CHAPTER X. DISEASES OF THE LUNGS AND PLEURA. (Part 6)

Remember that the eruption appears on the fourth day, beginning on the face. 234 INFECTIOUS DISEASES. Remember that, as a rule, there will be patches of skin between the eruptions that will be of normal color, but the boundary between the eruption and the healthy skin is always crescent in shape. Eemember that the eruption disappears on pres- sure, but in some cases hemorrhage, or petechia, occurs into the skin and they will not then disap- pear. Remember that, while there may be slight swell- ing of the cervical Ijinph glands at the height, it is never so pronounced as in scarlatina. Always look for Koplik's spots on the mucous membrane of the mouth. They occur, as a rule, on the first day of invasion, and consist of bluish-white specks surrounded by bright-red roseola. While they resemble that of thrush, they have not the yellowish center. Eemember that the rash fades on the third day, and fine, branny desquamation occurs that is fre- quently overlooked. Eemember that lobular pneumonia is exceedingly common, and usually occurs at the height of erup- tion or beginning of desquamation. Always ex- amine chest daily. Always look for otitis media, because it is com- mon in measles and may develop mastoid abscess. Never be in too great haste to differentiate measles and smallpox; it frequently requires some time for distinctive developments. MEASLES. 235 Treatment. The patient should be put to bed in a well- ventilated room. If photophobia be severe, the room should be darkened or yellow curtains hung. The diet should be liquid during febrile reaction. Milk and broths are best. Care in selecting a diet is necessary, that a troublesome diarrhea is not started. Cathartics should be used sparingly for the same reason. The best is castor oil with 2 or 3 drops of turpentine in it. If the fever is high, sponging, or the warm bath gradually cooled, is excellent. Some simple fever mixture may be used, as : B Potassii citratis 3 iv Tincturae aconiti TTL x Spiritus setheris nitrosi 3 ij Syrupi tolutani o j Aquae q. s. ad § ii j Misce. Sig. : Half to teaspoonful every two hours for child of 1 to 2 years. Or: B. Sodii bromidi gr. 1 Spiritus setheris nitrosi 3 ij Liquoris potassii acetatis . . q. s. ad 5 ii j Misce. Sig. : Teaspoonful every two hours for child of 1 to 3 years. The cough should be treated from the beginning of the attack. The fact should ever be kept in mind that tuberculosis very frequently follows measles. Paregoric may be added to either of the fever mix- 236 INFECTIOUS DISEASES. tures. Codein is probably better. The following combination is very efficient: I^ Codeinae phosphatis gr. ij Syrupi ipecacuanhse ,. 3 j Syrupi pruni virginiante 5 j Aquae camphorae q. s. ad 3 iij Misee. Sig. : Teaspoonful every two hours for child of 6 years ; one-half to one-quarter the amount for younger child. Or: IJ Codeinae phosphatis gr- ij Ammonii carbonatis gr. xxy Syrupi scillse 3 j Syrupi pruni virginianae § j Aquae camphorae q. s. ad § iij Misce. Sig.: Teaspoonful every two hours for child of 6 years; one-half to one-quarter the amount for younger child. Or: IJ Pellet aconitinae amorphae (Abbott) aagr. 1,^34 Sig. : Dissolve 1 for each year of child's age and 1 extra in 3 ounces of water and give teaspoonful hourly for fever. "When the eruption fails to come out, wrap the child in blankets wrung out of hot water and give hot drinks. During convalescence the child should be given careful attention and protected from cold. Scarlet Fever (Scarlatina). Remember that the mild cases of angina may spread the disease. This is usually the way epi- demics spread in schools. Remember that milk is responsible for many epi- demics. SCARLET FEVER. 237 Remember that a sudden onset, with vomiting and a rapid rise in the temperature, with a rapid, wiry pulse, is very characteristic of scarlatina in children. The next symptom in order of appearance and im- portance is the angina. Remember that the lymph glands behind the angle of the jaw are enlarged in scarlatina. Remember that the eruption comes early — usually by the second day — begins on the neck and chest, and spreads rapidly all over the body, with the ex- ception of certain parts of the face, especially the region of the mouth and chin, which are conspicuous by their pallor. Remember that there is a uniform blush of the skin, and the eruption is punctate and of a deeper color. There is no intervening healthy skin, and no crescentic arrangement of the eruption, as seen in measles. Remember that pressure causes blanching of the skin, but the blush quickly returns when pressure is removed. Remember that the tongue is very characteristic. On the first and second days the tip and margins are red, while the center is covered by a grayish- yellow coating. This coating disappears after the eruption is out, and the tongue now appears in- tensely red, with the papillae markedly swollen and raised, producing the "raspberry" or "strawberry" tongue, and this is very characteristic of scarlatina. Remember the following points in differentiating scarlatina and measles: 238 INFECTIOUS DISEASES. 1. The eruption of measles occurs first in the face, and is especially and markedly developed here, while in scarlet fever the neck and chest are first affected, and the face, under all circumstances, shows less eruption, and the region about the mouth is particularly free. 2. The eruption of measles occurs on the fourth day, while in scarlet fever it may occur on the first and never later than the second. 3. The onset of scarlet fever by vomiting and the severe angina, while the onset of measles is marked by inflammation of the mucosa of the respiratory tract — coryza. 4. The drop in the temperature on the morning of the second day, with a subsequent rise on the third or fourth, is found only in measles. 5. The ''raspberry" tongue of scarlet fever is rather characteristic of it and is not seen in measles. Always examine the urine often from the ninth day until the sixth week for the appearance of signs of nephritis. This is the most common complication, but fortunately it rarely becomes chronic. Always watch the ears closely for otitis media, as it very frequently occurs in scarlatina, and, if neglected, will lead to mastoid disease. Remember that a polyarthritis often follows scar- latina, and may be diagnosed acute inflammatory rheumatism, but the ordinary rheumatic therapy will have no effect upon it. scaklet fever. 239 Treatment. Prophylaxis. The patient should be isolated to prevent dissemination. As to the contagious periods, Forcheimer may be quoted: "The disease is not contagious during the period of incubation; little, if at all, during the period of invasion; most contagious during the period of eruption, and de- cidedly so during the period of desquamation." The patient should be placed in a well-ventilated room, and be clad in light flannel gown and lightly covered. Diet must be liquid. Milk, broths, and fresh fruits. Water should be given freely. The throat and mouth should be washed thor- oughly with an antiseptic solution to protect the ear. The following is a good gargle : IJ Phenolis gr. xxx Glycerini § j Aquae camphorae § j Potassii cUorati gr. x Aquae q. s. ad 5 vj Misce et fiat solutio. Sig. : Use as a gargle two times daily. Or: I^ Naphtolis 3 j Aquae camphorae 3 iv Glycerini § j Aquae rosae § ij Alcoholis 5 j Misce et fiat solutio. Sig.: Use as a gargle two times daily. 240 INFECTIOUS DISEASES. Or: IJ Acidi borici 3 ss Potassii chlorati 3 ij Tincturse ferri chloridi 3 ij Syrupi simplicis 5 ij Aquae q. s. ad § iv Misce. Sig. : Tablespoonful every two hours for child of 5 years. The pharynx and posterior nares may be sprayed with an atomizer, using chloretone inhalant (P. D. & Co.), or 5 grains of menthol to 1 ounce of aboline. Peroxid of hydrogen may be used, either pure or combined with glycerin. Careful attention to the nose and throat often prevents ear complications. When diphtheritic patches occur, they should be wiped off with a swab and Loffler's solution applied. This solution consists of: IJ. Mentholis 3 iiss Toluolis § j Liquoris ferri chloridi 3 j or creolin TTl, xxx Alcoholis absoluti § ij Misce et fiat misturse. Dispense in brown bottle. Sig.: Use as a gargle and swab the throat thoroughly. Fever is best combated by hydrotherapy. The cold bath of typhoid should not be used. In light cases, sponging with cool water or water and vine- gar, with cold applied to the head, either as ice bag or towel wrung out of ice water. Where the tem- perature runs high, the patient may be put in tepid bath and the temperature gradually reduced, but never below 75° F. SCARLET FEVER. 241 Aconite, either as the tincture irt j-ttl ij every hour, or the active principle aconitin amorphous gr. %34 every fifteen to thirty minutes, may be given to child of 5 years until effect, and then continued hourly. The following is a good fever mixture: I^ Liquoris ammonii acetatis 3vj Potassii chlorati 3 ss Tincturae aconiti Til, xxx Syrupi limonis 3 v Aquse q. s. ad § iij Misee et fiat solutio. Sig. : Teaspoonful every two hours, and may be given hourly if temperature be high. Quinin and phenacetin are very effective and bene- ficial in many ways. IJ Euquinini ( Merck ) gr. xxx Phenacetini gr v Syrupi pruni virginianse 5 vj Aquae menthae piperitae . . . . q. s. ad S ij Misce et fiat misturae. Sig. : Teaspoonful every two or three hours, as indicated, for child of 2 to 10 years. Delirium and muscular twitching call for sodium bromid. Usually ice pack to the head is sufficient, as the cerebral congestion from the fever causes delirium. Cardiac failure calls for stimulants. The follow- ing is very efficient: IJ Camphorse 3 ss Aetheris 3 v Misce. Sig. : Inject 20 minims subcutaneously. Whisky, brandy, or aromatic spirits of ammonia may be used. 242 ESTFECTIOUS DISEASES. Delayed eruption is best treated with atropin gr. /^so every hour until physiologic effect. Warm baths will assist also in bringing out the eruption. Calcium sulphid and urotropin should be given throughout the disease. Calcium sulphid gr. j-gr. ij should be given when the stomach is empty to prevent the action of HCl. Urotropin gr. %-gT. v, according to age, is given three times daily, as its antiseptic action on the urine is thought to protect the kidneys. Tincture of iodin, glycerin, and ichthyol, equal parts, painted over the enlarged tender glands of the neck and covered by rubber tissue, will prevent suppuration in many cases. Unguentum Crede may also be used, or unguentum hydrargyri ammoniati. When fluctuation can be detected, the gland should be opened and drained. Nephritis. As a preventive measure to a certain degree, the following gives good results, probably because it quiets the nervous system: 3 Chloral hydratis 3 ij Sodii bromidi 3 iij Syrupi tolutani 5 j Aquse q. s. ad § iij Misce. Sig. : Teaspoonful every two or three hours. Plenty of water and a milk diet are excellent pro- johylactic measure. The urine should be examined daily for albumin. When nephritis develops, the treatment in no way varies from that outlined under acute nephritis. SCARLET FEVER MALARIA. 243 During the period of eruption and desquamation the body should be rubbed daily with some oily sub- stance, as carbolated vaselin or plain olive oil, or where there is much itching the following: IJ IMentholis gr. xx Olei olivse 3 ij Adipis lanse § i j Misce et fiat unguentum. Sig. : Anoint body one or two times daily. A warm bath should be given daily to hasten the desquamation. The body should be thoroughly rubbed during the bath and dried with a tolerably rough towel, and some ointment applied. This pre- vents the scales from flying and lessens the danger of spreading the disease. Convalescence calls for tonics, especially those containing iron. There is none better than elixir of iron, quinin, and strychnin, and essence of pepsin, equal parts, and give a teaspoonful three times daily. Malaria. Remember that the disease is communicated to the well solely by the mosquito; hence the impor- tance of insisting upon a malarial patient being pro- tected from the mosquito. . Remember that the disease may remain dormant for a variable time and again produce the clinical symptoms. This is likely to be thought a reinfec- tion, when it is an old infection that has not been sufficiently treated to be cured. There are a number of types: 244 INFECTIOUS DISEASES. 1. Intermittent Fever. Remember that this is the common fever and ague, and is characterized by chill, fever, and sweat, fol- lowed by a total remission of fever. Remember that the chill may be light or severe, and begins gradually. The temperature rises during the chill. Remember that the chill may be overlooked, espe- cially in young children, but the lips are blue, the face is pale and pinched, the skin feels cold, and there is vomiting. In children the fever may cause nervous sjTiiptoms that may mislead in diagnosis. Remember that the pulse is small, hard, and fre- quent; the hands are cold, and the finger nails are blue. Remember that fever follows the chill, but that the temperature begins to rise even prior to the chill and usually reaches its maximum at the end of the chill or very soon thereafter. This is the period of circulatory reaction of the superficial ves- sels, and the skin becomes red, hot, and dry. Thirst is intense, and a throbbing headache announces the dilatation of the cerebral vessels. Remember that the sweating stage is the last in the paroxysm, and affords relief of all the symp- toms. The amount of sweating varies from a moist skin to a profuse, drenching the clothes and bed. Remember that the duration of the paroxysm va- ries from eight to twelve hours, and during the paroxysm the spleen is enlarged. MALAEIA. 245 Remember that herpes labialis occurs more fre- quently in malaria than in any other condition, and is very suggestive when it occurs. Remember that there are other conditions caus- ing chills, fever, and sweat. The two most common are tuberculosis of the lungs and p^^emia. Remember that the paroxysms of chill, fever, and sweat found in malaria are periodical, occurring with marked regularity, while the paroxysms occur- ring in the other infections are irregular, sometimes occurring daily and then less frequently. Remember that the blood examination will show the Plasmodium in malaria, while a blood culture will give a growth of streptococci in septic cases. Remember that in the nervous chill there is no fever, or at most the rise will be very little, while the other phenomena of malaria will be absent. 2. Remittent Fever. This is also called the estivo-autumnal fever, but is probably best known as bilious fever. Remember that the prodromal symptoms are pro- nounced and misleading. They are malaise, intense headache, coated tongue, and frequently nausea and vomiting. The vomiting may be of bilious matter, and there may be jaundice, with tenderness on pres- sure over the liver. Remember that the chill is less severe and lacks the characteristic periodicity of intermittent. Remember that the temperature is continually above normal, but there are remissions in the height. 246 INFECTIOUS DISEASES. Remember that the blood examination shows the small, active, motile, hyaline form of the plasmodia, while later the crescentic, ovoid bodies may be found. Remember that malarial infection of any type will yield when the patient is cinchonized, but don 't forget that there is a difference between giving quinin and cinchonizing a patient. Remember that typhoid and remittent malarial fever is frequently confused, but the following should determine the question: 1. Plasmodium found in the blood in malaria. 2. Eruption in first week in typhoid fever. 3. Widal reaction of agglutination present in ty- phoid and occurring from the fifth day on. 4. Cinchonizing patient with quinin will send the temperature to normal in malaria; no effect in typhoid. 3. Pernicious Malaria. Remember that the pernicious types may not be- gin with a chill and the onset may be sudden. Remember that there are two types — comatose and algid. In the comatose type there are low, mut- tering delirium, skin is hot and dry, temperature high, and may terminate fatally. The digestive sys- tem bears the brunt of the attack in the algid type. There are extreme nausea, vomiting, collapse, with coldness of the extremities. The pulse becomes small and feeble, the breathing is rapid and shallow. MALARIA. 247 suppressed urine, colicky pains, purging, and great thirst. Remember that the pernicious forms may be com- plicated by paraplegia, and acute ataxia has been described. Multiple gangrene may occur. Orchitis has occurred in some cases. 4-. Chronic Malaria. The cachexia is the most prominent symptom. It is caused by blood changes. Anemia is extreme, and causes breathlessness on exertion; edema of the ankles. The spleen is enlarged and hard; its border may extend to the iliac crest. Some cases are jaundiced, and all have a peculiar yellow color. Remember that leukemia causes an enlarged spleen, but the changes in the blood cells are very characteristic in leukemia, and, in addition, the Plas- modium is found in the blood in malaria. Remember that intense choleraic form occurs. The purging is very profuse and watery. There is fever and collapse, and death may occur. Remember that there is a gastralgic form, in which there is agonizing epigastric pain, abdominal tenderness, and perhaps diarrhea. It has been mis- taken for appendicitis by surgeons. Remember that malaria may closely simulate dysentery. There will