Second attacks of scarlet fever are ex tremely rare. They sometimes occur, but in most supposed cases there has been some error in diagnosis. Relapses are more common than second attacks. They result from autoinfection, and usually occur during the second or third weeks. Prognosis.—The younger the patient, the greater the mortality. Holt; after the study of a large number of American and European cases, concludes that the general mortality may be assumed to be from 12 to 14 per cent., while under five years it is from 20 to 30 per cent. It is much lower in private practice than in hospitals. The majority of fatal cases occurs in children under seven years.
Prognosis is rendered unfavorable by the appearance of the following symptoms, the gravity being in proportion to their severity: Violent onset, high tempera tures, convulsions, extensive branes or gangrenous pharyngitis, diph theria, croup, pneumonia, excessive 1 ulitis, superficial gangrene, nephritis, and exhaustion with general septic symp toms. The prognosis in uncomplicated cases, even when the disease runs an active course, is good.
Study of 1000 cases. The percentage of mortality, including moribund cases, was 9.S. Scarlet fever uncomplicated caused 56 deaths; broncho-pneumonia, 15; diph theria and scarlet fever combined, 10; diphtheria alone, 9; pneumonia, 4; scar let fever and erysipelas, 1; tubercular meningitis, 1; and 2 died from various complications. J. II. McCollom (Phila. Med. Jour., June 3, '99).
Study of 2627 cases treated during seven years in the Riverside and Willard Parker Hospitals. The mortality-rate was 9 per cent. In the very earliest cases of scarlet fever the eruption is frequently present on the anterior axillary fold. Projectile vomiting is a very common early symptom. In favorable cases the maximum temperature is about 103 de grees. W. L. Somerset (N. Y. Med. Jour., Dec. 8, 1900).
Prophylaxis.—In view of the gravity of the disease and the effectiveness of preventive measures, prophylaxis assumes unusual importance. The most impor tant of all prophylactic measures is com plete isolation of the sick. This applies to nurse as well as to patient. If pos sible, one person should be selected as an intermediary between the nurse and the family. The doctor should always wear in the sick-room a gown of muslin or calico fastened at the neck and wrists and long enough to completely cover his clothes. A stethoscope should be used in making physical examinations of the chest.
The period of isolation should not be less than forty days and as much longer as the presence of desquamation or puru lent discharges may demand. Discharges of the patient should be disinfected with strong sublimate solutions. The bed ding, carpet, and clothing should be dis infected with boiling water or steam. The mattress should be destroyed. The room itself should be thoroughly washed —floor, ceiling, and walls—with a 1 to 2000 sublimate solution.
One room on the top floor of every house should be arranged for a sick room: the moldings should be plain and the floor of hard wood; the walls and ceilings should be painted or covered with washable paper; the bedstead should be of enameled iron. It is a fallacy to suppose that dishes in the filled with antiseptic fluids, can limit the spread of the disease, or that there is any efficiency as a prophylactic in generat ing steam impregnated with medicinal agents. Their use is liable to generate a false sense of security and lead to the neglect of more important measures.
The most reliable prophylaxis of scar let fever is isolation of patients and nurses and thorough use of disinfectants in their rooms and on their persons. All articles not absolutely needed should be removed from the sick-room, and no one except nurses and physicians allowed to enter. Constant ventilation should be in sisted upon. Clothing used about the pa tient should, on removal from the sick room, be placed in a tub of boiling water containing carbolic acid and sulphate of zinc, or in corrosive-sublimate solution 1 to 1000, and allowed to soak at least an hour; then placed in boiling water for washing. Vessels used by the patient should have a disinfecting fluid con stantly in them, and be cleansed with boiling water immediately after using. Water-closets should be disinfected daily with lime or sulphate of zinc. Sterilized cloths should be used in place of hand kerchiefs, and burned after using. Dur ing desquamation the patient should be kept well anointed with carbolized vas elin or lysol and vaselin. The physician also should anoint his hands and face and put on a close-fitting gown and hood before entering the room, and should wash and disinfect his hands and face and put the gown and cap in a bag containing a sponge saturated with for maldehyde before leaving the house.