WESTMINSTER HOSPITAL,

W.R. Basham
1859 The Lancet  
more from each other than does the same epidemic disease differ in intensity and destructiveness at the various periods of its return. This remark is specially applicable to scarlet fever. In some years all, or the majority of cases, exhibit mild and favourable symptoms. A slight febrile disturbance, with sore-throat, is followed by a diffuse scarlet rash, which gradually pervades the whole body; and, fading on the sixth or seventh day, leaves the cuticle to desquamate, and the patient to a
more » ... d convalescence. Of this simple form of the epidemic, Sydenham has truly said that it deserves little more than the name of a disease, and that the patient is in little danger, but through the officious zeal of the physician. But the characteristics of other epidemics of the malady are very different, and the present visitation, now of more than three months' duration, has been particularly illustrative of the prefatory remark; for the majority of the cases have presented unfavourable, not to say fatal symptoms, the mortality, according to the Registrar-General's Reports, having been greater than for some years. In the more malignant form of the disease, sore-throat is a very prominent symptom; and it may be doubted whether a great number of the fatal cases recorded as diphtheria have not been scarlatina anginosa, or scarlatina maligna. In the scarlatina anginosa, the sore-throat is the symptom which alone attracts attention; and if the peculiarities of the inflammation be not closely noted, an inattentive observer might view the throat disease as a simple tonsillitis, or be ready, when unfavourable symptoms followed, to classify it under the title of diphtheria. In the true scarlatinal sore-throat, the tonsils, soft palate, uvula, and back of pharynx, are involved in a diffuse inflammatory redness of a brilliant hue; the tongue, partaking of this elevated colour, and oftentimes being furred, and the enlarged papillae, elevated in colour, appearing through, the similitude to a strawberry has been imagined, and hence "strawberry tongue" has been accepted as the characteristic of this stage of scarlet fever. The throat, however, not only presents an inflammatory redness, but there is considerable tumefaction, sufficient to impede deglutition and speech, and, extending to the external parts, produces swelling of the submaxillary glands, and stiffness and painful distension of the integuments about the throat. Specks or points of ulceration make their appearance on the tonsils, and a viscid, tenacious mucus is formed, which adheres to the parts, and sensibly increases the difficulty of deglutition. This viscid secretion may be mistaken for the croupous pellicle which is formed in diphtheria ; the specks of ulceration discoverable beneath this viscid mucus will, however, distinguish the scarlatinal from the diphtheritic inflammation. The eruption comes on late I and imperfectly, and may be, and is, often overlooked. Within ten days or a fortnight, the urine becomes scanty, dark-coloured, and albuminous. In many, the presence of blood is unmistakable ; in others, the urine acquires but a dirty or sooty appearance. This condition of the urine will, I believe, if any doubt remains, distinguish the scarlatinal from the diphtheritic disease. By some writers in the weekly medical journals the urine in diphtheria has been described as albuminous. But, with every respect for these communications, I should venture to classify the disease as scarlatina rather than diphtheria. It is this evidence of the disordered state of the renal organs which constitutes the element of danger in these cases, and which eventually leads to the development of the most unmanageable of all the forms of albuminuria-acute morbus Brightii. It is a singular fact, that the activity of the renal disorder bears no proportion to the apparent intensity of the original febrile poison. For it may be said that inversely as the manifestation of the symptoms of scarlet fever, is the susceptibility to the renal disorder; for the more highly developed the scarlet rash, the more complete will be the proof of the elimination from the blood of the febrile poison; and the less characteristic the rash, the more certain that the poison lurks in the system, unheeded and undestroyed, and eventually to implicate the kidneys in a disorder fatal in proportion to the tardiness with which it is recognised. In this type of cases, the eruption is slow to show itself ; and in place of a diffuse effiorescence, it occurs in patches, far less intense in colour than in the simpler and milder form of the disease. The constitutional disturbance is oftentimes great; but cases are frequently met with, where, ultimately, a fatal termination by renal disease takes place, in which the primary disorder was not marked by any symptoms of urgency. The patient appears to convalesce favourably, but, slowly and insidiously, evidence of lurking mischief becomes apparent. In some cases there may be symptoms of a secondary fever about the fourteenth day from the date of the sore-throat, some restlessness, loss of & p o u n d ; appetite, and chilliness. But these symptoms are sometimes wanting, or so feebly pronounced as to be unnoticed. Frequency of micturition, scanty, dark-coloured urine, and a puffiness of the face, may be, and often are, the first symptoms noticed by the patient. General anasarca of the surface follows, with a pallor so peculiar, of such alabaster whiteness and purity, as to become almost a specific feature of the disease. Frances G-, aged nineteen, was admitted into Queen Adelaide ward, on the 10th of November, suffering from general dropsy of the surface of the body. There was cedemaof the face, arms, wrists, and back of the hands, as well as of the trunk and lower extremities. The swollen state of the face usually subsided as the day advanced. There was the usual pallor of the skin. There was some dyspnœa, with occasional cough and trifling expectoration of catarrhal mucus. The urine had been very scanty, and micturition distressingly frequent: during the night, the desire to pass urine occurred every hour, and the rest was consequently much disturbed. The urine had a cloudy, dirty, soot-like appearance, was highly albuminous, threw down a copious, coarse deposit, and exhibited under the microscope blood corpuscles, coarse, granular, fibrinous flakes, containing blood discs; large, fibrinous blood casts, many large granule cells, and some scattered renal epithelial cells. She complained of a sense of fullness and aching across the lumbar region, and pain was excited by pressure over the region of each kidney. The chest was resonant; some catarrhal wheezing was heard in the large tubes. The sounds of the heart were natural. She stated that four weeks since she suffered from sore-throat, at a time when scarlet fever prevailed in the house in which she lived; that her voice and power of swallowing were affected; but that she had no distinct eruption on the skin; but was told she had, and was treated for, scarlet fever. As near as she can remember, a fortnight after the sore-throat, she noticed that her urine became very scanty, and of a dark-red colour, as if it contained blood. The catamenia had not appeared for the last six months. In a few days, she became conscious of a swelling in her face after sleep, and subsequently the hands, arms, feet, and ankles became anasarcous. She was ordered a warm bath daily, the compound jalap powder every morning, a diaphoretic mixture every four hours, and to be clothed in flannel. On the following day, she was dry-cupped across the loins, which, with the above treatment, diminished the sooty appearance of the urine; and in two days, the quantity of urine had considerably increased. A week after admission, the dropsy had completely disappeared. The urine was clear, specific gravity 1018, and albuminous. The deposit, examined by the microscope, consisted of dense fibrinous casts, some blood casts, a few scattered blood corpuscles; very little epithelium was visible, and no epithelial casts could be seen. She was ordered the sesquichloride of iron, and an improved diet. But this treatment appeared to have been commenced too early, for on the 25th of November there was a return of hasmaturia, which, however, disappeared by the loss of a few ounces of blood from the loins by cupping. On November 30th she again began to improve; there was no return of œdema, although the urine continued highly albuminous.
doi:10.1016/s0140-6736(02)44616-8 fatcat:nizu7o7spndyfncmyqluclx664