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TOPEKA, KANSAS, MARCH, 1890.
Scarlet Rever.—Symptoms and Diagnosis. It is pecular in being lamellar, sometimes oc
curring in very large shreds and exfoliations. Read before the Topeka, Academy of Medicine During the attack and for weeks subsequently and Surgery, January 7, 1890. there is a special predisposition to renal in
flammation. Scarlet fever attacks children BY THEO. W. PEERS, T'PEKA, KAS. more especially. It usually affects an individ
ual but once." (Reference Handbook, Vol. In looking up the authorities at my com- VI, page 302.) mand on this subject, I cannot say that I have
HISTORY. found anything very new, but propose to give Scarlatina is probably a disease of very ana sort of compilation, which I trust you will cient origin, though the first description of it, find interesting
which makes us at all certain that scarlatina I have consulted articles on the subject was the disease described, was given by Pauwritten by Drs. Pepper, J. Lewis Smith, Ellis, lus Restiva, in 1543. Not until more than a Palmer, Bartholow, Flint and Atkinson, and century after this, was it so studied and have used freely anything that I found inter- described as to make a clear differentiation esting to me, but without any attempt at literal between it and measles. It probably originatquotation, except a summary of the signs and ed in Europe, and seems to have failed to get symptoms of the disease by Dr. I. E. Atkinson. a foothold in Asia or Africa. Whether this In the Reference Handbook he gives it as his is due to race or climatic conditions is not dedefinition of the disease, and it seemed to me termined. It was brought to America, New so concise and pointed that I quote it verba- England, through European shipping in 1735, tim.
and slowly spread over the whole country. DEFINITION.
ETIOLOGY. “Scarlet fever is an eruptive contagious That there is a specific poison and that this fever. Its incubative period is brief, rarely poison is a solid, is generally believed, but as less than twenty-four hours, usually lasting yet we are not justified in saying just what it from four to six days, and not often exceeding is. Many investigators have searched earnestthis duration. This period is succeeded by a ly and long, and several low vegetable organperiod of invasion which is ushered in by fever isms have been discovered in the blood, pus, usually of considerable intensity, and by sore excretions or epidermis of scarlatina patients, throat. A scarlet eruption begins to appear but they have all failed to satisfy the critics, before the end of the second day, and marks and the true cause of scarlatina is yet to be the end of the prodromal and beginning of the discovered. eruptive period. The eruption rapidly be- The poison, whatever it is, is very tenacomes general and the tongue becomes strip- cious, and hard to destroy. It is usually reped of its coating and assumes a raspberry-red ceived into the body by the breath, though color. The eruption slowly fades after the frequently through the ingesta. Persons, first few days. The fever persists till the clothing, wall paper, books, (as in public sixth, seventh, or eighth day, or longer. As libraries,) milk, are the most frequent carriers. the eruption fades, desquamation begins and The spread of scarlatina has never been continues from eight to fourteen days or more. traced directly to water supply, but has often
been extended through the medium of milk. may show itself in such a mild form as to At Hendon, England, an outbreak was believ- actually escape notice, and again it may seize ed to be due to a disease among cows. It is upon its victim with sudden and relentless also stated that cows, in milk, inoculated with grasp and carry him speedily to his grave. the virus of scarlatina become infected with a
Usually the attack is sudden and only in disease of definite symptoms, and the infer
occasional cases are prodromal symptoms, ence is that on further investigation it will noted. In small children the first thing noticbe found that this disease among cows is often ed is usually fever though this is sometimes the origin of an outbreak among mankind.
preceded by a chill and in severe cases by The area of contagion is small; a few feet convulsions. One of the early symptoms is being the limit. When, however, it is concealed vomiting and its severity is often a premonition from the air, it may be carried hundreds of of the severity of the fever. The tongue is at miles and last years. Predisposing causes are; first coated with a creamy looking coat.
The an, impaired constitution, filthy surroundings, edges usually show a bright red color. As childhood, and individual susceptibility. It soon as the rash appears the coat is usually has been said that infants under twelve months cast off and the tongue presents the strawberare exempt, but the records show a number of ry appearance, which is so striking that 110 deaths in such cases, and even a case in utero. one forgets or fails to recognize it, after once Such infants however are less susceptible. seeing it. The pulse is very rapid and rather Some persons never take it no matter how weak. The fever is at first from 101° to 105° often nor how thoroughly exposed to it. according to the severity of the attack, and
Barthez and Rilliet state that it never affects increases until the eruption is well out, and tuberculous children, and Grisolle believed may be as high as 108° in severe cases.
Soon the same in regard to adults. The contagion after the fever the throat shows soreness, probably resides in the epidermis, and becomes which rapidly increases to all degrees of severdiffused as the exfoliation goes on. It is also ity. At times abscesses form and gangrene in the mucous membranes of the mouth and appears. On the second day, or from 14 to 36 throat, in the secretions, the lymph and blood. hours after the first symptoms a bright scarlet It may be interesting to note that some physi- rash begins to appear. This usually occurs cians believe the first few days only is it con-l on the chest and neck and soon extends over tagious. That others hold the period of ex- the whole trunk and limbs. · At times the foliation as the only time of contagion. The rash appears on other parts of the body first weight of authority however, seems to show and may not extend over the whole surface. that contagion is most likely when the erup- The parts of the body which are most likely to tion is fully out, and that it gradually decreas- show the rash are the regions of the joints and es until exfoliation is completed. The first especially the flexion side. It has been claimday or two the contagion is slight.
ed by some authors that the face is exempt,
but I have certainly seen it there. My own SYMPTOMS.
experience accords with Atkinson's: that the The period of incubation varies greatly in cheeks are usually involved and the forehead, duration. Richardson is said to have had nose and chin may have it, though the surface positive symptoms of the disease immediately around the mouth escapes. The eruption on after auscultating a child having the disease, the face is often modified. The cheeks, &c., and on the other hand some believe that it showing a dark congested appearance rather may last three weeks. It must be an extremely than the characteristic rash. The rash con
case in which the incubative period is sists of very minute dark scarlet points surlonger than two weeks, and in by far the rounded by an areola of bright scarlet, less greater number of cases it is from four to six dark than the center. These points may be days.
so close together as to show no skin which is The symptoms of scarlatina are varied not not colored, but usually there is a small patch only in intensity but in kind. The disease of clear skin between them. The points are
only slightly raised above the surface giving If we could withhold our decision until a feeling of roughness to the hand when rub- the disease had rnn its course, the difficulty bed over the surface. It is said that the would be small, but our patients, the Board of heavier the rash the severer will be the disease. Health and the public safety, demand an early Also that a severe case may be expected when diagnosis. the rash is delayed and fails to appear prompt- Let us see what we have on which to base ly with the fever.
our early diagnosis. I will mention six The rash usually lasts from five to eight things. days, when desquamation sets in, and may
First-Contagiousness of the disease. last three weeks, though ten days or two
Second-Mode of invasion.
Third-Fever. weeks usually suffices. We may always ex
Fourth-Sore throat. pect to find a sore throat in scarlatina; and at Fifth-Eruption. times it is the most annoying and serious
The disease must arise from some other At first there is a congested condition of case, and the patient should be closely questhe fauces, and deglutition is painful. The tioned as to whether he has been exposed. soreness then extends and becomes more
The sudden invasion of scarlatina is unlike severe. The direction of extension is usual- most of the diseases it would be likely to be ly to the posterior nares, though the buccal mistaken for. The usual chill or convulsion; surface, the tongue and even the lips may the initial vomiting, and its sudden free become inflamed. After a few days, if character; the immediate prostration and high the case is a severe one, a membrane begins fever, all are characteristic of the disease. to form and may extend rapidly over all the
The fever comes on usually with the first inflamed surfaces.. This is not diphtheritic, symptoms and gradually increases with the but is due to necrosis of tissue because of the rash, but does not disappear suddenly when severity of the inflammation. It may be read- the rash is out. At times the degree of fever ily brushed off, and does not have the tenden- acts as a diagnostic pointer. cy to extend into the trachea as the diphtheri
The sore throat with the fever, its painful tic membrane does.
character and the appearance of a membrane The nervous symptoms of scarlatina depend might lead us to suppose we had a case of upon the individual attacked and the severity diphtheria, but the redness is more scarlet, the of the disease. In severe cases there is often membrane forms later in the disease and is delirium, intense cephalalgia and in some not so adherent. cases great restlessness, while in other cases The rash is quite characteristic, and its there is sluggishness, the delirium is low and special features are, its punctate appearance, muttering and often deepens into coma and with the punctæ but little elevated above the death.
surface. The bright scarlet color over the J. Lewis Smith says, he never had, or heard whole of the surface involved, the freedom of of, a case which recovered when convulsions the surface around the mouth and the differoccurred after the complete development of ent character on the face, the flexure of the the eruption.
joints being especially involved. The evenly DIAGNOSIS.
distributed punctæ, with no tendency to defiA well marked case of scarlatina, is easily nite forms when closely collected. The tongue diagnosed, but so varied are the attacks that is usually a very definite and plain sign. great difficulty is met with at times. There Our diagnosis must not depend on any one are recorded cases where no rash appeared, of these signs or symptoms, for we may find the angina and fever being the only symp- that one may be absent and still have toms characteristic, but the fact being known scarlatina. If, however, we always conthat the patient was exposed to scarlatina and sider them all, there will nearly always be a having exfoliation and the usual sequelæ made majority in favor of or against, and we may the diagnosis all but positive.
safely abide with the majority in this case.
In my judgment we should be extremely in persons. Milk is a frequent and potent careful not to allow any case of scarlatina to carrier of the contagion, said Dr. J. Lewis go unreported or not diagnosed, and in a case of Smith; did not believe in cases in utero and doubt or resistance on the part of the patient's thought children under four months old not friends, counsel should be held. One case liable to have the disease. overlooked may bring death to many a house- Dr. Longshore was interested in the point hold, and he must be a heartless wretch who brought out by Dr. McClintock as regarding could see, with undisturbed conscience, such the eruption in the mouth; said she had noticed a catastrophe brought on by his carelessness it in measles and thought it a characteristic of or negligence.
eruptive diseases. DISCUSSION.
Dr. Stewart, speaking again, corroborated Dr. McGuire thought from Dr. Peer's paper Dr. McClintock's statement as regarded the the diagnosis should be easy. Spoke of cases eruption in the mouth. where there was no sore throat and yet the Dr. H. C. Minor had met with some very sequela showedthat the cases were scarlet fever. severe cases arising from unknown sources More danger of contagion during the period of unless traceable to old clothing, etc., etc. It desquamation. The poison can be carried had seemed to him that such germs inlong distances; spoke of treating four cases creased in virulence or produced more severe in 1885, in which the medium of contagion disease than those from fresh cases. Reported was a dress which had not been worn for three a marked case of unknown origin where there months until the owner came here from were several children in the family and none Chicago and putting it on, thus was the means of them took the disease. of causing the four cases.
Dr. R. E. McVey said the home of scarlet Dr. Lindsay said he never saw a case of fever was Sweden, and that the disease had scarlet fever without some redness of the been transported to this country and that havthroat, at least, although no complaint was ing once been introduced it was difficult to eradmade of soreness.
icate it. The spores of the germs are immortal Dr. "McClintock-In the early diagnosis in the dessicated state, and remain in the dry vomiting is an important symptom, the chill soil about places which have been infected not so diagnostic. We find vomiting present with the disease for long periods of time and in three cases out of five. A fine punctate may be developed by their contact with moiseruption over the palate occurs before any ture, which explains the occurrence of cases eruption appears on the skin. It seemed to him de novo. The cause of the epidemic here he that the germ given off during the early stages thought due to the wet summer. Thinks it of the disease did not give rise to as severe a only slightly contagious; the virulence of the form of the disease as those germs that had lain disease is due to the character of the tissues dormant a long time. Reported a case where a in which it gets hold. child had complained of being tired in the even- Dr. Minney did not believe that cases arose ing and in the morning the eruption was well de novo; spoke of the relative amount of desout and in twelve hours thereafter desquama- quamation in the white and black races. Destion occurred freely although not complete. quamation is not so free in the black race.
Dr.Stewart-Scarlet fever is most contagious Spoke of the difficulty in diagnosis between during the period of desquamation. Cited scarlet fever and diphtheria, measles and other cases where children played together dur- eruptive diseases at times, and mentioned a ing the eruptive period and yet none of case of diphtheria with an eruption similar to those so exposed contracted the disease. Con- scarlet fever. trary to the opinion that you cannot produce Dr. McGuire thought if it only required disease by inoculating with the scales, he said moisture to bring the germs to life every comthis had been done successfully. Referred to munity would have scarlet fever every year. the idea that cows with a similar disease had Thinks the poison transferred by other means been the cause of the spread of scarlet fever than the soil. Appearance of the tongue fre