Communicable Diseases, Table of Contents
CHAPTER XI
SCARLET FEVER
STATISTICAL CONSIDERATIONS
During the World War, scarlet fever stood forty-fifth on the list ofimportant diseases in the United States Army, based upon the number of primaryadmissions (11,675) to sick report. From the standpoint of deaths, scarlet feverstood ninth on the list of important diseases, being exceeded by the followingdiseases in the order named: Influenza, lobar pneumonia, bronchopneumonia,measles, tuberculosis of the lungs, epidemic meningitis, appendicitis, andbronchitis. There were reported 354 deaths from scarlet fever for the total Armyduring the World War among the primary admissions. The admission ratio per 1,000strength for the total Army was 2.83 and the death ratio 0.09.
There were 18 cases discharged from the service on account of disabilityfollowing scarlet fever. These cases were among white enlisted men.
aUnless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.-Ed.
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TABLE 60.-Scarlet fever. Admissions,deaths, discharges for disability, and days lost, by countries, officers andenlisted men, United States Army, April 1, 1917, to December 31, 1919, inclusive
| Total of mean annual strengths | Admissions | Deaths | Discharges for disability |
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Absolute numbers | Ratios per 1,000 strength | Absolute numbers | Ratios per 1,000 strength | Absolute numbers | Ratios per 1,000 strength | Absolute numbers | Noneffective ratios per 1,000 strength | ||
Total officers and enlisted men including native troops | 4,128,479 | 11,675 | 2.83 | 354 | 0.09 | 18 | 0.00 | 498,190 | 0.33 |
Total officers and enlisted men American troops | 4,092,457 | 11,673 | 2.85 | 354 | .09 | 18 | 0 | 498,144 | .33 |
Total officers | 206,382 | 222 | 1.08 | 4 | .02 | --- | --- | 8,342 | .11 |
Total American troops: |
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| White | 3,599,527 | 10,993 | 3.05 | 338 | .09 | 18 | .01 | 472,967 | .36 |
| Colored | 286,548 | 97 | .34 | 2 | .01 | --- | --- | 4,369 | .04 |
| Color not stated | --- | 361 | --- | 10 | --- | --- | --- | 12,466 | --- |
| Total | 3,886,075 | 11,451 | 2.95 | 350 | .09 | 18 | 0 | 489,802 | .35 |
Total native troops (enlisted) | 36,022 | 2 | .06 | --- | --- | --- | --- | 46 | 0 |
Total Army in the United States including Alaska: |
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| Officers | 124,266 | 173 | 1.39 | 1 | .01 | --- | --- | 6,547 | .14 |
| White enlisted | 1,965,297 | 8,778 | 4.47 | 265 | .13 | 15 | .01 | 372,267 | .52 |
| Colored enlisted | 145,826 | 87 | .60 | 2 | .01 | --- | --- | 3,814 | .07 |
| Total enlisted | 2,111,123 | 8,865 | 4.20 | 267 | .13 | 15 | .01 | 376,081 | .49 |
| Total officers and enlisted men | 2,235,389 | 9,038 | 4.04 | 268 | .12 | 15 | .01 | 382,628 | .47 |
U.S. Army in Europe, excluding Russia: |
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| Officers | 73,728 | 46 | 0.62 | 3 | 0.04 | --- | --- | 1,669 | 0.06 |
| White enlisted | 1,469,656 | 1,959 | 1.33 | 61 | .04 | 3 | 0 | 92,352 | .17 |
| Colored enlisted | 122,412 | 9 | .07 | --- | --- | --- | --- | 484 | .01 |
| Color not stated | --- | 356 | --- | 10 | --- | --- | --- | 12,372 | --- |
| Total enlisted | 1,592,068 | 2,324 | 1.46 | 71 | .04 | 3 | 0 | 105,208 | .18 |
| Total officers and enlisted men | 1,665,796 | 2,370 | 1.42 | 74 | .04 | 3 | 0 | 106,877 | .18 |
Officers-Other countries | 8,388 | 3 | .36 | --- | --- | --- | --- | 126 | .04 |
U.S. Army in Philippine Islands: |
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| White enlisted | 16,995 | 9 | .53 | 2 | .12 | --- | --- | 259 | .04 |
| Colored enlisted | 4,456 | --- | --- | --- | --- | --- | --- | --- | --- |
| Total enlisted | 21,451 | 9 | .42 | 2 | .09 | --- | --- | 259 | .03 |
U.S. Army in Hawaii: |
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| White enlisted | 16,161 | 12 | .74 | 1 | .06 | --- | --- | 444 | .08 |
| Colored enlisted | 3,319 | --- | --- | --- | --- | --- | --- | --- | --- |
| Total enlisted | 19,480 | 12 | .62 | 1 | .06 | --- | --- | 444 | .06 |
U.S. Army in Panama (white enlisted) | 19,688 | 2 | .10 | --- | --- | --- | --- | 46 |
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U.S. Army in other countries and not stated: |
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| White enlisted | (a) | 27 | --- | 1 | --- | --- | --- | 1,237 | --- |
| Colored enlisted | (a) | --- | --- | --- | --- | --- | --- | --- | --- |
| Color not stated | --- | 5 | --- | --- | --- | --- | --- | 94 | --- |
| Total enlisted | 14,232 | 32 | 2.25 | 1 | .07 | --- | --- | 1,331 | .26 |
Transports: |
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| White enlisted | 97,498 | 206 | 2.11 | 8 | .08 | --- | --- | 6,362 | .18 |
| Colored enlisted | 10,535 | 1 | .09 | --- | --- | --- | --- | 71 | .02 |
| Total enlisted | 108,033 | 207 | 1.92 | 8 | .07 | --- | --- | 6,433 | .16 |
Native troops enlisted: |
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| Philippine Scouts | 18,576 | 1 | .05 | --- | --- | --- | --- | 12 | 0 |
| Hawaiians | 5,615 | 1 | .18 | --- | --- | --- | --- | 34 | .02 |
| Porto Ricansa | 11,831 | --- | --- | --- | --- | --- | --- | --- | --- |
aSeparate strength of white andcolored not available.
This disease was much more common among white enlisted menthan among any other troops in the American Army, white enlisted men numbering10,993 primary admissions and colored, 97. Among the former, there were 338 deaths and among the latter, 2 deaths. The admission anddeath ratios are equally striking in comparison. White enlisted men had anadmission ratio of 3.05 and a death ratio of 0.09 per 1,000 strength, ascompared with the admission ratio of 0.34 and the death ratio of 0.01 forcolored enlisted men. This same difference between the two races is shown by thenumber of days lost: There were 472,967 days lost from duty among white enlistedmen and 4,369 among colored. It has long been known that the occurrence ofscarlet fever among the colored is far less than among white people; experienceduring the World War was in accordance with this. Although scarlet fever
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occurs in tropical countries among natives, its occurrencethere is of less importance than among white people in temperate zones. Theoccurrence of this disease among native troops of the American Army during theWorld War was of no importance from a disability standpoint. Among the 36,022native enlisted troops, there were 2 cases and no deaths.
When viewed from the standpoint of seasonal prevalence, theoccurrence of scarlet fever was greatest during January, February, and March,1918. Though this was true for some of the other epidemic diseases, namely,epidemic meningitis and mumps, the diseases just mentioned were more commonamong colored troops, while scarlet fever was more common among white troops.The largest number of primary admissions was reported for the month of March,1918. The largest number of deaths reported from scarlet fever for any monthduring the war was also in March, 1918. There were 40 deaths during that month,all of which were among white troops. The seasonal occurrence commencing inOctober, 1918, and ending in April, 1919, although marked, was to a much lessdegree than during the preceding year, not only in admissions, but also fordeaths. The warmer months of the World War period were marked by a very smalloccurrence of scarlet fever in the Army.
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TABLE 61.-Scarletfever. Admissions and deaths, white and colored enlisted men, United StatesArmy, United States and Europe, by months, April 1, 1917, to December 31, 1919
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OCCURRENCE IN THE ARMY IN THE UNITED STATES
Table 60 shows that there were 9,038 primary admissions forscarlet fever reported in the Army in the United States during the war. Theoccurrence of the disease among white enlisted men contributed the vast majorityof admissions. There were 8,778 primary admissions among these troops, with 265deaths. The admission ratio was 4.47 and the death ratio, 0.13 per 1,000 perannum.
As stated above in discussing the occurrence of scarlet feverin the total Army, the occurrence was of minor importance among colored troops.There were 97 primary admissions among these troops with 2 deaths, giving anadmission and death ratio of 0.34 and 0.01 per 1,000 per annum, respectively.Scarlet fever was responsible for the loss of 382,628 days from duty amongofficers and enlisted men in the United States admitted as primary admissions.The noneffective ratio per 1,000 strength was 0.47. The relative importance ofscarlet fever to the Army is better exemplified when compared with thenon-effective ratios for several other diseases; for example, the noneffectiveratio per 1,000 strength for influenza was 7.09; mumps, 2.58; epidemicmeningitis, 0.18; typhoid fever, 0.07. White enlisted men in the United Stateslost 372,267 days from duty; while colored enlisted men lost 3,814days. The average duration of hospitalization for white enlisted men was 42.4,for colored enlisted men 43.8, and for the total Army in the United States 42.3days.
The distribution of scarlet fever in the United States Armyduring the World War, is graphically represented by States in Chart XLIII. Ratioper 1,000 strength of total reported cases occurring in each State (includingcamps) is the basis upon which this chart is prepared. No cases were reportedfrom the States of Delaware and Nevada; the number of troops stationed in theseStates was very small, the mean strength being 3,338 and 165, respectively. Thehighest ratios, in general, are found in the northern and north central portionsof the United States. States in the southeastern part of the United States,generally speaking, had the lowest occurrences. The highest admission ratioswere for the States of Montana, Wyoming, Colorado, Utah, and Kansas. Theseratios were 53.51, 30.15, 14.99, and 10.55 per 1,000 per annum, respectively.The lowest ratio was for Vermont and Louisiana. This ratio was 0.17 per 1,000per annum for each of these States. Of the total 8,865 primary admissions forscarlet fever among enlisted men in the United States during the World War,4,816 occurred in the camps enumerated in Table 62, and 4,049 occurred amongenlisted men stationed outside of these camps, as extra-camp cases.
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The remarks made in the beginning of this chapter on theoccurrence of scarlet fever in the Army by race and season apply largely to suchoccurrences in the United States. It was to be expected that the occurrence ofthis disease, as in the case of other exanthematous diseases, would be greatestduring the first months of service, when unseasoned troops were massed incantonments. This was especially true, when considering the fact that manyrecruits came from rural districts where the percentage of persons immune toscarlet fever is generally accepted as being low. Although a high percentage ofpersons of the soldier age are immune to scarlet fever, yet among a large numberof soldiers nonimmunes will be found. The greater occurrence of scarletfever in the Army in the United States than in Europe is shown in Table 60. Theprimary admission rate for the total Army in the United States was 4.04 and forthe Army in Europe, excluding Russia, was 1.42 per 1,000 strength. Thisdifference is explained on the basis of length of service, which offeredopportunity for the majority of cases of scarlet fever to occur in the UnitedStates before the soldier was sent abroad.
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On the basis of length of service and season, the largestnumber of cases and the highest admission ratios were during the late fall,winter, and early spring of 1917 and 1918. (See Table 61.) The highest admissionratio for any period during the war, and for any country in which the Americantroops served, was 12.37 in January, 1918, for white troops serving in theUnited States. There were two waves in the Army stationed in the United Statesduring the World War. This is shown best by the occurrence among white enlistedmen. The first wave commenced in the fall of 1917, reaching the peak in January,1918, from which time there was a progressive decrease until the followingSeptember. The largest number of primary admissions per month was 1,130 forJanuary, 1918, and the smallest number during that year was in September, whichwas 46. The admission ratio among white troops was 12.37 in January, 1918, andprogressively decreased to 0.42 per 1,000 strength in September. The second waveof occurrence among white troops commenced in October, 1918, and, as in the caseof the previous year, ended in January of the following year, 1919, with 401primary admissions during that month. The admission ratio was 7.15 per 1,000strength during January. The downward trend commenced in February, 1919, with278 primary admissions, and reached the low point with two primary admissions inSeptember. The admission ratio decreased from 7.15 in January to 0.17 inSeptember.
OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES
The occurrence of scarlet fever in the American Army inEurope was not a matter of grave concern. The total number of primary admissionsin Europe (excluding Russia) was 2,370, or about one-fifth of the total numberof cases reported for the World War. The admission ratio was 1.42 per 1,000strength. The total number of deaths from this disease was 74, giving a deathrate of 0.04 per 1,000 per annum. There were 106,877 days lost from duty by thetotal Army in Europe, giving a noneffective ratio of 0.18 per 1,000 strength.
As in the United States the white enlisted men contributedthe majority of the cases. There were 1,959 primary admissions, with 61 deaths,among these troops, with admission and death ratios of 1.33 and 0.04,respectively, per 1,000 strength. The noneffective ratio was 0.17 per 1,000 perannum, based on 92,352 days lost from duty. Scarlet fever was rare among coloredtroops in Europe; there were nine primary admissions and no deaths. The averagetime lost among them from duty was 53.7 days and the case mortality was nil.
The seasonal occurrence among white troops in Europe followedthe same general seasonal trend as in the United States. Two waves of occurrencemarked the winters of 1917-18 and 1918-19. The crest of the first wave wasreached in January, 1918, with the report of 168 cases and an admission ratio of10.43 per 1,000 strength. The crest of the second wave was reached in December,1918, with 124 primary admissions, giving an admission ratio of 0.93 per 1,000per annum. The crest of this second wave occurred one month earlier than thecrest of the second wave in the United States.
Not only was the occurrence less marked among white troops inEurope than in the United States, but there were fewer deaths. The total numberof
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primary admissions for white troops in Europe was 1,959 andfor the United States 8,778. There were 61 deaths among white troops reported inEurope as compared with 265 in the United States.
The duration of hospitalization was longer for colored troopsin Europe than for white troops. The average number of days lost from duty bythe former in Europe was 53.7 and in the United States 43.8. It is of interestto note also that duration of hospitalization was longer for white men in Europethan in the United States. The duration of hospitalization was, respectively,47.1 and 42.4 days.
FACTORS INFLUENCING OCCURRENCE
Scarlet fever is an acute infectious disease andunquestionably has a specific cause. The virus, whatever it may be, is one oflow infectivity as compared, for example, with that of measles. It is believedthat the virus lies in the discharges from the nose and throat; also in thedischarges from patients with complications, such as suppurative otitis mediaoccurring during the course of the scarlet fever. There seems to be ampleevidence to justify the statement that desquamations during the course ofscarlet fever do not contain the virus and, therefore, are not a source ofcontagion. However, in view of the absence of any positive knowledge of theduration of the period in which patients remain a source of infection,desquamation still remains worthy of being a guide to quarantine. It is notknown at just what time the discharges are most heavily laden with the virus, orhow long the patient remains an active carrier.
The importance of certain factors influencing the occurrenceof scarlet fever has been demonstrated. This disease is a typical disease ofchildhood, with the majority of cases occurring before the tenth year1and 90per cent before the sixteenth year. From this time the occurrence by agediminishes. Race unquestionably has its influence, and our medical records ofthe war show conclusively that scarlet fever occurred far more frequently amongwhite troops than among colored troops. The occurrence of this disease amongnative Filipino, Hawaiian, and Port Rican soldiers was almost negligible. It istrue that the diagnosis of any disease which is largely dependent upon theinterpretation of skin manifestations is much more difficult in the negro thanin the white man. Although this might account for some missed cases, it wouldnot account for the great difference in occurrence in whites and negroes. As inthe case with the other exanthematous diseases, scarlet fever had distinctseasonal distributions, with the largest number of cases during the cold, dampmonths of the year, and the smallest number of cases during the hottest anddriest months.
Although scarlet fever was distributed over the United Statesand reported from nearly all States and camps, in certain camps and certainStates the incidence was much greater than in others. Camp Pike, Ark., was anotable center for this disease. The number of cases at Camp Hancock, Ga., wasgreater than the average in the camps of the United States. The greateroccurrence in these camps has been attributed to the poor physical condition ofthe troops drawn from Mississippi, Louisiana, Arkansas, Alabama, and Georgia.Vaughan and
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Palmer2 held that troops from the Southern States possesseda susceptibility that was general as well as specific; they were subject notonly to the ravages of pneumonia, but to other diseases as well, and their deathrate from all causes was higher and their sickness incidence was greater thanthat of troops from other parts of the country.
Statistics contained in the reports of the United StatesCensus Bureau show the occurrence of scarlet fever to be greater in the northernthan in the southern portions of the United States. The States of Montana andColorado showed the highest incidence of scarlet fever during the World War forextra-camp troops; that is, soldiers who were not a part of camp garrisons. TheStates showing the greatest occurrence among all troops, camp and extra-campwere Montana and Wyoming. Taken alone, the following three camps stood at thehead of the list during the war: Camp Lewis, Wash., 10.88; Camp Funston, Kans.,10.83; and Camp Hancock, Ga., 10.58 per 1,000 strength. These ratios includeboth white and colored troops, and are quoted here to show that, althoughscarlet fever is more common in the northern part of the United States, as arule, its occurrence was greatest in some of the camps located in the Southduring the war, although the troops in such camps were drawn largely fromSouthern States.
Scarlet fever has been called a "neighborly disease, asit spreads from family to family in direct proportion to the intercourse ofpeople and the interchange of things between families."1 These conditionsexist among troops, and in all probability contributed to the spread of thedisease in the Army.
PATHOLOGY
There are no known specific lesions of scarlet fever. Eventhe skin eruptions disappear after death except in the hemorrhagic form. Thepathological anatomy is that following fever and secondary infection by pusorganisms. The complications are usually incident to streptococcus invasion.Ludy, Hunt, and Cogswell3 reported a series of necropsies on scarletfever cases at Camp Hancock, Ga., and called special attention to the generaladenopathy, with involvement of the submaxillary and inguinal lymph glands, asbeing present "in 100 per cent of the cases." This enlargement wassuch that one could grasp the glands between the thumb and forefinger and in thefresh subject they gave a mushy feeling. The microscopic pathology was that ofhyperplasia, inflammatory in type. Hyperplasia of the mesenteric andretroperitoneal glands and spleen was also present.
SYMPTOMS
During the stage of invasion, scarlet fever is manifested bythe following cardinal symptoms and signs: Sudden onset, vomiting, sore throat,elevated temperature, rapid pulse, dryness of the skin, and acute fever.Diagnosis of scarlet fever can not be made with certainty during this stage;however, the above symptom complex served during the war as an index fortransferring patients to hospital and placing them in observation wards until anaccurate diagnosis could be made. Not until the appearance of the skin eruptionis it possible to diagnose scarlet fever, according to most observers. Thiseruption appears in from one to two days after onset of the disease as ascattered red
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punctate rash or a deep subcuticular flush. It appears firston the neck and chest, spreading rapidly to the armpits and over the body ingeneral. It is inflammatory in nature, producing an intense hyperemia; thebleaching of the skin, due to anemia produced by pressure, is quickly relievedupon the release of pressure. The skin, at first, is intensely red, theso-called "boiled lobster" appearance. The rash, scarlet at first,becomes darker in a few days.
The face shows an erythema, with a paleness surrounding themouth. This perioral pallor is commonly present in scarlet fever. Scalingcommences at different times in different cases. It may be slight, with finedesquamation, as was noted in many mild cases during the war; or it may be veryextensive, with scales as large as the palm of the hand, in this respectresembling dermatitis exfoliativa. The duration of desquamation also varies andmay extend into weeks.
Ludy, Hunt, and Cogswell3 reported the presence of the"strawberry tongue" in 92.8 per cent of their cases. The intensity ofthe sore throat is at times great; and when an organized exudate is present onthe tonsils, the examination suggests the diagnosis of diphtheria. Before thedays of microscopic examinations of throat swabs for the Klebs-Loefflerbacillus, the differential diagnosis of these two diseases was often confused.One hundred and eighty-eight of the primary admissions for scarlet fever duringthe World War were associated with diphtheria, the diagnosis of which was basedon microscopic examinations. These figures are quoted to show the occurrence ofdiphtheria and scarlet fever as concurrent diseases in the Army during the war.
In the beginning of the disease, the skin of scarlet feverpatients feels hot and dry. It later becomes moist and, if pinched, minutehemorrhages from the rupture of capillaries usually occur. This finding iscommon in scarlet fever, but occurs in some other diseases. The increasedfragility of the blood vessels is believed to be the underlying cause of theminute hemorrhages that occur in some of the more severe types of scarlet fever,designated as the hemorrhagic form.
Some writers have laid great stress on the enanthem, claimingthat a punctate eruption on the mucous membrane of the palate, tonsils, andcheeks, when combined with a punctate eruption over the armpits and in thegroin, is characteristic of scarlet fever. In the 500 cases of scarlet feverstudied at Camp Hancock,3 the eruption occurredon the neck, chest,and abdomen in 40 per cent; the entire body, 26.5 per cent; chest and neck, 17.6per cent; chest and back, 5.9 per cent; and chest and arms in 5.9 per cent oftheir cases.
Early albuminuria has long been looked upon as a frequentconcomitant of scarlet fever. In the 500 cases reported from Camp Hancockalbumin was found in 67.3 per cent and casts in 35.3 per cent cases during thefirst week.3 The urine usually shows urobilinogen and is negative forthe diazo reaction. The importance of these findings is in the differentialdiagnosis. Routine examination of the urine was commonly carried out in thebase hospitals during the war for the detection of nephritis. The presence ofred blood cells was considered of great importance in the diagnosis.
Much has been written on the blood picture in the earlydiagnosis of scarlet fever, the diagnostic points being leucocytosis andeosinophilia. Friedlander and McCord4 conducted investigations along theselines at Camp Sherman, Ohio, and reported that 78.9 per cent of the cases showedleucocytosis, while
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42.1 per cent showed eosinophilia. Where the white cell count was more than 10,000 they reported leucocytosis and where the number ofeosinophiles was more than 2 per cent they recorded eosinophilia. Of 75 cases,18.6 per cent showed an eosinophilia of 3 per cent or over. Ludy, Hunt, andCogswell2 reported eosinophilia of over 5 per cent in 36 per cent of theircases, 4 per cent in 10 per cent, and more than 2 per cent in 54 per cent. Theseauthors believe that the presence of an eosinophilia in a scarlet fever suspectis a valuable point in diagnosis, provided other causes of eosinophilia can beexcluded. Leucocytosis of over 12,000 occurred in 19 per cent of the CampHancock cases, 12 per cent showed between 10,000 and 12,000 leucocytes, and 40per cent between 7,000 and 10,000 leucocytes. The prevailing cell, whenleucocytosis occurred, was the polymorphonuclear neutrophile. The type of thedisease, the intensity of the eruption, and the degree of desquamation bore adefinite relationship to the blood picture. The more marked the prodromalsymptoms, the greater was the leucocytosis, the less the eosinophilia, and theless the desquamation.
Desquamation commences where the eruption first appears, as arule, and lasts several weeks. In some instances the desquamation is prolongedinto the seventh or eighth week. As previously stated, it is not believed thatthe scales contain the scarlatina virus, but desquamation was used during thewar as an index for releasing patients from quarantine. Desquamation is usuallyslowest on the palms of the hands and soles of the feet and reference to theseareas was usually made before reporting desquamation complete. Ludy, Hunt, andCogswell3 believed that scarlet fever, without eruption, exists andthat the diagnosis in such cases can be made on the presence of soft inguinaladenitis plus sore throat and some of the other symptoms described as common toscarlet fever.
COMPLICATIONS AND
SEQUEL?
There were 1,781 cases of scarlet fever reported asconcurrent with other diseases. The total number of cases reported for the war,primary and concurrent, was 13,456. Among the total primary admissions, 3,825developed complications or were associated with other diseases while inhospital; that is, 32.7 per cent.
Secondary diseases | Admissions | Deaths |
| Per cent of primary admissions |
Measles | 114 | 7 | 6.14 | 0.97 |
Diphtheria | 188 | 4 | 2.12 | 1.61 |
Erysipelas | 38 | 1 | 2.63 | .33 |
Diphtheria carrier | 71 | 0 | --- | .61 |
Meningitis carrier | 6 | 0 | --- | .05 |
German measles | 32 | 0 | --- | .27 |
Mumps | 259 | 10 | 3.86 | .22 |
Septicemia, general | 14 | 8 | 57.1 | .12 |
Acute articular rheumatism | 72 | 1 | 1.38 | .62 |
Arthritis | 81 | 7 | 8.6 | .69 |
Otitis media | 363 | 20 | 5.5 | 3.11 |
Mastoiditis | 74 | 6 | 8.1 | .63 |
Pericarditis | 16 | 5 | 31.2 | .14 |
Acute endocarditis | 32 | 4 | 12.8 | .27 |
Valvular heart diseases | 54 | 1 | 1.85 | .46 |
Myocarditis and myocardial insufficiency | 31 | 4 | 13.5 | .27 |
Diseases of the lymphatic system | 77 | 1 | 1.3 | .66 |
Pneumonia: |
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| Broncho | 257 | 123 | 47.8 | 2.20 |
| Lobar | 195 | 77 | 39.4 | 1.67 |
Nephritis: |
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| Acute | 84 | 14 | 16.6 | .72 |
| Chronic | 48 | 6 | 12.5 | .41 |
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The more important complications and diseases reported asconcurrent with scarlet fever in the Army during the World War are given inTable 63, from which it is seen that otitis media was the most commoncomplication. Otitis media and its complications are, perhaps, the mostimportant complications developing in the course of scarlet fever. This isparticularly true on account of the impairment of hearing, with partial or totaldeafness that often develops. The above table shows that otitis media developedin 3.11 per cent of the total primary admissions. There were 363 such cases, ofwhich 20 died, giving a case mortality of 5.5 per cent. The heart complicationswere also common. A total of 1.14 per cent of the primary admissions developedheart complications, of which 14 died. Nephritis was not a common complicationamong the soldiers suffering from scarlet fever, 84 cases of acute nephritis and48 cases of chronic nephritis having been reported among the total primaryadmissions. The case mortality, however, was high; that is, 16.6 per cent in theacute cases and 12.5 per cent in the chronic cases. Arthritis complicatingscarlet fever was not common during the war; 81 cases or 0.69 per cent of thetotal admissions, with 7 deaths, were reported. The case mortality was 8.6 percent. General septicemia was reported in 14 cases and, as would be expected, thecase mortality, 57.1 per cent, was high. Diphtheria was frequently associatedwith scarlet fever. Among the 188 cases, there were 4 deaths, giving a casemortality of 2.12 per cent. The total occurrence of diphtheria among the primaryadmissions amounted to 1.61 per cent. Measles occurred in 114 cases, with 7deaths, and German measles in 32 cases, with no deaths. The pneumonias wererelatively common among the primary admissions for scarlet fever. The recordsshow 257 cases of bronchopneumonia and 195 cases of lobar pneumonia ascomplications. The case mortality, as would be expected, was high. It was 47.8per cent for bronchopneumonia and 39.4 per cent for lobar pneumonia. Occurrenceof the pneumonias among the primary admissions totaled 3.87 per cent.
Scarlet fever occurred as a concurrent disease in 344 casesof measles, 64 cases of diphtheria, 54 cases of German measles, 288 cases ofmumps, 64 cases of pneumonia, 21 cases of arthritis, and 10 cases of nephritis(Table 64). The case mortality was 2.6 per cent among cases of scarlet feverreported as an associated disease of measles, while it was 6.1 per cent of casesof scarlet fever where measles occurred as a concurrent disease. This samedifference occurred where diphtheria and scarlet fever were concurrent. Wherediphtheria occurred as a concurrent disease, the case mortality was 2.12 percent; where the reverse condition existed-that is, where the primary admissionwas for diphtheria, and scarlet fever was the concurrent disease-the casemortality was 1.5 per cent. Among the 98,225 cases of measles reported asprimary admissions, scarlet fever was reported in 0.35 per cent. Among the10,909 cases of diphtheria, scarlet fever occurred as a concurrent disease in0.58 per cent.
Primary diseases |
| Deaths | Case mortality | Primary diseases | Admissions | Deaths | Case mortality |
Measles | 344 | 9 | 2.6 | Endocarditis | 4 | 2 | 50.0 |
Diphtheria | 64 | 1 | 1.5 | Bronchopneumonia | 30 | 2 | 6.6 |
German measles | 54 | 0 | 0 | Lobar pneumonia | 34 | 6 | 17.6 |
Mumps | 288 | 2 | .7 | Nephritis (all) | 10 | 0 | --- |
Arthritis | 21 | 0 | --- |
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According to Ludy, Hunt, and Cogswell,3 reportingtheir observations in cases of scarlet fever at Camp Hancock, Ga., albuminuriawas present in 67.3 per cent during the first week, 58.8 per cent during thesecond week, and 8.8 per cent at the end of the sixth week of the disease. Castswere present in 35.3 per cent during the first week, 14.4 per cent during thesecond week, and 2.9 per cent at the end of the sixth week. In another seriessuppurative otitis media developed in 11 per cent of 500 cases, arthritis in 5.9per cent, and bronchopneumonia in 6.5 per cent. Three of the cases had relapseand three developed jaundice. Streptococcus throat cultures were positive in36.2 per cent; 92.8 per cent had "strawberry tongue"; 35 per cent wereadmitted with skin eruption; 100 per cent had inguinal adenitis, and 65 per centhad the rash of scarlet fever before admission to hospital. An enanthem waspresent on the hard and soft palates in 92.9 per cent of the cases, and 70 percent developed marked desquamations. Nephritis was reported as not being commonat Camp Hancock. The only serious complications reported were otitis media andpneumonia. The pneumonia was said to have been of a peculiar type, markedlyresembling influenza-pneumonia. One case of severe arthritis was reported fromthis camp.
The occurrence of scarlet fever at Camp Lewis, Wash., wasreported as being of a mild type, with few important complications. Pneumoniaoccurred in three cases and nephritis and endocarditis each in one case.Transient albuminuria was reported in 14 per cent of the cases. Nephritisappears not to have been as common a complication of scarlet fever in the Armyas in civil life, where its occurrence is said to be from 10 per cent to 25 percent.5
DIAGNOSIS
The clinical diagnosis of scarlet fever is justified by thepresence of such manifestations as fever, with sudden onset; sore throat; finepunctiform rash, involving the hair follicles situated on a normal base,appearing first on the neck and chest, then becoming generalized, vividly red inthe beginning, turning darker as the disease progresses; pallor about the mouth;tongue coated and showing prominent red papill? protruding through this coat;vomiting; early albuminuria; rapid pulse; and eosinophilia. The justification ofthis diagnosis is increased by the feverish appearance of the patient, thepresence of urobilinogen in the urine, absence of the diazo reaction, andpresence of peripheral blood capillary fragility.
During the World War, the typical case of scarlet fever wasnot difficult to diagnose; however, medical officers reported mild cases thatdid not present the full clinical picture. There were cases also where thedifferentiation from measles and German measles was difficult. The latterdisease at times presented a fine, vivid erythematous rash that stronglyresembled that of scarlet fever. It was necessary at times to observe patientsin quarantine before a positive diagnosis could be made. Toxic erythema causedconfusion in some cases, but observation afforded opportunity to make thedifferential diagnosis.
The enanthem and submaxillary and inguinal adenopathy wereimportant diagnostic findings in the cases studied at Camp Hancock; the presenceof enanthem was reported in 92.9 per cent and the adenopathy in 100 per cent of
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the cases.2 Skin eruption was not present in allcases, and marked desquamation occurred in 70 per cent. Although scarlet feverwithout eruption was reported during the war,3 the difficulty ofdiagnosis was greatly increased without the presence of this valuable diagnosticsign.
PROGNOSIS
If the occurrence of deaths from scarlet fever be taken as anindex to the severity of the disease, the ratios for the various camps show agreat difference in severity during the war. The death ratios for the largecamps in the United States varied from 0 to 0.71 per 1,000 strength. No deathsoccurred from scarlet fever at 14 of the large camps. (Table 62.) Camp Hancock,Ga., reported the highest death rate; i. e., 0.71 per 1,000 strength. The deathrate at Camp Pike, Ark., was 0.58 per 1,000 per annum. The death ratio for theremaining camps was, in each instance, below this figure. The death ratio forthe 4,816 cases occurring in the large camps of the United States was 0.11 per1,000 strength, and the case mortality varied between broad limits. The highestcase mortality rates were reported from Camp Greenleaf, Ga.; Camp Gordon, Ga.;and Camp Johnston, Fla. These were, respectively, 14.8 per cent, 13.3 per cent,and 12.9 per cent. It is noted that the highest case mortality rates were in thesoutheastern part of the United States. The average case mortality for the campslocated in the United States was 2.96 per cent. As shown previously, scarletfever occurred more frequently among white troops and the death rate was higherthan among colored troops.
Scarlet fever was not, to any great extent, the cause ofpermanent disability in the Army during the war. Table 60 shows that 18 men weredischarged from the service on account of disability following this disease.All of these cases were among white enlisted men. The records do not permit suchdetailed analysis as to make it possible to state the disability morespecifically. Since scarlet fever is an acute disease, naturally the 18 casesdischarged from the service were discharged on account of some chroniccomplication, the exact nature of which can not be stated.
PREVENTIVE MEASURES
Since there were no specific preventive measures known forscarlet fever at the time of the World War, the discussion of prophylaxis inthis disease is confined to general preventive or control measures. The generalmeasures of value in preventing the spread of scarlet fever depend largely uponthe susceptibility of individuals to this disease. The control of this diseaseis easier than the control of some other acute infectious diseases, for example,measles. Fomites have been shown to harbor the virus; therefore, thoroughdisinfection or destruction of articles of clothing, etc., was taken cognizanceof in the control of the disease during the war. Occurrence of milk-borneepidemics are contained in the literature on this disease; however, milk-bornescarlet fever was not reported in the Army.
The exact time at which patients become a source of dangerand the duration of this period have never been determined; since there is noknown causative organism, there are no bacteriological guides upon which to basequarantine.
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The importance of missed cases and patients developing arelapse after being dismissed from quarantine was referred to by several medicalofficers during the war. Ludy, Hunt, and Cogswell3 reported that 35per cent of the 500 cases at Camp Hancock, Ga., were admitted to hospital withthe skin eruption present. These cases must, therefore, have been a source ofinfection for some time before being transferred to hospital. Some cases ofscarlet fever were so mild that the disease had developed fully before transferwas made. It seems probable, then, that cases occurred in many camps where thediagnosis was made late in the disease or not at all, allowing the patient toremain with his organization.
As a general preventive measure, it was customary toquarantine newly arrived troops 14 days before allowing them to mix freely withother members of the camp. This was possible where the number of men wassmall; however, in most instances this quarantine was never absolute. Thequarantine referred to was not solely for the purpose of preventing scarletfever, but was intended for other diseases as well, especially measles. Suchquarantined soldiers were examined once or twice daily for the appearance ofcontagious diseases.
The common practice, upon identification of a case of scarletfever, was to send the patient to hospital and place all contacts, or the entirecompany, in quarantine. This quarantine was regulated by the division surgeon orthe senior medical officer present, and was maintained for seven days. Theseven-day quarantine seems to have been satisfactory, although there are caseson record where the incubation period seemed to have been longer.
The length of quarantine of the patient was six weeks byregulations. The records show that the average time spent in hospital for allcases was 42.6 days. In the United States this average was 42.3 days, in Europe45.09 days. During the war, as noted, medical officers did not believe that thescales contained the virus of scarlet fever, but continued to use desquamationas throwing some light on the probable duration of infectivity. It was generallyaccepted that as long as the patient showed abnormal nasopharyngeal discharges,suppurating otitis media, discharge from an open lesion, or swollen lymph glandsabout the neck, he should not be discharged from quarantine. These symptomsusually cleared up promptly. The complication, as a rule, that had the longestduration was chronic suppurative otitis media. At Camp Grant, Ill., the presenceor absence of eosinophilia was taken as an index to releasing patients fromquarantine.
Although precautionary measures were used to prevent patientsfrom leaving the hospital too soon, relapses occurred. The records do not permitof an analysis of these cases. Ludy, Hunt, and Cogswell3 reportedthat 5.7 per cent of the cases at Camp Hancock gave a history of previouslyhaving had scarlet fever.
TREATMENT
No satisfactory specific treatment was known for scarletfever before the World War, and none was developed during that time. The courseof the disease can not be cut short, but certain precautionary measures haveproved of value, especially in reducing the incidence of complications. Allcases were
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sent to hospital as soon as the disease was suspected, andisolated in wards especially set aside for that purpose. These were wardsdesignated as isolation wards, with from one to a maximum of about six bedseach. Where two or more beds were in a room, they were separated by sheetcubicles. In the event of an increased occurrence of this disease in camp, or inthe case of contacts, transfer was often made to the hospital upon the presenceof fever alone, although of unknown type. Rest in bed during the early stages ofthe disease, liquid diet, a well-ventilated and well-heated ward, comprised thepalliative treatment. The diet was increased in proportion to the generalimprovement of the patient and falling of the temperature. The records show thatattempts were made to prevent otitis media by the use of alkaline antisepticmouth washes and gargles, and in some instances by the application of silverpreparations to the throat. The measures for preventing the occurrence ofnephritis included the prevention of body chilling by rest in bed untilconvalescence was well established, the free use of fluids, and the limitationof proteins in diet, especially in the form of meats. During the stage ofdesquamation, vaseline or olive oil was used on the skin; and in some basehospitals carbolized vaseline was used where itching was troublesome.
The treatment of complications was symptomatic. As regardsotitis media, which was present in more than 3 per cent of the cases, thetreatment was, in general, early incision of the drum membrane for drainage,followed by installation of 50 per cent alcohol several times a day into theexternal auditory canal. Paracentesis of the drum membrane was generally done inthe ward.
The nursing and diet services were generally separate forscarlet fever patients, and much attention was paid to the importance of boilingthe eating utensils after use, separate thermometers, and destruction of noseand throat secretions. Discharges from suppurating ears and open wounds thatdeveloped during the course of scarlet fever were treated in like manner.
REFERENCES
(1) Vaughan, V. C.: Epidemiology and Public Health, C. V. Mosby Co., St. Louis, 1922, Vol. I, Respiratory Infections, 242.
(2) Vaughan, V. C. and Palmer, Geo. T.: The Communicable Diseases in the National Army of the United States during the Six Months from September 29, 1917, to March 29, 1918. The Military Surgeon, Washington, 1918, xliii, No. 3, 251; Ibid., 1918, xliii, No. 4, 392.
(3) Ludy, John B.; Hunt, Ernest L.; and Cogswell, Lloyd H.: Observations on 500 Cases of Scarlet Fever. The Military Surgeon, Washington, 1919, xlv, No. 4, 414.
(4) Friedlander, Alfred, and McCord, C. P.: Notes on the Blood Picture in the early Stages of Scarlet Fever. On file, Historical Division, S. G. O.
(5) Osler, Sir Wm.: The Principles and Practice of Medicine. New York and London, D. Appleton & Co., 8th ed., 1914, 341.
