SCARLET FEVER, or SCARLATINA, names applied indifferently to an acute infectious disease, characterized by high fever, accompanied with sore throat and a diffuse red rash upon the skin (see PARASITIC DISEASES). This fever appears to have been first accurately described by Sydenham in 1676, before which period it had evidently been confounded with smallpox and measles. Klein in 1885 isolated a streptococcus which he termed the streptococcus scarlatinae. The scarlatinal throat is the chief habitat of the organism, though it has been found both by Klein and other observers in the discharges from the ears of scarlet fever patients. Mervyn Gordon also isolated from cases the streptococcus conglomerulatus. It is possible that septic cases of scarlet fever are the result of a mixed infection. The serum of patients has been found to contain agglutins to streptococci from cases of erysipelas, septicaemia and puerperal fever, as well as to the streptococci scarlatinae. F. B. Mallory in 1904 published his discovery of " protozoonlike " bodies in the cells of the epidermis. Other observers have found them in the skin of fatal cases, but failed to find them in the living. The contagion of scarlet fever takes place from a previous case either by the skin during the early stages of the disease or by the nasal or aural discharges of a patient. It may be conveyed by any article of clothing or furniture or by any person that has been in contact with a scarlet fever patient. Infectivity may also take place through a contaminated milk supply, as in the Marylebone epidemic, 1885. Klein her-; found disorder in cows which he considers analogous to scarlatina and communicable to man.
The period of incubation in scarlet fever may be as short as one or two days, but in most instances it is probably less than a week. The invasion of this fever is generally sudden and sharp, consisting in rigors, vomiting and sore throat, together with a rapid rise of temperature and increase in the pulse. Occasionally, especially in young children, the attack is ushered in by convulsions. These premonitory symptoms usually continue for about twenty-four hours, when the characteristic eruption makes its appearance. It is first seen on the neck, chest, arms and hands, but quickly spreads all over the body, although it is not distinctly marked on the face. This rash consists of minute thickly-set red spots, which coalesce to form a general diffuse redness, in appearance not unlike that produced by the application of mustard to the skin. In some instances the redness is accompanied with small vesicles containing fluid. In ordinary cases the rash comes out completely in about two days, when it begins to fade, and by the end of a week from its first appearance it is usually gone. The severity of a case is in some degree measured by the copiousness and brilliancy of the rash, except in the malignant varieties, where there may be little or no eruption. The tongue, which at first was furred, becomes about the fourth or fifth day denuded of its epithelium and acquires the peculiar " strawberry " appearance characteristic of this fever. The interior of the throat is red and somewhat swollen, especially the uvula, soft palate and tonsils, and a considerable amount of secretion exudes from the inflamed surface. There is also tenderness and slight swelling of the glands under the jaw. In favourable cases the fever departs with the disappearance of the eruption and convalescence sets in with the commencement of the process of " desquamation " or peeling of the cuticle, which first shows itself about the neck, and proceeds slowly over the whole surface of the body. Where the skin is thin the desquamation is in the form of fine branny scales; but where it is thicker, as about the hands and feet, it comes off in large pieces, which sometimes assume the form of casts of the fingers or toes. The duration of this process is variable, but it is rarely complete before the end of six or eight weeks, and not unfrequently goes on for several weeks beyond that period. It is during this stage that complications are apt to appear.
Scarlet fever shows itself in certain well-marked varieties, of which the following are the chief:
I. Scarlatina Simplex is the most common form; in this the symptoms, both local and general, are moderate, and the case usually runs a favourable course. In some rare instances it would seem that the evidences of the disease are so slight, as regards both fever and rash, that they escape observation and only become known by the patient subsequently suffering from some of the complications associated with it. In such cases the name latent scarlet fever ( scarlatina latens) is applied.
2. Septic Scarlatina or Scarlatina Anginosa is a more severe form of the fever, particularly as regards the throat symptoms. The rash may be well marked or not, but it is often slow in developing and in subsiding. There is intense inflammation of the throat, the tonsils, uvula and soft palate being swollen and ulcerated, or having upon them membranous patches not unlike those of diphtheria, while externally the gland tissues in the neck are enlarged and indurated and not unfrequently become the seat of abscesses. There is difficulty in opening the mouth; an acrid discharge exudes from the nostrils and excoriates the lips; and the countenance is pale and waxy-looking. This form of the disease is marked by great exhaustion and the gradual development of the symptoms of acute septicaemia, with sweating, albuminuria, delirium and septic rash, i 3. Toxic or atoxic scarlatina (scarlatina maligna). In this form the gravity of the condition is due to intense poisoning, and the patient may even die therefrom before the typical symptoms of the disease have had time to manifest themselves.
The typically malignant forms are those in which the attack sets in with great violence and the patient sinks from the very first. In such instances the rash either does not come out at all or is of the slightest amount and of livid rather than scarlet appearance, while the throat symptoms are often not prominent. A further example of a malignant form is occasionally observed in cases where the rash, which had previously been well developed, suddenly recedes, and convulsions or other nervous phenomena and rapid death supervene.
The complications and effects of scarlet fever are among the most important features in this disease, although their occurrence is exceptional. The most common and serious of these is inflammation of the kidneys, which may arise during any period in the course of the fever, but is specially apt to appear in the convalescence, while desquamation is in progress. Its onset is sometimes announced by a return of feverish symptoms, accompanied with vomiting and pain in the loins; but in a large number of instances it occurs without these and comes on insidiously. One of the most prominent symptoms is slight swelling of the face, particularly of the eyelids, which is rarely absent in this complication. If the urine is examined it will probably be observed to be diminished in quantity and of dark smoky or red appearance, due to the presence of blood; while it will also be found to contain a large quantity of albumen. This, together with the microscopic examination which reveals the presence of tube casts containing blood, epithelium, etc., testifies to a condition of acute inflammation of the kidney (glomerular and tubal nephritis). Occasionally this condition does not wholly pass off, and consequently lays the foundation for Blight's disease. Muco-purulent rninorrhoea and also rheumatism are others of the more common complications or results of scarlet fever, while suppuration of the ears is due to the extension of the inflammatory process from the throat along the Eustachian tube into the middle ear. This not unfrequently leads to permanent ear-discharge, with deafness from the disease affecting the inner ear and temporal bone, a condition implying a degree of risk from its proximity to the brain. Other maladies affecting the heart, lungs, pleura, etc., occasionally arise in connexion with scarlet fever, but they are of less common occurrence than those previously mentioned. < -- .
In the treatment of scarlet fever, one of the first requirements is the isolation of the case, with the view of preventing the spread of the disease. In convalescence, with the view of preventing the transmission of the desquamated cuticle, the inunction of the body with carbolized oil (i in 40) and the frequent use of a bath containing soda, are to be recommended. With respect to the duration of the infective period, it may be stated generally that it is seldom that a patient who has suffered from scarlet fever can safely go about before the expiry of eight weeks, while on the other hand the period may be considerably prolonged beyond this, should any nasal or aural discharge continue. As to general management during the progress of the fever, in favourable cases little is required beyond careful nursing and feeding. The diet all through the fever and convalescence should be of light character, consisting mainly of milk food. Soups and solid animal food should as far as possible be avoided owing to the frequency of nephritis. During the febrile stage a useful drink may be made by a weak solution of chlorate of potash in water (i drachm to the pint), and of this the patient may partake freely. The fauces should be irrigated every few hours with a mild antiseptic solution, and sucking ice often relieves local discomfort. Should the lymphatic glands be enlarged and tender, they should be fomented. If suppuration threatens they must be opened. In septic cases the nasofaucial passages must be cleansed with a more powerful antiseptic. Insomnia, restlessness and high temperature may be relieved by tepid sponging, and acute hyperpyrexia by cold baths. The treatment of kidney complications is similar to that of acute Bright's disease. A hot-air bath or wet pack is often useful. Otitis may be troublesome, and when otorrhoea is established the canal must be kept as aseptic as possible. The ears should be carefully syringed every four hours with an antiseptic solution and dried, and a little iodoform inserted into the meatus. Complications such as mastoid disease require special treatment. Recently a method of treatment introduced by Dr Robert Milne, and consisting of the inunction of the entire body with eucalyptus oil from the first day of the disease, together with swabbing the tonsils with a solution of I in 10 of carbolic oil, has been advocated as rendering the patient absolutely non-infectious as well as limiting the severity of the disease. The method is still on its trial, but it is possible it may revolutionize our mode of treatment.
Serumtherapy. Marmorek's original antistreptococci serum has been on the whole disappointing in its results, but polyvalent serums have been much more successful. Dr Besredka prepared a serum from the blood of fatal cases, and in the serum prepared at the Pasteur Institute no less than twenty separate strains of streptococci are used. In using serums, early and large dosage is necessary. Palmirski and Zebrowski have also prepared a serum from the streptococcus conglomerulatus, which has been used with considerable success in the children's hospital at Warsaw.