usually due to some perturbating cause, which is often a pre-existing
or co-existing disease, or a disordered state of system through causes
distinct from the scarlatinous disease. Thus, a little girl in my
practice had the symptoms of scarlet fever, such as febrile movement
and inflammation of the buccal and faucial surfaces, nearly a week
before the scarlatinous eruption appeared. During this time the
patient had an intestinal catarrh, with diarrhoea, which declined when
the rash occurred. This intestinal disease was the apparent cause of
the irregularity in the malady. If scarlatina occur during a severe
attack of entero-colitis attended by purging, the defluxion from the
external surface may be such that no efflorescence appears. Severe
scarlet fever itself sometimes appears to cause gastro-intestinal
catarrh so as to produce an afflux of blood toward the intestinal
tract and away from the skin. Practitioners occasionally meet cases
like the following, which I recall to mind: In a family where
scarlatina was prevailing a little child early after the commencement
of symptoms which seemed to be plainly referable to this exanthem was
seized with vomiting and purging, which continued till death {509}
occurred on the third day. No efflorescence appeared upon the skin,
but the symptoms indicated the presence of severe intestinal catarrh,
complicating and masking scarlatina. We are aided in the diagnosis of
such cases by observing the faucial redness, and we may discover a
faint efflorescence upon parts of the surface, as about the groin or
in the flexures of the joints. In another instance an infant in the
warm months having protracted entero-colitis, the usual summer
epidemic of the cities, had the characteristic symptoms of scarlet
fever, which was present in the family, but the diarrhoea continued
and no rash appeared.
In one who is much reduced by an antecedent disease, as phthisis, or
who has a disease, chronic or acute, which produces a decided afflux
of blood away from the surface and toward the interior of the body,
the eruption is commonly tardy in its appearance, indistinct, or
wholly absent. Thus, severe inflammations of internal organs not
infrequently render scarlet fever irregular. On the other hand, some
maladies occurring in connection with this exanthem do not change its
symptoms, but themselves undergo modification. Pertussis may be cited
as an example, the cough of which is sometimes modified by an
intercurrent attack of scarlet fever, the symptoms of the latter
disease undergoing little change.
Scarlet fever may also be irregular without any apparent perturbating
cause. In 1867 I attended a young lady whose previous health had been
good, and whose brother was sick at the time with scarlet fever. She
had considerable febrile movement, with severe pharyngitis, and,
though her surface was repeatedly examined, no efflorescence was seen.
Two weeks subsequently she was affected with severe nephritis,
anasarca, effusion into at least one of the pleural cavities, oedema
of the lungs, and probably hydro-pericardium, the case ending fatally.
Rilliet and Barthez state that a second attack of scarlet fever is
more apt to be irregular than the first. Probably this opinion is
correct, especially if only a short time have elapsed between the two
seizures. Still, as we have already stated, both seizures may be
typical, and the second more severe than the first.
It would be impossible to make a clear and positive diagnosis of
certain cases of irregular scarlet fever, in which cerebral,
pulmonary, or gastro-intestinal symptoms predominate, were it not for
the fact that they occur in connection with other cases of scarlet
fever or are followed by sequelæ which evidently have a scarlatinous
origin.
Occasionally, the eruption, if it be intense or if a certain condition
of system be present in the patient, is accompanied by more or less
extravasation of blood-corpuscles from the capillaries, so that the
redness does not entirely disappear on pressure, usually in points. In
rare instances certain of the exanthematic fevers present an extreme
hemorrhagic character, so as to be beyond the reach of remedies, and
of necessity speedily fatal. Hemorrhagic cases of this severe form are
probably more common in variola than in the other fevers, but I have
met a notable case in what was diagnosticated scarlatina. In June,
1881, a man in his thirty-second year, whose previous health had not
been good, though he had no defined ailment and had been able to
follow his occupation of harness-maker, suddenly became very ill, with
high febrile movement and faucial inflammation, attended by marked
prostration. After some hours an intense eruption of a scarlatinous
appearance covered nearly the entire surface, and on the following day
hemorrhages began to occur. The urine {510} contained a large
proportion of blood; each conjunctiva was raised by hemorrhages
underneath (ecchymosis), so that its natural color was lost and the
eyelids closed with difficulty; and blood flowed from the nostrils,
gums, and under the skin, forming hemorrhagic points and blotches. One
of the consulting physicians, perceiving the resemblance to
hemorrhagic variola as described by Hebra, suspected that we had a
case of this formidable malady to deal with, but the time for the
appearance of the variolous eruption passed by without its occurrence.
Death took place on the fifth day. The temperature during the sickness
was high, though the record of it has been mislaid. Fortunately, such
severe hemorrhagic cases, which are necessarily fatal, are rare.
COMPLICATIONS AND SEQUELÆ.--Scarlet fever, if its type be severe, is
in itself dangerous to life. Many, as we have seen, perish from its
direct effects when it produces profound blood-poisoning. But, while
the ordinary epidemics of this malady are necessarily attended by a
large mortality from the virulence and depressing effect of the
specific principle, unfortunately, of all the diseases of modern
times, scarlatina ranks first as regards the number and gravity of its
complications and sequelæ, so that nearly or quite as many perish from
these as from the direct effect of the poison.
Nervous accidents occur chiefly at two periods--to wit, in the first
days, when they are due to the severity and malignancy of the malady
and to the impressible nervous temperament of the child, and in the
declining stage, or after the termination of the fever, when they
occur from uræmia. If the type be malignant, delirium, jactitation,
profound stupor, and convulsions frequently occur on the first and
second days; and they are symptoms which properly excite the utmost
alarm and demand all the resources of our art, since they indicate a
form of the disease which is apt to end in speedy death. The eyes have
a dull or wild expression, the conjunctiva is suffused, the heat of
surface pungent, the pulse rapid and compressible or feeble, rising
above 150, even to 200, per minute, and the temperature is always
elevated to a degree that involves danger, the thermometer not
infrequently indicating 105° or 106°. But this severe form of scarlet
fever, attended by so great elevation of temperature, is much less
dangerous than in former times, even though it be complicated by
delirium and convulsions, since we no longer hesitate to reduce bodily
heat, when excessive, by the free use of cold baths, and have
discovered potent agents in the bromides and chloral for controlling
convulsions. Nevertheless, not a few perish in the commencement of
scarlet fever with predominating cerebral symptoms, as delirium or
eclampsia, followed by coma, under the best possible treatment.
Sometimes the symptoms have closely simulated those of acute
meningitis, and if the rash have been delayed and the sore throat is
as yet slight, the physician may suspect that he is dealing with this
disease; but autopsies in such cases show no inflammatory lesions, but
only congestion of the cerebral and meningeal vessels.
As is stated in a preceding page, in every case of normal scarlet
fever inflammation of the faucial surface is present, as indicated by
redness, tenderness, and increased secretion of mucus or muco-pus. It
precedes the efflorescence on the skin, and is announced by pain in
swallowing and on pressure with the fingers behind and below the
angles of the jaw. In that form of scarlet fever which has been
designated anginose the {511} pharyngitis is severe, and is a
prominent element in the malady, the uvula, the pillars of the fauces,
and the faucial surface in general being infiltrated and swollen.
Nevertheless, this inflammation, with the accompanying tumefaction, is
properly a part of the disease, rather than a complication, if it
abates with the subsidence of the scarlet fever or begin to abate soon
after, and if it produce but slight destructive change in the tissues
of the neck. The secretions from the fauces may be foul and offensive;
even superficial ulcerations or gangrene may occur upon the faucial
surface, causing it to present a dark brown or jagged appearance, and
the tissues of the neck may be infiltrated to a certain extent, and we
designate the disease a form of scarlet fever under the title
anginose. But when this condition is greatly aggravated, so that there
is extensive infiltration and swelling of the tissues of the neck,
with an amount of ulceration or gangrene which in itself involves
danger, continuing after the primary disease abates, prolonging the
fever and reducing the strength, it is proper to regard the state of
the throat as a complication. In addition to the pharyngitis, which is
severe as described above, the sides of the neck around the angles of
the jaw become swollen, hard, and tender. The inflammation has been
propagated to the deeper structures of the neck. Poisonous substances,
the result of decomposition or vitiated secretions, traverse the
lymphatic vessels from the faucial surface, and, being intercepted in
the lymphatic glands, cause adenitis, and the inflammation extends
from the glands to the adjacent connective tissue, which becomes hard,
tender, swollen, and infiltrated with inflammatory products. This
tumefaction sometimes begins by the second or third day, but it is
usually about the close of the first week or in the beginning of the
second week that it becomes so considerable as to constitute a source
of danger and anxiety. It is in most cases bilateral, though one side
may begin to swell before the other and remain larger throughout.
In severe cases of this complication the tumefaction extends from ear
to ear, filling up the space below and around the angles of the jaw
and under the chin. Not only is deglutition difficult, but it is
difficult to open the mouth sufficiently to inspect the fauces, and
attempts to do so cause much pain. The lymphatic glands, which lie in
the inflamed area and participate in the inflammation, are greatly
enlarged by hyperplasia, the round granular lymph-cells multiplying so
abundantly that the glands increase to many times their normal size.
Most of the tumefaction is, however, due to extension of the
inflammation to the connective tissue of the neck. The cellulitis,
which resembles that occurring in other conditions, is attended by
distension of the capillaries, the abundant formation of young round
cells, and transudation of serum (Billroth). A moderate amount of
tumefaction may disappear by resolution, but if it be considerable it
seldom abates in this way, but by the tedious and exhausting process
of suppuration or gangrene. If the swelling at its most prominent
point present a reddish hue, all hope of producing resolution must be
abandoned; it cannot be effected by any medicine or appliance within
the resources of our art. The abscess which forms is apt to be
diffuse, so as to involve danger of pyæmia, unless it be soon opened
and properly washed out. With the discharge of the pus the swelling
gradually softens and declines. In other cases gangrene results. The
vessels in the inflamed part are compressed by the inflammatory
products, so that {512} they no longer convey the blood which is
required for the purpose of nutrition. It is a law of the economy that
whenever the circulation ceases, the tissues which receive their
nutritive supply through the obstructed vessels lose their vitality.
Hence gangrene occurs in all that portion of the swelling in which the
circulation is arrested. The skin over it peels off, the dead tissue
underneath is brown or dark, and soon, if life be prolonged, the
slough begins to separate. The prognosis as regards this complication
depends largely on the size of the slough. If it be large, death will
probably result, since the strength of the system is already reduced
by the primary disease, and the reparative process will necessarily be
slow, while abundant suppuration tends to increase the exhaustion. In
some of the worst cases of cervical gangrene which I have seen the
slough has laid bare the muscles and vessels of the neck, producing in
one case a cavity or excavation sufficiently large to admit a hen's
egg. Often the slough extends under the skin, so that the deepest
recesses of the cavity are not visible, and occasionally in cases
which have ended fatally in my practice severe hemorrhage occurred
from the concealed vessels. If the ulcerative or gangrenous process
extends so deeply into the tissues of the neck that hemorrhages occur,
death is the common result; but if the destructive action be of
moderate extent and other conditions favorable, we may expect recovery
through cicatrization, with perhaps some deformity by contraction of
the cicatrix.
When the inflammation of the connective tissue of the neck is
extensive, involving both the lateral and anterior regions of the
neck, the patient is in a perilous state. The cellulitis, when
extensive and accompanied by much swelling, may produce oedema of the
glottis, may obstruct respiration by compressing the air-passages or
the laryngeal nerves, may cause compression of the jugular veins, and
thus give rise to dangerous cerebral symptoms, or may lay bare and
injure important muscles and nerves, as we have seen. If the
ulceration or gangrene be extensive, and death do not occur by
hemorrhage from arterial or venous twigs, septic poisoning may occur,
increasing still more the fatal nature of the malady.
Some cases of this complication are melancholy in the extreme, as one
related by Cremen, in which ulceration of the pharynx occurred,
allowing the escape of food and preventing deglutition. In severe
scarlatinous pharyngitis the inflammation is apt to extend along the
Eustachian tube, causing its occlusion. This accident will be
considered when we treat of otitis media, another grave complication.
It often also extends into the nares, causing catarrh of the
Schneiderian mucous membrane, with discharge of muco-pus from this
surface. Not infrequently ulceration or gangrene occurs in the faucial
surface, producing more or less destruction of tissue and forming
excavations which connect with the throat, while the cutaneous surface
retains its integrity and is not even reddened. The following case
shows how grave the complication which we are now considering
sometimes is when the external surface of the neck is not involved,
and how the inflammation by extension outward from the fauces may
involve the middle ear.
_Case 1._--Annie K----, aged two and a half years, an inmate of the
New York Foundling Asylum, was well, except an eczema of the scalp,
until the night of April 3, 1882, when she was attacked with vomiting
and {513} diarrhoea. She was feverish and drowsy, and at 2 P.M. on the
4th the scarlatinous efflorescence appeared upon her neck, body, and
lower extremities; tongue coated; pharynx red; temperature (axillary)
103°; pulse 160. The symptoms and aspect indicated a grave form of the
malady, and the usual sustaining treatment was ordered. On April 5th
the temperature was 102°, pulse 144, tongue less coated, eruption
fading, less stupor, no albumen in urine. April 6th, morning
temperature 102°, pulse 160; passed a restless night; stools thin and
too frequent; has grayish patches in the throat: P.M. temperature
103-1/5°, pulse 150. April 7th, the diarrhoea continues, and she has a
copious muco-purulent discharge from the nostrils; P.M. temperature
103-3/5°, pulse 160. April 10th, the temperature has continued at
about 103°; the patient is very sick, with a constant foul-smelling
discharge from the nostrils; breath very offensive; temperature
103.5°, pulse about 180. April 12th, general appearance a little
better, but the posterior surface of the fauces is completely covered
by a thick pseudo-membrane; had four loose stools last night;
temperature and pulse the same as at last record; a dark, offensive,
and jagged coating over the fauces, and a dark, foul discharge from
the nostrils, as before; examination of the chest negative. April
14th, is much prostrated; temperature 104.5°, pulse rapid and weak;
respiration noisy, diminished resonance over lower two-thirds of left
side of chest; ulcers upon the mouth and tongue; fauces red and
ulcerated. April 17th, pulse 150, temperature 100.5°; general
appearance somewhat better, but the diarrhoea continues, and patches
of a diphtheritic character have appeared upon the lips; moist râles
in left side of chest. The symptoms continued nearly the same until
April 23d, when she died. A dull percussion sound and distinct
bronchial respiration were observed in the left scapular region during
the last days of her life.
Autopsy nine hours after death by the curator, Dr. W. P. Northrup:
Body well nourished; the tissues have a jaundiced hue; lips sore; on
turning the head to one side pus runs from the left ear and dirty
muco-pus from the mouth. Brain normal; on opening the petrous portion
of the left temporal bone the middle ear is found full of pus, which
communicated freely with the external ear through a perforated
membrana tympani; the Eustachian tube cannot be traced in the sloughy
tissue, and a passage filled with pus extends from the ear to the
fauces; opposite the greater cornua of the hyoid bone are two deep
ulcers, each having about the diameter of a ten-cent piece, with
sloughy and offensive base and sides; the left ulcer communicates by a
ragged and wide sinus with a dark and sloughy cavity of about four
drachms capacity; this cavity is located in the neck under the angle
of the jaw, apparently occupying the site of a disintegrated gland,
and it opens upon the surface of the fauces. The surface of the larynx
has a dusky, dirty appearance, sprinkled with little cheesy-looking
spots, and covered by a dirty, foul-appearing liquid, as if some of
the ichorous pus had escaped into it from the neck; about one and a
half inches below the vocal chords there is an unmistakable
pseudo-membrane; below this, near the bifurcation, the trachea has a
bright-red color, as if a pseudo-membrane had been peeled from it,
leaving the surface raw. The detachment of a pseudo-membrane from this
part, if it did occur, must have been ante-mortem, for the organ had
been carefully handled {514} in making the autopsy. Between the apex
of the left lung and the median line the tissues of the neck,
dissected upward, are found indurated, yellow, and giving an offensive
odor, showing that the cervical cellulitis had extended downward
farther than usual. The bronchial glands have undergone hyperplasia,
being enlarged and hard. The right lung is normal; about one-half of
the left lower lobe is consolidated, and when cut is found to be
gangrenous and offensive. The liver is apparently somewhat enlarged;
spleen normal in size; gastric mucous membrane has a congested
appearance and is covered with mucus; mesenteric glands enlarged,
pale, and firm; Peyer's patches swollen and pale; at lower end of
ileum some pigmentation of these glands; in large intestine the
solitary glands are enlarged, and a few of them pigmented; kidneys
pale, cortex thickened, and markings indistinct. Microscopical
Examination.--In the pia mater perhaps a little increase of cells;
meninges of brain otherwise normal. The trachea shows well-marked
diphtheritic inflammation; it contains a film of pseudo-membrane;
evidences of inflammation occur also upon the laryngeal surface,
though less marked than in the trachea. The solidified portion of the
lung exhibits the ordinary lesions of broncho-pneumonia, with some
interstitial change. In the kidneys we find parenchymatous nephritis,
with some cell-growth in the Malpighian bodies.
The above case has been related at length, not only because it shows
how severe and destructive the inflammation of the throat, extending
into the tissues of the neck, sometimes is, but because four other
complications or sequelæ were also present--to wit, otitis media,
diphtheria, nephritis, and pneumonia. We see from the above case how
formidable a disease scarlet fever sometimes is when attended by the
inflammations to which it so frequently gives rise, for a child older
and stronger than this, if thus affected, would necessarily have
perished with the best possible treatment.
In localities where diphtheria is endemic, as in New York City and
Paris, scarlet fever is often complicated by a pseudo-membranous
inflammation of the fauces and air-passages. In severe cases of
scarlet fever the Schneiderian as well as the faucial surface is
covered with it, so that it can be readily seen on inspecting the
anterior nares. Occasionally, the pseudo-membrane appears upon the
laryngeal and tracheal surfaces, as in the case which I have related
above and in others presently to be related, causing dangerous
embarrassment of respiration. This complication sometimes begins
almost at the commencement of scarlet fever, but in most instances it
does not occur before the third or fourth day, and it sometimes does
not appear till in the declining stage of the fever. When it begins,
it intensifies the febrile movement and produces general aggravation
of symptoms.
The common opinion is, that whenever a pseudo-membrane occurs upon the
inflamed mucous surface in scarlatina true diphtheria has supervened;
but there are those who hold that scarlet fever itself, when the
inflammations which attend it are severe, may give rise to
pseudo-membranes, so that what seems to be diphtheritic is but an
element in the primary disease. My convictions are strong that when
pseudo-membranes occur on any of the inflamed mucous surfaces in
scarlet fever, true diphtheria has, with few exceptions, supervened if
the patient live in a {515} locality where diphtheria is prevalent.
That scarlet fever may occur in an individual along with another acute
infectious malady is shown by abundant cases. It often occurs with
varicella, and J. Herzog relates the following case, in which measles
and scarlet fever coexisted:[2] A boy aged eight years had measles,
with the usual catarrhal symptoms, and on the fourth day, as the
temperature was returning to the normal, it rose again suddenly, and
the scarlatinal rash and sore throat appeared. In due time these
subsided, and desquamation occurred. I have seen a similar case in
consultation during the current year, so that there is nothing
improbable in the theory that scarlet fever may coexist with other
infectious maladies; and it is admitted that diphtheria, like
erysipelas, may complicate the most diverse constitutional diseases.
Moreover, when a child with pertussis, measles, typhoid fever, or
tuberculosis suddenly develops a high fever with the occurrence of a
pseudo-membranous inflammation upon the fauces or air-passages, all
admit that diphtheria has supervened, since such inflammation is not
an element in any form or type of either of these diseases; and I see
no reason in the nature of the disease why scarlet fever should not be
equally liable to this complication.
[Footnote 2: _Berl klin. Woch._, 1882, No. 7.]