_Of Scarlatina. Characters by which it is distinguished from Continued
Fever, without an Eruption. Division into Scarlatina Synochodes and
Typhodes. Events which occasionally occur in Fever, but which form
no essential Part of it._
The only kind of continued fever attended with an eruption, which it
falls within the compass of the present work to notice, is that of
scarlatina, and, even in relation to this, after the full account which
has been given of the other forms of fever, it will be necessary to
state only the peculiarities by which it is distinguished.
1. The depression of the nervous system so characteristic of synochus
and typhus, is much less in degree in scarlatina. Neither the physical
nor the mental debility is as great. In the whole attitude and manner of
the patient, as well as in his own sensations, there is less
prostration. The disease is more nearly allied to a pure inflammatory
affection than either of the preceding forms of fever.
2. Accordingly, the circulation is not only more rapid, but it is also
more strong. It is not uncommon for the pulse to be 140 in a minute; in
severe cases it is seldom below 120. Without being hard, it is more full
and strong and less easily compressed than in the other forms of fever.
3. Corresponding with the activity and energy of the circulation is the
increase of the temperature; the heat over the whole surface of the body
is often intense and pungent. In this fever, the temperature, as
indicated by the thermometer, rises several degrees higher than in any
other.
4. The capillary vessels of the external skin, as is shewn by the bright
and vivid colour of its characteristic eruption, are filled with blood.
Often from the crown of the head to the sole of the foot, the external
covering of the body is in a state of inflammation, and this
inflammation constantly terminates in the death of the cuticle, whence
it is thrown off by the process of desquamation. It is not improbable
that the large quantity of blood which is thus spent upon the surface of
the body, and which is thereby diverted from the internal organs, is one
reason why the latter are not so much oppressed as in the other forms of
fever.
5. Much as the external skin is loaded with blood, the capillary vessels
of the internal skin appear to be equally turgid with it. This is
indicated by the bright and vivid redness of the mucous membrane
covering the mouth, the tongue, the fauces and the throat. That this
redness extends beyond these external parts into the internal organs
there is abundant evidence, because, although we cannot follow it with
the eye, we can trace it by the signs of disordered function which
arise.
6. Certain parts of the internal skin, as it covers particular organs,
is peculiarly apt to pass into inflammation, and to terminate, like
ordinary inflammation, in ulceration. The principal seats of
inflammation are the throat and the larynx; but that, on the one hand,
the inflammation extends from the throat into the stomach, is evident
from the peculiar tenderness of the epigastrium, which is almost
constant in scarlatina, and which is more acute than in ordinary fever;
and that, on the other hand, it extends from the larynx into the bronchi
and their ramifications, is evident from the symptoms of thoracic
affection, which are at once more prominent and more constant than in
the other forms of fever. The larynx, the cartilages of which are apt to
be destroyed by ulceration, in the severe and mortal cases, is now and
then attacked with a peculiar kind of laryngitis, to be further noticed
in the pathology, which is almost uniformly and most rapidly fatal.
7. From the preceding observations, the new symptoms which are added to
the febrile train in scarlatina, and which arise out of the modification
of the fever by its complication with an inflammatory condition of the
external and internal skin, are easily understood. They are the
following: namely,
Scarlet eruption on the skin; vivid and peculiar redness of the mouth,
tongue, fauces and throat: the presence of the disease may usually be
discovered by this peculiar and specific redness of the tongue and
throat alone, although every other characteristic symptom were absent:
pain in the throat, difficult deglutition, huskiness and hoarseness of
the voice. To these must be added other symptoms, which, though they are
sometimes present in ordinary fever, are both more constant and more
severe in scarlatina than in the latter, namely, pain in the chest,
cough, difficult and hurried respiration, duskiness, in severe cases
lividness of the cheek, often, especially in the commencement of the
attack, nausea and vomiting.
Such are the chief peculiarities by which scarlet fever is
distinguished: in all other respects the condition of the organs, and
the symptoms which denote their disordered state are the same as in
continued fever without an eruption.
Scarlatina occurs under two forms.—1st, With the symptoms common to
synochus, (scarlatina synochodes) a form which, however severe the
symptoms, if properly treated, rarely proves fatal. In general, it is a
trifling malady, and, when severe, its chief danger consists in its
tendency to pass into the second form, if it be neglected, or if it be
badly treated. Under the most formidable aspect it ever presents, if the
active treatment, which, when the symptoms are severe, ought always to
be employed, be resorted to with promptness and decision, in more than
ninety cases out of a hundred, those symptoms are certainly and
effectually subdued, and the disease, although it may not be cut short
at once, is at once rendered mild and safe.
2. The second form of the disease (scarlatina typhodes) presents a
striking contrast to the first: it is one of the most highly dangerous
diseases which the practitioner in this country is ever called to
witness. It is invariably attended with the symptoms which have been
described as proper to typhus gravior. And these symptoms may consist
either of those which belong to the first form of typhus gravior, and
which have been already described,[26] or they may be those which
characterize the second, or the congestive form.[27] The former is the
most frequent, but the latter is not uncommon. The most exquisite
specimens of congestive fever which it has happened to me to witness,
have been those afforded by scarlatina: and there is no disease incident
to this climate which is more alarming, more beyond the reach of
remedies, or more rapidly fatal. Though fortunately several years may
sometimes elapse without the occurrence of a single case of it, yet
occasionally seasons return in which many cases happen. I have witnessed
two such seasons in London, and all the persons I remember to have seen
affected with it were near the age of puberty and not beyond that of
thirty. For examples of it the reader is referred to the pathology.
* * * * *
Before bringing to a close this account of the general phenomena of
fever, it is necessary briefly to notice some events which, because they
occasionally occur in the progress of the disease, but are not constant,
may be considered as accidental.
1. It is not very common, but there sometimes takes place an extreme
degree of tenderness over the entire surface of the body. The
sensibility is so much increased that the patient cannot bear, without
pain, the slightest pressure. Several cases have occurred in which the
entire skin was as tender to the touch as the abdomen in some of the
abdominal cases. Whenever this preternatural sensibility occurs, it is
always in connexion with an exceedingly severe form of the disease.
2. One of the most common occurrences in severe and protracted cases is
excoriation of the skin, and the subsequent formation of a sloughing
sore. In bad and long-continued cases of fever the powers of life are so
much exhausted, and the sources of nourishment are so completely
vitiated, that the skin and the subjacent parts have not vitality
sufficient to bear even the pressure occasioned by the weight of the
body. The most common seats of these sores are the back, the sacrum, and
the hips. They often spread far and eat deep; they are additional
sources of irritation and exhaustion to a frame already reduced to the
last extremity of feebleness, and the scale which seemed to be equally
balanced between life and death, they often turn on the side of death.
3. In severe and protracted cases, and often coming to destroy the hope
that was beginning to spring up in favour of the patient, erysipelas is
no unusual visitant. It is the outward and visible sign of inward and
always most formidable disease. Many and many are the persons it
destroys who, but for it, would ultimately gain the victory over a
malady with which they have carried on a doubtful contest, perhaps for
fourteen or for one and twenty days.
4. Pain, swelling, hardness and suppuration of the glands in different
parts of the body are not uncommon. The gland which most commonly
suffers is the parotid, although the submaxillary, the axillary, and
even the inguinal, are occasionally involved. These glandular affections
never take place but in formidable cases, and their occurrence sometimes
changes at once the entire character of the disease, and destroys the
slightest hope of recovery.
5. Now and then there take place severe pain in the joints, together
with tumefaction and excessive tenderness on pressure. These events
usually come on towards the close of exceedingly bad cases, and they are
often attended with very acute suffering. Neither the occurrence of the
events nor the appearances presented on examination after death, have
hitherto been noticed, as far as I am aware, by any author. Every case
attended with this peculiar affection that I have seen, has proved
rapidly fatal. The condition of the joints, as ascertained by
dissection, will be stated in the pathology.
Purulent discharge from the ears, deafness, spasmodic contraction of the
extremities, convulsions, all depend upon certain states of the brain,
and will be noticed when these states are spoken of. Numerous maladies
arising from various degrees and complications of disease in the lungs,
heart, pleura, viscera of the abdomen and investing membrane, not
belonging to fever, but adding to its evils, are found on examination
after death, which often fully account for anomalous symptoms that
aggravated the case during life. Of these mention will be made in the
proper place.