(SCARLATINA)
=Definition.=—Scarlet fever is an acute, specific, contagious,
infective disease of unknown origin, characterized by very sudden
onset, fever, vomiting, sore throat and diffuse exanthem.
=History.=—It was first recognized in the sixteenth century, but first
fully described and differentiated from measles by Sydenham in 1660. It
was introduced into America about 1735.
=Etiology.=—The causative organism or agent is unknown. The virus
of scarlet fever produces severe necrosis, but no suppuration. The
streptococcus is the most important factor in the production of
complications and in their mortality. It is claimed to be the cause
of the malignancy of the disease but not of the disease itself.
Susceptibility to the disease is by no means universal as only 38% of
children and but 5% of adults exposed to the infection acquire the
disease. Over 90% of the cases occur under ten years of age, and rarely
during the first year of life.
“Scarlet fever is a toxic superficial expression of internal
malnutritive conditions of the blood as a tissue. The cause of the
toxicity is usually overfeeding, or the feeding beyond the demands
of the proximate principles of the body, or the overfeeding under
unhygienic conditions.—J. MARTIN LITTLEJOHN.
“It was once held that the virus was disseminated during desquamation,
but oral, nasal and otitic discharges probably perpetuate the
infection, perhaps months after scaling is complete. In no other
disease is the virus so tenacious. It may persist ten years on clothes,
furniture, etc.”—A. R. EDWARDS.
The light forms are as contagious as the severe ones, and inoculations
have occurred from the living subjects as well as from autopsy cuts.
In degree of infectiousness smallpox ranks first, measles second and
scarlet fever third. The infection may be spread by any third person
or by articles coming in contact with the patient, and often the mode
is obscure. Sporadic cases apparently frequently appear. The reason
for the sporadic cases may easily be explained by the theory of J.
Martin Littlejohn, given above. One attack usually confers immunity,
but not always. This disease occurs more often in the autumn and
winter, and is more prevalent in cities than in the country. (Measles
is more prevalent in the country.) Scarlatina sometimes occurs with
other infections, such as diphtheria or measles, and more rarely with
varicella, pertussis, etc.
=Predisposing Factors.=—Age, one to ten years; lowered resistance from
overfeeding, unhygienic environments, exposure to sudden temperature
changes; lesions, both muscular and interosseous which interfere with
the distribution of the fluids and vital forces of the body; season of
the year (autumn and winter); puerperal women, and wounds.
=Pathology.=—No specific lesions are found. No trace of the rash shows
after death except in the hemorrhagic form. The anatomical changes in
cases coming to autopsy are those of simple inflammation, follicular
tonsillitis, or diphtheroid angina. Streptococci are abundantly found
in the glands and foci of suppuration.
=Symptomatology.=—Scarlet fever is divided into four stages: (1)
Incubation, (2) Invasion, (3) Exanthem, (4) Desquamation.
=Incubation Stage.=—Has no noticeable symptoms and lasts from two to
four days. Some authors claim as high as ten to fourteen days.
=Invasion.=—The invasion lasts one day. The onset is very sudden
beginning with a chill which is followed by a characteristic vomiting,
occurring in 75% of the cases, which is more frequent than in any other
disease of childhood except pneumonia.
The vomiting is followed by headache and the beginning evidence of sore
throat, which usually soon develops into a tonsillitis. The severity
of the sore throat is indicative of the severity of the scarlet fever
that follows. The temperature suddenly rises to 103° or more, the
pulse becomes unduly rapid for the temperature, 120 to 160 per minute,
and the respiration is increased. The skin begins to burn, there is
dysphagia and intumescence of the cervical glands. The muscles of
the back become hypersensitive to touch and to extremes of heat and
cold; and particularly sensitive spots are found over the transverse
processes of the first to 4th cervical vertebras, the 4th and 5th
dorsal and the 11th and 12th dorsal vertebras. At these points will be
found intensely contractured tissues which must be kept relaxed.
=Exanthem.=—The eruption appears at the end of the first day or early
the second day, showing first over the clavicles and on the neck, then
over the upper trunk, next the lower trunk and limbs. The eruption
on the extremities appears particularly over the flexor surfaces of
the joints. By the end of the second day the eruption has covered
practically the entire body, leaving a white circle about the eyes and
mouth. The eruption pales, or disappears on pressure, quickly returning
to the scarlet color on the removal of the pressure. Frequently, the
skin itches and is very uncomfortable.
A punctiform eruption in the arm-pits, over the groins, or on the roof
of the mouth is considered positive proof of scarlet fever.
The eruption at first consists of small red spots which fuse as the
skin swells and results in an intense lobster-colored erythema. This
lasts four to six days. The tongue, at first, is red at the tip and
margins with a greyish-yellow or whitish fur in the center through
which is often seen the swollen red papillæ, the “strawberry tongue.”
The “fur” desquamates on the third or fourth day, leaving a surface
intensely red with marked raised, swollen papillæ, the “raspberry
or cat tongue,” which lasts nearly a week. The breath has a heavy,
sweet odor. The pharynx, uvula and tonsils become swollen, and often
creamy-white patches cover the mouths of the tonsillar follicles.
Between the second and third day the eruption reaches its height, when
it has a vivid scarlet hue unlike any other eruption, and becomes
darker each day until it may be a bluish-red, when it gradually fades
and desquamation begins. By the seventh or eighth day the rash has
disappeared, together with the fever.
=Desquamation.=—Scaling begins on the face first, from the sixth to the
ninth day and lasts several weeks. The skin looks somewhat stained,
is a little rough like “goose-flesh” and gradually the upper layer
begins to separate, and the scaling begins in large lamellæ or flakes.
Casts of the fingers or toes may be shed. The swelling of the glands
disappears, and the fever falls by lysis, and convalescence begins,
unless complications intervene.
=Diagnosis.=—In typical cases diagnosis is easy, especially during
epidemics or when the eruption is accompanied by other criteria.
1. Sudden onset, with nausea and vomiting, sore throat, quick
appearance of fever and rapid development.
2. Punctate spots in the throat, swelling and dysphagia are usually
present. The severe sore throat symptoms with the above are always very
suspicious.