DESCRIPTION OF SCARLET-FEVER
1. SCARLET-FEVER, OR SCARLATINA.
Is an eruptive fever, produced by
a peculiar contagious poison, and distinguished by
extreme heat, a rapid pulse, a severe affection of
the mucous membranes, especially those of the mouth
and throat, and by a burning scarlet eruption on the
skin.
2. DIVISION OF THE PROCESS OF THE DISEASE INTO
PERIODS.
Its course is commonly divided into
four distinct periods, viz.: the period
of incubation, the period of eruption, the period of
efflorescence, and the period of desquamation;
to which may be added: the period of convalescence.
3. PERIOD OF INCUBATION, OR HATCHING.
The time which passes between the
reception of the contagious poison into the system
and the appearance of the rash, is called the period
of incubation; incubation or incubus meaning, properly,
the sitting of birds on their nests, and figuratively,
the hatching or concoction of the poison within the
body, until prepared for its elimination. There
is no certainty about the time necessary for that
purpose, as the contagion, after the patient has come
in contact with it, may be lurking a longer or a shorter
time about his person, or in his clothes and furniture.
As in almost all eruptive fevers,
so in scarlatina, the patient begins with complaining
of shivering, pain in the thighs, lassitude, and rapidly
augmenting debility; frequently also of headache, which,
when severe, is accompanied with delirium, nausea
and vomiting. The fever soon becomes very high,
the pulse increasing to upwards of 120 to 130 strokes
in a minute, and more; the heat is extreme, raising
the natural temperature of the body from 98 to 110-112
degrees Fahrenheit, being intenser internally than
on the surface of the body. The patient complains
of severe pain in the throat, the organs of deglutition
located there becoming inflamed, and swelling to such
a degree that swallowing is extremely difficult, and
even breathing is impeded. The tongue is covered
with a white creamy coat, through which the points
of the elongated papillae project. Gradually
the white coat disappears, commencing at the end and
the edges of the organ, and leaves the same in a clean,
raw, inflamed state, looking much like a huge strawberry.
This is called the strawberry tongue of scarlet-fever,
and is one of the characteristic symptoms of that
disease. There is a peculiar smell about the
person of the patient, reminding one of salt fish,
old cheese, or the cages of a menagerie.
4. PERIOD OF ERUPTION, OR APPEARING OF THE RASH.
Commonly, on the second day, towards
evening, sometimes on the third, and only in very
bad cases later, the rash begins to make its appearance,
under an increase of the above symptoms, especially
of the fever and delirium, and continues to come out
for about twelve hours. Usually the eruption
commences in the face, on the throat and chest; thence
it spreads over the rest of the trunk, and finally
it extends to the extremities. The minute red
points, which appear at first, soon spread into large,
flat, irregular patches, which again coalesce and
cover the greater part, if not the whole, of the surface,
being densest on the upper part of the body, particularly
in front, in the face, on the neck, the inner side
of the arms, the loins, and the bend of the joints.
The scarlet color of the rash disappears under the
pressure of the finger, but reappears immediately
on the latter being removed. Sometimes the eruption
takes place with a profuse warm sweat, which prognosticates
a mild course and a favorable issue of the disorder.
Together with the appearance of the rash, the disease
develops itself also more internally: the inflammation
of the mouth and throat increases; the tonsils and
fauces swell to a high degree; the eyes become suffused
and sensitive to the light; the mucous membranes of
the nose and bronchia become also affected, the patient
sneezes and coughs, and all the symptoms denote the
intense struggle, in which the whole organism is engaged,
to rid itself of the enemy which has taken possession
of it.
5. PERIOD OF EFFLORESCENCE, OR STANDING OUT OF
THE RASH.
During the first day or two of the
period of efflorescence, which lasts three or four
days, the above symptoms usually continue to increase.
Sometimes, however, the patient is alleviated at once
on the rash being formed. This alleviation always
takes place when the rash comes with perspiration,
and also under a proper course of water-treatment.
If the rash continues to stand out steadily, the symptoms
decrease on the third day; the patient becomes more
quiet, the pulse slower (going down to 90 and even
to 80 strokes per minute); the rash, then, gradually
and steadily fades, and finally disappears altogether. -- Sometimes
the rash fades or disappears too early, in which cases,
usually, the internal symptoms increase, the brain
and spine become affected, and the situation of the
patient becomes critical.
6. PERIOD OF DESQUAMATION, OR PEELING-OFF.
About the sixth or seventh day, the
epidermis, or cuticle of the skin begins to peal off,
commencing in those places which first became the
seat of the rash, and gradually continuing all over
the body. In such parts as are covered with a
thin delicate cuticle (as the face, breast, &c.) the
cuticle comes off in small dry scurfs; in such parts
as are covered with a thicker epidermis, in large
flakes. There have been instances of almost complete
gloves and slippers coming away from patients’
hands and feet. -- The fever subsides entirely,
and so does the inflammation of the throat and mouth,
which become moist again. Also the epithelia,
or the delicate cuticles of the mucous membranes, which
have been affected by the disease, peal off and are
coughed up with the tough thick mucus covering the
throat, or they are evacuated with the faeces and
the urine, forming a sediment in the latter. -- Desquamation is usually
completed in from three to five days; sometimes it requires a longer time; under
hydriatic treatment it seldom lasts more than a few days. Whilst
desquamation is taking place, a new cuticle forms itself, which, being
exceedingly thin at first, gives the patient a redder color than usual for some
time, and requires him to be cautious, in order to prevent bad consequences from
exposure. --
Thus the disease makes its regular
course in about ten days, and, under a course of hydriatic
treatment, which not only assists the organism in
throwing off the morbid poison and keeps the patient
in good condition, but also protects him from the
influence of the atmosphere, the patient may consider
himself out of danger and leave the sick-room under
proper caution, of which we shall speak hereafter.
7. THE PERIOD OF CONVALESCENCE,
under the usual drug-treatment, is,
however, usually protracted to twice or thrice the
duration of the disease, the patient being compelled
to keep the house for five or six weeks, especially
from fear of anasarca, or dropsy of the skin,
frequently extending to the inner cavities of the
body, and proving fatal. This dangerous complaint
has been more frequently observed after mild cases
of scarlet-fever than after malignant cases, probably
from the fact that in mild cases the patient is more
apt to expose himself, than when the danger is more
obvious and all possible care is taken. -- Sometimes
also severe rheumatic pain, or rather neuralgia, in
the joints, swelling of the glands, and other sequels
prolong his sickness. I never observed a case
of dropsy, or of neuralgia, after a course of water-treatment.
8. VARIETIES OF FORMS OF SCARLATINA.
The above is the description of scarlet-fever,
as it most frequently occurs. But far from taking
always that regular course, the constitution of the
patient, the intensity of the epidemy and the virulence
of the poison, the treatment and other circumstances
influencing the development of the disease, cause
several anomalies, from scarlatina simplex to scarlatina
maligna, which too often baffles all the resources
of the Medical Art.
9. SCARLATINA SIMPLEX, OR SIMPLE SCARLET-FEVER.
In the mildest form of the
disease, called scarlatina simplex, or simple
scarlet-fever, there is no inflammation of the
throat, the fever is moderate, and the patient suffers
very little. Unfortunately this form is so rare,
that many experienced physicians never saw a case.
Probably, it was a case belonging to this class, which
was mentioned a number of years ago by one of the
writers on Priessnitz’s practice, when a lady
with scarlet-fever joined a dancing party at Graefenberg,
a case for reporting which the author has been
ridiculed by the opponents of the Water-Cure, but
which by no means belongs to impossibilities; for
scarlatina simplex having been declared by eminent
physicians (not of Priessnitz’s school) to be
“scarcely a disease," becoming fatal only
through the officiousness of the doctor, and other
physicians of note recommending cold rooms and open
air through the whole course of the disease, or
at least towards the latter part of it; I do not
see why a patient under water-treatment should not
be safer in producing perspiration by dancing than
in sitting in a cold room or in walking in the open
street. The fact, of course, is unusual, and I
do not exactly recommend its practice, but it is not
at all impossible, and ridiculing the reporter of
it shows either ignorance of the disease or a bad will
towards the new curative system, to which those are
most opposed who know the least of it.
10. SCARLATINA ANGINOSA, OR SORE-THROAT SCARLET-FEVER.
Wherever the throat is affected,
which is almost always the case, the disease is called
scarlatina anginosa, or sore-throat scarlet-fever.
This is the form described at the commencement of this
article. There are several varieties, however,
of scarlatina anginosa.
In any case, the organism, invaded
by the contagious poison, will try to rid itself of
its enemy. The reaction is necessarily in proportion
to the violence of the miasma and to the quantity
of organic power struggling against it.
11. MILD REACTION (ERETHIC).
If the poison is not virulent, and
the body of the patient in a favorable condition,
the reaction is mild, and the poison
is eliminated without any violent efforts on the part
of the organism. This is the case in scarlatina
simplex, and in mild forms of scarlatina anginosa.
12. VIOLENT REACTION (STHENIC).
If both, the contagious poison and
the organism, are very strong, a violent reaction
will take place, and the safety of the patient will
be endangered by the very violence of the struggle,
by which internal organs may be more or less affected.
13. TORPID REACTION (ASTHENIC).
The more violent the contagious poison,
and the weaker the organic power, the less decidedly
and the less successfully will the organism combat
against the poison, and the more inroad will the latter
make upon the system, affecting vital organs and paralyzing
the efforts of the nervous system by attacking it
in its centres. In such cases of torpid reaction,
the patient frequently passes at once into a typhoid
state. This is what we call scarlatina
maligna, or malignant scarlet-fever.
14. SCARLATINA MILIARIS
Sometimes the red patches of the rash
are covered with small vesicles of the size of mustard-seed,
which either dry up or discharge a watery liquid,
leaving thin white scurfs, that come away with the
cuticle during desquamation. Although this
form, called scarlatina miliaris, being the
result of exudation from the capillary vessels, shows
an intensely inflamed state of the skin, its course
is usually mild and its issue favorable; because the
morbid poison comes readily to the surface.
15. SCARLATINA SINE EXANTHEMATE.
There are also mild cases of scarlet-fever,
when little or no rash appears, and the throat is
very little affected. These are the result of
a particularly mild character of the epidemy, together
with a peculiar condition of the skin, the desquamation
of which shows that the poison went to the surface
without producing the usual state of inflammation,
or the rash peculiar to the disease. This form,
called scarlatina sine exanthemate, is extremely
rare.
16. THE MALIGNANT FORMS OF SCARLET-FEVER
are caused by the character of the
epidemy, but, perhaps, more frequently by the weak
and sickly constitution of the patient and the external
circumstances affecting it. Thus, persons of scrofulous
habit, being naturally of a low organization, without
much power of resistance, are much more liable to
experience the destructive effects of scarlatina than
those whose organism possesses sufficient energy to
resist the action of the morbid poison, and to expel
it before it can do any serious harm inside the body.
17. SUDDEN INVASION OF THE NERVOUS CENTRES.
Of the different forms of scarlatina
maligna the most dangerous is the sudden invasion
of the nervous system, particularly the brain,
the cerebellum and the spine, by which
the patient’s life is sometimes extinguished
in a few hours. In other cases the symptoms deepen
more gradually, and death ensues on the third, fifth
or seventh day.
18. AFFECTION OF THE BRAIN.
When the brain is affected,
the patient suddenly complains of violent headache,
vomits repeatedly, loses his eye-sight, has furious
delirium, or coma (a state of sleep from which it
is difficult to rouse the patient); his pupils dilate;
the pulse becomes small, intermits; sometimes the
skin becomes cold; there is dyspnoea (difficulty of
breathing), fainting, paralysis, convulsions, and finally
death; or, sometimes, the paroxysm passes suddenly
by with bleeding from the nose or with a profuse perspiration.
19. AFFECTION OF THE CEREBELLUM AND SPINE.
In affections of the cerebellum
and spinal marrow, the patient complains of
violent pain in the back of the head and neck, in the
spine, and frequently in the whole body. These
also frequently terminate with the destruction of
life.
20. During all these invasions
of the nervous centres there is little or no rash,
and what appears is of a pale, livid hue.
21. PUTRID SYMPTOMS.
Next to those most dangerous forms most
dangerous, because the organic power (the vis medicatrix
naturae), from which the restoration of health
must be expected, and without which no physician can
remove the slightest symptom of disease, becomes partly
paralyzed from the beginning putrid
symptoms present a good deal of danger, although
they give the organism and the physician more time
to act.
22. CONDITION OF THE THROAT, AND OTHER INTERNAL
ORGANS.
The condition of the throat
requires the most constant attention. From a
highly inflamed state, it often passes into a foul
and sloughy condition; the breath of the patient becomes
extremely fetid; the nostrils, the parotid and submaxillary
glands swell enormously, so that swallowing and breathing
become very difficult. There is an acrid discharge
from the nose; the gangrenous matter affects the alimentary
canal, causing pain in the stomach, the bowels, the
kidneys and the bladder; a smarting diarrhoea with
excoriation of the anus, and inflammatory symptoms
of the vulva. Also the bronchia, lungs, pleura
and pericardium become affected, as sneezing, cough
(the so-called scarlet-cough) and the pain across
the chest and in the region of the heart indicate.
23. OTHER BAD SYMPTOMS.
These symptoms may present themselves
with the rash standing out; but most frequently they
occur when there is little or no eruption, or when
it fades, becomes livid, or disappears altogether.
A sudden disappearance of the rash, before the sixth
day, commonly increases the typhoid symptoms, and
must be considered a bad omen. Also the invasion
of the larynx, which is happily of rare occurrence,
is commonly fatal.
24. DESTRUCTION OF THE ORGAN OF HEARING.
When the glands pass into a sloughing
state, the parts connected with them are frequently
damaged. Thus the ulceration of the parotid gland
often causes deafness, by the gangrenous matter communicating
to the eustachian tube and the inner ear, where it
destroys the membrane of the drum and the little bones
belonging thereto, or by closing up the tube.
When the discharge from the outer ear is observed,
the destruction has already taken place, and it is
too late to obviate the injury.
25. OTHER SEQUELS, DROPSY, &C.
Beside the ulceration of glands and
deafness, some of the sequels of scarlatina are white
swelling of one or more of the joints, usually the
knee, chronic inflammation of the eyes and eyelids,
and partial paralysis. These chiefly occur in
scrofulous subjects. Dropsy, which I have mentioned
before, is one of the sequels that frequently prove
fatal.
26. THE CONTAGION OF SCARLATINA VERY ACTIVE.
The contagion of scarlatina
is very active, and adheres for a long time to the
sick-room, bedding, clothes and furniture. The
best means to destroy it, is plenty of air. It
is difficult to say when the contagion is over, as
much depends on the season of the year and the care
with which the house is aired. Physicians and
visitors at the sick-room are very apt to carry it
about, unless they be exceedingly careful in changing
their clothes and washing themselves, hair and all,
before entering other rooms inhabited by persons who
had not had the disorder before. It is astonishing
how easily such persons are taken by it; and it even
sometimes happens that such as have gone through it,
take it again in after years. I am authorized
by experience, that the idea as if patients under
water-treatment, or even such as take a cold bath every
morning, were inaccessible to the contagion, is erroneous.
I have had patients under treatment for chronic diseases,
who had had scarlatina several years before, and neither
this nor the water-cure protected them from taking
it again. With some of them, however, the throat
only became affected and no desquamation took
place, whilst the character of the complaint with
the rest was rather mild. I have been astonished
to read that in a meeting of a medical society of
this country, which took place a very short time ago,
some members could have raised the question whether
scarlatina was really contagious. I admit that
the profession in general has not made great progress
in the cure of the complaint, but it does not require
great study and long experience to know that scarlet-fever
is contagious!
27. The form of the disorder
in one patient does not imply the necessity of another
who caught it from him having it in the same form.
A person can take the contagion from one who dies of
malignant scarlet-fever and have it in the mildest
form, and vice versa. The character of the disease
depends very much on the constitution, as I have said
above. However, if the epidemy in general is of
a malignant character (which may again depend, partly
at least, on the constitution of the atmosphere),
it will prove so in many individuals who are taken
with it, and the precautions ought to be so much the
more careful on that account.
28. DIAGNOSIS.
After what has been said about the
symptoms of scarlatina, it cannot be difficult to
distinguish it from similar eruptive diseases.
However, as there is much resemblance between scarlatina
and measles, at least in the milder form of
the former, I shall give a few symptoms of each, to
assist parents in making the distinction.
29. DIAGNOSIS FROM MEASLES.
In scarlatina the heat is much greater,
and the pulse is much quicker than in measles. -- In
scarlatina the throat is inflamed, usually the brain
affected, and the patient smells like salt-fish, old
cheese or the cages of a menagerie; in measles, the
eyes are affected, inflamed, and incapable of bearing
the light; the organs of respiration likewise (thence
coryza, sneezing, hoarseness, cough); the perspiration
smells like the feathers of geese freshly plucked. -- In
scarlatina the period of incubation is a day less
than in measles; namely, in scarlatina the rash appears
on the second day after the first symptoms, in measles
on the third. -- The scarlet-rash consists
of large, irregular, flat patches, which cover
large spaces with a uniform scarlet-red, being brightest
in those parts which are usually covered by the garments
of the patient; in measles the spots are small, roundish
or half-moon-like, with little grains upon them, and
usually of a darker color; the measle-rash is thickest
in such parts as are exposed to the air. -- In
scarlatina the symptoms of fever and the affection
of the mucous membranes continue two days after the
eruption has begun to make its appearance; in measles
the eruption diminishes those symptoms at once. -- The
scarlet-rash stands out a day or two less than the
measle-rash, and comes off in laminae, whilst
the latter comes off in small scales or scurfs.
30. THE PROGNOSIS,
under a well conducted course of hydriatic
treatment is, in general, favorable. Much depends,
however, on the season of the year (in damp and cold
weather partly owing to a lack of pure air
in the sick-room the disease is more dangerous
than in summer); on the general health of the patient
(not on his mere looks, for well-fed and stout children
are subject to affections of the brain); on the age
of the patient (adults are generally more in danger
than children); on the form of the disease and the
character of the fever (erethic or mild fever being
the most favorable, whilst typhoid fever is the worst;
a violent character of the fever is not very dangerous
under hydriatic treatment, as we have plenty of means
to limit its ravages without weakening the patient);
on the eruption, the condition of the throat, the
process of desquamation, &c.
31. FAVORABLE SYMPTOMS
are the following: Absence of
internal inflammation; a bright florid rash; a regular,
steady appearance, standing out, and disappearance
of the latter; a regular and complete pealing off
of the cuticle; a decrease of the pulse after the
eruption of the rash; an easy and regular respiration;
a natural expression of the features; a moist skin.
32. UNFAVORABLE SYMPTOMS
are: A fetid breath, with ulceration
and sloughing of the throat and glands; a smarting
and weakening diarrhoea; involuntary evacuations of
the bowels; dizziness, deafness, coma, grinding of
the teeth; retention of urine; petechiae; a rapid
decline of the patient’s strength; a quick,
small, weak pulse; rapid breathing; twitchings, tetanus,
hiccough, &c. -- Closing up of the nose frequently
precedes a dangerous affection of the brain.
A sudden disappearance of the rash, or of the inflammation
of the throat, is a bad omen. With such symptoms
as these, there is usually little or no rash, and
the little there is, of a pale, livid color, and the
skin, in general, inactive.