In a child of five years that died after a sickness of thirteen days Klein found evidence of intense interstitial inflammation, and also emboli, consisting of fibrin with a few cells, in the arteries, both in those of large size and in the arterioles, chiefly where they enter the Malpighian corpuscles. He states that in the specimens which he examined the more intense the degree of interstitial change, the greater was the enlargement of the kidneys, and the more distinct also were the evidences of parenchymatous nephritis in the urinary tubes, which either contained casts or were in the process of destruction. By being crowded with inflammatory products, especially cells, the Malpighian corpuscles were obliterated, undergoing fibrous degeneration. A very curious fact observed was the deposit of lime in the urinary tubes, first of the cortex, and then also of the pyramids, at an early stage of scarlet fever, when the kidneys otherwise showed only slight change. Several observers, as Biermer, Coats, and Wagner, have each described a case of scarlet fever with interstitial nephritis, which they consider unusual; but Klein has apparently demonstrated, as we have seen, by a large number of microscopic examinations, that this form of nephritis is common after the ninth or tenth day.
Nephritis, in proportion to its extent and gravity, is accompanied by languor, febrile movement, thirst, loss of appetite and strength. At first the patient experiences but slight pain in the head or elsewhere, and the quantity of urine is not notably diminished; but as the disease continues urination becomes less frequent and the urine more scanty. Albuminuria occurs, while the urea is only partially excreted, and therefore accumulates in the blood. If the nephritis be so severe or protracted that this principle accumulates to a certain extent, grave symptoms occur, as headache, vomiting, apathy or restlessness, and, more dangerous than all, eclampsia, which is not unusual in these cases. Microscopic examination of the urine shows the presence in this liquid of blood-corpuscles, granular epithelial cells, and hyaline or granular casts, or both. The specific gravity of the urine is diminished. But a large quantity of albumen in the urine may render the specific gravity as high or higher than in health.
The altered state of the blood soon gives rise to transudation of serum, first observed in most cases as an anasarca occurring in the feet and ankles. The oedema, if not checked by treatment or through mildness of the disease, extends over the limbs, scrotum, and sometimes upon the trunk. It is well if the dropsy remain limited to the subcutaneous connective tissue, but, unfortunately, it is apt to occur, if the nephritis continue, in and around the internal organs, producing, mentioned in the order of frequency, pulmonary oedema, effusion into the pleural and peritoneal cavities, the pericardium, the encephalon, and lastly into the connective tissue of the larynx, causing that very fatal complication, oedema of the glottis. Although this is the common order in which dropsies occur, exceptions are not infrequent. Even the anasarca may not be the first to appear, although in the vast majority of cases it has the precedence. Thus, Rilliet relates the case of a boy of five years who twenty days after the occurrence of scarlet fever, and six hours after the appearance of bloody and albuminous urine, had double hydrothorax, rapidly developed. As long as the hydrothorax continued no anasarca was observed, but as it declined anasarca appeared. Legendre cites a case in which oedema of the lungs occurred without anasarca or other dropsy. Occasionally, the anasarca and internal dropsies take place nearly simultaneously. The nephritis and consequent serous effusions usually appear within three weeks after scarlet fever ends, but cases occur in which the effusions are first observed as late as the fourth and fifth weeks. The patient may be considered to possess immunity from this sequel if he have reached the close of the fifth week after the abatement of scarlet fever without its occurrence.
The dropsy is usually acute, but it may assume the chronic form, since the nephritis which causes it, happily curable in most instances, may, if neglected, become chronic. Whether the dropsy in itself involve danger depends in great part on its location. Anasarca and ascites may exist a long time with little suffering or danger, but a small amount of serum in certain other localities causes alarming symptoms and speedy death. Oedema of the lungs, hydro-pericardium, oedema of the glottis, and intracranial effusions are always dangerous, and the last two are sometimes fatal within twenty-four to forty-eight hours. Oedema of the lungs has been fatal within twelve hours from the occurrence of the first symptoms of obstructed respiration.
Cerebral symptoms occurring during scarlatinous nephritis are probably sometimes due to the irritating effect of the retained urea on the nervous centre. In other cases the cause appears to be cerebral oedema or compression of the brain by effusion of serum within the ventricles and upon the surface of the brain. Headache, dull or severe, dilatation of the pupils or their oscillation in the same degree of light, vomiting with little apparent nausea, are common symptoms of scarlatinous nephritis when it has continued a few days, and the excretion of urea is so diminished that this substance begins to exert its poisonous effect on the system. Such symptoms are apt to be followed by somnolence, threatening coma, or by eclampsia, unless the patients are promptly and properly treated. In some patients that die of scarlatinous nephritis, death occurring in convulsions or coma, no appreciable lesions are observed within the cranium, unless more or less congestion, the fatal ending being attributable to the uræmia. In other instances we find an effusion of serum within the ventricles or upon the surface of the brain. Although the symptoms in scarlatinous nephritis and uræmia may appear very unfavorable, the prognosis is usually good under prompt and appropriate treatment. Thus severe convulsions and a degree of somnolence that bordered on coma may abate, and convalescence be fully established within a few days, and Rilliet and Barthez announce ten recoveries in thirteen patients affected with convulsions due to this renal affection.
ANATOMICAL CHARACTERS.—Scarlet fever being, as we have seen, a constitutional febrile disease of an ataxic nature, and accompanied by certain inflammations, necessarily affects the composition of the blood; but since this disease varies so greatly in type or severity, the state and appearance of this liquid also vary. At the autopsies of the more malignant cases we find the blood dark and fluid, with small, soft, and dark clots in the heart and large vessels. In other cases the clots are large, firm, and solid, as described in a preceding page. In malignant cases that end fatally Rilliet and Barthez state that both the large and small vessels of the cerebral meninges and the brain are found hyperæmic, but in a variable degree. In those who die in coma, preceded by delirium or convulsions, during the eruptive stage, the intracranial congestion is usually marked, with perhaps some transudation of serum, but without inflammatory lesions. The fibrin in scarlet fever remains in about normal proportion, except as it is increased by inflammatory complications. Andral found an increase in the proportion of blood-corpuscles from 127 to 136 parts in 1000.
The respiratory apparatus, except the Schneiderian membrane, is usually normal when no complications exist. Samuel Fenwick6 made post-mortem examinations in sixteen cases of scarlet fever, and concludes from them that inflammation of the mucous membrane of the stomach and intestines occurs like that of the skin, followed by desquamation of the epithelial cells, like that of the epidermis. I have had the opportunity of examining the stomach and intestines of those who died of scarlet fever in the eruptive stage, and have not found any unusual hyperæmia of the gastro-intestinal surface, except when gastro-intestinal inflammation, usually indicated by diarrhoea, had occurred as a complication.
6 London Lancet, July 23, 1864.
In some cases the abdominal organs exhibit changes which suggest a resemblance to typhoid fever. The spleen is enlarged and somewhat softened, and Peyer's patches and the solitary glands are thickened and prominent, but less in degree than in typhoid fever. The mesenteric glands also are in a state of hyperplasia. In other patients these parts appear normal.
Klein made microscopic examination of the liver in eight cases, and states that he found granular opaque swelling of liver-cells, and changes in the internal and middle coats of certain arteries similar to those observed in the kidneys, which have been described above. He also found evidences of interstitial inflammation, as an increase of round cells and connective tissue in the liver. He remarks also that he observed hyaline degeneration of the intima of arteries in the spleen. Rilliet and Barthez state that swelling and softening of the spleen are exceptional in scarlet fever, but are sufficiently common to merit attention. In post-mortem examinations which I have witnessed nothing noteworthy has appeared to the naked eye in the state of the liver, nor ordinarily in that of the spleen.