SCARLATINA

(W. M. Welch)

Synonyms.—Scarlet fever; Fr., Scarlatine; Ger., Scharlachfieber; ltal., Febbre
scarlatina.

Definition.—An acute infectious disease characterized by fever,
angina of variable intensity, a diffuse punctiform rash appearing on
the second day, and ending by a desquamation more or less copious.

Symptoms.—In studying the symptomatology of scarlet fever it

is found most convenient to divide the disease into three stages—namely,

the stage of invasion, the eruptive stage, and the stage of desquamation.

The stage of invasion is usually sudden in its onset. It is seldom ushered

in by a chill or chilly sensations, but in young children convulsions are

not uncommon. Along with some indisposition, sore throat and vomit-

¹ Pollitzer, “ Veronal Poisoning,” Jour. Cutan. Dis., April, 1912, p. 185 (case report,
with review of other cases, with references).

30

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ing are usually the earliest symptoms. The temperature rises rapidly,
often reaching, in the course of a few hours, 102 ° to 104⁰ F. The skin
is hot and dry, the tongue furred, the face flushed, there is intense thirst,
and the patient is restless. Taken together, the symptoms indicate the
beginning of an acute illness, the nature of which, however, is not re­
vealed until the rash appears, which is usually on the second day.

It is very common, indeed, for the eruption to appear within the
first twenty-four hours of illness, and in normal cases it is rarely delayed
longer than the second day. Almost always it is seen first on the trunk,
the skin being slightly reddened on the chest and abdomen, frequently
in the region of the groins. The redness rapidly increases, and on the
evening of the second day it may be distinctly seen on all parts of the
trunk and extremities. The face frequently escapes entirely. The
cheeks may be more or less flushed, while the lips and alæ of the nose very
often appear preternaturally pale. Pressure removes the redness
momentarily. By drawing one's fingers quickly over the rash the mo­
mentary pallor that is produced will be quickly replaced by the redness,
but presently the pale lines return again and persist for a minute or longer.
The rash may vary very greatly in its distribution and intensity. Some­
times it is so scanty as scarcely to be recognized, or it may be seen in
ill-defined patches, or it may be general and so intense as to suggest
the existence of acute dermatitis. In well-marked cases the efflorescence
covers all parts of the body, with perhaps the exception of the face, and
on passing the fingers over the skin it may appear smooth, but there
is in most cases a sensation of minute elevations, which are due to promi­
nence of some of the hair-follicles similar to the condition known as cutis
anserina. This condition may be so marked on some parts of the body
as to present a papular appearance and thus give rise to a suspicion of
measles, especially when there is normal skin intervening.

While the rash presents the general characteristics of a diffuse efflor­
escence, yet on close inspection it is found to be made up of innumerable
puncta of more intense redness, with intervening erythema of duller hue.
This gives to the rash a somewhat variegated appearance, being at the
same time diffuse and punctiform. The color of the rash is often de­
scribed as scarlet, but if it be compared at the bedside with a piece of
scarlet flannel, a wide difference will be observed, even when the rash
presents its brightest appearance. It is difficult to describe the color
exactly, but it may be said to be a dull red rather than a bright red.
When the rash begins to fade, it presents a dusky or brownish-red color.
It may disappear entirely in two or three days, but it frequently remains
as long as six or eight days, and sometimes even longer. In a rash of
extreme intensity minute hemorrhagic puncta may be seen, which gen­
erally disappear entirely on pressure. In such cases, as well as in many
milder ones, innumerable miliary vesicles appear at the height of the
eruption. These are much more frequent than is generally supposed,
being often overlooked on account of their small size. They are, as the
name implies, the size of a millet seed, conic in shape, and contain the
merest speck of milky fluid. They are more frequently seen on regions
of the skin in which the eruption is most intense, as upon the mons

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467

veneris and anterior axillary folds, yet they are by no means infrequently
present on the abdomen and chest. A magnifying glass will often bring
them into view, when they cannot be seen by the unaided eye. In certain
atypical cases the rash may be so indistinct that its true nature cannot
be recognized; or, indeed, it may be absent altogether. The only local
manifestation of the disease in such cases is a slight soreness of the throat.
It not infrequently happens during the prevalence of scarlet fever in a
family that one member will be affected by a sore throat, more or less
severe, without any eruption on the skin. Under such circumstances
the diagnosis is made of “scarlatina sine eruptione,” which diagnosis is
sometimes confirmed later by the occurrence of sequelae.

One of the earliest symptoms, as has already been mentioned, is
soreness of the throat. At first only slight redness may be seen in the
fauces, causing deglutition to be somewhat painful, and this condition
often increases pari passu with the development of the cutaneous rash.
In mild cases the throat symptoms may be moderate throughout the
attack, or even absent. But in severe cases the fauces are often intensely
inflamed and present an appearance comparable to the rash on the skin.
The soft palate particularly is of a vivid red color and shows punctiform
elevations. The tonsils are swollen and become partially covered with
yellowish-white exudation. The mucous membrane involvement fre­
quently extends to the nares, causing an irritating discharge from the
nose. The tongue at first is red at the tip, and covered with yellowish fur.
About the time the rash is developimg on the skin the papillae on the
tongue become prominent and often project through the coating, thus
giving the appearance described as “strawberry tongue.” In three or
four days the coating disappears entirely, leaving the tongue red and
raw looking, with its papillae very prominent, when the strawberry
appearance is even more suggestive. In certain cases of scarlet fever
the throat affection is so severe as to constitute an exceedingly promi­
nent feature of the disease. The name applied to these cases is “scar­
latina anginosa.” The tonsils are greatly swollen and covered with
membranous exudate. Deglutition is very painful and sometimes
almost impossible without regurgitation through the nostrils. The
tissues of the throat, particularly the soft palate, may undergo necrosis
and slough away in good part. The breath is fetid, and constitutional
depression profound. The glands of the neck in such cases are always
swollen, and there may occur extensive abscesses in this region; so ex­
tensive, indeed, as to destroy a large area of skin and the underlying
connective tissue, leaving the muscles and large blood-vessels exposed.
In these extreme cases death is liable to result either from toxemia or
exhaustion.

The fever, which is marked from the beginning, does not diminish,
but rather increases after the appearance of the eruption. As a rule,
the temperature ranges high. In the average case the axillary tem­
perature is from 102⁰ to 104⁰ during the progress of the rash. In mild
cases it may not rise above 102⁰, even when the rash is intensely marked.
But in severe cases the temperature not infrequently reaches 105⁰, and
even exceeds this. Hyperpyrexia sometimes occurs just before death,

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when the thermometer may register as high as 108⁰ or 109⁰. The pyrexia
in this disease, as in most other febrile affections, is characterized by
morning remissions and evening exacerbations. When the rash begins
to fade, the temperature declines, falling usually by lysis. Should it
continue high, some complication probably exists. During the pyrexia
the skin, of course, is hot and dry. The pulse is always rapid. This
symptom is perhaps more uniformly marked in scarlatina than in any
other infectious fever. In children the pulse ranges from 120 to 160.
The number of respirations are usually increased proportionately to the
height of the fever. It is only in exceptional cases that the stomach
continues irritable after the initial vomiting. Anorexia, however, con­
tinues throughout the eruptive stage, and thirst is usually intense. The
bowels are not necessarily disturbed. Nervous symptoms, such as
headache and slight muttering in the sleep, commonly appear with the
initial fever; and during the progress of the disease, especially when the
temperature ranges high, there may be restlessness, jactitation, and insom­
nia, or even active delirium. Slight albuminuria is present in a certain
proportion of cases during the eruptive stage, but its presence at this
time does not necessarily denote renal disease. This may occur at a
later stage as a complication or sequela and will be considered presently.

The lymphatic glands are involved in a large proportion of cases
of scarlet fever. They may be found swollen in the submaxillary region
at an early stage of the disease. According to Schamberg's¹ investiga­
tion, the inguinal glands are invariably enlarged, and those in the sub-
maxillary, cervical, and axillary regions are also very commonly enlarged.
The glandular intumescence usually bears some proportion to the toxemic
condition. Suppuration of the glands of the neck not infrequently
occurs; but those located in other parts of the body rarely suppurate.
This process, however, does not usually take place until the rash has
disappeared. An acute phlegmonous inflammation involving the glands
and connective tissue of the neck may occur and prove very destructive
to the parts, and consequently fatal to the patient.

In epidemics of scarlet fever some cases are sure to develop into a
malignant type of the disease. The tendency to the occurrence of this
type varies in different epidemics. The disease may be marked with
unusual severity from the beginning, presenting such symptoms as high
temperature, excessive irritability of the stomach, extreme restlessness
and delirium, or even convulsions. The delirium may be followed by
partial coma, a rapid and feeble pulse, intense fever, and disturbed
respirations. Death sometimes occurs within the first forty-eight hours
of the disease as a result of the intensity of the poison. The disease but
rarely assumes the hemorrhagic form, which is recognized by the livid
hue of the rash, the presence of petechiæ or purpuric spots, and by epis-
taxis and hematuria. From this variety recovery is rare, and the struggle
usually short.

When the rash of scarlet fever begins to fade, the skin assumes a
dusky or brownish hue, is dry and slightly rough, and begins to show
signs of shedding its upper layer. This process is known as desquama-
¹ Schamberg, Annals of Gynecology and Pediatry, Dec, 1899.

SCARLATINA                                           469

tion. In severe cases it usually begins before the rash has entirely dis­
appeared, being first seen on the neck and gradually extending to other
parts of the body. Quite frequently it is noticed first at the summits
of the miliary vesicles and spreads from each of these points by centrif­
ugal expansion. In its degree and extent it always bears a very distinct
relation to the diffuseness and intensity of the rash. When the latter
has been intense, the desquamative process is very copious, the epider­
mis being shed in flakes and scales. On the hands and feet, where the
horny layer of the skin is thicker, casts resembling gloves and slippers
are sometimes exfoliated. The finger-nails may be shed, but the hair
rarely falls out. When the rash has been extremely mild, the desquama-
tion is sometimes furfuraceous in character, and it may be even so slight
as to be scarcely perceptible; but it is rarely entirely absent, except per­
haps in cases of scarlatina sine eruptione. It has been known to occur
more than once in the same case. I am able to cite one instance in which
both the rash and desquamation recurred twice. The time required for
completion of the process, counting from the beginning of illness until
all parts of the body, including the palms of the hands and soles of the
feet, are perfectly smooth, is from six to eight weeks, and sometimes
longer.

Certain complications are liable to occur, and of these otitis media
is perhaps one of the most common. It most frequently appears during
the second week of illness. The earliest symptom is pain in the ear,
and this is soon followed by a purulent discharge from the external mea-
tus. Partial or complete deafness may result, although the majority of
cases recover without impairment of hearing. In some cases there is
suppuration in the mastoid cells, and even such serious results as menin­
gitis, thrombosis, or abscess of the brain. A mild form of arthritis, com­
monly called rheumatoid pains, often appears during the subsidence of
the fever. Abscesses of the neck are of frequent occurrence. Endo­
carditis, pericarditis, or myocarditis is not uncommon. Pneumonia or
pleurisy occurs occasionally during convalescence. The latter is some­
times associated with acute nephritis and a general dropsical condition,
and the effusion which takes place in the pleural cavity is often purulent.
Affections of the eye sometimes occur, but only rarely are they serious.
I recently saw a case of temporary blindness, doubtless caused by neph­
ritis; also two cases of exophthalmos from infiltration of the cellular
tissue of the orbit. Both of the latter were albuminuric, and death
resulted. I have also seen several cases of sloughing of the soft palate,
the trouble beginning as a perforating ulcer.

Albuminuria is not infrequent. It may be met with at an early stage
of the disease as the result of malignancy or intensity of the fever, but
far more frequently does it occur from the fourteenth to the twenty-first
day as the result of postscarlatinal nephritis. One of the earliest symp­
toms of this condition is extreme pallor, with puffiness about the face.
Whether or not this symptom is noticed it is advisable to examine the
urine frequently during the second, third, or even the fourth week of
illness. The presence of albumin in the urine does not always depend
upon the severity of the scarlatinal attack. Indeed, very severe forms

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of nephritis not infrequently follow extremely mild attacks of scarlet
fever. The quantity of albumin present may vary greatly in different
cases. It may be so scanty as scarcely to be found, or so abundant that
almost the entire column of urine in the test-tube solidifies by boiling.
The amount of urine secreted is usually diminished. In very severe
cases there may be almost complete anuria, and the small quantity that
is secreted is usually dark, often bloody, and contains, besides albumin,
tube-casts. The scanty elimination of urea may cause constant vomit­
ing and repeated convulsions, and death may result, with all the symp­
toms of acute uremia. In cases somewhat less severe there is a puffy
appearance of the face, especially about the eyelids, and often general
edema. The urine is scanty, sometimes bloody or smoky in appearance,
and contains tube-casts. The dropsy increases, effusion into the serous
cavities may occur, and the child, after suffering for several days, may
die from effusion into the pleura, edema of the lungs, or uremic poisoning;
or death may result suddenly from hydropericardium. Fortunately,
in most cases very much can be done by prompt and judicious treatment
for relief of the threatening symptoms of this complication.

Scarlet fever is sometimes complicated with diphtheria. It has been
found, by systematically culturing all cases admitted to the Municipal
Hospital, Philadelphia, that the Klebs-Löffler bacilli are present in from
10 to 15 per cent. Not infrequently, however, these organisms are
found in cases presenting no clinical evidence of diphtheria.

Diagnosis.—Except in atypical cases, the diagnosis of scarlet fever
is not difficult if attention be given to the following clinical points: The
disease begins abruptly, usually with vomiting, slight soreness of the
throat, and rise of temperature. In twenty-four hours or less the rash
appears on the neck, chest, and abdomen, being rather fine at first, but
rapidly increases in intensity and spreads to all parts of the cutaneous
surface except the face, which often escapes. When fully formed, it is
diffuse and punctiform in character. With the appearance of the rash
the fever increases, the tongue becomes furred, red at its tip and edges,
and the pulse is rapid. The lymphatic glands, especially those of the
groins, are almost always enlarged. The rash is quite invariably followed
by desquamation. Of the few diseases which may be confounded with
scarlet fever, only three are deemed worthy of consideration: measles,
erythema scarlatinoides, and septicemia. Measles may be differentiated
by the longer stage of invasion, and which is characterized by catarrhal
symptoms; by the rash first appearing on the face and extending to the
trunk and extremities; by the macular character of the rash and its so-
called crescentic arrangement; by the comparative absence of sore
throat, and by the branny character of the desquamation. Erythema
scarlatinoides may be distinguished by the uniform distribution of the
efflorescence instead of the punctiform character; by the longer duration
of the efflorescence and its tendency to recur; by the absence of marked
throat symptoms; and sometimes, also, by shedding the hair and the
nails, as well as the epidermis. The rash of septicemia is sometimes
quite similar to that of scarlet fever. But in this affection a history of
sepsis is almost always obtainable, the temperature usually shows

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471

greater variation, the “strawberry tongue” is wanting, and there is no
desquamation.

Drug-rashes are sometimes mistaken for scarlet fever. These are
usually transitory and rarely generalized. They are not associated with
fever, nor with the train of symptoms peculiar to scarlet fever. The rash
caused by belladonna, and less frequently that by quinin, gives perhaps
the best simulation.

It must be admitted, however, that in every epidemic there occur
atypical cases about which there is much doubt as to the diagnosis.
This doubt may sometimes be dispelled by the occurrence of nephritis
or subsequent well-marked cases of scarlet fever in the family.

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