be frequent, mucoid, bloody stools; colicky, abdominal pains; tenesmus, and pro- gressive emaciation. Remember that neuralgia may be of malarial origin. The proper administration of quinin is usually very efficacious in these cases. <Callout type="important" title="Proper Quinin Administration">Remember to control vomiting with calomel and cerium oxalate before administering quinin.</Callout> Hematuria may occur in any malarial infection, but is much more common in the tropics. This is a hemaglobinuria, and the parasite can always be found in the blood. It is doubtful as to quinin either causing it or making it worse.
Teeatment. Patients known to be malarial should be protected from mosquitoes, so that the infection may be limited. Calomel as a cathartic has no equal in beginning the treatment. Vomiting should be controlled by calomel and cerium oxalate. Quinin is the specific for malaria, but its action can be enhanced by proper combinations.
The following has given excellent results in a large number of cases: <Callout type="tip" title="Effective Malarial Treatment">IJ Codeinse pliosphatis gr. % Quininse hydrochloridi gr- iij Arseni trioxidi gr. y^Q Eerri ferrocyanidi gr. j Pulveris camphorse gr. j Misce et fiat capsula No. I. Dentur tales doses No. XX. Sig.: Capsule every three hours.</Callout> This is given after a good purge with calomel. MALARIA. 249 For children and those unable to take a capsule the following is good: <Callout type="risk" title="Risk of Ineffective Treatment">IJ Euquinini ( Merck ) 3 j Syrupi pruni virginianse 3 vj-3 viij Rub up the euquinini thoroughly with syrup. Codeinse phosphatis gr. iss-gr. iij Liquoris potassii arsenatis TT|. Ix-Tl^ Ixs Aquae menthae piperitse ... .q. s. ad § iij Misce et fiat misturse.</Callout> Sig.: Teaspoonful every three hours. Shake. For the pernicious forms quinin must be given hypodermatically. R Quininai hydrochloridi gr. xxx Antipyrini gr. xx Aquae destillatae 3 j Misce et fiat solutio. Sig.: Inject 10 minims every three or four hours. Quinin hydrobromid, in 3-grain doses, dissolved in 20 minims of pure warm water and sterilized, makes probably the best method of administering quinin hypodermatically. In injection of solution of any of the salts of quinin it should be made deep into the muscle. Where a solution of quinin is to be given per os, the following affords a good example. Never use any flavoring syrup, as it keeps the bitter taste in the mouth, while a good drink of water in a plain solution removes all the bitterness. R Quininse hydrochloridi 3 iv Tincturse ferri chloridi 3 iv Aquae q. s. ad § iij Misce. Sig.: Teaspoonful every three hours. 250 INFECTIOUS DISEASES. Where there exists an idiosyncrasy against quinin other drugs must be used. IJ Methylene blue 9 ij Arseni trioxidi gr. ss-gr. j Pulveris myristicse 3 ij Misce et fiant capsulte No. XX. Sig.: Capsule four times daily. Or: <Callout type="warning" title="Potential for Harmful Reactions">IJ Tincturse eucalypti § Sodii arsenatis S^•^^ Acacise, Aquae gaultherise aa q. s. ad 5 ij Misce et fiat emulsio.</Callout> Sig.: Teaspoonful every two or three hours. The treatment of malaria should be continued for at least two weeks after the subsidence of all symp- toms if the Plasmodia are to be completely eradi- cated. The amount of quinin given should be re- duced. Three grains three times daily are sufficient, but must be given so that it will be absorbed — best in capsule, followed by acid drink, as lemonade or dilute muriatic acid. During this period of conva- lescence iron should be given, and Blaud's pill can not be improved upon. Ferri carbonatis may be given in the quinin capsule. In chronic malaria, with the enlarged hard spleen, potassium iodid should be used and Fowler's solu- tion should be pushed. In administering Fowler's solution, it is better to begin with a small dose — 2 minims — three times daily after meals and in- crease 1 minim every third day until puffy eye-lids or diarrhea announce complete saturation, when the dose should be reduced by dropping 1 minim every third day until 2 minims are taken at a dose. Diphtheria. Remember that it is highly contagious, either di- rectly from sick to well or through some intervening body, as nurse, physician, or articles about the pa- tient. Remember that we have diphtheria carriers, as in typhoid. They show no signs of infection, yet the germ has been obtained from their throats. 252 INFECTIOUS DISEASES. Remember that milk is responsible for many epi- demics, the teats of the cow harboring a virulent organism. Remember that children from 2 to 5 years are most susceptible. Remember that not all cases that have a mem- brane in the throat have diphtheria. The strepto- cocci often cause a diphtheroid condition of the throat, but the clinical symptoms are not character- istic of true diphtheria. Remember that in the laryngeal form the child is usually hoarse at night and has a brassy, croupy cough. Remember that dyspnea, becoming extreme as the membrane advances until eventually cyanosis and carbonic acid poisoning, is the course of diphtheritic croup. Remember that otitis media is frequent in diph- theria, and in the nasal form the eyes may become involved. Remember that a serous, sanguinous, or bloody discharge from the nose that excoriates the mucosa and the skin is very suspicious of diphtheria. Remember that paralysis of the soft palate and the regurgitation of liquids through the nose is very characteristic of diphtheria. Always make a bacterial examination of the throat, as the presence of Klebs-Loffler bacilli makes it diphtheria, regardless of the presence or absence of a false membrane or other clinical signs. Remember that the systemic reaction caused by the local infection produces fatigue, drowsiness, pal- lor, coated tongue, anorexia, dysphagia, and vomit- ing. There may be a chill, but more often chilliness, and the temperature usually rises gradually until it reaches 102° or 103° F., remains stationary a couple or three days, then declines by lysis, and rises again from the fourth to the seventh day. The pharynx is red, edematous, and glistening. A gray- ish-white membrane, changing later to a dirty-gray, may be seen on the tonsils, fauces, or posterior wall of the pharynx. Remember that the peculiarities of the membrane, are its gradual growth until it covers the tonsils, faucial pillars, uvula, and palate; and, further, that it is firmly adherent, so that when removed a raw, bleeding surface is left, which is again soon covered by a membrane. The voice has a ' ' nasal twang, ' ' Remember that the lymph glands at the angles of the jaw are enlarged and may be tender. DIPHTHERIA. 253 Remember that the membrane may be absent, and nothing more than catarrhal condition of the throat be present on inspection and the patient have a cronpy cough. Remember that in some cases the tonsils are cov- ered by an exudate closely resembling that seen in follicular tonsillitis, and no true membrane be present. Remember that there are cases in which the tox- emia is so profound that the patient succumbs be- fore local lesions occur. Remember that when bacteriologic examination can not be made, all cases of 'sore throat' and croup, especially if there is swelling of the lymph glands at the angles of the jaw, must be regarded as diphtheria. Treatment. Hygienic. Confine patient to a room free of car- pet, curtains, and superfluous furniture. Keep the room temperature at 68° F. and air moistened by kettle. Good ventilation must be secured. No one but the nurse and the doctor in the room. All bed clothes and whatever is used about the patient should be immediately thrown into a solution of carbolic acid. Local treatment consists of swabbing, spraying, and gargle — peroxid of hydrogen full strength, car- bolic acid 1 to 3-percent solution, bichlorid of mer- cury 1:5000. A very excellent method is the application of 95- percent phenol by swab to the area covered by the membrane, and repeat once daily, making a thor- ough application. In laryngeal croup a steam tent may be arranged upon the bed, so that the air breathed by the child will be saturated with moisture. When signs of obstruction are marked, intubation or tracheotomy should be performed. Hot applications should be applied to the neck of children, while cold should be used in adults. Diet should be liquid — milk, soups, and broths. Albumen water and plain water should be used freely. The bowels must be kept open, and calomel in fractional doses is best. Sponging may be used to reduce the fever when the temperature is high. Stimulants should be used when indicated. It should never be forgotten that the toxin has a se- lective cardiac action, and the heart must be closely watched. The patient should be kept in bed and quiet, and all excitement avoided. Atropin sulphate gr. M.00- gr. Veo, adult dose, administered hypodermatically should be used at the first sign of heart weakening. Inasmuch as the toxins are retained in the body some time after the recovery, the child should be kept in bed two weeks after normal temperature has been established. Specific treatment is the only sane and rational way to treat. Antitoxin should be administered early and in sufficient doses. The earlier the antitoxin is given, the less likely to have complications, and especially of the heart. One should make it a rule to give it in cases that are at all suspicious. Dose enough is a hard c[uestion to decide, because the dosage is empirical. Administer 4,000 or 5,000 units, and repeat in twenty-four hours if no signs of the membrane loosening at the border and the symptoms do not improve. Antitoxin is harmless, and should be given until results are obtained. Rheumatic Fever (Inflammatory Rheumatism). Remember that this is an acute infectious disease, due to a micro-organism not yet isolated. Remember that exposure to cold and vet is more important as a cause than heredity. Remember the close relationship that exists between inflammatory rheumatism and tonsillitis, and frequently an apparent tonsillitis is but the onset of rheumatism. Remember that the onset is usually sudden, with rigor or chill and a rise of temperature. The pulse is soft and frequent, usually above 100. Remember the profuse acid sweat, with a peculiar sour odor. Remember that the joints soon become red, swollen, and exc[uisitely painful. The peculiarity of the joint involvement of skipping from joint to joint is characteristic of inflammatory rheumatism. Remember the anemia. No other acute febrile disease causes such a rapid anemia, which accounts for the pallor. Remember that the joint involvement is rare in children, and cardiac complication exceedingly common. The 'growing pains' of childhood are rheuma- tism, and should be carefully looked after. Remember that arthritis occurring in septico- pyemia is fixed, and few joints involved. The fever is more distinctly intermittent. Remember that in acute osteomyelitis the epiphy- sis is the seat of the trouble, and the joint is not in- volved, while the local and constitutional symptoms are more severe. Remember that gonorrheal arthritis is not migra- tory. The joints involved are more apt to be the knee, sternoclavicular, or vertebral joints, and the urethral discharge of the male or vaginal discharge of the female should be examined for the gonococci. Remember that an arthritis deformans may begin with an acute inflammation of joints and fever. It is usually the smaller joints that are involved, but in many cases it will require time to differen- tiate. When the acute symptoms pass in arthritis deformans we find joint changes with periarticular thickening, while in inflammatory rheumatism there are no permanent joint changes. Remember that acute rheumatism attacking the joints of the spine may closely simulate meningitis, but the severe headache, pupillary changes, hyper- esthesia, and Kernig's sign are absent. EHEUMATIC FEVER. 257 Remember that during the course of acute rheu- matic fever, cerebral rheumatism may develop, marked by rapid rise of temperature — 106° to 108° F. — rapid small pulse, nystagmus, vomiting, spastic paralysis, strabismus, and wild delirium. This is a very serious condition, which may terminate fatally. Treatment. The patient should be dressed in light flannel gown, and confined to his bed between blankets. The inflamed joints should be wrapped with cotton and bandaged. Diet should be liquid and light. Milk is best, and to it should be added a little bicarbonate of soda. Broths may be used, also farinaceous foods, but meat should not be allowed. Lemonade should be freely given. Hyperpyrexia must receive prompt and vigorous treatment to save life — the cold bath or cold applied along spine by rubbing with a piece of ice. When the temperature is reduced, there is great likelihood of its rising again. Pain may be so severe as to require hypodermic of morphin. Codein gr. % hourly usually gives relief. Sodium salicylate for the cure of inflammatory rheumatism is almost universally used. Salicylic acid is often used, but its irritating effect upon the stomach has lessened its general use. Strontium salicylate is used and highly recommended. All these salts should be given in 10 to 15-grain doses, and for the first twenty-four to forty-eight hours should be repeated often enough so that from 1 dram to IVi drams are taken in twenty-four hours. The important thing is not the quantity, but the complete saturation of the patient, which is manifested by buzzing in the ears. The drug should then be re- duced by lengthening the interval. An alkali should be combined with the salicylate treatment — either sodium or potassium bicarbonate, or potassium citrate. The following have given good service: T^ Sodii salicylatis 3 v Potassii bicarbonatis 3 iiss Vini colchici 3 iij Aquse menthse piperitse q. s. ad § iv Misce. Sig.: Teaspoonful every two hours for two days, then every three hours. Or: IJ Aeidi salicylatis, Potassii acetatis aa 3 iss Antipyrini 3 ij Syrupi simplicis 3 iss Aquse bullientis 5 vj Misce. Sig.: Tablespoonful every three hours. Or: IJ Antipyrini gr. xx Sodii salicylatis 3 ij Syrupi sarsaparillae compositae B iij Aquse menthse piperitse ... .q. s. ad § vj Misce. Sig.: Tablespoonful every three hours. Or: ^ Asperini 3 ij Fiant capsulae No. XII. Sig.: Capsule every two or three hours. KHEUMATIC FEVER. 259 The following is the best for local application, as it gives prompt relief: IJ Magnesii sulphatis 3 Jj Phenolis 3 j Aquae bullientis O j Misce. Sig.: Envelop the joint with cotton lightly squeezed out of this solution, cover with dry cotton, and apply roller bandage lightly. It is essential that the salicylates be kept up in smaller doses for some time after temperature is normal to prevent relapse. Convalescence. The administration of iron for anemia — the elixir of iron, quinin, and strychnin (U.S. P.)— is excellent.
Key Takeaways
- Quinine is the specific for malaria but its action can be enhanced by proper combinations.
- Malarial patients should be protected from mosquitoes to limit infection.
- Antitoxin should be administered early and in sufficient doses for diphtheria treatment.
Practical Tips
- Always keep a supply of quinine on hand, as it is crucial for treating malaria.
- Maintain good hygiene by keeping the patient's environment clean to prevent the spread of diseases like diphtheria.
- Use antitoxin early in cases suspected of being diphtheria to reduce complications.
Warnings & Risks
- Be cautious when administering quinine, as it can cause side effects and should be used under medical supervision.
- Avoid using flavoring syrups with quinine solutions as they can leave a bitter taste in the mouth.
- Ensure proper ventilation in rooms where patients are treated to prevent the spread of airborne diseases.
Modern Application
While historical treatments like quinine and antitoxin have been improved upon, understanding these methods is crucial for recognizing symptoms early. Modern diagnostics and medications offer more precise treatment options but still rely on accurate identification of pathogens such as those causing malaria and diphtheria.
Frequently Asked Questions
Q: What are the signs of a malarial infection according to this chapter?
Signs of a malarial infection include frequent, mucoid, bloody stools; colicky abdominal pains; tenesmus; progressive emaciation; and neuralgia. Hematuria may also occur but is more common in tropical regions.
Q: How should quinine be administered for malaria treatment?
Quinine should be given after a good purge with calomel, controlled by calomel and cerium oxalate to manage vomiting. It can also be administered hypodermatically in severe cases.
Q: What is the recommended course of action for diphtheria patients?
Diphtheria patients should be isolated, kept in a room free from carpets and curtains, with good ventilation. Local treatment includes swabbing and spraying with antiseptics like peroxide or phenol. Antitoxin should be administered early to prevent complications.
Q: What are the key symptoms of rheumatic fever?
Key symptoms include a sudden onset with rigor, chill, and rise in temperature; red, swollen, and painful joints that skip from one joint to another. The patient may also experience anemia and cardiac complications.
Q: What is the role of antitoxin in treating diphtheria?
Antitoxin should be administered early and in sufficient doses to prevent complications, especially affecting the heart. It is harmless but must be given until results are obtained.