A system of practical medicine. By American authors. Vol. 1

by Unknown

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.