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of the Eustachian tube. The disease may terminate in death and sloughing
of the tissues of the neck is not an unusual occurrence.
2. Malignant scarlatina is characterized by a severe toxaemia which may
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overwhelm the patient and result in death even before the diagnosis is made.
Hyperpyrexia is present, the pulse is very rapid, soon becoming weak, the
prostration is marked and the cerebral symptoms are profound. Death takes
place from adynamia.
3. Hcemorrhagic scarlatina is typified by the appearance of extravasations
of blood beneath the skin and mucous membranes resulting in epistaxis,
haematemesis, intestinal haemorrhage, haematuria, etc. This form of the
disease is usually fatal.
Complications. Of these nephritis is the most important and perhaps
the most frequent. It is of acute type and must not be confounded with the
albuminuria which so often occurs when the fever is at its height. It is
224 THE INFECTIOUS DISEASES.
usually evidenced by the appearance of albumin and casts in the urine but
instances have been noted in which renal changes have been found post mor-
tem when no symptoms suggesting nephritis had been present. The condition
is probably the result of the toxic action of the poison of the infection and
occurs in several forms: a, A mild type with slight oedema and albuminuria
and a few casts; h, a more severe type, with more marked oedema, dark urine
with more abundant albumin and casts and transudates into the serous cavities,
resulting in death with tiraemic symptoms, chronic nephritis or, as a rule,
recovery; c, a haemorrhagic type, with scanty urine containing blood, albumin
and numerous casts. Anuria may occur, vomiting and convulsions are fre-
quent; the outcome is usually rapidly fatal and due to ursemic poisoning.
Endocarditis is not rare. This may persist after recovery from the scarla-
tina or may occur in a malignant form which is usually fatal. Myocarditis
and pericarditis are less frequent but are complications to be dreaded.
Pleurisy, empycema, bronchitis and broncho-pneumonia are less common
complications.
An arthritis may occur in one of two forms : an arthritis similar to that occur-
ring in other infections such as enteric fever or gonorrhoea and involving
several joints as a rule, or a suppurative inflammation affecting one or more
articulations. The prognosis is good in either t^'pe.
Otitis is a serious and not uncommon complication and is the result of the
extension of the throat inflammation through the Eustachian tube to the
middle-ear. Perforation of the tympanic membrane is frequent and mastoid-
itis with all possible complications may foUow. Impairment of hearing or
complete deafness may result.
Adenitis accompanied by glandular enlargement in the cervical region
is very common and may go on to abscess formation and necrosis in the deep
tissues of the neck.
Complications referable to the nervous system are rare but sometimes
occiir. Of these the most important is chorea which may be associated with
the arthritis and endocarditis. Hemiplegia, progressive paralysis and cere-
bral thrombosis have been observed.
The diagnosis of scarlet fever is usually not difl&cult in typical instances,
the rash, the pharyngeal symptoms and the tongue being characteristic.
Scarlatina may be differentiated from measles by its more abrupt invasion,
the presence of throat symptoms, the absence of the buccal spots and catarrhal
symptoms and the desquamation; from rubella by its more severe constitutional
symptoms and characteristic tongue; from diphtheria by its eruption and by
bacteriological examination, but it must not be forgotten that the two infec-
tions may be present simultaneously; from drug eruptions by the presence of
constitutional symptoms and sore throat; and from acute exfoliative dermatitis
by the presence of the characteristic tongue and throat symptoms. In der-
SCARLATINA. 2 2$
matitis the desquamation differs, the skin being thrown off in crusts and
scales; a moist surface is frequently left.
The prognosis is variable. In some epidemics the mortality is high, but
as a rule the death rate in this disease is not great. It is higher in infants
and in institutions. The malignant and fulminating cases are fortunately
not common for they are almost certainly fatal. Complications are usually
responsible for death when this occurs in the ordinary t}'pe of the disease.
Relapses in scarlatina are rarely observed.
Treatment. Prophylaxis is most important for by proper methods the
disease may be to a great extent prevented. Isolation during the course of
the disease and thorough disinfection of the sick-room and its contents are
absolute essentials. The physician should always cover his ordinary clothing
with a long gown while visiting the patient and upon leaving should disinfect
his hands and his face and hair in so far as is possible. Only the persons
immediately concerned in the care of the patient should be allowed in the
sick-room, all the excreta should be rigidly disinfected and the skin, especially
during desquamation, should receive inunctions or baths in some antiseptic
solution to prevent dissemination of the exfoliated epidermis. The quarantine
should be continued for from 6 to 8 weeks after the inception of the disease.
A careful system of school inspection will do much to prevent the spread
of this infection.
The treatment of the disease itself consists in strict confinement to bed
during the febrile period and for a week or ten days thereafter, the control of
symptoms and in prevention of complications. The mild types of the disease
need little or no medication. The sick-room should be light, well-ventilated
and kept at a uniform temperature of from 65° to 68° F. (18.5° to 20° C).
The itching and burning caused by the eruption may be relieved by inunctions
of carboHzed vaseline, 5 percent, ichthyol ointment in lanolin, 5 percent,
boric acid ointment in vaseline. Sponging with very weak (| percent.) phenol
solution as well as dusting with talcum powder are also useful. Inunctions
of colloidal silver (unguentum Crede) may exert an effect upon the septic
nature of the disease as well as a beneficent influence upon the skin. Inunc-
tions are particularly indicated during desquamation to prevent the dissem-
ination of the scales. Baths of warm soapsuds may also be given and if
the skin is irritated, bran baths may be employed.
The temperature in ordinary cases may be neglected but should it rise
above 104° F. (40° C.) it may be reduced by the application of an ice coil
over the heart, cool sponging or cool packs. Quinine has been advocated;
the only effect which it can have in this disease is to temporarily lower the
temperature. For the cerebral symptoms cool sponging, the ice cap and
small doses of salipyrine, salophen, acetphenetidine or antipyrine may be em:-
ployed. These drugs while reducing the tendency to insomnia and restless-
15
226 THE INFECTIOUS DISEASES.
ness also have an antipyretic effect. A daily sponge bath with tepid water
and soap should be given for the sake of comfort and cleanliness.
Stimulation in the milder forms of the infection is unnecessary but in severe
cases of septic or anginose type with weak, rapid and irregular pulse it is
indicated. Brandy or whiskey is usually preferable, the dose depending
upon the condition in hand. Digitalis as the tincture may be given when the
pulse is rapid and of low tension, the dosage for a child 5 or 6 years old being
I drop (0.065) every 5 or 6 hours. Strychnine in doses of from 2'i-o to yiiy
of a grain (0.0003 to 0.0006) may be given alone or in connection with other
stimulants.
Throughout the disease the bowels should be kept freely open, an initial
course of fractional doses of calomel followed by a mild saline being indicated
at the onset. As the disease progresses saline laxatives may be given from
time to time or the high intestinal irrigation with hot water (112° F. — 44.5° C.)
may be employed. The latter is a most excellent stimulant and diuretic
and an aid of considerable value in the elimination of the poison of the
infection.
Pilocarpine has been recommended in the treatment of scarlatina; it is
said to reduce the temperature, to improve the condition of the throat and to
prevent glandular involvement. It should not be given with the coal tar
antipyretics and should idiosyncrasy to the drug be present atropine will
be found to be an effective antidote.
The simple form of pharyngitis needs no other treatment than a mild
antiseptic mouth wash or throat spray of Dobell's solution or of diluted liquor
antisepticus which should be applied every 4 hours. Nasal involvement
should be controlled by syringing or spraying with similar agents. The
severer throat inflammations should be carefully treated in order to prevent,
if possible, aural complications. Here hot or preferably cold applications
should be made to the throat externally and endeavors should be made to keep
the throat itself as nearly clean as possible. Frequent irrigations of hot, mildly
antiseptic solutions such as ^ satm-ated solution of boric acid, o.i percent,
iodine trichloride, 0.2 percent, salicylic acid, etc., are useful. The irrigation
should be of considerable quantity and given while the child is lying with its
head turned to one side and slightly lower than the rest of the body. It may
be given by means of a fountain or ordinary syringe to which a soft rubber
catheter is attached. If the swelling is marked and there is tendency to
oedema, sprays containing adrenalin chloride may be employed and steam
inhalations impregnated with compound tincture of benzoin or eucalyptol
may be prescribed. Insufflations of equal parts of sozoiodol and sublimed
sulphur are recormnended; 10 percent, phenol in glycerin may by injected
into the seat of the inflammation in instances of gangrenous tonsillitis.
Slight enlargements of the cervical glands usually subside without treat-
SCARLATINA. 227
ment but more marked glandular involvement necessitates the employ-
ment of continuous cold by means of the ice bag held in place by bandages.
Inunctions of ointment of colloidal silver (unguentum Crede) are useful and
a thin gauze compress impregnated with 10 percent, ichthyol ointment may
be applied to the glands beneath the ice bag. The presence of pus demands
immediate incision and drainage.
The prevention of complications is a most important part of the treatment
of this disease. While at times these occur in spite of all attempts at prophy-
laxis, this fact should not deter the physician from employing every means
in his power. In preventing the incidence of nephritis It is particularly
necessary to watch the urine carefully, examining it at least once a day, to
studiously guard the patient against exposure to draughts, to continue the fluid
diet and the confinement to bed for at least a week after all febrile symptoms
have disappeared and not to allow the patient to leave the sick-room too soon.
It is far better to err upon the safe side in this regard than to permit the patient
to go out too early. Recently the use of hexamethylene (urotropin) has
been advocated as a prophylactic against scarlatinal nephritis and has seemed
efficient in some instances while inert in others; it certainly can do no harm
when given in proper dosage and carefully watched. The prophylactic use
of digitalis has also been recommended and it would seem that the employ-
ment of high rectar irrigations of hot saline solution should be effective. The
treatment of scarlatinal nephritis when it occurs is identical with that of
acute nephritis when occurring from other causes.
The prevention of aural complications consists in the methodical and
thorough treatment of the pharyngeal conditions as laid down above. The
drum membranes should be inspected daily for any sign of bulging and when
necessary immediate paracentesis should be done, the opening to be kept
free as long as there is the slightest tendency to discharge. The discharging
ear should be irrigated with warm boric acid solution in considerable quantity
every 4 hours. The practitioner should never hesitate to summon the otolo-
gist in consultation when the condition is in the least doubtful, for upon
proper management of the aural complications of scarlatina the patient's
hearing may depend. Mastoiditis, internal ear involvement, sinus thrombosis,
etc., are conditions for the otologist alone and their discussion is beyond the
scope of this work.
The treatment of the joint complications consists in immobilization and
the application of hot moist compresses. While by no means always satis-
factory in its results, the administration of the salicylates should be under-
taken. These may be given in appropriate dosage by mouth, or salicylic
acid may be given by inunctions as suggested under the treatment of acute
articular rheumatism. Acetyl-salicylic acid (aspirin), adult dose from gr. x to
XV — 0.66 to i.o, may be employed. The chronic joint complications neces-
228 THE INFECTIOUS DISEASES.
sitate the internal and external exhibition of the preparations of iodine. The
presence of pus in a joint is an indication for immediate surgical inter-
ference.
The treatment of the other complications is identical with that to be insti-
tuted when these occur independently.
Advances have been made diiring recent years toward the serum treatment
of scarlatina by means of antistreptococcus serum; this serum is used rather
to combat the complications which are due to streptococcus infection than
with the hope of influencing the disease itself. The results, particularly
those attained with Moser's serum, would seem to justify the employment
of this means of treatment. It is particularly indicated in the severer and
complicated types of the infection. The serum is given in considerable
amounts and acts best when administered in the early stages. The initial
dose may be about 5 drachms (20.0) and a total quantity of 5^ ounces (180.0)
has been given. The disadvantages of the treatment are its costliness and the
large amount of serum necessary.
Von Leyden's so-called convalescent-serum is reported to achieve good
results.
The treatment of convalescence consists in the employment of tonics and
careful watching of the urine which should be examined at intervals for a
considerable period. Persistent nasal and throat symptoms necessitate
the employment of antiseptic sprays.
The diet of the disease should be of milk — ^plain or peptonized — only
throughout the febrile movement and as a preventive of nephritis for a week
or ten days after the normal temperature has been reached. After this time
an ordinary regimen may be gradually and carefully resumed.
FOURTH DISEASE.
Synonym. Dukes's Disease.
This affection is considered by Dukes to be an independent disease of mild
character which simulates mild scarlatina, but differs from it in that its incu-
bation period is much longer, being from 9 to 21 days, and in its lack of pro-
dromal symptoms. The eruption resembles that of scarlet fever except
that it appears first upon the face; it is usually followed by profuse desqua-
mation.
Many observers doubt the existence of this disease as a separate entity,
and it is certain that, before its identity can be clearly established, further
study must be made of rubella. It has been suggested that this affection
may be the result of a simultaneous infection with scarlatina and rubella.
Its treatment is entirely symptomatic and to be based upon that of the
other infectious exanthemata.
VARICELLA. 229
VARICELLA.
Synonym. Chicken-pox.
Definition. An acute infectious febrile disease of mild type characterized
by a vesicular eruption and usually seen in children.
.etiology. The disease occurs sporadically but from time to time epidem-
ics are observed. It is essentially a disease of children but adults who are
not immune through an attack in childhood are quite likely to contract the
infection. The affection is met in all climates and at all seasons and while its
specific cause has not yet been isolated it is presumably a micro-organism,
probably a protozoon. The contagium is found in the contents of the vesicles
and the disease may be reproduced by inoculation with this. The disease
is markedly contagious and is transmitted by direct contact and possibly
through a third person.
Symptoms. The incubation period is from 10 to 16 days and the appear-
ance of the eruption may be the first noticed symptom. In other instances
there may be mild prodromata such as irritability, malaise and slight fever.
The invasion may be marked by a chill of slight degree followed by a rise of
temperature to 101° to 103° F. (38.5° to 39.5° C), vomiting, headache and
perhaps general pains. The eruption appears, without other symptoms
or within 24 hours of the incidence of the invasion, first upon the upper part
of the trunk, although it is usually first observed upon the face; upon the
face the rash is usually scanty but the scalp is always involved. It occurs
first in the form of small reddish points which quickly become rounded rose-
colored macules. These become successively papules and vesicles within
a few hours. These last vary from yV to J an inch in diameter and later
contain turbid fluid. Usually they are not umbilicated but at times this
manifestation may be observed. In about 48 hours from their original appear-
ance the spots have become pustules which upon being pricked collapse
entirely, which is not the case with the pustules of smallpox. The rash lasts
from 2 to 5 days when the pustules begin to dry, a brownish crust resulting,
which soon falls leaving no scar; in certain instances a depression is left which,
however, is seldom permanent. Successive crops of the eruption appear
and the rash may be seen in all stages at the same time. If the vesicles are
scratched or irritated small cicatrices may remain. The rash is also seen
upon the lining of the mouth and pharynx and perhaps on that of the larynx.
A scarlatiniform blush may precede its appearance. The eruption of vari-
cella is always discrete and in mild cases there may be not more than 10 to
20 vesicles upon the whole body.
The temperature falls by lysis as the rash fades and as this occurs the other
symptoms, if any have been present, disappear. The disease in children
previously healthy is very mild but may be more severe in those less fortunate.
230 THE INFECTIOUS DISEASES.
In the latter complications such as nephritis and paralyses have been observed.
A haemorrhagic form of the disease with extravasations of blood into the
eruption and from the mucous membranes has been described and gangrene
of the skin about the pocks and of the scrotum has been noted in strumous
children. Erysipelas and adenitis are possible compHcations.
The diagnosis is not dif&cult. The lack of constitutional symptoms, the
occurrence of the eruption in all stages at one time, the absence of umbil-
ication of the vesicles and of a surrounding areola are characteristic. There
is no sjiotty feel under the skin as in smallpox. In infants the differential
diagnosis between severe t}^es of variola and mild cases of varioloid may