|Fig 1 Image from page 291 of Diseases of children for nurses. by Robert Shelmerdine McCombs. 1911. Internet Archive.|
Scarlet fever, named for the erythematous skin rash that may accompany streptococcal infections (Fig 1), is often considered a disease of Victorian times. Associated with high levels of morbidity and mortality (up to 25%) when epidemics were common in the eighteenth and nineteenth centuries in Europe and the US,1,2 it is seen less frequently in modern times because of widely available antibiotics, higher living standards, and improved hygiene. However, there has been a recent resurgence in the UK and worldwide.4-7 First described in the sixteenth century,8 scarlet fever is also known as “fourth disease” and “scarlatina.” Caused by the exotoxins produced by the streptococcus group A bacterium, signs and symptoms include pharyngitis, pyrexia, headaches, lymphadenopathy, and the characteristic “strawberry tongue.”9 Spread is through close contact and respiratory droplets and it is most common between the ages of five and fifteen. Complications may include tonsillar abscess, bacteremia, pneumonia, and non-suppurative sequelae such as rheumatic fever and streptococcal glomerulonephritis.9
Scarlet fever has been featured in many famous works of literature, especially children’s literature, which is not surprising given its widespread frequency and high mortality in past centuries. Some portrayals are realistic, but there are exceptions. It makes a brief but significant appearance in Mary Shelley’s famous novel Frankenstein.10 The protagonist, Victor Frankenstein, has a cousin called Elizabeth whom his family adopts and who ultimately becomes his wife. At the age of sixteen, Elizabeth contracts scarlet fever. Victor’s mother, Caroline, insists on nursing her adoptive daughter when she realizes how unwell she is and contracts scarlet fever herself after three days. In the book, Victor recalls that “her fever was accompanied by the most alarming symptoms” and although Elizabeth recovers, Caroline dies. This seems a sudden death but is probably quite realistic. Set sometime in the eighteenth century in Geneva, the novel takes place in the pre-antibiotic era.11 Penicillin was only discovered in 1928.12 Although Caroline had appeared healthy and was relatively young, she had undergone a period of hardship in her youth and was therefore not really so robust. Victor earlier refers to her “weakened frame” and reports that her health had “been shaken by what she went through” as a younger woman. While this is a brief episode in the novel, his mother’s untimely death has an effect on Victor and influences his subsequent actions in the novel.
Another well-known portrayal of scarlet fever occurs in The Velveteen Rabbit, a popular British children’s book written in 1922 by Margery Winifred Williams Bianco.13 The book has the alternate title How Toys Become Real, which also serves as a plot summary. The boy who is the owner of the velveteen rabbit falls ill with scarlet fever and displays many of the typical symptoms: “his face grew very flushed, and he talked in his sleep, and his little body was so hot that it burned the Rabbit when he held him close.” When he recovers, the family doctor insists that his room be disinfected and all his books and toys burned in order to reduce the chance of any transmission of the infection, something that was commonly done at the time.14 This threat propels the plot of the book forward to a happy conclusion, setting it apart from other portrayals of scarlet fever.
Perhaps the most well-known depiction of scarlet fever in literature occurs in Louisa May Alcott’s Little Women and its sequels. This famous series of books is partly autobiographical and focuses on the lives of the four March sisters in 1800s Concord, Massachusetts. Beth is the second youngest and the most pious. The sisters had been helping an impoverished immigrant family who live nearby, and as the baby of the family is sick, Beth visits almost every afternoon for a week. One afternoon, the baby dies in Beth’s arms and when the doctor arrives he quickly diagnoses scarlet fever. Beth has already started to develop symptoms and rapidly becomes very unwell. She is nursed at home and attended to by a family doctor. The youngest sister, Amy, who has not had scarlet fever before, is sent away to stay with an aunt. Beth soon becomes delirious with swinging pyrexia and it becomes apparent that she may not survive. Jo has already prepared for the worst and will try to “bear it if it comes.” Ultimately Beth survives this acute episode but has an extended convalescence, and there are hints that her recovery may be a temporary reprieve. The story is continued in the sequel, Good Wives. There are few specific details about the nature of Beth’s decline ie, she “remained delicate long after the fever was a thing of the past. Not an invalid exactly, but never again the rosy, healthy creature she had been.” She becomes progressively weaker and eventually dies in the arms of her mother at the age of nineteen. Although tragic for the whole family, Beth’s death particularly impacts Jo and is a central event in the novel. (Fig 2)
|Fig 2 Illustration of Jo and Beth from Good Wives. Louisa M. Alcott. 1869. Wikimedia.|
Although not specifically described, the most likely explanation for Beth’s death is rheumatic fever complicating her initial infective episode. This may then have led to rheumatic valvular heart disease or carditis leading to congestive cardiac failure,16 which could explain her decline. No specific heart failure signs are described but Beth’s fatigue and weakness could be ascribed to it. Only about 30% of those with acute rheumatic fever progress to severe valvular disease and only 10% develop cardiac failure,16 and there is usually a longer latent period than described in the book. Despite this, cardiac failure seems more likely than post-streptococcal glomerulonephritis—another long-term complication16—as none of the typical features are described and it would not normally lead to death in three years.
Although the portrayal of Beth’s illness may have some features not commonly seen in scarlet fever, it is based on real-life events. Louisa May Alcott based all of the March sisters on her own family17, 18 and Beth was based on her younger sister Elizabeth (Lizzie), who also contracted scarlet fever, recovered from the initial episode, but then died at the tragically young age of twenty-three.19 Their father had some progressive beliefs such as transcendentalism and veganism and reportedly no doctor was sent for during her initial illness.18, 20 Beth’s decline was very closely modeled on Lizzie’s according to Alcott’s journals, which describe a general physical deterioration over two years and state that she was “fading,” “failing fast,” and “a shadow.” When she died “at 23 she looked like a woman of 40.”19 Some biographers have suggested other illnesses such as anorexia were responsible21 and her doctor reportedly diagnosed her with “atrophy or consumption of the nervous system, with great development of hysteria.”18 Therefore there may have been factors in her decline not related to scarlet fever that influenced the portrayal of Beth in Little Women.
There are many parallels in the depiction of scarlet fever in the novels. In all cases the patient is nursed at home, despite suffering a serious illness. The idea of a previously healthy sixteen-year-old potentially dying at home from an infectious disease and not sent to a hospital highlights how healthcare has changed in modern times.22 Beth’s family almost expects her to die. All portrayals emphasize the contagious nature of the disease. In Little Women and Frankenstein, both victims are young, unselfish, pious characters who contract the disease after a period of caring for someone else who already has it. In Mary Shelley’s novel, Victor’s mother is aware of the contagious risk and is warned not to nurse her daughter, but puts her daughter’s safety before her own. Many patients with infectious diseases have been helped by those who risk their own health, both in literature and real life.23, 24
A final portrayal of note occurs in Laura Ingalls Wilder’s famous series of Little House on The Prairie books, although this may be a misrepresentation. In the books, which are based on Laura’s memoirs, her older sister Mary becomes completely blind at the age of fourteen after an acute episode of scarlet fever, which had also affected other family members.25 Although scarlet fever was one of the most common infectious causes of childhood death in the United States at that time,26 it was not a common cause of blindness. In an article published recently,27 Tarini and her co-authors have suggested that the cause of Mary’s illness was more likely meningo-encephalitis causing an optic neuritis, based on descriptions from Laura Ingalls Wilder’s journals and letters, from newspaper articles of the time period, and from Mary’s subsequent clinical course. The decision to attribute the episode to scarlet fever in the book may have been made by the author or her publisher, perhaps to make the events more relatable to readers at the time. Interestingly, there is a similar scenario involving Helen Keller, the famous author and advocate for those with disabilities, who became deaf and blind after an acute febrile illness at only nineteen months.28 Scarlet fever is often cited as the cause of her illness although it seems now that meningitis was the more likely diagnosis.28,29
Despite these misrepresentations, there is no shortage of well-known people who did have scarlet fever, including Thomas Edison, Johann Strauss, and two sons of Charles Darwin. It has overall been realistically portrayed in literature, although less frequently in recent times as now it is thankfully less of a health concern.
- Andrey DO, Posfay-Barbe KM. Re-emergence of scarlet fever: old players return? Expert Rev Anti Infect Ther 2016; 14: 687-9
- Guerrant R, Walker D, Weller P. Tropical Infectious Diseases: Principles, Pathogens and Practice. Third edition. Elsevier Saunders;2011
- Wessels MR. Pharyngitis and scarlet fever. In : Ferretti JJ, Stevens DL, Fischetti VA, editors. Streptococcus pyogenes : Basic Biology to Clinical Manifestations [Internet]. Oklahoma City (OK): University of Oklahoma Health Sciences Center; 2016-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK333424/
- Lamagni T, Guy R, Chand M et al. Resurgence of scarlet fever in England, 2014–16: a population-based surveillance study. Lancet Infect Dis2017; 18: 180-187
- Public Health England Group A streptococcal infections: fourth update on seasonal activity , 2015/16. England; Health Prot R. 2016;10(16):2.
- Baseti S. Scarlet fever: a guide for general practitioners. Lond J Prim Care 2017 ; 9(5): 77–79.
- Luk EY Scarlet fever epidemic, Hong Kong, 2011.Emerg Infect Dis 2012;18:1658–1661
- Ferretti J, Kohler W. History of Streptococcal Research. In: Ferretti JJ, Stevens DL, Fischetti VA, editors. Streptococcus pyogenes : Basic Biology to Clinical Manifestations [Internet]. Oklahoma City (OK): University of Oklahoma Health Sciences Center; 2016-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK333424/Streptococcus Pyogenes: Basic Biology to Clinical Manifestations.
- Managing scarlet fever BMJ2018;362:k3005
- Shelley M. Frankenstein. Seattle, Amazon Classics 2017
- Powers JH. Anti-microbial drug development – the past, present and future. Clin Microbiol Infect 2004; 10 (Suppl. 4): 23–31
- Haven KF.Marvels of Science : 50 Fascinating 5-Minute Reads. Littleton, CO: Libraries Unlimited; 1994. ISBN 978-1-56308-159-0.
- Bianco MMW. The Velveteen Rabbit. Doubleday and Company, Inc. Garden City, New York. Available at https://digital.library.upenn.edu/women/williams/rabbit/rabbit.html
- Alcott LM. Little Women. iBooks. https://books.apple.com/ie/book/little-women/id392614050
- Karthikeyan G, Guilherme L. Acute rheumatic fever. Lancet 2018; 392(10142)161-174
- Louisa May Alcott (Illustrated): Her Life, Letters, and Journals. Cheney E ed. Boston: Little Brown and Company; 1898
- Swanson J, Death by caring: Ebola and Alcott’s Little Women. Am J Med 2015; 128 (3): 325
- Wilder LI, Sewell H, Boyle M.By the Shores of Silver Lake. New York, NY: Harper & Brothers; 1939
- Katz AR, Morens DM. Severe streptococcal infections in historical perspective. Clin Infect Dis 1992;14(1):298–307
- Allexan SS, Byington CL, Finkelstein JI, Tarini BA. Blindness in Walnut Grove: How Did Mary Ingalls Lose Her Sight? Pediatrics, 2013; DOI: 1542/peds.2012-1438
- Herrmann D. Helen Keller: a life New York: Alfred A. Knopf ;1998 https://www.britannica.com/biography/Helen-Keller
- Gilsdorf JR. Into darkness and silence – what caused Helen Keller’s deafblindness? Clin Infect Dis 2018;67(9):1445-1449
EMILY BOYLE, MD, FRCS, FEBVS, received her medical degree in 2004 from the Royal College of Surgeons in Ireland. Having worked and trained in many hospitals around Ireland, she is now a Consultant Vascular Surgeon in Tallaght University Hospital in Dublin.
Highlighted in Frontispiece Volume 12, Issue 4 – Fall 2020