SCARLET FEVER 377 looking. This form of the disease is marked by great prostration of strength, and it is much more frequently fatal than the preceding. 3. Scarlatina Maligna is the most serious form of all. The malignancy may be variously displayed. Thus a case of scarlatina angiuosa may acquire such a severe character, both as to throat and general symptoms, as rapidly to produce profound exhaustion and death. But the typically malignant forms are those in which the attack sets in with great violence and the patient sinks from the very first. In such instances the rash either does not come out at all or is of the slightest amount and of livid rather than scarlet appearance, while the throat symptoms are often not prominent. Death in such cases may take place in from twenty- four to forty-eight hours, and is frequently preceded by great eleva- tion of the temperature of the body and by delirium, coma, or other nervous symptoms. A further example of a malignant form is occasionally observed in cases where the rash, which had previously been well-developed, suddenly recedes, and convulsions or other nervous phenomena and rapid death supervene. The complications and effects of scarlet fever are, as already indicated, among the most important features in this disease, and, although their occurrence is exceptional, they appear with sufficient frequency, and are of such a nature, as ought to make the medical attendant carefully watch every case for any of their early indications. The most common and serious of these is inflammation of the kidneys, which may arise during any period in the course of the fever, but is specially apt to appear in the con- valescence, while desquamation is in progress. Its onset is sometimes announced by a return of feverish symptoms, accompanied with vomiting and pain in the loins; but in a large number of instances it occurs without these and comes on insidiously. One of the most prominent symptoms is slight swelling of the face, particularly of the eyelids, which is rarely absent in this complication. If the urine is examined it will probably be observed to be diminished in quantity and of dark smoky or red appear- ance, due to the presence of blood ; while it will also be found to contain a large quantity of albumen. This, together with the microscopic examination which reveals the presence of tube casts containing blood, epithelium, &c., testifies to a condition of acute inflammation of the kidney (glornerular and tubal nephritis). In favourable cases these symptoms may soon disappear, but they may on the other hand prove extremely serious, the risks being the suppression of urine, leading to urasmic poisoning and causing convulsions which may terminate fatally, or, further, the rapid development of general dropsy, and death from this cause. Although thus a very formidable complication, it is yet one which is amenable to treatment, and by the prompt and judicious application of remedies lives may often be saved, even in desperate circumstances. Occasionally this condition does not wholly pass off, and consequently lays the foundation for BRIGHT'S DISEASE (q.v.). Another of the more common complications or results of scarlet fever is suppuration of the ears, due to the extension of the inflammatory process from the throat along the Eustachian tube into the middle ear. This not unfrequently leads to permanent ear- discharge, with deafness from the disease affecting the inner ear and temporal bone, a condition implying a degree of risk from its proximity to the brain. Other maladies affecting the heart, lungs, pleura, &c., occasionally arise in connection with scarlet fever, but they are of less common occurrence than those previously mentioned. Apart, however, from such definite forms of disease there may remain as the result of scarlet fever simply a general weakening of health, which may render the patient delicate and vulnerable for a long time. In the treatment of scarlet fever, one of the first require- ments is the isolation of the case, with the view of prevent- ing the spread of the disease. In large houses this may be possible, but in most instances it can only be satisfactorily accomplished by sending away those other members of the family who have not suffered from the fever. The establishment in many large towns of hospitals for infec- tious diseases, which provide accommodation for patients of all classes, affords the best of all opportunities for thorough isolation. In large families, where few or none of the members have had the disease, the prompt removal of a case to such an hospital will in many instances prevent the spread of the fever through the household, as well as beyond it, and at the same time obviate many difficulties connected with the cleansing and purification of the house, which, however carefully done, may still leave remaining some risk in the case of a fever the contagious power of which is so intense. When, however, the patient is treated at home, the sick room should contain only such furniture as may be re- quired, and the attendants should come as little as possible in contact with other members of the household. Should other children be in the house, they should be kept away from school during all the time that the risk of infection continues. The possibility of the fever being communi- cated by letters sent from the sick room should not be forgotten by those in attendance. Disinfectants, such as car- bolic acid, Condy's fluid, &c., may be used freely in the room and passages, and all body or bed clothes when removed should be placed at once in boiling water, or in some disin- fecting fluid. In convalescence, with the view of preventing the transmission of the desquamated cuticle, the inunction of the body with carbolized oil (1 in 40) and the frequent use of a bath containing soda are to be recommended. All books, toys, &c., used by the patient during the illness should be carefully destroyed or given to fever hospitals, as their preservation has frequently been known to cause an outbreak of the disease at a subsequent time. With respect to the duration of the infective period, it may be stated generally that it is seldom that a patient who has suffered from scarlet fever can safely go about before the expiry of eight weeks, while on the other hand the period may be considerably prolonged beyond this, the measure of the time being the completion of the pro- cess of desquamation in every portion of the surface of the body. As to general management during the progress of the fever, in favourable cases little is required beyond careful nursing and feeding. The diet all through the fever and convalescence should be of light character, con- sisting mainly of milk food. Soups may be taken, but solid animal food should as far as possible be avoided. During the febrile stage a useful drink may be made by a weak solution of chlorate of potash in water (1 drachm to the pint), and of this the patient may partake freely. In the more severe forms of the disease, where the throat is much affected, the application with a brush of a strong solution of Condy's fluid or other disinfectant, such as boroglyceride, glycerine of carbolic acid, quinine, &c., may be required, or gargling with these substances when this can be done. In the malignant variety, where the eruption is not appearing, or is but ill developed, stimulants inter- nally, and the hot bath or pack, may sometimes afford a chance, or the hypodermic use of pilocarpin, although it must be confessed that in such cases little can be expected from any remedies. The treatment of the kidney com- plication and its accompanying dropsy is similar to that for acute Bright's disease. Depletion by leeching or cup- ping the loins, and the promotion of cutaneous action by a hot air bath or a hot wet pack, or by pilocarpin, are the most useful measures, and will often succeed in saving life. The abscesses of the neck which occasionally occur as complications should be opened antiseptically, while the ear disorders, which are apt to continue long after the termination of convalescence, will demand the special attention of the aurist. (* o. A.) XXI. 48
