4. Eruption, typical in character, appearing on second day, first
showing on the neck above the clavicles, intense on the body and
practically absent around the mouth. Eruption confluent, with no
intervening free areas of the skin, followed by desquamation.
5. Lymphadenitis much more pronounced in the inguinal and other glands
than in the cervical.
6. Desquamation, tender joints and albuminuria will force the
conclusion of scarlet fever, if former symptoms have been indefinite.
In the atypical cases we may have very light attacks with all the
symptoms present but very poorly developed; or some symptoms absent
as in cases with no temperature, or others with no rash. Some cases
are so atypical as to be impossible of diagnosis. The writer has very
recently had the experience of one case when there were absolutely
no typical symptoms present after being called on the case, but four
days after the invasion of the disease in the patient a sister of
the child developed typical scarlet fever, and not until the sixth
day did any eruption or sore throat appear, and then the eruption
was more characteristically measles than scarlet fever. Consultants
with the writer agreed with him that the case was one of an atypical,
non-eruptive scarlet fever.
=Differentiation.=—Scarlet fever is not always easily differentiated
from other diseases, such as a septic rash, drug rashes, diphtheria,
measles and German measles.
A. R. Edwards gives this differentiation between scarlet fever and
septic rash.
=Scarlet Fever= =Sepsis=.
Bright red erythema, with small A very deep purple-red rash,
red papules. sometimes spreading over the
entire body.
The eruption is much the same in
both diseases, the same places
being exempt.
Miliaria are rare. Miliaria are frequent.
Rather typical desquamation. Desquamation observed less
frequently.
CRITERIA: angina, tongue, onset, Etiology, chills, sweats, fever
glands, etc. irregularity, polymorphous
exanthems, etc.
=Diphtheria.=—Often difficult to differentiate. The simple erythema is
sometimes observed in diphtheria, but is darker, more on the trunk, and
more transitory than in scarlet fever.
=Drug Rashes.=—These rashes are caused by belladonna, iodoform,
quinine, iodide, chloral, copaiba or aspirin. They may be easily
differentiated if the cardinal symptoms of scarlet fever are considered
instead of the rash alone. At the present time, perhaps the most
frequent drug rash that we meet is that produced by aspirin. It is
sometimes hard to diagnose because the aspirin has been taken for a
sore throat or tonsillitis, which so resemble the early symptoms of
scarlet fever.
=Measles and German Measles.=—The symptoms of the invasion stage of
these diseases is sometimes quite similar, and even the rash may be
quite similar; the differentiation will be discussed under measles
(q.v.).
=Types and Forms.=—(a) Mild and abortive form (scarlatina sine
eruptione). In this the rash may be scarcely perceptible, while the
fever, sore throat and strawberry tongue are present. Desquamation may
be present and it may be followed with a severe nephritis.
(b) Malignant forms, (1) Atactic variety, violent intoxication, onset
of great severity, fever very high (107° to 108°), extreme headache,
delirium, and often convulsions. Initial delirium gives place to coma;
dyspnea may be urgent; pulse very rapid and feeble; and death occurs
before eruption appears. (2) Hemorrhagic variety: there are hemorrhages
into the skin, beginning with scattered petechiæ, becoming more
extensive and ultimately involving the whole skin. It is characterized
by severe fever and brain symptoms at the onset; incomplete exanthem,
necrosing angina, marked glandular and splenic swelling; subcutaneous,
serous and mucous membrane hemorrhages with ulceration. Death may take
place on the second or third day. This is more common in enfeebled
children, although it may attack adults in apparently full health.
(c) Anginose form (Scarlatina anginosa.) This form resembles septic
diphtheria, with marked toxemia, necrosis and adenitis. The throat
symptoms appear early and progress rapidly. Temperature high, cyanosis,
diarrhea, rapid weak irregular pulse, and stupor occur. The fauces and
tonsils are covered with a thick membranous exudate which may extend to
the posterior wall of the pharynx, forward into the mouth, upward into
the nasal chambers, and may occasionally reach the trachea and bronchi.
The Eustachian tubes and middle ear are usually involved. The glands of
the neck rapidly enlarge and become the seat of brawny induration, and
the inflammation extends beyond their limits. Necrosis occurs in the
tissues of the throat, fetor is extreme, the constitutional symptoms
are great and the child dies of toxemia. If he does not die, extensive
abscess formation in the tissues of the neck takes place with sloughing
and danger of hemorrhage from the opening of a large artery.
=Blood Pressure.=—Rises at first, thereafter it follows the pulse
and temperature. After the seventh or eighth day it may be below
normal. Cases of albuminuria show hyperextension and slowing of heart
action. With the subsidence of the kidney irritation the pulse-rate is
increased and the blood pressure returns to normal.
=Urine.=—Shows ordinary febrile character, being scanty and high
colored. Slight albuminuria is rather common after the stage of
eruption, even a few tube casts may be present without any serious
irritation of the kidneys. Urinalysis should be made daily.
=Blood.=—The red cells are moderately reduced to 3,000,000 or 4,000,000
per c. mm. during convalescence. There may be some poikilocytosis, and
normoblasts are occasionally seen. Leucocytosis is early, 15,000 to
30,000 per c. mm., falling with the decline of the fever usually by
the fourteenth day, but may persist for weeks after the temperature is
normal. The count runs roughly parallel to the temperature. Over 40,000
leucocytes per c. mm. are of bad prognostic omen. Polymorphonuclear
cells are increased to 80% or 90%; early returning to normal in
favorable cases.
Eosinophilia is present in all but malignant cases. It reaches its
maximum two or three days after the rash appears and returns to
normal after the leucocytosis has disappeared. The early presence of
eosinophilia excludes septic conditions. When these cells are absent in
scarlet fever, myelocytes are to be found.
=Treatment.=—Clinically scarlet fever represents, from the osteopathic
viewpoint, (a) a toxic condition due to internal malnutrition and
a decrease of the detoxinating function of the thyroid gland; (b)
secondarily associated with the sore throat is a type of toxic
tonsillitis, but it is due to the toxic elements in the blood; (c) in
the lesion field it is associated with extreme stiffness and muscular
tension in the upper cervical area and also in the entire dorsal
area, overlapping the upper lumbar. The eruption is a superficial
expression of the attempt of the body to eliminate the toxins, and
this elimination should be aided by enhancing the activity of all the
other eliminative functions. Cases are on record where patients have
been exposed to scarlet fever, have gone the usual incubation period
and developed the invasion symptoms, and by thorough, oft-repeated
osteopathic treatments, with the aid of enemata and copious hot water
drinking, have not gone beyond the invasion period and the disease
apparently aborted within two or three days. It is therefore well to
give thorough, oft-repeated attention to these cases during the very
early stages.
(1) In all cases where the first symptoms indicate the possibility of a
contagious disease, the patient should be immediately isolated and kept
isolated until all danger of contagion is past. In scarlet fever cases
get a competent nurse. Keep room light, quiet and thoroughly ventilated
with a constant temperature of as nearly 70° as is possible. (It were
better to have two rooms if possible, one for day and one for night:
have room or rooms on upper floor if in a house). Arrange suitable
means for thorough disinfection of all articles used in the sickroom.
These are very essential.
(2) Patient should be clothed in usual night wearing apparel. The bed
clothing should be warm, but not heavy. The physician should wear an
operating gown or a sheet which thoroughly covers his clothing, also
a cap. He should carefully wash his face and hands immediately after
leaving the sickroom. The quarantine should be maintained for the
legally required period, and even after if there continue discharges
from the nose, nasopharynx or the ear. Bichloride wrappings should be
placed about the body of the dead, and funeral must be private.
(3) Have enema given immediately to cleanse the lower bowel. Follow
this with frequent draughts of hot water, or better hot lemonade for
the first day. Place hot water bottles at feet. If eruption is slow in
coming out, it may be aided by a hot bath, followed by wrapping the
patient in warm blankets to prevent chilling.
(4) Thorough osteopathic treatment should be given along the entire
spinal area from the atlas to the sacrum, inclusive, to keep the
muscles well relaxed, giving special attention to the relationship of
the vertebræ and the tension of the muscles from the occiput to the
fourth cervical; the third to the sixth dorsal; and the tenth to the
twelfth dorsal areas. Also give special attention to the deep cervical
muscles, particularly those at the angle of the inferior maxilla, and
at the articulation of the inferior and superior maxillæ. Remember the
tendency of the kidneys to complication in scarlet fever, therefore
do not neglect the renal splanchnics, for here you not only control
the renal functions but also regulate the adrenal functions and
their internal secretions. Keep the clavicles properly adjusted and
articulate them by bringing them well forward to relieve any irritation
that may have started in that area. Careful direct treatment to the
abdomen should usually be given at each visit besides the work in the
splanchnic area to keep the bowels, kidneys and liver active.
=Diet.=—Water must be given freely. If fever is very high, pellets
of ice held in the mouth will give comfort. During the height of
the fever it is preferable to withhold all nourishment, but if in a
particular case it seems to be indicated, confine the nourishment to
fruit juices, especially oranges. Never force feeding during the fever.
For infants cut down their feeding to at least half, making the milk
very thin with water or gruel. After defervescence, carefully increase
to a light diet using sparingly of nitrogenous foods except milk. After
four weeks in the usual case, gradually return to the ordinary diet.
This is a good time to make corrections in the ordinary diet if any are
needed.
The =bowels= must be kept regulated. An enema is usually indicated
after the onset of the disease. During the time that food is permitted
it should be of a laxative character. During the fever stage the enema
should be given daily to help keep the bowel cleansed and to help
reduce the temperature. If bowels are persistently sluggish and the
fever is constantly high the abdominal heating compress (so-called
“cold compress”) will give much relief.
The =nose and throat= should be constantly looked after. The nose may
be cleansed by instillation by means of a medicine dropper, using
normal salt solution. If the throat symptoms are mild, a gargle of warm
normal salt solution is enough for cleanliness of the membrane. If the
throat symptoms are too severe to permit the use of the gargle, or if
the patient is too small to be taught the use of the gargle or to wash
the throat, irrigation may be employed. The use of raw lemon juice, or
of raw pineapple juice, on a cotton swab is of great value in cleansing
the tonsils and throat. The swabbing should be repeated several times
per day.
The =teeth= should be carefully and thoroughly cleansed twice per day.
The =skin= must be constantly cared for. During the fever it is well
to cover the skin with linen or soft cotton. Daily sponge baths of
carbolized water (1:40) of tepid temperature followed by applications
of cocoa-butter will give much comfort. Use only good toilet soap and
do not use the so-called antiseptic soaps because, authorities claim,
there is a chance of renal injury. During the period of desquamation
the use of the cocoa-butter will assist in limiting the source of
infection by preventing the diffusion of the dry scales which are
considered infectious by many physicians. A. R. Edwards says: “During
desquamation, oil-rubs were once employed to decrease the dissemination
of dry scales, but they decrease the function of the skin, which is
of great importance when the kidneys are involved; also, infection is
carried by means of throat secretions. Soap and water serve equally
well.” Some authorities suggest that during the desquamation, after
bathing the patient, the skin should be thoroughly rubbed and then the
oily application used, using cocoa-butter, unmedicated cold cream,
liquid albolene or the like. Olive oil and vaseline are usually
irritating. The writer inclines to the opinion that the soap and water
bathing is sufficient, except perhaps the use of cocoa-butter over the
areas that are desquamating severely.
The =temperature= can usually be controlled by the usual osteopathic
methods; steady deep pressure applied in the suboccipital region for
a few minutes, followed by relaxing the muscles of the back from the
first to the eighth dorsal, by raising and spreading the ribs in the
mid-dorsal area, and by light inhibition over the solar plexus. The
tepid enema will assist in lowering the temperature. If temperature
is high and patient is delirious and has other nervous symptoms the
cold pack is useful. The ice cap may be used almost constantly in high
fever. If glands are swollen treat by crowding the tissues toward the
gland =but never work upon the gland itself=.
If pain is felt in the =ear= immediate attention must be given it.
Correct any deviations of the atlas or other upper cervical vertebræ,
relax the deep muscles at the angle of the jaw, and relieve any
impingements in the lower cervical and upper dorsal regions. The
ear should also be treated with copious boric solution irrigations,
as hot as can be borne and at low pressure. The condition of the
ear drum membrane must be watched daily and if there is bulging and
congestion it is safer to puncture the drum under cocaine than to await
spontaneous rupture. Use small amount of boric powder after rupturing.
The =heart= must be examined daily. Vigorous treatment through the
thoracic region is indicated, if cardiac symptoms appear, and the
patient must be kept quiet and in bed. If heart seems feeble it may be
well supported by the cold packs directly over the heart.
=Nephritis= is most common in the second and third weeks of the
illness, but may develop later. In all cases where any symptoms of
nephritis appear, light or severe, the patient must be =confined to
bed= for at least four weeks, and kept on a milk diet. All irritants
must be absolutely avoided. Hot baths should be given twice daily to
increase the sweat and the urinary functions, the bath lasting half an
hour and the patient kept afterward between blankets. Treat thoroughly,
daily, the splanchnic and renal areas, paying particular attention to
the tissue conditions in the lower dorsal region.
In the milder cases, the urine contains albumin and a few tube casts,
very rarely blood, and edema is slight or transient. Though the
patient improves, he remains pale and there is a slight trace of
albumin in the urine for months. If recovery does not take place, then
chronic nephritis becomes established.
In the more severe cases there may be a puffy appearance of the
eyelids, slight edema of the feet, urine diminished in quantity, smoky,
containing albumin and tube casts. The kidney symptoms dominate, dropsy
persists and there may be effusion into the serous sacs. The condition
may become chronic, the patient may succumb to uremia, but in the
majority of cases recovery takes place.
The nephritis may be hemorrhagic, in which the urine is suppressed or
there may be a very small amount of bloody fluid laden with albumin and
casts; constant vomiting and convulsions follow and the patient dies
with symptoms of acute uremia.
Other =complications= are arthritis, malignant endocarditis,
severe toxic myocarditis and acute phlegmonous inflammation, the
last three of which are usually fatal. Chorea is a fairly frequent
nervous complication. The mental symptoms are mania and melancholia.
Progressive paralysis of the limbs with wasting, may simulate infantile
paralysis. The fever may persist after the eruption disappears and the
child remain in a septic state (scarlatinal typhoid).
=Relapses= are rare. Scarlatina may coexist with almost any other acute
infection. It lowers the resistance of the body to disease and is often
followed by other acute infections or by tuberculosis. Therefore the
necessity of care during the entire convalescent stage.