U.S. Army Medical Department, Office of Medical History
Skip Navigation, go to content

HISTORY OF THE OFFICE OF MEDICAL HISTORY

AMEDD BIOGRAPHIES

AMEDD CORPS HISTORY

BOOKS AND DOCUMENTS

HISTORICAL ART WORK & IMAGES

MEDICAL MEMOIRS

AMEDD MEDAL OF HONOR RECIPIENTS External Link, Opens in New Window

ORGANIZATIONAL HISTORIES

THE SURGEONS GENERAL

ANNUAL REPORTS OF THE SURGEON GENERAL

AMEDD UNIT PATCHES AND LINEAGE

THE AMEDD HISTORIAN NEWSLETTER

Chapter XI

Communicable Diseases, Table of Contents

CHAPTER XI

SCARLET FEVER

STATISTICAL CONSIDERATIONS

During the World War, scarlet fever stood forty-fifth on the list of important diseases in the United States Army, based upon the number of primary admissions (11,675) to sick report. From the standpoint of deaths, scarlet fever stood ninth on the list of important diseases, being exceeded by the following diseases in the order named: Influenza, lobar pneumonia, bronchopneumonia, measles, tuberculosis of the lungs, epidemic meningitis, appendicitis, and bronchitis. There were reported 354 deaths from scarlet fever for the total Army during the World War among the primary admissions. The admission ratio per 1,000 strength for the total Army was 2.83 and the death ratio 0.09.

There were 18 cases discharged from the service on account of disability following 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.


392

TABLE 60.-Scarlet fever. Admissions, deaths, discharges for disability, and days lost, by countries, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919, inclusive

 

Total of mean annual strengths

Admissions

Deaths

Discharges for disability


Days lost

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:

 

 

 

 

 

 

 

 

 

    

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:

 

 

 

 

 

 

 

 

 

    

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:

 

 

 

 

 

 

 

 

 

    

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:

 

 

 

 

 

 

 

 

 

     

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:

 

 

 

 

 

 

 

 

 

    

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

 

U.S. Army in other countries and not stated:

 

 

 

 

 

 

 

 

 

    

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:

 

 

 

 

 

 

 

 

 

    

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:

 

 

 

 

 

 

 

 

 

    

Philippine Scouts

18,576

1

.05

---

---

---

---

12

0

    

Hawaiians

5,615

1

.18

---

---

---

---

34

.02

    

Porto Ricansa

11,831

---

---

---

---

---

---

---

---

aSeparate strength of white and colored not available.

This disease was much more common among white enlisted men than among any other troops in the American Army, white enlisted men numbering 10,993 primary admissions and colored, 97. Among the former, there were 338 deaths and among the latter, 2 deaths. The admission and death ratios are equally striking in comparison. White enlisted men had an admission ratio of 3.05 and a death ratio of 0.09 per 1,000 strength, as compared with the admission ratio of 0.34 and the death ratio of 0.01 for colored enlisted men. This same difference between the two races is shown by the number of days lost: There were 472,967 days lost from duty among white enlisted men and 4,369 among colored. It has long been known that the occurrence of scarlet fever among the colored is far less than among white people; experience during the World War was in accordance with this. Although scarlet fever


393

occurs in tropical countries among natives, its occurrence there is of less importance than among white people in temperate zones. The occurrence of this disease among native troops of the American Army during the World War was of no importance from a disability standpoint. Among the 36,022 native enlisted troops, there were 2 cases and no deaths.

When viewed from the standpoint of seasonal prevalence, the occurrence 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 common among 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 month during 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 in October, 1918, and ending in April, 1919, although marked, was to a much less degree than during the preceding year, not only in admissions, but also for deaths. The warmer months of the World War period were marked by a very small occurrence of scarlet fever in the Army.


394-395

TABLE 61.-Scarlet fever. Admissions and deaths, white and colored enlisted men, United States Army, United States and Europe, by months, April 1, 1917, to December 31, 1919


396

OCCURRENCE IN THE ARMY IN THE UNITED STATES

Table 60 shows that there were 9,038 primary admissions for scarlet fever reported in the Army in the United States during the war. The occurrence of the disease among white enlisted men contributed the vast majority of admissions. There were 8,778 primary admissions among these troops, with 265 deaths. The admission ratio was 4.47 and the death ratio, 0.13 per 1,000 per annum.

As stated above in discussing the occurrence of scarlet fever in the total Army, the occurrence was of minor importance among colored troops. There were 97 primary admissions among these troops with 2 deaths, giving an admission 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 among officers and enlisted men in the United States admitted as primary admissions. The noneffective ratio per 1,000 strength was 0.47. The relative importance of scarlet fever to the Army is better exemplified when compared with the non-effective ratios for several other diseases; for example, the noneffective ratio per 1,000 strength for influenza was 7.09; mumps, 2.58; epidemic meningitis, 0.18; typhoid fever, 0.07. White enlisted men in the United States lost 372,267 days from duty; while colored enlisted men lost 3,814 days. 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 42.3 days.

The distribution of scarlet fever in the United States Army during the World War, is graphically represented by States in Chart XLIII. Ratio per 1,000 strength of total reported cases occurring in each State (including camps) is the basis upon which this chart is prepared. No cases were reported from the States of Delaware and Nevada; the number of troops stationed in these States was very small, the mean strength being 3,338 and 165, respectively. The highest ratios, in general, are found in the northern and north central portions of the United States. States in the southeastern part of the United States, generally speaking, had the lowest occurrences. The highest admission ratios were for the States of Montana, Wyoming, Colorado, Utah, and Kansas. These ratios 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 1,000 per annum for each of these States. Of the total 8,865 primary admissions for scarlet 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 among enlisted men stationed outside of these camps, as extra-camp cases.


397

TABLE 62.-Scarlet fever. Admissions and deaths, by camps of occurrence, white and colored enlisted men, United States Army, April 1, 1917, to December 31, 1919


398

The remarks made in the beginning of this chapter on the occurrence of scarlet fever in the Army by race and season apply largely to such occurrences in the United States. It was to be expected that the occurrence of this disease, as in the case of other exanthematous diseases, would be greatest during the first months of service, when unseasoned troops were massed in cantonments. This was especially true, when considering the fact that many recruits came from rural districts where the percentage of persons immune to scarlet fever is generally accepted as being low. Although a high percentage of persons of the soldier age are immune to scarlet fever, yet among a large number of soldiers nonimmunes will be found. The greater occurrence of scarlet fever in the Army in the United States than in Europe is shown in Table 60. The primary admission rate for the total Army in the United States was 4.04 and for the Army in Europe, excluding Russia, was 1.42 per 1,000 strength. This difference is explained on the basis of length of service, which offered opportunity for the majority of cases of scarlet fever to occur in the United States before the soldier was sent abroad.

CHART XLIII


399

On the basis of length of service and season, the largest number 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 admission ratio for any period during the war, and for any country in which the American troops served, was 12.37 in January, 1918, for white troops serving in the United States. There were two waves in the Army stationed in the United States during the World War. This is shown best by the occurrence among white enlisted men. 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 following September. The largest number of primary admissions per month was 1,130 for January, 1918, and the smallest number during that year was in September, which was 46. The admission ratio among white troops was 12.37 in January, 1918, and progressively decreased to 0.42 per 1,000 strength in September. The second wave of occurrence among white troops commenced in October, 1918, and, as in the case of the previous year, ended in January of the following year, 1919, with 401 primary admissions during that month. The admission ratio was 7.15 per 1,000 strength during January. The downward trend commenced in February, 1919, with 278 primary admissions, and reached the low point with two primary admissions in September. The admission ratio decreased from 7.15 in January to 0.17 in September.

OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES

The occurrence of scarlet fever in the American Army in Europe was not a matter of grave concern. The total number of primary admissions in Europe (excluding Russia) was 2,370, or about one-fifth of the total number of cases reported for the World War. The admission ratio was 1.42 per 1,000 strength. The total number of deaths from this disease was 74, giving a death rate of 0.04 per 1,000 per annum. There were 106,877 days lost from duty by the total Army in Europe, giving a noneffective ratio of 0.18 per 1,000 strength.

As in the United States the white enlisted men contributed the 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 per annum, based on 92,352 days lost from duty. Scarlet fever was rare among colored troops in Europe; there were nine primary admissions and no deaths. The average time lost among them from duty was 53.7 days and the case mortality was nil.

The seasonal occurrence among white troops in Europe followed the same general seasonal trend as in the United States. Two waves of occurrence marked the winters of 1917-18 and 1918-19. The crest of the first wave was reached in January, 1918, with the report of 168 cases and an admission ratio of 10.43 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 1,000 per annum. The crest of this second wave occurred one month earlier than the crest of the second wave in the United States.

Not only was the occurrence less marked among white troops in Europe than in the United States, but there were fewer deaths. The total number of


400

primary admissions for white troops in Europe was 1,959 and for the United States 8,778. There were 61 deaths among white troops reported in Europe as compared with 265 in the United States.

The duration of hospitalization was longer for colored troops in Europe than for white troops. The average number of days lost from duty by the former in Europe was 53.7 and in the United States 43.8. It is of interest to note also that duration of hospitalization was longer for white men in Europe than 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 and unquestionably has a specific cause. The virus, whatever it may be, is one of low infectivity as compared, for example, with that of measles. It is believed that the virus lies in the discharges from the nose and throat; also in the discharges from patients with complications, such as suppurative otitis media occurring during the course of the scarlet fever. There seems to be ample evidence to justify the statement that desquamations during the course of scarlet fever do not contain the virus and, therefore, are not a source of contagion. However, in view of the absence of any positive knowledge of the duration of the period in which patients remain a source of infection, desquamation still remains worthy of being a guide to quarantine. It is not known at just what time the discharges are most heavily laden with the virus, or how long the patient remains an active carrier.

The importance of certain factors influencing the occurrence of scarlet fever has been demonstrated. This disease is a typical disease of childhood, with the majority of cases occurring before the tenth year1 and 90 per cent before the sixteenth year. From this time the occurrence by age diminishes. Race unquestionably has its influence, and our medical records of the war show conclusively that scarlet fever occurred far more frequently among white troops than among colored troops. The occurrence of this disease among native Filipino, Hawaiian, and Port Rican soldiers was almost negligible. It is true that the diagnosis of any disease which is largely dependent upon the interpretation of skin manifestations is much more difficult in the negro than in the white man. Although this might account for some missed cases, it would not account for the great difference in occurrence in whites and negroes. As in the case with the other exanthematous diseases, scarlet fever had distinct seasonal distributions, with the largest number of cases during the cold, damp months of the year, and the smallest number of cases during the hottest and driest months.

Although scarlet fever was distributed over the United States and reported from nearly all States and camps, in certain camps and certain States the incidence was much greater than in others. Camp Pike, Ark., was a notable center for this disease. The number of cases at Camp Hancock, Ga., was greater than the average in the camps of the United States. The greater occurrence in these camps has been attributed to the poor physical condition of the troops drawn from Mississippi, Louisiana, Arkansas, Alabama, and Georgia. Vaughan and


401

Palmer2 held that troops from the Southern States possessed a susceptibility that was general as well as specific; they were subject not only to the ravages of pneumonia, but to other diseases as well, and their death rate from all causes was higher and their sickness incidence was greater than that of troops from other parts of the country.

Statistics contained in the reports of the United States Census Bureau show the occurrence of scarlet fever to be greater in the northern than in the southern portions of the United States. The States of Montana and Colorado showed the highest incidence of scarlet fever during the World War for extra-camp troops; that is, soldiers who were not a part of camp garrisons. The States showing the greatest occurrence among all troops, camp and extra-camp were Montana and Wyoming. Taken alone, the following three camps stood at the head 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 include both white and colored troops, and are quoted here to show that, although scarlet fever is more common in the northern part of the United States, as a rule, its occurrence was greatest in some of the camps located in the South during the war, although the troops in such camps were drawn largely from Southern States.

Scarlet fever has been called a "neighborly disease, as it spreads from family to family in direct proportion to the intercourse of people and the interchange of things between families."1 These conditions exist among troops, and in all probability contributed to the spread of the disease in the Army.

PATHOLOGY

There are no known specific lesions of scarlet fever. Even the skin eruptions disappear after death except in the hemorrhagic form. The pathological anatomy is that following fever and secondary infection by pus organisms. The complications are usually incident to streptococcus invasion. Ludy, Hunt, and Cogswell3 reported a series of necropsies on scarlet fever cases at Camp Hancock, Ga., and called special attention to the general adenopathy, with involvement of the submaxillary and inguinal lymph glands, as being present "in 100 per cent of the cases." This enlargement was such that one could grasp the glands between the thumb and forefinger and in the fresh subject they gave a mushy feeling. The microscopic pathology was that of hyperplasia, inflammatory in type. Hyperplasia of the mesenteric and retroperitoneal glands and spleen was also present.

SYMPTOMS

During the stage of invasion, scarlet fever is manifested by the 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 for transferring patients to hospital and placing them in observation wards until an accurate diagnosis could be made. Not until the appearance of the skin eruption is it possible to diagnose scarlet fever, according to most observers. This eruption appears in from one to two days after onset of the disease as a scattered red


402

punctate rash or a deep subcuticular flush. It appears first on the neck and chest, spreading rapidly to the armpits and over the body in general. It is inflammatory in nature, producing an intense hyperemia; the bleaching of the skin, due to anemia produced by pressure, is quickly relieved upon the release of pressure. The skin, at first, is intensely red, the so-called "boiled lobster" appearance. The rash, scarlet at first, becomes darker in a few days.

The face shows an erythema, with a paleness surrounding the mouth. This perioral pallor is commonly present in scarlet fever. Scaling commences at different times in different cases. It may be slight, with fine desquamation, as was noted in many mild cases during the war; or it may be very extensive, with scales as large as the palm of the hand, in this respect resembling dermatitis exfoliativa. The duration of desquamation also varies and may extend into weeks.

Ludy, Hunt, and Cogswell3 reported the presence of the "strawberry tongue" in 92.8 per cent of their cases. The intensity of the sore throat is at times great; and when an organized exudate is present on the tonsils, the examination suggests the diagnosis of diphtheria. Before the days of microscopic examinations of throat swabs for the Klebs-Loeffler bacillus, the differential diagnosis of these two diseases was often confused. One hundred and eighty-eight of the primary admissions for scarlet fever during the World War were associated with diphtheria, the diagnosis of which was based on microscopic examinations. These figures are quoted to show the occurrence of diphtheria and scarlet fever as concurrent diseases in the Army during the war.

In the beginning of the disease, the skin of scarlet fever patients feels hot and dry. It later becomes moist and, if pinched, minute hemorrhages from the rupture of capillaries usually occur. This finding is common in scarlet fever, but occurs in some other diseases. The increased fragility of the blood vessels is believed to be the underlying cause of the minute 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, claiming that a punctate eruption on the mucous membrane of the palate, tonsils, and cheeks, when combined with a punctate eruption over the armpits and in the groin, is characteristic of scarlet fever. In the 500 cases of scarlet fever studied at Camp Hancock,3 the eruption occurred on the neck, chest, and abdomen in 40 per cent; the entire body, 26.5 per cent; chest and neck, 17.6 per cent; chest and back, 5.9 per cent; and chest and arms in 5.9 per cent of their cases.

Early albuminuria has long been looked upon as a frequent concomitant of scarlet fever. In the 500 cases reported from Camp Hancock albumin was found in 67.3 per cent and casts in 35.3 per cent cases during the first week.3 The urine usually shows urobilinogen and is negative for the diazo reaction. The importance of these findings is in the differential diagnosis. Routine examination of the urine was commonly carried out in the base hospitals during the war for the detection of nephritis. The presence of red blood cells was considered of great importance in the diagnosis.

Much has been written on the blood picture in the early diagnosis of scarlet fever, the diagnostic points being leucocytosis and eosinophilia. Friedlander and McCord4 conducted investigations along these lines at Camp Sherman, Ohio, and reported that 78.9 per cent of the cases showed leucocytosis, while


403

42.1 per cent showed eosinophilia. Where the white cell count was more than 10,000 they reported leucocytosis and where the number of eosinophiles 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, and Cogswell2 reported eosinophilia of over 5 per cent in 36 per cent of their cases, 4 per cent in 10 per cent, and more than 2 per cent in 54 per cent. These authors believe that the presence of an eosinophilia in a scarlet fever suspect is a valuable point in diagnosis, provided other causes of eosinophilia can be excluded. Leucocytosis of over 12,000 occurred in 19 per cent of the Camp Hancock cases, 12 per cent showed between 10,000 and 12,000 leucocytes, and 40 per cent between 7,000 and 10,000 leucocytes. The prevailing cell, when leucocytosis occurred, was the polymorphonuclear neutrophile. The type of the disease, the intensity of the eruption, and the degree of desquamation bore a definite relationship to the blood picture. The more marked the prodromal symptoms, the greater was the leucocytosis, the less the eosinophilia, and the less the desquamation.

Desquamation commences where the eruption first appears, as a rule, and lasts several weeks. In some instances the desquamation is prolonged into the seventh or eighth week. As previously stated, it is not believed that the scales contain the scarlatina virus, but desquamation was used during the war as an index for releasing patients from quarantine. Desquamation is usually slowest on the palms of the hands and soles of the feet and reference to these areas was usually made before reporting desquamation complete. Ludy, Hunt, and Cogswell3 believed that scarlet fever, without eruption, exists and that the diagnosis in such cases can be made on the presence of soft inguinal adenitis plus sore throat and some of the other symptoms described as common to scarlet fever.

COMPLICATIONS AND

SEQUELĘ

There were 1,781 cases of scarlet fever reported as concurrent with other diseases. The total number of cases reported for the war, primary and concurrent, was 13,456. Among the total primary admissions, 3,825 developed complications or were associated with other diseases while in hospital; that is, 32.7 per cent.

TABLE 63.-Scarlet fever. Complications, sequelę, and concurrent diseases, April 1, 1917, to December 31, 1919

Secondary diseases

Admissions

Deaths


Case fatality rates, per cent

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:

 

 

 

 

    

Broncho

257

123

47.8

2.20

    

Lobar

195

77

39.4

1.67

Nephritis:

 

 

 

 

    

Acute

84

14

16.6

.72

    

Chronic

48

6

12.5

.41

 


404

The more important complications and diseases reported as concurrent with scarlet fever in the Army during the World War are given in Table 63, from which it is seen that otitis media was the most common complication. Otitis media and its complications are, perhaps, the most important complications developing in the course of scarlet fever. This is particularly true on account of the impairment of hearing, with partial or total deafness that often develops. The above table shows that otitis media developed in 3.11 per cent of the total primary admissions. There were 363 such cases, of which 20 died, giving a case mortality of 5.5 per cent. The heart complications were also common. A total of 1.14 per cent of the primary admissions developed heart complications, of which 14 died. Nephritis was not a common complication among the soldiers suffering from scarlet fever, 84 cases of acute nephritis and 48 cases of chronic nephritis having been reported among the total primary admissions. The case mortality, however, was high; that is, 16.6 per cent in the acute cases and 12.5 per cent in the chronic cases. Arthritis complicating scarlet fever was not common during the war; 81 cases or 0.69 per cent of the total admissions, with 7 deaths, were reported. The case mortality was 8.6 per cent. General septicemia was reported in 14 cases and, as would be expected, the case mortality, 57.1 per cent, was high. Diphtheria was frequently associated with scarlet fever. Among the 188 cases, there were 4 deaths, giving a case mortality of 2.12 per cent. The total occurrence of diphtheria among the primary admissions amounted to 1.61 per cent. Measles occurred in 114 cases, with 7 deaths, and German measles in 32 cases, with no deaths. The pneumonias were relatively common among the primary admissions for scarlet fever. The records show 257 cases of bronchopneumonia and 195 cases of lobar pneumonia as complications. The case mortality, as would be expected, was high. It was 47.8 per cent for bronchopneumonia and 39.4 per cent for lobar pneumonia. Occurrence of the pneumonias among the primary admissions totaled 3.87 per cent.

Scarlet fever occurred as a concurrent disease in 344 cases of measles, 64 cases of diphtheria, 54 cases of German measles, 288 cases of mumps, 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 fever reported as an associated disease of measles, while it was 6.1 per cent of cases of scarlet fever where measles occurred as a concurrent disease. This same difference occurred where diphtheria and scarlet fever were concurrent. Where diphtheria occurred as a concurrent disease, the case mortality was 2.12 per cent; where the reverse condition existed-that is, where the primary admission was for diphtheria, and scarlet fever was the concurrent disease-the case mortality was 1.5 per cent. Among the 98,225 cases of measles reported as primary admissions, scarlet fever was reported in 0.35 per cent. Among the 10,909 cases of diphtheria, scarlet fever occurred as a concurrent disease in 0.58 per cent.

TABLE 64.-Admissions and deaths for scarlet fever, concurrent with other diseases, enlisted men, United States Army, United States and Europe, April 1, 1917, to December 31, 1919

Primary diseases


Admissions

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

---

 

 

 

 

 


405

According to Ludy, Hunt, and Cogswell,3 reporting their observations in cases of scarlet fever at Camp Hancock, Ga., albuminuria was present in 67.3 per cent during the first week, 58.8 per cent during the second week, and 8.8 per cent at the end of the sixth week of the disease. Casts were present in 35.3 per cent during the first week, 14.4 per cent during the second week, and 2.9 per cent at the end of the sixth week. In another series suppurative otitis media developed in 11 per cent of 500 cases, arthritis in 5.9 per cent, and bronchopneumonia in 6.5 per cent. Three of the cases had relapse and three developed jaundice. Streptococcus throat cultures were positive in 36.2 per cent; 92.8 per cent had "strawberry tongue"; 35 per cent were admitted with skin eruption; 100 per cent had inguinal adenitis, and 65 per cent had the rash of scarlet fever before admission to hospital. An enanthem was present on the hard and soft palates in 92.9 per cent of the cases, and 70 per cent developed marked desquamations. Nephritis was reported as not being common at Camp Hancock. The only serious complications reported were otitis media and pneumonia. The pneumonia was said to have been of a peculiar type, markedly resembling influenza-pneumonia. One case of severe arthritis was reported from this camp.

The occurrence of scarlet fever at Camp Lewis, Wash., was reported as being of a mild type, with few important complications. Pneumonia occurred in three cases and nephritis and endocarditis each in one case. Transient albuminuria was reported in 14 per cent of the cases. Nephritis appears not to have been as common a complication of scarlet fever in the Army as in civil life, where its occurrence is said to be from 10 per cent to 25 per cent.5

 DIAGNOSIS

The clinical diagnosis of scarlet fever is justified by the presence of such manifestations as fever, with sudden onset; sore throat; fine punctiform rash, involving the hair follicles situated on a normal base, appearing first on the neck and chest, then becoming generalized, vividly red in the beginning, turning darker as the disease progresses; pallor about the mouth; tongue coated and showing prominent red papillę protruding through this coat; vomiting; early albuminuria; rapid pulse; and eosinophilia. The justification of this diagnosis is increased by the feverish appearance of the patient, the presence of urobilinogen in the urine, absence of the diazo reaction, and presence of peripheral blood capillary fragility.

During the World War, the typical case of scarlet fever was not difficult to diagnose; however, medical officers reported mild cases that did not present the full clinical picture. There were cases also where the differentiation from measles and German measles was difficult. The latter disease at times presented a fine, vivid erythematous rash that strongly resembled that of scarlet fever. It was necessary at times to observe patients in quarantine before a positive diagnosis could be made. Toxic erythema caused confusion in some cases, but observation afforded opportunity to make the differential diagnosis.

The enanthem and submaxillary and inguinal adenopathy were important diagnostic findings in the cases studied at Camp Hancock; the presence of enanthem was reported in 92.9 per cent and the adenopathy in 100 per cent of


406

the cases.2 Skin eruption was not present in all cases, and marked desquamation occurred in 70 per cent. Although scarlet fever without eruption was reported during the war,3 the difficulty of diagnosis was greatly increased without the presence of this valuable diagnostic sign.

PROGNOSIS

If the occurrence of deaths from scarlet fever be taken as an index to the severity of the disease, the ratios for the various camps show a great difference in severity during the war. The death ratios for the large camps in the United States varied from 0 to 0.71 per 1,000 strength. No deaths occurred 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 death rate at Camp Pike, Ark., was 0.58 per 1,000 per annum. The death ratio for the remaining camps was, in each instance, below this figure. The death ratio for the 4,816 cases occurring in the large camps of the United States was 0.11 per 1,000 strength, and the case mortality varied between broad limits. The highest case 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 the southeastern part of the United States. The average case mortality for the camps located in the United States was 2.96 per cent. As shown previously, scarlet fever occurred more frequently among white troops and the death rate was higher than among colored troops.

Scarlet fever was not, to any great extent, the cause of permanent disability in the Army during the war. Table 60 shows that 18 men were discharged from the service on account of disability following this disease. All of these cases were among white enlisted men. The records do not permit such detailed analysis as to make it possible to state the disability more specifically. Since scarlet fever is an acute disease, naturally the 18 cases discharged from the service were discharged on account of some chronic complication, the exact nature of which can not be stated.

PREVENTIVE MEASURES

Since there were no specific preventive measures known for scarlet fever at the time of the World War, the discussion of prophylaxis in this disease is confined to general preventive or control measures. The general measures of value in preventing the spread of scarlet fever depend largely upon the susceptibility of individuals to this disease. The control of this disease is easier than the control of some other acute infectious diseases, for example, measles. Fomites have been shown to harbor the virus; therefore, thorough disinfection or destruction of articles of clothing, etc., was taken cognizance of in the control of the disease during the war. Occurrence of milk-borne epidemics are contained in the literature on this disease; however, milk-borne scarlet fever was not reported in the Army.

The exact time at which patients become a source of danger and the duration of this period have never been determined; since there is no known causative organism, there are no bacteriological guides upon which to base quarantine.


407

The importance of missed cases and patients developing a relapse after being dismissed from quarantine was referred to by several medical officers during the war. Ludy, Hunt, and Cogswell3 reported that 35 per cent of the 500 cases at Camp Hancock, Ga., were admitted to hospital with the skin eruption present. These cases must, therefore, have been a source of infection for some time before being transferred to hospital. Some cases of scarlet fever were so mild that the disease had developed fully before transfer was made. It seems probable, then, that cases occurred in many camps where the diagnosis was made late in the disease or not at all, allowing the patient to remain with his organization.

As a general preventive measure, it was customary to quarantine newly arrived troops 14 days before allowing them to mix freely with other members of the camp. This was possible where the number of men was small; however, in most instances this quarantine was never absolute. The quarantine referred to was not solely for the purpose of preventing scarlet fever, but was intended for other diseases as well, especially measles. Such quarantined soldiers were examined once or twice daily for the appearance of contagious diseases.

The common practice, upon identification of a case of scarlet fever, was to send the patient to hospital and place all contacts, or the entire company, in quarantine. This quarantine was regulated by the division surgeon or the senior medical officer present, and was maintained for seven days. The seven-day quarantine seems to have been satisfactory, although there are cases on record where the incubation period seemed to have been longer.

The length of quarantine of the patient was six weeks by regulations. The records show that the average time spent in hospital for all cases was 42.6 days. In the United States this average was 42.3 days, in Europe 45.09 days. During the war, as noted, medical officers did not believe that the scales contained the virus of scarlet fever, but continued to use desquamation as throwing some light on the probable duration of infectivity. It was generally accepted that as long as the patient showed abnormal nasopharyngeal discharges, suppurating otitis media, discharge from an open lesion, or swollen lymph glands about the neck, he should not be discharged from quarantine. These symptoms usually cleared up promptly. The complication, as a rule, that had the longest duration was chronic suppurative otitis media. At Camp Grant, Ill., the presence or absence of eosinophilia was taken as an index to releasing patients from quarantine.

Although precautionary measures were used to prevent patients from leaving the hospital too soon, relapses occurred. The records do not permit of an analysis of these cases. Ludy, Hunt, and Cogswell3 reported that 5.7 per cent of the cases at Camp Hancock gave a history of previously having had scarlet fever.

TREATMENT

No satisfactory specific treatment was known for scarlet fever before the World War, and none was developed during that time. The course of the disease can not be cut short, but certain precautionary measures have proved of value, especially in reducing the incidence of complications. All cases were


408

sent to hospital as soon as the disease was suspected, and isolated in wards especially set aside for that purpose. These were wards designated as isolation wards, with from one to a maximum of about six beds each. Where two or more beds were in a room, they were separated by sheet cubicles. In the event of an increased occurrence of this disease in camp, or in the case of contacts, transfer was often made to the hospital upon the presence of fever alone, although of unknown type. Rest in bed during the early stages of the disease, liquid diet, a well-ventilated and well-heated ward, comprised the palliative treatment. The diet was increased in proportion to the general improvement of the patient and falling of the temperature. The records show that attempts were made to prevent otitis media by the use of alkaline antiseptic mouth washes and gargles, and in some instances by the application of silver preparations to the throat. The measures for preventing the occurrence of nephritis included the prevention of body chilling by rest in bed until convalescence was well established, the free use of fluids, and the limitation of proteins in diet, especially in the form of meats. During the stage of desquamation, vaseline or olive oil was used on the skin; and in some base hospitals carbolized vaseline was used where itching was troublesome.

The treatment of complications was symptomatic. As regards otitis media, which was present in more than 3 per cent of the cases, the treatment was, in general, early incision of the drum membrane for drainage, followed by installation of 50 per cent alcohol several times a day into the external auditory canal. Paracentesis of the drum membrane was generally done in the ward.

The nursing and diet services were generally separate for scarlet fever patients, and much attention was paid to the importance of boiling the eating utensils after use, separate thermometers, and destruction of nose and throat secretions. Discharges from suppurating ears and open wounds that developed 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.