SCARLET FEVER.
BY J. LEWIS SMITH, M.D.
HISTORY.—The terms scarlet fever and scarlatina are used synonymously to designate one of the most common and fatal of the eruptive fevers. Whether this malady occurred prior to the Christian era is uncertain. It is believed by some that the plague of Athens, 430 years before Christ, vividly described by Lucretius, and by Thucydides, who was attacked by it, was scarlet fever of a peculiarly malignant type (Richardson); but, as will be seen from the following extracts from Thucydides, the plague differed in important particulars from scarlatina of the present time: "Internally, the throat and the tongue were quickly suffused with blood, and the breath became unnatural and fetid. There followed sneezing and hoarseness; in a short time the disorder, accompanied by a violent cough, reached the chest.... The body externally was not so very hot to the touch, nor yet pale: it was of a livid color, inclining to red, and breaking out in pustules and ulcers." Loss of sight and gangrene of the extremities were common results in those who recovered, and adults appear to have been affected as frequently as children. "The dead lay as they had died, one upon another, while others, hardly alive, wallowed in the streets and crawled about every fountain craving for water. The temples in which they lodged were full of the corpses of those who died in them." Lucretius says of this plague, "If any one for a time escaped death (as was possible, either by reason of the foul ulcers breaking or by means of a black discharge from the intestines), yet consumption and destruction awaited him at last; or, as was often the case, an excessive flux of corrupt blood, attended with violent pains in the head, issued from the obstructed nostrils, and by this outlet the whole strength and substance of the man passed away. He, moreover, who had escaped this violent flux of foul blood was not certain wholly to recover, for still the disease was ready to pass into his nerves and joints, and into the very genital organs of the body. And of those who suffered thus, some, fearing the gates of death, continued to live, though deprived by the steel of the virile part, and some, though without hands and feet, and though they lost their eyes, yet persisted to remain in life, so strong a dread of death had taken possession of them. Upon some, too, came forgetfulness of all things, so that they knew not even themselves."
Gangrene of the extremities, loss of sight, a violent cough, loss of memory, etc. are not symptoms of scarlet fever, so that in my opinion the plague of Athens, if correctly described by the historian, was a different malady.
Caspar Morris, in his essay on scarlet fever, states his belief that Seneca, who lived in the first century of the Christian era, described an epidemic of the malignant form of scarlatina in his portrayal of the pestilence that visited Thebes during the half-mythical age of Oedipus, six centuries before Christ. Seneca's description of the symptoms of this plague is as follows:
|
Piger ignavos Alligat artus languor, et ægro Rubor in vultu, maculæque caput Sparsere leves; tum vapor ipsam Corporis arcem flammeus urit Multoque genus sanguine tendit Oculique regent, et sacer ignis Pascitur artus. Resonant aures, Stillatque niger naris aducæ Cruor; at venas rumpit hiantes. |
Languor, redness of the face, light spots upon the head, distension of the cheeks with blood, distortion of the eyes, a flushed appearance of the limbs, tinnitus aurium, and a discharge of black blood from the nostrils, certainly indicated a very malignant form of disease, but to believe that it was identical with the scarlet fever of the present time requires considerable credulity. From the fact that it devastated Thebes we infer that it occurred largely among adults, differing, therefore, from the modern scarlet fever, whose victims are chiefly children. The same uncertainty hangs over epidemics during the first centuries of the Christian era.
The first clear and undoubted portrayal of scarlet fever is found in the medical literature of the sixteenth century. Sydenham and his contemporaries in the seventeenth century witnessed epidemics of it, studied its nature more thoroughly, and consequently acquired a more accurate knowledge of it than that possessed by their predecessors. It was in this century that measles and scarlet fever were differentiated. During the last two hundred years scarlatina has been the subject of monographs too numerous to mention. It has long been regarded as one of the most important maladies of childhood, on account of its frequency and the great mortality that attends it, so that numerous cases and many epidemics are every year related in the medical journals. By this vast accumulation of observations and the patient and thorough use of the microscope our knowledge of scarlet fever has become full and accurate.
As with most of the infectious maladies, scarlet fever extended to the Western World through European shipping. It was brought to North America about the year 1735. Tardily it spread to South America, where it appeared in 1829, and more recently it has been established in Australia. It entered Iceland in 1827, and Greenland in 1847.
ETIOLOGY.—The evidence is strong that scarlet fever does not originate de novo—that it does not spring from certain atmospheric or telluric conditions, but is produced by a definite specific principle, since countries have been free from it for centuries till it was imported by commerce. That it appears in certain localities without any known exposure is attributed to the fact that the poison is so subtle and transmissible that it is conveyed long distances in articles of merchandise, even in small packages, so that those who chance to open them or come in contact with them are infected. It is believed that reading matter transmitted through the mails has in many instances been the medium of infection.
The theory that the acute infectious maladies are caused by micro-organisms, or, as they are now designated, microbes, commonly discarded at first and believed to be chimerical, is rapidly gaining ground in the profession, and appears to be fully established as regards certain of them. These parasites, barely visible under high powers of the microscope, and ascertained to be vegetable by their behavior under certain chemical agents, exist in immense numbers in the blood, tissues, and secretions of patients suffering from the infectious maladies, especially in the graver cases of them; and the microscope shows that these organisms vary in shape and appearance so as to admit of classification.
The germ theory has now become so important that it cannot be ignored in a monograph relating to so important an infectious malady as scarlet fever. The relation of microbes to the infectious diseases has been made the subject of investigation by Pasteur, Toussaint, and others in France, and by many in Germany, with most interesting results. The belief held by many, and which seemed very plausible, was that the microbes, instead of sustaining a causative relation to the maladies in which they occur, were the result of these maladies—that they sprang into existence in consequence of the vitiated state of the blood and tissues, just as fungi appear on decaying substances or as the Oidium albicans appears in certain morbid conditions of the buccal surface and secretions. Obviously, in order to elucidate this matter and determine the relation of these parasites to the diseases in which they occur, it was necessary to experiment on animals, but, unfortunately, as a bar to successful experimentation many of the most important infectious maladies which afflict the human race, as typhus and typhoid fevers, the marsh fevers, and syphilis, do not occur in animals, or they occur in a changed and mitigated form. Others, however, can be produced in their typical character in animals, as diphtheria, and others still originate in animals and are transmitted from them to man, as anthrax or splenic fever of the herbivora and hydrophobia. Very interesting and important results have been produced by experimental researches with the microbes of certain of these diseases, which, if applicable to the common and fatal infectious maladies of an analogous nature in man, may yet result in immense benefit in mitigating the virulence of those affections which are the scourge of childhood and which sensibly diminish the increase of population. It has been found possible to cultivate the microbes contained in the blood, tissues, and secretions in certain of the infectious diseases, and after a series of cultivations, so that these organisms are far removed from the animal substance which contained them, and with which they were so intimately associated in the individual, they have been employed for inoculation—with this important result, that the primary disease was reproduced. This seems to indicate beyond question the causative relation of these parasites to the diseases in which they occur. Experiments with the result which I have stated have been made with the microbes of splenic fever, chicken cholera, murrain, and certain other maladies.
Pasteur employs as the media for cultivation—(1st) urine neutralized by a few drops of potash solution; (2d) a liquid prepared by boiling for twenty or thirty minutes the yeast of beer in water, neutralizing, and filtering; and (3d) chicken tea, prepared by boiling equal parts of water and the lean of muscles a quarter of an hour, filtering, and neutralizing. A small drop of infected blood is placed in the liquid of cultivation, and the microbes which it contains multiply so abundantly that the liquid becomes turbid in a short time, and they are found in all parts of it. A drop of this liquid is added to another portion of the medium, and this also soon becomes turbid from the immense development of organisms which have the same microscopic appearance and character as those in the drop of blood. The process is repeated many times, until the microbes are far removed from their original source in the blood and tissues, and a drop of the last cultivation, whether it be the fiftieth or the hundredth, is inserted under the skin of a healthy animal selected for the experiment. If it be true, as stated by the experimenters, that the original disease is thus reproduced with the microbes of at least three or four distinct maladies, this age is distinguished by one of the most important discoveries ever made in pathological studies. It remains to determine whether this great discovery is of general applicability to the infectious diseases with which man is afflicted. If so, it is not improbable that we are on the eve of finding a method by which some at least of these maladies may be prevented or mitigated, as small-pox has been since the time of Jenner. The result of experiments made by Pasteur with the microbes of that fatal malady of the herbivora, known under the various names of splenic fever, anthrax, wool-sorter's disease, and charbon, encourages this belief. Originating among the herbivorous animals, it has in many instances been contracted by individuals who have rapidly perished. Many engaged in assorting alpaca and mohair have lost their lives by it, some with all the symptoms of profound blood-poisoning, without external lesions, and others with redness and swelling at some point of infection where a sore or abrasion existed, but with speedy blood-contamination.
The microbe of this malady, the Bacillus anthracis, occurs in the form of straight filaments with little movement or only with oscillation, and producing bright-shining spores. Now comes a very interesting and important result of experimentation: Pasteur states if several days elapse between the cultivations the virulence of the parasite diminishes, so that he has been able to produce by inoculation with it a mild and never fatal form of charbon, which affords immunity in the animal from any subsequent attack. This opinion was sustained by a trial experiment on sixty sheep. Toussaint and Chauveau claim that they produce a similar attenuation of the virus by defibrinating infected blood, heating it to 55° C. (131° F.) and filtering it. These experiments awaken the hope that the time will come when the acute infectious maladies in man, scarlet fever among others, will be rendered less virulent. That one of them—to wit, small-pox—has for nearly a century been under our control certainly encourages the belief that there is some way to mitigate others of the same class which are equally fatal if not so loathsome.
As yet, observers do not agree in regard to the parasite which is supposed to sustain a causative relation to scarlet fever. Klebs states that it is highly probable that both measles and scarlet fever are produced by micrococci, and he has sketched the design and described the development of a microbe which he designates the Monas scarlatinosum.
The London Medical Times and Gazette for Jan. 28, 1882, contains an account of the supposed discovery of the scarlatinous microbe by Eklund of Stockholm, an authority in the microscopic examination of parasites. He says that scarlet fever is rarely absent from the Swedish capital and from the barracks and dwellings on the isle of Skeppsholm. In the urine of scarlatinous patients he has constantly found a prodigious number of discoid corpuscles, oval or round, their diameter being less than 1/1000 millimetre and from 1/30 to 1/10 that of a red blood-cell. They are colorless or yellowish white, surrounded by a distinct cell-wall, each containing a well-defined nucleus of a deeper hue. Sometimes one or more microbi may be seen. They exhibit rotatory or oscillatory movements, especially observed when a drop of water is added to the fluid. They multiply, as he has frequently seen, by fission—first in the microbes, next in the nucleus, and lastly in the cell-wall. He cannot say whether they develop into a mycelium. At any rate, the development of fine filaments seems to be exceptional. He has never seen them adhere in moniliform chains nor massed as zooglæa. He considers them to be veritable schizomycetes, and proposes the name Plox scindens.
Eklund asserts that he has found these same organisms in vast numbers in the soil- and ground-water of the isle of Skeppsholm, in the mud of the trenches dug for the water-mains, and in the greenish mould upon the walls of the old barracks, where scarlet fever was most rife. He states that scarlet fever has occurred in children after drinking milk mixed with the ground-water of the island, and he observed a case which followed immersion in one of the trenches of the island and the drying of the clothes in a small room. In another instance scarlet fever broke out in a block immediately after exposure of the ground-water by excavations.
It is evident that the discovery of this microbe under such circumstances does not prove that it is the cause of the disease. This can only be determined by inoculation, or by experiments which furnish the conditions of scientific exactness. Although great progress has been made in parasitology during the last decade, it is evident that several years of observation and experimentation must elapse before it is clearly and definitely ascertained whether or to what extent microbes cause scarlet fever and the other exanthematic fevers with which it is classified.
Whether the specific principle of scarlet fever be a micro-organism or a chemical substance, its mode of action and effects have been ascertained by clinical observations. Without doubt it commonly enters the system by the breath, but it may enter in the ingesta, and it infects the blood. That it resides in the blood has been ascertained by inoculation with this liquid, by which scarlet fever has been reproduced in its typical form. From the blood it enters the tissues and secretions. Hence handkerchiefs or linen containing the saliva or mucus of a patient, the epidermic scales shed abundantly in the desquamative period, and probably also the urinary and fecal evacuations, contain the poison, so as to be highly infectious. Even the discharge of a scarlatinous otorrhoea is thought by some to be contagious for a considerable time.
Scarlatina is communicable not only by direct exposure to a patient, but also by exposure to objects which happen to be in his room during his illness, and to which the poison becomes attached, such as clothing, books, and toys; small packages, even letters, it is believed, from cases which have occurred, sometimes convey and disseminate the contagious principle.
In England observations have been made which show that scarlatina has been communicated by infected milk. The disease occurred in the family of a milkman, and the milk, before it was distributed, remained for a time in a kitchen which had been occupied by the patients. This milk was taken by twelve families, and in six of these the disease occurred almost simultaneously at a time when few cases were occurring in the locality. There had been no direct exposure to the carrier of the milk nor to members of the affected family (Taylor). In another instance a woman and her son had scarlet fever while they were serving milk to several families, and the disease appeared in all these families except one, which consisted of old people (Bell). It is known that milk absorbs volatile substances so as to be flavored by them, as is shown in the experiment of placing it in an open vessel in a box with a pineapple; and it may in a similar manner become infected by the specific principle of scarlet fever, or it may be infected by detached particles of epidermis; which is not improbable when one convalescing from scarlet fever is allowed to milk the cows or prepare the milk for distribution.
The scarlatinous virus surpasses that of any other eruptive fever except small-pox in its tenacious attachment to objects and its portability to distant localities. Hence in the literature of the disease are the records of many cases in which the poison was conveyed long distances, retaining its virulence to the full extent and causing an outbreak of the malady in the localities to which it was carried. In New York, so frequently has scarlet fever as well as measles and diphtheria been contracted from the persons or clothing of well children who come from infected houses, that the Health Board now excludes from the public schools all children who come from such houses, even though they live on separate floors from those occupied by the sick. In one instance that came under my notice a washerwoman whose child had scarlet fever communicated the disease to an infant in the household where she was employed, by placing her shawl over the cradle in which it was lying. A physician of my acquaintance went from a scarlet-fever patient to a family several streets distant, and took one of their children upon his lap. After the usual incubative period this child sickened with a fatal form of the malady, and the remaining children of the household were in time affected. In New York scarlet fever has seemed to me to be not infrequently communicated through school-books, which, profusely illustrated by pictures and rendered attractive to the young, are often allowed to lie upon the bed of a scarlatinous patient and be handled by him during convalescence, or even during the course of the fever if it be mild. The young librarian of the circulating library of a Sunday-school, whose pupils came largely from the tenement-houses, was occupied a considerable part of a day in covering and arranging the books. After about the usual incubative period of scarlet fever he sickened with the disease. His two sisters were immediately removed to a rural township three hundred miles away, and to an isolated house where scarlatina had never occurred. About one month after his recovery, and after his room had been disinfected by burning sulphur and his bed-clothes and linen had been thoroughly washed, and all articles suspected to hold the poison had been either disinfected or destroyed, the brother visited his sisters in the country. Three weeks subsequently to his arrival one of these sisters sickened with scarlet fever, and a week later the other also. It seems that the exposure must have occurred several days after his arrival in the country from some book or other infected article in his possession. About two months elapsed after the last case; the family had returned to the city, the infected room in the country-house had been thoroughly fumigated by burning sulphur from morning till evening, when a little girl from an inland city remained a few days in this house, and probably often entered the room where the young ladies had been sick. In a few days she also sickened with a fatal form of scarlatina. Such histories and experiences are not infrequent. They are common during epidemics of scarlet fever. They indicate an extraordinary attachment of the scarlatinous poison to objects, and show that it is not gaseous nor readily volatilized.
A striking example of this fixity of the poison occurred in the practice of the late Kearney Rogers, formerly a prominent and much esteemed surgeon of New York City. Six children in a family had scarlet fever. Three and a half months subsequently another child, living at a distance, was allowed to return home and occupy the apartment in which the sickness had occurred. One week subsequently to the date of the return this child sickened with the same malady. Elliotson states that a patient with scarlet fever was admitted into one of the wards of St. Thomas's Hospital, and for two years subsequently young persons who were admitted into the ward were apt to take the disease. Richardson of London relates the following experiences of a family whom he attended in a rural district: "At a short distance from one of our villages there was situated on a slight eminence a small clump of laborers' cottages, with the thatch peering down on the beds of the sleepers. A man and his wife lived in one of these cottages with four lovely children. The poison of scarlet fever entered the poor man's door, and at once struck down one of the flock." The remaining children were now removed some miles away, and after several weeks one of them was allowed to return. Within twenty-four hours it also took the disease, and quickly died. The walls of the cottage were now thoroughly cleaned and whitewashed, the floors scoured, and all the wearing apparel either destroyed or washed. Four months elapsed after the last sickness when one of the remaining children returned. "He reached his father's cottage early in the morning; he seemed dull the next day, and at midnight I was sent for, to find him also the subject of scarlet fever. The disease again assumed the malignant type, and this child died." Richardson believes that the contagium was attached to the thatch, which could not be thoroughly disinfected. The fact of this remarkable long-continued attachment of the poison to objects, indicating by this fixity that it is a solid, is consonant with the theory that it is an organism.
INCUBATIVE PERIOD.—The duration of the incubative period varies in different cases. It is sometimes less than twenty-four hours, as in the above case reported by Richardson; in the following well-known case, observed by Trousseau, it was one day. A girl arrived in Paris from Pau, where there was no scarlet fever, and occupied the same apartment with her sister, who was sick with this disease. Twenty-four hours after her arrival she also was attacked with the same malady.
Russeberger attended a child who was exposed at noon to scarlet fever, and took the disease on the following night. B. W. Richardson (Clinical Essays, 1861, vol. i. p. 94) gives his own experience: He had applied his ear to the chest of a patient suffering from scarlet fever, and was conscious of a peculiar odor emitted from the patient. He was immediately nauseated and chilly, and from that moment he dated the beginning of an attack of scarlet fever. In the Transactions of the Clinical Society of London, vol. xi. 1878, the late Charles Murchison gives the statistics of 75 cases, showing the incubative period, as follows:
| In 4 cases it was not more than 24 hours. In 2 cases it was not more than 30 hours. In 3 cases it was not more than 36 hours. In 4 cases it was not more than 40 hours. In 1 case it was not more than 41 hours. In 4 cases it was not more than 58 hours. In 1 case it was not more than 54 hours. In 1 case it was not more than 2½ days. In 31 cases it was within (time not accurately ascertained) 4 days. In 2 cases the incubation did not exceed 4½ days. In 17 cases the incubation did not exceed 5 days. In 2 cases the incubation did not exceed 6 days. |
In three cases Murchison believes that the incubation was precisely fixed at thirty-six hours, three days, and four and a half days.
Watson says that a man reached Devonshire on mid-day to see his daughter, who had scarlet fever. Two days later he was also attacked. Rehn saw a child who was attacked two days after its grandmother returned from a case of scarlet fever; and Zengerle, a girl of ten years, residing at Wangen, where there was no scarlet fever, who took the disease two days after her mother had returned from visiting a family affected with it. Loochner states that a boy aged four and a half years was attacked one and a half days after admission into the infected wards of a hospital. Armistead, in his annual report on the health of the Newmarket rural district, states that three children, coming from a different part of the district, visited Westley, and stayed next door to a child who had scarlet fever six weeks previously, and who was allowed to play with these children on the evening of Aug. 13th and morning of the 14th. The family then returned home, and on the 18th, four days after the exposure, all three children sickened with scarlet fever (Brit Med. Jour., Sept. 30, 1882).
Ordinarily, therefore, the incubative period, though varying in different cases, is within six days. Many cases, however, occur in which it seems to be longer. Thus in my practice scarlet fever appeared in a family on April 26, 1882. The patient was immediately removed to the third floor and the other children to the basement. All communication between the infected room and the basement was forbidden, but on May 8th, twelve days after the separation, one of these children sickened with the disease. Many observers—among whom may be mentioned Niemeyer and Copland—believe that the incubative period may be longer than one week, but, on account of the subtlety of the poison and the many modes of transmission, it is possible that in the instances of an apparently long incubative period there were other and unsuspected exposures. When scarlet fever has been communicated by inoculation, as in the experiments of Rostan and others, the incubative period has been about seven days, but Gerhardt states that a man was attacked four days after an abscess was opened by a knife used upon a scarlatinous patient. This variation in the incubative period, which also occurs in some other infectious diseases, as diphtheria, is probably due mostly to individual differences, some being more susceptible than others; but it may be due partly to those obscure meteorological conditions which we designate the epidemic influence. Probably, as a rule, when the disease is quickly developed after exposure, the attack is more severe than when several days elapse.
CONTAGIOUSNESS.—The area of the contagiousness of scarlet fever is small. It apparently embraces only a few feet. Therefore, close proximity is the necessary condition of its propagation. Hence many who are exposed, particularly of those who are remotely exposed, do not contract the disease. There is also an idiosyncrasy in some children, so that they resist infection even when repeatedly and closely exposed. In the New York Medical Record for March 23, 1878, C. E. Billington states that of 90 children in 26 families who were exposed to scarlet fever, 43 contracted the disease and 47 escaped; whereas, as is well known, comparatively few unprotected children escape pertussis, variola, varicella, or measles if exposed to either of these diseases. By strict isolation, therefore, the spread of scarlet fever is more easily prevented than that of most other acute infectious maladies. In the New York Foundling Asylum for a number of years children with scarlet fever were isolated in a small room attached to one of the wards. The door between the two rooms was closed, and not opened during the continuance of the sickness. Entrance into the small room was through another door, and a nurse was assigned to the scarlet-fever cases, with strict directions that she should not mingle with the other children. These simple precautions were found sufficient in the various epidemics of scarlet fever which occurred in the city to prevent the spread of the malady through this institution; whereas, similar measures were much less effectual in arresting the spread of measles and pertussis. Consequently, an outbreak of scarlet fever in this institution was usually limited to a few cases, while the extension of measles and pertussis was arrested with difficulty till a more efficient quarantine was established.
VARIATIONS IN TYPE.—The type of scarlet fever varies greatly in different epidemics, and frequently also in cases which occur in the same epidemic, even in the same family. One child may have scarlatina so mildly that little treatment is required and convalescence soon begins, while another has the malignant form, and soon succumbs, notwithstanding the prompt employment of the most efficient and appropriate measures. Ordinarily, however, if the first case in a family be very severe, subsequent cases will present a similar type; but there are notable exceptions. This variation in type in different years and different epidemics is probably not equalled in any other infectious malady. Consecutive epidemics may present this variation, or the same type may continue for a series of years, and then, from some unknown cause, change to one milder or more severe. In England, during Sydenham's life, scarlet fever was so mild that he regarded it as a trivial affection, requiring little attention, like rötheln of the present time, but after the death of Sydenham, Morton and his contemporaries in London found, to their sorrow, that the type of scarlet fever was very different from that described by Sydenham's pen. The late Graves of Dublin and his contemporaries treated a mild type of scarlet fever with a very small percentage of deaths—much less than that during the preceding generation—and they attributed their success to their greater knowledge and more appropriate use of remedies than their ancestors possessed and employed. By and by the type changed, the mortality of former years was restored, and they discovered that their previous success in saving life had been due not to their skill, but to the mild form of the malady. A distinguished physician of New York treated more than fifty cases of scarlet fever in one of the institutions without a single death. A few months afterward the type of the malady changed, and his own son perished from it.
SURGICAL AND OBSTETRICAL SCARLATINA.—After surgical operations, and sometimes in surgical cases not requiring operative measures, a scarlatinous efflorescence occasionally appears upon the whole or nearly the whole body, and remains for several days. The following were cases of the kind alluded to. They occurred in Guy's Hospital, and were published by H. G. Howse in Guy's Hospital Reports for 1879: On March 15, 1878, Jacobson performed osteotomy upon a child suffering from extreme rachitis. The operation was followed by a moderate febrile movement (100° to 101°), and after three days by the appearance of an efflorescence, with sore throat and the strawberry tongue. The osteotomy had been performed under carbolic acid spray and with all the details of antiseptic surgery. The rash soon faded, the temperature fell, and the child, temporarily separated from the other patients from the suspicion that the disease was scarlet fever, was brought back to the ward. The subsequent history confirmed the diagnosis of scarlet fever, for the skin desquamated, and on April 1st abundant albumen was found in the urine. The case terminated favorably. Three months previously the same operation had been performed on the other leg, with no unfavorable symptoms. On April 5th, three weeks after the osteotomy, a lipoma was removed from another patient aged twenty-one years. The following day the temperature rose to 101°, and remained at that till April 8th, when it suddenly increased to 103°, and a rose-rash occurred over the body, with sore throat. On April 9th, Howse excised the elbow-joint of a girl of sixteen years having pulpy disease. On the 10th her temperature began to increase, and on the 11th reached 105.8°. Toward evening a roseoloid eruption appeared over her body, and she was isolated. On April 12th, Dr. H. excised a fibroid bursa patellaë from a woman of twenty-nine years. On the following day her temperature was 99°, but on the 14th it rose to 100°, and on the evening of the 15th she had rigors and headache. On the morning of the 16th the temperature was 102.5°, and a roseoloid eruption occurred over the face and chest. The surgeons now perceived that an epidemic of the so-called surgical scarlatina was occurring, so as to justify the postponement of other operations.
In the same volume of Guy's Hospital Reports, James F. Goodhart gives the histories of nearly thirty cases of this disease occurring during a series of years in the same hospital. The patients were chiefly children, having the most diverse surgical ailments, among which may be mentioned hip disease and abscess, genu valgum without operation, necrosis of femur, hydrocele with explorative operation, a scald, a sinus over the great trochanter, spinal disease with abscess, tenotomy for club-foot, and vesical calculus with operation. The most common disease was caries or necrosis with abscess. In cases operated on the intervals between the operations and the occurrence of the efflorescence varied from two days to more than two weeks. Goodhart, after a careful examination of these cases, came to the conclusion that they were for the most part examples of true scarlet fever, especially as a considerable proportion of them occurred in groups, and there was a known exposure of some of the patients to children admitted into the hospital with the sequelæ of scarlet fever.
In the British Med. Jour. for Jan., 1879, George May, Jr., reported a case of efflorescence in surgical practice which appears to have been scarlatinous. A child was operated on for the radical cure of hernia on Dec. 4th. Toward the close of the same day he became restless, vomited, and his pulse on the following day rose to 136. Forty-eight hours after the operation a rash appeared on the chest and arms, the abdomen became tense and painful, and on the following day he died. The poison, however, in this case may have been septic.
Hillier remarks (Diseases of Children): "In the hospital for sick children, of the children who contract scarlatina a very large proportion have been the subjects of a surgical operation within a week before the rash appears." Gee says (Reynolds's System of Medicine): "It has been doubted by some whether the scarlatiniform rash which sometimes follows operations is really scarlatinal. The eruption appears from the second to the sixth day after the operation, and in the cases which have caused the doubt is very fugitive and the first and only symptom. Yet that the disease really is scarlet fever would seem to be proved by the following observations: first, that the disease occurs in epidemics; secondly, that in a given epidemic a severe case occasionally relieves the monotonous recurrence of the very mild form; thirdly, that a precisely similar scarlatinilla attacks in the same epidemic patients who have not been subjected to operation and who have no open sore; and lastly, by way of a veritable experimentum crucis, that, however freely these patients are exposed to ordinary scarlet fever contagion afterward, they do not contract that disease." Paget and other distinguished London surgeons who have observed this complication of surgical cases, believe that the patients have been previously exposed to the scarlatinous poison, and that the surgical diseases or operations furnish favorable conditions for the occurrence of scarlet fever, so that the exposure, which probably would have been without result in ordinary health, causes an outbreak of the malady.
Those who have reported cases of this form of efflorescence have for the most part neglected to state whether the patients had had scarlet fever previously, knowledge of which would have aided in the diagnosis; but from an examination of the histories of cases, especially those published in the London journals in the last four or five years, there can, I think, be little doubt that surgical maladies of a certain kind, especially traumatism, do produce a state of system which predisposes to scarlet fever, so that this class of patients are especially liable to contract it. Therefore, in my opinion, a considerable proportion of reported cases of surgical scarlatina are genuine, but in a considerable number, perhaps an equal number of such cases, the histories and symptoms indicated a septic rather than scarlatinous efflorescence, and in not a few instances, when consultations have been held, opinions differed, some diagnosticating scarlet fever, others septicæmia. In some of the cases I find it stated that the fauces presented the normal appearance. Now, faucial redness is so generally present in scarlet fever, antedating that of the skin and coexisting with it, that its absence is strong evidence that the disease is not scarlatinous. Moreover, when, as was true of certain of the reported cases, the rash appeared irregularly upon the surface, and faded away in two or three days with the abatement of the fever, and the conditions for septic absorption were present, the efflorescence was probably septicæmic.
The following were apparently cases of septicæmia efflorescence: A child aged five years (Brit. Med. Jour., Feb. 15, 1879) had inflammation of the lymphatic glands in the groin, which suppurated. At the time when the abscess was fully formed a rash appeared over the entire body. It consisted of numerous red points, but was paler than that of ordinary scarlet fever; temperature never above 99°; no sore throat nor desquamation of cuticle. No child exposed to her took scarlet fever, and her sickness could not be traced to infection. In the British Med. Jour., Jan. 4, 1879, L. Braxton Hicks states that his son, attending school at Reading, was seized with a severe attack of pyrexia, accompanied on the second day by delirium and the occurrence of a rash like scarlet fever over the entire surface. He had no decided redness of the fauces, though it was perhaps slightly flushed. The right buttock was swollen from inflammation, and a large, deep-seated abscess formed near the tuberosity of the ischium. When the delirium abated the boy said that he was standing the day before the fever began with his legs far apart, when a schoolfellow stretched them farther by suddenly pulling on one of them. The rash, which was nearly universal, lasted three days, and was not followed by desquamation. No case of scarlet fever occurred in the school before or afterward. In the same volume of the British Medical Journal, Surgeon Frolliott of the East India Service relates the case of a private, aged twenty-three years, and three years in India, who, when on duty in the Punjab, was injured by the explosion of an Afghan powder-magazine. The accident occurred Dec. 21, 1878. On Dec. 25th a bright scarlet rash appeared upon the abdomen and spread over the entire body. The following day the eruption was very vivid, like a boiled lobster, and it lasted five days. The temperature, which in the beginning had been 101°, abated to the normal after the rash appeared. No soreness of throat nor redness of the buccal surface occurred, but the epidermis desquamated even from the palms of the hands and soles of the feet. Now, the febrile movement of scarlet fever does not cease while the efflorescence is distinct. It does not even diminish when the eruption appears, while in the above case it fell to the normal—a common occurrence in septicæmia, even when the blood-poisoning is profound. Moreover, scarlet fever is so rare in India that Frolliott, after twelve years' service, had only heard of one case among Europeans and natives. The surgeons who consulted over the case of this private disagreed in opinion, some regarding the disease as septicæmic, others as scarlatinous. But a better knowledge of the clinical history of scarlet fever on the part of these army surgeons would, I think, have removed all doubt as to the diagnosis.
It is the opinion of some reputable surgeons that the exposure of traumatic patients to the scarlatinous poison sometimes aggravates the inflammation of wounds, causing them to assume an unhealthy appearance even though no scarlatina be produced. The late Solly made the remark, "Whenever a case of surgery in private practice takes on a highly phlegmonous appearance I am always sure to find break out, in the inmates of the house, either erysipelas or scarlet fever" (British Med. Jour., Feb. 15, 1879). We will see that the scarlatinous poison sometimes causes pharyngitis or nephritis without producing the general disease. In a similar manner it seems that it may aggravate open wounds, intensifying the inflammation in them, while there is no efflorescence or other symptom to show that scarlatina itself is present. The poison appears to act entirely locally in such cases.
Paget, in his Clinical Lectures, says: "I think it not improbable that in some cases results occurring with obscure symptoms within two or three days after operations have been due to the scarlet-fever poison, hindered in some way from its usual progress." Playfair, in his remarks on the puerperal state, adds: "Mr. Spencer Wells informs me that he has seen cases of surgical pyæmia which he had reason to believe originated in the scarlatinal poison; and his well-known success as an ovariotomist is no doubt, in a great measure, to be attributed to his extreme care in seeing that no one likely to come in contact with his patients has been exposed to any such source of infection." Opinions like these, held by such prominent members of the profession and sustained by many observations, should certainly induce physicians to prevent, so far as possible, any exposure of their surgical patients, especially if they have any sores or wounds, whether by traumatism or the scalpel, to the scarlatinal poison.
OBSTETRICAL SCARLATINA.—Women during convalescence after childbirth are very liable to contract scarlet fever. In the New York Infant Asylum, which has maternity wards, a woman was admitted from a house in which scarlet fever was prevailing, and assigned to a cot next that occupied by one of the waiting women, who was confined soon afterward. Her labor was favorable, but three days afterward she took scarlet fever, and another lying-in-patient contracted it from her. The sore throat and desquamation were characteristic. It has come to my knowledge that a physician of New York, in whose family scarlet fever was occurring, attended three women in succession in their confinement, and all contracted scarlet fever, which presented the characteristic symptoms, and two of them died. Experienced and cautious physicians of New York, aware of the danger, do not go directly from a scarlatinous patient to an obstetrical case, but avoid the risk by intermediate visits to other patients or by remaining for a time in the open air.
Playfair, remarking on this subject, says: "There is good reason to believe that the contagium of zymotic diseases may produce a form of disease indistinguishable from ordinary puerperal septicæmia, and presenting none of the characteristic features of the specific complaint from which the contagium was derived. This is admitted to be a fact by the majority of our most eminent British obstetricians, although it does not seem to be allowed by continental authorities, and it is strongly controverted by some writers in this country. It is certainly difficult to reconcile this with the theory of septicæmia, and we are not in a position to give a satisfactory explanation of it. I believe, however, that the evidence in favor of the possibility of puerperal septicæmia originating in this way is too strong to be assailable. The scarlatinal poison is that regarding which the greatest number of observations has been made. Numerous cases of this kind are to be found scattered through our obstetric literature, but the largest number are to be met with in a paper by Braxton Hicks. Out of 68 cases of puerperal disease seen in consultation, no less than 37 were distinctly traceable to the scarlatinal poison. Of these, 20 had the characteristic rash of the disease, but the remaining 17, although the history clearly proved exposure to the contagium of scarlet fever, showed none of its usual symptoms, and were not to be distinguished from ordinary typical cases of the so-called puerperal fever. On the theory that it is impossible for the specific contagious diseases to be modified by the puerperal state, we have to admit that one physician met with 17 cases of puerperal septicæmia in which, by a mere coincidence, the contagion of scarlet fever had been traced, and that the disease nevertheless originated from some other source—a hypothesis so improbable that its mere mention carries its own refutation."
Parturition, like traumatism, furnishes in an eminent degree the conditions in which septic poisoning occurs, and the efflorescence which often accompanies septicæmia bears, as we have seen, a very close resemblance to that of scarlet fever. Hence in many instances the same difficulty is present in making a differential diagnosis between septic and scarlatinous blood-poisoning in obstetrical cases which occurs in surgical practice. But, according to my observations, an efflorescence occurring during the week following parturition is in most instances septic. It is only in exceptional cases that it is scarlatinous, and there is little danger that the accoucheur, engaged in general practice and visiting scarlatinous patients, will communicate scarlet fever through his person or clothing if he exercise proper precautions. His short stay in the sick room and his out-door exercise in visiting cases prevent infection of his person or dress. But if, as Playfair believes, the scarlatinal poison sometimes produces in parturient women a puerperal fever in which the characteristic scarlatinal symptoms are lacking, and which, in the present state of our knowledge, is not distinguishable from ordinary septic fever, certainly the scarlatinous virus sustains a much more frequent causative relation to childbed fever than has been heretofore supposed.
Infants under the age of six months do not ordinarily contract scarlet fever, although fully exposed, and those under four months nearly possess immunity. Still, this disease has been observed in new-born infants, contracted, apparently, through the placental circulation. Tourtual states that a woman waited upon her own husband and child, both of whom had scarlet fever, during the eighth and ninth months of her pregnancy, till near her confinement. Though she had no symptoms of scarlet fever, her infant had unusual redness of the skin and buccal surface and difficulty of swallowing up to the fifth day. On the ninth day desquamation began, and at a later stage the nails of the fingers and toes separated. A case having a history in some respects similar is related by Megnert, but the symptoms were anomalous for scarlet fever, and the disease may have been ordinary septic fever. On the other hand, in one instance in my practice a mother had scarlet fever, beginning about the third day after her confinement, and although she suckled her infant and it was constantly in bed with her, it had no symptoms of scarlet fever, although it became affected immediately afterward by a severe form of eczema, probably from the altered quality of the milk; and in two instances observed by Murchison new-born infants remained healthy, although their mothers suffered from scarlet fever.
After the age of six months the liability to scarlet fever increases till the close of infancy, children between the ages of six months and one year being less liable to contract the malady than during the second year, and those in the second year being less liable to it than those in the third year. Murchison collected the statistics of deaths from scarlet fever in England and Wales during a series of years ending with 1861. The number of deaths aggregated 148,829, and the percentage of deaths at different ages was as follows:
| Deaths under 1 year, | 6.7 | per cent. |
| Deaths between 1 and 2 years, | 14.09 | per cent. |
| Deaths between 2 and 3 years, | 16.00 | per cent. |
| Deaths between 3 and 4 years, | 15.13 | per cent. |
| Deaths between 4 and 5 years, | 11.9 | per cent. |
| Deaths between 5 and 10 years, | 25.9 | per cent. |
| Deaths between 10 and 15 years, | 5.8 | per cent. |
| Deaths between 15 and 25 years, | 2.6 | per cent. |
| Deaths between 25 and 35 years, | 0.8 | per cent. |
| Deaths over age of 35 years, | 0.8 | per cent. |
Among the deaths were ten cases above the age of eighty-five years, so that scarlet fever, though especially a disease of childhood, may occur in any decade of life; but old age, like early infancy, almost possesses immunity from it.
I have preserved the records of the ages of 145 consecutive cases occurring in private practice. If we add to these 58 cases observed by Prof. Octerlony (Amer. Jour. of Med. Sci., July, 1882) we have the statistics of the ages of 203 cases, which are embraced in the following table:
| Under 1 year, | 3 |
| From 1 to 2 years, | 25 |
| From 2 to 3 years, | 43 |
| From 3 to 5 years, | 57 |
| From 5 to 10 years, | 53 |
| From 10 to 15 years, | 13 |
| From 15 to 20 years, | 3 |
| From 20 to 30 years, | 4 |
| From 30 to 40 years, | 2 |
| Total, | 203 |
CLINICAL FACTS REGARDING SCARLET FEVER.—As a rule, scarlet fever occurs but once, one attack conferring immunity from the disease for life; but there are exceptions. In 1869, I attended a child with fatal scarlet fever who three years previously, it was stated, had passed through a first attack with all the characteristic symptoms. The following case occurred in a family attended by the late Dr. Herzog: R——, a boy of six years, had scarlet fever in a mild form in January and February, 1875, followed by moderate desquamation. In July of the same year he was kicked by a horse in the street, receiving a deep scalp-wound which required three stitches. Three days afterward he had, to appearance, a second attack of scarlet fever, attended by high febrile movement, and followed also by desquamation. It was believed by Dr. H. to be a genuine case, and was so treated. I am not able to state as regards the presence of soreness of the throat, and doubt arises whether this second attack may not have been septicæmic. In April, 1876, a third attack occurred, which I saw from the beginning. It was accompanied by all the characteristic symptoms—injection of the fauces, an efflorescence continuing the usual time, followed by desquamation and albuminuria, the latter continuing several weeks. Richardson states that three distinct attacks occurred in his own person, and a student attending the lecture at which this was mentioned informed the doctor that he also had had scarlet fever three times.
Sometimes a second attack occurs so soon after the first that it has been described as a relapse. The following was a case in point in the practice of Godneff (Meditz. Vestnik., No. iv., N.Y. Med. Rec., April 30, 1881): A youth of seventeen years contracted scarlet fever while taking care of a child. It began with a chill, and he had the usual efflorescence, sore throat, and tumefaction of the cervical glands. An exudation appeared upon his tonsils and uvula, and his temperature reached 104°. The urine contained a trace of albumen, the rash in due time faded, and the epidermis exfoliated. On the fifteenth day, when he was about ready to leave the hospital, he again had a chill, followed by fever. The temperature reached 105.2°, the rash reappeared over the entire surface except the face, diphtheritic exudations occurred upon the fauces, and the urine, the quantity of which was diminished, again became albuminous. This second efflorescence faded on the twenty-fourth day, and on the twenty-seventh exfoliation began. Hillier says: "I have seen a young woman in the fever hospital suffering from a second attack of scarlatina, the first attack having occurred five weeks previously. She had quite recovered from her first illness, and was acting as nurse. In both seizures the rash, the sore throat, and other symptoms were characteristic. The relapse or recurrence was less severe than the primary disease." Cases of a fourth, or even of a greater number of attacks, have been reported. The first seizure is sometimes milder, but in other instances is more severe, than those which follow.
Exposure to the scarlatinous poison not infrequently produces pharyngitis without the occurrence of scarlatina, and the inflammation is apt to be severe, accompanied by pain in swallowing and marked febrile movement. This phlegmasia is distinguished from scarlet fever by its shorter duration and the absence of the efflorescence. It occurs in adults as well as in children, and in those who have had, as well as in those who have not had scarlatina. So far as I have observed, it is very seldom accompanied or followed by any of the complications or sequelæ so common in and after scarlet fever. It cannot be distinguished from ordinary pharyngitis except in the manner in which it occurs, and one attack does not preclude another. The late George B. Wood made the remark that he never attended a case of scarlet fever without suffering from sore throat. The following were examples of this form of pharyngitis: On Jan. 17th, 1882, I was called to a boy of three years with severe scarlet fever, ushered in by convulsions. On the following day his sister, aged seven and three-fourths years, whom I had attended a year previously during a severe attack of scarlatina, and who had been almost constantly with the brother, became very ill, with a temperature of 103.5°. Examination revealed severe inflammation of the fauces, without pseudo-membrane or any other exudation except muco-pus. On Jan. 19th an older brother, nine years, whom I had attended in scarlet fever three years previously, was affected in the same way, his temperature being 104° and his respiration guttural and noisy, especially during sleep, in consequence of the great amount of faucial swelling. At times he was delirious. The inflammation in both cases began to abate about the third day, and had disappeared by the close of the week. That the contagium of scarlet fever may be received into the system and cause pharyngitis, while the patient has immunity from scarlet fever through a previous attack, and that this inflammation may occur any number of times, as in the case of Dr. Wood, are remarkable facts.
Now and then cases occur which appear to show that the scarlatinous poison may affect the kidneys, producing nephritis, while there is no other manifestation of its influence. Thus in my practice a lady of about forty-five years constantly attended her son, sleeping by his side, during an attack of scarlet fever. Her health had previously been good. When the boy was convalescent, as her appetite failed and she was indisposed, a careful examination revealed the fact that she had albuminuria, although she had had no sore throat or other symptom of scarlet fever. After several weeks of treatment her disease was removed, and she has remained well since. In the British Med. Jour. for Nov. 29, 1879, it is stated that in a family four girls were found to be suffering from desquamative nephritis. One of them had recently had scarlet fever, but the other three had presented no symptoms whatever of this disease. Such cases, although probably rare, appear to show that, as the scarlatinous poison may produce inflammation of the fauces without the occurrence of scarlet fever, so it may cause nephritis without producing the general disease, or apparently disturbing the functions, or changing the state of other parts, except the kidneys.
SYMPTOMS.—ORDINARY FORM. Scarlet fever usually begins abruptly, so that the exact time of its commencement can be fixed. If any premonitory symptoms occur, they are slight, so as scarcely to attract attention, as languor or the appearance of fatigue. A dusky aspect of the surface may occasionally be observed during the few hours preceding the attack. In some children the first symptom is chilliness, and occasionally a distinct chill occurs. In the adult a chill is ordinarily the first symptom. With or without the initial chilliness, febrile movement occurs, of variable intensity according to the severity of the type, and accompanied by such symptoms as usually arise in a febrile state of system, as cephalalgia, anorexia, and thirst. The pulse rises to 110, 120, or more per minute, the temperature to 102°, 103°, or 104°; the skin is hot, face flushed, and the eyes bright. Even in cases that are not malignant or grave, and that give indications of a favorable result, there is often more or less stupor, with transient delirium and sudden starting or twitching of the extremities, showing that the cerebro-spinal axis is involved.
Vomiting is a common symptom in the beginning of scarlet fever, occurring before the appearance of the efflorescence. It therefore has diagnostic value when the nature of the case is still doubtful. In some patients it is an initial symptom, but in others some hours have elapsed when it occurs. I recorded its presence or absence in 214 patients, with the following result: present in 162 patients, absent in 52. In severe forms of the disease it is rarely absent, and if it do not occur it is probable that the case will be mild, requiring little treatment and having a favorable termination. In epidemics of unusual mildness the number of cases without vomiting may be in excess of those in which this symptom occurs. It appears to be due to functional disturbance of the cerebro-spinal system, and it may therefore be properly regarded as a nervous symptom. In severe cases the vomiting is apt to be repeated, not only on the first but on subsequent days, and we shall see that in cases of great gravity, in which a fatal termination is not improbable, persistent vomiting, by which the food and stimulants so urgently required are rejected, interferes seriously with successful treatment. In a few cases embraced in my statistics nausea without vomiting was recorded. The bowels in ordinary scarlatina act regularly or are slightly constipated. Diarrhoea, which so commonly accompanies the persistent vomiting in malignant cases, if it occur in this form of the malady is slight and transient and due to accidental causes. The food, if it be given in the liquid form and cool, is usually taken readily, on account of the thirst, except when deglutition is rendered painful by the pharyngitis.
The symptoms pertaining to the nervous system vary according to the severity of the disease and the temperament of the patient. Many children during the progress of the common form of scarlet fever present a dull or apathetic appearance. They lie much of the time with their eyes closed; others are more restless, and not a few, if the fever be considerable, have occasional twitching of the limbs and more or less headache. Eclampsia sometimes occurs on the first day, especially in those predisposed to it, even when the subsequent course of the disease is mild and favorable. This complication, very grave and usually fatal when it occurs at a later stage, is in most instances, when it takes place on the first day, readily controlled by proper remedies and with little detriment to the patient. But if it be attended by high elevation of temperature and marked drowsiness, approaching the comatose state, it is very serious upon the first as well as upon subsequent days. Nervous symptoms occurring in the beginning of scarlet fever, when it has the ordinary favorable type, begin to abate in three or four days, but if they supervene at a later date, and especially in the declining stage, they possess more gravity, since they then not infrequently result from and indicate renal complication.
Early in the disease, nearly as soon as the commencement of the fever, the faucial and buccal surfaces become inflamed, as shown by redness, swelling, and tenderness. The physician summoned in the beginning of an attack will already, at his first visit, observe hyperæmia of the fauces, with points of deeper injection than over the general faucial surface, and soon the buccal surface also participates. The inflammation at first produces preternatural dryness, and this is followed by a viscid secretion. The papillæ of the tongue enlarge and become prominent, giving rise to the appearance known as strawberry tongue which is so common in scarlet fever. This state of the buccal and faucial membrane continues throughout the disease. A thin fur appears upon the tongue on the first day, and it increases on the second and third days, after which it is apt to be detached, exposing the surface of the organ, which has a deep red hue, but in not a few patients the fur remains or is reproduced as soon as shed. Except in the mildest cases the Schneiderian membrane also participates in the inflammation as the disease advances, so that a thin, irritating discharge, containing leucocytes or pus-cells, flows from the nostrils. The skin is hot and dry, and cutaneous transpiration nearly checked. The respiratory system is rarely involved in any notable manner unless there be a complication. Many have no cough whatever, while others have a slight cough, due to the fact that the inflammation, of a catarrhal form, has extended from the fauces to the surface of the glottis. Slight acceleration of respiration, corresponding with the degree of fever, may also be observed. The kidneys commonly act regularly and normally during the first days, any serious impairment of their functions being rare before the close of the first week.
When the symptoms described above have continued from six to eighteen hours the efflorescence appears. It is first observed about the ears, neck, and shoulders, in reddish patches fading into the normal hue. These patches extend and unite, and in the course of a few hours the trunk and upper extremities, and finally the legs, are covered. The scarlatinous rash usually, when fully developed, resembles that produced by external heat or the application of a sinapism. It has been likened to the appearance of a boiled lobster, but there are numerous minute points of a deeper or duskier hue than the surface generally. In many patients the rash appears, especially over the abdomen and lower extremities, as minute, thickly-set points, with the skin of normal appearance between them. Henoch of Berlin says of scarlet fever: "In general, the moderate grades of eruption prevail, the skin, when seen from a distance, presenting a diffuse, more or less scarlet redness, while on closer inspection it is found that this redness is composed of innumerable red points closely situated together, and separated from one another by very small paler portions of skin. The dark-red points appear to correspond to the hair-follicles." On passing the finger over the efflorescence no distinct prominences are observed, but a sensation of roughness is sometimes imparted from engorgement of the cutaneous papillæ. The rash disappears on pressure, but it immediately reappears when the pressure is removed. Its slow return is evidence of sluggish circulation, and it indicates a grave and dangerous form of the malady. The color is then usually a dusky instead of a bright red. The efflorescence is most marked in dependent parts, as along the back, over the chest and abdomen, and in the flexures of the joints. Parts pressed upon by the bed-clothes, which confine and intensify the heat, present a deeper coloration than other portions of the surface. Often, especially in mild cases, the rash is absent from portions of the surface where it commonly appears, while it presents a typical character elsewhere. Tardy and incomplete establishment of the rash when the symptoms indicate an attack of ordinary or more than ordinary severity is commonly due to some perturbating cause, especially diarrhoea. In the London Lancet for Aug. 16, 1879, cases are related of supposed scarlet fever without the rash, cases in which pharyngitis and stomatitis with the strawberry tongue occurred, without efflorescence upon the skin; but it is to be remembered, as stated above, that the inflammations which commonly attend or follow scarlet fever, particularly the pharyngitis and nephritis, not infrequently occur in those who have already had scarlatina, and occur more than once from fresh exposure to scarlatina patients. These inflammations, occurring under such circumstances, appear to be purely local maladies, produced by the scarlatinous virus; and it seems to me a question whether, in the so-called scarlatina without efflorescence, the inflammations which are present, and which undoubtedly have a scarlatinous origin, are not local in their nature, instead of being local manifestations of the constitutional disease. The burning and itching sensation produced by the rash increases the restlessness of the patient, and is sometimes the most annoying of the symptoms.
The temperature in the common favorable forms of scarlet fever usually varies from 101° in the mildest cases to 103° or 104° in those more severe. If it attain 105° or over, the case is properly designated grave or severe. The febrile movement commonly fluctuates but little from day to day till the fourth or fifth day, when, if the case be favorable and no complication occur, it begins to decline. The temperature is as high in the beginning of the attack as subsequently.
The symptoms pertaining to the digestive system during the initial period of scarlet fever have been sufficiently described. The subsequent symptoms referable to this system do not differ materially from those present in the beginning, except the absence of vomiting. The lips are dry and often cracked. The inflammation of the mouth and throat continues, with anorexia and thirst. With the decline of the disease the appetite gradually returns, but it is not till the close of the second week that it is fully restored. Great and continued disturbance of the digestive apparatus, seriously interfering with the nutrition, pertains to the malignant forms of scarlet fever.
The urine is high-colored, and in robust children during the first days of scarlet fever it frequently deposits urates on cooling. Gee, who has carefully investigated the state of the urine in scarlet fever, says that the quantity of water is diminished and the urea is not necessarily increased during the pyrexia; that the chloride of sodium is diminished till the fourth, fifth, or sixth day, and that the phosphoric acid is diminished during the climax of the pyrexia, though not during the first three or four days. In one case he made a daily estimation of the amount of uric acid, and found it greatly diminished on the second and third days, normal on the fourth, and much increased on the fifth. He believes that similar variations are common in the quantity of the products excreted in the urine. Bile may also appear in the urine, coincident with a yellow tinge of the conjunctiva.1
1 Article on scarlatina in Reynolds's System of Medicine.
The duration of scarlet fever varies in different cases. If the attack be very mild, with little efflorescence, the febrile movement may decline by the fourth or fifth day; but if the disease be severe, little or no amelioration of symptoms may occur before the twelfth or fourteenth day, even when no complication has occurred to increase the temperature or cause aggravation of symptoms. Octerlony, who estimated the duration of scarlet fever from the commencement of febrile symptoms to "the disappearance of fever, with marked improvement in leading symptoms," ... "found that the average duration of the disease in forty cases was six and one-sixth days. The minimum duration in a very slightly-marked case was three days: the maximum duration was fourteen days." In general, prolongation of fever beyond the usual time is due to some complication—more frequently to unusually severe pharyngitis, with accompanying cellulitis, than to any other cause.
The malady whose commencement was so abrupt declines gradually. In ordinary cases, by the close of the first week or in the beginning of the second the rash becomes less and less distinct, and finally disappears, as do also the redness and swelling of the buccal and faucial surfaces. The engorgement of the tonsils and of the papillæ of the tongue subsides, the appetite returns, the countenance brightens and becomes natural, and the child, who during the height of the fever scarcely noticed objects or noticed them with indifference or even repugnance, can be amused as before his sickness.
Desquamation succeeds. This begins at about the sixth day, and is not completed till the tenth or twelfth day; often not till the close of the third or in the fourth week. The amount of desquamation corresponds with the intensity and duration of the efflorescence, or rather of the dermatitis which produces the efflorescence. If the efflorescence have been slight and partial, it will be slight, perhaps scarcely appreciable, but if the rash have been general, full, and protracted, exfoliation occurs upon every part. It begins about the face and neck, and within a day or two appears upon other parts. Where the skin is thin the epidermis as it is detached presents a furfuracous appearance; where it is thick, as upon the palms of the hands or soles of the feet, it separates in layers of considerable thickness.
Such is a brief description of scarlet fever when it pursues its normal course without any disturbing element, but there is no other disease in which complications and sequelæ so frequently occur. The liability to them renders the prognosis in every case doubtful. They largely increase the percentage of deaths. They occur both in mild and severe forms of scarlatina.
The difference in type in different cases and epidemics has already been alluded to. Scarlet fever is sometimes so mild, and its symptoms so slight, that the diagnosis is necessarily uncertain. In the spring of 1866 I was called to an infant thirteen months old who had slight pharyngitis and an indistinct rash over a part of the surface. In two days the eruption had disappeared, and the health within a day or two later was apparently fully restored. Diagnosis would have been doubtful except for sequelæ which clearly indicated the scarlatinous nature of the attack. In another instance two children passed through the entire course of scarlet fever playing every day in the street. Although the intelligent grandmother saw the rash upon them, its nature was not suspected, as it was midsummer and cases of prickly heat common, till nearly two weeks afterward, when one of the children had nephritis and anasarca ending fatally. In cases so mild as these the heat of surface is but slightly increased, the pulse but little accelerated, and the rash usually does not occupy so much of the surface as in ordinary cases; the appetite is not lost, though diminished, and the thirst is moderate.
Between scarlet fever so mild that it terminates in four or five days, and that of the grave or malignant type presently to be described, all grades of severity exist. Scarlet fever occurs in all forms from mild to severe, but certain symptoms characterize grave or malignant cases—symptoms which are absent or much less prominent in ordinary scarlet fever. Therefore the grouping of cases according to the type is proper, and facilitates the studying of the disease.
GRAVE FORM (malignant scarlet fever).—This form of the disease is in some epidemics common, while in others it is rare. The symptoms which characterize it are severe from the beginning, those of the nervous system predominating at first, such as intense cephalalgia, restlessness or stupor, sudden twitching of the muscles, and perhaps delirium, or even convulsions. Many pass rapidly into coma and die within two or three days, succumbing to the intensity of the scarlatinous poison while the malady is still in its commencement. The rash is dusky. It disappears by pressure, and returns slowly when the pressure is removed, showing extreme sluggishness of the capillary circulation. Some patients are very drowsy, lying in a semi-comatose state except when aroused, and if aroused are very restless. Others are constantly restless. If placed in one position on the bed, they throw themselves in another in a half-conscious or unconscious state. They do not speak, or they mutter like those affected by the graver forms of typhus, calling the names of playmates or talking incoherently about things which interested them when well. The thermometer placed in the axilla is found to rise above 103°, which is a safe average, to 105° or even 107°, and the heat of the surface is pungent except when the case approaches a fatal termination, when the extremities, ears, and nose may be cool while the trunk and head are extremely hot. The pulse from the first is rapid, ranging from 130 as the minimum in a malignant case to a frequency which can scarcely be counted. A very frequent pulse is nearly always feeble and compressible. Irritability of the stomach is one of the most common symptoms in grave cases, so that many patients immediately reject the nutriment and stimulants which are so urgently required to sustain the vital powers. The vomiting, therefore, if frequent and severe, greatly increases the danger, and in not a few instances this symptom is associated with diarrhoea, which also tends to increase the prostration.
Severe and dangerous nervous symptoms, due to the intensity or activity of the scarlatinous poison, occur chiefly within the first three or four days. Grinding the teeth, sudden muscular twitching, delirium, convulsions, and profound stupor occur for the most part within this time. Afterward the danger is mainly from exhaustion, unless in the second week or subsequently, when nervous symptoms may arise from uræmia.
Those who survive the onset of malignant scarlet fever often have in the course of a few days severe pharyngitis, with extension of the inflammation to the lymphatic glands and connective tissue around the angle of the jaw. These inflammations cause more or less external swelling. The faucial turgescence around the entrance of the larynx, with the accompanying secretion of viscid mucus or muco-pus, often causes noisy respiration, and many at this stage of the attack breathe with the mouth constantly open to facilitate the ingress of air.
Ordinarily, no discharge occurs at first from the nasal surface, but as the disease continues, if the type remain severe, defluxion of thin muco-pus takes place from the Schneiderian surface, which frequently excoriates the cheek. The lips also are apt to be sore and swollen.
In malignant cases the disease is more protracted than when the type is mild. Thus in a recent case in my practice the rash was still distinct at the close of the second week, though the temperature had fallen from 105° to 102° and some desquamation had appeared. Long continuance of the febrile movement is, however, oftener attributable to some inflammatory complication than to the primary disease.
In all epidemics of a severe type cases now and then occur in which the poison is so intense, or it acts with such frightful energy, that death occurs even within the first day. The patient is overpowered at the outset of the disease by the virulence of the specific principle, perishing in coma, preceded perhaps by convulsions. The autopsy in such cases reveals hyperæmia of the brain and cranial sinuses, blood of a dark-red color, capillary hemorrhages in various parts, a flabby heart, and perhaps some engorgement of the spleen and kidneys.
Usually, malignant scarlet fever exhibits its severe type from the first, but cases sometimes occur which seem mild and favorable for a few days, when severe symptoms suddenly supervene. This change from a mild to a dangerous disease is, however, most frequently, I think, due to some complication.
IRREGULAR FORMS.—Deviation from the normal type in scarlet fever is usually due to some perturbating cause, which is often a pre-existing or co-existing disease, or a disordered state of system through causes distinct from the scarlatinous disease. Thus, a little girl in my practice had the symptoms of scarlet fever, such as febrile movement and inflammation of the buccal and faucial surfaces, nearly a week before the scarlatinous eruption appeared. During this time the patient had an intestinal catarrh, with diarrhoea, which declined when the rash occurred. This intestinal disease was the apparent cause of the irregularity in the malady. If scarlatina occur during a severe attack of entero-colitis attended by purging, the defluxion from the external surface may be such that no efflorescence appears. Severe scarlet fever itself sometimes appears to cause gastro-intestinal catarrh so as to produce an afflux of blood toward the intestinal tract and away from the skin. Practitioners occasionally meet cases like the following, which I recall to mind: In a family where scarlatina was prevailing a little child early after the commencement of symptoms which seemed to be plainly referable to this exanthem was seized with vomiting and purging, which continued till death occurred on the third day. No efflorescence appeared upon the skin, but the symptoms indicated the presence of severe intestinal catarrh, complicating and masking scarlatina. We are aided in the diagnosis of such cases by observing the faucial redness, and we may discover a faint efflorescence upon parts of the surface, as about the groin or in the flexures of the joints. In another instance an infant in the warm months having protracted entero-colitis, the usual summer epidemic of the cities, had the characteristic symptoms of scarlet fever, which was present in the family, but the diarrhoea continued and no rash appeared.
In one who is much reduced by an antecedent disease, as phthisis, or who has a disease, chronic or acute, which produces a decided afflux of blood away from the surface and toward the interior of the body, the eruption is commonly tardy in its appearance, indistinct, or wholly absent. Thus, severe inflammations of internal organs not infrequently render scarlet fever irregular. On the other hand, some maladies occurring in connection with this exanthem do not change its symptoms, but themselves undergo modification. Pertussis may be cited as an example, the cough of which is sometimes modified by an intercurrent attack of scarlet fever, the symptoms of the latter disease undergoing little change.
Scarlet fever may also be irregular without any apparent perturbating cause. In 1867 I attended a young lady whose previous health had been good, and whose brother was sick at the time with scarlet fever. She had considerable febrile movement, with severe pharyngitis, and, though her surface was repeatedly examined, no efflorescence was seen. Two weeks subsequently she was affected with severe nephritis, anasarca, effusion into at least one of the pleural cavities, oedema of the lungs, and probably hydro-pericardium, the case ending fatally. Rilliet and Barthez state that a second attack of scarlet fever is more apt to be irregular than the first. Probably this opinion is correct, especially if only a short time have elapsed between the two seizures. Still, as we have already stated, both seizures may be typical, and the second more severe than the first.
It would be impossible to make a clear and positive diagnosis of certain cases of irregular scarlet fever, in which cerebral, pulmonary, or gastro-intestinal symptoms predominate, were it not for the fact that they occur in connection with other cases of scarlet fever or are followed by sequelæ which evidently have a scarlatinous origin.
Occasionally, the eruption, if it be intense or if a certain condition of system be present in the patient, is accompanied by more or less extravasation of blood-corpuscles from the capillaries, so that the redness does not entirely disappear on pressure, usually in points. In rare instances certain of the exanthematic fevers present an extreme hemorrhagic character, so as to be beyond the reach of remedies, and of necessity speedily fatal. Hemorrhagic cases of this severe form are probably more common in variola than in the other fevers, but I have met a notable case in what was diagnosticated scarlatina. In June, 1881, a man in his thirty-second year, whose previous health had not been good, though he had no defined ailment and had been able to follow his occupation of harness-maker, suddenly became very ill, with high febrile movement and faucial inflammation, attended by marked prostration. After some hours an intense eruption of a scarlatinous appearance covered nearly the entire surface, and on the following day hemorrhages began to occur. The urine contained a large proportion of blood; each conjunctiva was raised by hemorrhages underneath (ecchymosis), so that its natural color was lost and the eyelids closed with difficulty; and blood flowed from the nostrils, gums, and under the skin, forming hemorrhagic points and blotches. One of the consulting physicians, perceiving the resemblance to hemorrhagic variola as described by Hebra, suspected that we had a case of this formidable malady to deal with, but the time for the appearance of the variolous eruption passed by without its occurrence. Death took place on the fifth day. The temperature during the sickness was high, though the record of it has been mislaid. Fortunately, such severe hemorrhagic cases, which are necessarily fatal, are rare.
COMPLICATIONS AND SEQUELÆ.—Scarlet fever, if its type be severe, is in itself dangerous to life. Many, as we have seen, perish from its direct effects when it produces profound blood-poisoning. But, while the ordinary epidemics of this malady are necessarily attended by a large mortality from the virulence and depressing effect of the specific principle, unfortunately, of all the diseases of modern times, scarlatina ranks first as regards the number and gravity of its complications and sequelæ, so that nearly or quite as many perish from these as from the direct effect of the poison.
Nervous accidents occur chiefly at two periods—to wit, in the first days, when they are due to the severity and malignancy of the malady and to the impressible nervous temperament of the child, and in the declining stage, or after the termination of the fever, when they occur from uræmia. If the type be malignant, delirium, jactitation, profound stupor, and convulsions frequently occur on the first and second days; and they are symptoms which properly excite the utmost alarm and demand all the resources of our art, since they indicate a form of the disease which is apt to end in speedy death. The eyes have a dull or wild expression, the conjunctiva is suffused, the heat of surface pungent, the pulse rapid and compressible or feeble, rising above 150, even to 200, per minute, and the temperature is always elevated to a degree that involves danger, the thermometer not infrequently indicating 105° or 106°. But this severe form of scarlet fever, attended by so great elevation of temperature, is much less dangerous than in former times, even though it be complicated by delirium and convulsions, since we no longer hesitate to reduce bodily heat, when excessive, by the free use of cold baths, and have discovered potent agents in the bromides and chloral for controlling convulsions. Nevertheless, not a few perish in the commencement of scarlet fever with predominating cerebral symptoms, as delirium or eclampsia, followed by coma, under the best possible treatment. Sometimes the symptoms have closely simulated those of acute meningitis, and if the rash have been delayed and the sore throat is as yet slight, the physician may suspect that he is dealing with this disease; but autopsies in such cases show no inflammatory lesions, but only congestion of the cerebral and meningeal vessels.
As is stated in a preceding page, in every case of normal scarlet fever inflammation of the faucial surface is present, as indicated by redness, tenderness, and increased secretion of mucus or muco-pus. It precedes the efflorescence on the skin, and is announced by pain in swallowing and on pressure with the fingers behind and below the angles of the jaw. In that form of scarlet fever which has been designated anginose the pharyngitis is severe, and is a prominent element in the malady, the uvula, the pillars of the fauces, and the faucial surface in general being infiltrated and swollen. Nevertheless, this inflammation, with the accompanying tumefaction, is properly a part of the disease, rather than a complication, if it abates with the subsidence of the scarlet fever or begin to abate soon after, and if it produce but slight destructive change in the tissues of the neck. The secretions from the fauces may be foul and offensive; even superficial ulcerations or gangrene may occur upon the faucial surface, causing it to present a dark brown or jagged appearance, and the tissues of the neck may be infiltrated to a certain extent, and we designate the disease a form of scarlet fever under the title anginose. But when this condition is greatly aggravated, so that there is extensive infiltration and swelling of the tissues of the neck, with an amount of ulceration or gangrene which in itself involves danger, continuing after the primary disease abates, prolonging the fever and reducing the strength, it is proper to regard the state of the throat as a complication. In addition to the pharyngitis, which is severe as described above, the sides of the neck around the angles of the jaw become swollen, hard, and tender. The inflammation has been propagated to the deeper structures of the neck. Poisonous substances, the result of decomposition or vitiated secretions, traverse the lymphatic vessels from the faucial surface, and, being intercepted in the lymphatic glands, cause adenitis, and the inflammation extends from the glands to the adjacent connective tissue, which becomes hard, tender, swollen, and infiltrated with inflammatory products. This tumefaction sometimes begins by the second or third day, but it is usually about the close of the first week or in the beginning of the second week that it becomes so considerable as to constitute a source of danger and anxiety. It is in most cases bilateral, though one side may begin to swell before the other and remain larger throughout.
In severe cases of this complication the tumefaction extends from ear to ear, filling up the space below and around the angles of the jaw and under the chin. Not only is deglutition difficult, but it is difficult to open the mouth sufficiently to inspect the fauces, and attempts to do so cause much pain. The lymphatic glands, which lie in the inflamed area and participate in the inflammation, are greatly enlarged by hyperplasia, the round granular lymph-cells multiplying so abundantly that the glands increase to many times their normal size. Most of the tumefaction is, however, due to extension of the inflammation to the connective tissue of the neck. The cellulitis, which resembles that occurring in other conditions, is attended by distension of the capillaries, the abundant formation of young round cells, and transudation of serum (Billroth). A moderate amount of tumefaction may disappear by resolution, but if it be considerable it seldom abates in this way, but by the tedious and exhausting process of suppuration or gangrene. If the swelling at its most prominent point present a reddish hue, all hope of producing resolution must be abandoned; it cannot be effected by any medicine or appliance within the resources of our art. The abscess which forms is apt to be diffuse, so as to involve danger of pyæmia, unless it be soon opened and properly washed out. With the discharge of the pus the swelling gradually softens and declines. In other cases gangrene results. The vessels in the inflamed part are compressed by the inflammatory products, so that they no longer convey the blood which is required for the purpose of nutrition. It is a law of the economy that whenever the circulation ceases, the tissues which receive their nutritive supply through the obstructed vessels lose their vitality. Hence gangrene occurs in all that portion of the swelling in which the circulation is arrested. The skin over it peels off, the dead tissue underneath is brown or dark, and soon, if life be prolonged, the slough begins to separate. The prognosis as regards this complication depends largely on the size of the slough. If it be large, death will probably result, since the strength of the system is already reduced by the primary disease, and the reparative process will necessarily be slow, while abundant suppuration tends to increase the exhaustion. In some of the worst cases of cervical gangrene which I have seen the slough has laid bare the muscles and vessels of the neck, producing in one case a cavity or excavation sufficiently large to admit a hen's egg. Often the slough extends under the skin, so that the deepest recesses of the cavity are not visible, and occasionally in cases which have ended fatally in my practice severe hemorrhage occurred from the concealed vessels. If the ulcerative or gangrenous process extends so deeply into the tissues of the neck that hemorrhages occur, death is the common result; but if the destructive action be of moderate extent and other conditions favorable, we may expect recovery through cicatrization, with perhaps some deformity by contraction of the cicatrix.
When the inflammation of the connective tissue of the neck is extensive, involving both the lateral and anterior regions of the neck, the patient is in a perilous state. The cellulitis, when extensive and accompanied by much swelling, may produce oedema of the glottis, may obstruct respiration by compressing the air-passages or the laryngeal nerves, may cause compression of the jugular veins, and thus give rise to dangerous cerebral symptoms, or may lay bare and injure important muscles and nerves, as we have seen. If the ulceration or gangrene be extensive, and death do not occur by hemorrhage from arterial or venous twigs, septic poisoning may occur, increasing still more the fatal nature of the malady.
Some cases of this complication are melancholy in the extreme, as one related by Cremen, in which ulceration of the pharynx occurred, allowing the escape of food and preventing deglutition. In severe scarlatinous pharyngitis the inflammation is apt to extend along the Eustachian tube, causing its occlusion. This accident will be considered when we treat of otitis media, another grave complication. It often also extends into the nares, causing catarrh of the Schneiderian mucous membrane, with discharge of muco-pus from this surface. Not infrequently ulceration or gangrene occurs in the faucial surface, producing more or less destruction of tissue and forming excavations which connect with the throat, while the cutaneous surface retains its integrity and is not even reddened. The following case shows how grave the complication which we are now considering sometimes is when the external surface of the neck is not involved, and how the inflammation by extension outward from the fauces may involve the middle ear.
Case 1.—Annie K——, aged two and a half years, an inmate of the New York Foundling Asylum, was well, except an eczema of the scalp, until the night of April 3, 1882, when she was attacked with vomiting and diarrhoea. She was feverish and drowsy, and at 2 P.M. on the 4th the scarlatinous efflorescence appeared upon her neck, body, and lower extremities; tongue coated; pharynx red; temperature (axillary) 103°; pulse 160. The symptoms and aspect indicated a grave form of the malady, and the usual sustaining treatment was ordered. On April 5th the temperature was 102°, pulse 144, tongue less coated, eruption fading, less stupor, no albumen in urine. April 6th, morning temperature 102°, pulse 160; passed a restless night; stools thin and too frequent; has grayish patches in the throat: P.M. temperature 103.2°, pulse 150. April 7th, the diarrhoea continues, and she has a copious muco-purulent discharge from the nostrils; P.M. temperature 103.6°, pulse 160. April 10th, the temperature has continued at about 103°; the patient is very sick, with a constant foul-smelling discharge from the nostrils; breath very offensive; temperature 103.5°, pulse about 180. April 12th, general appearance a little better, but the posterior surface of the fauces is completely covered by a thick pseudo-membrane; had four loose stools last night; temperature and pulse the same as at last record; a dark, offensive, and jagged coating over the fauces, and a dark, foul discharge from the nostrils, as before; examination of the chest negative. April 14th, is much prostrated; temperature 104.5°, pulse rapid and weak; respiration noisy, diminished resonance over lower two-thirds of left side of chest; ulcers upon the mouth and tongue; fauces red and ulcerated. April 17th, pulse 150, temperature 100.5°; general appearance somewhat better, but the diarrhoea continues, and patches of a diphtheritic character have appeared upon the lips; moist râles in left side of chest. The symptoms continued nearly the same until April 23d, when she died. A dull percussion sound and distinct bronchial respiration were observed in the left scapular region during the last days of her life.
Autopsy nine hours after death by the curator, Dr. W. P. Northrup: Body well nourished; the tissues have a jaundiced hue; lips sore; on turning the head to one side pus runs from the left ear and dirty muco-pus from the mouth. Brain normal; on opening the petrous portion of the left temporal bone the middle ear is found full of pus, which communicated freely with the external ear through a perforated membrana tympani; the Eustachian tube cannot be traced in the sloughy tissue, and a passage filled with pus extends from the ear to the fauces; opposite the greater cornua of the hyoid bone are two deep ulcers, each having about the diameter of a ten-cent piece, with sloughy and offensive base and sides; the left ulcer communicates by a ragged and wide sinus with a dark and sloughy cavity of about four drachms capacity; this cavity is located in the neck under the angle of the jaw, apparently occupying the site of a disintegrated gland, and it opens upon the surface of the fauces. The surface of the larynx has a dusky, dirty appearance, sprinkled with little cheesy-looking spots, and covered by a dirty, foul-appearing liquid, as if some of the ichorous pus had escaped into it from the neck; about one and a half inches below the vocal chords there is an unmistakable pseudo-membrane; below this, near the bifurcation, the trachea has a bright-red color, as if a pseudo-membrane had been peeled from it, leaving the surface raw. The detachment of a pseudo-membrane from this part, if it did occur, must have been ante-mortem, for the organ had been carefully handled in making the autopsy. Between the apex of the left lung and the median line the tissues of the neck, dissected upward, are found indurated, yellow, and giving an offensive odor, showing that the cervical cellulitis had extended downward farther than usual. The bronchial glands have undergone hyperplasia, being enlarged and hard. The right lung is normal; about one-half of the left lower lobe is consolidated, and when cut is found to be gangrenous and offensive. The liver is apparently somewhat enlarged; spleen normal in size; gastric mucous membrane has a congested appearance and is covered with mucus; mesenteric glands enlarged, pale, and firm; Peyer's patches swollen and pale; at lower end of ileum some pigmentation of these glands; in large intestine the solitary glands are enlarged, and a few of them pigmented; kidneys pale, cortex thickened, and markings indistinct. Microscopical Examination.—In the pia mater perhaps a little increase of cells; meninges of brain otherwise normal. The trachea shows well-marked diphtheritic inflammation; it contains a film of pseudo-membrane; evidences of inflammation occur also upon the laryngeal surface, though less marked than in the trachea. The solidified portion of the lung exhibits the ordinary lesions of broncho-pneumonia, with some interstitial change. In the kidneys we find parenchymatous nephritis, with some cell-growth in the Malpighian bodies.
The above case has been related at length, not only because it shows how severe and destructive the inflammation of the throat, extending into the tissues of the neck, sometimes is, but because four other complications or sequelæ were also present—to wit, otitis media, diphtheria, nephritis, and pneumonia. We see from the above case how formidable a disease scarlet fever sometimes is when attended by the inflammations to which it so frequently gives rise, for a child older and stronger than this, if thus affected, would necessarily have perished with the best possible treatment.
In localities where diphtheria is endemic, as in New York City and Paris, scarlet fever is often complicated by a pseudo-membranous inflammation of the fauces and air-passages. In severe cases of scarlet fever the Schneiderian as well as the faucial surface is covered with it, so that it can be readily seen on inspecting the anterior nares. Occasionally, the pseudo-membrane appears upon the laryngeal and tracheal surfaces, as in the case which I have related above and in others presently to be related, causing dangerous embarrassment of respiration. This complication sometimes begins almost at the commencement of scarlet fever, but in most instances it does not occur before the third or fourth day, and it sometimes does not appear till in the declining stage of the fever. When it begins, it intensifies the febrile movement and produces general aggravation of symptoms.
The common opinion is, that whenever a pseudo-membrane occurs upon the inflamed mucous surface in scarlatina true diphtheria has supervened; but there are those who hold that scarlet fever itself, when the inflammations which attend it are severe, may give rise to pseudo-membranes, so that what seems to be diphtheritic is but an element in the primary disease. My convictions are strong that when pseudo-membranes occur on any of the inflamed mucous surfaces in scarlet fever, true diphtheria has, with few exceptions, supervened if the patient live in a locality where diphtheria is prevalent. That scarlet fever may occur in an individual along with another acute infectious malady is shown by abundant cases. It often occurs with varicella, and J. Herzog relates the following case, in which measles and scarlet fever coexisted:2 A boy aged eight years had measles, with the usual catarrhal symptoms, and on the fourth day, as the temperature was returning to the normal, it rose again suddenly, and the scarlatinal rash and sore throat appeared. In due time these subsided, and desquamation occurred. I have seen a similar case in consultation during the current year, so that there is nothing improbable in the theory that scarlet fever may coexist with other infectious maladies; and it is admitted that diphtheria, like erysipelas, may complicate the most diverse constitutional diseases. Moreover, when a child with pertussis, measles, typhoid fever, or tuberculosis suddenly develops a high fever with the occurrence of a pseudo-membranous inflammation upon the fauces or air-passages, all admit that diphtheria has supervened, since such inflammation is not an element in any form or type of either of these diseases; and I see no reason in the nature of the disease why scarlet fever should not be equally liable to this complication.
2 Berl klin. Woch., 1882, No. 7.
The elaborate treatise by Sanné of Paris on diphtheria contains a chapter entitled "Secondary Diphtheria." In it the author says, what all who are familiar with diphtheria will agree to, that secondary diphtheria does not differ in nature from the primary form, and that it exhibits a tendency "to occupy the organs which are themselves the seat of the more pronounced local determinations of the primitive malady.... Diphtheria is seen in the course or sequel of numerous diseases. Some appear to have a special proclivity for engendering diphtheria; these are specific maladies: measles, scarlet fever, pertussis." I have tabulated as follows Sanné's statistics of secondary diphtheria:
| Diphtheria complicating measles, | 100 cases, | 83 deaths, | 15 cures, | 2 doubtful. |
| Diphtheria complicating scarlet fever, | 43 cases, | 22 deaths, | 17 cures, | 4 doubtful. |
| Diphtheria complicating pertussis, | 20 cases, | 12 deaths, | 6 cures, | 2 doubtful. |
| Diphtheria complicating typhoid fever, | 8 cases, | 8 deaths. | ||
| Diphtheria complicating tuberculosis, | 19 cases, | 19 deaths. |
Sanné's statistics relating to the seat of scarlatinous diphtheria are as follows:
| Fauces alone | attacked, | 15 cases. |
| Fauces with larynx | attacked, | 4 cases. |
| Fauces with nasal fossa | attacked, | 8 cases. |
| Fauces with larynx and nasal fossa | attacked, | 4 cases. |
| Fauces with larynx and bronchi | attacked, | 1 case. |
| Fauces with nasal fossa and lips | attacked, | 1 case. |
| Fauces with lips and skin | attacked, | 1 case. |
| Fauces unaffected, | 3 cases. | |
| Diphtheria generalized, | 2 cases. | |
| Larynx only affected, | 2 cases. | |
| Nasal fossa affected, | 1 case. |
The opinion of so good an observer as Sanné, that when in scarlet fever, pseudo-membranous exudation appears upon the mucous surfaces which are the seat of scarlatinous inflammation, diphtheria has supervened, and not a croupous form of scarlatinous phlegmasia, carries with it great weight. That it was diphtheria in four instances in my practice I had sufficient proof, for this disease became dissociated from scarlet fever, and extended to other members of these families as idiopathic diphtheria.
Nevertheless, one of the most difficult problems which we have to deal with in certain cases is to distinguish diphtheritic from non-diphtheritic inflammation; and I see no reason why the scarlatinous inflammation when intense may not be sometimes membranous; and those no doubt err who ignore this, and consider every inflammation attended by a pellicular exudation diphtheritic. We know that in some cases of dysentery a fibrinous exudation occurs upon the surface of the colon; that in croupous pneumonia fibrin exudes into the bronchioles and alveoli of the lungs; and that physicians in localities where there is no diphtheria meet, though at long intervals, cases which they designate croupous pharyngitis and laryngitis; and it seems to me that the intense inflammation of anginose scarlatina probably sometimes produces the same exudation. Moreover, it is very difficult to distinguish in the swollen fauces between a membranous exudation and ulceration or superficial gangrene so common in malignant scarlet fever. The grayish-white surface, jagged and foul, may be the one or the other, an exudation or a sphacelus, and in certain instances it is impossible to discriminate between the two conditions at the bedside.
Diphtheria complicating scarlet fever sometimes begins nearly simultaneously with the latter. Henoch states that exceptionally he has observed suspicious patches upon the fauces before the appearance of the scarlatinous eruption upon the skin; and he adds: "I have had repeated opportunities of observing this unusual beginning. In such cases we must ask ourselves whether the first affection was really connected with the second, or whether the former was a true primary diphtheria, rapidly followed by scarlatina. This opinion is favored by the fact that I have only observed such cases in the hospital, in which infection with various forms of contagion can scarcely be avoided."
But usually it is not till the third or fourth day of scarlet fever that this complication begins. The patient has been progressing favorably with the scarlet fever, till on a certain day a marked aggravation of symptoms occurs. A higher temperature, more pungent heat, and the physiognomy of a more serious malady are present. On inspecting the fauces to discover the cause we observe a pellicle forming over the tonsils and perhaps other portions of the faucial surface. Often the entire aspect of the case changes by the occurrence of this complication, a mild case of scarlet fever becoming grave and fatal in consequence. Thus in a case which I saw with Dr. Hardy of New York the membranous inflammation of diphtheria, commencing upon the fauces on the third day of scarlet fever, extended to the Schneiderian membrane, and thence along the left lachrymal sac to the eyelids, producing redness and swelling along the side of the nose and upon the cheek like that of erysipelas. A thick diphtheritic pellicle occurred upon the under surface of each eyelid on the left side, with great tumefaction of both lids, gangrene of the cornea, and destruction of the eye. The case soon ended fatally.
The diphtheritic inflammation sometimes extends to the larynx and trachea, producing hoarseness and more or less obstruction to respiration. A thin film or flakes of fibrinous exudation, rendering the respiration noisy, developed on the laryngeal or tracheal surface, is, I think, not infrequent in diphtheria complicating scarlet fever, but the rapid development of a thick and firm pseudo-membrane, so as to imperil the life of the patient from the stenosis in the air-passages, has been much less frequent in my practice than it is in primary diphtheria and in diphtheria complicating measles or pertussis. The following were cases of this severe complication occurring in a recent epidemic in the New York Foundling Asylum. In these cases the respiration was noisy, but the obstruction to breathing seemed to be due to infiltration and swelling around the aperture of the glottis, rather than to diphtheritic croup, which the autopsies showed to be present.
Case 2.—A child aged three and a half years, who previously had symptoms of mild catarrhal croup, with moderate redness of the fauces, sickened with scarlet fever on Oct. 1, 1882, the rash being profuse and soon covering nearly the entire body. The axillary temperature was 103°, pulse 140; slight stridor in breathing and some cough; fauces very red, but free from membrane. Oct. 2d, restless, sleeping but little; has vomited four times. Oct. 3d, temp. 103.5°, pulse 120; fauces much swollen; still vomiting; rash abundant. 4 P.M., temp. 104.3°, pulse 128; tongue clean; some discharge from nares; urine not albuminous, but its quantity diminished. Oct. 4th, aspect that of very severe sickness; profuse discharge from nostrils; fauces of a deep red color, and a diphtheritic pellicle over tonsils and uvula; tumefaction along the sides of the neck; temp. 104°, pulse 140; breathing moderately stridulous; urine is passed more freely than yesterday; evening temp. 105°. Oct. 6th, croupy symptoms more marked; tonsils and uvula greatly swollen, so that the fauces are almost occluded; temp. 103.5°; breathing difficult, but apparently sufficient oxygen is received; profuse nasal discharge, and other symptoms as before. About 1.30 P.M. he was raised to take some milk, and suddenly became asphyxiated. His face was dusky, his eyes protruded, and he voided urine and feces. Dr. Swift, who attended the child, and to whom I am indebted for this history, immediately performed tracheotomy, which gave temporary relief by the expulsion of a considerable quantity of pseudo-membrane through the opening. On the following day the respiration again became obstructed at some point below the canula, so that it could not be removed; the features grew livid, and death occurred in convulsions twenty-six hours after the tracheotomy.
The autopsy was made by Dr. W. P. Northrup, curator of the asylum, who found the pharynx covered by a membrane which was traced to the posterior nares; larynx, trachea, and bronchial tubes as far as the third divisions also covered with membrane; portions of the tracheal surface denuded, and the mucous membrane underneath of a bright red color and smooth; tonsils sloughy and fetid; mucous membrane of smaller bronchial tubes very red and covered with viscid mucus and pus; a portion of the left lung, extending from the root posteriorly to the surface, gangrenous, discolored, and honeycombed; two or three intensely hyperæmic spots, as large as a bean, in left lung; right lung congested, but not consolidated; slight catarrh of stomach; circumscribed areas of congestion in intestines; solitary glands of intestines swollen, and some of them ulcerated; spleen of normal size, rather pale; liver congested and somewhat enlarged.
Case 3.—Katie, aged six and a third years, was returned to the asylum on Nov. 18th. Three days later (Nov. 21st) she had sore throat, reddened fauces, coated tongue, and a faint rash upon the neck, chest, and arms; eyes injected; temperature 102°. In the afternoon temperature 103°; eruption still faint. Nov. 22d, temperature 103.5°; an eruption on chest, abdomen, arms, and legs in patches. Evening, temperature 104°; voice clear. Nov. 23d, temperature 103.5°; tongue red; fauces deeply reddened, but without any visible pseudo-membrane; eruption of a scarlatinous appearance over the back and abdomen; on the extremities dusky, livid patches. P.M., temperature 104°; is slightly delirious; eruption abundant. Nov. 24th, temperature 103.5°; eruption well out on abdomen; it is the same as yesterday upon the extremities, except perhaps a little more dusky; still no pseudo-membrane to be seen upon the fauces; is restless and delirious. P.M., during the day has been very restless, suffering from dyspnoea; no croupy voice nor croupy cough, though the dyspnoea continues, and a pseudo-membrane is now visible over the tonsils and adjacent faucial surface; eruption dusky; skin cool; pulse very frequent and feeble. From this time she sank steadily, and died at 11.30 P.M. During her sickness her urine seemed to be diminished, but it was not properly examined.
Autopsy Nov. 25th by Dr. W. P. Northrup, curator: Points of redness, apparently a hemorrhagic eruption, over the face, shoulders, and parts of the trunk; a few of the same on the extremities; no pseudo-membrane visible in nostrils or in buccal cavity; brain not examined. Naso-pharynx covered by a thick fibro-purulent membrane. Larynx contains a well-marked pseudo-membrane, but not continuous. Trachea covered by a pseudo-membrane, continuous over most of its surface, but in places broken and flaky. Where it is detached the mucous membrane is seen underneath, dusky and deeply injected. At the root of the lungs the pseudo-membrane can be traced along the tubes about an inch in all directions. Lungs oedematous, with deep congestion in places, but apparently no pneumonia; about two drachms of clear, straw-colored fluid in pericardium; a few stringy decolorized clots in the cavities of the heart; left ventricle contracted. The heart-fibres, carefully examined, microscopically, in the laboratory, are found to be normal, not having undergone granular or fatty degeneration. Liver normal in size; pale-yellow areas upon the superior surface, either from anæmia or fatty deposition. Kidneys of usual size, capsule not adherent; pyramids congested; cortex pale; markings distinct. Spleen enlarged about one-third; consistence normal. Stomach and intestines not examined.
Case 4.—Scarlet fever complicated by diphtheria, nephritis, and broncho-pneumonia. (History by house physician, Dr. Swift.) Phoebe, aged three and a quarter years, was delicate, but in her usual health till Oct. 29, 1882, when she became languid and vomited several times, and her tongue was coated. Oct. 30th, occasional vomiting; fauces reddened; tongue coated. Oct. 31st, remains languid; fauces deeply reddened; a faint scarlatinous eruption over back, wrists, and feet; temperature 100.5°. P.M., eruption of scarlet fever well out over the surface; tongue cleaner. Nov. 1st, rash over entire body; temperature 100.2°. Nov. 2d, fauces deep-red; tonsils and uvula swollen; diarrhoea and vomiting. Nov. 3d, temperature 102.5°; the eruption, which has been bright red, is now more dusky. Nov. 5th, temperature 104.5°; dusky-red color of the eruption; skin beginning to desquamate in places; urine normal; a discharge from nostrils. Nov. 6th, temperature 103.5°; eruption still present, but skin of abdomen and back desquamating; has otorrhoea on both sides; fauces deeply hyperæmic, but no pseudo-membrane visible upon them. Nov. 7th, temperature 103°; respiration and cough have a slight croupy character; other symptoms as yesterday. Nov. 8th, temperature 101°. A careful inspection of the fauces shows that it contains no pseudo-membrane; nostrils discharging a dark-brownish liquid; examination of urine negative. Nov. 11th, eruption, which appears to have been hemorrhagic in points, is fading and the desquamation is less. Nov. 14th, nostrils still discharging; glands of neck swollen. Nov. 16th, temperature 103°; sp. gr. of urine 1010, no casts, nor albumen; the chest seems clear; less discharge from nostrils; fauces clean and but slightly inflamed. Nov. 17th, 18th, temperature 103.5°; vomits; lungs healthy, but breathes with considerable effort, though without stridor; urine diminished; its sp. gr. 1020, albuminous, contains blood-corpuscles and granular casts. Nov. 19th, is very pallid; temperature 104°; very restless; vomits; urine diminished; bowels freely open. Nov. 20th, respiration still embarrassed; subcrepitant râles over the entire chest and percussion resonance not clear; temperature 102.5°. Nov. 21st, physical signs the same; temperature 103.5°; respiration 80. Nov. 22d, urgent dyspnoea; dulness on percussion over top of right lung and over lower part of left lung; is delirious; no perspiration; urine scanty; bowels freely open. From this date the dyspnoea became more urgent, and death occurred at 4 P.M. on the 23d.
Autopsy by Dr. W. P. Northrup, curator: Body well nourished; slight oedema of both legs; swelling at angles of jaws, most marked on left side. Vessels of brain moderately injected; otherwise appearance normal. Cicatrizing ulcers on both sides of fauces; a diphtheritic pseudo-membrane on septum of nose, larynx normal. Trachea, upper half apparently normal; a thin film of pseudo-membrane extends from just above the bifurcation upward to nearly the middle of trachea. About an ounce of fluid in each pleural cavity; on the right side a few loose flakes of fibrin floating in the serum, and consolidation of lung at apex; collapse in one or two places. Left side, recent adhesions over whole of posterior surface and base; surface of lower lobe dark, and when it is detached strings of fibrin adhere to it, and it is consolidated. The cut surface shows marked oedema, injection, increase of mucus in bronchi, and disseminated miliary tubercles in every part; no tubercles in the pleura, and none elsewhere in the body except in the left lung; tubercles in the lower lobe larger and more thickly grouped than in the upper lobe. Decolorized clots in heart, extending from ventricles into auricles of both sides. The capacity of the ventricles seems normal. Liver and spleen, normal. Kidneys rather large; capsules not adherent; superficial veins injected. The cut surface shows congested pyramids and pale cortex; markings indistinct and irregular; about four ounces of clear straw-colored fluid in abdominal cavity, and the solitary follicles of large intestines show pigmentation; two simple intussusceptions, each three-fourths inch in length, in small intestines.
Coryza frequently commences at or about the time of the pharyngitis. The inflammation of the Schneiderian membrane is continuous posteriorly with that of the fauces, and is announced by redness and swelling, inability to breathe freely through the nostrils, and an irritating ichorous discharge. Simple coryza in itself involves little danger, though it is an unpleasant complication, and in the nursing infant it may interfere with sucking. Diphtheritic coryza, on the other hand, which is frequently present when diphtheria complicates scarlet fever, involves danger, since it is apt to cause ulcerations, hemorrhages, and septic poisoning. When the local symptoms are unusually severe and the discharge abundant, it is probable that inflammation has in some cases extended to the antrum of Highmore.
Inflammation of the middle ear is another unpleasant and not infrequent complication. It is attributed to extension of the catarrh from the pharynx along the Eustachian tube to the tympanum. In a considerable proportion of cases of otitis media this tube is occluded by the infiltration and swelling of its mucous membrane, so that the muco-pus escapes with difficulty or is retained. Hence severe earache, an increase of the febrile movement, and outward bulging of the membrana tympani occur. Sometimes headache or other cerebral symptoms arise, probably from the fact that the meningeal artery, which supplies the meninges, is connected by anastomosing branches with the tympanum. In one of the cases related above it will be recollected that the ulceration and abscess extended from the fauces to the middle ear, the entire Eustachian tube having disappeared in the ulcerative process.
Frequently, the otitis escapes detection, its symptoms being masked or obscured by the general disease, until the membrana tympani is perforated and otorrhoea begins; but by careful examination the nature of the complication can usually be ascertained before the ear is injured to this extent, for a patient too young to speak will often press with the fingers against the painful ear or lie with the ear pressed upon the pillow, evidently having an increase of suffering if placed in any other position. One old enough to speak and in proper mental condition makes known the earache as soon as it occurs.
The mucous membrane of the tympanum, red and swollen from inflammation, secretes muco-pus abundantly; and this, pent up in the cavity, must obtain an exit before relief occurs. It is well if this secretion escape, though with difficulty, down the Eustachian tube. The destructive action of the pus upon the delicate structure of the ear is often such that, within a few days, irreparable harm is done and more or less deafness results. Relief can occur, if the Eustachian tube remain closed, only by perforation of the membrane and the discharge of the secretions into the external meatus. When this occurs the inflammation in the most favorable cases gradually abates, the aperture in the drum closes, and the integrity of the auditory apparatus is preserved. In severe cases the mastoid cells participating in the inflammation become filled with muco-pus and tender to the touch, and often the collateral oedema causes tumefaction and narrowing of the external ear, which subside with the discharge of pus from the tympanum.
Unfortunately, there is for many a more melancholy history—a more destructive inflammation, involving permanent impairment or total loss of hearing. This is especially apt to occur in strumous and feeble children. All grades of inflammation and destructive action occur in different cases. The perforation in the drum-membrane may be large or the membrane may be completely destroyed, and the detached ossicles escape one by one into the external meatus, and in a few instances, fortunately rare, this occurs in both ears, producing complete and permanent deafness. In my own practice this has never occurred, but I have met one or two adults who were totally deaf from this cause.
The mucous membrane which lines the bony wall of the middle ear has the function of the periosteum, and therefore, when inflamed and subjected to pressure, is liable to ulcerate. As in other parts of the skeleton under similar conditions, superficial caries or necrosis of the underlying bone is apt to occur. The carious or necrotic process may extend to the mastoid cells. An offensive otorrhoea, continuing for months or years, indicates the persistence of this pathological state of the tympanum, which is rendered so obstinate by the presence of dead bone. A moment's survey of the anatomical relations of the middle ear shows the danger to which these patients are liable. A thin bony septum, perforated with blood-vessels and sometimes containing congenital apertures, separates the tympanum from the cranial cavity above. Posteriorly lie the mastoid cells, connected with the tympanum by one large and several small apertures. Anteriorly is the commencement of the Eustachian tube and in close proximity to the tympanum lies the carotid canal, and at one point also the superior petrosal sinus. Virchow has shown how inflammation extending from the ear in otitis media sometimes produces such compression of the veins or sinuses by the swelling from the infiltration and exudation that the circulation is arrested, and the fibrin contained in the blood of these vessels is precipitated, forming thrombi, with the most disastrous effect upon the individual. Pus may also burrow in the interstices of the bone, causing great pain, or the pent-up secretions, having no outlet for escape, may in time undergo caseous degeneration, producing the conditions in which tuberculosis so often originates.
Death not infrequently occurs in chronic otitis media in another way. The otorrhoea, after months or years, suddenly ceases, the child complains of constant severe headache and is feverish, and the case ends in coma, preceded perhaps by convulsions. Meningitis has occurred, produced by extension of the inflammation through the thin bony septum which divides the tympanum from the cranial cavity, and at the autopsy hyperæmia of the meninges, fibrin, pus, perhaps softening of the brain and an abscess, are formed in the portion of the encephalon adjacent to the tympanum. Therefore, otitis media, though it often ends favorably, is in many patients an obstinate, dangerous, and even fatal sequel of scarlet fever.
The complication known as scarlatinous rheumatism is regarded by some as a synovitis, but its symptoms, especially its shifting from joint to joint, seem to ally it to the rheumatic affections. In some epidemics it is common. It usually begins toward the close of the first week or in the second week, and its common seat is in the ankle, phalangeal, and wrist joints. It is attended by very little swelling in most patients, though the joints are tender and painful on pressure. It does not seem to retard convalescence materially, though it produces suffering and involves danger as regards the heart. It subsides in a few days with the ordinary treatment of acute rheumatism, and even without special treatment, the chief danger being that, as in idiopathic rheumatism, endocarditis may arise, with permanent crippling of the valves. The following was a case of valvular disease having this origin. It occurred in my practice.
Case 5.—Freddy M., aged four years, sickened with scarlet fever March 6, 1879. The usual vomiting occurred on the first day, and the temperature was 104°. The case progressed favorably till March 14th, when he complained of pain in both wrists, both ankles, and both knees. On March 17th the general condition was good, the urine contained no albumen, and apparently few urates, but he still had pain in the joints of the upper and lower extremities and in the back; pulse 140, temp. 103°; breathes with a slight moan; urates in the urine, but no albumen. A distinct mitral regurgitant murmur is now heard for the first time. Under the use of salicylate of sodium the pain in the joints soon ceased, but the mitral murmur is permanent.
The following prescription is for a child of five years:
| Rx. | Ol. Gaultheriæ | fl. drachm iss; |
| Sodii Salicylat. | drachm iii; | |
| Syrupi | fl. oz. ii; | |
| Aquæ | fl. oz. iv. M. |
S. Give one teaspoonful every four hours.
Of the serous inflammations occurring in scarlet fever, pericarditis has been, according to Rilliet and Barthez, most frequently observed. In this country it is probably more frequent than is usually supposed, but it is less frequently detected than pleuritis, the symptoms of which are more conspicuous. It is apt to occur in connection with endocarditis.
The following case, showing the liability to pericarditis and other serous inflammation which exists in scarlet fever, occurred in my practice:
Case 6.—C——, girl aged five years and ten months, sickened with severe scarlet fever on April 4th. Was delirious; pulse 158; had vomiting and constipation. April 10th, pulse varies from 124 to 153, no delirium; a considerable quantity of urates in the urine. April 11th, has to-day, for the first time, severe pain in the epigastrium, with tenderness and moderate distension. Otherwise symptoms favorable, but severe; pulse 140; respiration moderately accelerated, and vesicular in every part of the chest. From this date the symptoms continued about the same till April 14th, when the dyspnoea became more marked and the action of the heart rapid and tumultuous. The epigastric pain, distension, and tenderness continued; the percussion sound was dull over the lower part of the chest; the dyspnoea became rapidly worse, although the pulse had considerable volume; and at 5 P.M. death occurred. At the autopsy about one ounce of turbid serum, with a soft deposit of fibrin, was found in the pericardium. Each pleural cavity contained from six to eight ounces of transparent serum, and both lungs were readily inflated, except a little of the posterior portion of each lower lobe, which could not be; no fibrinous exudation over the lungs. The liver extended four inches below the margin of the ribs, and upon its convex surface in the epigastrium, corresponding with the seat of the pain, was a rough patch of fibrin about one and a half inches in diameter. The bronchial mucous membrane was moderately injected, as was also that of the colon, and the kidneys appeared hyperæmic.
Among the serous inflammations which complicate or follow scarlet fever, pleuritis is one of the most important. It usually begins in the desquamative stage, and is apt to be suppurative on account of the feeble state of the patient when it commences. It has always, in my practice, been tedious, as all empyemas are, and it does not differ in its clinical history from the idiopathic disease. I have met cases of scarlatinous empyema in which, from opposition of the family or for other reasons, thoracentesis was not performed, and death occurred; others in which this operation effected a cure, and one at least in which the patient recovered by escape of pus through a bronchial tube. The pleuritis is seldom latent, or so masked by the symptoms of the general disease that it is apt to be overlooked. On the other hand, the cough, embarrassment of respiration, and pain referred to the affected side render diagnosis easy.
Dilatation of the heart is common in grave cases of scarlet fever, such cases as are properly termed malignant. It is indicated by a feeble and quick pulse. Acute infectious maladies, especially those of a malignant type and accompanied by high febrile movement, are very apt to cause parenchymatous degenerations in organs, prominent among which is granulo-fatty degeneration of the muscular fibres of the heart. This weakens very much the contractile power of these fibres. But early in malignant cases, probably before the muscular fibres are damaged, the contractile power of the heart is feeble from impaired innervation, the result of the general weakness. Hence this organ, when weakened by structural change and insufficiently stimulated through diminished innervation, may not fully empty itself during the systole, and consequently it becomes dilated. Dilatation of the heart and imperfect contraction of the auricular and ventricular walls are apt to result in the formation of clots in the cavities of the heart; and this appears to be the immediate cause of death in not a few instances. An ante-mortem clot occurring in any of the cavities of the heart necessarily seriously obstructs the circulation, unless it be of small size. Hence the dyspnoea, which may occur perhaps suddenly, and the change of pulse to one of marked feebleness and frequency. Large, firm white clots are most frequently found in the right cavities. They interlace with the chordæ tendineæ, lie even within the auriculo-ventricular opening, and send prolongations into the pulmonary artery and the cavæ. Associated with the white clots are dark, soft clots and fluid blood. The left cavities may be contracted and empty, or they may contain dark, soft clots or white ante-mortem clots. Clots in the left ventricle are sometimes prolonged into the aorta as far as the brachio-cephalic branches, while those in the left auricle may extend to the pulmonary veins. If dilatation of the heart be so great that clots form in its cavities, speedy death is probable. Sometimes a patient passes through scarlet fever and appears in a fair way to recover, when he succumbs to some exhausting sequel distinct from the heart, and at the autopsy the heart is found dilated and containing whitish clots, which are probably ante-mortem, and which hastened death by obstructing the circulation. Under such circumstances this state of the heart is attributable in great measure to the complication which has weakened its contractile power.
The following was a case in point. It occurred in the New York Foundling Asylum:
Case 7.—R. A., aged three years, had scarlet fever, beginning March 23, 1882. The symptoms were favorable at first, but serious complications and sequelæ occurred, which were fatal. The record of April 18th reads: "Appears well nourished, but is anæmic; has otorrhoea; no oedema; skin desquamating; dulness on percussion over upper third of right side of chest, anteriorly and posteriorly; mucous râles and rude breathing over same area; fine râles posteriorly over lower part of left side of chest; pulse 160, respiration 68, temperature 101.4°." April 20th, is feeble and takes nutriment with difficulty; tongue thickly coated; pulse 160, respiration 68, temperature 101.4°. April 26th, condition about the same as at last record, but he is evidently weaker; the lips are ulcerated and fauces still swollen. May 2d, cannot speak distinctly; a brownish, foul-smelling secretion lodges on the spoon used in depressing the tongue; left side of face swollen. On the following night eight convulsions occurred, attended by orthopnoea, and mucous râles in the chest from pulmonary oedema. Diarrhoea supervened and the patient died about midnight. Autopsy: Body moderately wasted and very white, several dark-blue spots on scalp and face from hemorrhages underneath; lips covered with dry crusts; brain of normal appearance; aperture of the larynx narrowed at the chink by infiltration and swelling of the tissues; surface of the vocal cords covered by a thin white film, apparently a fibrinous exudation; tracheal surface hyperæmic; about a drachm of straw-colored fluid in each pleural cavity; right lung wholly adherent by recent exudation of fibrin; left lung also largely adherent. A careful examination showed the presence of broncho-pneumonia in each lung, with considerable infiltration of the walls of the bronchi, and cylindrical dilatation of many of them; cavities of the heart dilated, so that this organ appears much enlarged, and its shape approaches the globular; its apex is rounded or obtuse; transverse diameter of the right ventricle, when its walls were open and drawn apart, was three and one-quarter inches; that of the left ventricle three and a half inches. Similar measurements of the heart of another child of about the same age, believed to be normal, were about one inch less in each direction. All the cavities contain white firm clots along with soft dark clots. Liver of normal size, pale; the outer surface and all cut surfaces are studded with nodules of the size of a pin's head, of a dull, opaque white color. These white spots, examined microscopically by Professor Delafield, are found to be neither tubercles nor gummy tumors, but to consist of polygonal cells, lying in the meshes of the capillary plexus of veins, which are perfectly preserved. He has not observed a similar case. The walls of the gall-bladder are one line or more in thickness, and the gall-duct is pervious. The microscope shows general hypertrophy of the gall-bladder and hypertrophy of its papillæ. The urine removed from the bladder was found to contain albumen and hyaline casts, and a microscopic examination showed a small amount of parenchymatous inflammation. The spleen was somewhat enlarged. Punctate congestion of small areas of gastric surface, no increase of mucus; mesenteric glands uniformly enlarged; jejunum, ileum, and colon exhibited a slightly increased vascularity. The immediate cause of death appeared to be imperfect contraction of the heart and the formation of clots in its cavities, due, apparently to the pleuro-pneumonia as much as, or more than, to the primary disease, scarlatina.3
3 Dr. Goodhart (Guy's Hospital Reports, 1879) reports several interesting cases to confirm his opinion that acute dilatation of the heart is a not infrequent sequel of scarlatinous nephritis, and is the cause of death in some apparently inexplicable cases.
There can be little doubt that nephritis in its milder form is much more common than was formerly supposed. A few years since little attention was given by a large proportion of physicians to the state of the kidneys, and the urine was not examined till dropsy made its appearance, which only occurs in the more severe forms of nephritis and is a late symptom. It is now known that catarrh of the renal tubes frequently occurs in a mild form early in scarlet fever, without causing albuminuria, dropsy, or any notable symptom. It may produce a smoky color of the urine, and the appearance in it of granular epithelial cells, with an increase of mucus, but no albumen. With careful treatment and no exposure to cold, the renal catarrh abates with the decline of the scarlet fever. It is scarcely severe enough to merit the name desquamative, tubal, or parenchymatous nephritis, though it is a mild form of the same pathological state. Steiner states, as the result of many careful examinations of cases, that hyperæmia of the kidneys was always present in those who died early in scarlet fever, and that in a certain proportion of these cases catarrh of the renal tubules was present in addition to the congestion. Even in some who died on the second or third day he found cloudiness of the epithelium in the renal tubes, although the urine had not indicated such a change. The opinion has even been expressed that catarrh of the renal tubes is as common in scarlet fever as that of the bronchial tubes in measles; that is, that it is a uniform element in the disease; but this appears to be an exaggerated statement, for others have failed to find any evidence of renal catarrh in certain cases.
The nephritis which gives rise to symptoms, and therefore interests the practitioner, commonly begins in the declining period of scarlet fever or during the desquamative stage, and is in many instances plainly attributable to exposure to cold or to currents of air. It originates either during this period, or, if it have previously existed as a mild renal catarrh, it now becomes aggravated. Dropsy, which always attracts attention, does not occur till the nephritis has continued for some time.
Why nephritis, with the subsequent dropsy, so frequently occurs after scarlet fever is not fully understood. Rilliet and Barthez attribute it to disturbance of the function of the skin. The fact has long been observed that the kidneys become affected nearly if not quite as frequently after mild as after severe cases. Indeed, the chief danger in mild cases, when the patients are but a short time in bed and are soon allowed to go about, is from the nephritis. Chilling the surface and checking cutaneous transpiration appear to be the immediate cause of this inflammation in a considerable proportion of cases. Therefore, severe attacks of scarlet fever with abundant rash and desquamation, which require the patient to be kept in bed the proper time and in a warm room two or three weeks, appear to be less frequently followed by this renal disease than are milder cases which are more carelessly treated.
The most thorough and minute microscopic examination of the state of the kidneys in scarlet fever which have come to my notice were those by E. Klein, published in the Lond. Path. Soc. Trans., and illustrated by microscopic drawings. It appears from these examinations that the changes in the kidneys are complex, among which we recognize both those of parenchymatous or desquamative nephritis and interstitial nephritis; but we would infer that the interstitial nephritis is mild in degree and quite subordinate, or else confined to portions of the organ, from the fact that so many permanently and fully recover. The following is a resumé of Klein's examinations in twenty-three cases: We conclude from these microscopic researches that the anatomical changes of both parenchymatous and interstitial nephritis are commonly present in greater or less degree in cases of scarlet fever. If they are mild or confined to portions of the kidneys, no symptoms occur; but if they are sufficient in extent or degree to impair the function of these organs, then symptoms, as albuminuria, diminution of urine, etc., appear.
1. Parenchymatous Nephritis, Proliferation of Nuclei, Hyaline Degeneration of Arterioles, the Glomerulo-Nephritis of Klebs.—Klein found increase of nuclei (probably epithelial) upon the glomeruli and hyaline degeneration of the intima of minute arteries, especially marked in the afferent arterioles of the Malpighian bodies. The intima of these vessels was in places so swollen as to resemble cylindrical or spindle-shaped hyaline masses, and cause narrowing of the lumina of the vessels in which this degeneration occurred. Klein observed in some specimens so great hyaline degeneration of the capillaries of the Malpighian bodies that circulation through them was obstructed. In the more advanced or protracted cases this hyaline substance in the glomeruli began to assume a fibrous appearance. Bowman's capsule was considerably thickened. This hyaline degeneration of the Malpighian bodies Klein discovered in the earliest cases which fell under his observation.
Also in the earliest cases the multiplication or germination of the nuclei of the muscular coat of the arterioles was observed, with a corresponding increase in the thickness of the walls of these vessels. This change in the muscular element was observed in the arterioles in different parts of the kidney, but it was most conspicuous in arterioles at their point of entrance into the Malpighian bodies; and it was distinctly observed in other arterioles, both in the cortex and in the base of the pyramids.
In the glandular portion of the kidneys other anatomical alterations were observed, indicating parenchymatous nephritis. There were swelling of the epithelial lining of the convoluted tubes; multiplication of nuclei of epithelial cells, especially in ascending tubules, which lay close to the afferent arterioles of Malpighian corpuscles; granular matter, and even blood, in the cavity of Bowman's capsule and in the convoluted tubes; cloudy swelling and granular disintegration of epithelium in some parts of the convoluted tubes; detachment of epithelium from the membrane of larger ducts of the pyramids in some cases. These parenchymatous changes are already known to the profession through the observations and writings of Dickinson, Fenwick, Johnson, John Simon, and others.
Klein, in commenting on the hyaline degeneration which he observed, states that Neelsen found the walls of the capillaries of the pia mater thickened, highly refractive, and of a lardaceous appearance in certain acute infectious maladies, as variola, typhoid fever, measles, and in one case of scarlet fever.4 Usually, only a small portion of the capillaries were thus affected, most frequently at the point of division into branchlets. In a few instances Neelsen observed degeneration of arterioles extending a considerable distance, with fusion of the intima, media and adventitia, and chemical examination showed that the substance produced by this degeneration had similar properties to elastic tissue. Although the examinations by Neelsen relate to the pia mater, two of his observations are especially interesting—first, that the hyaline change affects chiefly vessels near their point of branching; and, secondly, that the hyaline substance is of the nature of elastic tissue, for in the kidney in scarlatinous nephritis the arterioles undergo the change in question chiefly near their point of branching into the capillaries of the glomerulus; and the intima being the part which undergoes the hyaline change, it is probable, in the opinion of Klein, that the same substance is produced by the degeneration in walls of the vessels of the kidney which Neelsen observed in the pia mater, and therefore that it is of the nature of elastic tissue.
4 Archiv der Heilkunde, 1876.
This hyaline degeneration of the arterioles is also very marked in the spleen in scarlet fever; and in studying the minute anatomy of the intestines and spleen in typhoid fever Klein has found the same degeneration of the intima of the minute vessels. He believes that this hyaline change and the proliferation of muscle-nuclei which thus occur at an early period in scarlet fever in the renal vessels when the kidneys become affected are due to an irritating cause acting similarly to that in typhoid fever.
Klein calls attention to the interesting examinations of the scarlatinous kidney made by Klebs, who attributed the diminished urination and the uræmic poisoning in certain cases in which the kidneys do not exhibit any marked change to the naked eye, to what he designates glomerulo-nephritis. Klebs says: "In the post-mortem examination the kidneys are found slightly or not at all enlarged, firm, ... the parenchyma very hyperæmic. Only the glomeruli appear, on close inspection, pale like small white dots. The urinary tubes are often not changed at all. Occasionally the convoluted tubes are slightly cloudy. The microscopic examination shows that there are neither interstitial changes nor proliferation of epithelium, the so-called renal catarrh generally supposed to be present in these conditions on account of the absence of other perceptible derangements; and there seems, therefore, leaving out the glomeruli, the congestion of the kidneys alone to remain to account for the symptoms during life." But that mere congestion is insufficient to produce the symptoms appears from the fact that it does not produce them under other circumstances. Klebs finds, "on microscopic examination of the glomerulus, the whole space of the capsule filled with small somewhat angular nuclei, imbedded in a finely granular mass. The vessels of the glomerulus are almost completely covered by nuclear masses."
Klein, commenting on these examinations by Klebs, states that in all early cases which he examined he observed great abundance of nuclei of the glomeruli, but a condition like that described and figured by Klebs5 he has seen in only a few glomeruli; for a general state of these bodies, as described by this observer, and such an excessive proliferation of the nuclei that the blood-vessels are completely compressed, was not seen in one of the twenty-three cases. Klein therefore questions whether the diminished urination and retention of urea in scarlet fever, when the kidneys do not exhibit any conspicuous catarrhal or other change, is due, unless in exceptional instances, to compression of the vessels of the glomeruli by nuclear germination, but believes, rather, that the obstructed circulation, and consequent diminished urinary excretion, is largely due to the changed state of the arterioles. Klein adds that perhaps undue contraction of the arterioles, through stimulation by the blood-irritant, may also be a factor in causing arrest of circulation in the Malpighian corpuscles. As regards cases that perished early, he found the parenchymatous change slight, so that a careful examination was required in order to detect cloudy swelling and granular degeneration.
5 Handbuch der Pathol., p. 646, fig. 72.
2. Interstitial Nephritis.—A second set of changes Klein observed in cases that died on about the ninth or tenth day. In such cases he found changes due to interstitial, in addition to those produced by parenchymatous, nephritis. Round cells, lymphoid cells, or whatever else they should be called, were seen in the connective tissue of the kidneys. In the kidneys of those that died at the end of the first week after the commencement of nephritis, infiltration with round cells was observed in the connective tissue around the large vascular trunks. At a later stage this infiltration had extended into the bases of the pyramids and into the cortex. The gradual increase in extent and intensity of this infiltration was so decided in the cases which Klein observed that he has no hesitation in concluding that when interstitial nephritis occurs it begins about the end of the first week, in the manner already stated—to wit, as a slight infiltration of the tissue around the large vascular trunks, and gradually extends, so that portions of the cortex, and rarely portions of the base of the pyramids, are changed into firm, pale, round-cell tissue, in which the original tubes of the cortex become lost.
The infiltration of the cortex with round cells, beginning at the roots of the interlobular vessels, spreads rapidly toward the capsule of the kidney, and laterally among the convoluted tubes around the Malpighian bodies.... In the course of this process considerable parts of the peripheral cortex, occasionally of a more or less distinctly cuneiform shape, with the base nearest the capsule of the kidney, become changed into whitish, firm, bloodless, cellular masses, in which Malpighian corpuscles and urinary tubes are only imperfectly recognized, being more or less degenerated. In some cases attended by this infiltration of the cortex Klein observed a more or less dense reticulation of fibres, especially around the interlobular arteries, containing in its meshes lymph-cells, chiefly uninuclear.
In a child of five years that died after a sickness of thirteen days Klein found evidence of intense interstitial inflammation, and also emboli, consisting of fibrin with a few cells, in the arteries, both in those of large size and in the arterioles, chiefly where they enter the Malpighian corpuscles. He states that in the specimens which he examined the more intense the degree of interstitial change, the greater was the enlargement of the kidneys, and the more distinct also were the evidences of parenchymatous nephritis in the urinary tubes, which either contained casts or were in the process of destruction. By being crowded with inflammatory products, especially cells, the Malpighian corpuscles were obliterated, undergoing fibrous degeneration. A very curious fact observed was the deposit of lime in the urinary tubes, first of the cortex, and then also of the pyramids, at an early stage of scarlet fever, when the kidneys otherwise showed only slight change. Several observers, as Biermer, Coats, and Wagner, have each described a case of scarlet fever with interstitial nephritis, which they consider unusual; but Klein has apparently demonstrated, as we have seen, by a large number of microscopic examinations, that this form of nephritis is common after the ninth or tenth day.
Nephritis, in proportion to its extent and gravity, is accompanied by languor, febrile movement, thirst, loss of appetite and strength. At first the patient experiences but slight pain in the head or elsewhere, and the quantity of urine is not notably diminished; but as the disease continues urination becomes less frequent and the urine more scanty. Albuminuria occurs, while the urea is only partially excreted, and therefore accumulates in the blood. If the nephritis be so severe or protracted that this principle accumulates to a certain extent, grave symptoms occur, as headache, vomiting, apathy or restlessness, and, more dangerous than all, eclampsia, which is not unusual in these cases. Microscopic examination of the urine shows the presence in this liquid of blood-corpuscles, granular epithelial cells, and hyaline or granular casts, or both. The specific gravity of the urine is diminished. But a large quantity of albumen in the urine may render the specific gravity as high or higher than in health.
The altered state of the blood soon gives rise to transudation of serum, first observed in most cases as an anasarca occurring in the feet and ankles. The oedema, if not checked by treatment or through mildness of the disease, extends over the limbs, scrotum, and sometimes upon the trunk. It is well if the dropsy remain limited to the subcutaneous connective tissue, but, unfortunately, it is apt to occur, if the nephritis continue, in and around the internal organs, producing, mentioned in the order of frequency, pulmonary oedema, effusion into the pleural and peritoneal cavities, the pericardium, the encephalon, and lastly into the connective tissue of the larynx, causing that very fatal complication, oedema of the glottis. Although this is the common order in which dropsies occur, exceptions are not infrequent. Even the anasarca may not be the first to appear, although in the vast majority of cases it has the precedence. Thus, Rilliet relates the case of a boy of five years who twenty days after the occurrence of scarlet fever, and six hours after the appearance of bloody and albuminous urine, had double hydrothorax, rapidly developed. As long as the hydrothorax continued no anasarca was observed, but as it declined anasarca appeared. Legendre cites a case in which oedema of the lungs occurred without anasarca or other dropsy. Occasionally, the anasarca and internal dropsies take place nearly simultaneously. The nephritis and consequent serous effusions usually appear within three weeks after scarlet fever ends, but cases occur in which the effusions are first observed as late as the fourth and fifth weeks. The patient may be considered to possess immunity from this sequel if he have reached the close of the fifth week after the abatement of scarlet fever without its occurrence.
The dropsy is usually acute, but it may assume the chronic form, since the nephritis which causes it, happily curable in most instances, may, if neglected, become chronic. Whether the dropsy in itself involve danger depends in great part on its location. Anasarca and ascites may exist a long time with little suffering or danger, but a small amount of serum in certain other localities causes alarming symptoms and speedy death. Oedema of the lungs, hydro-pericardium, oedema of the glottis, and intracranial effusions are always dangerous, and the last two are sometimes fatal within twenty-four to forty-eight hours. Oedema of the lungs has been fatal within twelve hours from the occurrence of the first symptoms of obstructed respiration.
Cerebral symptoms occurring during scarlatinous nephritis are probably sometimes due to the irritating effect of the retained urea on the nervous centre. In other cases the cause appears to be cerebral oedema or compression of the brain by effusion of serum within the ventricles and upon the surface of the brain. Headache, dull or severe, dilatation of the pupils or their oscillation in the same degree of light, vomiting with little apparent nausea, are common symptoms of scarlatinous nephritis when it has continued a few days, and the excretion of urea is so diminished that this substance begins to exert its poisonous effect on the system. Such symptoms are apt to be followed by somnolence, threatening coma, or by eclampsia, unless the patients are promptly and properly treated. In some patients that die of scarlatinous nephritis, death occurring in convulsions or coma, no appreciable lesions are observed within the cranium, unless more or less congestion, the fatal ending being attributable to the uræmia. In other instances we find an effusion of serum within the ventricles or upon the surface of the brain. Although the symptoms in scarlatinous nephritis and uræmia may appear very unfavorable, the prognosis is usually good under prompt and appropriate treatment. Thus severe convulsions and a degree of somnolence that bordered on coma may abate, and convalescence be fully established within a few days, and Rilliet and Barthez announce ten recoveries in thirteen patients affected with convulsions due to this renal affection.
ANATOMICAL CHARACTERS.—Scarlet fever being, as we have seen, a constitutional febrile disease of an ataxic nature, and accompanied by certain inflammations, necessarily affects the composition of the blood; but since this disease varies so greatly in type or severity, the state and appearance of this liquid also vary. At the autopsies of the more malignant cases we find the blood dark and fluid, with small, soft, and dark clots in the heart and large vessels. In other cases the clots are large, firm, and solid, as described in a preceding page. In malignant cases that end fatally Rilliet and Barthez state that both the large and small vessels of the cerebral meninges and the brain are found hyperæmic, but in a variable degree. In those who die in coma, preceded by delirium or convulsions, during the eruptive stage, the intracranial congestion is usually marked, with perhaps some transudation of serum, but without inflammatory lesions. The fibrin in scarlet fever remains in about normal proportion, except as it is increased by inflammatory complications. Andral found an increase in the proportion of blood-corpuscles from 127 to 136 parts in 1000.
The respiratory apparatus, except the Schneiderian membrane, is usually normal when no complications exist. Samuel Fenwick6 made post-mortem examinations in sixteen cases of scarlet fever, and concludes from them that inflammation of the mucous membrane of the stomach and intestines occurs like that of the skin, followed by desquamation of the epithelial cells, like that of the epidermis. I have had the opportunity of examining the stomach and intestines of those who died of scarlet fever in the eruptive stage, and have not found any unusual hyperæmia of the gastro-intestinal surface, except when gastro-intestinal inflammation, usually indicated by diarrhoea, had occurred as a complication.
6 London Lancet, July 23, 1864.
In some cases the abdominal organs exhibit changes which suggest a resemblance to typhoid fever. The spleen is enlarged and somewhat softened, and Peyer's patches and the solitary glands are thickened and prominent, but less in degree than in typhoid fever. The mesenteric glands also are in a state of hyperplasia. In other patients these parts appear normal.
Klein made microscopic examination of the liver in eight cases, and states that he found granular opaque swelling of liver-cells, and changes in the internal and middle coats of certain arteries similar to those observed in the kidneys, which have been described above. He also found evidences of interstitial inflammation, as an increase of round cells and connective tissue in the liver. He remarks also that he observed hyaline degeneration of the intima of arteries in the spleen. Rilliet and Barthez state that swelling and softening of the spleen are exceptional in scarlet fever, but are sufficiently common to merit attention. In post-mortem examinations which I have witnessed nothing noteworthy has appeared to the naked eye in the state of the liver, nor ordinarily in that of the spleen.
The efflorescence, though one of the anatomical characters, has perhaps been sufficiently described in the foregoing pages. It begins over the neck, chest, and groins as numerous reddish points not larger than a pin's head, closely crowded together, but with skin of normal color between. It is estimated that the aggregate efflorescence and aggregate normal skin over a given area are about equal. If the cutaneous circulation be active and the febrile movement be considerable these spots extend and coalesce, producing an efflorescence like erythema or like the hue of a boiled lobster, to which it has been likened. The efflorescence, less upon the face than upon the trunk, contrasts in this respect with that of measles, in which the rash is full in the face, often causing some swelling of the features. It is also less upon the palmar and plantar surfaces than elsewhere. It scarcely causes any perceptible elevation of the skin, but in certain localities, as upon the backs of the hands and upon the fore-arms, it communicates the sensation of slight roughness. The seat of the efflorescence is mainly in the superficial layers of the skin, but it is said that it sometimes has occurred upon a cicatrix, as that from a burn. In the robust and in favorable cases in which the circulation is active the rash has a scarlet hue, and when the cutaneous capillaries are emptied and the skin rendered pale by pressure with the fingers, the circulation immediately returns when the pressure is removed. In malignant cases the color is not scarlet, but dusky red, and so sluggish is the capillary circulation that the skin when pressed upon recovers the blood very slowly. In grave cases also extravasation of blood in minute points or transudation of its coloring matter is apt to occur in portions of the surface, when of course decolorization is not fully produced by pressure. In cases ending fatally, during the eruptive stage the efflorescence may entirely disappear in the cadaver, or it remains upon parts of the surface, especially depending portions. Desquamation is attributable to the exaggerated proliferation of the epidermis and the loosening of its attachment by the inflammation.
DIAGNOSIS.—In the commencement of scarlet fever, prior to the eruption, no symptoms or appearances exist which enable us to make a positive diagnosis. Positive statement in reference to the nature of the attack should be deferred, for the credit of the physician. Still, if a child with no appreciable local disease sufficient to cause the symptoms a few days after exposure to scarlet fever, or during an epidemic of this malady, be suddenly seized with fever, the pulse rising to 110, 120, or more, and the temperature to 102°, 103°, or 105°, scarlatina should be suspected. The diagnosis is rendered more certain at this early stage if vomiting occur, and especially if the fauces be red, for hyperæmia of the fauces, due to commencing pharyngitis, is one of the earliest and most constant of the local manifestations of scarlatina.
When the eruption has appeared the nature of the malady is in most instances apparent. The punctate character of the eruption before it becomes confluent, its occurrence within twenty-four hours after the fever begins over almost the entire surface, but its absence or scantiness upon the face, and especially around the mouth, serve to distinguish it from other diseases.
Scarlet fever and measles were long considered identical by the profession, and, though the ordinary forms of these maladies can be readily distinguished from each other, cases occur in which the differential diagnosis is attended by some difficulty. But there are differences in the symptoms and course of the two diseases which aid in discriminating one from the other. Measles begins with marked catarrhal symptoms, as if from a severe cold. Mild conjunctivitis, causing weak and watery eyes, coryza, and mild laryngo-bronchitis, with accompanying cough, precede the eruption three or four days and continue during the eruptive stage. The febrile movement in the prodromic stage of measles is remittent, the evening temperature being two or three degrees higher than that in the morning. Contrast this with the invasion of scarlet fever, in which the only catarrh is that of the buccal and faucial surfaces, and there is consequently little or no cough, and the febrile movement, ordinarily high in the beginning, is nearly uniform in the different hours of the day. The scarlatinous eruption appears, as we have seen, within twelve to twenty-four hours about the neck and upper part of the chest, and spreads over the body in a shorter time than that of measles, which appears on the third day. The rash of measles begins to fade at the close of the third or in the fourth day after its appearance, that of scarlet fever not till from the sixth to the eighth day. In nearly all cases of measles, even when the rash is confluent upon the face and a considerable part of the trunk, in consequence of the high febrile movement and vigorous cutaneous circulation, we observe the characteristic rubeolar eruption upon certain parts of the surface, as the extremities, which, in connection with the history, renders diagnosis certain.
Erythema resembles the scarlatinous eruption, but its duration is commonly shorter. It is limited to a part of the surface, and it is accompanied by much less febrile movement. The temperature in erythema does not usually rise above 100°, unless for a few hours, whereas in scarlet fever it continues considerably above 100° for several days. The scarlatinous efflorescence has also a brighter red or more scarlet hue than that of erythema, except in the more malignant cases, in which the severity of the symptoms renders the diagnosis clear. But an important aid in differentiating the one from the other of these diseases is the fact that in erythema there is, with few exceptions, no faucial inflammation, and in the few instances in which it is present it is slight and transient, fading within a day or two.
Scarlet fever is readily diagnosticated from diphtheria, although the affinity is close between these two maladies. The early appearance of the pseudo-membrane upon the fauces in diphtheria, its absence in scarlet fever, and the absence of any appearance resembling it until the fever has continued some days, and the characteristic efflorescence upon the skin in scarlet fever, render diagnosis easy. If scarlet fever have continued some days when first seen by the physician, the diphtheritic pseudo-membrane may be present as a complication, or the fauces may present an appearance like diphtheria from ulceration or sloughing and the presence of foul and offensive secretions, which produce a dark-grayish and fetid mass over the faucial surface. Under such circumstances the character of the disease is ascertained by the history of the case, and especially by the occurrence of the scarlatinous eruption. An erythema transient and limited to a part of the surface sometimes appears in the commencement of diphtheria, and at a later period, as a result of the toxæmia, points of a roseoloid appearance and irregular patches, often located upon the extremities. Both kinds of rash can be readily diagnosticated from that of scarlet fever, for the erythema, as has been stated, is transient and partial, and does not exhibit minute points of deeper injection, while the toxæmic rash differs in form and aspect from that of scarlet fever, and appears at a stage of the case when the scarlatinous efflorescence would have faded or begun to fade.
The efflorescence of rötheln sometimes closely resembles that of scarlet fever, though it is usually more like that of measles; but it is ordinarily accompanied by symptoms which are much milder than those of scarlet fever, and it begins to abate as early as the third, and disappears on the fourth, day. The eyes have a suffused appearance, the temperature may reach 102° or 103°, and the efflorescence may be as general over the body as that of scarlet fever, but there is not the aspect of serious indisposition, and the speedy abatement of the symptoms shows that the disease is not scarlet fever.
PROGNOSIS.—The prognosis depends on the form of scarlet fever, whether mild or severe, the strength of the patient, and the presence or absence of complications or sequelæ. The type of this disease is sometimes so mild throughout an epidemic or during a series of years that death seldom occurs, whatever the mode of treatment; but afterward the type changes, and the percentage of deaths increases and remains high till another mitigation in the type occurs.
Sydenham in the middle of the seventeenth century stated that scarlet fever, as he saw it in London, was so mild that it scarcely deserved the name of disease: "Vix nomen morbi merebatur." Morton some years later, and Huxham in the following century, had abundant reason to regret the change of type, and now throughout Great Britain scarlet fever is one of the most fatal and most dreaded of the diseases of childhood. In Dublin during the present century, prior to 1834, scarlet fever was uniformly mild, so that on one occasion of eighty patients in an institution all recovered. In 1834 the type of the disease totally changed and epidemics of unusual virulence occurred. The type frequently changes from mild to severe or severe to mild, not only in consecutive years, but in consecutive months. A few years since a distinguished physician of New York treated about fifty cases of scarlet fever in one of the institutions without a single death, but a few months later the type of the malady changed, and his own son was among those who perished from it. The prevailing type of the disease should therefore be considered in giving the prognosis when in the commencement of a case we are asked the probability as regards the termination.
Extensive statistics, including those collected by Murchison from various sources, show that in different epidemics the mortality may vary as much as from 3 per cent. (Eulenberg of Coblentz) to 19.3 per cent. (cases seen by myself in New York City in 1881-82, many of which were complicated by diphtheria), or even to 34 per cent. (epidemic in the Palatinate in 1868-69). The hospital statistics of Rilliet and Barthez gave 46 deaths in 87 cases, or about 53 per cent.
Observations have thus far failed to establish any connection in the atmospheric conditions of temperature or moisture and the type of scarlet fever. Grave as well as mild epidemics have occurred in all climates and seasons.
The mortality is nearly equal in the two sexes, but age bears a marked influence on the percentage of deaths. Comparatively few contract scarlet fever under the age of one year, and the period of its greatest mortality, since it is of its greatest frequency, is between the ages of one and six years. The following are statistics bearing on the relation of the age to the percentage of deaths:
| Under 1 year. | From the close of 1st till close of 5th year. | From the 5th to the 12th year. | |||
| Fleishman, | Cases | 8 | 204 | 260 | |
| Deaths | 6 | 88 | 51 | ||
| 1st to close of 6th year. | 6th to 12th year. | From the 12th to 20th year. | |||
| Kraus, | Cases | 13 | 113 | 106 | 40 |
| Deaths | 4 | 29 | 10 | 2 | |
| 7th to 16th year. | |||||
| Voit, | Cases | 5 | 166 | 109 | |
| Deaths | 1 | 24 | 10 | ||
| 1st to close of 5th year. | Over 5 years. | ||||
| Röset, | Cases | 43 | 156 | 88 | |
| Deaths | 16 | 31 | 3 | ||
| Under 5 years. | 5th to 10th year. | 10th to 15th year. | Over 15 years. | ||
| Rusigger, | Cases | 101 | 126 | 47 | 27 |
| Deaths | 21 | 20 | 3 | 0 |
These statistics, which I believe correspond with the observations of others, show that although few cases occur in the first year, the percentage of deaths is large, and that a majority of the deaths occur under the age of six years. After the sixth year the greater the age the less the proportionate number of deaths.
Scarlet fever is liable to so many complications and sequelæ that a physician should not predict a certain favorable termination in the beginning, however mild and regular the symptoms may be. But a favorable result may be expected if the attack be mild, the efflorescence appear at the proper time and extend over the entire surface, the angina be moderate and accompanied by little or no cellulitis or adenitis, with pulse under 140, temperature not above 103°, and no marked nervous symptoms.
Whether the complications or sequelæ be dangerous depends upon their character. Rheumatism has never in my practice been dangerous, nor has it materially retarded convalescence, except when it affected the heart, causing pericarditis or endocarditis, when it involves great danger. Nephritis, if it be moderate, attended by little albuminuria and serous effusion, and by the occurrence of few renal casts in the urine, commonly ends favorably under judicious treatment, as we have already stated; but severe nephritis, with abundant albuminuria and casts and serous effusions, soon gives rise to alarming symptoms, and is the cause of death in a considerable number of instances. A similar remark is applicable to the angina, which occurs in all grades of severity. If it be attended by much cellulitis, with considerable ulceration or necrosis, the state is one of danger, in consequence of the difficulty in administering sufficient nutriment, of the diminished assimilation and of the loss of strength from the prolonged inflammatory fever, the septic poisoning, and the occasional hemorrhages. Complication by pharyngeal or nasal diphtheria, now so common where diphtheria is endemic, also greatly increases the danger.
Many cases, even when their course is normal and without complications, involve danger, and some are necessarily fatal, from the direct effect of the scarlatinous blood-poisoning. Such are grave or malignant forms of the disease which the experienced eye recognizes at a glance. Death often occurs rapidly from the toxæmia. Such cases are characterized by high temperature (105° or 106°), rapid pulse, a dusky-red hue of the surface from languid capillary circulation, pungent heat, frequent vomiting, diarrhoeal stools, a dry-brown tongue, and marked nervous symptoms, such as delirium, great restlessness, or stupor. Not a few in this form of scarlet fever take eclampsia, which is apt to be severe and repeated, and to end in fatal coma.
Other inflammatory complications and sequelæ, which have been described in the preceding pages, retard convalescence and jeopardize the life of the patient, such as empyema, endocarditis, pericarditis, and pneumonia. Otitis media is seldom immediately dangerous, although it may be painful and involve serious consequences, even a fatal meningitis, as has been stated above, after months or years of otorrhoea. Anomalous cases are believed to be, as a rule, more dangerous than such as are attended by an early and full efflorescence and have the usual symptoms.
TREATMENT.—PROPHYLAXIS. Since the discovery by Jenner of the prophylactic power of vaccination as regards small-pox, the attention of the profession has been frequently directed to the prevention of scarlet fever. Belladonna has been employed for this purpose by a class of practitioners who believe in the theory that an agent which produces symptoms similar to those of a disease is antagonistic to that disease, and therefore tends to prevent it, or, if it be present, to render it milder; and since this herb causes an efflorescence upon the skin and redness of the fauces, it was selected as the proper preventive and remedial agent for scarlet fever. Its use, however, for this purpose has been fruitless, and it is now nearly or quite discarded.
It is probable, from a considerable number of observations, that scarlet fever occasionally occurs in the domestic animals during epidemics of the disease in children. It is stated that Spinola observed it in the horse; that Heim saw a dog that occupied the same bed with a scarlatinous patient sicken with fever, which was followed by desquamation; that Letheby saw scarlatina in swine, and Kraus in young cattle. Prominent veterinary surgeons, as Williams of Great Britain, admit the occurrence of scarlatina in animals, and the hope has arisen that since small-pox is modified in cattle so as to afford us the vaccine virus, perhaps scarlet fever may also be modified by passing through one of the lower animals, so that a milder and less fatal form of the disease might be produced in man by inoculation from the animal. This theory, though it deserves investigation, is far from being established. It has not yet, so far as I am aware, been shown that scarlet fever is milder in any animal than in man, nor, if we admit that it is modified in the animal, is it certain that the disease could be returned to man in the modified form. In the N.Y. Medical Record for March 24, 1883, some experiments are detailed by S. W. Strickler of Orange, New Jersey. He cites the experiments of Caze and Feltz, who injected scarlatinal blood under the skin of sixty-six rabbits, and of these sixty-two died within eighteen hours to fourteen days, which indicated a highly poisonous state of the blood employed, either septic or scarlatinous, and certainly no mitigation of the virulence of the scarlet fever. Strickler obtained from Williams of Edinburgh nasal mucus from a horse supposed to have scarlatina, and with it inoculated twelve children, all of whom had sores at the point of inoculation, with redness of the skin around the sores, and in some instances swelling of the adjacent lymphatic glands. It is stated that the children thus inoculated did not contract scarlet fever subsequently when they were exposed to scarlatina. Obviously, there is a serious objection to such experiments upon children, so that they may not be repeated, but a movement has been made in one of the New York medical societies looking to the appointment of a competent committee to investigate them. Some of the prominent veterinary surgeons of this city do not attach much importance to the experiments thus far made, as they are in doubt whether the virus employed was that of the genuine disease.
It is a matter of great interest and importance, and one not yet elucidated, whether or to what extent disinfectant and antiseptic remedies administered internally prevent the occurrence of the infectious maladies in those who have been exposed, and aid in curing those who are sick with them. Sodium sulpho-carbolate, from which, by decomposition in the system, carbolic acid is supposed to be set free, has been used for this purpose. It is administered to adults in doses of ten to thirty grains, and to children in doses proportionate to their age. Declat has prepared a syrup of phenic (carbolic) acid as a preventive and curative agent in the infectious diseases. It is now employed by several of the New York physicians, but thus far the statistics of its use are not sufficient to determine its efficacy. It is a question whether the so-called antiseptics can, on account of their toxic properties, be used with safety in doses sufficiently large to be antidotal to the specific principle of any of the infectious maladies.
It is not my intention to recommend in this treatise any remedial agent that has not been fully tried and its efficacy determined; but from observations made by myself in nearly twenty families in which scarlet fever was prevailing, I am convinced that boracic acid (acidum boricum), an antiseptic recently introduced into our Pharmacopoeia, deserves trial as a preventive and antidote of scarlet fever as well as diphtheria. The good result in my practice from the use of this agent, which only extends over about six months, may be due to the present type of scarlet fever, but I have been surprised at the favorable progress of the cases which appeared very grave in the beginning, at the small mortality, and at the large proportion of well children exposed to scarlatinous cases that escaped infection, to whom this medicine was regularly administered. Boric (boracic) acid has been recently used by aurists with remarkable success in suppurating and granulating otitis media, and by oculists as an eye-wash. E. R. Squibbs says of it (Ephemeris, May, 1883): "A solution saturated at ordinary temperatures contains between 4 and 5 per cent.... It is a very bland and soothing application, whether applied in powder or solution, relieving irritation and reducing suppuration.... It has been administered internally in large doses without any disturbing effects." The preparation which I have employed is one found in the shops, with the name listerine, prepared by a Western pharmaceutical firm. It contains, according to the manufacturers, the "essential antiseptic constituents of thyme, eucalyptus, baptisia, gaultheria, and mentha arvensis," and also two grains of benzo-boracic acid in each drachm. The dose of listerine which I have employed for an adult is one teaspoonful, considerably diluted with cold water. A child of five years can take ten to fifteen drops every two to four hours. I call the attention of the profession to the use of boracic acid as an antidote to the scarlatinous poison, without sufficient experience to enable me to speak positively of its efficacy, but with the hope and expectation, from observing its apparent effects in seventeen families afflicted with scarlet fever, that it will be found a useful addition to our means of controlling this much-dreaded and fatal malady.
In the present state of our knowledge the most reliable and certain prophylaxis is the isolation of patient and nurses, and the thorough and judicious employment of disinfectants upon their persons and in the apartments. All furniture and articles not absolutely required should be removed from the sick room, and no one should be allowed to enter it except the medical attendant and nurses. Constant ventilation should be insisted on by lowering the upper and raising the lower sash of the window two or three inches in mild weather. Even in stormy weather sufficient ventilation can be obtained in this way without exposing the patient to currents of air, which should be avoided.
Since the exhalations from the body, the various excretions, and the epidermic cells shed so abundantly in the desquamative period contain the scarlatinous poison, measures should be employed to disinfect them, in so far as the comfort and well-being of the patient will allow. Vessels which receive the excretions should contain carbolic acid, chloride of lime or other disinfectant, and they should be immediately emptied and cleaned after use. By the frequent application of disinfecting washes to the nostrils and fauces the secretions from these surfaces are to a great extent deprived of their contagiousness. If otorrhoea occur, boracic acid, so serviceable in its treatment, acts as a disinfectant, but in addition the ear should be syringed with warm carbolized water, one drachm of carbolic acid to the pint of water, and this should be continued during convalescence, for cases occur which show that the discharge from the ear is probably the vehicle by which the virus is communicated. Even as late as the fourth week after the disappearance of the rash children in scarlet fever experience relief from inunction of the surface, and if carbolic acid be added to the substance which is employed for this purpose, and the inunction be made twice daily over the entire surface, contamination of the air through the exfoliations and exhalations from the skin is in great part prevented. The late William Budd of Bristol, England, was in the habit of recommending inunction of the surface twice daily with sweet oil, which answered the purpose of preventing dissemination of epidermic particles through the air; and we will presently see how successful were his precautionary measures.
A convalescent child should not be allowed to mingle with other children till three or four weeks have elapsed and desquamation has ceased; and all who are liable to take the malady should be excluded from the room in which a case has occurred for a longer period, and until it has been thoroughly disinfected by burning sulphur or other methods.
The New York Board of Health enforces the following excellent regulations to prevent the spread of scarlet fever as well as other acute infectious maladies:
"Care of Patients.—The patient should be placed in a separate room, and no person except the physician, nurse, or mother allowed to enter the room or to touch the bedding or clothing used in the sick-room until they have been thoroughly disinfected.
"Infected Articles.—All clothing, bedding, or other articles not absolutely necessary for the use of the patient should be removed from the sick room. Articles used about the patients, such as sheets, pillow-cases, blankets, or clothes, must not be removed from the sick room until they have been disinfected by placing them in a tub with the following disinfecting fluid; eight ounces of sulphate of zinc, one ounce of carbolic acid, three gallons of water. They should be soaked in this fluid for at least an hour, and then placed in boiling water for washing.
"A piece of muslin one foot square should be dipped in the same solution and suspended in the sick room constantly, and the same should be done in the hallway adjoining the sick room.
"All vessels used for receiving the discharges of patients should have some of the same disinfecting fluid constantly therein, and immediately after being used by the patient should be emptied and cleansed with boiling water. Water-closets and privies should also be disinfected daily with the same fluid or a solution of chloride of iron, one pound to a gallon of water, adding one or two ounces of carbolic acid.
"All straw beds should be burned.
"It is advised not to use handkerchiefs about the patients, but rather soft rags, for cleansing the nostrils and mouth, which should be immediately thereafter burned.
"The ceilings and side-walls of a sick-room after removal of the patient should be thoroughly cleaned and lime-washed, and the woodwork and floor thoroughly scrubbed with soap and water."
By such measures of prevention there can be no doubt that the number of cases of scarlet fever would be greatly reduced.
Budd for years recommended similar precautions in the families which he attended, and the following is his testimony in regard to the result: "The success of this method in my own hands has been very remarkable. For a period of nearly twenty years, during which I have employed it in a very wide field, I have never known the disease to spread beyond the sick-room in a single instance, and in very few instances within it. Time after time I have treated this fever in houses crowded from attic to basement with children and others, who have nevertheless escaped infection. The two elements in the method are separation on the one hand, and disinfection on the other."7
7 British Medical Journal, Jan. 9, 1869.
HYGIENIC TREATMENT.—The room occupied by a scarlatinous patient should be commodious and sufficiently ventilated. Its temperature should be uniform at about 70° during the course of the fever. When the fever begins to abate and desquamation commences, a temperature of 72° to 75° is preferable, so that there is less danger that the surface may be chilled during unguarded moments, as at night, when the body may be accidentally uncovered, since sudden cooling of the surface at this time may cause nephritis or some other dangerous inflammation. Henoch does not believe in the theory that the nephritis is commonly produced by catching cold, but many observations show that those who are carefully protected from vicissitudes of temperature, who remain during convalescence in a warm room, and are protected by abundant clothing, more frequently escape this complication than such as are under no restraint of this kind and are carelessly exposed in times of changeable weather. Nevertheless, it is true that a certain proportion suffer from nephritis however judicious the after-treatment may be. The best hygienic management does not always prevent its occurrence. The patient should not, therefore, leave the house until four weeks after the beginning of the fever, and in inclement weather not till a longer time has elapsed. So long as desquamation is going on and the skin has not regained its normal function the patient should remain indoor, and when finally he is allowed to leave the house he should be warmly clothed.
THERAPEUTIC TREATMENT.—In order to treat scarlet fever successfully it is necessary to bear in mind that it is a self-limited disease, running for a certain time and through certain stages, and that it is not abbreviated by any known treatment. Therapeutic measures can only moderate its symptoms and render it milder. The severity of the disease is indicated by its symptoms, and the symptoms are to a certain extent under our control.
MILD CASES.—A patient with a temperature under 103°, and with only a moderate angina, does not require active treatment, but, however light the disease, he should always be in bed and in a room of uniform temperature, as stated above. Instances have come to my notice in the poor families of New York in which scarlet fever was not diagnosticated, and the patients were allowed to go about the house, and even in the open air, in the eruptive stage, till some severe complication or an aggravation of the type created alarm and medical advice was sought, when it appeared that a grave and dangerous condition had, through carelessness and ignorance, resulted from a mild and favorable form of the malady. The physician, when summoned to a case however mild, should never fail to take the temperature, note the pulse, inspect the fauces, and inquire in reference to the fecal and urinary evacuations, that he may detect early any unfavorable changes which may occur.
Since in all cases angina and more or less blood-deterioration are present, the following prescription will be found useful in mild as well as severe scarlet fever:
| Rx. | Potass. Chlorat. | drachm ii; |
| Tr. Ferri Chloridi | fl. drachm ii; | |
| Syrupi | fl. oz. iv. M. |
S. Half a teaspoonful every hour to two hours to a child of three years; a teaspoonful to a child of six years.
Small doses of this medicine frequently administered act beneficially on the surface of the throat and tend to prevent the anæmia which is so common after scarlet fever. If the medicine be given gradually diluted with only a moderate amount of water, the effect is better on the inflamed fauces. Potassium chlorate is known to be an irritant to the kidneys in large doses, causing intense hyperæmia of these organs, with bloody urine or suppression of urine. The melancholy fate of Fountaine, who died from the effects of one ounce of this medicine, is known to the profession. I have seen a similar instance in a child. But doses of one to four grains, according to the age, can be administered with safety to children, so that half a drachm to a drachm and a half are taken in twenty-four hours. A quantity much exceeding this amount involves risk. In mild cases it is not necessary to treat the throat by topical measures, the above prescription producing sufficient local effect, but camphorated oil may be used externally. I ordinarily prescribe quinine in small doses for this form of scarlatina, as in the following formula:
| Rx. | Quiniæ Sulphat. | gr. xvi; |
| Ext. Glycyrrhizæ | scruple ss; | |
| Syr. Pruni Virginianæ | fl. oz. ii. M. |
S. One teaspoonful every fourth hour to a child of three to five years, the potassium chlorate and iron mixture being administered twice between.
The treatment of scarlatina by antiseptic remedies will be considered hereafter.
The itching and dryness of the surface, which increase the discomfort of the patient in mild as well as severe scarlatina, are relieved by frequently anointing the whole body with vaseline, cold cream, or butter of cocoa. Carbolic acid is an efficient remedy for pruritus, while it is also a disinfectant. It may be used in the following formula:
| Rx. | Acidi Carbolici | drachm i; |
| Vaseline | oz. iv. M. |
S. To be applied over the entire surface.
In New York leaf lard has long been employed as an unguent over the entire surface in scarlet fever, and patients experience benefit from it. Alcohol and water or vinegar and water are sometimes employed for the same purpose. The linen should be changed every day and the bed thoroughly aired.
ORDINARY CASES AND CASES OF SEVERE TYPE.—A safe temperature in scarlet fever may be considered at or below 103°. If it rise above this, measures designed to abstract heat are very important—more important even in many cases than the medicinal agents which are commonly used to combat this disease. Since a high temperature retards assimilation, promotes deleterious tissue-change, and causes rapid emaciation and loss of strength, measures designed to reduce it are urgently needed. "The production of heat depends chiefly on oxidation of the constituents of the body" (Billroth). Therefore fever indicates an increase of the oxidation and a molecular disintegration above the healthy standard. Hence the augmentation of urea in the urine and the progressive emaciation and loss of weight which characterize the febrile state. Fever also diminishes the secretions by which food is digested and destroys the appetite, so that repair of the waste is insufficient. Moreover, a high temperature continuing for a time tends to produce degenerative changes, albuminous and fatty, in the tissues, the more rapidly the higher the temperature, so that the functions of organs are seriously impaired. Among the most dangerous of the tissue-changes is granulo-fatty degeneration of the muscular fibres of the heart. In dogs and rabbits that have perished from a high temperature artificially produced by experimenters granular clouding of the elementary tissues has been found after death.8 A high temperature, therefore, in itself involves danger, and if it occur in an ataxic disease like scarlet fever, and be protracted, it greatly diminishes the chances of a favorable issue.
8 See experiments by Mr. J. W. Legg, Lond. Path. Soc. Trans., vol. xxiv., and others.
The temperature can be reduced without shock or injury to the child by the judicious use of cold water externally. The cold-water treatment is not necessary if the temperature be under 103°, though useful if judiciously employed by sponging when the temperature is at 102° or 103°; but if it rise above 103° it is required, and the more urgently the higher the temperature. The external use of cold water as an antipyretic in the febrile diseases is now almost universally recommended by physicians, but it still meets with opposition on the part of families, especially in the treatment of the exanthematic fevers, and the directions for its employment are therefore not apt to be fully carried out during the absence of the medical attendant. The old theory that the fevers require warmth and sweating has such a firm hold on the popular mind that some years longer will be required for its removal.
The modes of applying cold water recommended by cautious and experienced physicians are various. Von Ziemssen recommended that the patient be immersed in water at a temperature of 90°, and cool water be gradually added till the temperature fall to 77°. In a few minutes the patient is returned to his bed, his surface dried, and he is covered by the proper bed-clothes, when his temperature will probably be found reduced two or two and a half degrees. If the patient complain of chillness or his pulse be feeble, he should be immediately removed from the bath and stimulants administered, either whiskey or brandy, for if the extremities remain cool and the capillary circulation sluggish, the effect may be injurious, since some internal inflammation may arise to complicate the fever. Under such circumstances increased alcoholic stimulation is required.
The cold pack is also effectual for reducing the temperature. The patient is placed upon a mattrass protected by oil-cloth, and is covered by a sheet wrung out of water at a temperature of 70°. This is covered by one or two blankets. In half an hour he is returned to bed, and will be found to have a temperature two or three degrees less than that before the bath. Another method is to apply the sheet wrung out of water at 90°, and then reduce the temperature by adding water at a lower degree from a sprinkler. In most cases, however, I prefer to reduce the temperature by the constant application to the head of an india-rubber bag containing ice. The bag should be about one-third filled, so that it should fit over the head like a cap. At the same time, as a potent means of abstracting heat, at least when the temperature is at or above 104°, a similar application should be made by an elongated rubber bag lying over the neck and extending from ear to ear. Cold applied over the great vessels of the neck promptly abstracts heat from the blood, while it diminishes the pharyngitis, adenitis, and cellulitis; which is an important gain. At the same time, it is proper to sponge frequently the hands and arms with cool water. If the temperature with this treatment be not sufficiently reduced, one or two thicknesses of muslin frequently wrung out of ice-water should be placed along the arms and upon either side of the face. By such local measures, which are agreeable to the patient and without any shock or perturbing effect on the system, we can reduce the temperature two or three degrees. By adding alcohol or one of the alcoholic compounds to the water the popular objection to the use of cold is overcome.
Trousseau, in the treatment of sthenic cases attended by a high temperature, was in the habit of placing the patient naked in a bath-tub and directing three or four pailsful of water to be thrown over him in a space of time varying from one quarter of a minute to one minute, after which he was returned to bed and covered by the bed-clothes without being dried. Reaction immediately occurred, often with more or less perspiration. This treatment was repeated once or twice daily, according to the gravity of the symptoms. Trousseau, alluding to this treatment, says: "I have never administered it without deriving some benefit." But the application of cold water in a manner that does not excite or frighten the patient seems preferable. Henoch, having a large experience, gives the following advice in reference to the water treatment: "If the fever continue high and the apparently malignant symptoms described above develop, the head should be covered with an ice-bag, ... and the child placed in a lukewarm bath, not under 25° R. (88.25° F.). I decidedly oppose cooler baths, because in scarlatina, which presents a tendency to heart-failure, cold may produce an unexpected rapid collapse more than in any other affection. But I strongly recommend washing the entire body every three hours with a sponge dipped in cool water and vinegar."9 In grave cases with a high temperature the application of cold should be sufficient to produce a decided reduction of heat, otherwise the full benefit from its use is not obtained. With proper stimulation and proper precautions prostration does not occur from the ice-bags to the head and neck and cool sponging of other parts, so long as the temperature does not fall below 102° or 103°. The danger alluded to by Henoch can only occur from the use of the pack or general bath, and the water treatment can be efficiently carried out and the temperature sufficiently reduced without resorting to these. Even Currie of Edinburgh, who first drew attention to the benefit from the cold-water treatment of scarlet fever in an age when the sweating treatment, and even the exclusion of cool and fresh air from the apartment, were deemed necessary, recommended cold affusion only in sthenic cases with full and strong pulse, and he mentions as a warning two cases with quick and feeble pulse and cool extremities in which death occurred immediately after the use of the water.
9 Diseases of Children.
Sodium salicylate is in some instances a useful remedy for the reduction of heat in the infectious diseases. It seems to be more decidedly antipyretic than quinine in the febrile and inflammatory diseases, though somewhat depressing to the heart's action. James Couldrey writes to the London Lancet (Dec., 1882, p. 1064) that he has derived great benefit from its use in seven cases of scarlet fever. He administered it every two hours till ringing in the ears was produced, and afterward every four hours, prescribing one grain for each year in the age of the patient. It is, in my opinion, a proper remedy when the pulse is full and strong and the temperature is not sufficiently reduced by the cold-water treatment.
Aconite and veratrum viride reduce fever, but they are too depressing to be safely employed in grave scarlet fever, and their antipyretic effect is less than that of water. The use of digitalis might be suggested by the quick and feeble pulse in certain cases that are attended by high temperature, but the judgment of the profession is for the most part against its use in such cases. What Stillé and Maisch state of its employment in typhoid fever appears equally applicable to scarlet fever: "Even its advocates have not shown that it abridges the disease or lessens its mortality, while it is abundantly demonstrated to impair the digestion, reduce the strength, and even to occasion sudden death. The use of digitalis in other forms of fever is equally unsatisfactory, and justifies the judgment of Traube, that the true field of action for digitalis is not fever."
Quinine is the medicine which above all others has been heretofore most used, by almost common consent of the profession, to reduce the temperature in malignant scarlet fever, but its use for this purpose is, according to my observations, far from satisfactory. To obtain its antipyretic action it must be administered in large doses, and if any of the quinine salts in ordinary use be administered by the mouth in sufficient quantity, they are apt to be vomited. To a child of five years five grains should be administered twice daily by the mouth, or ten grains of a soluble salt, as the bisulphate, may be given per rectum, dissolved in a little warm water. Administered per rectum, it is frequently not retained unless held for a time by a napkin. A considerable proportion of the malignant cases are attended by not only irritability of the stomach, already alluded to, but by diarrhoea, so that quinine, if administered at all, should be employed hypodermically. The double salt of quinia and urea answers for this purpose, as it is very soluble in water and does not produce inflammation of the connective tissue. When the antipyretic doses of quinine are discontinued, this agent may be prescribed as a tonic in the doses recommended for the treatment of mild scarlet fever.
In severe cases with frequent and rapid pulse, in which ante-mortem heart-clots are apt to occur, the ammonium carbonate is often useful. It should be dissolved in water and given in milk, in as large doses as five grains every hour or second hour to a child of five years. It aids in producing stronger contraction of the cardiac muscular fibres, and thus diminishes the danger of the formation of thrombi. Ten-drop doses of the aromatic spirits of ammonia may be employed instead of the carbonate, given in sweetened water. It is especially useful if the stomach be irritable.
In severe cases attended by considerable angina and foul and offensive secretions upon the faucial surface an antiseptic, as boracic acid in small quantity, should be added to the potash and iron mixture recommended above. If no drink be allowed for a few minutes after the dose, so as not to wash it too soon from the fauces, the antiseptic effect is more certainly produced. Those old enough should be directed to hold the medicine for a moment like a gargle in the throat before swallowing it. I employ boracic acid by preference, as in the following formula:
| Rx. | Acid. Boracic. | drachm ss; |
| Potass. Chlorat. | drachm ii; | |
| Tr. Ferri Chloridi | fl. drachm ii; | |
| Glycerinæ, | ||
| Syrupi aa. | fl. oz. i; | |
| Aquæ | fl. oz. ii. M. |
S. Give one tablespoonful every two hours to a child of five years.
More minute directions will presently be given for the treatment of the pharyngitis when we speak of the complications.
Alcohol, whether administered in one of the stronger wines, as sherry, or in whisky or brandy, is a most useful remedy in scarlet fever, and is indeed indispensable in all grave cases which are attended by feeble capillary circulation and evidences of prostration. Milk is also the best vehicle for this agent. The wine-whey or milk-punch should be given every hour or second hour. In scarlet fever, as well as diphtheria, comparatively large doses are required, as a teaspoonful of the stimulant every hour or second hour for a child of five years.
During convalescence the hygienic treatment already described is important. Nutritious diet and a moderate amount of alcoholic stimulants are required, while the patient is kept indoors and protected from currents of air as long as desquamation is occurring. More or less anæmia is present in most convalescent patients, so that a mild tonic containing iron will aid in restoring the health. Elixir of calisaya-bark and iron; preparations of beef, iron, and wine, or the following prescription, will be found useful under such circumstances:
| Rx. | Ferri et Ammon. Citrat., | |
| Ammon. Carbonat. aa. | gr. xxiv; | |
| Syrupi | fl. oz. i; | |
| Aquæ | fl. oz. ii. M. |
S. Dose, one or two teaspoonfuls, according to the age, every third hour.
ANTISEPTIC TREATMENT.—It is still to be determined whether or to what extent antiseptics, administered internally, antagonize and control the scarlatinous poison, and are therefore curative of scarlet fever. The most important agent of this class, carbolic acid, can only be employed in small doses, for a dose much exceeding a drop for a child, or even exceeding a fractional part of a drop for a young child, might produce poisonous symptoms. Carbolic acid is a cardiac and arterial sedative, and it appears to reduce temperature. Intra-uterine injections of carbolized water in the treatment of puerperal fever are known to reduce temperature, even when there is no septic matter in the uterus to be disinfected and washed away, as in a case related to me in which the fever proved to be due to measles. It is not improbable that the antipyretic action in patients of this class who have no septic substance within the uterus is due largely, if not mainly, to the absorption of carbolic acid from the uterine surface and its sedative action on the vascular system. Whether this agent, so highly extolled by Declat, and to which I have alluded in a preceding page, can be safely employed in doses large enough to be efficient and curative will be determined by future observations. The same remark is applicable to the sulphocarbolate of sodium, whose antiseptic action is supposed to be due, as already stated, to the liberation of carbolic acid in the system. Since boracic acid does not seem to have any deleterious action, this agent has been administered to most of my scarlatinous patients during the last year, in addition to the older and better known remedies, and with a very small percentage of deaths. What may be the result in a more severe type of the disease remains to be seen.
TREATMENT OF COMPLICATIONS AND SEQUELÆ.—Local measures designed to diminish or cure the pharyngitis are important in all but the mildest cases. They are more especially required in the anginose variety and in those not infrequent cases in which diphtheria complicates scarlatina. Formerly it was necessary, in making applications to the fauces, to employ the brush or probang for those too young to use the gargle, but hand-atomizers, as Richardson's or Delano's, which are now in common use, afford a quick and easy method for making such applications. Six or eight compressions of the bulb of a good atomizer are sufficient to cover the fauces with the spray. Those hand-atomizers in the shops which have slender metallic points are apt to prick the buccal surface and cause bleeding if the child resist and toss the head. To prevent this, I am in the habit of directing india-rubber tubing to be drawn over the point in such a way as not to obstruct its action. The following will be found useful mixtures for the atomizer: For ordinary cases,
| Rx. | Acidi Carbolici | drachm ss, vel. Acid. Boracic. drachm ii; |
| Potass. Chlorat. | drachm ii; | |
| Glycerinæ | fl. oz. ii; | |
| Aquæ | fl. oz. vi. M. |
If the surface of the throat be covered by foul secretions,
| Rx. | Acidi Carbolici | drachm ss; |
| Potass. Chlorat. | drachm ii; | |
| Glycerinæ | fl. oz. j; | |
| Aquæ Calcis | fl. oz. vii. M. |
Or else,
| Rx. | Tinc. Ferri Chloridi | fl. oz. ss; |
| Acidi Sulphurosi | fl. drachm ii; | |
| Potass. Chlorat. | drachm ii; | |
| Glycerinæ | fl. oz. i; | |
| Aquæ q. s. ad. | fl. oz. vi. M. |
If diphtheritic exudation complicate the scarlatinous angina, or the surface of the throat in consequence of ulceration or necrosis present an appearance like that in diphtheria when the exudation begins to soften, being foul, jagged, of a dirty brown appearance from dead matter and fetid secretions, the following should be prescribed for use in the atomizer:
| Rx. | Acidi Carbolici | drachm i, vel. Acidi Boracici drachm iii; |
| Liq. Potassæ | fl. drachm i; | |
| Potass. Chlorat. | drachm ii; | |
| Glycerinæ | fl. oz. ii; | |
| Aquæ Calcis | fl. oz. viii. M. |
Liquor potassæ, although a very efficient solvent of pseudo-membranes, is too irritating for use in the atomizer unless largely diluted. One part to eighty, as in the above mixture, will not be found too concentrated. The following powder, used every third hour through the insufflator, is also useful in cases of diphtheritic exudation:
| Rx. | Acidi Salicylici | drachm ii; |
| Bismuth. Subnitrat. | oz. ii. M. |
To be used every third hour. It is the favorite remedy of some of the prominent New York physicians in the local treatment of diphtheria.
The following mixture is also beneficial for local treatment when the faucial surface is foul and offensive from the exudations and secretions. It should be applied by a large camel's-hair pencil every three to six hours:
| Rx. | Acidi Carbolici | gtt. x; |
| Liq. Ferri Subsulphatis | fl. drachm ii; | |
| Glycerinæ | fl. oz. i. M. |
In all cases of scarlatinous pharyngitis sufficiently severe to require special treatment, cool applications should be made over the neck from ear to ear, as by two thicknesses of muslin frequently squeezed out of cold water, or by the elongated india-rubber bag already recommended in our remarks relating to methods to reduce temperature.
In the first days of scarlet fever the coryza is slight, and no discharge from the nostrils occurs, so that no local treatment is required; but before the termination of the malady, in cases of ordinary gravity, a nasal discharge usually supervenes, producing more or less redness and excoriating the upper lip. Moreover, in localities where diphtheria occurs, if this malady complicate scarlet fever, it is apt to affect the nostrils at the same time that the fauces are invaded. These conditions require local treatment of the nares. It should be remembered that the Schneiderian membrane is midway in sensitiveness, as it is in location, between the conjunctival and buccal surfaces, and is readily irritated by strong applications. Medicinal applications made to it must be much milder than those which the fauces tolerate. They should always be applied warm, and a teaspoonful of any mixture properly employed is sufficient for each nostril at one sitting. The applications should usually be made every two or four hours, according to the gravity of the case and the amount of discharge. The best instrument for this purpose is a small syringe of glass or brass with curved neck and bulbous tip. The child's head should be thrown back and the piston depressed rapidly, so as to thoroughly wash out the nasal cavity. The application can also be made through an atomizer with a rounded tip or a tip covered by rubber tubing. The following is a useful prescription:
| Rx. | Acidi Carbolici | drachm ss; |
| Sodii Chloridi | drachm ii; | |
| Aquæ | Oj. |
The substitution of 2 or 3 drachms of boracic acid in place of the carbolic acid makes a nicer preparation. If the diphtheritic pseudo-membrane appear in the nares, the officinal lime-water, injected every hour or second hour, is beneficial in consequence of its solvent action on pseudo-membranes.
It is evident, from what has been stated above, that the condition of the ear should be closely observed in and after scarlet fever. If the patient have earache, considerable relief may be obtained in the commencement by dropping a few drops of laudanum and sweet oil into the ear and covering it by some hot application, either dry or moist, which will retain the heat. A light bag containing common table-salt, heated, or dry and hot chamomile flowers will also answer the purpose. Water as hot as can be well tolerated dropped into the ear or allowed to trickle from a fountain syringe, so as to fill the ear, is also very beneficial in allaying the pain. If a few drops of laudanum be added it is more useful. If the pain be not quickly relieved, a leech should be applied at the base of the tragus. O. D. Pomeroy, an experienced aurist of New York, says: "Leeching employed at the right time rarely fails to subdue the pain and inflammation. The posterior face of the tragus is ordinarily the best place for applying the leech, but it may be applied in front of the ear or behind, wherever the tenderness on pressure is greatest. In my opinion, paracentesis may frequently be rendered unnecessary by the timely use of one or two leeches applied to the meatus."
If the otitis continue, as shown by pain in the ear, of which children old enough to speak bitterly complain, and which causes those too young to speak to press their fingers into or against their ears, this inflammation should not be neglected, as it may involve serious consequences. Multitudes of children have had permanent impairment or even loss of hearing, with caries or necrosis of the walls of the middle ear and of the mastoid cells, which might have been prevented by prompt and skilful management of the ear in the early stage of the inflammation. If, therefore, the otitis continue without mitigation of pain after the above measures have been employed, paracentesis of the drumhead is probably required. The following directions for performing this operation, which will be useful to country practitioners who may not be able to obtain the assistance of a specialist, are from the pen of Pomeroy: "The forehead mirror should be worn, in order to leave the hands free to operate by either artificial or day light. A good-sized speculum is introduced into the meatus. Then an ordinary broad needle, about one line in diameter, with a shank of about two inches, such as oculists use for puncturing the cornea, should be held between the thumb and fingers, lightly pressed, so as not to dull delicate tactile sensibility. The part being well under light, the most bulging portion of the membrane should be lightly and quickly punctured with a very slight amount of force. The posterior and superior portion of the membrane is most likely to bulge. The chordæ tympani nerve ordinarily lies too high up to be wounded. The ossicles are avoided by selecting a posterior portion of the membrane. After puncture the ear should be inflated by an ear-bag whose nozzle is inserted into a nostril, both nostrils being closed, so as to force the fluid from the tympanum. The puncture may need to be repeated at intervals of a day or two, provided that the pain and bulging return."
Albert H. Buck of New York, in a highly instructive paper read before the International Medical Congress in 1876, writes as follows of paracentesis of the membrana tympani in scarlatinous otitis: "In this one slight operation, which in itself is neither dangerous nor very painful, lies the power to prevent the whole train of disagreeable and dangerous symptoms." Buck relates an instructive example: The age of the patient was three years, and the earache had been complained of only about twenty-four hours. "Toward morning," says he, "I was sent for, as the pain had become constant.... An examination with the speculum and reflected light showed an oedematous and bulging membrana tympani (posterior half), the neighboring parts being very red, though as yet but little swollen. In the most prominent portion of the membrane I made an incision scarcely three millimetres (one-tenth inch) in length, and involving simply the different layers of the membrana tympani. This was almost immediately followed by a watery discharge (without the aid of inflation), which ran down over the child's cheek. At the end of three or four minutes the child had ceased crying, and in less than a quarter of an hour she was fast asleep. At first, the discharge was very abundant and mainly watery in character, but it steadily diminished in quantity and became thicker, till finally, on the fourth day, it ceased altogether. On the tenth day the most careful examination of the ear could not detect any trace of either the inflammation or the artificial opening." The ear had probably been saved from ulceration of the drum membrane, long-continued suppurative otitis, and perhaps from permanent impairment of hearing.
When an opening has been made in the membrana tympani either by incision or ulceration, it is advisable in some instances to inflate the tympanum by Politzer's method, which has been alluded to above. The nozzle of an india-rubber bag, with a flexible tube attached, is introduced into the nostril on the affected side, and both nostrils are compressed against it. The patient fills his mouth with water, which he swallows at a given signal, as after the words one, two, three, spoken by the operator. During the act of swallowing, which opens the Eustachian tube, the rubber bag is forcibly compressed, which forces the air along the tube into the middle ear and facilitates the escape of the pent-up secretions in the tympanic cavity.
If the otitis have continued unchecked by treatment until the secretions within it, after days and nights of suffering, have escaped by ulceration through the drumhead, the opportunity for prompt and certain cure is passed. Still, the patient under these circumstances may quickly recover, or there may be the other alternative described above, in which the ear is badly damaged and chronic inflammation established in the walls of the tympanum, giving rise to an offensive otorrhoea. In this state of the ear internal remedies are indicated, such as surgeons employ in suppurative inflammations of bone occurring in other parts of the system. Cod-liver oil and iodide of iron are required, especially by patients of strumous diathesis, the object being to promote a more healthy state of system, so as to prevent extension of the inflammation and facilitate the healing process. Carbolized solutions, as the following, syringed warm into the ear in which otorrhoea is occurring, are useful in promoting cleanliness and increasing the comfort of the patient:
| Rx. | Acidi Carbolici | drachm ss; |
| Glycerinæ | fl. oz. ii; | |
| Aquæ | fl. oz. iv. M. |
But recently a much more effectual curative agent for local treatment has been discovered in boracic acid, by the use of which the discharge more quickly diminishes and the condition of the ear more certainly and rapidly improves than by the use of the carbolized mixtures. When the inflammation is recent and the ear sensitive and painful, the following prescription should be used:
| Rx. | Acidi Boracici | drachm iiss; |
| Morphiæ Sulphat. | gr. i; | |
| Glycerinæ | ||
| Aquæ aa. | fl. oz. i. M. |
S. Drop one to three drops into the ear three times daily.
If the acute stage of the otitis have passed, with fever and pain, and no tenderness be present on pressure, the following prescription, which causes too much pain in the acute stage, will be found useful to check the inflammation and otorrhoea and restore a healthy state to the granulating surface:
| Rx. | Acidi Boracici | drachm iiss; |
| Alcohol. | ||
| Aquæ aa. | fl. oz. i. |
S. Drop one to three drops into the ear three times daily.
The beneficial effects observed from the use of boracic acid in aural surgery have given it nearly the same position as a curative agent to diseases of the ear which atropine holds to diseases of the eye. Recently, aurists are employing finely-triturated powder of boracic acid dusted into the ear. The patient lies upon the side with the affected ear uppermost. The ear is thoroughly cleaned by syringing with tepid water, and by means of a little scoop made of stiff paper or pasteboard or the segment of quill as much of the powder is introduced into the ear as would cover a five-cent silver piece. By working the ear it descends to the drumhead. I can bear witness to its efficacy in the otorrhoea of children when it is used in this manner three times daily.
The following astringent has also been employed with good results for the otorrhoea resulting from scarlet fever as well as from other causes:
| Rx. | Zinci Sulphatis, | |
| Aluminis aa. | gr. v; | |
| Aquæ | fl. oz. i. M. |
A few drops of this should be dropped into the ear, or, if the ear be sensitive and painful, five drops should be added to a teaspoonful of warm water and dropped or syringed into the ear.
But in recent times aurists have discovered a remedy superior to the above in iodoform, the action of which is safe and efficient for protracted otorrhoea with granulations, and it is superseding to a great extent the agents heretofore used in the treatment of this disease. The ear should first be thoroughly cleaned by syringing with warm water and dried, and iodoform, to which a little balsam of Peru is added to cover the disagreeable odor, should be pressed down to the bottom of the auditory canal by any convenient instrument. It is anodyne, astringent, and disinfectant, and should be employed in a dry state in considerable quantity.
The sequelæ of otitis media, such as granulations sprouting out from the drumhead, some of which may be of large size and are known as polypi, may require treatment by the aurist. A polypus may sometimes be removal by the forceps or better by the snare. Polypi not large and favorably located can sometimes be cured by an astringent powder, as iodoform, sulphate of zinc, or alum, or by applying the liquid subsulphate of iron. The otitis externa produced by the irritating discharge which flows from the middle ear soon disappears when the flow ceases.
The renal affection, which, as we have seen, so often commences in the declining period of scarlet fever or during convalescence in mild as well as severe cases, is frequently more dangerous than the primary disease. It largely increases the percentage of deaths. A clear appreciation of its therapeutic requirements is important, since by judicious treatment many recover who would inevitably be sacrificed by improper measures. The family should be informed that the danger from scarlet fever does not cease with the decline of the eruption, and that the kidneys may become seriously affected by too early exposure of the patient to currents of air or sudden changes of temperature, by which cutaneous transpiration is checked. He should therefore be kept indoors in a comfortable and uniform temperature three or four weeks after the termination of the fever, until desquamation has entirely ceased and the new epiderm is sufficiently thick and firm to protect the surface. During the changeable temperature of the autumnal, winter, and spring months even longer confinement at home may be advisable.
The nephritis and consequent albuminuria antedate by some days the occurrence of dropsy, and a physician should never discharge a scarlatinous patient without one or more examinations of his urine. When his visits cease the nurse should be instructed to make the examinations by heat and nitric acid during the ensuing month, and if any evidence, however slight, appear that the kidneys are involved, he should be notified, in order that appropriate treatment may be immediately commenced. Early and correct treatment of the nephritis is attended by much better results than delayed treatment, and many more patients are doubtless now saved than in former times, when little attention was given to the state of the kidneys until dropsy or other prominent symptoms appeared. I have found no mother or nurse so ignorant that she could not properly employ the test of nitric acid and heat, and, if she be solicitous for the welfare of the child, she will not hesitate to carry out the directions and immediately notify the physician if the tests employed produce the least cloudiness or turbidity of the urine.
The patient as soon as nephritis commences, as shown by the state of the urine, should be put to bed in a room of warm and equable temperature (72° to 75° F.). His diet should be liquid, consisting of milk, farinaceous food, and a moderate quantity of animal broths. He may drink liquids freely, especially water not too cool, to which spiritus ætheris nitrosi is added. If he be prostrated by the primary disease, alcoholic stimulants should be allowed.
The indications are to relieve the hyperæmic kidneys by diaphoresis and purgation. To produce the former the patient should be immersed in a warm bath at about the temperature of the body (98° to 100°), in which, if he be quiet and comfortable, he should remain from fifteen to twenty minutes, but if restless and frightened by the water a less time, after which he should be placed in a warm bed and well covered by blankets. If perspiration result, the bath has been useful, and it may be employed in grave cases two or three times daily. If perspiration do not result, it may be produced by surrounding the body either by hot dry or moist air. Hot dry air may be produced by burning alcohol in a thin layer upon a plate under a chair upon which the patient sits while he is surrounded by a blanket, or he may be covered in bed and the hot air introduced under the bed-clothes. In New York a convenient apparatus is used for this purpose, consisting of a small sheet-iron pipe enclosed in a small box of the same material. The box is in the form of a trunk, with a handle for convenience in carrying, and the lower end of the pipe, which extends nearly to the floor, contains an alcohol lamp. Hot moist air may be produced by placing against the patient bottles of hot water surrounded by towels wrung out of water. The steam arising from them and enveloping the body and limbs produces a prompt sudorific effect. There is in use in this city, in the treatment of these and similar cases requiring diaphoresis, a convenient apparatus for generating steam. It consists of a cylinder pierced with holes for the admission of air and containing a spirit lamp, over which is a pan or pail holding a little water. The patient, nearly naked, is placed in a chair with the apparatus underneath, and is covered by a blanket, so that the steam surrounds the body. This gives rise to free perspiration, which continues after the patient is placed in bed. This treatment should be repeated one or more times daily, according to the gravity of the case.
The sudorific effect of the treatment by external warmth described above should be aided by employing diaphoretics. Those which have been most used are the acetates of ammonium and potassium, the bitartrate and citrate of potassium, and spiritus ætheris nitrosi. If employed when the surface is cool, they act rather as diuretics than diaphoretics. These agents, being simple in their action and without deleterious effects, may be given frequently and in large proportionate doses for the age.
But lately a diaphoretic which far surpasses these in efficiency has been discovered in pilocarpine, the active principle of jaborandi. Being soluble in water and tasteless, it is easily administered, and is retained when, on account of the uræmic poisoning present in scarlatinous nephritis, the stomach is irritable and other medicines, as digitalis, are rejected. Ether may be employed with it, or the amount of alcoholic stimulant may be increased at the time of its exhibition in order to guard against any depressing effect. To a child of two years one-fortieth to one-twentieth of a grain may be given every six hours by the mouth. It may also be employed hypodermically, as one-twentieth of a grain to a child of five years. It has both a diaphoretic and diuretic action, while it stimulates both the salivary and mucous secretions. According to one observer, an adult when fully under the influence of pilocarpine secretes from one pint to one quart of saliva within two hours, and Leyden reports a case of diphtheritic nephritis in which the quantity of urine rose from half a pint to five pints daily. But its most prompt and certain action is upon the sweat-glands. Hirschfelder speaks of its beneficial action in relieving various forms of dropsy, and adds: "In one morbid condition of the kidney, however, jaborandi is the remedy par excellence, and that is the acute parenchymatous nephritis which frequently follows scarlatina.... This disease heals spontaneously if the danger that threatens life from reduction of the urine and from the effusions of fluid into the cavities of the body be averted. In this disease jaborandi works wonders." I have also found it an invaluable agent when the older remedies failed and death seemed imminent. The following cases, in which the beneficial action of this agent was apparent, occurred in my practice:
Case 8.—G——, male, aged five years and six months, sickened with scarlet fever on June 2, 1882. It began with vomiting, and was attended by a degree of febrile movement which indicated an attack of rather more than the average gravity. The fauces at one time exhibited a slight exudation like that of diphtheria. In the declining stage of the malady rheumatic pain and tenderness occurred in the wrist and finger-joints, but not in those of the lower extremities. The case, however, progressed favorably, and during the convalescence my attendance ceased. On June 24th my attention was again called to the child, when the urine was found to be scanty and very albuminous. External measures, such as are described in the foregoing pages, were employed, and the infusion of digitalis with potassium acetate ordered to be given every three hours, but this medicine was for the most part vomited. The bowels were kept open by jalap and the potassium bitartrate. The urine, however, continued scanty, and on June 28th severe convulsions occurred. At this time the quantity of urine was only fl. oz. ij in twenty-four hours. The pulse in the convulsions was quick and feeble, the skin very hot, and the axillary temperature 103°. The eclampsia continued one hour, and were controlled by large and repeated doses of bromide of potassium, aided by clysters of five grains of hydrate of chloral in water. Muriate of pilocarpine was now directed to be given in doses of one-thirty-second of a grain every three hours, dissolved in cold water. This agent was not vomited, and it must have been given by the parents in their fright and anxiety in larger or more frequent doses than were directed, for on July 1st the bottle containing one grain was empty. Free diaphoresis resulted from the pilocarpine, and the quantity of urine was increased. The mother stated that the child had taken only two doses, or one-sixteenth of a grain, of pilocarpine when the diuretic effect was apparent and free diaphoresis also occurred. She also stated subsequently that the quantity of urine was larger when the pilocarpine was administered every third hour than when given at a longer interval. A flaxseed poultice on which mustard was dusted was also applied over the kidneys. On June 29th the pulse was 96, temperature 100.5°; occasional convulsive attacks occurred, which were readily controlled by enemata of hydrate of chloral. On June 30th the symptoms were all better; no more attacks of eclampsia had occurred, and the urine was more abundant and less albuminous. The mother remarked that the new medicine (pilocarpine) had settled the stomach and increased the urine. The patient continued to improve, and on July 4th the record states: "Now takes the pilocarpine, gr. 1/32, every six hours; passes urine freely since yesterday; has not vomited since he began to take the pilocarpine; pulse 106, axillary temperature 99°; is playful and takes milk freely, nearly three quarts in twenty-four hours, with some farinaceous food. Digitalis with potassium acetate is also given in occasional doses." July 6th, pulse 92, temperature 99°; perspires much, and urine nearly normal in quantity and character.
Case 9.—Mary S——, aged five years, on Dec. 22, 1882, presented the symptoms of severe nephritis. Her brother had scarlet fever two weeks previously, and she had sore throat at about the same time, but without efflorescence; pulse 98, temperature 98.5°; her urine highly albuminous, and reduced to fl. oz. iv in twenty-four hours; bowels constipated. Ordered a single dose of
| Rx. | Hydrarg. Chlor. Mitis | gr. iii; |
| Resin. Podophylli | gr. 1/6. M. |
The muriate of pilocarpine was also ordered, gr. 1/20, but the patient vomited soon after taking it. Another dose was retained, and was followed by considerable perspiration. Dec. 23d, had one stool from the powder of yesterday. Has taken five doses of pilocarpine, but vomited after three of them. The last dose was administered at 10 P.M., and the mother says she "sweat fearfully" during the night. The patient was kept warm in bed; stimulating poultices of mustard and flaxseed, one to sixteen, were constantly in use over the kidneys, and the pilocarpine was administered three or four times a day. The record for Dec. 26 states: "Took the pilocarpine four times since yesterday morning, and each dose is followed by perspiration lasting from one to one and a half hours; quantity of urine, from fl. oz. vj to fl. oz. viij daily; vomited twice yesterday, not to-day; pulse 104, temperature 97.75°; complains of frontal headache; bowels regular; has considerable salivation. The patient is warm in bed, and the flaxseed and mustard poultice over the kidneys is continued." Dec. 28th, specific gravity of urine 1019; urine still quite albuminous, and containing blood-corpuscles and granular casts, also crystals of oxalate of lime. Dec. 30th, takes gr. 1/20 pilocarpine twice daily, and occasional doses of infusion of digitalis; urine more abundant; its specific gravity 1014, slightly albuminous, and containing very few granular casts and blood-corpuscles; has lost its smoky appearance; reaction alkaline; perspiration slight; patient convalescent.
In another instance, a child of five years, from three to four weeks after scarlet fever was noticed to have anasarca of the face and extremities, with scanty and albuminous urine. One-thirty-second of a grain of muriate of pilocarpine was administered every six hours without the desired sudorific effect. It was then administered every four hours, with an increase of perspiration and urination, so that the nephritic symptoms were relieved and the patient apparently out of danger within three or four days.
In a fourth patient, a girl of three years, having scarlatinous nephritis, with symptoms very similar to those in the last case, the administration of one-twentieth grain doses of pilocarpine in conjunction with the hot-air bath, was followed by increased perspiration and urination, and progressive and rather rapid convalescence. This child had been taking bichloride of mercury in one-fiftieth grain doses, prescribed by a homoeopathic physician, without appreciable benefit. It had been for the most part vomited.
Given, as in the above cases, in moderate doses and with sufficient interval, pilocarpine has never in my practice had any deleterious effect, and I regard it as a very important addition to the remedies for the relief of scarlatinous nephritis. It is apparently the most useful and important diaphoretic for this disease which we possess.
Cathartics, especially those of a hydragogue nature, are also very beneficial. Their action is more certain than that of most diaphoretics and diuretics, and their employment is imperatively required in severe or dangerous cases in which it is necessary to remove as soon as possible the serum or urea which endangers life. Young children or those with delicate stomach, and those much enfeebled by the primary disease, may take magnesia, either the citrate or the calcined. A good cathartic for ordinary cases is a mixture of jalap and potassium bitartrate, the pulvis jalapæ compositus, consisting of one part of jalap and two of cream of tartar. Ten grains of the mixture may be given to a child of five years, and repeated according to circumstances. Its effect is increased by dissolving a teaspoonful of potassium bitartrate in a gobletful of water, and allowing the patient to drink from it. The following is a good cathartic in some instances, especially if the stomach be irritable, so that the more bulky and nauseating cathartics are rejected. Care should be taken to obtain a good article, as some of the podophyllin of the shops is not reliable:
| Rx. | Resinæ Podophylli | gr. j; |
| Sacchari | scruple j. M. | |
| Ft. in chart. | No. v.-x. |
S. Give one powder, and repeat according to circumstances.
In the treatment of one of the cases reported above it will be recollected that the mild chloride of mercury mite was given with the podophyllin, with a good result.
After the use of laxative agents the kidneys, being less congested on account of the diversion that has occurred, often begin to excrete urine more freely. But if the patient be anæmic or enfeebled and the symptoms are not urgent, it is frequently better to avoid active catharsis, which more or less reduces the strength, and employ remedies of a sustaining character, as in the following case, which occurred in my practice: A little boy, pallid and scrofulous, began to have anasarca after scarlet fever, chiefly in the scrotum, accompanied by a moderate degree of ascites. The urine, which was passed in nearly the normal quantity, contained albumen, but not in large amount. This patient gradually and fully recovered, with no treatment except the use of an oil-silk jacket over the kidneys and abdomen to promote diaphoresis, and the use of iron. Such a patient, treated by the powerful eliminatives which we employ for the more urgent and robust cases, would probably have been injured rather than benefited. No treatment can therefore be recommended in a treatise on scarlatinous nephritis which will be strictly applicable for all cases. Variations are demanded according to the state of the patient and the form and gravity of the disease.
Diuretics which do not stimulate the kidneys are proper at an early as well as late period of the renal malady, and digitalis is the one usually prescribed. I do not hesitate to order it from the first day in combination with the acetate of potassium. One teaspoonful of the infusion may be given every third hour to a child of five years. The following formula is for one of this age in good general condition:
| Rx. | Potass. Acetatis | oz. ss; |
| Infus. Digitalis | fl. oz. vi. M. |
The following formulæ are recommended by Meigs and Pepper:
| Rx. | Potass. Bitart. | drachm i; |
| Spt. Junip. Comp. | fl. drachm ii; | |
| Spt. Æther. Nitros. | fl. drachm i; | |
| Tr. Digitalis, | minim xv; | |
| Syrupi | fl. drachm v; | |
| Aquæ | fl oz. ii. M. |
Dose one teaspoonful every two hours to a child of two to four years.
| Rx. | Potass. Acetat. | drachm i; |
| Tr. Digitalis | fl. drachm ss; | |
| Syr. Scillæ, | fl. drachm i-ii; | |
| Syr. Zingib. | fl. drachm v; | |
| Aquæ q. s. ad | fl. oz. iii. M. |
Dose, a teaspoonful every two or three hours to children two or three years old.
Local treatment is important. L. Thomas, Romberg, and others recommend the application of leeches, three or more, over the kidneys. Thomas says: "In many cases the abstraction of blood causes immediate and permanent relief; the fever and the pain in the region of the kidneys cease, the secretion of urine becomes augmented, the albuminuria lessens from day to day, and the moderate degree of dropsy that has been developed disappears." It is only in the more robust children, who have been but little reduced by the primary disease, that leeching is, in my opinion, admissible. In the majority of cases instead of depletion a poultice slightly irritating, so as to cause redness of the skin, should be applied over the kidneys, or for older children, not likely to be frightened by the process, the dry cups may be applied daily. In subacute cases, not attended by any alarming symptoms, sufficient redness may be produced by one of the irritating plasters which the shops contain, constantly worn.
Eclampsia, described in the preceding pages, is produced, as we have seen, during the course of scarlet fever by the irritating effect of the scarlatinous poison upon the nervous centres, but, occurring after the decline of scarlet fever, it is ordinarily produced by the retained urea. The same remedies are required to control the convulsive movements as when they occur under other circumstances. The bromide of potassium should be immediately administered in large and frequent doses whenever eclamptic symptoms arise. During eclampsia a child of three years should take five grains of this agent every five to ten minutes till the attack ceases, and then at longer intervals. The hydrate of chloral is a more powerful agent, and if the eclampsia be not quickly controlled, I commonly employ it per rectum, dissolved in one or two teaspoonfuls of water. For a child of three to five years five grains should be thrown into the rectum by a small glass or gutta-percha syringe, and retained by pressure. Properly administered and retained, it rarely fails to control the eclampsia within ten or fifteen minutes. Subsequently, occasional doses of the bromide should be given to prevent the occurrence of eclampsia while the measures described above are being employed to relieve the uræmic condition.
Rheumatism, endocarditis, and pericarditis, arising as complications or sequelæ, require the treatment which is appropriate when they occur under other circumstances, but the remedies should not be depressing, as the system is already enfeebled by the primary disease. The rheumatism, if mild, usually abates in a few days without medication, and the affected joints require only some soothing lotion and support by a bandage. The following liniment may be applied upon muslin and covered by cotton wadding:
| Rx. | Acid. Carbolici | fl. drachm i; |
| Tinc. Belladonna | fl. oz. i; | |
| Ol. Camphorati | fl. oz. ii; |
If the rheumatism be severe and affect several joints, the sodium salicylate should be prescribed, as in the idiopathic disease, with an occasional opiate to procure rest.
Endocarditis and pericarditis require rest in the horizontal position, avoidance of all excitement, the use of the tincture or infusion of digitalis or of the fluid extract of convalaria to procure a slow and steady action of the heart. Three drops of the tincture of digitalis or five minims of the fluid extract of convalaria may be given every four hours to a child of five years. The same external measures should be employed as in acute pleuritis. I prefer the application of a thin poultice of flaxseed containing one-sixteenth part of mustard and covered with oiled silk. The cardiac inflammations, as well as rheumatism, require opiates in sufficient doses to procure rest and sleep.
Pleuritis, which we have stated is apt to be suppurative, demands the same treatment as the idiopathic disease when it occurs in cachectic patients.
RUBEOLA.1
BY W. A. HARDAWAY, M.D.
1 In the preparation of this article the writer has consulted the following works: Thomas, in Ziemssen's Cyclop. Pract. Med., vol. ii., N.Y., 1875, Am. edit.; Bohn, in Gerhardt's Handbuch der Kinderkrankh., Zweiter Band, Tübingen, 1877; Squire, in Quain's Dict. Med., N.Y., 1883; Ringer, in Reynolds's System Med., vol. i., Phila., 1879; Meigs and Pepper, Dis. of Children, Phila., 1882; J. Lewis Smith, Dis. of Children, Phila., 1882; Hebra, Dis. of Skin, London. 1866; Vogel, Dis. of Children, N.Y., 1871; Niemeyer, Handbook of Pract. Med., N.Y., 1869; Trousseau, Clinical Med., Phila., 1871. Other references will be found in the foot-notes to the text.
SYNONYMS.—Rubeola, Morbilli, Measles, Masern, Flecken, Rougeole.
DEFINITION.—Measles is an acute infectious disease involving the skin and mucous membranes, characterized by successive stages and a maculo-papular eruption, which terminates in a fine branny desquamation. In normal cases it runs a definite course, which from the date of invasion to the end of desquamation occupies about fourteen days. It is highly contagious, and occurs, as a rule, but once in the same person.
HISTORY.—The word rubeola is probably of Spanish origin and was formerly written rubiola or rubiolo. The designation morbilli is the diminutive of the Italian il morbo, the plague. Although it is doubtful, as claimed by Willan, that the Greek and Roman physicians were acquainted with measles, there is no question that Rhazes was one of the first to describe the affection correctly. Rubeola is said to have been distinguished from variola by the Arabians in the twelfth century; but, nevertheless, as late as the middle of the seventeenth century we find Sennertus discussing the question "why the disease in some constitutions assumed the form of small-pox, and in others that of measles;" and in a posthumous work of Diemerbroeck, published in 1687, it is asserted that small-pox and measles are only different degrees of the same affection.2 According to Mayr, the merit of having shown measles to be a distinct malady from scarlatina must be ascribed to Forestus and Sydenham. It is not clear, however, that the two diseases were accurately differentiated till the close of the last century, and notably by Withering in 1792.
2 Cyclop. Pract. Med., London, 1834, p. 625.
ETIOLOGY.—The exact nature of the measles contagium has never been satisfactorily established, although we are in possession of numerous researches in that direction, which, however, are to a great extent contradictory. A brief examination of these various observations will not prove uninteresting. Hallier found in the blood and sputa numbers of free cocci, which fructified upon various substrata, but was invariably the same fungus—mucor mucedo verus, Fres. In 1862, Salisbury3 published his observations on the relation of the straw fungus to measles. He recorded instances of inoculation with this organism that resulted, according to him, in the production of a modified form of rubeola, and, moreover, was protective against further attacks of the same disease. In an exhaustive paper bearing on this question H. C. Wood4 quotes certain experimental inoculations made by William Pepper, which showed conclusively that measles was not propagated in this way, and that where any symptoms were developed they were not those of true measles, nor did they protect the subjects from unquestioned measles. Salisbury also claimed that measles had occurred in camps where damp and mouldy straw had been employed for bedding. J. J. Woodward in his work on Camp Diseases points out that camp measles prevailed almost exclusively in regiments from the rural districts, while men enlisted in towns and cities were more or less completely exempt. The explanation was, that those from the country had hitherto escaped the disease, while townspeople had suffered from it at some previous time—a condition of affairs inconsistent with the theory of the straw fungus. Coxe and Felz found numerous bacteria in the blood of measles patients, especially in regions where the eruption was most pronounced. The nasal mucus also contained similar germs. Inoculation of the blood from the subjects of measles upon rabbits did not produce an analogous affection (Thomas). Klebs5 obtained micrococci from the trachea and from blood taken from the hearts of infant cadavers. "In the latter, collected in flattened capillary tubes, there developed balls of micrococci; in the trachea both micrococci and bacteria were present in large quantities. Under observation, pale, finely-granular micrococcus balls developed and changed very quickly to bacteria, which moved about very actively. These sought the periphery, about ½ mm. distant from the centre of development, and formed a zone, comparable with a hedge or fence that is composed of rods. From this were formed new masses of micrococci, but further no regular process of arrangement or development could be observed."
3 Am. Jour. Med. Sci., July and Oct., 1862.
4 Ibid., Oct., 1868, p. 333.
5 Würzbr. Verh., N. F., v., 1874, quoted by Forchheimer in Supplement to Ziemssen's Cyclopedia, W. T., 1881, p. 102.
Braidwood and Vacher,6 as the result of a number of experiments, believed that they had sufficient evidence for concluding that the most active mode of the transmission of measles was through the breath, and accordingly instituted a series of experiments by carefully examining the breath of children in the acute stage of the disease.7 With this object in view they coated over with glycerine the inside of several clean glass tubes of a diameter of a half to three-quarters of an inch. As soon as the nature of the eruption was manifest the patient was required to breathe through one or more of the tubes, and so on each day till the eruption had faded. Upon examination of the glycerine with an one-eighth objective every specimen showed numerous sparkling bodies, something like those found in vaccine, but larger. Some were spherical; others were elongated, with sharpened ends. They were most abundant during the first and second days of the eruption. Healthy children and patients suffering from typhoid and scarlet fevers were made to imitate these experiments, but no such bodies were to be seen in their specimens. They conclude from these observations that the small spherical elements discovered in the breath are perhaps the active agents in the propagation of measles. Upon post-mortem of patients who had died of rubeola these germs were found in the lungs and liver, and, particularly, close to the walls of the capillaries. They believe that the "lungs are the favorite breeding-ground of the contagium."
6 Brit. Med. Jour., Jan. 21, 1882.
7 Several years ago Ransome of Manchester obtained particles from the breath of two persons suffering from measles (Squire).
That inoculation of morbillous blood may convey the disease was first demonstrated by Home in 1757, which experiments were verified by Speranza in 1822 and by Katona in 1842. The inoculations of the latter are especially noteworthy, as they numbered more than a thousand. No person inoculated by him died, and only 7 per cent. of the inoculations failed. On the other hand, inoculations made by Mayr gave negative results. It is stated that Monro and Locke communicated measles by inoculating with the tears and saliva. Attempts of the same kind were fruitlessly made in Philadelphia in 1801, although the blood, the tears, the nasal and bronchial mucus, and the exfoliated lamellæ of the epidermis were successively employed in the trials.8
8 Rayer, Diseases of the Skin, Phila., 1845.
Mayr has shown that the nasal mucus is capable upon inoculation of propagating the disease. He performed the experiment upon two healthy children living at a distance from each other, at a time when the disease had ceased to be epidemic. Some nasal mucus taken from the patient during the stadium flavitionis, and kept fluid in a glass tube, was the same day placed upon the mucous membrane of each of these children. In one of them the first symptom of sneezing occurred after eight days, in the other at the expiration of nine days. Febrile symptoms set in two days later. In each child the rash appeared on the thirteenth day after infection. The inoculated disease was mild and regular in its course.
While it is perhaps true that the contagion of measles is not so tenacious as that of small-pox and scarlatina, it is a matter of observation that susceptible persons are liable to contract the disease, even if not directly exposed to its influence. There is incontestable evidence that it is conveyed by fomites—a fact well worth bearing in mind.
It is but just to say that so excellent an observer as Mayr taught that measles could not be conveyed by clothes, linen, etc. unless transferred immediately from one individual to another. Panum, however, showed that contagion could be carried many miles by an unaffected third person without losing its activity. Aitken9 has also pointed out the fact that children's clothes sent home in boxes from schools where the disease has raged communicated the disease, and that susceptible children who had slept in the same beds, in the same rooms, after they had been occupied by persons suffering from measles, have taken the malady. Squire observes that the contagium of measles, except in the catarrhal stage, is not far diffusible in the air, but clings to surfaces, and may be thus carried from place to place; on the other hand, children have been brought, while in full eruption, into a house among others, and nursed in a room apart, without any extension of the disease to the most susceptible.
9 Science and Pract. of Med., Phila., 1868.
Various circumstances render it probable that measles is most readily propagated during the stage of efflorescence; but that it is also highly infectious during the prodromal period is now universally acknowledged.
According to Niemeyer, the probability of infection during the prodromal stage is supported by the wonderful spread of measles through schools; for, while the strictest surveillance is established over children with any suspicious eruptions, and those known to have had the disease are not allowed to return till long past the stage of desquamation, no heed is paid to those exhibiting the premonitory cough and coryza. There is no reason for believing that measles can be propagated during the period of incubation; on the other hand, there is no satisfactory argument for the denial of its infectiousness in the desquamative stage. Although Panum is inclined to doubt its contagiousness at this time—and his observations are worthy of the greatest confidence—other good authorities differ from him materially, and extend the stage of personal infection to a period of from three weeks (Squire) to forty days (Hillairet).
Reasoning from analogy, we would naturally expect that the period of incubation in measles suffered a certain amount of variation; the result of numerous observations confirms this expectation. It is manifestly a difficult matter in densely populated communities to establish with accuracy the date of a given infection, but from a study of more or less carefully noted cases it will be found that the period of incubation may vary from three to thirty days. For the vast majority of cases the average time between the reception of the measles poison and the appearance of the characteristic eruption will be about from thirteen to fourteen days. Panum, under exceptionally favorable surroundings, found it more frequently fourteen than thirteen days. Therefore, deducting the three or four days occupied by the invasion stage, we shall find that the real incubation period is from nine to ten days from the date of exposure. Mayr's two cases of inoculation with nasal mucus showed no departure from this rule, but in the inoculations made by Katona with blood the prodromic symptoms made their appearance in seven days, the cutaneous lesions developing two, and at the most three, days afterward.
Minor epidemics of measles are said to occur every three to five years, more extensive and severe ones every seven or eight years. In the centres of population measles may be said to be endemic; in isolated regions the visitations of the disease may be widely separated. Measles is a less severe disease in warm than in cold climates, and, as a rule, we also find the affection more common and more intense in the fall, winter, and spring than in the summer months.10 Epidemics of measles are usually short, and it is thought that there is a definite relation between the severity of their onset and their duration, this being in general short in proportion as the given epidemic was at first severe (Mayr). Intestinal complications are more frequent in summer, and involvements of the respiratory organs more common in winter. The varying aspects of different epidemics—sthenic, asthenic, etc.—depend on changes in the weather, season of the year, the presence of complications, and other agencies not very clearly understood. Epidemics of whooping cough may precede, accompany, or follow in the wake of measles, and it has therefore been suggested that it stands in some peculiarly close connection with the latter; but, aside from this often-observed coincidence, we are not justified in our present state of knowledge in assuming any definite relation of cause and effect between the two diseases.
10 Aitken (op. cit., p. 295) declares that the mortality returns from England and Wales show that the influence of season is most trifling. Occasionally it has been found that the deaths in summer exceeded those in winter, but we believe that the statement made above is, in the main, correct. For instance, Parson's figures for Berlin for the years 1863-67, inclusive, are: spring, 11.9 per cent.; summer, 13.3; autumn, 33.4; winter, 41.4. Voit's statistics in an average of thirty years at the Children's Clinic at Würzburg establish the same general principles (Thomas).
There would seem to be neither geographical nor racial bar to the propagation of measles, for it has been observed in all countries and among all peoples. As in the case of other zymotic diseases, a tolerance is established for measles in countries where the disease is more or less constantly prevalent; but where the affection becomes epidemic for the first time, or reappears after many years, it rages with terrific violence. This fact was particularly exemplified in the epidemic in the Faroe Islands, and more especially in the recent (1877) visitation of the Fiji Islands, where one-fourth of the population succumbed in a comparatively short time.
It is quite probable, as asserted by Mayr, that children affected with scrofulous complaints, as well as those who are the subjects of diseases of the respiratory organs—pertussis, bronchitis, or tuberculosis—are eminently susceptible of measles; but his statement that sufferers from epilepsy, chorea, and paralysis exhibit an unusual power of resistance cannot be accepted without reservation. Acute diseases often appear to delay the outbreak of measles, so that the latter does not appear till convalescence from the former (Thomas). The development of vaccinia is occasionally interfered with by an attack of rubeola; on the other hand, the two diseases may be seen running their courses together.11 The emphatic statement made by Hebra, that measles is never seen to occupy a patient simultaneously with another acute exanthem, has not been confirmed by other observers. My own experience furnishes several examples. Measles may also occur during the course of other acute or chronic maladies. From a study of the literature of measles complicating pregnancy and parturition Underhill12 finds it to be quite uncommon, due probably to the fact that most adults are insusceptible of further attacks; but when it does occur in pregnancy he regards it as a very serious and frequently fatal complication. Underhill believes measles to be most fatal when it supervenes soon after delivery, while those who are confined during the course of the malady stand a better chance of recovering from it. That puerperal women are not always unfavorably affected by measles is well shown in two remarkable cases reported by Nelson13 of St. Louis and Chantier14 of Geneva, in which the mothers were safely delivered, though suffering from measles contracted at the end of their pregnancies.
11 Hardaway, Essentials of Vaccination, p. 60.
12 Obstet. Jour. Great Britain and Ireland, July, 1880.
13 St. Louis Courier of Med., Sept., 1879.
14 Annales de Gynécologie, May, 1879.
All ages are susceptible to the measles poison, and the apparent exemption enjoyed by adults is due to the fact that most grown-up people have already suffered the disease in childhood; but in Panum's epidemic, mentioned above, it was discovered that nearly all who had not had measles elsewhere, or were not old enough to have been exposed at the last visitation, sixty-five years before, acquired the affection regardless of age. It is quite probable, however, that the law of decrease of susceptibility with age holds good for measles as well as for variola, etc., but to a less degree. It will therefore be seen that measles is not essentially a disease of childhood. Although there is no special limit to the susceptibility of rubeola at one extreme of life, it would seem to be quite well established that it is much modified at the other—namely, that infants under six months are rarely attacked. This latter fact is conceded by individual experience, by the records of epidemics, and by the testimony of most observers.15
15 On the other hand, as quoted by Forchheimer (loc. cit.), H. C. Fox publishes some tables which show that for England and London a much larger number of young children are attacked by measles than other statistics would lead us to believe.
| England. | London. | |||
| Males. | Females. | Males. | Females. | |
| Under one year | 3022 | 2530 | 3571 | 2987 |
| One and under two years | 6086 | 5825 | 8630 | 8050 |
| Two and under three years | 3178 | 3255 | 4683 | 4757 |
| Three and under four years | 1730 | 1851 | 2594 | 2620 |
| Four and under five years | 980 | 1028 | 1358 | 1466 |
| Five and under ten years | 255 | 278 | 301 | 316 |
| Ten and under fifteen years | 29 | 38 | 24 | 32 |
| Fifteen and under twenty years | 9 | 13 | 9 | 11 |
| Twenty and under twenty-five years | 7 | 9 | 5 | 7 |
| Twenty-five and under thirty-five years | 5 | 8 | 5 | 7 |
| Thirty-five and under forty-five years | 3 | 5 | 2 | 3 |
Even sucklings do not enjoy a complete immunity from measles. Steiner16 states that he has met with it in children only four or five weeks old. Monti has recorded ten cases of rubeola in children under two months of age. A case is reported by Kunze where a mother in the stage of efflorescence gave birth to a child, which contracted the disease five days afterward. Quite a number of cases of congenital measles have been put on record from time to time; but Thomas, after a careful investigation, says that he has been able to discover but six authentic accounts of such occurrences.17 That children born to mothers suffering at the time of parturition from measles may yet escape it themselves is proven by the cases of Nelson and Gautier mentioned above. Whether a pregnant woman attacked by measles transmits the disease to the foetus in utero, thereby securing immunity from it in after life, is a question difficult of decision, especially as we have not yet been able to decide this same inquiry, with infinitely better opportunities, for vaccinia.18
16 Compendium of Children's Diseases, N.Y., 1875, p. 396.
17 I believe that, under certain circumstances, the erythema papulatum of the new-born is often mistaken for measles.
18 See experiments of Burckhardt, Rickett, Gart, and others, quoted in Hardaway's Essentials of Vaccination, p. 38.
There is no good reason to believe that sex is of much importance in establishing a predisposition to measles, although the statement has been repeatedly made that males are more frequently attacked than females. Fox's statistics show a slight preponderance in favor of the male sex; but a careful examination of accessible statistics proves, as would be expected, that this degree of susceptibility varies at different times in obedience to circumstances not readily understood.
By the older writers (Willan, Rosenstein, Fuchs) it was very dogmatically asserted that one attack of measles completely extinguished all future susceptibility to the disease. Of late years this dogma has met with much opposition, and numerous observations have been recorded which, if entirely trustworthy, would lead us to believe that rubeola may occur not only twice, but several times, in the same individual. While from analogy and actual experience we are quite sure that the recurrence of measles is not so uncommon an event as it was once held to be, a closer examination of the question in all its bearings clearly confirms us in the belief that subsequent attacks are much more infrequent than is now thought to be the case by many, and that other diseases, more or less resembling true measles, are largely responsible for errors of diagnosis in this regard. Panum found that all the old people who had measles during the epidemic on the Faroe Islands in 1781 escaped it in 1846. Both Rosenstein and Willan declared that they had never witnessed an instance of the true recurrence of measles. Among other facts, it may be stated in this connection that Woodward (loc. cit.) has shown that during our late war, while members of regiments recruited from the rural districts, who had never before had measles, largely took it when exposed to its influence, regiments from the cities, who had presumably acquired the disease in childhood, remained almost entirely exempt.19 Other arguments of a similar sort could be readily adduced. There is no question that mistakes in diagnosis have occurred from confounding rötheln, roseola, etc., which closely simulate measles, with that disease. Those particularly engaged in the treatment of cutaneous affections could multiply instances of such errors. It is quite significant that for certain analogous infectious diseases—e.g. variola and scarlatina—the same frequency of recurrence is not claimed, although as a matter of fact they do occur. The explanation would seem to lie in the fact that neither small-pox nor scarlet fever is so closely counterfeited by other skin affections, notably by rötheln, as is measles. But it would be entirely contrary to analogy and indubitable experience to go to the extreme of the older writers and absolutely deny the possibility of second, and even third, attacks of rubeola. The frequency of such cases is, however, as Henoch20 truly states, much overestimated.
19 These observations of Woodward were made without any reference to the question at issue.
20 Lectures on Diseases of Children, N.Y., 1882, p. 282.
Occupying quite a different position from the measles induced by reinfection from without are the so-called relapses of rubeola. These relapses, which may occur in from two to four weeks after the original invasion, are analogous to the similar occurrences in scarlatina and typhoid fever. I am cognizant of but a single case of this sort, but Steiner and other accurate observers record a number of such instances.
SYMPTOMS AND COURSE.—It is generally stated that the stage of incubation exhibits no symptoms whatever; but it is undoubtedly true that the patient will sometimes appear dull and listless, and, on occasion, even give evidence of some slight and ephemeral elevations of temperature. As a rule, however, this period is devoid of any marked indication of the presence of the measles poison in the system.21
21 Some writers describe a much more marked train of symptoms as prevailing at this time than seems warranted by general experience, and Rehn has gone so far as to declare that the prodromal period, as usually understood, properly commences in the stage of incubation. Bohn is inclined to a similar view. The prodromic stage of authors is, then, to be looked upon as the "period of the mucous membrane exanthem."
The prodromal stage is usually ushered in by symptoms of general malaise, fretfulness, more or less frontal headache, shiverings, nausea, loss of appetite, excited sleep, and sometimes delirium. Vomiting is not so common in measles as in scarlatina, and may occur at any time previous to the appearance of the rash. The tongue is apt to be coated, although it may remain clean; the taste is bad, and pressure over the stomach and bowels occasionally elicits considerable pain; an aching pain over the sternum is also noted. As a general thing, at this time patients are drowsy and inclined to sleep much. Meigs and Pepper found this a very constant symptom, which they state is in no way alarming unless associated with other more serious symptoms of local or general disturbance. Constipation is present in some cases, or the bowels may be relaxed or remain in their natural state.
The prodromal fever of measles follows a peculiar course. It is remarkably remittent in character, and is rarely of such intensity as to threaten life, as is often the case in scarlet fever. The temperature will rise on the first day to 102°-104° F., and the height of the fever at this time will measurably foreshadow the character of the subsequent course. On the second day of the prodromal stage the fever suffers a marked remission, or may even entirely disappear, to again rise in the evening. Smith has observed two exacerbations in the day. Again, in some instances, after the high initiatory fever, the temperature may remain normal till just before the rash comes out (Bohn). It is this peculiar behavior of the fever, together with the fact that the child may regain its usual vivacity in the fever-free intervals, which so often misleads the physician into the diagnosis of malarial poisoning.
The most pronounced feature of this stage of the disease is, beyond all others, the catarrhal affection of the mucous membranes. The mucous membranes of the eyes, nose, mouth, and air-passages are all more or less involved, and the patient suffers in varying degrees from photophobia, coryza, hoarseness, cough, and pain in swallowing. Sneezing is frequent and annoying, and slight epistaxis is not uncommon. The cough usually appears on the first day, simultaneously with the fever. It is not very troublesome at first, but by the fourth day it becomes more frequent, assuming a hoarse, barking, paroxysmal character. Expectoration is scanty, and auscultation reveals a harsh vesicular murmur or else sibilant râles. Alarming but not dangerous attacks of false croup may come on during the night. Many observers have called attention to the red spots (papules) in the oral cavity, which make their appearance during the period of invasion. According to Bohn, usually on the second or third day from the beginning of the fever there appear upon the slightly hyperæmic mucous membrane of the soft palate, palatal arch, and uvula small or large, dark, red spots that spread to the mucous membrane of the cheeks, and sometimes to the hard palate, lips, and gums. Soon they become more defined, and are to be distinguished by shape and coloring from the membrane upon which they are situated. According to the same authority, they also afford an index to the intensity and extent of the coming cutaneous eruption. It is also stated that if the latter partakes of a hemorrhagic character, the spots on the mucous membrane may also become livid. This same punctate reddening has been demonstrated in the epiglottis, larynx, and trachea (Gerhardt), and upon the bronchi and small intestines of children who had died during this stage of the eruption. It is also to be noted on the conjunctivæ. It has been assumed that this period of this disease is not to be looked upon as the stadium prodromorum, but as the period of the "exanthem of the mucous membrane." This view of the pathology of measles seems to me most reasonable; but in whatever way we may look upon the question, the practical importance of this precutaneous eruptive stage is to be insisted upon for diagnostic purposes, just as is the analogous eruption upon the mucous membrane in small-pox.
In ordinary cases of measles we do not find such profound reaction of the nervous system as in scarlatina. I believe that convulsions in the prodromal stage are much more common than available statistics would have us believe; at least, this is my own experience. Meigs and Pepper met with convulsions but five times in 314 cases at the beginning of the eruption, while Rilliet and Barthez observed but one convulsion in 167 cases. Thomas says that convulsions are almost always absent. On the other hand, Trousseau and Bohn expressly declare that they are very common, the former stating that they occur with greater frequency than in scarlatina. I consider that convulsive seizures occurring in connection with marked catarrhal affection of the mucous membranes are very important aids in forecasting a probable attack of rubeola. Fortunately, convulsions at this stage are not very serious unless repeated or injudiciously treated.
The duration of the period of invasion in regular cases is from three to five days, with an average of about four, but in perfectly uncomplicated attacks this period may be extended to six or eight days, or even longer. But that the duration of this stage may be much shorter than the average is not sufficiently insisted upon by writers. Ringer,22 for instance, says that he had an opportunity of testing the earliest appearance of the rash in an epidemic of measles in a large public school for boys under twelve. In every case during the epidemic the rash appeared on the first day, the cases being severe, though of short duration, the temperature rising to 103° and to 104° F. In some instances the rash preceded (?) the fever. Thus, several of the boys feeling poorly, their temperature was carefully taken night and morning under the tongue, and in several cases the rash appeared in the morning about the face and collar-bone, while the temperature remained normal, and did not rise till the evening, when it ran up to 101°-103° F., and even higher. These cases certainly resemble rötheln more than measles. In two cases, which I observed under very favorable conditions, the eruption commenced to appear on the morning of the second day, and more or less similar experiences are recorded by others.
22 Handbook of Therapeutics, 6th ed., London, 1868—note to p. 26.
The skin eruption, which appears, as a rule, on the third, fourth, or fifth day of the attack, is ushered in with an increase in the general and local symptoms of the disease. It is particularly to be remarked that the fever does not subside at this time, as is the case in variola. The eruption appears first upon the face, about the cheeks and forehead, then on the chin and neck, and thence gradually overspreads the trunk, and finally reaches the extremities. When the eruption is intense no part of the body is free from it, the rash being found upon the palms and soles and upon the hairy scalp. The cutaneous lesions proper consist at first of hyperæmic spots of about a line in diameter, which gradually increase in size, until at their full development they may attain a diameter of from one-twentieth to a quarter of an inch. In the beginning they bear a very close resemblance to the sub-papular lesions of small-pox. The maculo-papules, when fully developed, are slightly elevated above the level of the skin, the elevation, however, being more appreciable to touch than sight, have a smooth velvety feel, and are so arranged as to enclose areas of healthy skin. In the individual spots we may frequently observe one or several minute, darker-colored papules, due to follicular congestion, which when more intense constitutes the morbilli papulari presently to be described. The maculæ are, as a rule, roundish, or they may be moon-shaped, or their borders may present an indented or notched appearance. Where the capillary circulation is active—on the cheeks, for example—or upon parts subjected to pressure, the eruption may become confluent; that is to say, the usually pale intervening skin becomes injected or the papules coalesce, and in this way produce a uniform redness over large single tracts of skin. This scarlatinoid rash, however, never occupies the whole surface of the body, but only limited regions, and in other situations may be detected the characteristic discrete papules of rubeola; the color is not uniform, but is broken here and there by the darker streaks and spots of the measly eruption. The rash, which disappears upon pressure to return when the pressure is removed, is of a more or less rosy red, with a tendency in some to deep red, and has occasionally a purplish hue. According to Mayr and Hebra, it is of the precise color which is obtained by adding a little yellow or brown to a red pigment.
According to the researches of Thomas, Squire, and Wunderlich, as abstracted by Seguin, the fever of the eruptive period is divided into a moderately febrile stage and the fastigium or acme. The moderately febrile stage averages thirty-six to thirty-eight hours, and is made up of one or two exacerbations of 100.4° to 102.2° F., but not quite so high as the initial fever. If there are two exacerbations, the second one is the higher; the intervening remissions are not so low as those of the prodromal stage, yet even now the norm may be noted on a single occasion. The fastigium commences early in the day or in the evening; if the rise should occur in the morning, the evening temperature rises still higher, with or without a slight remission the following morning, and the next evening attains the maximum. If the acme begins in the evening, the remission on the next morning is either absent or very slight. The greatest height of the fever in normal cases corresponds to the greatest intensity and development of the eruption. This rule is not invariable, however, for sometimes the fever is higher soon after the eruption appears, and has fallen when the exanthem has reached its highest point. The whole fastigium lasts from one and a half to two and a half days, so that the complete eruptive fever occupies from three to four and one-half days.23 The pulse in general preserves a proportionate correspondence to the temperature, and never attains the great frequency to be observed in scarlatina.
23 According to Ringer, the highest temperature reached in normal cases is 103° F. Thomas places it as high as 104° F., but states that it may go up to 105° F. without the intervention of any complication.
The general symptoms, with the exception of the fever, do not greatly differ from those common to the prodromal stage. The skin is hot and more or less swollen, particularly about the face; there are anorexia, photophobia, lachrymation, and sometimes epistaxis; the cough continues, and is generally frequent and harassing, and attended with little or no expectoration; the voice is hoarse. The tongue is coated, principally in the middle, through which the swollen papillæ protrude, while the tip and sides are red. The blotchy redness of the oral cavity is visible for some days, and finally becomes indistinguishable from the surrounding congestion. The tonsils sometimes become considerably enlarged, though suppuration must be rare. Enlargement of the glands behind the jaw and in the neck and groin are to be observed. At the outset of the eruption a profuse diarrhoea supervenes in most cases—a symptom which Trousseau rightly insists to be an essential feature of measles. This occurrence is interpreted by some writers as an evidence of the implication of the mucous membranes in the specific exanthem of the disease. This flux, which is sometimes accompanied by a little blood and tenesmus, rarely continues long, and may be succeeded by a degree of constipation. The respiration is generally somewhat accelerated, mostly in correspondence to the amount of fever present. Some degree of deafness is not uncommon, owing to the extension of inflammation along the Eustachian tubes. The urine is scanty and high colored; there is sometimes scalding in urination and vesical tenesmus, and at the acme of the fever traces of albumen may be detected.
The eruption, in fact, generally occupies the skin an average of four days, and, although this period may be shortened materially, it is less apt to be lengthened. The duration of the eruption at its maximum of development over the whole surface is about half a day, more or less, and, as a rule, corresponds with the greatest elevation of the temperature. The retrocession of the rash takes place in the order of its appearance—viz. first from the face, then from the trunk and upper parts of the extremities, and last from about the feet and hands, where, indeed, it may remain vivid, or even progress for a short time longer, after the eruption has begun to subside in other situations. Sometimes the almost faded spots will be temporarily renewed by an abnormal rise in the temperature.
With the decline of the eruption the other symptoms begin to subside. The cough loses its hacking, paroxysmal character, and becomes less and less frequent, and gradually disappears. The voice regains its normal tone, the tongue loses its fur, cleaning up in patches, and expectoration, which was absent or scanty and viscid in the beginning, increases and is free, the masses coughed up being coin-shaped and floating in a clear watery mucus—a symptom much dwelt upon by the older writers. The behavior of the temperature at this period—the stage of decline—is quite characteristic. The fall usually begins at night, and generally the next morning it has reached the norm or else fallen below it. On the other hand, the descent may be less precipitate, and the fall continues less rapidly all through the day; or there may be a slight rise again in the evening, the norm being reached the following morning. The termination by lysis—that is, slight elevations in the evening for several days—is much rarer, and while it may occur in perfectly regular cases, it should put the medical attendant on his guard against complications.
The comparatively normal course of measles portrayed in the preceding paragraphs does not always occur, but, on the contrary, the disease may depart from the more usual type in one or more particulars, either in especial stages of its progress or in the greater or less intensity of the malady as a whole.
In addition to those cases of measles where the eruptive and catarrhal symptoms are so slight as to almost escape observation, except for the existence of other cases in the same house or family, there are to be recognized two other trivial varieties of the disease—namely, measles without the catarrh, and measles without the rash.
That the eruption of measles should occur upon the skin without implication of the mucous membranes seems to be much more doubtful than that the catarrh should appear without the eruption. It is quite probable, at any rate, that many so-called cases of rubeola sine catarrho are merely instances of rötheln, which we know may occur without any reference to an existing epidemic of measles. But that this form of measles does exist is admitted by trustworthy observers, although its diagnosis under any circumstances must be a matter of great difficulty. Measles without the eruption (rubeola sine eruptione) is more readily recognized, especially and only, however, when a susceptible person is exposed, and as a result acquires the characteristic catarrhal symptoms. Since in recent years more attention has been paid to the eruption on the mucous membranes, it may be that its discovery in these situations may lend positive assistance to the diagnosis in such cases. It is hard to understand how this variety of measles, which presents no inflammatory changes in the skin, should be followed by desquamation; yet this observation has been made. The assertion that these anomalous forms of the affection afford no protection against subsequent attacks seems to be founded in error, and is undoubtedly due to the confusion existing between measles and rötheln or other exanthems.
Continental writers, especially, describe a form of measles called by them inflammatory or synochal. It is simply an exaggeration of the symptoms, particularly those appertaining to the mucous membranes, found in ordinary measles (morbilli vulgaris). The prodromal stage is much more violent, the nervous symptoms more threatening, the implication of the mucous membranes more pronounced and persistent, the febrile movement is of a higher inflammatory character, and the eruption, which instantly covers the whole body (Vogel), is made up of dark-red or purplish spots which fade slowly. It is this form of measles, according to Niemeyer, which is chiefly attended by croupous instead of catarrhal laryngitis, in which the inflammation of the air-passages often extends to the alveoli of the lungs, and in which the gastric and intestinal coats are often affected with catarrh.
Let the contagion of measles be a grade more virulent, or perhaps the resisting power of the patient more feeble, and the case will assume the features of the septic, typhous, or hemorrhagic variety (rubeola nigra). It is said that the hemorrhagic measles is most apt to occur in epidemics; certain it is that the dreaded black measles of former times is very infrequent now-a-days, due, no doubt, to a more rational treatment and a better hygiene. Isolated cases, however, are occasionally encountered. As a rule, from the beginning all the symptoms evidence an overwhelming of the system by the virulence of the poison—a condition of things much more common in scarlatina. The pulse becomes weak, thready, and frequent; the temperature lacks the typical remittent character of normal measles; there is unusual prostration; and the nervous centres are profoundly concerned, as shown by delirium, convulsions, and coma. The eruption lags, and finally makes its appearance in an imperfect or irregular manner. The spots are of a livid hue, interspersed with larger or smaller ecchymoses. Hemorrhages from the mucous cavities take place, and the patient dies in convulsions or sinks into fatal coma. It has been said that the grave constitutional symptoms do not generally make their appearance till the eruptive stage, but I know from experience that the patient may be overwhelmed quite early, as in purpura variolosa.
Too much stress should not be laid on these different types of the disease, whether mild or grave, since they depend upon a common cause, however much modified in one way or another; but they may be allowed to stand for the sake of clinical convenience.
Measles may also present certain irregularities in its various stages without necessarily departing from the otherwise benign character of the disease.
As stated elsewhere, it is believed by some writers that a greater part of the period of incubation is occupied by symptoms which already indicate the activity of the measles poison in the system, and that, therefore, this stadium in reality lasts but a few days. This opinion does not seem to be generally accepted; at any rate, I think we are quite safe in saying that in the majority of cases no departure from the usual latency is observed. The deviations in the stage of invasion have been considered above, and mostly concern its duration and the character of the temperature. Evanescent rashes, which have nothing in common with the specific exanthem, are sometimes observed at this period. The eruption of measles may present certain peculiarities. First, as to localization. Instead of coming out on the face first, it may primarily develop on other parts of the body, provoked into existence, as it were, by local exciting causes; thus, where ointments or plasters have been applied or upon a part subjected to constant pressure. It may affect only one-half of the body, or entirely spare paralyzed extremities (Mayr). In some instances the papules are so sparse, indistinct, and short-lived as to be scarcely appreciable.
Second, as to the physical characters of the eruption. Hebra and Mayr recognize the following modifications:
Morbilli lævis. The efflorescence is smooth and flat, and the individual lesions are separated from each other by normal integument. This is the common form of measles.
Morbilli papulosi. The papules are dark red and more elevated, are about the size of hempseeds, and situated at the mouths of the hair-follicles.
Morbilli vesiculosi. In this variety the mouths of the hair-follicles are filled with fluid and produce delicate transparent vesicles.
Morbilli confluentes. The maculæ are here so crowded together that no healthy skin intervenes.
Morbilli hæmorrhagici. The efflorescence consists of maculæ or papulæ of a dark-red color, due to extravasations of blood, and do not fade on pressure. It is well to mention in this connection the fact, particularly noted by Meigs and Pepper in this country, that hemorrhages into the skin may occur in cases which otherwise run a benign course. They are best seen after the eruption has faded. In some cases the efflorescence of measles may remain visible for a week or ten days.
As heretofore observed, there may be a relapse of the measles eruption after some weeks, accompanied by fever. It is said that the spots appear on parts of the skin hitherto normal (Thomas). So far as I know, Hebra was one of the first to point out the fact that the so-called striking-in of the eruption was the result, and not the cause, of some complication in the disease; for, as this author states, before the rash fades or disappears the internal disease is always present. It is well known, for instance, that syphilitic eruptions will sometimes disappear upon the supervention of some acute intercurrent affection, such as pneumonia, acute rheumatism, etc.; but no one will suppose for a moment that the retrocession of the syphilides was the cause of these affections.24 The pathological explanation seems obvious.
24 See Bumstead and Taylor on Venereal Diseases, 4th edit., p. 513.
COMPLICATIONS.—The complications of measles consist, as a rule, in the exaggerated morbid action of organs or parts that are essentially implicated in the disease; therefore we are most apt to encounter such affections as laryngitis, bronchitis, pneumonia, etc. Inflammation of serous membranes, on the other hand, are rare; thus, pleurisy is infrequent unless in connection with a lobar pneumonia.
The exact causes of the complications are not always obvious, but in many instances can be traced to the previous bad health of the patient, to the influence of insanitation, or, finally, to certain ill-understood features attendant upon some epidemics.
Simple bleeding from the nose, not associated with the hemorrhagic diathesis, is not an uncommon accompaniment of the prodromal stage, and is rarely a dangerous symptom—rather the contrary. It may also arise after the development of the rash, and occasionally proves a complication of serious import.
The aural complications, unlike those in scarlatina, are generally not sufficiently prominent at first to attract attention. The symptoms, particularly pain and deafness, are apt to be masked. Purulent processes and consequent perforation may occur during the eruption, but are more frequent at the stage of desquamation (Spencer).25
25 Oral communication.
Various disorders of the skin have been observed during the course of measles—viz. miliary vesicles, and even pustules, as already described; herpes facialis, zoster femoralis (Thomas), and erythematous rashes, which may precede, accompany, or, it is said, follow the eruption. Of considerably more importance is the pemphigoid eruption mentioned by several observers. In Henoch's26 case, a girl of four years, the usual remission of the fever on the evening of the second day was absent, and from the third day there appeared over nearly the whole surface blebs filled with a limpid fluid, which varied in size from a hazel-nut to a thaler, and even larger. The cheeks and the backs of the hands were each covered with a single bleb. The exanthem was of a hemorrhagic character, and the intervening skin was red and the face swollen. The bullæ appeared not only where the eruption existed, but also on parts of the body free from it. The fever remained at the same height till the fifth day, when, upon the cessation of the bullous eruption, it fell to 100° F. A.M., and 101° F. P.M. The child died on the eighth day of a pneumonia which developed between the sixth and seventh days. Other cases have been reported by Steiner, Klüppel, and Löschner. Henoch rejects the theory that the bullæ are the result of the morbillous dermatitis, but thinks that they are merely instances of the coincidence of a contagious pemphigus.
26 Berl. klin. Woch., No. 13, 1882.
The severe affections of the eye described by continental writers—blennorrhoea, keratitis, iritis, etc.—are certainly very rare in this country as complications of measles. Various so-called strumous disorders of this organ, as will be seen hereafter, not uncommonly, however, come under the care of the ophthalmologist as sequelæ of the disease.
The tonsils and the mucous membrane of the pharynx may become severely inflamed. The tonsils are sometimes very much enlarged, but suppuration, if it occur, is certainly rare. Slight ulceration of the gums close to the teeth is occasionally noted, also aphthous ulcerations on the lips, tongue, and gums (Ringer).
Some degree of laryngitis is an accompaniment of all cases of measles. It has already been stated that catarrhal or false croup is frequently observed during the stage of invasion. Inflammation of the larynx may be present in all grades of severity. Rilliet and Barthez found ulcerations and erosions, especially of the vocal cords, upon post-mortem examination of a large proportion of measles subjects; and Gerhardt, both during life and by autopsy, has verified these observations. Loeri27 states that inflammatory changes are more marked in the larynx and trachea than in the pharynx. According to his examinations, hemorrhages or ecchymoses seldom occur, but more frequently superficial or even deep catarrhal ulcers, especially on the anterior aspect of the posterior wall of the larynx at the apices of the cartilages of Santorini, or on the posterior portion of the vocal cords. The physical condition of these parts readily accounts for the frequent and harassing cough and attacks of spasmodic laryngitis which are such frequent complications of the invasion and eruptive stages of measles.
27 Jahrb. f. Kinderheilk., xix. B., 1 H.
There may be an extension of the tracheo-bronchitis to the finer bronchial tubes, thus producing capillary bronchitis (suffocative catarrh). It is apt to prove fatal to very young children. It occurs more generally during or after the eruption.
Pneumonia is one of the most frequent and, directly and indirectly, most dangerous complications of measles. Catarrhal pneumonia (broncho-pneumonia) is, for obvious reasons, more common than the lobar or croupous variety. Pneumonia may develop at almost any stage of measles, but experience does not confirm the statement occasionally made that it is most frequent in the initial stage. Most observers will agree as to its greater frequency just at the end of the eruption or during the desquamative period. The occurrence of epileptoid convulsions, or an untoward increase of the fever, or an unexplained continuance of the same, should direct the attention of the attendant to the chest, if his anxiety have not already been aroused by a change in the character of the respiration or other symptoms. It may be mistaken for meningitis (Squire). In estimating the prognosis it should be remembered that croupous and catarrhal pneumonias run quite different courses. The influence of inflammation of the lungs upon the rash is quite decided. If an intense pneumonia should develop in the initial stage, the eruption will be pale and sparse, or else absent; if the eruption is already out at the time of the attack, it may become temporarily more vivid, to rapidly fade later.28
28 A scanty rash by no means indicates an unfavorable course of the disease; this symptom is only serious when evidently due to some complication.
Chadbourne29 has the merit of calling attention to the occurrence of heart-clot and subsequent pulmonary oedema as a fatal complication of measles. In a number of autopsies he found that in each case the heart contained clear gelatinous clots of a very firm consistence, which in most instances extended to the pulmonary arteries, and in some to the extent of one and one-fourth inches. In the series of cases observed by him pneumonic consolidation was mostly absent, and there was very little evidence of collapse, but the lungs were exceedingly oedematous. But Keating has also found heart-clot to be the cause of death in some cases, and believes, as the result of his investigations, that the presence of large numbers of micrococci in the blood and in the white blood-corpuscles is responsible for this condition.30
29 Am. Jour. Obstet., Oct., 1880.
30 Phila. Med. Times, Aug. 12, 1882.
There is a strong tendency in measles to intestinal catarrh. As already stated, a quite sharp diarrhoea is not uncommon at the beginning of the eruptive stage; but, unless it should prove very profuse and long-continued, it is not to be looked upon as of very serious import, especially if the other general symptoms of the disease are following a normal course. In other instances the bowel affection may be much more severe, giving rise to tenesmus, bloody stools, and the other phenomena of colitis. In weakly children the early diarrhoea may persist in spite of treatment for many days; indeed, under the influence of high temperatures it may take on a true choleraic character. Diarrhoea is a very frequent and grave complication of the broncho-pneumonia of measles.
Acute miliary tuberculosis as an immediate concomitant of measles is rare. According to Thomas, the disease at times immediately follows the exanthem, and reaches a fatal issue in a few days or weeks. The tubercles are more particularly to be found in the lungs and in the membranes of the brain.
Among the more common disturbances of the nervous system convulsions play an important rôle. The epileptoid seizures of the prodromal stage generally terminate favorably, but in some cases of a malignant character the onset of the disease may be ushered in with fatal convulsions. Convulsions in the later stages are apt to have a lethal termination, as they usually occur in connection with some grave complication, particularly of the thoracic organs.
Diphtheria is an exceedingly grave complication of measles, although not necessarily a fatal one. It is of less frequent occurrence than in scarlatina. It may attack any of the usual oral, nasal, or laryngeal regions, sometimes extending into the bronchi, but suffers no modifications in its symptoms and course from the primary disease. It may also rarely involve other parts—e.g. genitals, eyelids, etc. There is reason to believe that it is most prone to attack those cases in which the mucous membranes have undergone the greatest inflammatory alterations.31
31 Loeri (loc. cit.) says that diphtheria may appear at any stage of measles, and commences generally in the larynx, and sometimes in the trachea simultaneously; seldom in the pharynx, as in primary diphtheria or in that complicating other diseases than measles.
Many other complications of measles have been recorded in literature (see Thomas, op. cit.); but it is no doubt true, as observed by Bohn, that very few of them have a real essential connection with that affection, and might as readily be associated with any other malady, especially in already vitiated constitutions. In the above sketch the endeavor has been made to indicate those disorders which from the nature of measles would seem to have a more or less close and definite relationship to it. It is certain that the more serious complications and sequelæ of measles are comparatively infrequent in private practice in America, although common enough in continental Europe, and to a certain extent in the children's asylums and foundling hospitals in this country.
SEQUELÆ.—It is a difficult matter to dissociate the complications and sequelæ of measles. Properly speaking, the sequelæ are to be looked upon as the complications which have continued in existence after the subsidence of the exanthem; but it is also customary to include under this head certain affections that are the result of the derangement of the system by the morbillous process.
As would be expected, among the most frequent sequelæ of measles are those diseases which have their seat in the mucous membranes. Thus, we may observe various grades of inflammation and ulceration of the larynx, trachea, and bronchial tubes. According to Loeri, follicular ulcers of the larynx always give a bad prognosis, for these cases usually succumb to tuberculosis. It is not uncommon to observe a bronchial catarrh, apparently simple in nature, which persists with frequent exacerbations for many months. The very frequent broncho-pneumonia, which occurs as a complication, always remains as a sequel, or it may develop after the morbillous process has come to an end. In favorable cases recovery may take place in two or three weeks, or, preceded by hectic and progressive emaciation, the disease may prove fatal after a number of months. But even here it is not impossible for affected persons to recover.
Chronic pulmonary tuberculosis is one of the most formidable and frequent sequelæ of measles. It is a not uncommon occurrence that, with the exception of some trivial bronchitis, a patient may apparently recover his health completely, and only after a lapse of time slight daily elevations of temperature, accompanied by loss of appetite and emaciation, first give warning of the impending danger. This form of phthisis may follow either croupous or catarrhal pneumonia. Granular meningitis or general miliary tuberculosis also frequently follows in the wake of measles, connected in many cases with foci of caseous degeneration in the involved lymphatic glands or unabsorbed pneumonic exudation.
Various gangrenous affections, particularly of the oral cavity (noma) and genitals, but also of the skin, subcutaneous connective tissue, cartilages of the nose, ear, etc., are often to be observed after an attack of measles. Cancrum oris is to be especially noted.
Albuminuria is not an essential sequel of measles, although it may occasionally occur as the result of great exposure and neglect.
A large group of chronic affections may follow in the track of measles, either in the form of sequelæ to the complications which arise during the course of the disease or in the nature of secondary accidents. Some few, perhaps, are more common after measles than after any other complaint, but the majority are such as might arise in weakly children subsequent to any specific disturbance of the health. In addition to those already mentioned we may especially designate chronic intestinal disease, together with ulcerations and strictures of the bowel; chronic coryza, in varying degrees of obstinacy and severity; chronic ophthalmia, under which title may be included ciliary blepharitis, granulations, trachoma, phlyctenular conjunctivitis, ulcers of the cornea, etc. (Michel32); aural affections in the form of chronic suppurative inflammation, and, more rarely, chronic catarrh of the middle ear (Spencer); certain cutaneous diseases, more especially in my experience furunculosis and pustular eczema; chronic bone and joint disorders (strumous), which, according to Gibney,33 may not only be evoked in the already hereditarily predisposed, but also induced when the diathesis has not heretofore existed; and, lastly, various derangements of the nervous system.
32 Oral communication.
33 See valuable statistical article in N.Y. Med. Record, June 3, 1882.
In Thomas's valuable and freely-quoted monograph on measles (op. cit.) it is stated that secondary measles can exert various influences upon the primary disturbance. In most instances when measles attacks a person already the subject of some other disease, particularly when the latter belongs to the common complications of the former, it usually is aggravated. This is a matter of common experience; but this author further declares—and supports his assertion with numerous references—that, on the other hand, should measles appear during the existence of a disease to which it does not usually give rise, it may favorably influence the course of the latter. In spite of the cases quoted in support of this view, such results would appear to be contrary to pathological laws.34
34 Thus, while Thomas seems to be without personal experience in the matter, he quotes without dissent a number of observations in support of his assertion—viz.: Behrend saw a chronic eczema of the scalp permanently disappear after measles; Rilliet found that a chronic coxitis improved noticeably after measles; various chronic skin symptoms, and also chorea, epilepsy, incontinence of urine, mania, worms, dropsy, joint diseases, ophthalmia, gonorrhoea, etc., have been known to recover under the same influence. Gibney (loc. cit.) in his valuable paper states that he can readily believe that, occasionally, any acute disease, occurring in the course of a chronic one, will prove beneficial to the other, but that he is far from considering this to be anything more than an exception to a very general rule to the contrary. Chronic joint disease, he continues, is especially a disease of exacerbations, and any one not familiar with their natural history may interpret the post hoc as a propter hoc. Gibney has collected 24 cases of chronic bone disease in children, 21 of whom were under ten years of age and all under thirteen. On analysis he found that 12 of these came out of the intercurrent disease in a worse condition, 11 were unaffected, and 1 only seemed a little better. In my personal experience I have invariably seen the eczemas of children made worse by measles. I have no wish to dispute the trustworthiness of the statistics quoted by Thomas; indeed, I regard them as mostly thoroughly reliable instances of exceptions to a general pathological law; but I wish it to be clearly understood that they are such, and that measles is not a disease to be slightly regarded as to its effects upon the system.
MORBID ANATOMY.—The normal rash of measles is not to be observed on the dead body, and the only lesions of the skin to be noted are those resulting from extravasation of blood into that tissue. Examination of the skin removed during life from a patient with measles reveals the following anatomical changes, according to Morris.35 In the earliest stages are found usually slight hyperæmia around the orifice of a sebaceous follicle, with slight swelling from effusion of plasma. Occasionally swelling alone is present, and more rarely hyperæmia only. Round the small hyperæmic papule thus developed—often pierced by a hair—a roseolar patch, due to congestion of the papillary body, soon makes its appearance. Slight exudation of plasma, with a few corpuscles, usually follows, and produces elevation of the papule itself. As most of the deaths in measles are due to the presence of some complication, the post-mortem changes will be found to correspond to the lesions produced by these diseases, principally affections of the respiratory organs and intestinal tract.
35 Skin Diseases, Phila., 1880, p. 57.
DIAGNOSIS.—As a rule, the diagnosis of measles offers no great difficulties, especially if a correct clinical picture of the disease has been thoroughly impressed upon the mind. The salient points may be thus summarized: A period of incubation of about fourteen days—i.e. from the date of infection to the commencement of the eruption; a prodromic stage of about four days, ushered in with fever and marked implication of the mucous tract, notably cough, coryza, epistaxis, and photophobia; in this stage may also be noted the punctated redness of the conjunctivæ and of the palatal mucous membrane, which is to be regarded as a diagnostic sign of great value and importance; finally, there appears at the conclusion of the stage of invasion, simultaneously with increase of the febrile movement, a characteristic eruption upon the cutaneous surface, this eruption coming out first upon the face, and composed of large maculo-papules of brownish-red color, arranged in a crescentic form with tracts of normal integument intervening. Of all the symptoms of measles, the catarrh of the mucous membranes is undoubtedly the most pathognomonic. In the colored races, where the recognition of the skin lesion is often a matter of difficulty, this combination of symptoms should be borne in mind.36
36 Corre (La Mère et l'Enfant dans les races humaines, Paris, 1882) states that measles and scarlatina exist in all climates and among all races; however, they are less frequent in warm than in cold climates. This relative rarity may be only apparent, and has only been established by reason of the difficulty of recognizing exanthems among dark-skinned peoples. In the negro the eruption (of measles) often escapes observation, but the general symptoms, the angina, coryza, and bronchitis, and the special coloration of the bucco-pharyngeal membranes, permit the establishment of the diagnosis. The skin appears more tense, and the face especially is puffed and glossy; in passing the hand over the different regions of the body slight elevations are felt—a difference in the level of the skin exists in the affected and unaffected portions. On examining the surface of the body obliquely at a well-pronounced angle of incidence, these elevations can be perceived by the eye. Desquamation, which is very manifest in the negro, also confirms the diagnosis; this desquamation is formed of epidermic débris; it gives rise to a white dust, which is well defined against the black skin. The skin itself seems to have lost its gloss; it is completely dry, and no longer gives the abundant and odoriferous secretion characteristic of the subjects of that race.
In the way of conjectural diagnosis, the presence of an epidemic of measles in the community should be taken into account. Although measles possesses features so characteristic and pronounced, there are a number of other diseases with which it may be confounded, especially in its earlier stages.
There is no other disease which presents so close a resemblance to measles as does rötheln, and it must be confessed that under certain circumstances the question of diagnosis is a perplexing one. In rötheln the appearance of the eruption is often the first symptom of the affection, whereas in measles there is a prodromic period, having a peculiar remittent type of fever, which continues for three or four days. According to Liveing, the short duration of the febrile attack before the eruption appears is one of the most constant and distinctive features wherein rötheln differs from ordinary measles. In some instances, in rötheln the premonitory fever is not at all appreciable. The catarrhal involvement of the mucous membranes is not nearly so marked as in measles, while the very frequent sore throat bears more resemblance to the angina of scarlet fever. In many instances, although by no means constantly, the eruption of rötheln first appears on the chest, and not on the face, as is the rule in measles. It is quite evident that the eruptive spots of rötheln have presented different physical features in different epidemics; but, as a general thing, it may be said that they are smaller than those in measles, of a paler color, and, according to Thomas, not so angular, less indented, and not so often provided with processes, therefore less apt to assume the crescentic arrangement so often seen in measles.37 The incubation period is longer in rötheln than in measles.
37 According to Curtman (St. Louis Courier Med., June, 1882), the eruption of rötheln consists, when not confluent, of single papules, each separated by a distinct small red areola. Not infrequently the papules are large, and sometimes a few pass into vesicles or pustules. In measles the papules are very small, mostly confluent, from four to six landing on a single areola, which is larger than that of rötheln.
In scarlet fever the incubation stage is shorter than in measles, and the constitutional symptoms are apt to be more pronounced; the temperature is higher, the pulse more rapid, and vomiting more frequent. The stage of invasion in scarlatina is but twenty-four hours; in measles, seventy-two. There is absence of the characteristic catarrh of measles, and the presence of severe sore throat, strawberry tongue, and swelling of the lymphatics at the angle of the jaws. In measles the rash begins on the face; in scarlatina, on the neck and chest. In measles the eruption consists of large papules arranged somewhat crescentically, with intervening normal skin, followed by bran-like desquamation; in scarlatina the rash is made up of large patches formed of minute red spots on a bright red, hyperæmic base, and is followed by desquamation in large lamellæ. In measles the rash is brightest on exposed parts; in scarlatina, most vivid on covered regions. The sequelæ of the two diseases are quite different.
There is no great difference in the duration of the invasion stages of variola and rubeola; but in the former disease we have the marked lumbar and sacral pains and vomiting, while in the latter the catarrhal symptoms and photophobia are pathognomonic. When the eruption of small-pox appears there is subsidence of fever; in measles, an exacerbation. A point of great importance in the diagnosis of variola is found in an examination of the mouth and pharynx, for in these situations on the fourth day we will often find the vesicles fully developed, while on the skin they are still in the stage of papulation. When measles assumes the papular form (morbilli papulosi, rougeole bouttoneuse), it is often confounded with the papular stage of small-pox. I have seen a number of such mistakes made. Attention to the general symptoms of the two diseases, however, and particularly an examination of the mucous membranes, will generally clear up any doubt. At any rate, the question will generally settle itself in the next twenty-four hours, for if it be variola the papules will have undergone their specific development and the rubeolous elevations will have become more decidedly macular.
Typhus sometimes offers a certain resemblance to measles. According to Buchanan,38 the eruption of typhus is occasionally, though not commonly, a good deal like that of measles, and appears about the same time after invasion. Coryza, when present and distinct, points to measles. The eruption of typhus is of a smaller pattern, discrete, and not raised; that of measles, often coalescent, crescentic, and elevated. Subcuticular mottling is present in typhus, and absent in measles. The palatal mucous membrane should always be examined in suspected measles.
38 Art. "Typhus" in Reynolds's System Med., Am. ed., p. 262.
As I have never been able to convince myself of the existence of an independent disease called roseola, I am at a loss to give the points of differential diagnosis; on the other hand, the various forms of symptomatic erythema, occurring either as the result of numerous slight derangements of the system, or in connection with grave constitutional disease, should be carefully considered. In the first group of cases the absence of premonitory symptoms, catarrh, etc., and the presence of the smooth, rose-colored macules, mostly on the trunk, and in the latter the existence of symptoms belonging to the primary disease, should prove of assistance. The erythema papulatum of new-born children I have seen mistaken for measles, but the fact that rubeola is exceedingly rare in sucklings, and the absence of fever and catarrhal disturbances, are sufficient grounds for a differential diagnosis.
The erythematous syphilide (roseola syphilitica), particularly when accompanied by fever, may bear some resemblance to the rash of measles; but the history of the case, the circumscribed, indolent character of the syphilide, in many instances sparing the face, the absence of pathognomonic catarrhal symptoms of measles, and the coexistence of other features of syphilis, are quite distinctive.
PROGNOSIS.—The prognosis of normal uncomplicated measles is very favorable. Thus, of 257 cases observed by Meigs and Pepper (op. cit.), all terminated favorably. But in coming to any conclusion in regard to prognosis a number of different factors must be taken into consideration. Among the more important are—the hygienic surroundings of the patient, the age, the nature of the complications, whether the measles be primary or secondary, and the character of the epidemic. In the first place, rubeola in foundling hospitals and among the poorer classes in large cities gives a larger ratio of deaths than among the well-to-do members of the community. For instance, Bartels has shown that catarrhal pneumonia, one of the most frequent causes of mortality in this disease, is particularly prone to occur among those dwelling in crowded, poorly-ventilated houses. Then, again, the asylums and hospitals for children are peopled in many instances with the victims of depraved constitutions, who readily succumb to intercurrent maladies.
Leaving out of consideration sucklings under six months of age, in whom measles is rare and said to be slight, most deaths from the disease occur among very young children, from their greater liability to complications. According to Beddoes,39 the mortality from measles is, beyond all comparison, greatest in the second year of life, and by the tenth has become quite trifling. An examination of the statistics bearing on this question coincides with this general statement; but Fox's tables, already quoted, would show that more infants under one year of age die of measles than has hitherto been supposed. The susceptibility to measles decreases with years, perhaps on account of the fact that most adults have already contracted the disease; but when it does attack the unprotected adult it may prove fatal. This statement is borne out by the large death-rate in the so-called camp measles of our late war.40 The ravages of measles in virgin communities have been referred to in preceding pages. The general temper of the epidemic must also be considered, since it is well recognized that the essential character of epidemics differs much as to severity.
39 Art. "Mortality" in Quain's Dictionary Med., p. 1002.
40 In the general field hospital at Chattanooga the death-rate was 22.4 in 100 cases. In General Hospital No. 1, at Nashville, it was 19.6 in 100, or nearly 1 in 5. Many died or became permanently disabled from the sequelæ (Bartholow).
Such complications as diphtheria, catarrhal pneumonia, diarrhoea, convulsions, etc. necessarily affect the prognosis of measles most seriously. More patients die of measles in the second than in the first week of the disease. The careful studies of temperature made by Thomas, Bohn, and others show that an unusually high and increasing fever in the prodromal stage is of ill omen, particularly on the second and third days, and a fever heat measuring over 105° F. at any stage should be considered as very unfavorable.41 Particularly to be feared is continuation of the fever after the subsidence of the eruption, or a sudden elevation after the normal curve has been reached. In fact, it is a safe rule to look upon all anomalies of the curve with suspicion. Secondary measles, or measles grafted upon some serious existing affection, is particularly fatal.
41 In adolescence a body heat of 107° F. has been safely passed during the decline of measles with no marked complication (Squire).
TREATMENT.—There is no remedy which will destroy the susceptibility to measles. The future may develop some form of vaccination against rubeola, for, certainly, the hopes held out by the inoculation of measles upon the healthy subject have not been realized, as this procedure merely reproduces the original complaint, without any diminution in its intensity, and does not lessen the probability of complications (Mayr). The matter of carrying out a practical and efficient quarantine in measles is one of unusual difficulty, for the reason that the disease is capable of active propagation at a time—the prodromal stage—when it is not yet sufficiently characteristic for positive diagnosis. But, as measles is by no means as trivial a disease as would seem to be the common impression, I hold it as a well-established principle of preventive medicine that a strict isolation should be enforced whenever, from the nature of the case, it is at all possible; certainly, very young children and those suffering from or showing a tendency to other diseases should be jealously shielded from exposure.
The usual precautions as to disinfection and purification of the room, bedding, and utensils used by patients should be observed, as in other infectious diseases. Squire is of opinion that there is danger of personal infection for perhaps a month, and Hillairet that isolation for forty days should be enjoined. It is quite certain that inunction lessens the danger of infection, and Kaposi42 is authority for the statement that a warm bath administered after the completion of desquamation, or about fourteen days from the beginning of the attack, will effectually prevent contagiousness.
42 Pathologie u. Therapie der Hautkrankh., Wien, 1880.
The apartment occupied by a patient suffering from measles should be kept at a uniform temperature of from 66° to 70° F., and free ventilation, at the same time avoiding draughts, should be enforced. The room should be kept moderately dark. The bed-clothing should be light, yet sufficiently warm, and the old notion of keeping the patient in a profuse sweat the better to bring out the eruption should be discouraged. The diet should be bland and nutritious, and may preferably consist of milk, gruel, tapioca, and such like substances. As convalescence progresses there may be a gradual return to more substantial food. The patient may be allowed cool water in moderation, as it is cruel and useless, and even harmful, to restrict one suffering with fever to warm or sweetened drink. The patient should be confined to his room until convalescence has been fully established, and should not be allowed to leave the house, both on his own account and that of others, until the usual health has been regained. Any of the lingering results of the disease, such as bronchitis, otorrhoea, conjunctivitis, etc., should receive prompt attention; iron and cod-liver oil should be prescribed for the weakly and strumous, and regular hours of sleep, careful diet, and appropriate bathing and exercise should be advised. It may be said, without exaggeration, that neglect of the after-care of measles patients is, in some instances, more to be deprecated than a similar neglect in the actual treatment of the disease itself.
Since we are powerless to cut short an attack of measles by any remedial agents at present known to therapeutics, the intervention of the physician is limited to assisting the cases through to a safe termination. Quite a number of cases, as seen in private practice, require no special medicinal treatment, or at most one that is merely symptomatic. The value of the so-called specific treatment, such as by carbonate of ammonium, etc., has not been verified by experience.
In ordinary uncomplicated attacks, if the temperature should run high, in addition to the general rules as to diet and hygiene referred to before it will usually be found advisable to put the patient on some diaphoretic mixture, to which may be added a mild opiate. I know of nothing better than the formula found in the work of Meigs and Pepper on the Diseases of Children:
| Rx. | Potass. Citrat. | drachm i; |
| Spt. Ætheris Nit. | fl. drachm ii; | |
| Tr. Opii Deodorat. | minim xii vel xxiv; | |
| Syrupi | fl. drachm ii; | |
| Aquæ | fl. oz. ii. M. |
S. A teaspoonful every two or three hours for a child of five years of age.
Aconite in small doses has been well spoken of in this connection, but I have no personal experience in its use. Bromide of potassium, together with a few drops of syrup of ipecac., dissolved in syrup of wild cherry, acts pleasantly both on the cough and the nervous system.
The inunction of fatty substances, as originally proposed by Schonemann, and recently urged by Milton,43 is an excellent routine practice, and in addition to adding very much to the patient's comfort, has, perhaps, the merit of lessening somewhat the danger of infection to others. For this purpose one may use leaf lard, cold cream, or vaseline, to each ounce of which it is well to add a few minims of carbolic acid.
43 Archives of Dermatology.
Stimulants are rarely needed in uncomplicated measles, but Squire very wisely calls attention to the great value of wine in the depression following upon the crisis.
In spite of some excellent authority to the contrary, I cannot see that any benefit is to be derived from using severe measures to bring out an eruption that has undergone retrocession. As stated in another part of this article, the so-called striking-in of the rash is the result of the supervention of some complication, and not the cause of it; therefore, a rational course of action would be to ascertain the nature of the complicating trouble, and to endeavor to correct it, which, at the same time, would be the very best means of restoring the normal course of the disease.
Quinia is of great value in controlling the excessively high temperature which is sometimes observed either in connection with, or independent of, complications. If the quinia should prove ineffectual or else be rejected by the patient, the physician should not hesitate to abstract heat by cold water in the shape of the wet pack or the general bath. I think the latter method is to be preferred. It is but to employ the gradually cooled bath of Ziemssen, perhaps, commencing at 90° F. and going to 80° or 70° F. The condition of the patient, as ascertained by the thermometer and also the state of the pulse, must be the guide as to the duration and repetition of the baths. In Germany excellent results are claimed for the treatment of hyperpyrexia in measles by the cold pack, even when the excessive temperature is due to such a complication as broncho-pneumonia.
There is little hope from therapeutical interference in malignant forms of measles, but the medical attendant should endeavor to reduce temperature and support the strength by free stimulation and nourishing food.
It will now be advisable, at the risk of some repetition, to call attention to the treatment of some of the more prominent disturbances and complications of measles.
Epistaxis, if severe, should be checked by cold applications and astringents. Plugging will rarely be found necessary. Trousseau recommends the injection of water as hot as can be borne. Ergotine by the mouth or hypodermically will sometimes prove highly valuable.
The lids should be anointed with vaseline or cold cream to prevent their sticking together, and it is well to occasionally evert them to see that no serious mischief has happened to the eye. If the conjunctivitis is intense, the discharges should be removed and cold compresses applied.
Since aural complications are due to extension of inflammation from the oral and nasal cavities, Spencer urges the importance of early and systematic treatment of these parts. He advises astringent applications (Monsell's solution 1 to 4 of glycerine) to the pharyngeal mucous membrane. Ointments of boracic acid, zinc, or iodoform are likewise useful when introduced through the nostril. Earache will require warm opiated poultices and inflation. Otorrhoea is best treated after the dry method.
For sickness of the stomach a spice poultice may be applied and small bits of ice given to suck. If constipation exist, a little oil or syrup of rhubarb or some stewed prunes, or an enema, may be ordered. Active purgation should be withheld.
The early diarrhoea need give little concern, as it usually soon ceases; but if it should persist, recourse must be had to more energetic measures, such as the use of opium by mouth or enema, given cautiously in the case of children, vegetable and metallic astringents, and the application of hot poultices to the abdomen. The diet should be carefully guarded.
The cough, even in mild cases, generally requires some slight palliative, such as syrup of ipecac., and an occasional small dose of Dover's powder. Loeri very properly advises against the use of irritating expectorants. I think it advisable to keep the chest well smeared with camphorated oil, over which should be worn an oil-silk jacket. These simple measures, perhaps, diminish the tendency to thoracic complications. The sometimes violent paroxysms of false croup are very satisfactorily managed, after the manner of Graves, by gently pressing a sponge, soaked in very hot water, under the chin and over the front of the neck. When the dyspnoea is alarming, emetics, and the general warm bath should be brought into requisition.
Convulsions in the early stage require little treatment other than the warm bath and appropriate doses of the bromide of potassium; occurring later, they are very fatal under any treatment, as they generally supervene in connection with some of the grave complications of the disease. Chloral, preferably by enema, and chloroform may be tried. The management of the severe bronchitis and pneumonia of measles requires great care and circumspection on the part of the physician. The application of a well-made flaxseed poultice, which should be neither too heavy nor too hot, is to be regarded as invaluable. To the flaxseed may be added a small quantity of mustard. Over the whole is to be placed an oil-silk jacket. Alcoholic stimulants, nourishing, easily-digested food, and expectorants containing carbonate of ammonium are to be recommended.
For the treatment of the other complications and sequelæ of measles the reader is referred to the appropriate sections of this work.
RÖTHELN.1
BY W. A. HARDAWAY, M.D.
1 In the preparation of this article the author has consulted the following authorities: Emminghaus, in Gerhardt's Handb. der Kinderkrankh., Zweiter Band, 1877; Thomas, in Ziemssen's Cyclop. Pract. Med., vol. iii., Am. ed., 1875; Squire, in Quain's Dict. Med., 1883. References to current literature will be found in foot-notes to the text.
SYNONYMS.—Rubeola, Rubella, Roseola, Epidemic Roseola, German Measles, French Measles, Hybrid Measles, False Measles, Rubeola Morbillosæ et Scarlatinosæ.
DEFINITION.—Rötheln is an acute infectious disease, presenting an eruption of reddish macules upon the skin, accompanied by mild catarrhal symptoms, and usually producing but slight disturbance of the general system. It is self-protective, and occurs but once in the same individual. It has no relationship to measles or scarlatina.
HISTORY.—A rapid glance at the interesting historical evolution of rötheln to a specific position among the acute infectious diseases is all that our space will allow. Some writers have attempted to show that this affection was known to the Arabian physicians; but since it is only in comparatively recent times that the contagious epidemic exanthemata in general have been thoroughly differentiated, it is quite likely that the modern conception of it was not held by them nor by other medical men till many centuries later. Indeed, in our day, physicians are yet to be found, though the number is rapidly diminishing, who refuse to recognize in rötheln a distinctive specific malady. Certain German observers in the middle of the last century (De Bergen, 1752; Orlow, 1758) favored the idea of specificity, but these views were soon disputed. In the years following a number of other physicians announced their belief in the specific nature of rötheln, while, on the other hand, various noted authorities still insisted upon its connection with scarlet fever or measles. In 1815, Maton, an English physician, most unequivocally declared that he had observed cases of an eruptive disorder which resembled neither measles, scarlatina, nor roseola, and which was worthy of a new designation.2 In the second and third decades of this century Hildebrand, and afterward the celebrated Schönlein, taught that rötheln was a hybrid of measles and scarlatina, although at this time Wagner (1834) advocated the essential independence of rötheln. There is no doubt that under the name of rubeola sine catarrho Willan, Bateman, and later writers described what we now call rötheln, for they stated that this variety of measles was not self-protective. Space will not allow of a detailed mention of the various writers who, during the first half of this century, have contended for or against the autonomy of rötheln. It will be well to state, however, that Hebra, from the standpoint of the dermatologist, very properly regards the manifold roseolæ of Willan as in many instances merely symptomatic erythemata, or else as irregular forms of measles or scarlatina; but he also fails to recognize the distinctive features of rötheln. Even so recent a writer as Niemeyer declares that roseola arising from infection consists in a modification of measles or scarlet fever. It is only in the last twenty years that our present exact ideas of rötheln have obtained. For example, while Trousseau3 asserts that rubeola (rötheln) is a perfectly distinct nosological species, he speaks of the rash as appearing and disappearing alternately for some days, of its frequent recurrence in the same individual, etc. American physicians were almost entirely ignorant of rötheln till within the last ten years, when they were made acquainted with it through the medium of a careful paper on the subject from the pen of J. Lewis Smith of New York.4 Before this time, however, cases had been described by Homans, Sr., of Boston (1845), and in 1853 and 1871 by Cotting. Very few authorities now dispute the distinctive specific nature of rötheln; which statement is borne out by the fact that at the last meeting of the International Medical Congress, held at London in 1881, there were but two dissentients to this view in the section before which it was discussed.5
2 Squire, Trans. Internat. Med. Congress, London, 1881.
3 Clinical Medicine, vol. ii.
4 Archives of Dermatology, Oct., 1874.
5 See especially Kassowitz's paper, "Die Wirkliche Stellung der sogenannten Rubeola," etc., Trans. Internat. Med. Cong., 1881.
ETIOLOGY.—The contagium of rötheln is unknown, but that the disease is contagious has been fully demonstrated by numerous observations of epidemics and sporadic cases. From my own experience I should judge that unprotected persons are not so susceptible of it as is known to be the case under similar conditions in measles;6 yet cases are recorded which would prove that the contagion may be conveyed through a third person and for some distance. It is probable that the vehicles of contagion are the same as in measles. At what period of its course the disease is most capable of transmission has not been satisfactorily determined. Squire is of the opinion, however, that the disease is contagious before the appearance of the rash, and may continue so for some days or for two or three weeks. Rötheln may be called a disease of childhood for the same reason that the other contagious exanthemata are—namely, that the majority of adults have already been attacked. From an examination of available statistics I am inclined to regard the ages between five and fifteen—the years of school attendance—as the period of life most susceptible of the influence of rötheln, although, of course, no time of life is entirely exempt. The non-susceptibility of sucklings, as in measles, holds true as a rule, although I am in a position to supply exceptions to this from my own experience, as well as from that of others. Sex seems to be without influence in determining liability to the disease.
6 In this regard it resembles scarlatina more than measles, for I have a number of times seen the disease introduced into families, where it would attack one or two of a number equally exposed. J. L. Smith regards it as feebly contagious, and quotes Chadbourne's experience to the same effect. Liveing declares that rötheln is more distinctly epidemic in Great Britain than either measles or scarlet fever, although probably less contagious.
The period of incubation is not very definitely settled, and, indeed, owing to the generally trivial character of the affection, evidence on this point is difficult to obtain. Taken as a whole, it is probably longer than is observed in measles. According to J. Lewis Smith, in the epidemic observed by him the incubation period varied from seven, or less than seven, to twenty-one days; Emminghaus places it at from two to three weeks; Thomas, from two and a half to three weeks; Squire, mostly a fortnight, the extreme being twenty-one days; Cheadle, from eleven to twelve days.
There is nowhere recorded a trustworthy instance of a second attack of rötheln, although from analogy such an event is to be expected. As in measles, true recurrences of rötheln—that is, the result of a fresh infection—are not to be confounded with relapses. I have never witnessed a relapse, but cases of such a nature have been recorded by other observers (Lindwurm, Emminghaus, Körtlin, Kingsley).
Rötheln is a disease sui generis, and is in no way related to either measles or scarlatina; that is to say, it is not an irregular form of either of these nor a hybrid of them, nor has it ever been observed to propagate anything but itself. That it is not connected with any of the symptomatic skin eruptions—the so-called roseolæ—is proved by its contagiousness and epidemic character. I quite agree with other observers in declaring that rötheln has very little clinical resemblance to scarlatina, and that, on the other hand, in the greatest number of cases the points of likeness are with measles. In the section on diagnosis the differential points between rötheln, measles, and scarlatina will be considered; therefore in this place it will only be necessary to call attention to certain general facts. Thus, aside from the marked divergence in clinical symptoms—incubation, invasion, fever, eruption, complications, and sequelæ—we are at once met by the positive fact that epidemics of rötheln, while always presenting identical features, prevail without regard to the existence of similar epidemics of measles and scarlatina—following or preceding them—and that attacks of rötheln offer no bar to the reception of their contagions, or vice versâ. Literature is so full of examples of this statement that it need scarcely be dwelt upon. By way of illustration, however, the accurate observations of J. Lewis Smith may be quoted in this connection. Of 48 cases recorded by him prior to May 1st in the New York epidemic of 1874, 19 had had measles. Rötheln in the N.Y. Foundling Hospital in 1873-74 followed an epidemic of measles. During the epidemic of 1880-81 the same fact was observed—namely, that a previous attack of measles, as well as scarlatina, afforded no protection from rötheln. I could multiply such examples from my own experience. A single interesting instance may be noted here. A physician asked the writer to examine his child, suffering, as he thought, from measles. A careful investigation revealed a typical rötheln. A number of weeks later an older child got measles, from which the rötheln patient acquired a characteristic attack of the same. In the following year both children were taken with scarlet fever.
The only escape for those who would deny the autonomy of rötheln is in the bold assertion that both measles and scarlatina more frequently recur in the same individual than universal experience and observation will allow; and this leaves them in the dilemma of determining to which group rötheln must be relegated. The hypothesis of the hybrid nature of rötheln cannot be accepted by the pathologist nor the clinician, if for no other reason than that no one has ever seen rötheln generate anything but rötheln, and in no case give rise to either scarlatina or measles.
SYMPTOMS AND COURSE.—As already stated, the probable average duration of the incubation period in rötheln is about fourteen days, varying, however, within the limits of from six to twenty-one days. In this respect rötheln resembles scarlatina more than measles, the period of latency in the latter observing considerable uniformity. No deviations from the general health are to be noted in the incubation stage.
In most cases prodromal symptoms are entirely absent, the presence of the eruption being the first thing to show the existence of rötheln in the system. On the other hand, in a certain proportion of cases there will be present for a half day, or even longer, the general symptoms of malaise, such as slight nausea, some sore throat, pain in the limbs, stiffness of the neck, etc. Vomiting is generally absent. J. L. Smith records one case of convulsions in the stage of invasion, and I have notes of a single case in which the prodromal stage was initiated by mild delirium and fever, the latter anticipating the eruption for two days and a half, and disappearing when the rash came out. As Thomas well observes, however, such cases are anomalous, and indicate either abnormal sensibility on the part of the patient or are due to a secondary rötheln.
Most observers (Emminghaus, Thomas, Smith, Squire) describe the rash as coming out in the order usual in measles—namely, first upon the face, scalp, and neck, then the trunk and arms, and finally the legs. Others (Liveing, Morris) have stated that the rash first appears upon the back and chest. In many cases in my own experience this has seemed to be true. It is quite probable that the situation of the exanthem in rötheln, as in measles and scarlatina, may present various irregularities; but I am inclined to believe that a careful investigation will in most instances show that the normal course of the eruption is as first stated. Now, a marked characteristic of the rash of rötheln is that, unlike that of measles, there is no period, however short, in which its maximum is simultaneous over the whole body; on the contrary, the eruption will have reached its full development upon the face, and will be almost or quite faded again, before the exanthem, for example, will have blossomed upon the trunk, and especially upon the lower extremities. The duration of the eruption upon individual parts of the body is probably from a few hours to half a day at most (Thomas). A consideration of these facts explains, according to Emminghaus, how different observers have described the eruption as having its seat upon this or that region of the body; in other words, it is probable that in a certain proportion of the cases in which the rash was supposed to have begun on the chest it had already run its course upon the face. The eruption usually continues altogether about four days, sometimes disappearing sooner, and sometimes being visible, especially as a fine mottling, for some days longer. So far as the individual lesions of the eruption are concerned, there is no question that they present, within a certain range, varying aspects; and this clinical fact has been taken advantage of by the opponents of the idea of specificity in order to make it appear that the disease is not sui generis, inasmuch as it lacks uniformity of expression. Such an argument wants force when we consider that in making up a given diagnosis we lay stress not upon special, but upon the ensemble of, symptoms. For example, no one would deny to measles an independent position because the eruption, as is well known, may assume this or that form (morbilli lævis, m. papulosi, etc.); on the contrary, we recognize a particular case or series of cases to be measles from a due appreciation of all the symptoms present. So it is to be expected that while the cutaneous lesions will present a certain similarity of feature, as they do, there will also exist minor differences in detail.
In the greatest number of cases in my own experience the exanthem is composed of ill-defined, roundish, punctate macules, without special grouping. These are usually discrete, but in certain situations they may coalesce. The color is of a pale rosy red, quite difficult to describe, but less purplish than in measles, and not so livid a red as in scarlatina. I have occasionally observed large irregular spots not unlike those of measles.7
7 According to Emminghaus (op. cit., p. 345), the eruption generally forms roseolæ of pin-head, lentil, or small bean size. They are mostly round, sometimes oval, and bordered by well-defined or by blurred edges. The intervening skin is not always unchanged, for here and there we find upon it small dilated blood-vessels, and from the spots processes extend with a certain regularity to other spots in such a way as to give the skin a marbled appearance.
Thomas distinguishes three types of eruption—one with large spots, which is rare; one with medium-sized spots; and one with small spots. Emminghaus describes a discrete and a more confluent variety. I have observed one case where the maculæ on the back had undergone a vesicular transformation. Others have mentioned this occurrence. Itching of the skin is marked in some cases, and a fine desquamation is observed after the rash, but by no means invariably.
The mucous membranes are implicated to a slight degree in rötheln, but the amount of involvement varies considerably. In some cases that I have observed the catarrh of the mucous membranes has been barely appreciable. As a rule, however, the eyes are somewhat suffused, and there is slight lachrymation and photophobia. Sneezing may be noted, but there is little discharge from the nose. Sore throat is not uncommon, perhaps the most constant feature, and, according to Liveing, is apt to persist after the subsidence of the rash. The fauces are injected, and the tonsils are red and swollen, but with no evidence of ulceration. J. Lewis Smith and others state that the buccal mucous membrane shows a more or less diffuse patchy and spotted redness. The tongue may be, and usually is, covered by a white fur, through which protrude a few enlarged red papillæ. There may be slight cough. Loeri8 describes the mucous membranes of the pharynx, larynx, and trachea as presenting a spotted or uniform hyperæmia. There is no marked participation of the intestines in the catarrh. Some few writers have noted a transient albuminuria, but it is safe to say that such cases are entirely anomalous, if not, indeed, in some instances, examples of mistaken diagnosis.
8 Jahrb. f. Kinderk., xix. Bd., 1 Heft.
A very constant feature is the swelling of the lymphatic glands of the neck, especially those back of the sterno-mastoid; the swellings may come on before the rash appears. In all the cases that have fallen under my notice this symptom has not been absent in a single instance. Less constantly, and it would seem in proportion to the development of the rash, engorgement of the glands may be noted elsewhere.
There is but slight disturbance of the temperature in rötheln, and when it does occur it is usually limited to the first few hours of the eruption. This has been the rule in my observation, and certainly holds good for the majority of cases. In a minority, varying degrees of fever may be present; thus, the temperature may reach 102° F. or 103° F., and then rapidly sink by the second day of the disease, or, having fallen a degree, it may continue at this point till the subsidence of the rash, or, it is said, may retain its initial height till the end of the disease. During the following week Squire states that the temperature may be readily disturbed—either elevated by exertion or depressed by fatigue or chill. A relapse or recrudescence of the rash may be looked for at this time.9
9 Cheadle (Trans. Internat. Med. Congress, London, 1881) has reported an epidemic of rötheln of a very severe type, all the symptoms of the disease as ordinarily recognized being very much exaggerated.
COMPLICATIONS AND SEQUELÆ.—In the vast majority of cases neither complications nor sequelæ have been observed in connection with rötheln. J. Lewis Smith has recorded instances of diphtheritic inflammation as a complication, which, however, as he justly remarks, may, when prevalent, attack any inflamed surface. Pneumonia and bronchitis have been occasionally reported as complicating or following rötheln. Liveing and Duckworth mention albuminuria, but, so far as I know, they are alone in this experience. I have known otorrhoea and ciliary blepharitis to occur as sequelæ. It would not be a matter of surprise that in weakly children various chronic ailments should be set up by rötheln, as by any other disturbance of the general health.
DIAGNOSIS.—There is no other disease which so much resembles rötheln as measles. Especially is this true of atypical cases occurring sporadically. In rötheln the whole course of the disease is much milder than in measles, the incubation is longer as a rule, and the fact of a previous attack of rubeola is of much importance, since we know that recurrences are very rare. In measles there is a prodromic period, having a characteristic temperature curve, and presenting pathognomonic catarrhal symptoms, which precedes the eruption for three or four days; in rötheln the appearance of the rash is often the first sign of the affection. The sore throat of rötheln resembles that seen in scarlatina more than the angina of measles, and the general catarrhal implication of the mucous membranes, so marked a feature of measles, is either absent in rötheln or exists to a very trivial extent. Measles is essentially a febrile disease, having a peculiar type of fever; rötheln may run its whole course without appreciable rise of temperature. As will be seen in the preceding pages, the development and progress of the exanthem of measles differs materially from that witnessed in rötheln. In measles the lesions are larger, more vivid, more angular and indented, more frequently provided with processes, and therefore more apt to assume the crescentic arrangement, than in rötheln. Finally, it must be urged that the tout ensemble of the case should be taken into consideration, and not some special feature of the skin eruption.
The incubation period of scarlet fever is much shorter than in rötheln, and all of the constitutional symptoms are, as a rule, infinitely graver. In scarlatina there is a febrile invasion stage of twenty-four hours; in rötheln, if fever is present at all, it is most generally simultaneous with the rash, and rapidly disappears, while in the former it persists for a number of days longer. Vomiting is common in scarlet fever, rare in rötheln. In scarlet fever the lymphatic glands are notably involved at the angles of the jaw, in rötheln at the sides and back of the neck. Sore throat is a feature common to both scarlet fever and rötheln, but it is very much less marked in the latter. Thomas10 says that in scarlatina only the posterior parts, the uvula, the arches of the palate and their vicinity are affected, while in rötheln the anterior parts are also affected, and both in much the same degree. In scarlet fever the rash, which mostly begins on the neck and chest, is made up of large patches formed of minute red spots on a bright-red hyperæmic base; in rötheln the eruption is composed of roundish pea-sized macules, with normal integument intervening. In cases of doubt—for example, when the rash of rötheln consists of very small spots which have become confluent—the further development and persistence of the scarlatinal efflorescence, the temperature, the pulse, the angina, and the character of the desquamation must be taken into consideration. The complications and sequelæ are very different in the two diseases.
10 Article "Scarlatina," op. cit.
The symptomatic eruptions of the skin which pass under the name of roseola bear no resemblance to rötheln. They usually occur as the result of some trivial derangement of the system or in the course of some primary affection. They are not contagious, the lymphatic glands and the mucous membranes are not involved, and the rash is quite different in character.
PROGNOSIS.—The prognosis of simple uncomplicated rötheln is invariably good. Complications arising in delicate children necessarily affect the prognosis, as would any other disturbance of the general health.
TREATMENT.—Simple cases of rötheln require no treatment, as the patients are rarely sick enough to be confined to bed. Graver forms of the disease must be met by such measures as are indicated by the symptoms present. The after-management must be conducted on general principles having reference to the previous and present condition of the person attacked.