Names.—Scarlet fever takes its name from the redness of the skin, which appears early in the sickness. Many cases are extremely mild and show only a faint redness. Some doctors are unwilling to consider these cases to be true scarlet fever, and so they call them scarlatina, scarlet rash, or roseola, or rose fever, or rose rash. Scarlatina is the scientific name for scarlet fever, and means any case of scarlet fever whether it is mild or severe. The other names are used only to deceive the public. They mean scarlet fever. If there is doubt as to the nature of the disease in any particular case, the patient is entitled to the benefit of the doubt, and to receive the care that is due to a severe scarlet fever case, for a mild case may suddenly become severely sick.

Cause.—Scarlet fever is caused by an unidentified microorganism which is readily transmissible from the sick to other persons. Virulent streptococci are always associated with the special organisms of the disease itself, and are known to be the cause of many of the severe conditions that sometimes arise in the course of the disease. The sickness develops in from three to seven days after exposure to the infection.

Signs.—Scarlet fever begins suddenly, usually with vomiting and a fever. After about twenty-four hours the skin breaks out with a red eruption beginning in the throat and on the chest. The eruption in the throat causes it to be sore and the tongue to be red like a strawberry. The principal diagnostic marks are a sudden onset of fever with vomiting and sore throat, followed in a few hours by a red eruption on the skin. The scarlet fever germs themselves may be so virulent that they produce death. They may produce poisons which often cause kidney diseases. The severe complications of the disease are usually due to streptococci that grow with the special germs of scarlet fever. The streptococci often produce earache, running ears, mastoid disease, enlarged glands, and abscesses of the neck. They often produce a membrane in the throat resembling that in diphtheria and septic sore throat.

The eruption in scarlet fever is due to an inflammation of the skin and to microscopic blisters which form in the deeper layers of the epitheluim and loosen the cells. When recovery takes place, the loosened epithelium peels off, or desquamates, in flakes. The peeling usually begins in from fourteen to twenty-one days after the onset of the sickness. It usually commences around the roots of the nails and extends over the whole body, including the palms and soles.

There is no certain test for scarlet fever as there is for diphtheria and other diseases whose germs are known. Many cases are not sick enough to have a physician, and break out so slightly that the eruption is not noticed. An almost constant sign is the desquamation of the skin. If a child has a desquamation of the skin two or three weeks after it has had a slight fever, it may be considered to have had scarlet fever.

Method of Transmission.—The living germs of scarlet fever are found in the excretions of the nose and mouth, but they are not found in the skin, even during desquamation. The germs may also be present in discharges from the ear and from abscesses. The germs disappear when the nose and throat become normal and the discharges from the ears and abscesses cease, but they are present as long as the discharges from the nose, throat, ears, or abscesses continue. Many children who have had the disease in an unrecognized form go among other children while they are still carriers of the germs. These carriers are the cause of most of the cases of scarlet fever that are now seen.

Scarlet fever is transmitted by contact with the fresh discharges of the sick or with those of a carrier. The germs produce the disease in from two to seven days after they enter the body. If a child has been exposed to the disease and does not become sick within a week, it may safely mingle with other children. An attack of the disease usually produces an immunity that lasts for life.

Scarlet fever may also be milk-borne by means of germs introduced into the milk by a carrier working in a dairy.

Duty of the Health Officer.—Scarlet fever is a treacherous disease, owing largely to the presence of streptococci which are ready to attack any tissue that has been weakened by the special germ of the scarlet fever. Severe kidney troubles or ear diseases are likely to occur in mild cases which are exposed to the weather, overwork, and overeating. The disease is always a source of danger, and whenever a case occurs, it is the recognized duty of a health officer to take special precautions against its spread. These precautions include: 1, the discovery of cases; 2, isolation; 3, the disposal of excretions; 4, the protection of school children; 5, the treatment of cases; 6, the education of the public.

Discovery of Cases.—When a case of scarlet fever occurs, a health officer knows that it came from a previous case. The old case has usually been a mild one whose nature was not suspected. Children in school are frequently discovered with peeling skins and giving histories of a transient vomiting and sickness two or three weeks previously. These are probably missed scarlet fever cases, and many will be found during an epidemic. They would be discovered between epidemics if the school and health authorities would look for them.

The recognition of scarlet fever is often difficult. Mild cases are often called simple tonsillitis. Scarlet fever often resembles septic sore throat. Experiences with epidemics of septic sore throat seem to indicate that hemolytic streptococci of bovine origin may produce a disease in which there is a skin eruption like that of scarlet fever, but no sore throat.

A skin eruption like that in scarlet fever may be produced by drugs, by antitoxin, by certain foods, and by burns. Harmless skin eruptions, such as unusual forms of hives, often resemble scarlet fever. The public will be fortunate if the health officer enjoys the confidence of the physicians to such an extent that they are willing to report all doubtful cases to him, and to leave the final diagnosis to his judgment. If the health officer is in doubt, his wisest course is to inform the head of the afflicted household of his doubt, and to ask that the suspected person be kept at home and away from the rest of the family; and to wait two or three weeks for the appearance of the desquamation of the skin. If the case is scarlet fever, the desquamation will nearly always appear. It may not be an absolutely sure sign of scarlet fever, hut it is the best sign that we have. Extremely severe cases of scarlet fever may resemble smallpox, but the infective nature of these cases is evident, and the health officer will order all precautions to be taken in all of them.

Isolation.—The rule of New York State is that a case shall be isolated for thirty days, or until the nose and throat become normal and there are no more abnormal discharges, such as those from the ear and abscesses. Peeling of the skin may be disregarded, but it would be unwise to frighten the public by allowing a child with evident peeling to mingle with others. There is a tendency among health workers to govern the length of time of isolation by the state of the diseased parts rather than by any fixed or arbitrary length of time.

If a child is properly isolated in one part of a house, grown persons living in the same house may safely continue at their work, provided they do not handle food products. If they handle food, and especially milk, they must not continue at their work unless they stay away from the house.

Children who live in a scarlet fever house must not attend school or mingle with other children. The reason for this rule is the unreliability of children and the ever-present possibility that they may come in contact with the sick person.

Children who live in a house in which there is scarlet fever may be divided into two groups: 1, the immunes, or those who have had the disease; and 2, the non-immunes, or those who have not had it. If the immune children leave the house, they may be released from isolation and quarantine. If the non-immune children leave the house, they must be kept under observation for seven days, in order to be sure that they do not develop the disease. If then they do not come down with the disease, they may be discharged.

Disposal of Excretions.—The infective material in scarlet fever is found in the excretions of the nose and throat, and of the bowels and bladder. The excretions of the nose and throat may safely be received in cloths and papers and burned. The excretions of the bowel and bladder may safely be emptied into a sewer or cesspool, or they may be buried. Those that remain on the face and hands of the patient and on his clothing and bedclothes and on the floors and furniture of the room may be readily killed or removed by the ordinary processes of washing and cleanliness. The germs are not particularly long lived, hut they are readliy killed by the same processes by which other disease germs are killed. It was formerly supposed that scarlet fever could be spread by the germs that had survived for months on clothes and playthings. The existence of many unrecognized carriers would account for the cases of the disease which have followed the use of articles which had been handled by scarlet fever patients months previously. Practical experience has abundantly demonstrated that ordinary cleanliness is sufficient to render articles free from scarlet fever germs.

Protection of School Children.—When scarlet fever develops among the children of a school, almost the only danger is that from mild and unrecognized cases. Any child who is likely to spread the disease will give signs which teachers, the school nurses, the medical inspectors, or the health officers can readily recognize if they are on their guard. An inspection of the school children may reveal three suspicious groups: 1, children who are taken suddenly with a mild sickness; 2, children with sore throats; and 3, children whose skins are peeling. These children may possibly have the disease or have had it recently. If they are discovered and excluded, the school may continue its sessions as usual.

Treatment of Cases.—Getting scarlet fever cases well as soon as possible is essential in preventing the spread of the disease. It is the duty of a health officer to know the modern methods of handling scarlet fever, and to place his knowledge at the disposal of family physicians.

Most of the dangerous complications of scarlet fever arise from unclean conditions of the nose and throat. A nose that is stopped up and full of mucus is a culture place for streptococci, and a center from which the streptococci spread to the ears and the tissues of the neck. An efficient method of preventing the complications is that of cleansing the nose with normal salt solution (6/10 per cent. of salt in water). The salt solution may be sprayed up the nose, or it may be poured into the nose while the child lies upon its side. The solution may frighten a child at first, but the relief and comfort after its use is so great that children often ask for it. If a child who needs it objects to its use, the kindest procedure is to hold the child firmly and apply the solution thoroughly. It is surprising how quickly and gladly children in contagious disease hospitals submit to having their noses cleansed.

The blood of a person who has recently recovered from scarlet fever contains the antibodies against scarlet fever. This blood has been used with excellent results in the treatment of severe cases of scarlet fever. The method is as follows: Draw from 4 to 8 ounces of blood from the donor's vein with a hypodermic syringe, and inject it at once deep into the muscles of the recipient. The blood is soon absorbed, and the dangers of an intravenous injection are avoided.

Education.—The efficient control of scarlet fever depends on the intelligent co-operation of the public with the health officer. Some of the modern methods of dealing with contagious diseases often seem lax to the public, and the people wonder at the omission of old and discredited procedures. The people will co-operate with the health officer when they become famliiar with the new methods of public health work. Every case of scarlet fever is a center for educating the family and the neighbors. Every case in a school affords an opportunity to explain the new methods of handling contagious diseases. Nothing is gained by secrecy concerning contagious diseases, but a health officer will promote his work by taking advantage of every opportunity to educate the people in all phases of preventive work.

Epidemiology.—When a scarlet fever epidemic breaks out, the health officer or visiting epidemiologist will make an investigation. He will obtain information from all the cases, and will analyze it to see if there has been a common milk-supply or other common source of infection. He will also seek to make an accurate diagnosis in every case. It is possible to have an epidemic of scarlet fever intermingled with one of septic sore throat. If both diseases exist side by side, an accurate diagnosis is not necessary, provided all the cases are subjected to the measures of control which are proper in scarlet fever. Both diseases may be spread by personal contact, and by milk, and the same measures of investigation and control apply to each. If an epidemic is milk-borne, the exclusion of the milk from market, or its pasteurization, will control the grosser routes of the spread of infection; but an isolation of the individual cases will be necessary to prevent the development of secondary cases.

Scarlet fever is usually spread by contact, and the chief difficulty in its control is to discover and isolate the individual cases which have not been recognized or treated, but which continue to mingle with other persons. The signs which make a health officer suspicious that a person has had scarlet fever very recently are a peeling of the skin, a redness of the throat, a history of vomiting or other signs of a slight sickness from one to three weeks previously, a history of the exposure of the suspected person to a previous case, and the development of fever in a child who has been exposed to the suspected person. The presence of any of these signs during an epidemic is strongly suggestive of scarlet fever. The control of these cases consists in excluding them from contact with other people.

Frank Overton

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