Scarlet fever is the popular name of a disease which is developed from an epidemic and infectious poison. Children who have not had the disorder will be certain to take it from visiting a house where it prevails, or even where it has recently prevailed; and children in houses miles away from any others, with no direct communication, are stricken down with the disease, the infection being conveyed by the winds, for long distances across the country. This disease consists then in the development of a peculiar poisonous miasm, principally upon the skin; where the eruption forms a salutary crisis of the fever. With this development upon the skin there may also be a development upon the mucous membranes, which becomes more or less deeply and extensively involved, in proportion to the malignancy of the morbid influence by which it is caused. And finally, failing this sufficient development upon the skin, in the fauces, nostrils, &c., or deserting the skin, the disease may attack the meninges of the brain, producing convulsions necessarily fatal, unless relieved with the utmost promptitude. As a consequence of the ravages made by this disorder in the system, ravages which are dreadful just in proportion to the amount of pre-existing psoric dyscrasia which the scarlatina poison finds and with which it unites itself, all the latent psoric miasm in the system is developed; and there results a post-scarlatina dropsy, or some form of “scrofulous” disease.
Symptoms. Vomiting is usually the first symptoms which indicates the onset of either variety of scarlet fever; and we think a malignant form of the disease, and especially of the scarlet rash, may be apprehended when the vomiting is very severe and persistent. In other respects, the more generally the eruption is developed over the entire surface of the skin the less apt is the throat to become seriously affected; for in all but the worst cases the disease thus seems in a measure to expend itself upon the exterior surface. While the mucous surface, the throat and nostrils are apt to become the seat of the development of the disease in proportion as it fails to be sufficiently developed upon the skin. And yet in the malignant forms of the disease the eruption involves the entire surface, and in the worst cases assume a livid hue, while the fauces and nostrils are affected to the extent of ulceration, putrid exudations, gangrene, and sloughing of the swollen and compressed portions of the tonsils, &c. This is the old scarlet fever and canker-rash, or cynanche maligna.
The fever which forms the continued crisis of the eruption is characterized by being steady and almost uninterrupted in its course; gradually increasing till the eruption is well out; continuing with little or no abatement during its continuance, and in favorable cases gradually subsiding as the eruption itself gradually fades away. The pulse also maintains a corresponding uniform height, showing scarcely any of the decline and aggravation, day and night, which is common to true synochal fever. Many of the other symptoms, as the nervous restlessness, may be relieved by the accession of the eruption; but the fever itself holds on its steady course of intensity until at the full term, the appearance and continuance of the efflorescence gives place to its decline. And even then, in badly managed cases, instead of sensibly abating, the fever may take a fresh start under the typhoid form.
The eruption in the true Sydenham scarlet fever, or smooth variety, scarlatina laevigata, is a mere blush or efflorescence, a redness of the skin which beginning about the face and neck gradually spreads over the whole surface of the body, and of the extremities. This full development of the eruption is only arrived at by the third day; and a similar redness may be seen in the mouth and fauces and even in the nostrils. The eruption in the scarlet rash, scarlatina rubeola, the more common form of the disease, gives a perceptible roughness of the skin, and a sensation as if its surface were covered with minute granules. This is caused by an enlargement of the cutaneous papillae; and is more evident on the extremities and front of the body.
On the fourth day the eruption is at its height; and even after the rash has extended pretty generally over the surface of the skin; it will come out much more fully and assume more and more the boiled lobster appearance, both in color and in the sensation of roughness which it imparts to the applied hand. On the fifth, sixth and seventh days the eruption declines. First remaining stationery a day or so, or commencing very gradually it fade away. And in favorable cases the decline corresponds to its original mode of appearance, but in the reverse order, gradually disappearing, in a uniform manner, and from the extremities first. Next succeeds desquamation of the cuticle, a process which often occupies many days before it is completed. Compared to the old form of scarlet fever proper, scarlet rash is a very uncertain and treacherous disorder. All may be going on well, when at once some untoward change, some unlooked for and dangerous symptoms may arise. Sudden fading away of the eruption in different parts of the body, its partial recession, its premature decline, or increasing lividity, symptoms which may occur in apparently favorable cases, but which are more apt to appear in the malignant forms of the disease, will necessarily awaken the greatest anxiety; and the remedy should be at once most carefully selected to meet the imminent danger.
The tongue affords some very characteristic indications in scarlet fever, in either variety; since, as will subsequently appear also in the fauces, the mucous membrane develops an appearance corresponding to that of the external skin. We give Dr. Waston’s concise description of what, in different degrees of intensity, may be always seen in this disorder. “The appearances of the tongue in scarlet fever are also peculiar and characteristic. In the scarlatina simplex, and anginosa, it is often covered at the outset with a thick white, cream-like fur, through which are seen projecting the red and exaggerated papillae; the edges of the tongue being likewise of a bright-red color. The red points gradually multiply, and the white fur clears away, and at length the whole surface of the tongue becomes preternaturally red, and clean and raw-looking; and after becoming thus clean as well as red and rough, and like a strawberry, it will sometimes, when the disease goes on unpromisingly, get dry and hard and brown, as you know it is apt to be in certain species and stages of continued fever. In the milder, as well as in the severer cases of the disease, the tongue and fauces should always be inspected at each visit.
The fauces present a still more striking resemblance to the eruption on the external surface. If able to speak, the patient will complain of soreness of the throat, and upon examination will be found a greater or less amount of swelling, with redness of the tonsils uvula and palate; either smooth and bright red, corresponding to a similar eruption on the skin; or rough and granular, of a darker color or dusky hue, corresponding to the accompanying external scarlet rash. After the first day or two, the tonsils and uvula may be seen to be covered with a whitish exudation, or gray, aphthous formations, like false membranes, which, being removed, leave an ulcerated or sloughy surface. The tonsils, uvula and palate are very much inflamed and swollen; but the aphthous or false membrane-like formation which covers them, although it may extend to the nares and even in some measure involve the oesophagus, does not affect the larynx; in this important respect differing from the more firmly organized exudations of croup and diphtheria.
The skin becomes dry and hot, in proportion to the intensity of the fever; the pulse is quick and hard, varying from one hundred to one hundred and fifty per minute, according to the severity of the case and the age of the patient. The thirst is not remarkable; the appetite is of course lost; and the bowels are usually bound up, or if they are opened, the stools are observed to be of a much darker color than is natural.
The preceding account of the natural history and principal and most characteristic symptoms of simple scarlet fever has reference rather to those cases of the ordinary severity. In those which run a regular course and terminate favorably, the eruption consumes three or four days in reaching its height; remains apparently stationary a day or two, and then in the course of three or four days more gradually fades away; so that by the eighth or ninth day the period of desquamation will have been reached; and this may consume an equal or still greater amount of time, in proportion to the severity of the case. And until this process is entirely completed, and the old cuticle, destroyed by the intense cutaneous inflammation,. is replaced by new skin, it will be absolutely essential to have the patient very carefully watched over, to guard him from any exposure, which even in comparatively mild cases might be rapidly followed by a new and still more dangerous disease in the form of some one of the various Sequelae of scarlet fever.
