The malignant forms of scarlet fever are almost invariably fatal, es pecially those in which the nervous symptoms are violent. A mild noc turnal delirium is not of unfavourable omen ; and slight wandering in the daytime, if there be no other symptom of nervous disturbance, need excite no anxiety ; but if the delirium is active and persistent, with violent agita tion and sleeplessness passing rapidly into stupor and prostration, we can have little hope of a favourable issue. Convulsions occurring after the first day, especially if repeated, are very serious. No indication is to be derived from the colour of the rash, for a dark tint of the eruption is not necessarily an unfavourable sign. There is cause for great anxiety if the temperature rise continuously ; if the throat affection be severe ; if there be frequent and long-continued vomiting or copious dysenteric diarrhoea ; if nephritis appear early ; or if there be great diminution or suppression of the urinary secretion. Unemic symptoms are not so severe in the child as they are in the adult. At least, according to my experience, it is not common for a child to die of unumic poisoning, if judiciously treated.
Treatment.—In cases where any member of a family is taken with scarlet fever, it is of importance to prevent the illness spreading to the others. Prompt isolation of the patient is of course to be insisted on ; and it is well, if the step can be conveniently adopted, to send the other children away from the neighbourhood of the sufferer.
Various prophylactic measures have been recommended to arrest the disease in the incubative stage and prevent its further development. Belladonna, which was at one time largely employed with this object, has been now proved to be useless. It seems likely, however, that in arsenic we have an agent of greater value. It has been noticed that a person who is being treated with arsenic cannot be successfully vaccinated ; and it is possible that the drug may have a counteracting influence upon other forms of infective matter. Practitioners who have made use of the remedy with this object speak favourably of its prophylactic virtue. Dr. W. G. Wal ford has given the drug largely to children who had been exposed to the infection of scarlatina, and states that out of nearly a hundred such cases in only two did the development of the fever follow, and both cases were extremely mild. He recommends the ordinary liq. arsenicalis (P.B.) in as large a dose as the age of the child will allow, with sulphurous acid xv.-xxx.), and a little syrup of poppy. The child should take the dose regularly three times a day at the first ; afterwards less frequently.
When the disease actually declares itself, prophylactic measures must of course be laid aside. In a malady such as scarlatina, where the gen eral symptoms are often violent, and the complications are various and may be severe, the therapeutic measures at our disposal are necessarily very numerous. Still, we must depend for a successful result more upon vigilant nursing than upon the actual administration of drugs ; although these, especially when complications occur, are often of sensible value.
However mild the symptoms may be, the child should be kept in bed in a well-ventilated room, from which all carpets, curtains, rugs, cushions, and other woollen articles not required for the comfort of the patient have been previously removed. In order to prevent the spread of the disease, a
sheet kept wet with a solution of carbolic acid (one part in forty parts of water) should be fastened so as to hang over the door-way ; and care should be taken to disinfect all excreta, soiled linen, etc., before they are removed from the room. The child may be allowed to drink as often as he desires of pure filtered water, but the quantity taken at each time of drinking must be limited. His diet should consist of milk, broth, light puddings, bread and butter, etc. The heat and irritation of the skin is greatly relieved by sponging the surface of the body several times a day with tepid water, and afterwards drying with a soft towel. This is a more pleasant operation than the inunction of fats, which is sometimes recom mended, and is quite as serviceable to the patient.
In an ordinary case little medicine is required ; but if the throat is painful, a draught of chlorate of potash may be ordered. Should the throat become much inflamed, and the cervical glands of the neck swell and be tender, the child should be made to suck ice, and hot applications (linseed-meal poultices, frequently renewed) should be applied to the neck ; or we may use the cold compress, which, becoming heated by con tact with the skin, acts in the same way. Cold thus applied internally, while the outside of the throat is kept warm, often produces a rapid amelioration in the symptoms. If, however, the throat affection, instead of improving, becomes worse, and ulceration is noticed, it will be neces sary to apply some local application to the fauces. In such a case the throat having been carefully cleansed with a brush dipped in warm water, a solution of nitrate of silver (half a drachm to the ounce) should be applied freely to the whole of the ulcerated surface. Moreover, any special ulcer may be touched once with the solid caustic. The weaker application must be repeated every morning for three or four days • and in the interval a solution of common salt in water (half an ounce to the pint) can be injected frequently into the fauces. It is very important in these cases to keep the throat clean inside, in order to remove quickly the poisonous secretions thrown out from the diseased surfaces ; and frequent syringing or gargling of the throat with a saline solution such as the above, which dissolves mucus and facilitates the separation of tenacious secretions, will be attended by marked benefit. If required to clean the mucous surfaces, the saline solution may be applied from time to time with a brush. In addition to these measures, disinfecting applications may be made use of ; such as a weak solution (two per cent.) of carbolic acid, or a lotion composed of liq. sods chlorinatm xx. to the ounce of water). In these cases of severe sore throat it is advisable, as much for the sake of others as for the benefit of the patient, to keep the air of the room saturated with a solution of carbolic acid (one part in thirty of water) by Dr. R. J. Lee's steam draught inhaler, or some similar apparatus. The application of sulphurous acid to the throat, as recommended by the late Dr, Dewees, is also useful. This remedy should be used with an atomizer, and the acid, pure or diluted with an equal proportion of water, should be sprayed into the throat for a few minutes every two or three hours.