The sudorific effect of the treatment by external warmth described above should be aided by employing diaphoretics. Those which have been most used are the acetates of ammonium and potassium, the bitartrate and citrate of potassium, and spiritus ætheris nitrosi. If employed when the surface is cool, they act rather as diuretics than diaphoretics. These agents, being simple in their action and without deleterious effects, may be given frequently and in large proportionate doses for the age.
But lately a diaphoretic which far surpasses these in efficiency has been discovered in pilocarpine, the active principle of jaborandi. Being soluble in water and tasteless, it is easily administered, and is retained when, on account of the uræmic poisoning present in scarlatinous nephritis, the stomach is irritable and other medicines, as digitalis, are rejected. Ether may be employed with it, or the amount of alcoholic stimulant may be increased at the time of its exhibition in order to guard against any depressing effect. To a child of two years one-fortieth to one-twentieth of a grain may be given every six hours by the mouth. It may also be employed hypodermically, as one-twentieth of a grain to a child of five years. It has both a diaphoretic and diuretic action, while it stimulates both the salivary and mucous secretions. According to one observer, an adult when fully under the influence of pilocarpine secretes from one pint to one quart of saliva within two hours, and Leyden reports a case of diphtheritic nephritis in which the quantity of urine rose from half a pint to five pints daily. But its most prompt and certain action is upon the sweat-glands. Hirschfelder speaks of its beneficial action in relieving various forms of dropsy, and adds: "In one morbid condition of the kidney, however, jaborandi is the remedy par excellence, and that is the acute parenchymatous nephritis which frequently follows scarlatina.... This disease heals spontaneously if the danger that threatens life from reduction of the urine and from the effusions of fluid into the cavities of the body be averted. In this disease jaborandi works wonders." I have also found it an invaluable agent when the older remedies failed and death seemed imminent. The following cases, in which the beneficial action of this agent was apparent, occurred in my practice:
Case 8.—G——, male, aged five years and six months, sickened with scarlet fever on June 2, 1882. It began with vomiting, and was attended by a degree of febrile movement which indicated an attack of rather more than the average gravity. The fauces at one time exhibited a slight exudation like that of diphtheria. In the declining stage of the malady rheumatic pain and tenderness occurred in the wrist and finger-joints, but not in those of the lower extremities. The case, however, progressed favorably, and during the convalescence my attendance ceased. On June 24th my attention was again called to the child, when the urine was found to be scanty and very albuminous. External measures, such as are described in the foregoing pages, were employed, and the infusion of digitalis with potassium acetate ordered to be given every three hours, but this medicine was for the most part vomited. The bowels were kept open by jalap and the potassium bitartrate. The urine, however, continued scanty, and on June 28th severe convulsions occurred. At this time the quantity of urine was only fl. oz. ij in twenty-four hours. The pulse in the convulsions was quick and feeble, the skin very hot, and the axillary temperature 103°. The eclampsia continued one hour, and were controlled by large and repeated doses of bromide of potassium, aided by clysters of five grains of hydrate of chloral in water. Muriate of pilocarpine was now directed to be given in doses of one-thirty-second of a grain every three hours, dissolved in cold water. This agent was not vomited, and it must have been given by the parents in their fright and anxiety in larger or more frequent doses than were directed, for on July 1st the bottle containing one grain was empty. Free diaphoresis resulted from the pilocarpine, and the quantity of urine was increased. The mother stated that the child had taken only two doses, or one-sixteenth of a grain, of pilocarpine when the diuretic effect was apparent and free diaphoresis also occurred. She also stated subsequently that the quantity of urine was larger when the pilocarpine was administered every third hour than when given at a longer interval. A flaxseed poultice on which mustard was dusted was also applied over the kidneys. On June 29th the pulse was 96, temperature 100.5°; occasional convulsive attacks occurred, which were readily controlled by enemata of hydrate of chloral. On June 30th the symptoms were all better; no more attacks of eclampsia had occurred, and the urine was more abundant and less albuminous. The mother remarked that the new medicine (pilocarpine) had settled the stomach and increased the urine. The patient continued to improve, and on July 4th the record states: "Now takes the pilocarpine, gr. 1/32, every six hours; passes urine freely since yesterday; has not vomited since he began to take the pilocarpine; pulse 106, axillary temperature 99°; is playful and takes milk freely, nearly three quarts in twenty-four hours, with some farinaceous food. Digitalis with potassium acetate is also given in occasional doses." July 6th, pulse 92, temperature 99°; perspires much, and urine nearly normal in quantity and character.
Case 9.—Mary S——, aged five years, on Dec. 22, 1882, presented the symptoms of severe nephritis. Her brother had scarlet fever two weeks previously, and she had sore throat at about the same time, but without efflorescence; pulse 98, temperature 98.5°; her urine highly albuminous, and reduced to fl. oz. iv in twenty-four hours; bowels constipated. Ordered a single dose of
| Rx. | Hydrarg. Chlor. Mitis | gr. iii; |
| Resin. Podophylli | gr. 1/6. M. |
The muriate of pilocarpine was also ordered, gr. 1/20, but the patient vomited soon after taking it. Another dose was retained, and was followed by considerable perspiration. Dec. 23d, had one stool from the powder of yesterday. Has taken five doses of pilocarpine, but vomited after three of them. The last dose was administered at 10 P.M., and the mother says she "sweat fearfully" during the night. The patient was kept warm in bed; stimulating poultices of mustard and flaxseed, one to sixteen, were constantly in use over the kidneys, and the pilocarpine was administered three or four times a day. The record for Dec. 26 states: "Took the pilocarpine four times since yesterday morning, and each dose is followed by perspiration lasting from one to one and a half hours; quantity of urine, from fl. oz. vj to fl. oz. viij daily; vomited twice yesterday, not to-day; pulse 104, temperature 97.75°; complains of frontal headache; bowels regular; has considerable salivation. The patient is warm in bed, and the flaxseed and mustard poultice over the kidneys is continued." Dec. 28th, specific gravity of urine 1019; urine still quite albuminous, and containing blood-corpuscles and granular casts, also crystals of oxalate of lime. Dec. 30th, takes gr. 1/20 pilocarpine twice daily, and occasional doses of infusion of digitalis; urine more abundant; its specific gravity 1014, slightly albuminous, and containing very few granular casts and blood-corpuscles; has lost its smoky appearance; reaction alkaline; perspiration slight; patient convalescent.
In another instance, a child of five years, from three to four weeks after scarlet fever was noticed to have anasarca of the face and extremities, with scanty and albuminous urine. One-thirty-second of a grain of muriate of pilocarpine was administered every six hours without the desired sudorific effect. It was then administered every four hours, with an increase of perspiration and urination, so that the nephritic symptoms were relieved and the patient apparently out of danger within three or four days.
In a fourth patient, a girl of three years, having scarlatinous nephritis, with symptoms very similar to those in the last case, the administration of one-twentieth grain doses of pilocarpine in conjunction with the hot-air bath, was followed by increased perspiration and urination, and progressive and rather rapid convalescence. This child had been taking bichloride of mercury in one-fiftieth grain doses, prescribed by a homoeopathic physician, without appreciable benefit. It had been for the most part vomited.
Given, as in the above cases, in moderate doses and with sufficient interval, pilocarpine has never in my practice had any deleterious effect, and I regard it as a very important addition to the remedies for the relief of scarlatinous nephritis. It is apparently the most useful and important diaphoretic for this disease which we possess.
Cathartics, especially those of a hydragogue nature, are also very beneficial. Their action is more certain than that of most diaphoretics and diuretics, and their employment is imperatively required in severe or dangerous cases in which it is necessary to remove as soon as possible the serum or urea which endangers life. Young children or those with delicate stomach, and those much enfeebled by the primary disease, may take magnesia, either the citrate or the calcined. A good cathartic for ordinary cases is a mixture of jalap and potassium bitartrate, the pulvis jalapæ compositus, consisting of one part of jalap and two of cream of tartar. Ten grains of the mixture may be given to a child of five years, and repeated according to circumstances. Its effect is increased by dissolving a teaspoonful of potassium bitartrate in a gobletful of water, and allowing the patient to drink from it. The following is a good cathartic in some instances, especially if the stomach be irritable, so that the more bulky and nauseating cathartics are rejected. Care should be taken to obtain a good article, as some of the podophyllin of the shops is not reliable: