Klein found evidence of intense interstitial inflammation, and also
emboli, consisting of fibrin with a few cells, in the arteries, both
in those of large size and in the arterioles, chiefly where they enter
the Malpighian corpuscles. {529} He states that in the specimens which
he examined the more intense the degree of interstitial change, the
greater was the enlargement of the kidneys, and the more distinct also
were the evidences of parenchymatous nephritis in the urinary tubes,
which either contained casts or were in the process of destruction. By
being crowded with inflammatory products, especially cells, the
Malpighian corpuscles were obliterated, undergoing fibrous
degeneration. A very curious fact observed was the deposit of lime in
the urinary tubes, first of the cortex, and then also of the pyramids,
at an early stage of scarlet fever, when the kidneys otherwise showed
only slight change. Several observers, as Biermer, Coats, and Wagner,
have each described a case of scarlet fever with interstitial
nephritis, which they consider unusual; but Klein has apparently
demonstrated, as we have seen, by a large number of microscopic
examinations, that this form of nephritis is common after the ninth or
tenth day.
Nephritis, in proportion to its extent and gravity, is accompanied by
languor, febrile movement, thirst, loss of appetite and strength. At
first the patient experiences but slight pain in the head or
elsewhere, and the quantity of urine is not notably diminished; but as
the disease continues urination becomes less frequent and the urine
more scanty. Albuminuria occurs, while the urea is only partially
excreted, and therefore accumulates in the blood. If the nephritis be
so severe or protracted that this principle accumulates to a certain
extent, grave symptoms occur, as headache, vomiting, apathy or
restlessness, and, more dangerous than all, eclampsia, which is not
unusual in these cases. Microscopic examination of the urine shows the
presence in this liquid of blood-corpuscles, granular epithelial
cells, and hyaline or granular casts, or both. The specific gravity of
the urine is diminished. But a large quantity of albumen in the urine
may render the specific gravity as high or higher than in health.
The altered state of the blood soon gives rise to transudation of
serum, first observed in most cases as an anasarca occurring in the
feet and ankles. The oedema, if not checked by treatment or through
mildness of the disease, extends over the limbs, scrotum, and
sometimes upon the trunk. It is well if the dropsy remain limited to
the subcutaneous connective tissue, but, unfortunately, it is apt to
occur, if the nephritis continue, in and around the internal organs,
producing, mentioned in the order of frequency, pulmonary oedema,
effusion into the pleural and peritoneal cavities, the pericardium,
the encephalon, and lastly into the connective tissue of the larynx,
causing that very fatal complication, oedema of the glottis. Although
this is the common order in which dropsies occur, exceptions are not
infrequent. Even the anasarca may not be the first to appear, although
in the vast majority of cases it has the precedence. Thus, Rilliet
relates the case of a boy of five years who twenty days after the
occurrence of scarlet fever, and six hours after the appearance of
bloody and albuminous urine, had double hydrothorax, rapidly
developed. As long as the hydrothorax continued no anasarca was
observed, but as it declined anasarca appeared. Legendre cites a case
in which oedema of the lungs occurred without anasarca or other
dropsy. Occasionally, the anasarca and internal dropsies take place
nearly simultaneously. The nephritis and consequent serous effusions
usually appear within three weeks after scarlet fever ends, but cases
occur in which the effusions are first observed as late as the fourth
and fifth weeks. The patient may be {530} considered to possess
immunity from this sequel if he have reached the close of the fifth
week after the abatement of scarlet fever without its occurrence.
The dropsy is usually acute, but it may assume the chronic form, since
the nephritis which causes it, happily curable in most instances, may,
if neglected, become chronic. Whether the dropsy in itself involve
danger depends in great part on its location. Anasarca and ascites may
exist a long time with little suffering or danger, but a small amount
of serum in certain other localities causes alarming symptoms and
speedy death. Oedema of the lungs, hydro-pericardium, oedema of the
glottis, and intracranial effusions are always dangerous, and the last
two are sometimes fatal within twenty-four to forty-eight hours.
Oedema of the lungs has been fatal within twelve hours from the
occurrence of the first symptoms of obstructed respiration.
Cerebral symptoms occurring during scarlatinous nephritis are probably
sometimes due to the irritating effect of the retained urea on the
nervous centre. In other cases the cause appears to be cerebral oedema
or compression of the brain by effusion of serum within the ventricles
and upon the surface of the brain. Headache, dull or severe,
dilatation of the pupils or their oscillation in the same degree of
light, vomiting with little apparent nausea, are common symptoms of
scarlatinous nephritis when it has continued a few days, and the
excretion of urea is so diminished that this substance begins to exert
its poisonous effect on the system. Such symptoms are apt to be
followed by somnolence, threatening coma, or by eclampsia, unless the
patients are promptly and properly treated. In some patients that die
of scarlatinous nephritis, death occurring in convulsions or coma, no
appreciable lesions are observed within the cranium, unless more or
less congestion, the fatal ending being attributable to the uræmia. In
other instances we find an effusion of serum within the ventricles or
upon the surface of the brain. Although the symptoms in scarlatinous
nephritis and uræmia may appear very unfavorable, the prognosis is
usually good under prompt and appropriate treatment. Thus severe
convulsions and a degree of somnolence that bordered on coma may
abate, and convalescence be fully established within a few days, and
Rilliet and Barthez announce ten recoveries in thirteen patients
affected with convulsions due to this renal affection.
ANATOMICAL CHARACTERS.--Scarlet fever being, as we have seen, a
constitutional febrile disease of an ataxic nature, and accompanied by
certain inflammations, necessarily affects the composition of the
blood; but since this disease varies so greatly in type or severity,
the state and appearance of this liquid also vary. At the autopsies of
the more malignant cases we find the blood dark and fluid, with small,
soft, and dark clots in the heart and large vessels. In other cases
the clots are large, firm, and solid, as described in a preceding
page. In malignant cases that end fatally Rilliet and Barthez state
that both the large and small vessels of the cerebral meninges and the
brain are found hyperæmic, but in a variable degree. In those who die
in coma, preceded by delirium or convulsions, during the eruptive
stage, the intracranial congestion is usually marked, with perhaps
some transudation of serum, but without inflammatory lesions. The
fibrin in scarlet fever remains in about normal proportion, except as
it is increased by inflammatory {531} complications. Andral found an
increase in the proportion of blood-corpuscles from 127 to 136 parts
in 1000.
The respiratory apparatus, except the Schneiderian membrane, is
usually normal when no complications exist. Samuel Fenwick[6] made
post-mortem examinations in sixteen cases of scarlet fever, and
concludes from them that inflammation of the mucous membrane of the
stomach and intestines occurs like that of the skin, followed by
desquamation of the epithelial cells, like that of the epidermis. I
have had the opportunity of examining the stomach and intestines of
those who died of scarlet fever in the eruptive stage, and have not
found any unusual hyperæmia of the gastro-intestinal surface, except
when gastro-intestinal inflammation, usually indicated by diarrhoea,
had occurred as a complication.
[Footnote 6: _London Lancet_, July 23, 1864.]
In some cases the abdominal organs exhibit changes which suggest a
resemblance to typhoid fever. The spleen is enlarged and somewhat
softened, and Peyer's patches and the solitary glands are thickened
and prominent, but less in degree than in typhoid fever. The
mesenteric glands also are in a state of hyperplasia. In other
patients these parts appear normal.
Klein made microscopic examination of the liver in eight cases, and
states that he found granular opaque swelling of liver-cells, and
changes in the internal and middle coats of certain arteries similar
to those observed in the kidneys, which have been described above. He
also found evidences of interstitial inflammation, as an increase of
round cells and connective tissue in the liver. He remarks also that
he observed hyaline degeneration of the intima of arteries in the
spleen. Rilliet and Barthez state that swelling and softening of the
spleen are exceptional in scarlet fever, but are sufficiently common
to merit attention. In post-mortem examinations which I have witnessed
nothing noteworthy has appeared to the naked eye in the state of the
liver, nor ordinarily in that of the spleen.
The efflorescence, though one of the anatomical characters, has
perhaps been sufficiently described in the foregoing pages. It begins
over the neck, chest, and groins as numerous reddish points not larger
than a pin's head, closely crowded together, but with skin of normal
color between. It is estimated that the aggregate efflorescence and
aggregate normal skin over a given area are about equal. If the
cutaneous circulation be active and the febrile movement be
considerable these spots extend and coalesce, producing an
efflorescence like erythema or like the hue of a boiled lobster, to
which it has been likened. The efflorescence, less upon the face than
upon the trunk, contrasts in this respect with that of measles, in
which the rash is full in the face, often causing some swelling of the
features. It is also less upon the palmar and plantar surfaces than
elsewhere. It scarcely causes any perceptible elevation of the skin,
but in certain localities, as upon the backs of the hands and upon the
fore-arms, it communicates the sensation of slight roughness. The seat
of the efflorescence is mainly in the superficial layers of the skin,
but it is said that it sometimes has occurred upon a cicatrix, as that
from a burn. In the robust and in favorable cases in which the
circulation is active the rash has a scarlet hue, and when the
cutaneous capillaries are emptied and the skin rendered pale by
pressure with the {532} fingers, the circulation immediately returns
when the pressure is removed. In malignant cases the color is not
scarlet, but dusky red, and so sluggish is the capillary circulation
that the skin when pressed upon recovers the blood very slowly. In
grave cases also extravasation of blood in minute points or
transudation of its coloring matter is apt to occur in portions of the
surface, when of course decolorization is not fully produced by
pressure. In cases ending fatally, during the eruptive stage the
efflorescence may entirely disappear in the cadaver, or it remains
upon parts of the surface, especially depending portions. Desquamation
is attributable to the exaggerated proliferation of the epidermis and
the loosening of its attachment by the inflammation.
DIAGNOSIS.--In the commencement of scarlet fever, prior to the
eruption, no symptoms or appearances exist which enable us to make a
positive diagnosis. Positive statement in reference to the nature of
the attack should be deferred, for the credit of the physician. Still,
if a child with no appreciable local disease sufficient to cause the
symptoms a few days after exposure to scarlet fever, or during an
epidemic of this malady, be suddenly seized with fever, the pulse
rising to 110, 120, or more, and the temperature to 102°, 103°, or
105°, scarlatina should be suspected. The diagnosis is rendered more
certain at this early stage if vomiting occur, and especially if the
fauces be red, for hyperæmia of the fauces, due to commencing
pharyngitis, is one of the earliest and most constant of the local
manifestations of scarlatina.
When the eruption has appeared the nature of the malady is in most
instances apparent. The punctate character of the eruption before it
becomes confluent, its occurrence within twenty-four hours after the
fever begins over almost the entire surface, but its absence or
scantiness upon the face, and especially around the mouth, serve to
distinguish it from other diseases.
Scarlet fever and measles were long considered identical by the
profession, and, though the ordinary forms of these maladies can be
readily distinguished from each other, cases occur in which the
differential diagnosis is attended by some difficulty. But there are
differences in the symptoms and course of the two diseases which aid
in discriminating one from the other. Measles begins with marked
catarrhal symptoms, as if from a severe cold. Mild conjunctivitis,
causing weak and watery eyes, coryza, and mild laryngo-bronchitis,
with accompanying cough, precede the eruption three or four days and
continue during the eruptive stage. The febrile movement in the
prodromic stage of measles is remittent, the evening temperature being
two or three degrees higher than that in the morning. Contrast this
with the invasion of scarlet fever, in which the only catarrh is that
of the buccal and faucial surfaces, and there is consequently little
or no cough, and the febrile movement, ordinarily high in the
beginning, is nearly uniform in the different hours of the day. The
scarlatinous eruption appears, as we have seen, within twelve to
twenty-four hours about the neck and upper part of the chest, and
spreads over the body in a shorter time than that of measles, which
appears on the third day. The rash of measles begins to fade at the
close of the third or in the fourth day after its appearance, that of
scarlet fever not till from the sixth to the eighth day. In nearly all
cases of measles, even when the rash is confluent upon the face and a
{533} considerable part of the trunk, in consequence of the high
febrile movement and vigorous cutaneous circulation, we observe the
characteristic rubeolar eruption upon certain parts of the surface, as
the extremities, which, in connection with the history, renders
diagnosis certain.
Erythema resembles the scarlatinous eruption, but its duration is
commonly shorter. It is limited to a part of the surface, and it is
accompanied by much less febrile movement. The temperature in erythema
does not usually rise above 100°, unless for a few hours, whereas in
scarlet fever it continues considerably above 100° for several days.
The scarlatinous efflorescence has also a brighter red or more scarlet
hue than that of erythema, except in the more malignant cases, in
which the severity of the symptoms renders the diagnosis clear. But an
important aid in differentiating the one from the other of these
diseases is the fact that in erythema there is, with few exceptions,
no faucial inflammation, and in the few instances in which it is
present it is slight and transient, fading within a day or two.
Scarlet fever is readily diagnosticated from diphtheria, although the
affinity is close between these two maladies. The early appearance of
the pseudo-membrane upon the fauces in diphtheria, its absence in
scarlet fever, and the absence of any appearance resembling it until
the fever has continued some days, and the characteristic
efflorescence upon the skin in scarlet fever, render diagnosis easy.
If scarlet fever have continued some days when first seen by the
physician, the diphtheritic pseudo-membrane may be present as a
complication, or the fauces may present an appearance like diphtheria
from ulceration or sloughing and the presence of foul and offensive
secretions, which produce a dark-grayish and fetid mass over the
faucial surface. Under such circumstances the character of the disease
is ascertained by the history of the case, and especially by the
occurrence of the scarlatinous eruption. An erythema transient and
limited to a part of the surface sometimes appears in the commencement
of diphtheria, and at a later period, as a result of the toxæmia,
points of a roseoloid appearance and irregular patches, often located
upon the extremities. Both kinds of rash can be readily diagnosticated
from that of scarlet fever, for the erythema, as has been stated, is
transient and partial, and does not exhibit minute points of deeper
injection, while the toxæmic rash differs in form and aspect from that
of scarlet fever, and appears at a stage of the case when the
scarlatinous efflorescence would have faded or begun to fade.
The efflorescence of rötheln sometimes closely resembles that of
scarlet fever, though it is usually more like that of measles; but it
is ordinarily accompanied by symptoms which are much milder than those
of scarlet fever, and it begins to abate as early as the third, and
disappears on the fourth, day. The eyes have a suffused appearance,
the temperature may reach 102° or 103°, and the efflorescence may be
as general over the body as that of scarlet fever, but there is not
the aspect of serious indisposition, and the speedy abatement of the
symptoms shows that the disease is not scarlet fever.
PROGNOSIS.--The prognosis depends on the form of scarlet fever,
whether mild or severe, the strength of the patient, and the presence
or absence of complications or sequelæ. The type of this disease is
sometimes so mild throughout an epidemic or during a series of years
that {534} death seldom occurs, whatever the mode of treatment; but
afterward the type changes, and the percentage of deaths increases and
remains high till another mitigation in the type occurs.
Sydenham in the middle of the seventeenth century stated that scarlet
fever, as he saw it in London, was so mild that it scarcely deserved
the name of disease: "Vix nomen morbi merebatur." Morton some years
later, and Huxham in the following century, had abundant reason to
regret the change of type, and now throughout Great Britain scarlet
fever is one of the most fatal and most dreaded of the diseases of
childhood. In Dublin during the present century, prior to 1834,
scarlet fever was uniformly mild, so that on one occasion of eighty
patients in an institution all recovered. In 1834 the type of the
disease totally changed and epidemics of unusual virulence occurred.
The type frequently changes from mild to severe or severe to mild, not
only in consecutive years, but in consecutive months. A few years
since a distinguished physician of New York treated about fifty cases
of scarlet fever in one of the institutions without a single death,
but a few months later the type of the malady changed, and his own son
was among those who perished from it. The prevailing type of the
disease should therefore be considered in giving the prognosis when in
the commencement of a case we are asked the probability as regards the
termination.
Extensive statistics, including those collected by Murchison from
various sources, show that in different epidemics the mortality may
vary as much as from 3 per cent. (Eulenberg of Coblentz) to 19.3 per
cent. (cases seen by myself in New York City in 1881-82, many of which
were complicated by diphtheria), or even to 34 per cent. (epidemic in
the Palatinate in 1868-69). The hospital statistics of Rilliet and
Barthez gave 46 deaths in 87 cases, or about 53 per cent.
Observations have thus far failed to establish any connection in the
atmospheric conditions of temperature or moisture and the type of
scarlet fever. Grave as well as mild epidemics have occurred in all
climates and seasons.
The mortality is nearly equal in the two sexes, but age bears a marked
influence on the percentage of deaths. Comparatively few contract
scarlet fever under the age of one year, and the period of its
greatest mortality, since it is of its greatest frequency, is between
the ages of one and six years. The following are statistics bearing on
the relation of the age to the percentage of deaths:
From the
close of From the
1st till 5th to
Under close of the 12th
1 year. 5th year. year.
------- --------- --------
Fleishman, Cases 8 204 260
Deaths 6 88 51
1st to From the
close of 6th to 12th to
6th year. 12th year. 20th year.
--------- ---------- ----------
Kraus, Cases 13 113 106 40
Deaths 4 29 10 2
7th to
16th year.
----------
Voit, Cases 5 166 109
Deaths 1 24 10
1st to
close of Over
5th year. 5 years.
--------- --------
Röset, Cases 43 156 88
Deaths 26 31 3
{535} Under 5th to 10th to Over
5 years. 10th year. 15th year. 15 years.
-------- ---------- ---------- ---------
Rusigger, Cases 101 126 47 27
Deaths 21 20 3 0
These statistics, which I believe correspond with the observations of
others, show that although few cases occur in the first year, the
percentage of deaths is large, and that a majority of the deaths occur
under the age of six years. After the sixth year the greater the age
the less the proportionate number of deaths.
Scarlet fever is liable to so many complications and sequelæ that a
physician should not predict a certain favorable termination in the
beginning, however mild and regular the symptoms may be. But a
favorable result may be expected if the attack be mild, the
efflorescence appear at the proper time and extend over the entire
surface, the angina be moderate and accompanied by little or no
cellulitis or adenitis, with pulse under 140, temperature not above
103°, and no marked nervous symptoms.
Whether the complications or sequelæ be dangerous depends upon their
character. Rheumatism has never in my practice been dangerous, nor has
it materially retarded convalescence, except when it affected the
heart, causing pericarditis or endocarditis, when it involves great
danger. Nephritis, if it be moderate, attended by little albuminuria
and serous effusion, and by the occurrence of few renal casts in the
urine, commonly ends favorably under judicious treatment, as we have
already stated; but severe nephritis, with abundant albuminuria and
casts and serous effusions, soon gives rise to alarming symptoms, and
is the cause of death in a considerable number of instances. A similar
remark is applicable to the angina, which occurs in all grades of
severity. If it be attended by much cellulitis, with considerable
ulceration or necrosis, the state is one of danger, in consequence of
the difficulty in administering sufficient nutriment, of the
diminished assimilation and of the loss of strength from the prolonged
inflammatory fever, the septic poisoning, and the occasional
hemorrhages. Complication by pharyngeal or nasal diphtheria, now so
common where diphtheria is endemic, also greatly increases the danger.
Many cases, even when their course is normal and without
complications, involve danger, and some are necessarily fatal, from
the direct effect of the scarlatinous blood-poisoning. Such are grave
or malignant forms of the disease which the experienced eye recognizes
at a glance. Death often occurs rapidly from the toxæmia. Such cases
are characterized by high temperature (105° or 106°), rapid pulse, a
dusky-red hue of the surface from languid capillary circulation,
pungent heat, frequent vomiting, diarrhoeal stools, a dry-brown
tongue, and marked nervous symptoms, such as delirium, great
restlessness, or stupor. Not a few in this form of scarlet fever take
eclampsia, which is apt to be severe and repeated, and to end in fatal
coma.
Other inflammatory complications and sequelæ, which have been
described in the preceding pages, retard convalescence and jeopardize
the life of the patient, such as empyema, endocarditis, pericarditis,
and pneumonia. Otitis media is seldom immediately dangerous, although
it may be painful and involve serious consequences, even a fatal
meningitis, as has been stated above, after months or years of
otorrhoea. Anomalous cases are believed to be, as a rule, more
dangerous than such as are {536} attended by an early and full
efflorescence and have the usual symptoms.