Sodii Salicylat. drachm iii;
Syrupi fl. oz. ii;
Aquæ fl. oz. iv. M.
S. Give one teaspoonful every four hours.
Of the serous inflammations occurring in scarlet fever, pericarditis
has been, according to Rilliet and Barthez, most frequently observed.
In this country it is probably more frequent than is usually supposed,
but it is less frequently detected than pleuritis, the symptoms of
which are more conspicuous. It is apt to occur in connection with
endocarditis.
The following case, showing the liability to pericarditis and other
serous inflammation which exists in scarlet fever, occurred in my
practice:
_Case 6._--C----, girl aged five years and ten months, sickened with
severe scarlet fever on April 4th. Was delirious; pulse 158; had
vomiting and constipation. April 10th, pulse varies from 124 to 153,
no delirium; a considerable quantity of urates in the urine. April
11th, has to-day, for the first time, severe pain in the epigastrium,
with tenderness and moderate distension. Otherwise symptoms favorable,
but severe; pulse 140; respiration moderately accelerated, and
vesicular in every part of the chest. From this date the symptoms
continued about the same till April 14th, when the dyspnoea became
more marked and the action of the heart rapid and tumultuous. The
epigastric pain, distension, and tenderness continued; the percussion
sound was dull over the lower part of the chest; the dyspnoea became
rapidly worse, although the pulse had considerable volume; and at 5
P.M. death occurred. At the autopsy about one ounce of turbid serum,
with a soft deposit of fibrin, was found in the pericardium. Each
pleural cavity contained from six to eight ounces of transparent
serum, and both lungs were readily inflated, except a little of the
posterior portion of each lower lobe, which could not be; no fibrinous
exudation over the lungs. The liver extended four inches below the
margin of the ribs, and upon its convex {523} surface in the
epigastrium, corresponding with the seat of the pain, was a rough
patch of fibrin about one and a half inches in diameter. The bronchial
mucous membrane was moderately injected, as was also that of the
colon, and the kidneys appeared hyperæmic.
Among the serous inflammations which complicate or follow scarlet
fever, pleuritis is one of the most important. It usually begins in
the desquamative stage, and is apt to be suppurative on account of the
feeble state of the patient when it commences. It has always, in my
practice, been tedious, as all empyemas are, and it does not differ in
its clinical history from the idiopathic disease. I have met cases of
scarlatinous empyema in which, from opposition of the family or for
other reasons, thoracentesis was not performed, and death occurred;
others in which this operation effected a cure, and one at least in
which the patient recovered by escape of pus through a bronchial tube.
The pleuritis is seldom latent, or so masked by the symptoms of the
general disease that it is apt to be overlooked. On the other hand,
the cough, embarrassment of respiration, and pain referred to the
affected side render diagnosis easy.
Dilatation of the heart is common in grave cases of scarlet fever,
such cases as are properly termed malignant. It is indicated by a
feeble and quick pulse. Acute infectious maladies, especially those of
a malignant type and accompanied by high febrile movement, are very
apt to cause parenchymatous degenerations in organs, prominent among
which is granulo-fatty degeneration of the muscular fibres of the
heart. This weakens very much the contractile power of these fibres.
But early in malignant cases, probably before the muscular fibres are
damaged, the contractile power of the heart is feeble from impaired
innervation, the result of the general weakness. Hence this organ,
when weakened by structural change and insufficiently stimulated
through diminished innervation, may not fully empty itself during the
systole, and consequently it becomes dilated. Dilatation of the heart
and imperfect contraction of the auricular and ventricular walls are
apt to result in the formation of clots in the cavities of the heart;
and this appears to be the immediate cause of death in not a few
instances. An ante-mortem clot occurring in any of the cavities of the
heart necessarily seriously obstructs the circulation, unless it be of
small size. Hence the dyspnoea, which may occur perhaps suddenly, and
the change of pulse to one of marked feebleness and frequency. Large,
firm white clots are most frequently found in the right cavities. They
interlace with the chordæ tendineæ, lie even within the
auriculo-ventricular opening, and send prolongations into the
pulmonary artery and the cavæ. Associated with the white clots are
dark, soft clots and fluid blood. The left cavities may be contracted
and empty, or they may contain dark, soft clots or white ante-mortem
clots. Clots in the left ventricle are sometimes prolonged into the
aorta as far as the brachio-cephalic branches, while those in the left
auricle may extend to the pulmonary veins. If dilatation of the heart
be so great that clots form in its cavities, speedy death is probable.
Sometimes a patient passes through scarlet fever and appears in a fair
way to recover, when he succumbs to some exhausting sequel distinct
from the heart, and at the autopsy the heart is found dilated and
containing whitish clots, which are probably ante-mortem, and which
hastened {524} death by obstructing the circulation. Under such
circumstances this state of the heart is attributable in great measure
to the complication which has weakened its contractile power.
The following was a case in point. It occurred in the New York
Foundling Asylum:
_Case 7._--R. A., aged three years, had scarlet fever, beginning March
23, 1882. The symptoms were favorable at first, but serious
complications and sequelæ occurred, which were fatal. The record of
April 18th reads: "Appears well nourished, but is anæmic; has
otorrhoea; no oedema; skin desquamating; dulness on percussion over
upper third of right side of chest, anteriorly and posteriorly; mucous
râles and rude breathing over same area; fine râles posteriorly over
lower part of left side of chest; pulse 160, respiration 68,
temperature 101-2/5°." April 20th, is feeble and takes nutriment with
difficulty; tongue thickly coated; pulse 160, respiration 68,
temperature 101-2/5°. April 26th, condition about the same as at last
record, but he is evidently weaker; the lips are ulcerated and fauces
still swollen. May 2d, cannot speak distinctly; a brownish,
foul-smelling secretion lodges on the spoon used in depressing the
tongue; left side of face swollen. On the following night eight
convulsions occurred, attended by orthopnoea, and mucous râles in the
chest from pulmonary oedema. Diarrhoea supervened and the patient died
about midnight. Autopsy: Body moderately wasted and very white,
several dark-blue spots on scalp and face from hemorrhages underneath;
lips covered with dry crusts; brain of normal appearance; aperture of
the larynx narrowed at the chink by infiltration and swelling of the
tissues; surface of the vocal cords covered by a thin white film,
apparently a fibrinous exudation; tracheal surface hyperæmic; about a
drachm of straw-colored fluid in each pleural cavity; right lung
wholly adherent by recent exudation of fibrin; left lung also largely
adherent. A careful examination showed the presence of
broncho-pneumonia in each lung, with considerable infiltration of the
walls of the bronchi, and cylindrical dilatation of many of them;
cavities of the heart dilated, so that this organ appears much
enlarged, and its shape approaches the globular; its apex is rounded
or obtuse; transverse diameter of the right ventricle, when its walls
were open and drawn apart, was three and one-quarter inches; that of
the left ventricle three and a half inches. Similar measurements of
the heart of another child of about the same age, believed to be
normal, were about one inch less in each direction. All the cavities
contain white firm clots along with soft dark clots. Liver of normal
size, pale; the outer surface and all cut surfaces are studded with
nodules of the size of a pin's head, of a dull, opaque white color.
These white spots, examined microscopically by Professor Delafield,
are found to be neither tubercles nor gummy tumors, but to consist of
polygonal cells, lying in the meshes of the capillary plexus of veins,
which are perfectly preserved. He has not observed a similar case. The
walls of the gall-bladder are one line or more in thickness, and the
gall-duct is pervious. The microscope shows general hypertrophy of the
gall-bladder and hypertrophy of its papillæ. The urine removed from
the bladder was found to contain albumen and hyaline casts, and a
microscopic examination showed a small amount of parenchymatous
inflammation. The spleen was somewhat enlarged. Punctate congestion of
small areas of {525} gastric surface, no increase of mucus; mesenteric
glands uniformly enlarged; jejunum, ileum, and colon exhibited a
slightly increased vascularity. The immediate cause of death appeared
to be imperfect contraction of the heart and the formation of clots in
its cavities, due, apparently to the pleuro-pneumonia as much as, or
more than, to the primary disease, scarlatina.[3]
[Footnote 3: Dr. Goodhart (_Guy's Hospital Reports_, 1879) reports
several interesting cases to confirm his opinion that acute dilatation
of the heart is a not infrequent sequel of scarlatinous nephritis, and
is the cause of death in some apparently inexplicable cases.]
There can be little doubt that nephritis in its milder form is much
more common than was formerly supposed. A few years since little
attention was given by a large proportion of physicians to the state
of the kidneys, and the urine was not examined till dropsy made its
appearance, which only occurs in the more severe forms of nephritis
and is a late symptom. It is now known that catarrh of the renal tubes
frequently occurs in a mild form early in scarlet fever, without
causing albuminuria, dropsy, or any notable symptom. It may produce a
smoky color of the urine, and the appearance in it of granular
epithelial cells, with an increase of mucus, but no albumen. With
careful treatment and no exposure to cold, the renal catarrh abates
with the decline of the scarlet fever. It is scarcely severe enough to
merit the name desquamative, tubal, or parenchymatous nephritis,
though it is a mild form of the same pathological state. Steiner
states, as the result of many careful examinations of cases, that
hyperæmia of the kidneys was always present in those who died early in
scarlet fever, and that in a certain proportion of these cases catarrh
of the renal tubules was present in addition to the congestion. Even
in some who died on the second or third day he found cloudiness of the
epithelium in the renal tubes, although the urine had not indicated
such a change. The opinion has even been expressed that catarrh of the
renal tubes is as common in scarlet fever as that of the bronchial
tubes in measles; that is, that it is a uniform element in the
disease; but this appears to be an exaggerated statement, for others
have failed to find any evidence of renal catarrh in certain cases.
The nephritis which gives rise to symptoms, and therefore interests
the practitioner, commonly begins in the declining period of scarlet
fever or during the desquamative stage, and is in many instances
plainly attributable to exposure to cold or to currents of air. It
originates either during this period, or, if it have previously
existed as a mild renal catarrh, it now becomes aggravated. Dropsy,
which always attracts attention, does not occur till the nephritis has
continued for some time.
Why nephritis, with the subsequent dropsy, so frequently occurs after
scarlet fever is not fully understood. Rilliet and Barthez attribute
it to disturbance of the function of the skin. The fact has long been
observed that the kidneys become affected nearly if not quite as
frequently after mild as after severe cases. Indeed, the chief danger
in mild cases, when the patients are but a short time in bed and are
soon allowed to go about, is from the nephritis. Chilling the surface
and checking cutaneous transpiration appear to be the immediate cause
of this inflammation in a considerable proportion of cases. Therefore,
severe attacks of scarlet fever with abundant rash and desquamation,
which require the patient to be kept in bed the proper time and in a
warm room two or three {526} weeks, appear to be less frequently
followed by this renal disease than are milder cases which are more
carelessly treated.
The most thorough and minute microscopic examination of the state of
the kidneys in scarlet fever which have come to my notice were those
by E. Klein, published in the _Lond. Path. Soc. Trans._, and
illustrated by microscopic drawings. It appears from these
examinations that the changes in the kidneys are complex, among which
we recognize both those of parenchymatous or desquamative nephritis
and interstitial nephritis; but we would infer that the interstitial
nephritis is mild in degree and quite subordinate, or else confined to
portions of the organ, from the fact that so many permanently and
fully recover. The following is a resumé of Klein's examinations in
twenty-three cases: We conclude from these microscopic researches that
the anatomical changes of both parenchymatous and interstitial
nephritis are commonly present in greater or less degree in cases of
scarlet fever. If they are mild or confined to portions of the
kidneys, no symptoms occur; but if they are sufficient in extent or
degree to impair the function of these organs, then symptoms, as
albuminuria, diminution of urine, etc., appear.
1. Parenchymatous Nephritis, Proliferation of Nuclei, Hyaline
Degeneration of Arterioles, the Glomerulo-Nephritis of Klebs.--Klein
found increase of nuclei (probably epithelial) upon the glomeruli and
hyaline degeneration of the intima of minute arteries, especially
marked in the afferent arterioles of the Malpighian bodies. The intima
of these vessels was in places so swollen as to resemble cylindrical
or spindle-shaped hyaline masses, and cause narrowing of the lumina of
the vessels in which this degeneration occurred. Klein observed in
some specimens so great hyaline degeneration of the capillaries of the
Malpighian bodies that circulation through them was obstructed. In the
more advanced or protracted cases this hyaline substance in the
glomeruli began to assume a fibrous appearance. Bowman's capsule was
considerably thickened. This hyaline degeneration of the Malpighian
bodies Klein discovered in the earliest cases which fell under his
observation.
Also in the earliest cases the multiplication or germination of the
nuclei of the muscular coat of the arterioles was observed, with a
corresponding increase in the thickness of the walls of these vessels.
This change in the muscular element was observed in the arterioles in
different parts of the kidney, but it was most conspicuous in
arterioles at their point of entrance into the Malpighian bodies; and
it was distinctly observed in other arterioles, both in the cortex and
in the base of the pyramids.
In the glandular portion of the kidneys other anatomical alterations
were observed, indicating parenchymatous nephritis. There were
swelling of the epithelial lining of the convoluted tubes;
multiplication of nuclei of epithelial cells, especially in ascending
tubules, which lay close to the afferent arterioles of Malpighian
corpuscles; granular matter, and even blood, in the cavity of Bowman's
capsule and in the convoluted tubes; cloudy swelling and granular
disintegration of epithelium in some parts of the convoluted tubes;
detachment of epithelium from the membrane of larger ducts of the
pyramids in some cases. These parenchymatous changes are already known
to the profession through the observations and writings of Dickinson,
Fenwick, Johnson, John Simon, and others.
{527} Klein, in commenting on the hyaline degeneration which he
observed, states that Neelsen found the walls of the capillaries of
the pia mater thickened, highly refractive, and of a lardaceous
appearance in certain acute infectious maladies, as variola, typhoid
fever, measles, and in one case of scarlet fever.[4] Usually, only a
small portion of the capillaries were thus affected, most frequently
at the point of division into branchlets. In a few instances Neelsen
observed degeneration of arterioles extending a considerable distance,
with fusion of the intima, media and adventitia, and chemical
examination showed that the substance produced by this degeneration
had similar properties to elastic tissue. Although the examinations by
Neelsen relate to the pia mater, two of his observations are
especially interesting--first, that the hyaline change affects chiefly
vessels near their point of branching; and, secondly, that the hyaline
substance is of the nature of elastic tissue, for in the kidney in
scarlatinous nephritis the arterioles undergo the change in question
chiefly near their point of branching into the capillaries of the
glomerulus; and the intima being the part which undergoes the hyaline
change, it is probable, in the opinion of Klein, that the same
substance is produced by the degeneration in walls of the vessels of
the kidney which Neelsen observed in the pia mater, and therefore that
it is of the nature of elastic tissue.
[Footnote 4: _Archiv der Heilkunde_, 1876.]
This hyaline degeneration of the arterioles is also very marked in the
spleen in scarlet fever; and in studying the minute anatomy of the
intestines and spleen in typhoid fever Klein has found the same
degeneration of the intima of the minute vessels. He believes that
this hyaline change and the proliferation of muscle-nuclei which thus
occur at an early period in scarlet fever in the renal vessels when
the kidneys become affected are due to an irritating cause acting
similarly to that in typhoid fever.
Klein calls attention to the interesting examinations of the
scarlatinous kidney made by Klebs, who attributed the diminished
urination and the uræmic poisoning in certain cases in which the
kidneys do not exhibit any marked change to the naked eye, to what he
designates glomerulo-nephritis. Klebs says: "In the post-mortem
examination the kidneys are found slightly or not at all enlarged,
firm, ... the parenchyma very hyperæmic. Only the glomeruli appear, on
close inspection, pale like small white dots. The urinary tubes are
often not changed at all. Occasionally the convoluted tubes are
slightly cloudy. The microscopic examination shows that there are
neither interstitial changes nor proliferation of epithelium, the
so-called renal catarrh generally supposed to be present in these
conditions on account of the absence of other perceptible
derangements; and there seems, therefore, leaving out the glomeruli,
the congestion of the kidneys alone to remain to account for the
symptoms during life." But that mere congestion is insufficient to
produce the symptoms appears from the fact that it does not produce
them under other circumstances. Klebs finds, "on microscopic
examination of the glomerulus, the whole space of the capsule filled
with small somewhat angular nuclei, imbedded in a finely granular
mass. The vessels of the glomerulus are almost completely covered by
nuclear masses."
Klein, commenting on these examinations by Klebs, states that in all
{528} early cases which he examined he observed great abundance of
nuclei of the glomeruli, but a condition like that described and
figured by Klebs[5] he has seen in only a few glomeruli; for a general
state of these bodies, as described by this observer, and such an
excessive proliferation of the nuclei that the blood-vessels are
completely compressed, was not seen in one of the twenty-three cases.
Klein therefore questions whether the diminished urination and
retention of urea in scarlet fever, when the kidneys do not exhibit
any conspicuous catarrhal or other change, is due, unless in
exceptional instances, to compression of the vessels of the glomeruli
by nuclear germination, but believes, rather, that the obstructed
circulation, and consequent diminished urinary excretion, is largely
due to the changed state of the arterioles. Klein adds that perhaps
undue contraction of the arterioles, through stimulation by the
blood-irritant, may also be a factor in causing arrest of circulation
in the Malpighian corpuscles. As regards cases that perished early, he
found the parenchymatous change slight, so that a careful examination
was required in order to detect cloudy swelling and granular
degeneration.
[Footnote 5: _Handbuch der Pathol._, p. 646, fig. 72.]
2. Interstitial Nephritis.--A second set of changes Klein observed in
cases that died on about the ninth or tenth day. In such cases he
found changes due to interstitial, in addition to those produced by
parenchymatous, nephritis. Round cells, lymphoid cells, or whatever
else they should be called, were seen in the connective tissue of the
kidneys. In the kidneys of those that died at the end of the first
week after the commencement of nephritis, infiltration with round
cells was observed in the connective tissue around the large vascular
trunks. At a later stage this infiltration had extended into the bases
of the pyramids and into the cortex. The gradual increase in extent
and intensity of this infiltration was so decided in the cases which
Klein observed that he has no hesitation in concluding that when
interstitial nephritis occurs it begins about the end of the first
week, in the manner already stated--to wit, as a slight infiltration
of the tissue around the large vascular trunks, and gradually extends,
so that portions of the cortex, and rarely portions of the base of the
pyramids, are changed into firm, pale, round-cell tissue, in which the
original tubes of the cortex become lost.
The infiltration of the cortex with round cells, beginning at the
roots of the interlobular vessels, spreads rapidly toward the capsule
of the kidney, and laterally among the convoluted tubes around the
Malpighian bodies.... In the course of this process considerable parts
of the peripheral cortex, occasionally of a more or less distinctly
cuneiform shape, with the base nearest the capsule of the kidney,
become changed into whitish, firm, bloodless, cellular masses, in
which Malpighian corpuscles and urinary tubes are only imperfectly
recognized, being more or less degenerated. In some cases attended by
this infiltration of the cortex Klein observed a more or less dense
reticulation of fibres, especially around the interlobular arteries,
containing in its meshes lymph-cells, chiefly uninuclear.