Definition

An infectious disease with a diffuse exanthem (scarlet rash) and sore throat.

Etiology

None of the infectious diseases vary so greatly in intensity. This is probably due to the interference with radiation that takes place on account of the skin complications, The disease is more common in the fall than in the summer or spring. Like all other diseases, in some years it is mild and in others more malignant. It acts epidemically, endemically, and sporadically. I have seen the most intense cases isolated, when there was no possible chance to trace the contagion, and the disease ended with those cases. One case had gangrene of the throat, which ran rapidly to a fatal termination. In seventy-two hours the throat had melted away and the child died. The malignant type of scarlet fever and diphtheria has almost disappeared.

Ninety per cent of the cases occur in children under ten years of age. Children at the breast are rarely attacked. It is thought to be less liable to occur than measles, and it is held that there are more prostrations from measles than there are from scarlet fever. Years ago, when this disease was very much more common and fatal than it is today, it was not uncommon to have two or three children die in one family, while at the same time many children were exposed to the infection who did not take it. It is strictly a disease of filth--the same as all contagious and infectious diseases. Authors declare that an attack confers subsequent immunity. This is in line with a great deal of professional opinion in regard to infectious diseases. When the great majority of mankind do not take a disease at all, it would be strange if those who do take it would develop the disease two or three times. Thus it is simply a gratuitous statement for authors to say that one attack brings immunity. More than one, and sometimes three, attacks have been observed in all contagious diseases. There is no contagion in the sense now understood.

The disease does not seem to affect the people of India. The reason for this perhaps is that such diseases as cholera and bubonic plague kill off those who are susceptible to so-called contagion.

Concerning the cause or character of scarlet-fever infection nothing is known. In this disease there have yet been no germs discovered, hence no serums made for its cure--for its immunization; but the disease has kept steadily declining in mortality for the past twenty years, and is today as much under control (?) as is diphtheria--and that, too, without the profession knowing anything at all about the character of the infection. If antitoxin has caused the rapid decline in severity and mortality of diphtheria, what is the cause of a like decline in scarlet fever? This is a question that should be answered before too much boasting is indulged in regarding the immunizing of diphtheria, smallpox, and other diseases.

It is generally conceded that the poison in scarlet fever is given off from the skin by the shedding of the skin after the rash is gone. This desquamation is supposed to be carried by the air and distributed in communities, thereby causing the disease to spread. I do not agree with this idea at all; for I have known of children desquamating (shedding dead skin) while in school, going among children day after day, until the skin had thrown off all the dead cuticle; yet not a case of the disease developed in the entire school. During a so-called epidemic I found, when in active general practice, that there were about twenty cases of scarlatinal angina to one case of scarlet fever Those presenting a sore throat probably were not in the physical condition required for a full development of the disease. All cases have indigestion preceding the attack. After holidays, feasts, and social affairs, which break down resistance, those who have been brought to a stage of enervation by improper indulgence are the ones who develop these diseases. Children in full vigor, with perfect digestion and regular bowels, can pass through all the epidemics peculiar to children without taking any of them. Authors declare that no germ has been found, but that the streptococcus pyogenes has often been found in the blood during life and after death, These germs are to be found in the blood of all cases that die of septic poisoning. Children who die of scarlet fever, diphtheria, measles, or typhoid fever, die of septic poisoning; and the streptococcus would be found in all such cases, if an investigation were made after death. If these diseases had been treated properly there would not have been these complications.

Symptoms

Incubation is said to be from two to seven days. The disease usually starts suddenly. It may be preceded by a stage of irritability, nervousness, and a slight chill. In severe cases the temperature runs very high within the first twenty-four hours. A very common type will begin suddenly--six, eight, or twelve hours after apparently full health. The child may eat a very hearty dinner at noon or in the evening, and the next day be prostrated with the disease.

Vomiting is almost invariably at the beginning of the disease. Vomiting in such cases means imprudent eating up to the time of the vomiting, and if children were not indulged in overeating, they probably would not have such diseases at all. Convulsions are not uncommon. The fever, in severe cases, always runs high--104°, 105°, and even 106° and 107° F. Cases that run from 106° to 107° are almost invariably fatal. The tongue is furred, and the breath is always pungent--just such a breath as one would expect in gastric fever. This, however, does not last very long; for when septic poisoning begins, the breath becomes fetid, There is always throat trouble, and sometimes this is very severe. The nasal passages will also take on inflammation. Indeed, I have noticed symptoms of throat and nose so very like diphtheria, and so often, that I have associated the two diseases together as being one and the same. In one type there is an exanthem, and in the other the skin complication is absent. The symptoms from the start of a severe attack indicate a very grave disease. The eruption begins within seventy-two hours. Some cases show an eruption in from thirty-six to forty-eight hours. It begins with little points of redness on the surface of the body--on the chest, inside the thighs, in the bend of the elbow, and around the neck. At first it is of a flushed appearance, more than an indication of a rash. Often the entire body is covered with an intense redness within forty-eight hours after the rash begins to appear, which is three days from the beginning of the disease. The rash remains from two to three days, and then begins to disappear.

The tongue has the appearance of a strawberry. It is called a "strawberry tongue." This condition of the tongue is sometimes present in gastric fevers. Indeed, so common are these symptoms in gastric fever and in scarlet fever that I have always recognized gastric, or a pronounced gastric, irritation as one of the symptoms of scarlet fever. Sometimes I have been persuaded to the idea that the disease originates in the stomach--starts as a profound gastric fever, superinduced by toxins generated from putrefaction. If differs from the ordinary gastric fever in the intense toxemia from putrefaction; the lighter forms of the disease brought on from simple fermentation without putrefaction.

When the toxic state grows more profound, the surface becomes darker; the rash loses its scarlet redness and becomes dull in appearance. The skin gets rough, and in some cases feels like goose flesh. The eruption sometimes appears in the roof of the mouth, and by some authors this is considered diagnostic; but in pronounced cases of scarlet fever no one need be in doubt about the disease. Sometimes the eruption does not come out on the face at all. At times itching becomes intense at the end of the first week. The throat trouble differs widely. In some cases it is very mild; in others it is the most serious symptom connected with the disease. Where the mucous membrane of the nose becomes involved, the inflammation may be carried to the eyes through the lachrymal ducts.

Dr. Osler, in his last work on the "Practice of Medicine," reports the temperature of mild cases at 103° F., and in severe cases hyperpyrexia of 108° to 109°. In one case that comes to my mind the temperature was 111°. Of course, the child was dying. This was the most intense fever that I have ever observed. While the temperature runs very high, the pulse seldom goes above 120--usually about 115 to 116. Sometimes it becomes more rapid when hyperpyrexia is established. In severe cases the shedding of the skin is very intense--even the hair and nails are shed. In some cases the shedding will not be finished until the sixth or seventh week. Children in this state should not be exposed to sudden changes of temperature. They should be carefully looked after; for it is this class of cases that leaves sequels, such as scarlatinal nephritis. In malignant forms of the disease the throat symptoms become very intense, and often spread to the ear through the eustachian tube, or through the nose down through the trachea. Death may take place in from three to five days. Some cases could not be distinguished from malignant diphtheria if it were not for the rash. There are many complications, such as nephritis and arthritis. Derangements of the heart, lungs, and bronchial tubes are other frequent complications. Adenitis and tuberculosis sometimes follow.

Mild Forms Of The Disease

Some cases are so mild that they will be passed unnoticed. The mother may notice a little rash, to which she pays no attention, the child not being sick enough to complain, more than to be a little cross and irritable. In due course of time there will be a little scaling, or shedding of the skin; and even this may pass without notice. In the course of a few weeks or months the child will begin to show symptoms that force the parents to call or consult a physician. If the urine is examined, it will be found albuminous. The disease was so slight in the first place that the child was not cared for properly. It was allowed to be more or less exposed to weather of all kinds. Kidney and ear complications not infrequently follow scarlet fever of so light a type that it escapes notice.

Prophylaxis

Good health is the best immunization that can be given any child. Children can have good health if they are fed and cared for properly; but so long as haphazard reigns in all families of children--so long as no attention is paid to what children eat, except to give them all they want and anything they select--there will be socalled contagious diseases. For, whatever may be said of the infection, there must be a system prepared for the infection; and improper eating--improperly combined foods, overeating, and too frequent eating--to develop fermentation in the alimentary canal, creates a favorable culture-soil medium for the ever-present ferment of disease.

Treatment

The treatment of scarlet fever should not be different from that of fevers in general. The patient is to be made comfortable, If necessary, when the temperature is runnning high--104° to 106° F.--he should have a bath every three hours. Start with hot water, of a temperature of 100°. Then add cold water until the temperature is reduced to 90°. If in the course of ten minutes there is no indication of a decrease in temperature, reduce the water ten more degrees, and end the bath at about twenty minutes. No possible harm can come to a child by bathing in this way about every three hours until the high temperature has been brought down and confined at 103° and below. Authorities say that the disease cannot be cut short. I say it can. If I should feed broths and fruit, I should not expect to cut the disease short. There should not be any fruit juice fed until after the temperature has been reduced to 100°. Nothing but water should be given.

An enema should be given every night. Start with two quarts of water and a teaspoonful of baking-soda. Use as much in the bowels as can be used without giving the patient too much distress. The bowels should be washed out; for, while scarlet fever has the reputation of being an infectious disease, its establishment and continuance are wholly dependent upon putrefaction in the intestine and the absorption of toxins from this source.

When desquamation, or shedding of the skin, begins, it will be well to give the child a thorough oil rubbing every night, and then a warm bath in the morning. It will not be necessary to use soap. After the bath, a reasonable amount of light rubbing by the open hand is advisable. When children are nervous, the nurse should be instructed to give a gentle spinal rubbing, the same as described under the treatment of typhoid fever. If the hot bath is given as directed, food is avoided, and the bowels are kept cleared out by enemas, there will be very little danger of renal complications, or any other complications.

As for drugs, they are an abomination and can do nothing except to complicate the case and make the patient feel uncomfortable. In cases of hyperpyrexia (fevers from 107 degrees and up) the bathing should be managed very carefully. When possible, a physician should be with the patient during a few of the first baths, so as to educate the attendant or nurse in knowing how it is to be managed. As advised before, the bath should be started at a temperature of 100°. Allow the patient to be in the bath two or three minutes. Then reduce the temperature by allowing the cold water to run in at the head of the tub while the warm water runs out at the foot; or the hot water may be dipped in a little at a time, and thoroughly stirred around the patient, so as to keep the water at a uniform temperature. Reduce to 80°. Watch for five minutes. If there is no lowering of the patient's temperature, reduce that of the water to 70°. If the fever still stays high, do not hesitate to reduce to 60°. If that does not effect a lowering of the temperature, go to 50°, and then to 40°. The heart must be watched. If the temperature begins to subside, and the pulse goes down in frequency, take the patient out of the bath and put him to bed. Then, if the temperature goes up in three hours, give another just such bath as before; and keep doing this every three hours until the fever is thoroughly controlled.

This disease kills because of the high grade of fever more than because of anything else. By not feeding, and by keeping the bowels washed out, there can be no continuation of the absorption of the toxins or putrefaction in the bowels. When the temperature is normal, the pulse normal, and there is no discomfort, feeding may be started.

Fruit juices and water, half and half, the first day; then orange juice in the morning, salad at noon, and fresh fruit in the evening, for a day or so. If all goes well, have fruit in the morning, salad at noon, broth and salad in the evening.