking care the while to close both windows and door; let every room be lime-washed and then be white-washed; if the contagion have been virulent, let every bedroom be freshly papered (the walls having been previously stripped of the old paper and then lime-washed); let the bed, the holsters, the pillows, and the mattresses be cleansed and purified; let the blankets and coverlids be thoroughly washed, and then let them be exposed to the open air—if taken into a field so much the better; let the rooms be well scoured; let the windows, top and bottom, be thrown wide open; let the drains be carefully examined; let the pump water be scrutinised, to see that it be not contaminated by faecal matter, either from the water-closet, from the privy, from the pig-stye, or from the stable; let privies be emptied of their contents—remember this is most important advice—then put, into the empty places, either lime and powdered charcoal or carbolic acid, for it is a well ascertained fact that it is frequently impossible to rid a house of the infection of scarlet fever without adopting such a course. "In St George's, Southwark, the medical officer reports that scarlatina 'has raged fatally, almost exclusively where privy or drain, smells are to be perceived in the houses.'" [Footnote: Quarterly Report of the Board of Health upon Sickness in the Metropolis.] Let the children, who have not had, or who do not appear to be sickening for scarlet fever, be sent away from home—if to a farm house so much the better. Indeed, leave no stone unturned, no means untried, to exterminate the disease from the house and from the neighbourhood. Remember the young are more prone to catch contagious diseases than adults; for
"in the morn and liquid dew of youth Contagious blastments are most imminent."—Shakspeare.
227. Have you any further observations to offer on the precautions to be taken against the spread of Scarlet Fever?
Great care should be taken to separate the healthy from the infected. The nurses selected for attending scarlet fever patients should be those who have previously had scarlet fever themselves. Dirty linen should be removed at once, and be put into boiling water. Very little furniture should be in the room of a scarlet fever patient—the less the better—it only obstructs the circulation of the air, and harbours the scarlet fever poison. The most scrupulous attention to cleanliness should, in these cases, be observed. A patient who has recovered from scarlet fever, and before he mixes with healthy people, should, for three or four consecutive mornings, have a warm bath, and well wash himself, while in the bath, with soap; he will, by adopting this plan, get rid of the dead skin, and thus remove the infected particles of the disease. If scarlet fever should appear in a school, the school must for a time be broken up, in order that the disease might be stamped out There must be no half measures where such a fearful disease is in question. A house containing scarlet fever patients should, by parents, be avoided as the plague; it is a folly at any time to put one's head into the lion's mouth! Chloralum and carbolic acid, and chloride of lime, and Condy's fluid, are each and all good disinfectants; but not one is to be compared to perfect cleanliness and to an abundance of fresh and pure air—the last of which may truly par excellence be called God's disinfectant! Either a table-spoonful of chloralum, or two tea-spoonfuls of carbolic acid, or two tea-spoonfuls of Condy's fluid, or a tea-spoonful of chloride of lime in a pint of water, are useful to sprinkle the soiled handkerchiefs as soon as they be done with, and before the be washed, to put in the pot-de-chambre, and to keep in saucers about the room; but, remember, as I have said before, and cannot repeat too often, there is no preventative like the air of heaven, which should be allowed to permeate and circulate freely through the apartment and through the house: air, air, air is the best disinfectant, curative, and preventative of scarlet fever in the world!
I could only wish that my Treatment of Scarlet Fever were, in all its integrity, more generally adopted; if it were, I am quite sure that thousands of children would annually be saved from broken health and from death. Time still further convinces me that my treatment is based on truth as I have every year additional proofs of its value and of its success; but error and prejudice are unfortunately ever at work, striving all they can to defeat truth and common sense. One of my principal remedies in the treatment of scarlet fever is an abundance of fresh air; but many people prefer their own miserable complicated inventions to God's grand and yet simple remedies—they pretend that they know better than the Mighty Framer of the universe!
228. Will you describe the symptoms of Chicken pox?
It is occasionally, but not always, ushered in with a slight shivering fit; the eruption shows itself in about twenty-four hours from the child first appearing poorly. It is a vesicular [Footnote: Vesicles. Small elevations of the cuticle, covering a fluid which is generally clear and colourless at first, but afterwards whitish and opaque, or pearly.—Watson.] disease. The eruption comes out in the form of small pimples, and principally attacks the scalp, the neck, the back, the chest, and the shoulders, but rarely the face; while in small-pox the face is generally the part most affected. The next day these pimples fill with water, and thus become vesicles; on the third day they are at maturity. The vesicles are quite separate and distinct from each other. There is a slight redness around each of them. Fresh ones, whilst the others are dying away, make their appearance. Chicken-pox is usually attended with a slight itching of the skin; when the vesicles are scratched the fluid escapes, and leaves hard pearl-like substances, which, in a few days, disappear. Chicken-pox never leaves pit marks behind. It is a child's complaint; adults scarcely, if ever, have it.
229. Is there any danger in Chicken-pox; and what treatment do you advise?
It is not at all a dangerous, but, on the contrary, a trivial complaint. It lasts only a few days, and requires but little medicine. The patient ought, for three or four days, to keep the house, and should abstain from animal food. On the sixth day, but not until then, a dose or two of a mild aperient is all that will be required.
230. Is Chicken-pox infectious?
There is a diversity of opinion on this head, but one thing is certain—it cannot be communicated by inoculation.
231. What are the symptoms of Modified Small-pox?
The Modified Small-pox—that is to say, small-pox that has been robbed of its virulence by the patient having been either already vaccinated, or by his having had a previous attack of small-pox—is ushered in with severe symptoms, with symptoms almost as severe as though the patient had not been already somewhat protected either by vaccination or by the previous attack of small-pox—that is to say, he has a shivering fit, great depression of spirits and debility, malaise, sickness, headache, and occasionally delirium. After the above symptoms have lasted about three days, the eruption shows itself. The immense value of the previous vaccination, or the previous attack of small-pox, now comes into play. In a case of unprotected small-pox, the appearance of the eruption aggravates all the above symptoms, and the danger begins; while in the modified small-pox, the moment the eruption shows itself the patient feels better, and, as a rule, rapidly recovers. The eruption, of modified small-pox varies materially from the eruption of the unprotected small-pox. The former eruption assumes a varied character, and is composed, first, of vesicles (containing water); and, secondly, of pustules (containing matter), each of which pustules has a depression in the centre; and, thirdly, of several red pimples without either water or matter in them, and which sometimes assume a livid appearance. These "breakings-out" generally show themselves more upon the wrist, and sometimes up one or both of the nostrils. While in the latter disease—the unprotected small-pox—the "breaking-out" is composed entirely of pustules containing matter, and which pustules are more on the face than on any other part of the body. There is generally a peculiar smell in both diseases—an odour once smelt never to be forgotten.
Now, there is one most important remark I have to make,—the modified small-pox is contagious. This ought to be borne in mind, as a person labouring under the disease must, if there be children in the house, either be sent away himself, or else the children ought to be banished both the house and the neighbourhood. Another important piece of advice is,—let all in the house—children and adults, one and all—be vaccinated, even if any or all have been previously vaccinated.
Treatment.—Let the patient keep his room, and if he be very ill, his bed. Let the chamber be well ventilated. If it be winter time, a small fire in the grate will encourage ventilation. If it be summer, a fire is out of the question; indeed, in such a case, the window-sash ought to be opened, as thorough ventilation is an important requisite of cure, both in small-pox and in modified small-pox. While the eruption is out, do not on any account give aperient medicine. In ten days from the commencement of the illness a mild aperient may be given. The best medicine in these cases is, the sweetened Acidulated Infusion of Roses, [Footnote: See page 178] which ought to be given from the commencement of the disease, and should be continued until the fever be abated. For the first few days, as long as the fever lasts, the patient ought not to be allowed either meat or broth, but should be kept on a low diet, such as on gruel, arrow-root, milk-puddings, &c. As soon as the fever is abated he ought gradually to resume his usual diet. When he is convalescent, it is well, where practicable, that he should have change of air for a month.