been described as a relapse. The following was a case in point in the
practice of Godneff (_Meditz. Vestnik._, No. iv., _N.Y. Med. Rec._,
April 30, 1881): A youth of seventeen years contracted scarlet fever
while taking care of a child. It began with a chill, and he had the
usual efflorescence, sore throat, and tumefaction of the cervical
glands. An exudation appeared upon his tonsils and uvula, and his
temperature reached 104°. The urine contained a trace of albumen, the
rash in due time faded, and the epidermis exfoliated. On the fifteenth
day, when he was about ready to leave the hospital, he again had a
chill, followed by fever. The temperature reached 105.2°, the rash
reappeared over the entire surface except the face, diphtheritic
exudations occurred upon the fauces, and the urine, the quantity of
which was diminished, again became albuminous. This second
efflorescence faded on the twenty-fourth day, and on the
twenty-seventh exfoliation began. Hillier says: "I have seen a young
woman in the fever hospital suffering from a second attack of
scarlatina, the first attack having occurred five weeks previously.
She had quite recovered from her first illness, and was acting as
nurse. In both seizures the rash, the sore throat, and other symptoms
were characteristic. The relapse or recurrence was less severe than
the primary disease." Cases of a fourth, or even of a greater number
of attacks, have been reported. The first seizure is sometimes milder,
but in other instances is more severe, than those which follow.
Exposure to the scarlatinous poison not infrequently produces
pharyngitis without the occurrence of scarlatina, and the inflammation
is apt to be severe, accompanied by pain in swallowing and marked
febrile movement. This phlegmasia is distinguished from scarlet fever
by its shorter duration and the absence of the efflorescence. It
occurs in adults as well as in children, and in those who have had, as
well as in those who have not {502} had scarlatina. So far as I have
observed, it is very seldom accompanied or followed by any of the
complications or sequelæ so common in and after scarlet fever. It
cannot be distinguished from ordinary pharyngitis except in the manner
in which it occurs, and one attack does not preclude another. The late
George B. Wood made the remark that he never attended a case of
scarlet fever without suffering from sore throat. The following were
examples of this form of pharyngitis: On Jan. 17th, 1882, I was called
to a boy of three years with severe scarlet fever, ushered in by
convulsions. On the following day his sister, aged seven and
three-fourths years, whom I had attended a year previously during a
severe attack of scarlatina, and who had been almost constantly with
the brother, became very ill, with a temperature of 103.5°.
Examination revealed severe inflammation of the fauces, without
pseudo-membrane or any other exudation except muco-pus. On Jan. 19th
an older brother, nine years, whom I had attended in scarlet fever
three years previously, was affected in the same way, his temperature
being 104° and his respiration guttural and noisy, especially during
sleep, in consequence of the great amount of faucial swelling. At
times he was delirious. The inflammation in both cases began to abate
about the third day, and had disappeared by the close of the week.
That the contagium of scarlet fever may be received into the system
and cause pharyngitis, while the patient has immunity from scarlet
fever through a previous attack, and that this inflammation may occur
any number of times, as in the case of Dr. Wood, are remarkable facts.
Now and then cases occur which appear to show that the scarlatinous
poison may affect the kidneys, producing nephritis, while there is no
other manifestation of its influence. Thus in my practice a lady of
about forty-five years constantly attended her son, sleeping by his
side, during an attack of scarlet fever. Her health had previously
been good. When the boy was convalescent, as her appetite failed and
she was indisposed, a careful examination revealed the fact that she
had albuminuria, although she had had no sore throat or other symptom
of scarlet fever. After several weeks of treatment her disease was
removed, and she has remained well since. In the _British Med. Jour._
for Nov. 29, 1879, it is stated that in a family four girls were found
to be suffering from desquamative nephritis. One of them had recently
had scarlet fever, but the other three had presented no symptoms
whatever of this disease. Such cases, although probably rare, appear
to show that, as the scarlatinous poison may produce inflammation of
the fauces without the occurrence of scarlet fever, so it may cause
nephritis without producing the general disease, or apparently
disturbing the functions, or changing the state of other parts, except
the kidneys.
SYMPTOMS.--ORDINARY FORM. Scarlet fever usually begins abruptly, so
that the exact time of its commencement can be fixed. If any
premonitory symptoms occur, they are slight, so as scarcely to attract
attention, as languor or the appearance of fatigue. A dusky aspect of
the surface may occasionally be observed during the few hours
preceding the attack. In some children the first symptom is
chilliness, and occasionally a distinct chill occurs. In the adult a
chill is ordinarily the first symptom. With or without the initial
chilliness, febrile movement occurs, of variable intensity according
to the severity of the type, and {503} accompanied by such symptoms as
usually arise in a febrile state of system, as cephalalgia, anorexia,
and thirst. The pulse rises to 110, 120, or more per minute, the
temperature to 102°, 103°, or 104°; the skin is hot, face flushed, and
the eyes bright. Even in cases that are not malignant or grave, and
that give indications of a favorable result, there is often more or
less stupor, with transient delirium and sudden starting or twitching
of the extremities, showing that the cerebro-spinal axis is involved.
Vomiting is a common symptom in the beginning of scarlet fever,
occurring before the appearance of the efflorescence. It therefore has
diagnostic value when the nature of the case is still doubtful. In
some patients it is an initial symptom, but in others some hours have
elapsed when it occurs. I recorded its presence or absence in 214
patients, with the following result: present in 162 patients, absent
in 52. In severe forms of the disease it is rarely absent, and if it
do not occur it is probable that the case will be mild, requiring
little treatment and having a favorable termination. In epidemics of
unusual mildness the number of cases without vomiting may be in excess
of those in which this symptom occurs. It appears to be due to
functional disturbance of the cerebro-spinal system, and it may
therefore be properly regarded as a nervous symptom. In severe cases
the vomiting is apt to be repeated, not only on the first but on
subsequent days, and we shall see that in cases of great gravity, in
which a fatal termination is not improbable, persistent vomiting, by
which the food and stimulants so urgently required are rejected,
interferes seriously with successful treatment. In a few cases
embraced in my statistics nausea without vomiting was recorded. The
bowels in ordinary scarlatina act regularly or are slightly
constipated. Diarrhoea, which so commonly accompanies the persistent
vomiting in malignant cases, if it occur in this form of the malady is
slight and transient and due to accidental causes. The food, if it be
given in the liquid form and cool, is usually taken readily, on
account of the thirst, except when deglutition is rendered painful by
the pharyngitis.
The symptoms pertaining to the nervous system vary according to the
severity of the disease and the temperament of the patient. Many
children during the progress of the common form of scarlet fever
present a dull or apathetic appearance. They lie much of the time with
their eyes closed; others are more restless, and not a few, if the
fever be considerable, have occasional twitching of the limbs and more
or less headache. Eclampsia sometimes occurs on the first day,
especially in those predisposed to it, even when the subsequent course
of the disease is mild and favorable. This complication, very grave
and usually fatal when it occurs at a later stage, is in most
instances, when it takes place on the first day, readily controlled by
proper remedies and with little detriment to the patient. But if it be
attended by high elevation of temperature and marked drowsiness,
approaching the comatose state, it is very serious upon the first as
well as upon subsequent days. Nervous symptoms occurring in the
beginning of scarlet fever, when it has the ordinary favorable type,
begin to abate in three or four days, but if they supervene at a later
date, and especially in the declining stage, they possess more
gravity, since they then not infrequently result from and indicate
renal complication.
{504} Early in the disease, nearly as soon as the commencement of the
fever, the faucial and buccal surfaces become inflamed, as shown by
redness, swelling, and tenderness. The physician summoned in the
beginning of an attack will already, at his first visit, observe
hyperæmia of the fauces, with points of deeper injection than over the
general faucial surface, and soon the buccal surface also
participates. The inflammation at first produces preternatural
dryness, and this is followed by a viscid secretion. The papillæ of
the tongue enlarge and become prominent, giving rise to the appearance
known as strawberry tongue which is so common in scarlet fever. This
state of the buccal and faucial membrane continues throughout the
disease. A thin fur appears upon the tongue on the first day, and it
increases on the second and third days, after which it is apt to be
detached, exposing the surface of the organ, which has a deep red hue,
but in not a few patients the fur remains or is reproduced as soon as
shed. Except in the mildest cases the Schneiderian membrane also
participates in the inflammation as the disease advances, so that a
thin, irritating discharge, containing leucocytes or pus-cells, flows
from the nostrils. The skin is hot and dry, and cutaneous
transpiration nearly checked. The respiratory system is rarely
involved in any notable manner unless there be a complication. Many
have no cough whatever, while others have a slight cough, due to the
fact that the inflammation, of a catarrhal form, has extended from the
fauces to the surface of the glottis. Slight acceleration of
respiration, corresponding with the degree of fever, may also be
observed. The kidneys commonly act regularly and normally during the
first days, any serious impairment of their functions being rare
before the close of the first week.
When the symptoms described above have continued from six to eighteen
hours the efflorescence appears. It is first observed about the ears,
neck, and shoulders, in reddish patches fading into the normal hue.
These patches extend and unite, and in the course of a few hours the
trunk and upper extremities, and finally the legs, are covered. The
scarlatinous rash usually, when fully developed, resembles that
produced by external heat or the application of a sinapism. It has
been likened to the appearance of a boiled lobster, but there are
numerous minute points of a deeper or duskier hue than the surface
generally. In many patients the rash appears, especially over the
abdomen and lower extremities, as minute, thickly-set points, with the
skin of normal appearance between them. Henoch of Berlin says of
scarlet fever: "In general, the moderate grades of eruption prevail,
the skin, when seen from a distance, presenting a diffuse, more or
less scarlet redness, while on closer inspection it is found that this
redness is composed of innumerable red points closely situated
together, and separated from one another by very small paler portions
of skin. The dark-red points appear to correspond to the
hair-follicles." On passing the finger over the efflorescence no
distinct prominences are observed, but a sensation of roughness is
sometimes imparted from engorgement of the cutaneous papillæ. The rash
disappears on pressure, but it immediately reappears when the pressure
is removed. Its slow return is evidence of sluggish circulation, and
it indicates a grave and dangerous form of the malady. The color is
then usually a dusky instead of a bright red. The efflorescence is
most marked in dependent parts, as along the back, over the chest and
{505} abdomen, and in the flexures of the joints. Parts pressed upon
by the bed-clothes, which confine and intensify the heat, present a
deeper coloration than other portions of the surface. Often,
especially in mild cases, the rash is absent from portions of the
surface where it commonly appears, while it presents a typical
character elsewhere. Tardy and incomplete establishment of the rash
when the symptoms indicate an attack of ordinary or more than ordinary
severity is commonly due to some perturbating cause, especially
diarrhoea. In the _London Lancet_ for Aug. 16, 1879, cases are related
of supposed scarlet fever without the rash, cases in which pharyngitis
and stomatitis with the strawberry tongue occurred, without
efflorescence upon the skin; but it is to be remembered, as stated
above, that the inflammations which commonly attend or follow scarlet
fever, particularly the pharyngitis and nephritis, not infrequently
occur in those who have already had scarlatina, and occur more than
once from fresh exposure to scarlatina patients. These inflammations,
occurring under such circumstances, appear to be purely local
maladies, produced by the scarlatinous virus; and it seems to me a
question whether, in the so-called scarlatina without efflorescence,
the inflammations which are present, and which undoubtedly have a
scarlatinous origin, are not local in their nature, instead of being
local manifestations of the constitutional disease. The burning and
itching sensation produced by the rash increases the restlessness of
the patient, and is sometimes the most annoying of the symptoms.
The temperature in the common favorable forms of scarlet fever usually
varies from 101° in the mildest cases to 103° or 104° in those more
severe. If it attain 105° or over, the case is properly designated
grave or severe. The febrile movement commonly fluctuates but little
from day to day till the fourth or fifth day, when, if the case be
favorable and no complication occur, it begins to decline. The
temperature is as high in the beginning of the attack as subsequently.
The symptoms pertaining to the digestive system during the initial
period of scarlet fever have been sufficiently described. The
subsequent symptoms referable to this system do not differ materially
from those present in the beginning, except the absence of vomiting.
The lips are dry and often cracked. The inflammation of the mouth and
throat continues, with anorexia and thirst. With the decline of the
disease the appetite gradually returns, but it is not till the close
of the second week that it is fully restored. Great and continued
disturbance of the digestive apparatus, seriously interfering with the
nutrition, pertains to the malignant forms of scarlet fever.
The urine is high-colored, and in robust children during the first
days of scarlet fever it frequently deposits urates on cooling. Gee,
who has carefully investigated the state of the urine in scarlet
fever, says that the quantity of water is diminished and the urea is
not necessarily increased during the pyrexia; that the chloride of
sodium is diminished till the fourth, fifth, or sixth day, and that
the phosphoric acid is diminished during the climax of the pyrexia,
though not during the first three or four days. In one case he made a
daily estimation of the amount of uric acid, and found it greatly
diminished on the second and third days, normal on the fourth, and
much increased on the fifth. He believes that similar variations are
common in the quantity of the products excreted {506} in the urine.
Bile may also appear in the urine, coincident with a yellow tinge of
the conjunctiva.[1]
[Footnote 1: Article on scarlatina in Reynolds's _System of
Medicine_.]
The duration of scarlet fever varies in different cases. If the attack
be very mild, with little efflorescence, the febrile movement may
decline by the fourth or fifth day; but if the disease be severe,
little or no amelioration of symptoms may occur before the twelfth or
fourteenth day, even when no complication has occurred to increase the
temperature or cause aggravation of symptoms. Octerlony, who estimated
the duration of scarlet fever from the commencement of febrile
symptoms to "the disappearance of fever, with marked improvement in
leading symptoms," ... "found that the average duration of the disease
in forty cases was six and one-sixth days. The minimum duration in a
very slightly-marked case was three days: the maximum duration was
fourteen days." In general, prolongation of fever beyond the usual
time is due to some complication--more frequently to unusually severe
pharyngitis, with accompanying cellulitis, than to any other cause.
The malady whose commencement was so abrupt declines gradually. In
ordinary cases, by the close of the first week or in the beginning of
the second the rash becomes less and less distinct, and finally
disappears, as do also the redness and swelling of the buccal and
faucial surfaces. The engorgement of the tonsils and of the papillæ of
the tongue subsides, the appetite returns, the countenance brightens
and becomes natural, and the child, who during the height of the fever
scarcely noticed objects or noticed them with indifference or even
repugnance, can be amused as before his sickness.
Desquamation succeeds. This begins at about the sixth day, and is not
completed till the tenth or twelfth day; often not till the close of
the third or in the fourth week. The amount of desquamation
corresponds with the intensity and duration of the efflorescence, or
rather of the dermatitis which produces the efflorescence. If the
efflorescence have been slight and partial, it will be slight, perhaps
scarcely appreciable, but if the rash have been general, full, and
protracted, exfoliation occurs upon every part. It begins about the
face and neck, and within a day or two appears upon other parts. Where
the skin is thin the epidermis as it is detached presents a
furfuracous appearance; where it is thick, as upon the palms of the
hands or soles of the feet, it separates in layers of considerable
thickness.
Such is a brief description of scarlet fever when it pursues its
normal course without any disturbing element, but there is no other
disease in which complications and sequelæ so frequently occur. The
liability to them renders the prognosis in every case doubtful. They
largely increase the percentage of deaths. They occur both in mild and
severe forms of scarlatina.
The difference in type in different cases and epidemics has already
been alluded to. Scarlet fever is sometimes so mild, and its symptoms
so slight, that the diagnosis is necessarily uncertain. In the spring
of 1866 I was called to an infant thirteen months old who had slight
pharyngitis and an indistinct rash over a part of the surface. In two
days the eruption had disappeared, and the health within a day or two
later was apparently fully restored. Diagnosis would have been
doubtful except for sequelæ {507} which clearly indicated the
scarlatinous nature of the attack. In another instance two children
passed through the entire course of scarlet fever playing every day in
the street. Although the intelligent grandmother saw the rash upon
them, its nature was not suspected, as it was midsummer and cases of
prickly heat common, till nearly two weeks afterward, when one of the
children had nephritis and anasarca ending fatally. In cases so mild
as these the heat of surface is but slightly increased, the pulse but
little accelerated, and the rash usually does not occupy so much of
the surface as in ordinary cases; the appetite is not lost, though
diminished, and the thirst is moderate.
Between scarlet fever so mild that it terminates in four or five days,
and that of the grave or malignant type presently to be described, all
grades of severity exist. Scarlet fever occurs in all forms from mild
to severe, but certain symptoms characterize grave or malignant
cases--symptoms which are absent or much less prominent in ordinary
scarlet fever. Therefore the grouping of cases according to the type
is proper, and facilitates the studying of the disease.
GRAVE FORM (malignant scarlet fever).--This form of the disease is in
some epidemics common, while in others it is rare. The symptoms which
characterize it are severe from the beginning, those of the nervous
system predominating at first, such as intense cephalalgia,
restlessness or stupor, sudden twitching of the muscles, and perhaps
delirium, or even convulsions. Many pass rapidly into coma and die
within two or three days, succumbing to the intensity of the
scarlatinous poison while the malady is still in its commencement. The
rash is dusky. It disappears by pressure, and returns slowly when the
pressure is removed, showing extreme sluggishness of the capillary
circulation. Some patients are very drowsy, lying in a semi-comatose
state except when aroused, and if aroused are very restless. Others
are constantly restless. If placed in one position on the bed, they
throw themselves in another in a half-conscious or unconscious state.
They do not speak, or they mutter like those affected by the graver
forms of typhus, calling the names of playmates or talking
incoherently about things which interested them when well. The
thermometer placed in the axilla is found to rise above 103°, which is
a safe average, to 105° or even 107°, and the heat of the surface is
pungent except when the case approaches a fatal termination, when the
extremities, ears, and nose may be cool while the trunk and head are
extremely hot. The pulse from the first is rapid, ranging from 130 as
the minimum in a malignant case to a frequency which can scarcely be
counted. A very frequent pulse is nearly always feeble and
compressible. Irritability of the stomach is one of the most common
symptoms in grave cases, so that many patients immediately reject the
nutriment and stimulants which are so urgently required to sustain the
vital powers. The vomiting, therefore, if frequent and severe, greatly
increases the danger, and in not a few instances this symptom is
associated with diarrhoea, which also tends to increase the
prostration.
Severe and dangerous nervous symptoms, due to the intensity or
activity of the scarlatinous poison, occur chiefly within the first
three or four days. Grinding the teeth, sudden muscular twitching,
delirium, convulsions, and profound stupor occur for the most part
within this time. Afterward the danger is mainly from exhaustion,
unless in the {508} second week or subsequently, when nervous symptoms
may arise from uræmia.
Those who survive the onset of malignant scarlet fever often have in
the course of a few days severe pharyngitis, with extension of the
inflammation to the lymphatic glands and connective tissue around the
angle of the jaw. These inflammations cause more or less external
swelling. The faucial turgescence around the entrance of the larynx,
with the accompanying secretion of viscid mucus or muco-pus, often
causes noisy respiration, and many at this stage of the attack breathe
with the mouth constantly open to facilitate the ingress of air.
Ordinarily, no discharge occurs at first from the nasal surface, but
as the disease continues, if the type remain severe, defluxion of thin
muco-pus takes place from the Schneiderian surface, which frequently
excoriates the cheek. The lips also are apt to be sore and swollen.
In malignant cases the disease is more protracted than when the type
is mild. Thus in a recent case in my practice the rash was still
distinct at the close of the second week, though the temperature had
fallen from 105° to 102° and some desquamation had appeared. Long
continuance of the febrile movement is, however, oftener attributable
to some inflammatory complication than to the primary disease.
In all epidemics of a severe type cases now and then occur in which
the poison is so intense, or it acts with such frightful energy, that
death occurs even within the first day. The patient is overpowered at
the outset of the disease by the virulence of the specific principle,
perishing in coma, preceded perhaps by convulsions. The autopsy in
such cases reveals hyperæmia of the brain and cranial sinuses, blood
of a dark-red color, capillary hemorrhages in various parts, a flabby
heart, and perhaps some engorgement of the spleen and kidneys.
Usually, malignant scarlet fever exhibits its severe type from the
first, but cases sometimes occur which seem mild and favorable for a
few days, when severe symptoms suddenly supervene. This change from a
mild to a dangerous disease is, however, most frequently, I think, due
to some complication.