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Scarlet Fever.

Problems:

Synonyms:—Scarlatina, scarlet rash.

There is a quite commonly accepted opinion among the laity that the term scarlatina designates a mild, a benign variety of this disease, and that from this variety, the same form only can be contracted. This is an erroneous and misleading opinion. The term scarlatina is in every way synonymous in its application with the term scarlet fever.

In an occasional epidemic and in some sporadic cases, a mild rash covering the neck perhaps and shoulders or appearing lighter upon the face, with a slight fever, arc the only symptoms exhibited. This is termed a scarlet rash, but as other children will contract the disease in all its severity with all its characteristic phenomena from this mild rash it will be seen that this is only a mild manifestation of scarlet fever proper.

Definition:—An acute, highly infectious, self-limiting disease of childhood, epidemic and endemic in occurrence, exhibiting as symptoms, initial vomiting, a typical fever, sore throat and a highly characteristic eruption.

Etiology:—The contagion is supposed to be conveyed by the minute epidermal scales thrown off in the free desquamation that takes place from the rash. It is also without doubt conveyed by the breath, from the excretions, from the membranes of the nose, throat and ear, or from the discharges which occur from disease of these organs induced by this disorder. Immediate contact with the infected individual is not essential, as the germ of the disease is very tenacious of life and adheres to the clothing or to any article from the room in which the patient was confined. These have been known to transmit the disease after the lapse of two, three or more years.

The disease is one of childhood and early youth, as not more than five per cent of the exposed cases in adults are attacked. In early life twenty-five per cent of the exposed cases develop the disease. It is less common than measles. Children from two to six years of age are more susceptible. Children at the breast do not readily contract it.

The disease is more prevalent in the fall and winter months, but occurs to a less extent at other seasons of the year.

Careful observation confirms the belief that the disease is not transmitted until the rash appears, and that the most actively contagious period is at the time the rash is fully developed and desquamation is established. The infection persists until the desquamation has ceased.

No micro-organism has as yet been isolated which is found to exercise an etiological influence in all cases of scarlet fever. The infection is probably of a mixed character, as both a diplococcus and streptococci of several varieties have been found.

The disease varies in severity in different cases and in different epidemics. It may exhibit only a mild rash, with a slight fever and an absence of throat symptoms, the patient not being confined to the bed. Or it may exhibit violent and serious symptoms at its onset, which increase in severity rapidly, with malignant sore throat, extreme toxaemia, enlarged glands, especially of the throat and neck, swollen tissues, delirium and sordes.

Symptomatology:—The premonitory symptoms, when observed, are marked indisposition and lassitude, dullness, headache, nervous irritability, and in small children occasionally convulsions. Anorexia and sore throat also appear. These may not last twenty-four hours, and at the most three or four days, as the period of incubation is the shortest of any of the exanthemata. After passing a restless night the patient, a short time after awakening in the morning, has a violent vomiting spell, after which he seems very weak and ill. The pulse is feeble and rapid—from 140 to 160 beats per minute in small children, small and rather hard. The fever, which may not have been previously observed, develops rapidly and reaches about 104° F. within two or three hours.

Nausea is sometimes present, but abrupt and explosive vomiting, when no nausea has been complained of, is often one of the first symptoms. In other cases the sore throat is the first symptom observed. In all cases the mucous membranes of the pharynx are engorged and inflamed to a greater or less extent, and are usually dry and irritable. The skin is hot and dry, with a burning sensation, especially when the rash appears. The eyes are bright and pupils contracted, usually as the fever develops. The tongue quickly becomes furred and there is a feverish odor to the breath.

After from twenty-four to thirty-six hours, in typical cases, the rash appears, at which time the pungent heat in the skin is intense, is perceptible to the hand and is complained of by the patient. The appearance of the rash is abrupt; spreading rapidly it covers the body and limbs within four or five hours of its first appearance. It usually appears first upon the neck, but it may appear only upon the body or hands in mild cases, or upon the chest and shoulders alone. It passes through all the characteristic stages of its development, to full maturity, in from thirty-six to forty-eight hours. The rash is of a bright scarlet color, as its name would indicate—a uniformly diffused redness, which disappears entirely upon pressure, leaving a white, bloodless skin for a moment after the pressure is removed. The eruption is distinctly punctuated around each hair follicle, these minute points having a distinct red base, which ultimately coalesce. In some cases the appearance is that of "goose flesh." Usually around the mouth and the chin the skin is very pale, in marked contrast to the redness of the skin elsewhere.

Occasionally the disease assumes a malignant form, in which the skin is dark, cool, mottled in appearance, but the rash is suppressed, or appears more like that of measles, macular in character and blotched or spotted upon the skin. In these cases there may be a convulsion early and mental dulness, stupor or coma, resulting from uraemia or other toxaemia, may exist.

The temperature in scarlet fever rises abruptly within the first few hours to 105° F. or perhaps 106° F. and continues high for a period of about forty-eight hours, when, if the progress of the disease is favorable, it gradually declines for three or four days to normal, when desquamation is pronounced. The course of the disease is from five to eight days and its decline is marked by a fading of the rash and by amelioration of all the symptoms.

The desquamation begins usually in about six days, the skin becomes rough, dry and faded in appearance. The scarf skin on the face and neck separates first, in both fine scales and in large flakes. This desquamation soon becomes general and sometimes great shreds of cuticle may be removed, especially from the palms of the hands and soles of the feet. The nails of the fingers and toes are sometimes cast off also. The more severe the disease the more profuse is the desquamation. This exfoliation may continue from four to eight weeks, and it must be remembered that there is danger of contagion as long as there is desquamation.

Complications:—The urine in all cases of scarlet fever is scanty and high colored. In severe cases, symptoms of renal congestion, with albuminuria, are apparent after perhaps the second day. There are various manifestations of kidney disorder. In the mildest cases the albuminuria continues and declines with the fever. In others it persists and increases after the decline of the fever, and there are tube casts present, with but few other evidences. In yet other cases, with the above symptoms, there is marked scantiness of the urine, with puffiness under the eyes or swelling of the ankles, or general anasarca. I have met with a few cases in which the abdominal dropsy alone existed, the face and extremities showing great emaciation. General dropsy is present in exceptional cases, also with marked evidences of uraemic poisoning.

So great is the work of elimination thrown upon the kidneys that nephritis may develop as soon as the stress of elimination becomes great, or at the decline of the fever, when the desquamation is at its height. In some cases the patient has nearly recovered, when upon some indiscretion, or from cold, a sudden and more or less complete suppression of urine occurs, as in other cases of profound septic invasion, or other evidence of acute nephritis may develop. In the larger proportion of cases it does not appear until the patient has about recovered from all the active symptoms of the disease. The fever, which has been absent for a period, reappears, but the temperature at first is not high, the pulse is sharp, quick and hard, the patient is restless and thirsty, the urine becomes very scanty and highly albuminous and usually contains blood. There is usually soreness and severe aching in the region of the kidneys. At this time dropsy, as above indicated, in its various forms may appear, or uremia, with slow pulse, subnormal temperature, hemorrhage from the nose, vomiting, and generally, suppression of the secretions, which is apparent by very dry skin, dry, deep red mucous membranes and dry, brown tongue, with at first pronounced constipation, but with ultimate diarrhoea from the septicaemia.

These conditions so increase blood pressure that cardiac dilatation occurs, with consequent valvular insufficiency, or endocarditis or pericarditis may develop. Pulmonary oedema is thought to be present in some cases, as sudden death is not uncommon in these complicated cases. This may result either from the oedema or from the heart complications.

A common complication is otitis media. The inflammation in the post nasal membranes extends upward through the eustachian tube and develops with all the phenomena of an original infection in the middle ear. This may occur early and pus developing in the cavity will escape through the membrana tympani. Or this disease occurring later with local distress and pain from the presence of pus, the high temperature may return and persist. This sometimes becomes a serious complication and in an extreme case the mastoid cells are involved, with possibly abscess of the brain, or meningeal complications may appear. Permanent deafness may result either in one or in both ears.

Scarlatinal synovitis, rheumatic synovitis or septic arthritis are common sequelae of scarlet fever. They appear with characteristic symptoms, and are not difficult of diagnosis. The arthritis must be treated with measures calculated to prevent pus development and necrosis of bone.

Inflammation of the lungs or bronchi is not uncommon as a result of this disease. They occur with all the characteristic phenomena, but are more difficult of treatment, tending in their termination toward empyema.

Pyaemia is a serious result of the septic infection which may occur in this disease. It may be found upon post mortem examination, to have occurred from a marked kidney infection, as evidence of which minute abscesses will have become diffused throughout the kidney structure. Or the tonsils may be found to be the seat of the disorder, or the cervical glands may become involved to a serious extent, simulating an acute purulent adenitis.

In rare cases chorea, ascending paralysis from neuritis in the lower limbs, paraplegia or hemiplegia may result.

It must be remembered that the throat may be subject to diphtheritic invasion during the course of the characteristic inflammation and must be so recognized at once and treated specifically.

Diagnosis:—The pathognomonic phenomena of scarlet fever are so clearly marked in a typical case that a diagnosis is not difficult. These are the abrupt vomiting, with sudden high temperature, rapid, hard pulse, sore throat and the characteristic redness of the skin after about thirty-six hours, which can be pressed out entirely by the finger, leaving a very white skin, to which the redness slowly returns. The punctate eruption is characteristic. There are various forms of dermatitis in which there is a rash which closely resembles this, but all of these are devoid of the other characteristic symptoms above described. When the disease appears in its mildest forms an unmistakable diagnosis must be made and the child must be isolated, for, as has been previously stated, the infection from these cases may induce the most serious forms of the disease in susceptible cases.

There is a characteristic appearance of the tongue of scarlet fever patients which is known as the strawberry tongue. There is a white, thin coat at first on the surface, which is in sharp contrast to the bright red appearance of the mucous membrane and mouth. Soon the papillae of the upper surface of the tongue become elongated and clubbed, as it were, on their tips and stand up above or through the white coating like the surface of a ripe strawberry. The tongue may become ultimately elongated, thin and pointed, but the above appearance is unchanged in the active stage.

Prognosis:—In uncomplicated cases of scarlet fever the prognosis depends largely upon the environment and the care of the patient. Under favorable circumstances, there being no dyscrasia or previous ill health, although the disease is a serious one, the patient will recover in a large majority of the cases. The mortality which statistics give as about twelve per cent of all cases, should be reduced to five per cent by care and good treatment. In mild epidemics the mortality rate in uncomplicated cases may be nil. In severe epidemics it may reach twenty-five per cent among the younger children, but this is exceedingly rare under modern methods. Malignant scarlet fever is very fatal. Complications are to blame for by far the larger per cent of fatalities in this disease.

Prophylaxis:—Much can be done by intelligent measures to prevent the spread of the disease. Physicians are usually very careless of the fact that the infection is readily carried upon the person. A surgeon's apron should be taken to the house of the patient and left in an out-room, where it should be put on over the vest, the coat having been removed before the physician enters the sick chamber. A clean linen duster in the absence of a surgeon's apron will serve the same purpose. On leaving the chamber the physician should remove the apron and wash thoroughly in a from three to five per cent solution of carbolic acid, paying especial attention to the dampening of the hair, mustache or beard thoroughly with the solution.

A whisk broom dipped in the carbolized solution should be then used to thoroughly brush the clothes.

Other solutions are advised, or the use of chlorine gas or formalin is suggested. I have found carbolic acid solution sufficient.

Treatment:—The patient should be effectually quarantined in a large, well ventilated room, with an experienced nurse, who will carefully change her clothes before mingling with others outside. As in measles, diphtheria and other infectious diseases that are apt to affect the bronchial tubes or the throat, the author twenty-five years ago advised the volatilization of the oil of eucalyptus, or eucalyptus and turpentine in the room and to maintain a constant supply of steam to keep the air more than usually moist. This course is now quite generally advised. The turpentine can be dispensed with usually except in the diphtheritic cases, but is very effectual where bronchitis with a dry irritating cough has developed as a complication.

Ten drops of one or both of the oils are dropped on the surface of water in an open vessel and this is kept boiling.

Every means must be taken to prevent the patient becoming chilled or the hands and feet or surface of the body from becoming cold, as this prevents a free development of the rash. This same care must be continued throughout the entire course of the disease to the end of convalescence in order to prevent renal congestion, which is always imminent. This threatening danger may be averted in most cases if it is never forgotten. A mild acidulated drink of an infusion of triticum or marsh mallows, or of epigea repens, will often supply an additional quantity of water to keep the kidneys flushed and to retain the mass of debris excreted, in perfect solution. This not only soothes the kidney structure, but prevents irritation and consequent congestion from the precipitation of the urinary constituents, as the phosphates and urates, etc., in deficient water. This can be iced and drunk ad libitum during the fever, and fruit juices, or fruit jellies may be dissolved in the infusion to impart a pleasant taste and nutritious properties.

The food should be liberal, but nutritious and readily digestible, or in part predigested. Milk in various forms may be given with eggs, which may be beaten together and to which, in prostrate cases, brandy may be added to advantage. Broths, gruels and jellies .are of much service with toast during the fever. Upon its abatement the diet may be increased with care, including the usual articles of plain food.

The first consideration in the medical treatment of this disease is elimination. The author was at one time acquainted with a very successful old French physician of whom it was widely claimed that he never was known to have lost a case of scarlet fever in any epidemic, however severe. He had no hesitation in stating that his success was due to the fact that he induced perspiration as soon as possible after the diagnosis of the disease, and kept as free action from the skin as was consistent during the entire course of the disorder. When the initial fever was established he would wrap the patient to the neck in a cool wet sheet—not cold—and then in dry flannel blankets. The result of this was a reaction and a development of warmth from the body heat and a free perspiration, which was maintained mildly for perhaps two hours. Dry clothes were then put on warm and enough covers with warm drinks to sustain a fair transpiration for some hours. If the temperature would increase and the skin become dry again within twenty-four or thirty-six hours the wet sheet was again applied. This was done during the period of the fever. The course of every phase of the disease was much more rapid than usual under this treatment, the final abatement of the fever and of the desquamation was more quickly induced. An almost entire absence of complications, especially of those of the kidneys, was the doctor's constant boast.

Notwithstanding the sentiment against the belief and the argument that it is inconsistent with the accepted theories of the origin of the disease, I have on many occasions given small doses of belladonna four or five times daily to children thoroughly exposed in a family where one was very ill from the disease, with the result that no other case occurred in the family. This I did during one severe epidemic in a family of six children where all were supposed to have had the same exposure. One was attacked. The others were treated freely, but there was no disinfection. The remaining five escaped. I invariably advise the measure as prophylatic and have seldom known the disease to develop where it was used. Its action in this line, if any, is difficult of explanation, but my own conviction is that of many others who have adopted the same course. Ten drops of the ordinary tincture of belladonna in four ounces of water, a teaspoonful before meals and at bed time, is the proper dosage for children under ten years of age. For infants, half teaspoonful doses will be sufficient.

In any case the pulse nearly always indicates aconite. It is hard, wiry, sharp, staccato like and unusually rapid; from 140 to 170. A pathological characteristic of this disease is congestion, first of the skin and later of the various organs. Belladonna is so actively opposed to congestion that it must not be omitted. There is a marvelous harmony of action between these two remedies in small frequent dosage in scarlet fever. In no remedy is a dual action more apparent than in belladonna. With the homoeopathists this is the characteristic similimum of this disease. Certain it is, and confirmed by sufficient experience, to permanently establish it in its position, that belladonna is of great service here. Five drops each of the tinctures of aconite and belladonna in a glass with sixteen teaspoonfuls of water should be given from the onset of the fever in teaspoonful doses every hour, or in half teaspoonful doses every half hour in cases with severe initiative. In this dose belladonna rather stimulates the secretions than diminishes them, and the aconite in every way favors increased secretion. If the skin is very dry, jaborandi in small doses may be given. It will increase all secretions. Rhus toxicodendron is indicated in this disease by the dark red or livid appearance of the skin, especially if the mucous membranes of the mouth are red and the tongue is red and glazed or narrow, pointed, and dark, with a brown coat and other evidences of typhoid with offensive breath, offensive discharges and rapidly failing vitality. It soothes cerebral irritation and controls delirium, inducing quiet and rest. There are certain eye symptoms occasionally present, when this remedy is of signal service. These are injection of the conjunctivae, swelling of the palpebrae, extreme lachrymation and photophobia. The remedy acts in harmony with baptisia, which may be administered with it for the same indications, especially in scarlatina maligna.

Other remedies found useful in the various phases of this disease are lobelia, myrica, capsicum, ailanthus and sticta. Dr. Pike a few years ago was enthusiastic concerning the action of sarracenia, claiming that this remedy would meet all indications alone. Dr. Peart of England gave small doses every hour of the ammonium carbonate in three hundred cases of this disease and claimed success in every case. It stimulated the action of the kidneys and skin and induced rest and sleep. It developed the rash readily, especially where there was a recession of the eruption.

If the above remedies are judiciously selected and free elimination is sustained from the start, especially from the skin, kidney complications will be avoided. In the treatment of the nephritis action must be prompt and thorough. Heat over the kidneys is the first requisite. This must be applied either dry or by means of a hot compress of salt and water over which a rubber water bag is placed. This must be persisted in day and night until the quantity of urine approaches the normal. This is especially required in those cases where, with no premonitory evidences, there is a sudden suppression of the urine. In cases where nervous irritation is great, gelsemium in full doses should be given unless there is depression and feeble heart action, in which case belladonna is the superior remedy. Prof. Whit-ford's specific and most successful treatment is to give belladonna and santonin alternately in this disease. Ten drops of the official tincture of belladonna or three drops of specific belladonna in two ounces of water in dram doses is alternated every two hours with dram doses of a mixture of twelve or fifteen grains of powdered santonin rubbed very thoroughly in a mortar with two ounces of syrup or mucilage of acacia. The influence of these remedies is prompt and satisfactory.

Dropsy is best combated with small frequent doses of specific apocynum, or larger doses of the distilled extract of apocynum. This latter form is devoid of the irritating properties of the first. This agent sustains the heart action to a considerable extent, but in cases of extreme failure it should be combined with cactus, digitalis or strychnin, as the indications would seem to demand.

In the treatment of the throat complications the internal use of phytolacca, either alone or with the tincture of capsicum, is important. A wash or spray of hydrogen peroxide is excellent. I use as indicated either this or a strong infusion of white oak bark with boric acid as a gargle, or dram doses of a solution of dilute sulphurous acid in simple syrup, which contain from five to ten minims to the dram. The tincture of the chlorid of iron, from five to ten minims, largely diluted, is of value in sore throat, and for its influence on the anaemia, and especially if septicaemia or pyaemia complicate. If these latter conditions are pronounced echinacea must be given also. This remedy will be found of service in warding off toxemia from any cause.


The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.



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