The attack is inaugurated most universally with a severe chill, and with or without more or less severe anginal symptoms, early declared fever ensues, characterized by exceedingly high temperature, carrying the mercury up to 103 5/10 degree Fahr. to 104 degree and 104 5/10 degree Fahr. and all this within the period of twenty-four hours. In case anginal symptoms accompany, the attack is more often imputed to cold, so called, or some special and extreme meteorological changes. The fever will rage on hardly longer than thirty-six or forty-eight hours when abortive phenomena ensue, with a declared rash on face, hands, and arms.
The discharge from the womb soon become tainted, either patent or detectable only on close observation. The rash runs down over the body and limbs and feet not uniformly in one unbroken blush, but in detached areas. As the rash extends the febrile phenomena continue with increased intensity, complicated and blended with the metritic irritation and distresses of the abortive act. The intense blood heat, the thirst, the dry tongue and mouth, the burning or stinging or itching rash, the uterine suffering, the offensive discharges lochial or otherwise, the vigilance and restlessness and more or less delirium, make the case extreme and critical.
Here will arise, if not before, the problematic question of the greatest import. Is this rash, faintly outlined it may be, and occurring not in a continuous blush, but in detached areas, zymotic from scarlet fever infection or is it the skin discoloring of septic position? Is the case, in brief, one of zymotic or non-zymotic puerperal fever? There is demanded the most searching and exhaustive inquiry into the history of the patient and family with the view to determine the exact provocation of the attack, whether it was autogenetic or heterogenetic. For the infection ma have run through very circuitous and unexpected routes.
Apart from the presumptive evidence of a clearly defined tracery of exposure to scarlet fever infection there are points of differential diagnosis that will contribute to the solution of the problem.
1. In scarlet fever infection the onset and progress of the puerperal fever are more violent and carry a higher average temperature.
2. The anginal symptoms, if any accompany the case, are more extreme than what pertains to a non-specific sore throat.
3. The tongue becomes red and dry much sooner and more papillary than in septic fever.
4. The rash rarely appears until after the abortive act is completed, so far as the loss of the embryo is concerned, but appears earlier than the rash of septic infection would declare itself.
5. The rash or skin discoloration is a different rash and closely examined is found more diffused and miliary in character which is not true of septic staining of the skin.
II.-As declaring itself in the puerperal state.
If the exposure to scarlet fever occurs in the later months of gestation, the infection may remain and is prone to remain a latent, dormant force until labor at full term is declared and completely, but immediately thereafter will burst forth in form of a declared puerperal scarlet fever. This incubation ma have an extension back away to the seventh and a half and even to the seventh month, and give no evidence whatever of itself for this protracted period, as has occurred in a case of recent experience of mine. The mother had been called upon by a neighboring friend at this date of her gestation, whose sister, very ill with scarlet fever, she had visited and nursed. This was, in her case, the only possible source of infection, as was determined by the most searching inquiry.
For nearly two months the infecting virus had remained in dormant incubation and manifested its true character not until twelve hours after delivery, when there was first noticeable a rash on the mother’s face, which gradually extended to her neck and throat, arms, wrists and back of hands, and in twenty-four hours the entire body became stained with the rash. The fever was inaugurated with the rash and intensified wit its extension, carrying the temperature to 104 5/10 degree Fahr. in twenty-four hours, with all its ordinary phenomena. No anginal symptoms appeared. The itching and burning of the skin was extreme.
Her lochia became exceedingly tainted; her milk fully formed but rapidly disappeared, though partially returned after established convalescence which took place at the expiration of the middle of the second week. On the morning of the second day her babe, fair of skin at birth, showed the same rash phenomena with the mother, and became covered from head to foot; its fever gradually increased as the rash progressed. The babe survived and became convalescent soon after the mother’s restoration to normal temperature. The exfoliation in the two cases exceeded anything I had ever before seen.
The problematic question in this case was, what was this fever? Was it septic or zymotic? Here was a women apparently perfectly well at the close of her gestation, and whose labor was primiparous and every way natural, at the end of twelve hours gave evidence of febrile symptoms and whose face showed stains of rash, and at the end of thirty-six hours carried a temperature of 104 5/10 degree Fahr., whose lochia became checked and very offensive and whose breasts collapsed with entire loss of milk.
Anxiety and alarm gathered around the case, and the matter of diagnosis as well as prognosis became serious and embarrassing. Reliance was put upon the diagnostic points before made, but one of the factors was wanting. There had been no conscious exposure. Not until several days after the case had been designated scarletina, were the facts recalled of the neighbor friend’s ill- timed visit, while nursing her sister, very ill with the malady. This at once poured a flood of light upon the case and removed all ambiguity.
One object of this brief paper is to awaken a caution which I am convinced has been too little heeded by the profession at large, as to the exposure of the gestative woman to this very common zymotic malady, freighted as it is with such grave suffering, such embarrassing problems of aetiology and diagnosis and such imperiling possibilities both to the mother and her embryo or child. Against any such exposure the gestative woman should be guarded to the limit of every possibility.
Another object is to being into prominence the surprising possibility of so protracted and so dormant incubation of the infecting virus, as the full appreciation of this possibility may furnish a key to some puerperal histories, that carried to their issue, whether of resolution or death, unsettled questions as to their exact character.
Another object is to elicit expressions of opinion with the view of determining what shall be regarded as indisputable diagnostic evidence by which we can unerringly differentiate between the rash of true scarletina as affecting the gestative and puerperal states, and the rash that is contingent upon septic poison.
