Scarlet Fever.

This disease, technically called scarlatina, is distinguished by
a great diversity of symptoms as well as by varying degrees of
severity. The mildest form is comparatively trivial in its effects
upon the individual, while its severest form is one of the most
destructive diseases with which we are acquainted. Physicians
generally distinguish for convenience three varieties of the disease,
according to the degree of severity, and to the amount of compli­
cation in the throat. These varieties are called scarlatina simplex,
scarlatina anginosa, and scarlatina maligna. It must be under­
stood, however, that these are not distinct diseases, but merely
convenient terms for the designation of different manifestations of
the same disease.

Cause.—Scarlatina, like the other infectious diseases, is due
to a specific virus or poison, as to the exact nature of which we are
not yet informed. Like the other infectious diseases, it seems to
arise only by communication from individuals who are already
afflicted. Some cases, it is true, cannot be traced to contagion,
but seem to arise quite spontaneously, without previous exposure
to the disease; but it must be remembered that scarlet fever, like
small­pox, can be communicated by articles of clothing or of furni­
ture which have once been impregnated with the virus. Yet it by
no means follows that exposure to the contagion will induce the dis­
ease. This general principle is applicable, of course, to all infectious
diseases. There must be not only exposure to contagion, but also
a certain susceptibility on the part of the exposed individual, in
order that the disease may be developed. Yet the susceptibility
to scarlet fever seems to be less general than in any other of the
infectio’us diseases ; for it is no uncommon observation that several
of the children, even in the same family, who are exposed at the
same time to the scarlet fever contagion, escape the disease. Indeed,
it is even observed that while one child in a family suffers from the
disease, others living in the same house during the entire illness of
the first, escape completely. Such facts as these have caused some
physicians to doubt the contagiousness of scarlet fever. But it
must be remembered that there is precisely the same ground for
doub ng the contagiousness of any other infectious disease, since  
similar facts, not perhaps so numerous, can be adduced in regard to
each. The specific virus of scarlatina, like that of certain other
infectious diseases, retains its power of inducing the disease for
months, and may be transferred in the clothes of the attendants or
visitors.

The disease rarely occurs twice in the same individual, although
such repetition is more frequent in the case of scarlet fever than of
most of the other infectious diseases ; instances are known in which
the same individual has suffered even three times from scarlet fever.
The disease occurs most frequently in the third and fourth years of
life ; the susceptibility to it seems to decrease rapidly after the fifth
year, and almost subsides in adult life. During the first and second
years also the susceptibility seems to be slight, for cases in children
of that age are certainly rare. Instances are reported in which the
fcetus has contracted the disease before birth, though such cases are
certainly far less numerous than the analogous ones of small­pox.
Symptoms.—The period of incubation, so called—that is, the
interval between exposure and the first manifestation of the dis­
ease—is shorter in scarlet fever than in most of the eruptive fevers.
It is usually stated at two to five days, though it seems to vary be­
tween one and six days. At this interval, after exposure there com­
monly occurs a pronounced chill, which may, however, be absent.
Another symptom is usually vomiting, a symptom rarely absent in
children. The child in many cases complains of soreness of the
throat and pain upon swallowing, though it is a by no means con­
stant symptom. When it does occur there is usually also consider­
able reddening of the inside of the throat, and swelling of the
glands at the angle of the jaw. The other symptoms vary with
the intensity of the attack. In some there is intense fever, head­
ache and general prostration, perhaps even delirium; on the other
hand, there may be no indication of constitutional affection except
slight fever.

This stage of invasion usually lasts only twenty-four or, at
most, forty-eight hours. On the second day there appears, usually
first on the body and limbs, rapidly extending over the entire sur­
face, a brilliant scarlet rash. While this is the usual order of its
occurrence, it sometimes happens that the rash will be first percep­
tible on the face and neck. It consists at first of minute red specks
or dots, which soon run together, forming irregular shaped patches;  
yet even in these patches it can be seen, upon close inspection, that
the redness is not uniform and continuous, but is made up of a
mass of minute points of a deep red color, while the intervening
skin is tinged less intensely red. The color disappears upon press­
ure with the finger, and white lines may be made by drawing a
pencil or a finger-nail over the surface. The redness is usually
most intense and persistent on those parts where the skin is espe­
cially thin and delicate—along the inner surface of the arms and
legs and at the elbow. In some instances the entire surface is con­
tinuously red, producing the appearance which has been likened to
that of a boiled lobster. The surface is usually smooth, but may
cause a feeling of minute elevations. Sometimes very small watery
blisters may be scattered over the skin.

The patient is usually annoyed by a general itching sensation
which may amount even to positive pain; the skin is somewhat
swollen, a condition which becomes evident when the patient
attempts to close the hands, or places the feet upon the floor. Just
as there are great differences in the intensity of the skin eruptions
so the soreness of the throat may vary extremely; at times the
entire difficulty seems to be concentrated in the throat. In all cases,
probably, there is more or less swelling of the tonsils, and usually a
whitish deposit upon their surface; in the severer cases the swelling
in the throat becomes so great as to prevent the patient from swal­
lowing anything but liquids, and even to interfere seriously with
breathing, so that the voice acquires a nasal twang. Sometimes
there is an escape of blood into and on the surface of the throat.
The tongue usually presents certain characteristic appearances
in scarlet fever; it is often sprinkled over with projecting red points,
looking as if it had been dusted with red sand. Later the coating
of the tongue is cast off, leaving its surface clean and red, the points
above described now projecting so as to resemble the appearance of
a strawberry; hence the name strawberry tongue, an appearance
quite characteristic of this disease.

In scarlet fever the appearance of the eruption is not accom­
panied as in small­pox by a cessation of the fever; on the contrary
the constitutional symptoms are often increased; the degree of fever
is more intense during the eruptive stage of scarlet fever than in
any of the other eruptive fevers. During this stage, too, the most
serious mental and constitutional symptoms occur; delirium is usual,  
and convulsions (in children) very common; hence the greatest care
is required on the part of the attendants, since patients not in­
frequently injure themselves, even precipitate themselves from
windows during such delirium.

The eruption ordinarily lasts four to six days, though here, too,
variations occur. Of fifty-four cases reported by Jenner, the rash
disappeared on the fifth day of the disease in one case; in three
cases on the sixth day; in five cases on the seventh day; in thirteen
cases on the eighth day; in twelve cases on the ninth day; in eight
on the tenth; in four on the eleventh, and in two on the thirteenth,
fourteenth and sixteenth day respectively.

Stage of Desquamation.—About the sixth day the rash be­
gins to fade, and in the succeeding days the surface of the skin is
cast off in the shape of scales, usually of small size, like bran,
though some times in large pieces; indeed the entire skin of a finger
of a hand may be cast off entire like the finger of a glove. This
desquamation may last from six to twelve days, or may not be
finished for several weeks.

Such is the history of an ordinary mild case of scarlet fever
without complications; yet a large number of cases, whether mild or
severe during the original disease, are accompanied by
complications which are often more serious in the permanence of their effects
than any feature of the disease itself. Among these complications
are serious affections of the throat. These are so common that one
variety of the disease has been accordingly named scarlatina
anginosa. In these cases (which are probably sometimes considered
diphtheria) the swelling and ulceration in the throat and the conse­
quent interference with respiration are so great as to concentrate
the attention upon this part of the body. The rash is usually slight,
and maybe overlooked. The tonsils become enormously enlarged,
ulcerated, covered with a brown film or false membrane, and often
produce a great amount of matter; in these cases the glands around
the angle of the jaw are greatly enlarged and sometimes become
abcesses, which either break spontaneously or are opened. Another
complication, especially apt to occur in these cases of severe sore
throat, is deafness, partial or complete. The reason for this lies in
the fact that the cavity of the ear is connected with the throat by
means of a bony channel called the enstachian tube. The inflamma­
tion may, and frequently does, spread from the throat into and  
through this tube into the middle ear ; the result is the formation
of matter—an abscess—in the ear and the consequent loss of
hearing. In some cases there may be recovery of a certain amount of
hearing even after suppuration has occurred in the ear. Some­
times the local disease in the throat is so violent as to cause exten­
sive mortification of these structures,—sloughing—and this may
extend even to the mouth. Then, again, a severe inflammation of
the larynx (the upper part of the windpipe) may cause speedy
death. Sometimes, too, the membrane surrounding the brain, and
even this organ itself, becomes inflamed, resulting in more or less
permanent derangements of the mental functions. From the same
cause paralysis of the face or of the limbs may follow. Sometimes,
too, affections of the eyes, resulting in serious impairment of vision,
are observed.

But one of the most frequent and serious complications of
scarlet fever is inflammation of the kidneys. It would seem, indeed,
that this should be regarded almost as an essential part of the
disease, though in a considerable number of cases the kidneys resume
their natural state soon after the fever subsides. The complication
with inflammation of the kidneys is indicated by swelling of the skin
— dropsy — usually first noticed under the eyes, and then spreading
over the face, trunk, and extremities. A certain amount of dropsy
is a usual feature in all but the mildest cases of scarlet fever, and it
is often one of the last symptoms to disappear. But a dropsy which
persists for some time after recovery usually indicates serious inflam­
mation of the kidneys. This inflammation may exist without
noticeable dropsy, and can be, under these circumstances, detected
only by an examination of the urine, microscopical as well as chem­
ical. In every case of scarlet fever the physician should acquaint
himself by frequent examination of the urine as to the condition of
the kidneys ; for, though everything else may go on well, the
patient may succumb to this kidney disease even at a time when
convalescence seems at hand. In every case in which, after the
appearance of the eruption, the patient has repeated convulsions, or
lies stupid and unconscious, the condition of the kidneys may afford
a key to the situation. 
 

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