Western World through European shipping. It was brought to North
America about the year 1735. Tardily it spread to South America, where
it appeared in 1829, and more recently it has been established in
Australia. It entered Iceland in 1827, and Greenland in 1847.
ETIOLOGY.--The evidence is strong that scarlet fever does not
originate de novo--that it does not spring from certain atmospheric or
telluric conditions, but is produced by a definite specific principle,
since countries have been free from it for centuries till it was
imported by commerce. That it appears in certain localities without
any known exposure is attributed to the fact that the poison is so
subtle and transmissible that it is {488} conveyed long distances in
articles of merchandise, even in small packages, so that those who
chance to open them or come in contact with them are infected. It is
believed that reading matter transmitted through the mails has in many
instances been the medium of infection.
The theory that the acute infectious maladies are caused by
micro-organisms, or, as they are now designated, microbes, commonly
discarded at first and believed to be chimerical, is rapidly gaining
ground in the profession, and appears to be fully established as
regards certain of them. These parasites, barely visible under high
powers of the microscope, and ascertained to be vegetable by their
behavior under certain chemical agents, exist in immense numbers in
the blood, tissues, and secretions of patients suffering from the
infectious maladies, especially in the graver cases of them; and the
microscope shows that these organisms vary in shape and appearance so
as to admit of classification.
The germ theory has now become so important that it cannot be ignored
in a monograph relating to so important an infectious malady as
scarlet fever. The relation of microbes to the infectious diseases has
been made the subject of investigation by Pasteur, Toussaint, and
others in France, and by many in Germany, with most interesting
results. The belief held by many, and which seemed very plausible, was
that the microbes, instead of sustaining a causative relation to the
maladies in which they occur, were the result of these maladies--that
they sprang into existence in consequence of the vitiated state of the
blood and tissues, just as fungi appear on decaying substances or as
the Oidium albicans appears in certain morbid conditions of the buccal
surface and secretions. Obviously, in order to elucidate this matter
and determine the relation of these parasites to the diseases in which
they occur, it was necessary to experiment on animals, but,
unfortunately, as a bar to successful experimentation many of the most
important infectious maladies which afflict the human race, as typhus
and typhoid fevers, the marsh fevers, and syphilis, do not occur in
animals, or they occur in a changed and mitigated form. Others,
however, can be produced in their typical character in animals, as
diphtheria, and others still originate in animals and are transmitted
from them to man, as anthrax or splenic fever of the herbivora and
hydrophobia. Very interesting and important results have been produced
by experimental researches with the microbes of certain of these
diseases, which, if applicable to the common and fatal infectious
maladies of an analogous nature in man, may yet result in immense
benefit in mitigating the virulence of those affections which are the
scourge of childhood and which sensibly diminish the increase of
population. It has been found possible to cultivate the microbes
contained in the blood, tissues, and secretions in certain of the
infectious diseases, and after a series of cultivations, so that these
organisms are far removed from the animal substance which contained
them, and with which they were so intimately associated in the
individual, they have been employed for inoculation--with this
important result, that the primary disease was reproduced. This seems
to indicate beyond question the causative relation of these parasites
to the diseases in which they occur. Experiments with the result which
I have stated have been made with the microbes of splenic fever,
chicken cholera, murrain, and certain other maladies.
Pasteur employs as the media for cultivation--(1st) urine neutralized
{489} by a few drops of potash solution; (2d) a liquid prepared by
boiling for twenty or thirty minutes the yeast of beer in water,
neutralizing, and filtering; and (3d) chicken tea, prepared by boiling
equal parts of water and the lean of muscles a quarter of an hour,
filtering, and neutralizing. A small drop of infected blood is placed
in the liquid of cultivation, and the microbes which it contains
multiply so abundantly that the liquid becomes turbid in a short time,
and they are found in all parts of it. A drop of this liquid is added
to another portion of the medium, and this also soon becomes turbid
from the immense development of organisms which have the same
microscopic appearance and character as those in the drop of blood.
The process is repeated many times, until the microbes are far removed
from their original source in the blood and tissues, and a drop of the
last cultivation, whether it be the fiftieth or the hundredth, is
inserted under the skin of a healthy animal selected for the
experiment. If it be true, as stated by the experimenters, that the
original disease is thus reproduced with the microbes of at least
three or four distinct maladies, this age is distinguished by one of
the most important discoveries ever made in pathological studies. It
remains to determine whether this great discovery is of general
applicability to the infectious diseases with which man is afflicted.
If so, it is not improbable that we are on the eve of finding a method
by which some at least of these maladies may be prevented or
mitigated, as small-pox has been since the time of Jenner. The result
of experiments made by Pasteur with the microbes of that fatal malady
of the herbivora, known under the various names of splenic fever,
anthrax, wool-sorter's disease, and charbon, encourages this belief.
Originating among the herbivorous animals, it has in many instances
been contracted by individuals who have rapidly perished. Many engaged
in assorting alpaca and mohair have lost their lives by it, some with
all the symptoms of profound blood-poisoning, without external
lesions, and others with redness and swelling at some point of
infection where a sore or abrasion existed, but with speedy
blood-contamination.
The microbe of this malady, the Bacillus anthracis, occurs in the form
of straight filaments with little movement or only with oscillation,
and producing bright-shining spores. Now comes a very interesting and
important result of experimentation: Pasteur states if several days
elapse between the cultivations the virulence of the parasite
diminishes, so that he has been able to produce by inoculation with it
a mild and never fatal form of charbon, which affords immunity in the
animal from any subsequent attack. This opinion was sustained by a
trial experiment on sixty sheep. Toussaint and Chauveau claim that
they produce a similar attenuation of the virus by defibrinating
infected blood, heating it to 55° C. (131° F.) and filtering it. These
experiments awaken the hope that the time will come when the acute
infectious maladies in man, scarlet fever among others, will be
rendered less virulent. That one of them--to wit, small-pox--has for
nearly a century been under our control certainly encourages the
belief that there is some way to mitigate others of the same class
which are equally fatal if not so loathsome.
As yet, observers do not agree in regard to the parasite which is
supposed to sustain a causative relation to scarlet fever. Klebs
states that it is highly probable that both measles and scarlet fever
are produced by {490} micrococci, and he has sketched the design and
described the development of a microbe which he designates the Monas
scarlatinosum.
The _London Medical Times and Gazette_ for Jan. 28, 1882, contains an
account of the supposed discovery of the scarlatinous microbe by
Eklund of Stockholm, an authority in the microscopic examination of
parasites. He says that scarlet fever is rarely absent from the
Swedish capital and from the barracks and dwellings on the isle of
Skeppsholm. In the urine of scarlatinous patients he has constantly
found a prodigious number of discoid corpuscles, oval or round, their
diameter being less than 1/1000 millimetre and from 1/30 to 1/10 that
of a red blood-cell. They are colorless or yellowish white, surrounded
by a distinct cell-wall, each containing a well-defined nucleus of a
deeper hue. Sometimes one or more microbi may be seen. They exhibit
rotatory or oscillatory movements, especially observed when a drop of
water is added to the fluid. They multiply, as he has frequently seen,
by fission--first in the microbes, next in the nucleus, and lastly in
the cell-wall. He cannot say whether they develop into a mycelium. At
any rate, the development of fine filaments seems to be exceptional.
He has never seen them adhere in moniliform chains nor massed as
zooglæa. He considers them to be veritable schizomycetes, and proposes
the name Plox scindens.
Eklund asserts that he has found these same organisms in vast numbers
in the soil- and ground-water of the isle of Skeppsholm, in the mud of
the trenches dug for the water-mains, and in the greenish mould upon
the walls of the old barracks, where scarlet fever was most rife. He
states that scarlet fever has occurred in children after drinking milk
mixed with the ground-water of the island, and he observed a case
which followed immersion in one of the trenches of the island and the
drying of the clothes in a small room. In another instance scarlet
fever broke out in a block immediately after exposure of the
ground-water by excavations.
It is evident that the discovery of this microbe under such
circumstances does not prove that it is the cause of the disease. This
can only be determined by inoculation, or by experiments which furnish
the conditions of scientific exactness. Although great progress has
been made in parasitology during the last decade, it is evident that
several years of observation and experimentation must elapse before it
is clearly and definitely ascertained whether or to what extent
microbes cause scarlet fever and the other exanthematic fevers with
which it is classified.
Whether the specific principle of scarlet fever be a micro-organism or
a chemical substance, its mode of action and effects have been
ascertained by clinical observations. Without doubt it commonly enters
the system by the breath, but it may enter in the ingesta, and it
infects the blood. That it resides in the blood has been ascertained
by inoculation with this liquid, by which scarlet fever has been
reproduced in its typical form. From the blood it enters the tissues
and secretions. Hence handkerchiefs or linen containing the saliva or
mucus of a patient, the epidermic scales shed abundantly in the
desquamative period, and probably also the urinary and fecal
evacuations, contain the poison, so as to be highly infectious. Even
the discharge of a scarlatinous otorrhoea is thought by some to be
contagious for a considerable time.
Scarlatina is communicable not only by direct exposure to a patient,
{491} but also by exposure to objects which happen to be in his room
during his illness, and to which the poison becomes attached, such as
clothing, books, and toys; small packages, even letters, it is
believed, from cases which have occurred, sometimes convey and
disseminate the contagious principle.
In England observations have been made which show that scarlatina has
been communicated by infected milk. The disease occurred in the family
of a milkman, and the milk, before it was distributed, remained for a
time in a kitchen which had been occupied by the patients. This milk
was taken by twelve families, and in six of these the disease occurred
almost simultaneously at a time when few cases were occurring in the
locality. There had been no direct exposure to the carrier of the milk
nor to members of the affected family (Taylor). In another instance a
woman and her son had scarlet fever while they were serving milk to
several families, and the disease appeared in all these families
except one, which consisted of old people (Bell). It is known that
milk absorbs volatile substances so as to be flavored by them, as is
shown in the experiment of placing it in an open vessel in a box with
a pineapple; and it may in a similar manner become infected by the
specific principle of scarlet fever, or it may be infected by detached
particles of epidermis; which is not improbable when one convalescing
from scarlet fever is allowed to milk the cows or prepare the milk for
distribution.
The scarlatinous virus surpasses that of any other eruptive fever
except small-pox in its tenacious attachment to objects and its
portability to distant localities. Hence in the literature of the
disease are the records of many cases in which the poison was conveyed
long distances, retaining its virulence to the full extent and causing
an outbreak of the malady in the localities to which it was carried.
In New York, so frequently has scarlet fever as well as measles and
diphtheria been contracted from the persons or clothing of well
children who come from infected houses, that the Health Board now
excludes from the public schools all children who come from such
houses, even though they live on separate floors from those occupied
by the sick. In one instance that came under my notice a washerwoman
whose child had scarlet fever communicated the disease to an infant in
the household where she was employed, by placing her shawl over the
cradle in which it was lying. A physician of my acquaintance went from
a scarlet-fever patient to a family several streets distant, and took
one of their children upon his lap. After the usual incubative period
this child sickened with a fatal form of the malady, and the remaining
children of the household were in time affected. In New York scarlet
fever has seemed to me to be not infrequently communicated through
school-books, which, profusely illustrated by pictures and rendered
attractive to the young, are often allowed to lie upon the bed of a
scarlatinous patient and be handled by him during convalescence, or
even during the course of the fever if it be mild. The young librarian
of the circulating library of a Sunday-school, whose pupils came
largely from the tenement-houses, was occupied a considerable part of
a day in covering and arranging the books. After about the usual
incubative period of scarlet fever he sickened with the disease. His
two sisters were immediately removed to a rural township three hundred
miles away, and to an isolated house where scarlatina had never
occurred. About one {492} month after his recovery, and after his room
had been disinfected by burning sulphur and his bed-clothes and linen
had been thoroughly washed, and all articles suspected to hold the
poison had been either disinfected or destroyed, the brother visited
his sisters in the country. Three weeks subsequently to his arrival
one of these sisters sickened with scarlet fever, and a week later the
other also. It seems that the exposure must have occurred several days
after his arrival in the country from some book or other infected
article in his possession. About two months elapsed after the last
case; the family had returned to the city, the infected room in the
country-house had been thoroughly fumigated by burning sulphur from
morning till evening, when a little girl from an inland city remained
a few days in this house, and probably often entered the room where
the young ladies had been sick. In a few days she also sickened with a
fatal form of scarlatina. Such histories and experiences are not
infrequent. They are common during epidemics of scarlet fever. They
indicate an extraordinary attachment of the scarlatinous poison to
objects, and show that it is not gaseous nor readily volatilized.
A striking example of this fixity of the poison occurred in the
practice of the late Kearney Rogers, formerly a prominent and much
esteemed surgeon of New York City. Six children in a family had
scarlet fever. Three and a half months subsequently another child,
living at a distance, was allowed to return home and occupy the
apartment in which the sickness had occurred. One week subsequently to
the date of the return this child sickened with the same malady.
Elliotson states that a patient with scarlet fever was admitted into
one of the wards of St. Thomas's Hospital, and for two years
subsequently young persons who were admitted into the ward were apt to
take the disease. Richardson of London relates the following
experiences of a family whom he attended in a rural district: "At a
short distance from one of our villages there was situated on a slight
eminence a small clump of laborers' cottages, with the thatch peering
down on the beds of the sleepers. A man and his wife lived in one of
these cottages with four lovely children. The poison of scarlet fever
entered the poor man's door, and at once struck down one of the
flock." The remaining children were now removed some miles away, and
after several weeks one of them was allowed to return. Within
twenty-four hours it also took the disease, and quickly died. The
walls of the cottage were now thoroughly cleaned and whitewashed, the
floors scoured, and all the wearing apparel either destroyed or
washed. Four months elapsed after the last sickness when one of the
remaining children returned. "He reached his father's cottage early in
the morning; he seemed dull the next day, and at midnight I was sent
for, to find him also the subject of scarlet fever. The disease again
assumed the malignant type, and this child died." Richardson believes
that the contagium was attached to the thatch, which could not be
thoroughly disinfected. The fact of this remarkable long-continued
attachment of the poison to objects, indicating by this fixity that it
is a solid, is consonant with the theory that it is an organism.
INCUBATIVE PERIOD.--The duration of the incubative period varies in
different cases. It is sometimes less than twenty-four hours, as in
{493} the above case reported by Richardson; in the following
well-known case, observed by Trousseau, it was one day. A girl arrived
in Paris from Pau, where there was no scarlet fever, and occupied the
same apartment with her sister, who was sick with this disease.
Twenty-four hours after her arrival she also was attacked with the
same malady.
Russeberger attended a child who was exposed at noon to scarlet fever,
and took the disease on the following night. B. W. Richardson
(_Clinical Essays_, 1861, vol. i. p. 94) gives his own experience: He
had applied his ear to the chest of a patient suffering from scarlet
fever, and was conscious of a peculiar odor emitted from the patient.
He was immediately nauseated and chilly, and from that moment he dated
the beginning of an attack of scarlet fever. In the _Transactions_ of
the Clinical Society of London, vol. xi. 1878, the late Charles
Murchison gives the statistics of 75 cases, showing the incubative
period, as follows:
In 4 cases it was not more than 24 hours.
" 2 " " " " 30 "
" 3 " " " " 36 "
" 4 " " " " 40 "
" 1 " " " " 41 "
" 4 " " " " 58 "
" 1 " " " " 54 "
" 1 " " " " 2-1/2 days.
" 31 " " within (time not accurately ascertained) 4 days.
" 2 " the incubation did not exceed 4-1/2 days.
" 17 " " " " " 5 "
" 2 " " " " " 6 "
In three cases Murchison believes that the incubation was precisely
fixed at thirty-six hours, three days, and four and a half days.
Watson says that a man reached Devonshire on mid-day to see his
daughter, who had scarlet fever. Two days later he was also attacked.
Rehn saw a child who was attacked two days after its grandmother
returned from a case of scarlet fever; and Zengerle, a girl of ten
years, residing at Wangen, where there was no scarlet fever, who took
the disease two days after her mother had returned from visiting a
family affected with it. Loochner states that a boy aged four and a
half years was attacked one and a half days after admission into the
infected wards of a hospital. Armistead, in his annual report on the
health of the Newmarket rural district, states that three children,
coming from a different part of the district, visited Westley, and
stayed next door to a child who had scarlet fever six weeks
previously, and who was allowed to play with these children on the
evening of Aug. 13th and morning of the 14th. The family then returned
home, and on the 18th, four days after the exposure, all three
children sickened with scarlet fever (_Brit Med. Jour._, Sept. 30,
1882).
Ordinarily, therefore, the incubative period, though varying in
different cases, is within six days. Many cases, however, occur in
which it seems to be longer. Thus in my practice scarlet fever
appeared in a family on April 26, 1882. The patient was immediately
removed to the third floor and the other children to the basement. All
communication between the infected room and the basement was
forbidden, but on May 8th, twelve days after the separation, one of
these children sickened with the disease. {494} Many observers--among
whom may be mentioned Niemeyer and Copland--believe that the
incubative period may be longer than one week, but, on account of the
subtlety of the poison and the many modes of transmission, it is
possible that in the instances of an apparently long incubative period
there were other and unsuspected exposures. When scarlet fever has
been communicated by inoculation, as in the experiments of Rostan and
others, the incubative period has been about seven days, but Gerhardt
states that a man was attacked four days after an abscess was opened
by a knife used upon a scarlatinous patient. This variation in the
incubative period, which also occurs in some other infectious
diseases, as diphtheria, is probably due mostly to individual
differences, some being more susceptible than others; but it may be
due partly to those obscure meteorological conditions which we
designate the epidemic influence. Probably, as a rule, when the
disease is quickly developed after exposure, the attack is more severe
than when several days elapse.