Observations on the scarlet-fever (Hahnemann, 1808)

The malignant scarlet-fever that has prevailed in Germany for eight years and proved fatal to many thousands of children and older persons, often so unexpectedly, so rapidly, and with symptoms never before heard of under such circumstances, this murderous disease, termed scarlet-fever by almost every one, is really anything but scarlet-fever; it is a new disease never seen in Germany before the year 1800, which, on account of the red rash that usually accompanies it, might be termed purpura miliaris, and which, then for the first time, spread from the west, over Hesse, Bamberg, Beyreuth, Thuringia and Voigtland, to Saxony, and thence since that time has extended in all directions.

If it can be proved that this is a new disease and is widely different from the old genuine scarlet-fever (which old people can still very well remember to have noticed in their youth in themselves and others), we can very well understand how it happened, that the medical men did not know how to act in this new disease, and that at first all who were likely to die, slipped through their hands; indeed that their endeavours did more harm than good, as they were always under the delusion that they had to do with the old genuine scarlet-fever, and thus they were misled by this extraordinary confounding of names and things, to treat the new disease in the same way as they had been used to treat the true scarlet-fever (by means of keeping the patient warm, administering elder-flower tea, andc.). Such a mistake, such a confounding in diagnosis and treatment of two such very different diseases, must naturally have a very unfortunate result, as experience has shewn it to have had by the many thousands who have fallen victims to this new disease.

This disease is new among us, I repeat, for there is not the slightest trace of such a purple miliary fever having ever before prevailed in Germany.

The epidemic in Strasburg, described seventy-three years ago by Salzmann, was a white miliary fever-white vesicles on a white skin-and differed from our new miliary fever in this, that children and old people were almost entirely exempted from it, and it chiefly affected youths and adults between twenty and forty years of age; sore throat was very rarely met with in it.

The miliary epidemic described by Welsch, of Leipzig, 150 years ago, consisted of a white, millet-seed size dexanthema, and only affected lying-in women; probably it was a disease brought on by keeping them too warm.

The most recent miliary epidemic which Brüning observed thirty-six years ago, in the neighbourhood of the Lower Rhine, differs also from our new disease in this, that children of five years and under generally remained free from it, and women were more frequently attacked than men,-that it had its critical days, and was likewise a white miliary rash, resting for the first few days on red spots, which went off on the seventh day, leaving the white miliary rash standing from three to seven days longer on the white skin.

 The epidemics that bear the greatest resemblance to our present purple miliary, are those observed by David Hamilton, long ago (1710) in India, and Charles Allione (in 1758) in Turin.

 Other observers only mention having occasionally observed a miliary fever in single individuals, which were usually only brought on by the use of heating) diaphoretic remedies, especially of opiates, did not prevail epidemically, and are described by them in a most vague manner.

 That our miliary fever is new and very different from the true scarlet-fever, the following comparison will shew. 

The new red miliary-fever The old genuine scarlet-fever
attacks persons of all ages; attacks only children until their 12th year (Sim. Schulze)-attacks only children, almost never adults (Plenciz, Sennert);
the eruption consists of purple-red (Jani), of dark red spots (verging on brown), which on being pressed with the finger do not leave a white spot but remain unchanged, of a dark red colour, the redness of the skin is an erysipelatous fire-coloured redness (Sennert);-a bright scarlet redness, resembling erysipelas in colour and in this, that it immediately disappears on pressure with the finger and shews a white spot, which however immediately resumes its red colour (Navier); the redness is like the colour of a boiled lobster (Act. med. Berol.);-a cinnabar redness (Plenciz).
of sharply defined, discrete patches of redness, The smooth shining redness of the skin runs imperceptibly into the neighbouring white parts, in unnoticeable shades, like erysipelas, and is never well defined;-it becomes from time to time, now a little paler, now a little redder, and almost every instant it spreads imperceptibly farther, and then retires to its original seat (Navier).
Always thickly studded with dark-red miliary papulae, which are not so much elevated above the level of the skin as stuck deep in it, yet distinctly perceptible to both the eye and the touch. None of the above-mentioned authors allude to miliary elevations of the bright red parts of the skin;-the skin of the reddened parts is quite even and smooth (Hahnemann);-the red parts of the skin are quite smooth and destitute of inequalities or elevations (Plenciz, Op. tract. iii, p. 49)-and in this the scarlet-fever differs from every kind of miliary fever (Plenciz, ib., p. 58).
This exanthema attacks in an indeterminate manner, now this, now that part of the body-there is no part of the body for which it has a peculiar affection, or to which it attaches itself in a peculiar manner (Stieglitz). Most frequently the favourite spots for its attack are the covered parts and flexures of the joints; most rarely the face. The rash is usually accompanied by swelling (Stieglitz). The redness of the true scarlet-fever prefers attacking first the uncovered and but slightly covered parts, which swell as far as the redness extends. At first the redness and swelling occur on the face (De Gorter, Plenciz)-at first in the face, neck, and chest (Plenciz)-the scarlet redness first appears, with some swelling, on the face (neck and chest), the hands, and the outside of the feet and from these parts it spreads out in an erysipelatous manner (in the worst cases) all over the body (Hahnemann).
This exanthematous fever has not a determined, regular course, like other exanthematous fevers (Stieglitz);-the eruption remains here and there for an indeterminate period, often several weeks; there is no fixed period for its departure. In every genuine scarlet-fever the redness appears on the parts named simultaneously with the febrile heat, and in mild cases is perceptible for from three to four days (Plenciz, Sennert), in bad cases, seven days (Plenciz)-and goes off by becoming gradually paler from day to day. The parts that first became red, become first pale (Plenciz).
The red miliary rash often disappears suddenly at indeterminate times, with increased danger to life, usually followed suddenly by death. None of the above authors makes mention of the sudden disappearance of the redness of true scarlet fever during the fever. After the gradual fading of the redness up to the fixed days mentioned above, there occur apyrexia and desquamation (Sennert, Plenciz, De Gorter, Sim. Schulze). Even after death the hitherto red spots remain coloured and turn violet (Navier.
The eruption may be copious or almost not at all present, the mildness or malignancy of the disease not depending on that (Stieglitz). Where the eruption is almost imperceptible the danger is often greatest, the fever most malignant;-where there is a general full eruption, the disease is often mild and slight. The fuller and more extended the redness of true scarlet-fever is, the more malignant is the fever always (Hahnemann).
It is only the dark red miliary patches that perspire, and it is only when the whole body is covered with it that the patient perspires all over, as in the epidemic at Wittenberg None of the reddened parts in true scarlet-fever perspire during the disease (in all this the authors I have mentioned are agreed), if the skin is moist, it is so only on the parts that are not yet reddened. No erysipelas perspires, and as little does the scarlatina redness. It is only when the fever comes to an end, and the redness has gradually gone off, that there sometimes occurs general perspiration, and thereafter desquamation of the skin (Sim. Schulze), and the disease may also go off without any perspiration.-(Act. med. Beral.)
This new miliary disease, falsely said to be scarlet-fever, which first appeared about the middle of the year 1800, and, like every new pestilence, raged as a most murderous epidemic where it first appeared (there was no mild epidemic of it), and then from time to time recurred, often several times in a year in the same place (not unfrequently attacking the same persons a second time), during the first years still attacked several families in succession; during the last years did not, it is true, cease for any length of time, but did not prevail quite epidemically again, but rather attacked single families, or even single individuals, in one place (though it was not less fatal)-it seems in the course of a few years to have a tendency to become extinguished completely, like the English sweating-sickness at the commencement of the 16th century. The true scarlet-fever is an old disease, which has been accurately observed for two centuries in Germany and other countries, always appeared only as an epidemic and pandemic, always attacked indiscriminately, and with scarcely any exception, every child that had not had the disease (never those who had already had it), seldom prevailed in malignant, often in mild, sometimes in perfectly mild epidemics (Sydenham, De Gorter, Nenter, Junker), scarcely proving fatal to one child in a thousand, never, or very seldom, occurred sporadically, and the reason of this was, that as it almost always attacked pandemically all children who had not previously had it, there were not under 6 or 8 years enough subjects to infect in order to show its epidemic character, hence it almost never recurred in less than 6, 8, or 12 years, and on account of this rarity of its recurrence, the oldest practitioners scarcely ever saw it oftener than three times in their lives, and it was quite unknown to our younger practitioners.
Besides the diaphoretics, elder-flower tea, andc., and the warm beds wherewith it was sought to retain the eruption on the skin (usually without success), purgatives, especially mercurial medicines, are said to have done good in this exanethematous fever; but aconite, along with a moderately cool regimen saved the most. It were foolish to judge of the power of belladonna from its administration in this new miliary fever, which, as we see, is anything but scarlet-fever. In this old, true scarlet-fever, belladonna is useful, both as a prophylactic, and as a remedy.
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