STATE OF THE SKIN IN SCARLATINA.

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III. THE CONDITION OF THE SKIN IS SIMILAR TO THAT OF THE MUCOUS MEMBRANE OF THE STOMACH IN SCARLATINA.

I have only examined the skin in three cases of scarlatina. In the first, death took place after a few days' illness, and the morbid appearances in the cutis consisted of slight extravasations of blood in the neighbourhood of the sudoriferous ducts. The rete mucosum was greatly thickened, and numerous round cells with large nuclei nuclei were everywhere visible, intermixed with the natural cells. The basement membrane of the sweat glands was thickened, and the epithelial lining so much increased, that in most cases it obstructed their channels. In some of the sweat glands, the coils composing them were loaded with coagulated blood, and were greatly and irregularly distended. (See (See plate 4, fig. 2.)

In the other recent case the appearances were similar, excepting that the external layers of the cuticle were stained with blood in minute patches, and the sweat ducts were also reddened; but there was no extravasation of blood either in the glands or cutis. In some of the ducts the epithelium was detached from the basement membrane.

In the case of a man who died in the third week of the disease the sudoriferous tubes were still choked up; but in the glands the epithelium seemed in many places detached, the basement membrane being bare, or covered only with ragged particles.

It will be remembered that the morbid condition in these specimens is similar to what has been before described as existing in the mucous membrane of the stomach, viz., an increase in the vascularity of the part, effusion of fatty and granular matters, and alterations in the epithelium, with but little affection of the other structures.

It is evident from the foregoing facts that in scarlatina the mucous membrane of the digestive tube is as generally inflamed as the skin. As we know that the particles thrown off from the skin are capable of reproducing the disease, and that the external surface of the body is therefore an eliminator of the poison, we are justified in looking upon the mucous membrane as performing a similar office.

The process of elimination in scarlatina differs from that in cattle-plague, inasmuch as in the former the gastric tubes continue loaded with granular matters for some time after the cessation of the fever. It is probable, therefore, that the poison is in the first instance deposited in the outer and inner surfaces of the body, and afterwards only gradually removed from the system.

But the question arises, how is this removal effected? No doubt, in part by means of desquamation, the old cells carrying away a certain amount of the effused material. This is not, however, sufficient altogether to account for its disappearance, as will be seen in the following experiment. Some sections were made of the mucous membrane of the stomach of a person who had died of scarlatina in the second week of the disease. When examined microscopi

CAUSE OF ALBUMINURIA AFTER SCARLATINA. 109

cally, the tubes were observed to be distended, and the cells very obscure; but, after digesting the sections in a weak solution of nitrate of potash at blood heat for some hours, a complete change in the appearance was produced. The granular matter was entirely removed, and a cavity could be seen in the closed ends of the tubes bounded on all sides by the cells with which the basement membrane was lined.

If, then, the granular material remains at the closed ends of the tubes after the layers of cells at their upper and free ends have come into contact, it is evident that desquamation alone is not sufficient to account for its ultimate removal. Its ready solubility in the saline solution naturally excites the suspicion that it may be resorbed into the circulation, and that in this way the mucous membrane is gradually restored to its normal condition.

We know that albumen in a state of solution, when injected into the veins of an animal, is eliminated by the kidneys; and, as in scarlatina, the urine becomes albuminous in the majority of cases in the second or third week,—the very time at which the skin and mucous membrane begin to lose the material deposited in them, we may conclude, that in this fact we see an explanation of the method which nature takes to repair the injury inflicted upon the tissues by the disease.

The view generally taken is, that the albuminous urine results from congestion of the kidneys produced by the application of cold to the surface of the body, whilst the functions of the skin are enfeebled by the fever. But this seems contradicted by the well-known fact that, in many of the worst cases of albuminuria following scarlatina, the rash had been scarcely

observed, and that consequently the skin had been but little affected. In one epidemic in which dropsy was an unusually common sequence of the disease I paid especial attention to protecting every patient most carefully from cold, and yet the albumen appeared in the urine of numbers of those who had been thus vigilantly watched.

We must remember that we have not merely to account for the presence of albumen in the urine, as in cattle plague, cholera, typhus, and other blood disorders; but we have in scarlatina an accompanying irritation of the kidney, which is one of the principal causes of death. On dissection of a fatal case, we find general swelling of this organ from congestion of its vessels, and alterations of the epithelium of its secreting tubes, exactly analogous to what we have proved to take place in the skin and mucous membrane whilst the poison is being deposited in them. This is precisely what we might expect according to the view I have advocated; for if the poison is accompanied by acute inflammation of the tubes of the skin and mucous membrane in which it is first deposited, we might conclude that similar effects would be produced in the structures of any other organ which it which it may traverse in its elimination from the body.

It is generally remarked that the kidney is seldom implicated in cases of malignant scarlatina, and the following case may tend to explain the reason of this.

OBSERVATION 17.-A boy, aged eighteen, died on the fourth day of malignant scarlatina. The blood