small. It apparently embraces only a few feet. Therefore, close
proximity is the necessary condition of its propagation. Hence many
who are exposed, particularly of those who are remotely exposed, do
not contract the disease. There is also an idiosyncrasy in some
children, so that they resist infection even when repeatedly and
closely exposed. In the _New York Medical Record_ for March 23, 1878,
C. E. Billington states that of 90 children in 26 families who were
exposed to scarlet fever, 43 contracted the disease and 47 escaped;
whereas, as is well known, comparatively few unprotected children
escape pertussis, variola, varicella, or measles if exposed to either
of these diseases. By strict isolation, therefore, the spread of
scarlet fever is more easily prevented than that of most other acute
infectious maladies. In the New York Foundling Asylum for a number of
years children with scarlet fever were isolated in a small room
attached to one of the wards. The door between the two rooms was
closed, and not opened during the continuance of the sickness.
Entrance into the small room was through another door, and a nurse was
assigned to the scarlet-fever cases, with strict directions that she
should not mingle with the other children. These simple precautions
were found sufficient in the various epidemics of scarlet fever which
occurred in the city to prevent the spread of the malady through this
institution; whereas, similar measures were much less effectual in
arresting the spread of measles and pertussis. Consequently, an
outbreak of scarlet fever in this institution was usually limited to a
few cases, while the extension of measles and pertussis was arrested
with difficulty till a more efficient quarantine was established.
VARIATIONS IN TYPE.--The type of scarlet fever varies greatly in
different epidemics, and frequently also in cases which occur in the
same epidemic, even in the same family. One child may have scarlatina
so mildly that little treatment is required and convalescence soon
begins, while another has the malignant form, and soon succumbs,
notwithstanding the prompt employment of the most efficient and
appropriate measures. Ordinarily, however, if the first case in a
family be very severe, subsequent cases will present a similar type;
but there are notable exceptions. This variation in type in different
years and different epidemics is probably not equalled in any other
infectious malady. Consecutive {495} epidemics may present this
variation, or the same type may continue for a series of years, and
then, from some unknown cause, change to one milder or more severe. In
England, during Sydenham's life, scarlet fever was so mild that he
regarded it as a trivial affection, requiring little attention, like
rötheln of the present time, but after the death of Sydenham, Morton
and his contemporaries in London found, to their sorrow, that the type
of scarlet fever was very different from that described by Sydenham's
pen. The late Graves of Dublin and his contemporaries treated a mild
type of scarlet fever with a very small percentage of deaths--much
less than that during the preceding generation--and they attributed
their success to their greater knowledge and more appropriate use of
remedies than their ancestors possessed and employed. By and by the
type changed, the mortality of former years was restored, and they
discovered that their previous success in saving life had been due not
to their skill, but to the mild form of the malady. A distinguished
physician of New York treated more than fifty cases of scarlet fever
in one of the institutions without a single death. A few months
afterward the type of the malady changed, and his own son perished
from it.
SURGICAL AND OBSTETRICAL SCARLATINA.--After surgical operations, and
sometimes in surgical cases not requiring operative measures, a
scarlatinous efflorescence occasionally appears upon the whole or
nearly the whole body, and remains for several days. The following
were cases of the kind alluded to. They occurred in Guy's Hospital,
and were published by H. G. Howse in _Guy's Hospital Reports_ for
1879: On March 15, 1878, Jacobson performed osteotomy upon a child
suffering from extreme rachitis. The operation was followed by a
moderate febrile movement (100° to 101°), and after three days by the
appearance of an efflorescence, with sore throat and the strawberry
tongue. The osteotomy had been performed under carbolic acid spray and
with all the details of antiseptic surgery. The rash soon faded, the
temperature fell, and the child, temporarily separated from the other
patients from the suspicion that the disease was scarlet fever, was
brought back to the ward. The subsequent history confirmed the
diagnosis of scarlet fever, for the skin desquamated, and on April 1st
abundant albumen was found in the urine. The case terminated
favorably. Three months previously the same operation had been
performed on the other leg, with no unfavorable symptoms. On April
5th, three weeks after the osteotomy, a lipoma was removed from
another patient aged twenty-one years. The following day the
temperature rose to 101°, and remained at that till April 8th, when it
suddenly increased to 103°, and a rose-rash occurred over the body,
with sore throat. On April 9th, Howse excised the elbow-joint of a
girl of sixteen years having pulpy disease. On the 10th her
temperature began to increase, and on the 11th reached 105.8°. Toward
evening a roseoloid eruption appeared over her body, and she was
isolated. On April 12th, Dr. H. excised a fibroid bursa patellaë from
a woman of twenty-nine years. On the following day her temperature was
99°, but on the 14th it rose to 100°, and on the evening of the 15th
she had rigors and headache. On the morning of the 16th the
temperature was 102.5°, and a roseoloid eruption occurred over the
face and chest. The surgeons now perceived that an epidemic of the
so-called surgical scarlatina was occurring, so as to justify the
postponement of other operations.
{496} In the same volume of _Guy's Hospital Reports_, James F.
Goodhart gives the histories of nearly thirty cases of this disease
occurring during a series of years in the same hospital. The patients
were chiefly children, having the most diverse surgical ailments,
among which may be mentioned hip disease and abscess, genu valgum
without operation, necrosis of femur, hydrocele with explorative
operation, a scald, a sinus over the great trochanter, spinal disease
with abscess, tenotomy for club-foot, and vesical calculus with
operation. The most common disease was caries or necrosis with
abscess. In cases operated on the intervals between the operations and
the occurrence of the efflorescence varied from two days to more than
two weeks. Goodhart, after a careful examination of these cases, came
to the conclusion that they were for the most part examples of true
scarlet fever, especially as a considerable proportion of them
occurred in groups, and there was a known exposure of some of the
patients to children admitted into the hospital with the sequelæ of
scarlet fever.
In the _British Med. Jour._ for Jan., 1879, George May, Jr., reported
a case of efflorescence in surgical practice which appears to have
been scarlatinous. A child was operated on for the radical cure of
hernia on Dec. 4th. Toward the close of the same day he became
restless, vomited, and his pulse on the following day rose to 136.
Forty-eight hours after the operation a rash appeared on the chest and
arms, the abdomen became tense and painful, and on the following day
he died. The poison, however, in this case may have been septic.
Hillier remarks (_Diseases of Children_): "In the hospital for sick
children, of the children who contract scarlatina a very large
proportion have been the subjects of a surgical operation within a
week before the rash appears." Gee says (Reynolds's _System of
Medicine_): "It has been doubted by some whether the scarlatiniform
rash which sometimes follows operations is really scarlatinal. The
eruption appears from the second to the sixth day after the operation,
and in the cases which have caused the doubt is very fugitive and the
first and only symptom. Yet that the disease really is scarlet fever
would seem to be proved by the following observations: first, that the
disease occurs in epidemics; secondly, that in a given epidemic a
severe case occasionally relieves the monotonous recurrence of the
very mild form; thirdly, that a precisely similar scarlatinilla
attacks in the same epidemic patients who have not been subjected to
operation and who have no open sore; and lastly, by way of a veritable
experimentum crucis, that, however freely these patients are exposed
to ordinary scarlet fever contagion afterward, they do not contract
that disease." Paget and other distinguished London surgeons who have
observed this complication of surgical cases, believe that the
patients have been previously exposed to the scarlatinous poison, and
that the surgical diseases or operations furnish favorable conditions
for the occurrence of scarlet fever, so that the exposure, which
probably would have been without result in ordinary health, causes an
outbreak of the malady.
Those who have reported cases of this form of efflorescence have for
the most part neglected to state whether the patients had had scarlet
fever previously, knowledge of which would have aided in the
diagnosis; but from an examination of the histories of cases,
especially those {497} published in the London journals in the last
four or five years, there can, I think, be little doubt that surgical
maladies of a certain kind, especially traumatism, do produce a state
of system which predisposes to scarlet fever, so that this class of
patients are especially liable to contract it. Therefore, in my
opinion, a considerable proportion of reported cases of surgical
scarlatina are genuine, but in a considerable number, perhaps an equal
number of such cases, the histories and symptoms indicated a septic
rather than scarlatinous efflorescence, and in not a few instances,
when consultations have been held, opinions differed, some
diagnosticating scarlet fever, others septicæmia. In some of the cases
I find it stated that the fauces presented the normal appearance. Now,
faucial redness is so generally present in scarlet fever, antedating
that of the skin and coexisting with it, that its absence is strong
evidence that the disease is not scarlatinous. Moreover, when, as was
true of certain of the reported cases, the rash appeared irregularly
upon the surface, and faded away in two or three days with the
abatement of the fever, and the conditions for septic absorption were
present, the efflorescence was probably septicæmic.
The following were apparently cases of septicæmia efflorescence: A
child aged five years (_Brit. Med. Jour._, Feb. 15, 1879) had
inflammation of the lymphatic glands in the groin, which suppurated.
At the time when the abscess was fully formed a rash appeared over the
entire body. It consisted of numerous red points, but was paler than
that of ordinary scarlet fever; temperature never above 99°; no sore
throat nor desquamation of cuticle. No child exposed to her took
scarlet fever, and her sickness could not be traced to infection. In
the _British Med. Jour._, Jan. 4, 1879, L. Braxton Hicks states that
his son, attending school at Reading, was seized with a severe attack
of pyrexia, accompanied on the second day by delirium and the
occurrence of a rash like scarlet fever over the entire surface. He
had no decided redness of the fauces, though it was perhaps slightly
flushed. The right buttock was swollen from inflammation, and a large,
deep-seated abscess formed near the tuberosity of the ischium. When
the delirium abated the boy said that he was standing the day before
the fever began with his legs far apart, when a schoolfellow stretched
them farther by suddenly pulling on one of them. The rash, which was
nearly universal, lasted three days, and was not followed by
desquamation. No case of scarlet fever occurred in the school before
or afterward. In the same volume of the _British Medical Journal_,
Surgeon Frolliott of the East India Service relates the case of a
private, aged twenty-three years, and three years in India, who, when
on duty in the Punjab, was injured by the explosion of an Afghan
powder-magazine. The accident occurred Dec. 21, 1878. On Dec. 25th a
bright scarlet rash appeared upon the abdomen and spread over the
entire body. The following day the eruption was very vivid, like a
boiled lobster, and it lasted five days. The temperature, which in the
beginning had been 101°, abated to the normal after the rash appeared.
No soreness of throat nor redness of the buccal surface occurred, but
the epidermis desquamated even from the palms of the hands and soles
of the feet. Now, the febrile movement of scarlet fever does not cease
while the efflorescence is distinct. It does not even diminish when
the eruption appears, while in the above case it fell to the normal--a
common {498} occurrence in septicæmia, even when the blood-poisoning
is profound. Moreover, scarlet fever is so rare in India that
Frolliott, after twelve years' service, had only heard of one case
among Europeans and natives. The surgeons who consulted over the case
of this private disagreed in opinion, some regarding the disease as
septicæmic, others as scarlatinous. But a better knowledge of the
clinical history of scarlet fever on the part of these army surgeons
would, I think, have removed all doubt as to the diagnosis.
It is the opinion of some reputable surgeons that the exposure of
traumatic patients to the scarlatinous poison sometimes aggravates the
inflammation of wounds, causing them to assume an unhealthy appearance
even though no scarlatina be produced. The late Solly made the remark,
"Whenever a case of surgery in private practice takes on a highly
phlegmonous appearance I am always sure to find break out, in the
inmates of the house, either erysipelas or scarlet fever" (_British
Med. Jour._, Feb. 15, 1879). We will see that the scarlatinous poison
sometimes causes pharyngitis or nephritis without producing the
general disease. In a similar manner it seems that it may aggravate
open wounds, intensifying the inflammation in them, while there is no
efflorescence or other symptom to show that scarlatina itself is
present. The poison appears to act entirely locally in such cases.
Paget, in his _Clinical Lectures_, says: "I think it not improbable
that in some cases results occurring with obscure symptoms within two
or three days after operations have been due to the scarlet-fever
poison, hindered in some way from its usual progress." Playfair, in
his remarks on the puerperal state, adds: "Mr. Spencer Wells informs
me that he has seen cases of surgical pyæmia which he had reason to
believe originated in the scarlatinal poison; and his well-known
success as an ovariotomist is no doubt, in a great measure, to be
attributed to his extreme care in seeing that no one likely to come in
contact with his patients has been exposed to any such source of
infection." Opinions like these, held by such prominent members of the
profession and sustained by many observations, should certainly induce
physicians to prevent, so far as possible, any exposure of their
surgical patients, especially if they have any sores or wounds,
whether by traumatism or the scalpel, to the scarlatinal poison.
OBSTETRICAL SCARLATINA.--Women during convalescence after childbirth
are very liable to contract scarlet fever. In the New York Infant
Asylum, which has maternity wards, a woman was admitted from a house
in which scarlet fever was prevailing, and assigned to a cot next that
occupied by one of the waiting women, who was confined soon afterward.
Her labor was favorable, but three days afterward she took scarlet
fever, and another lying-in-patient contracted it from her. The sore
throat and desquamation were characteristic. It has come to my
knowledge that a physician of New York, in whose family scarlet fever
was occurring, attended three women in succession in their
confinement, and all contracted scarlet fever, which presented the
characteristic symptoms, and two of them died. Experienced and
cautious physicians of New York, aware of the danger, do not go
directly from a scarlatinous patient to an obstetrical case, but avoid
the risk by intermediate visits to other patients or by remaining for
a time in the open air.
{499} Playfair, remarking on this subject, says: "There is good reason
to believe that the contagium of zymotic diseases may produce a form
of disease indistinguishable from ordinary puerperal septicæmia, and
presenting none of the characteristic features of the specific
complaint from which the contagium was derived. This is admitted to be
a fact by the majority of our most eminent British obstetricians,
although it does not seem to be allowed by continental authorities,
and it is strongly controverted by some writers in this country. It is
certainly difficult to reconcile this with the theory of septicæmia,
and we are not in a position to give a satisfactory explanation of it.
I believe, however, that the evidence in favor of the possibility of
puerperal septicæmia originating in this way is too strong to be
assailable. The scarlatinal poison is that regarding which the
greatest number of observations has been made. Numerous cases of this
kind are to be found scattered through our obstetric literature, but
the largest number are to be met with in a paper by Braxton Hicks. Out
of 68 cases of puerperal disease seen in consultation, no less than 37
were distinctly traceable to the scarlatinal poison. Of these, 20 had
the characteristic rash of the disease, but the remaining 17, although
the history clearly proved exposure to the contagium of scarlet fever,
showed none of its usual symptoms, and were not to be distinguished
from ordinary typical cases of the so-called puerperal fever. On the
theory that it is impossible for the specific contagious diseases to
be modified by the puerperal state, we have to admit that one
physician met with 17 cases of puerperal septicæmia in which, by a
mere coincidence, the contagion of scarlet fever had been traced, and
that the disease nevertheless originated from some other source--a
hypothesis so improbable that its mere mention carries its own
refutation."
Parturition, like traumatism, furnishes in an eminent degree the
conditions in which septic poisoning occurs, and the efflorescence
which often accompanies septicæmia bears, as we have seen, a very
close resemblance to that of scarlet fever. Hence in many instances
the same difficulty is present in making a differential diagnosis
between septic and scarlatinous blood-poisoning in obstetrical cases
which occurs in surgical practice. But, according to my observations,
an efflorescence occurring during the week following parturition is in
most instances septic. It is only in exceptional cases that it is
scarlatinous, and there is little danger that the accoucheur, engaged
in general practice and visiting scarlatinous patients, will
communicate scarlet fever through his person or clothing if he
exercise proper precautions. His short stay in the sick room and his
out-door exercise in visiting cases prevent infection of his person or
dress. But if, as Playfair believes, the scarlatinal poison sometimes
produces in parturient women a puerperal fever in which the
characteristic scarlatinal symptoms are lacking, and which, in the
present state of our knowledge, is not distinguishable from ordinary
septic fever, certainly the scarlatinous virus sustains a much more
frequent causative relation to childbed fever than has been heretofore
supposed.
Infants under the age of six months do not ordinarily contract scarlet
fever, although fully exposed, and those under four months nearly
possess immunity. Still, this disease has been observed in new-born
infants, contracted, apparently, through the placental circulation.
{500} Tourtual states that a woman waited upon her own husband and
child, both of whom had scarlet fever, during the eighth and ninth
months of her pregnancy, till near her confinement. Though she had no
symptoms of scarlet fever, her infant had unusual redness of the skin
and buccal surface and difficulty of swallowing up to the fifth day.
On the ninth day desquamation began, and at a later stage the nails of
the fingers and toes separated. A case having a history in some
respects similar is related by Megnert, but the symptoms were
anomalous for scarlet fever, and the disease may have been ordinary
septic fever. On the other hand, in one instance in my practice a
mother had scarlet fever, beginning about the third day after her
confinement, and although she suckled her infant and it was constantly
in bed with her, it had no symptoms of scarlet fever, although it
became affected immediately afterward by a severe form of eczema,
probably from the altered quality of the milk; and in two instances
observed by Murchison new-born infants remained healthy, although
their mothers suffered from scarlet fever.
After the age of six months the liability to scarlet fever increases
till the close of infancy, children between the ages of six months and
one year being less liable to contract the malady than during the
second year, and those in the second year being less liable to it than
those in the third year. Murchison collected the statistics of deaths
from scarlet fever in England and Wales during a series of years
ending with 1861. The number of deaths aggregated 148,829, and the
percentage of deaths at different ages was as follows:
Deaths under 1 year, 6.7 per cent.
" between 1 and 2 years, 14.09 " "
" " 2 " 3 " 16.00 " "
" " 3 " 4 " 15.13 " "
" " 4 " 5 " 11.9 " "
" " 5 " 10 " 25.9 " "
" " 10 " 15 " 5.8 " "
" " 15 " 25 " 2.6 " "
" " 25 " 35 " 0.8 " "
" over age of 35 years, 0.8 " "
Among the deaths were ten cases above the age of eighty-five years, so
that scarlet fever, though especially a disease of childhood, may
occur in any decade of life; but old age, like early infancy, almost
possesses immunity from it.
I have preserved the records of the ages of 145 consecutive cases
occurring in private practice. If we add to these 58 cases observed by
Prof. Octerlony (_Amer. Jour. of Med. Sci._, July, 1882) we have the
statistics of the ages of 203 cases, which are embraced in the
following table:
Under 1 year, 3
From 1 to 2 years, 25
" 2 " 3 " 43
" 3 " 5 " 57
" 5 " 10 " 53
" 10 " 15 " 13
" 15 " 20 " 3
" 20 " 30 " 4
" 30 " 40 " 2
---
Total, 203
{501} CLINICAL FACTS REGARDING SCARLET FEVER.--As a rule, scarlet
fever occurs but once, one attack conferring immunity from the disease
for life; but there are exceptions. In 1869, I attended a child with
fatal scarlet fever who three years previously, it was stated, had
passed through a first attack with all the characteristic symptoms.
The following case occurred in a family attended by the late Dr.
Herzog: R----, a boy of six years, had scarlet fever in a mild form in
January and February, 1875, followed by moderate desquamation. In July
of the same year he was kicked by a horse in the street, receiving a
deep scalp-wound which required three stitches. Three days afterward
he had, to appearance, a second attack of scarlet fever, attended by
high febrile movement, and followed also by desquamation. It was
believed by Dr. H. to be a genuine case, and was so treated. I am not
able to state as regards the presence of soreness of the throat, and
doubt arises whether this second attack may not have been septicæmic.
In April, 1876, a third attack occurred, which I saw from the
beginning. It was accompanied by all the characteristic
symptoms--injection of the fauces, an efflorescence continuing the
usual time, followed by desquamation and albuminuria, the latter
continuing several weeks. Richardson states that three distinct
attacks occurred in his own person, and a student attending the
lecture at which this was mentioned informed the doctor that he also
had had scarlet fever three times.