1862 The Lancet  
in commencing his paper, said that it was his wish to take the sense of the meeting on the question, Whether it is not time for the profession to come to some decision respecting the definition of certain exanthematous eruptions which at the present moment lie out of all known and acknowledged systems of classification?" After narrating the various and serious difficulties which lie in the way of the practitioner in the determination of the contagious as distinguished from the non-contagious
more » ... nthems, the author said I that they were confined to two diseases, measles and scarlet fever ; and he then proceeded to describe cases in which doubts respecting the presence of these disorders were presented in a remarkable degree. Having completed this survey, he added: And now we are brought to consider the great point before us-What is the nature of the cases to which attention has been directed ? The answer resolves itself into one of the following propositions: (1) Either there is a distinct and contagious epidemic which is not isolated in our nosologies, which has its own poison and its symptoms, and with the positive identity of which the profession is not acquainted; or (2) there is a combined form of disease, of which scarlet fever and measles are the elements; or (3) there is an unrecognised form of the disease, scarlet fever; or (4) there is some known disease which assumes an anomalous character, simulating the combination of measles and scarlet fever above named ; or (5) there is some unknown form of accidental disease from absorption of an organic poison with which we are not familiar, the disease being idiopathic and non-contagious. The author next proceeded to discuss one by one these several propositions, with a view to eliminate such of them as did not answer to reasonable and fair scrutiny. After negativing the first three propositions, he dwelt at some length on the fourth, and discussed Dr. Ross's view that there is a form of urticaria which puts on symptoms that are confounded sometimes with measles, sometimes with scarlet fever, sometimes with both, and which he regards as the source of many of the doubts respecting scarlet fever. In reference to this view of the question Dr. Richardson observed, that in the cases he had named he did not think that urticaria was the misleading disease. If so, urticaria, is open to a definition so wide under the term species that our formula must be revised in regard to it. If that is urticaria which is unattended with wheals and with itching of the skin, but which is attended with sore-throat and ulceration, universal redness of the skin, and which sometimes terminates fatally, surely the old reading of urticaria must be replaced by one more distinctive in form and more extensible in symptom. Dr. Richardson next discussed the last issue : Is there some distinct disease, arising from organic poison, which is not yet recognised, and which is the source of all our difficulties ? He believes that there is, and he is of opinion that it has the following distinctive forms :-It is an eruptive disorder, in which the skin and mucous membrane of the stomach and alimentary canal mainly, and perhaps exclusively, share. The disease has its origin in the alimentary tract, and is either primarily or secondarily connected with derangement of the nerves of organic life, The surface eruption, both on the skin and mucous membrane, is due to a loss of the controlling influence of nerve over bloodvessel. The disease is not contagious (the poison being fixed in character) except by direct inoculation. The disorder shows no tendency to produce disease of the kidney, or uraemia.. Unlike scarlet fever and measles, it is variable in its course : it may terminate at once, and favourably, by active purging or vomiting, by which means offending matters are thrown out of the canal; or it may continue till it terminates in death. It is probably most common in persons predisposed to rheumatism. The prime seat of the disorder seems to be in the alimentary :-anal. In the irregular digestion of some particular forms oi food, some product, probably of the character of a non-volatile acid, is yielded, and, being absorbed from the canal into thE blood, is the poison on which the symptoms depend. From the disease not being contagious, and from the fact that it arises in the body from malassimilation, it might be very appropriately named " Idiopathic Rosalia." Dr. Ross remarked that he had himself, many years ago, recognised the peculiar form of disease described by Dr. Richardson, and had called professional attention to it. He looked upon it as a species of urticaria, to which opinion Dr. Richardson objected. He (Dr. Ross) admitted that in ordinary acute urticaria the heat and itching were intense, symptoms which were not observable in the affection under consideration; yet he thought that there was an alliance between the two diseases. This particular form of exanthem was generally mistaken for scarlatina, sometimes for measles. It was characterized by a diffuse scarlet rash associated with red fauces, as in scarlet fever, but without enlargement of the tonsils. The elongated papillæ of the tongue characteristic of scarlet fever he had not noticed in this affection, though the surface of the tongue would occasionally become smooth and red. In about two days the scarlet rash would change colour, becoming crimson ; aud then it was that the practitioner, fancying he had made a mistake in diagnosis, would conclude the case to be one of measles,an opinion which would be strengthened by observing, on a closer examination, that the diffused rash was in large patches, and that the circumference of the patch was mottled and concentric. The eyes would be watery. In some of these cases he had noticed that towards the circumference of the patch there was a small white spot-one or two; while in other cases, and in other patches on the same child, these spots did not exist. These papules had a marked resemblance to urticaria, hence he was induced to call the disease by that name. This disease was by no means uncommon, and occasionally prevailed epidemically like scarlet fever or measles, and was almost invariably mistaken for one or other of them. It was owing to the non-recognition of this affection that there were so many reputed cases of secondary attacks of scarlatina and measles. It was not severe, according to his experience; and the eruption rarely lasted more than four days. He had never met with a case running so grave and fatal a course as one described by Dr. Richardson, and considered that the unfortunate ending of the case referred to must have been owing to complications. Mr. RADCLIFFE directed attention to the fact that Dr. Copland had described under the head " Rubeola" an anomalous exanthematous affection, similar in many respects to the majority of the cases detailed by Dr. Richardson, and which he (Dr. Copland) considered to be a hybrid, combining many of the chief characteristics of scarlet fever and measles. The most extraordinary and the gravest case related by Dr. Richardson he (Mr. Radcliffe) had seen in conjunction with him, but he had looked upon the case at the time, and still regarded it, as an instance of anomalous scarlet fever, the anomalousness arising from irregularity of the circulation dependent upon cardiac disease. The most singular feature of the case was, that the eruption, which had appeared early, and was pretty equally diffused over the body and limbs, was interrupted by large, and late in the disease irregular, patches of seemingly healthy skin. The edges of the patches were singularly well defined. At times the circulation in the extremities was so imperfect that they became cold and shrivelled as in the extreme collapse of cholera, the patches upon the limbs assuming a livid aspect. One of the patches sloughed. Dr. Mason Good has stated that occasionally the eruption of scarlet fever is broken by patches of the character described. Assuming that there was a distinct and hitherto unrecognised disease such' as Dr. Richardson described, he (Mr. Radcliffe) objected to the term Rosalia being applied to it, this term having already been made use of by Dr. Mason Good as the synonym of scarlet fever, and being recognised as a synonym of that disease. Dr. CAMPS objected to the phraseology of Dr. Richardson's argument, particularly his use of the words " identity" and ' analogy," and also demurred to the conclusion. Dr. J. EDMUNDS said that during the last few weeks he had seen no less than three children in which, on the first day, a full and universally diffused lobster rash had led him unhesi-' tatingly to pronounce the cases to be scarlet fever; yet, a day or two later, unmistakable catarrhal accompaniments developed themselves, and the rash became so dark, patchy, and altogether so characteristic of measles, that he had been under the necessity of explaining away the discrepancy to the minds of the family ' by designating the cases mixed ones. His experience did not enable him to follow Dr. Ross in comprising scarlatinoid erup-! tions with urticaria. Certain febrile conditions, attended by a ] scarlatinnid blush, and sometimes also by mild sore-throat, ]were difficult to be distinguished from scarlet fever; and he
doi:10.1016/s0140-6736(02)61125-0 fatcat:4t6dwlhsavcolp7tpfj4y6nesi