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VOL. II.

PUBLISHED MONTHLY

TOPEKA, KANSAS, MARCH, 1890.

No. 3.

Scarlet Fever.-Symptoms and Diagnosis. It is pecular in being lamellar, sometimes oc

Read before the Topeka, Academy of Medicine and Surgery, January 7, 1890.

BY THEO. W. PEERS, TOPEKA, KAS.

In looking up the authorities at my command on this subject, I cannot say that I have found anything very new, but propose to give a sort of compilation, which I trust you will find interesting.

I have consulted articles on the subject written by Drs. Pepper, J. Lewis Smith, Ellis, Palmer, Bartholow, Flint and Atkinson, and have used freely anything that I found interesting to me, but without any attempt at literal quotation, except a summary of the signs and symptoms of the disease by Dr. I. E. Atkinson. In the Reference Handbook he gives it as his definition of the disease, and it seemed to me so concise and pointed that I quote it verbatim.

DEFINITION.

curring in very large shreds and exfoliations. During the attack and for weeks subsequently there is a special predisposition to renal inflammation. Scarlet fever attacks children more especially. It usually affects an individual but once." (Reference Handbook, Vol. VI, page 302.)

HISTORY.

Scarlatina is probably a disease of very ancient origin, though the first description of it, which makes us at all certain that scarlatina was the disease described, was given by Paulus Restiva, in 1543. Not until more than a century after this, was it so studied and described as to make a clear differentiation between it and measles. It probably originated in Europe, and seems to have failed to get a foothold in Asia or Africa. Whether this is due to race or climatic conditions is not determined. It was brought to America, New England, through European shipping in 1735, and slowly spread over the whole country.

ETIOLOGY.

ly and long, and several low vegetable organisms have been discovered in the blood, pus, excretions or epidermis of scarlatina patients, but they have all failed to satisfy the critics, and the true cause of scarlatina is yet to be discovered.

"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 period of invasion which is ushered in by fever usually of considerable intensity, and by sore throat. A scarlet eruption begins to appear before the end of the second day, and marks the end of the prodromal and beginning of the 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 noted. In small children the first thing noticed is usually fever though this is sometimes preceded by a chill and in severe cases by convulsions. One of the early symptoms is vomiting and its severity is often a premonition of the severity of the fever. The tongue is at first coated with a creamy looking coat. The edges usually show a bright red color. As soon as the rash appears the coat is usually cast off and the tongue presents the strawberry appearance, which is so striking that no one forgets or fails to recognize it, after once seeing it. The pulse is very rapid and rather weak. The fever is at first from 101° to 105° according to the severity of the attack, and increases until the eruption is well out, and may be as high as 108° in severe cases. Soon

disease of definite symptoms, and the infer- occasional cases are prodromal symptoms, ence is that on further investigation it will be found that this disease among cows is often the origin of an outbreak among mankind.

The area of contagion is small; a few feet being the limit. When, however, it is concealed from the air, it may be carried hundreds of miles and last years. Predisposing causes are: an, impaired constitution, filthy surroundings, childhood, and individual susceptibility. It has been said that infants under twelve months are exempt, but the records show a number of deaths in such cases, and even a case in utero. Such infants however are less susceptible. Some persons never take it no matter how often nor how thoroughly exposed to it.

Barthez and Rilliet state that it never affects tuberculous children, and Grisolle believed the same in regard to adults. The contagion after the fever the throat shows soreness, probably resides in the epidermis, and becomes diffused as the exfoliation goes on. It is also in the mucous membranes of the mouth and throat, in the secretions, the lymph and blood. It may be interesting to note that some physicians believe the first few days only is it contagious. That others hold the period of exfoliation as the only time of contagion. The weight of authority however, seems to show that contagion is most likely when the eruption is fully out, and that it gradually decreases until exfoliation is completed. The first day or two the contagion is slight.

SYMPTOMS.

The period of incubation varies greatly in duration. Richardson is said to have had positive symptoms of the disease immediately after auscultating a child having the disease, and on the other hand some believe that it may last three weeks. It must be an extremely rare case in which the incubative period is longer than two weeks, and in by far the greater number of cases it is from four to six days.

The symptoms of scarlatina are varied not only in intensity but in kind. The disease

which rapidly increases to all degrees of severity. At times abscesses form and gangrene appears. On the second day, or from 14 to 36 hours after the first symptoms a bright scarlet rash begins to appear. This usually occurs on the chest and neck and soon extends over the whole trunk and limbs. At times the rash appears on other parts of the body first and may not extend over the whole surface. The parts of the body which are most likely to show the rash are the regions of the joints and especially the flexion side. It has been claimed by some authors that the face is exempt, but I have certainly seen it there. My own experience accords with Atkinson's: that the cheeks are usually involved and the forehead, nose and chin may have it, though the surface around the mouth escapes. The eruption on the face is often modified. The cheeks, &c., showing a dark congested appearance rather than the characteristic rash. The rash consists of very minute dark scarlet points surrounded by an areola of bright scarlet, less dark than the center. These points may be so close together as to show no skin which is not colored, but usually there is a small patch of clear skin between them. The points are

only slightly raised above the surface giving a feeling of roughness to the hand when rubbed over the surface. It is said that the heavier the rash the severer will be the disease. Also that a severe case may be expected when the rash is delayed and fails to appear promptly with the fever.

The rash usually lasts from five to eight days, when desquamation sets in, and may last three weeks, though ten days or two weeks usually suffices. We may always expect to find a sore throat in scarlatina; and at times it is the most annoying and serious symptom.

At first there is a congested condition of the fauces, and deglutition is painful. The

If we could withhold our decision until the disease had rnn its course, the difficulty would be small, but our patients, the Board of Health and the public safety, demand an early diagnosis.

Let us see what we have on which to base our early diagnosis. I will mention six things.

First-Contagiousness of the disease.
Second-Mode of invasion.
Third-Fever.

Fourth-Sore throat.
Fifth-Eruption.
Sixth-Tongue.

The disease must arise from some other case, and the patient should be closely questioned 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 inflamed surfaces. This is not diphtheritic, but is due to necrosis of tissue because of the severity of the inflammation. It may be readily brushed off, and does not have the tendency to extend into the trachea as the diphtheritic membrane does.

The fever comes on usually with the first symptoms and gradually increases with the rash, but does not disappear suddenly when the rash is out. At times the degree of fever acts as a diagnostic pointer.

The sore throat with the fever, its painful 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 there is sluggishness, the delirium is low and muttering and often deepens into coma and

death.

J. Lewis Smith says, he never had, or heard of, a case which recovered when convulsions occurred after the complete development of the eruption.

DIAGNOSIS.

The rash is quite characteristic, and its special features are, its punctate appearance, with the punctæ but little elevated above the surface. The bright scarlet color over the whole of the surface involved, the freedom of the surface around the mouth and the different character on the face, the flexure of the joints being especially involved. The evenly distributed punctæ, with no tendency to definite forms when closely collected. The tongue is usually a very definite and plain sign.

A well marked case of scarlatina, is easily diagnosed, but so varied are the attacks that 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 household, and he must be a heartless wretch who could see, with undisturbed conscience, such a catastrophe brought on by his carelessness or negligence.

Dr. McGuire thought from Dr. Peer's paper the diagnosis should be easy. Spoke of cases where there was no sore throat and yet the Dr. H. C. Minor had met with some very sequelæ 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.