Scarlet fever, or scarlatina, represented one of the most formidable public health crises of the 19th century, particularly impacting children. Since germ theory was only beginning to be developed, the disease was often attributed to environmental factors like “miasmas” or vague notions of contagion. This lack of understanding about the bacterial cause—Streptococcus pyogenes—meant physicians had no curative treatment for the widespread epidemics in rapidly growing urban centers. The medical approach focused entirely on symptom management and supportive care, hoping the patient’s body would overcome the infection.
Recognizing Scarlet Fever in the 1800s
Physicians in the 19th century relied entirely on observable clinical signs to identify scarlet fever, as no laboratory tests existed. The disease was characterized by a sudden onset of high fever and a distinctive, generalized rash that gave the illness its name. This rash was often described as “sandpaper-like” to the touch and typically spared the area immediately around the mouth, creating a noticeable paleness on the face.
Another important diagnostic sign was the appearance of the tongue. It often developed a white coating with red, swollen papillae, known as the “white strawberry tongue,” which would later peel to become a bright red “red strawberry tongue.” The accompanying pharyngitis, or severe sore throat, helped differentiate scarlatina from other common childhood diseases.
Despite these characteristic signs, 19th-century doctors faced significant challenges in clinical practice. Distinguishing scarlet fever from other exanthematous diseases like measles or rubella, especially in mild cases, required a keen clinical eye. The severity of the illness also varied dramatically, ranging from a relatively mild presentation to fulminant cases that could cause death within 48 hours.
The Standard Medical Interventions
The medical interventions for scarlet fever were generally palliative, aimed at mitigating symptoms rather than attacking the underlying cause. In the early 1800s, the remnants of “heroic medicine” persisted, leading to treatments that seem harsh by modern standards. These practices included bloodletting, sometimes performed on children, and the use of harsh purgatives like calomel or castor oil to “cleanse” the body of disease.
Other common interventions included emetics, or medicines intended to induce vomiting, to restore a perceived balance within the body. These aggressive treatments were based on outdated theories of disease and likely caused more harm than good in weakened patients. For the severe sore throat, patients were often given various gargles, sometimes containing vinegar or diluted acids, to soothe the inflammation.
More supportive and less invasive methods were also employed, representing the most beneficial care patients received. This included strict bed rest and a limited, bland diet consisting of liquids like rennet-whey, rice water, or broth. To combat the dangerously high fever, physicians would prescribe cold sponging or the application of cool rags to the patient’s head.
Quarantine, Contagion, and Historical Mortality
The primary public health strategy for controlling scarlet fever centered on contagion and mandatory isolation. Once a case was identified, public authorities would enforce a strict quarantine of the infected household, sometimes placing notices on windows to warn the community. Patients with severe cases were frequently transported to isolation hospitals in specialized horse-drawn “fever cabs” to prevent community spread.
Upon a patient’s recovery or death, all personal belongings, including clothing and bedding, were often destroyed by burning to eliminate any source of infection. This societal response was the most effective means of controlling the cyclical epidemics. Mortality rates from scarlatina were alarmingly high, reaching up to 30% in some urban epidemics between 1840 and 1883, making the disease a leading cause of death among young children.
Those who survived often faced severe long-term complications, such as scarlatinal nephritis (inflammation of the kidneys) or rheumatic fever, which could lead to permanent heart damage. These severe after-effects were poorly understood, viewed simply as the disease’s continued progression. Late in the century, improved sanitation and public health measures, including quarantining, began to contribute to a slight decline in mortality.