Of Scarlatina. Characters by which it is distinguished from Continued Fever, without an Eruption. Division into Scarlatina Synochodes and Typhodes. Events which occasionally occur in Fever, but which form no essential Part of it.

The only kind of continued fever attended with an eruption, which it falls within the compass of the present work to notice, is that of scarlatina, and, even in relation to this, after the full account which has been given of the other forms of fever, it will be necessary to state only the peculiarities by which it is distinguished.

1. The depression of the nervous system so characteristic of synochus and typhus, is much less in degree in scarlatina. Neither the physical nor the mental debility is as great. In the whole attitude and manner of the patient, as well as in his own sensations, there is less prostration. The disease is more nearly allied to a pure inflammatory affection than either of the preceding forms of fever.

2. Accordingly, the circulation is not only more rapid, but it is also more strong. It is not uncommon for the pulse to be 140 in a minute; in severe cases it is seldom below 120. Without being hard, it is more full and strong and less easily compressed than in the other forms of fever.

3. Corresponding with the activity and energy of the circulation is the increase of the temperature; the heat over the whole surface of the body is often intense and pungent. In this fever, the temperature, as indicated by the thermometer, rises several degrees higher than in any other.

4. The capillary vessels of the external skin, as is shewn by the bright and vivid colour of its characteristic eruption, are filled with blood. Often from the crown of the head to the sole of the foot, the external covering of the body is in a state of inflammation, and this inflammation constantly terminates in the death of the cuticle, whence it is thrown off by the process of desquamation. It is not improbable that the large quantity of blood which is thus spent upon the surface of the body, and which is thereby diverted from the internal organs, is one reason why the latter are not so much oppressed as in the other forms of fever.

5. Much as the external skin is loaded with blood, the capillary vessels of the internal skin appear to be equally turgid with it. This is indicated by the bright and vivid redness of the mucous membrane covering the mouth, the tongue, the fauces and the throat. That this redness extends beyond these external parts into the internal organs there is abundant evidence, because, although we cannot follow it with the eye, we can trace it by the signs of disordered function which arise.

6. Certain parts of the internal skin, as it covers particular organs, is peculiarly apt to pass into inflammation, and to terminate, like ordinary inflammation, in ulceration. The principal seats of inflammation are the throat and the larynx; but that, on the one hand, the inflammation extends from the throat into the stomach, is evident from the peculiar tenderness of the epigastrium, which is almost constant in scarlatina, and which is more acute than in ordinary fever; and that, on the other hand, it extends from the larynx into the bronchi and their ramifications, is evident from the symptoms of thoracic affection, which are at once more prominent and more constant than in the other forms of fever. The larynx, the cartilages of which are apt to be destroyed by ulceration, in the severe and mortal cases, is now and then attacked with a peculiar kind of laryngitis, to be further noticed in the pathology, which is almost uniformly and most rapidly fatal.

7. From the preceding observations, the new symptoms which are added to the febrile train in scarlatina, and which arise out of the modification of the fever by its complication with an inflammatory condition of the external and internal skin, are easily understood. They are the following: namely,

Scarlet eruption on the skin; vivid and peculiar redness of the mouth, tongue, fauces and throat: the presence of the disease may usually be discovered by this peculiar and specific redness of the tongue and throat alone, although every other characteristic symptom were absent: pain in the throat, difficult deglutition, huskiness and hoarseness of the voice. To these must be added other symptoms, which, though they are sometimes present in ordinary fever, are both more constant and more severe in scarlatina than in the latter, namely, pain in the chest, cough, difficult and hurried respiration, duskiness, in severe cases lividness of the cheek, often, especially in the commencement of the attack, nausea and vomiting.

Such are the chief peculiarities by which scarlet fever is distinguished: in all other respects the condition of the organs, and the symptoms which denote their disordered state are the same as in continued fever without an eruption.

Scarlatina occurs under two forms.—1st, With the symptoms common to synochus, (scarlatina synochodes) a form which, however severe the symptoms, if properly treated, rarely proves fatal. In general, it is a trifling malady, and, when severe, its chief danger consists in its tendency to pass into the second form, if it be neglected, or if it be badly treated. Under the most formidable aspect it ever presents, if the active treatment, which, when the symptoms are severe, ought always to be employed, be resorted to with promptness and decision, in more than ninety cases out of a hundred, those symptoms are certainly and effectually subdued, and the disease, although it may not be cut short at once, is at once rendered mild and safe.

2. The second form of the disease (scarlatina typhodes) presents a striking contrast to the first: it is one of the most highly dangerous diseases which the practitioner in this country is ever called to witness. It is invariably attended with the symptoms which have been described as proper to typhus gravior. And these symptoms may consist either of those which belong to the first form of typhus gravior, and which have been already described,^[26] or they may be those which characterize the second, or the congestive form.^[27] The former is the most frequent, but the latter is not uncommon. The most exquisite specimens of congestive fever which it has happened to me to witness, have been those afforded by scarlatina: and there is no disease incident to this climate which is more alarming, more beyond the reach of remedies, or more rapidly fatal. Though fortunately several years may sometimes elapse without the occurrence of a single case of it, yet occasionally seasons return in which many cases happen. I have witnessed two such seasons in London, and all the persons I remember to have seen affected with it were near the age of puberty and not beyond that of thirty. For examples of it the reader is referred to the pathology.

Before bringing to a close this account of the general phenomena of fever, it is necessary briefly to notice some events which, because they occasionally occur in the progress of the disease, but are not constant, may be considered as accidental.

1. It is not very common, but there sometimes takes place an extreme degree of tenderness over the entire surface of the body. The sensibility is so much increased that the patient cannot bear, without pain, the slightest pressure. Several cases have occurred in which the entire skin was as tender to the touch as the abdomen in some of the abdominal cases. Whenever this preternatural sensibility occurs, it is always in connexion with an exceedingly severe form of the disease.

2. One of the most common occurrences in severe and protracted cases is excoriation of the skin, and the subsequent formation of a sloughing sore. In bad and long-continued cases of fever the powers of life are so much exhausted, and the sources of nourishment are so completely vitiated, that the skin and the subjacent parts have not vitality sufficient to bear even the pressure occasioned by the weight of the body. The most common seats of these sores are the back, the sacrum, and the hips. They often spread far and eat deep; they are additional sources of irritation and exhaustion to a frame already reduced to the last extremity of feebleness, and the scale which seemed to be equally balanced between life and death, they often turn on the side of death.

3. In severe and protracted cases, and often coming to destroy the hope that was beginning to spring up in favour of the patient, erysipelas is no unusual visitant. It is the outward and visible sign of inward and always most formidable disease. Many and many are the persons it destroys who, but for it, would ultimately gain the victory over a malady with which they have carried on a doubtful contest, perhaps for fourteen or for one and twenty days.

4. Pain, swelling, hardness and suppuration of the glands in different parts of the body are not uncommon. The gland which most commonly suffers is the parotid, although the submaxillary, the axillary, and even the inguinal, are occasionally involved. These glandular affections never take place but in formidable cases, and their occurrence sometimes changes at once the entire character of the disease, and destroys the slightest hope of recovery.

5. Now and then there take place severe pain in the joints, together with tumefaction and excessive tenderness on pressure. These events usually come on towards the close of exceedingly bad cases, and they are often attended with very acute suffering. Neither the occurrence of the events nor the appearances presented on examination after death, have hitherto been noticed, as far as I am aware, by any author. Every case attended with this peculiar affection that I have seen, has proved rapidly fatal. The condition of the joints, as ascertained by dissection, will be stated in the pathology.

Purulent discharge from the ears, deafness, spasmodic contraction of the extremities, convulsions, all depend upon certain states of the brain, and will be noticed when these states are spoken of. Numerous maladies arising from various degrees and complications of disease in the lungs, heart, pleura, viscera of the abdomen and investing membrane, not belonging to fever, but adding to its evils, are found on examination after death, which often fully account for anomalous symptoms that aggravated the case during life. Of these mention will be made in the proper place.