Definition.—Scarlet fever, or scarlatina, is an acute contagious disease of childhood, characterized by a bright, scarlet-colored, punctiform eruption, diffused over the entire body; by an angina more or less severe; by a fever so variable in character that it may only be detected by the thermometer, or so severe as to rapidly destroy life, the thermometer registering higher in this than in any other fever; and by a marked tendency to nephritis, the disease finally terminating' by desquamation of the skin.
History.—The early history of scarlet fever is not very reliable, as it was for a long time regarded as a variety of measles, and the first definite and distinctive name that gave it as a separate and distinct disease must be credited to Sydenham, who carefully studied its characteristic features and clearly separated it from the other exanthemata.
Early writers—viz., those of the Italian school—may have used the term scarlatina, yet it is very doubtful if it was applied to this distinctive fever.
From the time of Sydenham, 1685, till the present, scarlet fever has prevailed, progressively increasing as the years have passed, until to-day it has become endemic in all the large cities of the world, while epidemics of varying severity have visited, from time to time, Europe and America.
The disease may occur sporadically or as an epidemic, and, though essentially a disease of childhood, no age is exempt. It is the most severe and fatal of all the exanthematous fevers. One attack renders the patient immune.
Etiology.—Ever since scarlet fever became isolated as a specific disease, the medical profession has been studying the nature of the poison, and yet the materies morbi has elusively escaped the search of the student.
For thirty years the bacteriologist has sought in vain for a micro-organism as a cause of the contagion, and though several observers have found, what seemed at first, satisfactory evidence of a specific germ, closer investigations have revealed their mistakes.
Klein thought he had, discovered the poison to be due to a disease of the cow. An epidemic of scarlet fever broke out in London in December, 1885, and the outbreak could be traced to the milk supplied by a herd in Hendon. The cows were affected by a peculiar disease which he believed to be scarlet fever, and he discovered from the discharges that occurred from the ulcers on the affected cows, a micro-organism which he believed to be identical with the micro-organism which he had found in the blood of human scarlet fever patients.
C. B. Brown's investigation, however, showed that milk from other herds affected with the same disease did not cause scarlet fever, and that milk from the Hendon herd must have been contaminated by scarlet fever existing in the neighborhood. So of other animals that have conveyed scarlet fever, they have only been the media of conveying the disease from one person to another.
All that we know positively is, that there is a specific infection, that it is volatile, minutely divisible, and diffused so quickly that it spreads from one to another with marvelous rapidity.
It possesses great tenacity and vitality, and may reproduce itself in a favorable soil after lying for years. Thus Hildebrand's coat is said to have transmitted the disease eighteen months after it had been in contact with scarlet fever, while Boech reports a case in which two children of a physician contracted scarlet fever by playing with locks of hair which had been cut from the heads of two children who died from scarlet fever twenty years before, the hair having been enclosed in a drawer during the interim.
The infection is found in the expired air, the secretions and in the epidermis. It fastens itself upon the clothing, furniture, drapery, toys, letters, flowers, hair, in fact anything animate or inanimate that comes in contact with it. It may be carried in a letter written in the sick-room to one many miles distant. All that seems necessary to contract the disease is to come in contact, for ever so brief a period, with the impregnated air or body upon which the infection is found.
It is probably most contagious after the eruption makes its appearance and during the period of desquamation.
Predisposing Cause.—Age.—While no age is exempt, it is essentially a disease of childhood. Infants are not so liable to contract the disease, although cases have been recorded where the child was born with it. The ages most susceptible are between two and eight years. After ten the susceptibility diminishes, very few indeed contracting the disease after reaching adult life.
The great value of isolation is thus seen; for if one can protect the child until he is ten years old, but little danger exists. Neither sex nor race seems to influence the predisposition. Social position seems to have but little influence, the rich and favored suffering alike with the- poor.
Season.—Autumn and winter show a greater number of cases than spring and summer.
Wounds.—Open wounds, either accidental or surgical, increase the susceptibility to the poison.
Pathology.—There are no characteristic or specific changes to record, the changes which do take place in the viscera being-the same as are found in all fevers of an intense character. The blood is dark, diffluent, and does not coagulate readily, owing to a defect in the fibrin.
Should death be delayed to an advanced stage of the disease, it is usually the result of septicemia, nephritis with dropsy, or the result of an endocarditis, pericarditis, or meningitis.
The eruption is due to the hyperemia of the skin during the dermatitis, and disappears after death, except in those malignant cases where the eruption failed to appear during life, and appears upon the death of the patient, confirming the diagnosis.
The change which takes place in the throat resembles that of simple inflammation, tonsillitis, or cynanche maligna. In some, only the superficial tissues are involved, as may be seen by the vivid redness, while in others the inflammation assumes a phagedenic character, dipping down into the deeper tissues, which, sloughing, reveal ragged and foul-looking ulcers. Extending to the deeper tissues of the neck, large abscesses may form. The cervical glands become involved in the malignant form, and occasionally suppurate, leaving ugly, cold abscesses.
Where the angina is severe, there may appear early a membranous exudation, pseudo-diphtheria; but if the exudation does not occur for a week or ten days, it is usually true diphtheria with its attendant symptoms. The kidneys present the characteristics of acute nephritis or Bright's disease. (See Bright's Disease.)
Symptoms.—The symptoms of scarlet fever depend largely upon the form or variety. In some cases the disease is so mild as to require considerable skill in recognizing it, while in others it will be so severe as to destroy life in thirty-six or forty-eight hours. This great diversity of symptoms has led authors to divide the disease into three varieties: Scarlatina Simplex; Scarlatina Anginosa; and Scarlatina Maligna.
In some seasons the disease will prevail in the simple form, while another season will reveal all of the anginose form, or the epidemic may show the most malignant type.
Incubation.—The period of incubation varies from two to eight days, though the average time is from four to five days; but where the disease is intense it may not be over twenty-four hours. Prodromal symptoms are usually absent, though the child may show slight indisposition.
Invasion.—The invasion of the disease is sudden. Frequently the chill is the first evidence, followed by a high fever, and very grave symptoms are present in a few hours. Again in highly sensitive children a convulsion will mark the beginning of the disease. Either case is usually accompanied by vomiting. The pulse is very rapid, the temperature rapidly increases, and the child complains of great heat, which is pungent in character.
The angina very early develops, and, even where the child has not complained of pain, an inspection of the throat will reveal the fauces, tonsils, and uvula a vivid red, with considerable swelling and the sensation as though something was filling or obstructing the throat. In the simple form these symptoms are not so marked.
In twenty-four or forty-eight hours, though it may be delayed to the fourth day, the eruption appears upon the neck and chest, soon extending over the entire body. The exanthem consists of an infinite number of punctate points surrounded by an erythema that gives the bright scarlet color from which the disease takes its name. There is no cessation in the fever with the appearance of the eruption, as in other fevers. The eruption remains from two to six days, gradually fading away, and is followed by a branny desquamation.
Anginosa.—Dr. Scudder has given so realistic a picture of this form that I will quote him in full: "In S. anginosa, the chill is usually marked; there is nausea and vomiting, pain in the head and back, thirst, etc. The fever which follows is intense; the skin is dry, husky, and burning; the eyes dry and painful; the face congested and tumid; bowels constipated; urine is scanty, frequently voided, high-colored, with marked irritability of the nervous system. Soreness of the throat is complained of from the first, with difficult deglutition, and, on examination, we find the fauces tumid and red and the tonsils somewhat swollen. The nares are frequently implicated with the angina, and there is consequently stuffing of the nose, with difficult respiration, and consequent increased restlessness.
"The eruption sometimes makes its appearance during the latter part of the first day of the fever, but, more frequently, not until the second or third day, and about the third or fourth day it has reached its height. At the commencement, there appears slight tumefaction of a portion of the surface, which gradually assumes a rose color, and the minute red points are developed. These patches increase in size until the greater portion of the surface is involved. During the eruption there is an expression of anxiety and suffering; the child is restless, uneasy, and sleepless, which resists the usual means of rest, is caused by the heat and stinging of the surface, and soreness of the throat.
"The throat affection is here the most prominent feature; the soreness increases, the mucous membrane and subjacent tissues are engorged and tumid, and the secretion from the mucous follicles and salivary glands is so viscid and tenacious as to cause great distress. In some cases ulceration commences by the fifth or sixth day of the disease, and the secretion is difficult of removal and exceedingly offensive; occasionally the ulceration assumes a phagedenic form, and speedily terminates the life of the patient. Frequently enlargement of the cervical lymphatics commences from the third to the sixth day, and, if not promptly treated, terminates in inflammation and suppuration.
"The fever, under appropriate treatment, commences to abate when the eruption has made its appearance, and disappears entirely by the fourth or sixth day, when desquamation commences. As this progresses, the surface becomes paler, the epidermis exfoliating in whitish scales, or in large pieces where it is thick; sometimes desquamation is retarded for two or three weeks."
Scarlatina Maligna.—Some seasons, for reasons unaccountable, scarlet fever appears in a malignant form. Such an epidemic occurred in the winter of 1879 in the little village of Harrison, Ohio, nearly every case resulting fatally, and this was my first introduction to scarlet fever. So intense was it, and so fatal in its results, that I have ever had a dread of this disease, and when scarlet fever appears, there rises before me a picture of that epidemic of 1879.
We may divide this variety into two forms,—the nervous, and the excessively toxic. In the first form the child is suddenly stricken; the chill is short and the febrile reaction extreme. The skin is intensely hot, dry, and pungent; the mouth is dry and parched; the eyes are brilliant and burning; the face is turgid; the head is hot and painful; the throat becomes dry, tumid, and swollen; the patient is restless and delirium early ensues. There is nausea and vomiting of a persistent character; convulsions are the rule.
Within twenty-four hours the intense excitement gives away to stupor. The child lies with the eyes partly open, the pupils are dilated, the surface seems dusky and swollen, the temperature reaches 104° to 105°, the pulse ranges from 160 to 170 beats per minute, and within thirty-six to forty-eight hours death ends the scene. In this case, if the eruption appears, it is a dingy red, and appears slowly, though the patient may succumb before it shows itself upon the surface.
In the second form, the disease is but little less fatal, though not so rapid. There is great prostration from the beginning. The chill is greatly prolonged, febrile reaction coming up slowly, the evidence of extreme sepsis being seen from the beginning. The child is dull and stupid, and the countenance vacant and besotted. The face is dusky or turgid and the heat of the body pungent, though the extremities are inclined to be cold. The tongue is broad and heavily coated, or dry and parched. Nausea and vomiting frequently occur, and diarrhea is common. The urine is highly albuminous.
The throat affection is characteristic; at first dry and tumid, it soon shows a dirty, moist exudate, so that it is not infrequently taken for diphtheria. The deeper tissues become infiltrated, and a foul phagedenic ulceration is seen. The nares becomes involved, and an acrid secretion is discharged.
As the sepsis increases, a cellulitis develops, the cervical glands enlarge, the neck becomes greatly swollen, extending in some cases beyond the ears. The eyes are glued together with a brownish secretion, while the ears discharge the same characteristic material. The system seems to have more of the poison than it can carry, and the overflow escapes by way of the orifices.
The cervical glands suppurate, and a disgusting, pultaceous abscess is the result. The extremities become cold, the pulse is small, weak, and rapid, the mind is dull, coma comes on, and the child dies from toxemia.
The eruption, when it makes its appearance, is of a dull, dusky red color. Sometimes it appears as petechise, which, enlarging, form ecchymotic patches. At other times it appears the second or third day, only to remain a few hours, when there is a retrocession of the eruption.
Desquamation.—From six to ten days after the eruption first makes its appearance, desquamation begins. The eruption fades, the skin becomes dry and constricted and is shed in the form of dry, bran-like scales. Sometimes it comes off in large flakes or even in ribbon-like strips a foot or more in length, and in rare cases, where the epidermis is thick, like on the hand or foot, a complete cast of the member is shed.
Desquamation lasts from ten days to ten weeks.
Complications.—In scarlet fever, diphtheria, measles, and influenza, the middle ear is often affected by extension through the Eustachian tubes and the process may also affect the labyrinth.
In quite a number of cases the labyrinth is affected directly by the systemic poison, the middle ear escaping any morbid inflammation whatever. (Foltz.)
Respiratory Apparatus.—The inflammation may pass from the throat to adjacent parts of the respiratory apparatus, and bronchitis or broncho-pneumonia may render the disease still more serious. Nephritis is a very common complication, though more frequently it is one of the sequelae.
Post Scarlatinal Nephritis is the most serious of all the results of scarlet fever. This may occur from the first to the fourth week after convalescence, though many times it comes on so insidiously that it is difficult to trace its beginning. Albumen is found in the urine, and the child is inclined to be dull and lifeless. The skin is dry and more or less constricted, the pulse small and wiry, the tongue dry and fissured, the face puffy, and the feet edematous. There is pain in the back and loins, the urine is scanty and high colored.
If the treatment be successful, the urine increases in quantity, is light in color, the skin becomes moist, and soon convalescence is established. In the graver cases, however, the dullness increases to coma, the pulse becomes small and feeble, the extremities are kept warm with difficulty, the temperature is sub-normal, the. tongue is dry and brown, nausea and vomiting ensue, and diarrhea is not uncommon.
Hemorrhages may occur from the mucous surfaces, and muscular twitchings announce the approaching convulsion which often terminates the attack. During the course of inflammation of the kidney there is a tendency to cardiac changes. Dilatation of this heart, or endocarditis, or pericarditis may so weaken the heart that death may occur suddenly and when least expected.
Ear Complications.—One of the serious results of scarlet fever is deafness. The inflammation extending along the Eustachian tube is followed by suppuration and perforation of the membrane. A mastoid abscess is not infrequent. The patient may be left with a fetid discharge from the ear.
Diagnosis.—The diagnosis of scarlet fever is usually, readily made by the rose-colored efflorescence upon which are the innumerable small red points. The eruption is readily effaced by pressure, which leaves a white mark for several seconds before the redness is re-established. The characteristic sore throat and the strawberry tongue are also suggestive.
Belladonna produces a scarlatinal rash, but the history and absence of sore throat will enable one to avoid a mistake in diagnosis. It is distinguished from measles by the absence of catarrhal symptoms and by the irregular eruption commencing on the face and occurring in blotches.
Prognosis.—The prognosis will depend largely upon the character of the epidemic, the previous health and age of the patient, and the complications which may attend the attack. Thus in scarlatina simplex, the prognosis will be favorable, every patient recovering, while the epidemic may show such intense malignancy that nearly every case may prove fatal. For example, in the winter of 1879 in the village of Harrison, Ohio, containing two thousand inhabitants, nearly every child who contracted the disease died. The prognosis is more unfavorable among infants, where nephritis occurs, and where there are cardiac changes. The older the patient the more favorable, the prognosis being just the reverse of measles.
Treatment.—Prophylaxis.—As this is one of the most contagious of all the eruptive fevers, and also the most serious, great care must be exercised to exclude the well members of the family. The child should be isolated and all intercourse with the patient prohibited. All upholstered furniture and unnecessary draperies, as well as carpets and rugs, should be removed from the sickroom.
The nurse should not mingle with the family, and all clothing worn by the nurse and patient, together with the bed linen, should be thoroughly disinfected before others come in contact with the sick-room. During the period of desquamation the patient may be anointed daily with olive-oil, after sponging with warm water and asepsin soap. The rooms should be thoroughly aired each day, care being taken that no draughts be allowed on the patient.
As a prophylactic, the members of the family who have been exposed may take belladonna, although it is questionable whether it possesses the virtue attributed to it as a preventive of the disease. Dr. Webster suggests "the use of echinacea as a prophylactic, or rather as an agent to fortify the blood against sepsis, the tissue against phagedena, and the cerebro-spinal centers against acute morbid changes." The medical treatment for scarlet fever, like that for any other disease, depends upon the conditions present.
In mild cases the treatment is simple. Aconite and belladonna, of each five drops; water, four ounces, teaspoonful every hour. For local throat trouble use a gargle of chlorate of potassium and phosphate of hydrastine. Sponge the patient once or twice a day in warm alkaline solution, which carries off the surplus heat, renders the skin soft and pliant, and favors the eruption. If the child is restless, with flushed face, gelsemium will replace the belladonna. For the itching, nothing serves a better purpose than the old, though crude, bacon-rind.
In scarlatina anginosa greater skill will be required. For the high grade of fever, to assist the sedative aconite or veratrum, the patient should be sponged frequently with warm soda-water. If the stomach will retain jaborandi, this agent will be found useful, one or two drachms to four ounces of water; teaspoonful every hour.
The throat affection is here the most prominent lesion. Cloths wrung out of hot water and vinegar and applied to the throat, over which a dry flannel should be placed, will be found of much benefit. The patient may also inhale the steam from vinegar and hops, which will give relief to the dryness of the throat.
Internally phytolacca and echinacea will be given. A gargle of potassium chlorate and hydrastis will also give relief, or a spray or gargle of echinacea may take the place of the potash. Where there is nausea and vomiting, with the characteristic strawberry tongue, or wmere the patient is restless-and unable to sleep, rhus tox. will be found the best agent. Hydrochlorate of ammonia, in from one to three grain doses, is highly recommended by many, though I have never used it, and can not speak from experience.
In the malignant form of the disease, sepsis is the condition to overcome, and antiseptics will be especially indicated. For the dirty, moist, pasty tongue, a saturated solution of sodium sulphite, both internally and as a gargle, will be our best agent. If there be a foul breath, a cadaveric odor, I know of nothing that will equal potassium chlorate and hydrastis. Where the tissues are infiltrated and dusky, echinacea given internally, used as a spray, and applied to the neck, will give good results. Baptisia may be combined with the latter agent, as the action is similar. Where there is marked dullness, the surface dusky, and the eruption retarded, the old-time emetic of capsicum and lobelia will prove of great value. Where there is enlargement of the lymphatics, phytolacca, twenty to sixty drops to a half glass of water, will be the indicated remedy. Where the face becomes puffy and edematous, apocynum, ten to twenty drops in a half glass of water and a teaspoonful every hour, will give great satisfaction.
The nourishment must be fluid in character, milk being the best food when it can be taken. Great care must be taken during convalescence, the quantity of urine noted, and occasionally examined for albumin. There are so many unpleasant sequelae following scarlet fever that the physician can hardly be too careful during this period.