It is almost needless to emphasize the importance of feeding in all septic cases; strong beef juices, nourishing soups, alcoholic stimulation, beaten-up eggs and rectal alimentation will be needed.
Malignant scarlatina is nearly always fatal. Though the rash may show little sign of development, the hyperpyrexia must be promptly met by the cold pack, and comatose symptoms should be attacked by the ice-bag applied to the shaven scalp, whilst a mustard poultice is placed over the nucha. Normal serum may prove useful in some cases, but the advisability of subsequent venesection has not been proven; neverthe less, the writer, in the presence of a profound and probably fatal comatose condition, would not hesitate to recommend it. Lumbar puncture has been proved to he useful in cases wherever meningeal congestion has been present and the intravenous injection of Collargo] has been recom mended. The hypodermic injection of Pilocarpine where the rash is suppressed is a treatment which is open to the gravest doubt, since the heart is always profoundly depressed by the toxins of the disease. Strychnine hypodermically will be often indicated, and it may advantage ously be administered before placing the patient in the cold pack. Poly valent Antistreptococcic serum should always be injected when pro curable.
Treatment of Complications.--Some of these have been already in cidentally dealt with. Rheumatic inflammation of the joints is best relieved by full doses of Salicylates and by enveloping the articulations in dry cotton-wool without the application of any impervious dressing. In all such cases a very vital point is to compel the patient to remain in the horizontal position in bed all through the month or six weeks' convalescence, and longer if necessary. There is quite as much danger of the heart at some remote period suffering from permanent valvular crippling as if the attack was one of rheumatic fever. Paine has, more over, demonstrated the presence of a minute diplococcus in so-called " scarlatinal rheumatism " apparently identical with the Diplococcus rheumaticus, and which is capable of producing arthritis, and cardiac mischief when injected into rabbits.
Cardiac complications are to be treated as in rheumatic fever, and the supervention of ulcerative endocarditis is a clear indication for the administration of an autogenous vaccine prepared from the patient's blood.
Otitis.—This is a complication which sometimes leads to permanent deafness; it should be met by prompt treatment. The preventive measures consist of continuous irrigation and sterilisation of the naso pharynx and a 25 per cent. Argyrol solution as a swab may advantage ously be employed after cleansing.
Earache may be relieved by Cocaine—the pure alkaloid 4 per cent. dissolved in warm oil being instilled into the meatus, and leeches may be applied over the mastoid behind the ear. The important matter is to inspect the tympanum twice daily, and as soon as bulging manifests itself to make a free incision. The after-treatment and that of such complica tions as suppuration of the mastoid cells and abscesses under the dura mater must be met by the radical operation first introduced by the late Dr. Joseph Nelson (see under Ear Diseases, Otitis Media). Vaccine treat ment should always be resorted to in chronic cases.
Nephritis.—No importance need be attached to the slight albuminuria which nearly always appears when the fever is at its height, but in the later stages of convalescence the urine should always be closely watched for evidence of glomerulitis, otherwise the first symptom of this grave condition may show itself in a urmmic convulsion or a sudden attack of coma. The treatment must be that approved of for acute Bright's Disease or for urmmia—viz., a strong saline purge—as soon as the patient is able to swallow and immediate resort to the hot mustard pack and the administration of Pilocarpine hypodermically as soon as sweating is established. Saline Solution should be injected and venesection per formed in comatose and convulsive cases.
Buttersack recommends the prolonged administration of Urotropine up to the end of the third week as a certain preventive of nephritis.
Hemorrhagic manifestations as in the so-called " hfernorrhagic type of scarlatina " are a clear indication for the administration of Calcium Chloride or Lactate.
Cellulitis and Rhinorrhcea.—The treatment of these complications has been detailed in the description of the management of the anginose or septic type of the disease.
Puerperal Scarlatina and the scarlatina arising during pregnancy are to be treated upon the same lines as in the management of the ordinary disease. Many cases of so-called " puerperal scarlatina " are really examples of severe sepsis.