CAUSE OF ALBUMINURIA AFTER SCARLATINA.

111

seemed very fluid; the skin and even the cartilages of the trachea were deeply stained with it. But I could find no anatomical alterations either in the glands of the skin or in the tubes of the stomach excepting the dark-red colour of these structures.

This is the only case of scarlatina in which I have failed to discover structural changes in the skin and digestive canal; and if further observation should show that this is usual in the malignant form of the disease, it will serve to explain how it is so rare to find in it the subsequent affection of the kidneys.

I have entered upon this point at some length because it is one of practical importance, and not of merely theoretical interest. It is above all things necessary that we should in the treatment of disease distinguish between. our friends and our foes; between those phenomena that tend to restore the structures of the body to their normal condition and those that only produce disorganization of the tissues. To the former I believe we must refer albuminuria after scarlatina; and the small amount of mortality that accompanies this condition, the comparative rarity with which serious kidney disease follows it, and the limited period during which it is liable to occur, all tend to favour the opinion I have advanced. Dr. Dickenson has recommended the free internal use of water as the best treatment for this complication of scarlatina, and from the results of my own practice I believe that all that is necessary in the majority of these cases is to guard the patient from cold and improper food, and to leave the kidney alone to free the system from the deposited material.

These anatomical changes in the mucous mem

brane of the digestive tube are necessarily connected with alterations in the functions of the parts affected. In the earlier stages of the disease the stomach seldom shows any signs of post-mortem solution, and in one case in which I tested the contents they were alkaline and albuminous.

The

There is not, as might have been expected, any deficiency in the amount of the characteristic secretion of the stomach. I mixed two drachms of the gastric mucous membrane of a patient who had died of scarlatina with one ounce of distilled water, and after allowing it to stand for twelve hours at the ordinary temperature strained off the solid particles. fluid thus obtained was acidulated with hydrochloric acid, and a cube of coagulated albumen, 10 grains in weight, was placed in it. This was digested for twelve hours at a temperature of 98° F., when only 7 grains remained, much softened and translucent at the edges. In a second case, 3 grains; and in a third, 5 grains of albumen were dissolved. The average amount of albumen digested was therefore 3 grains. But as in similar experiments with the mucous membrane of the stomach of eleven persons dying of other diseases there were on the average 4 grains of albumen dissolved, it is evident that in this form of eruptive fever there is but little deficiency in the secretion of pepsin.

We must therefore refer the impaired functional activity of the stomach not so much to any change in its powers of secretion, as to the inability of the tubes to discharge the gastric juice, on account of their being blocked up with cells and granular matters. The mucous membrane is no doubt in a

EFFECTS OF SCARLATINA ON DIGESTION.

113

similar state of functional inactivity to the skin, in which the perspiration only gradually returns as the sweat glands become relieved of the materials obstructing their canals.

We can scarcely estimate the injury inflicted upon the pancreas and the glandular structures of the intestine, as we are not are not fully aware of the functions which these organs perform in a state of health.

As regards the absorbent power of the mucous membrane, I can only state that I have not as yet found the villi distended with fat in any case in which death had taken place in the earlier stages of the disease. In most dissections they appear to contain some fatty matters, but in a state of very minute division, and not in the form which is usually presented when the intestine is examined whilst digestion has been going on.

When we regard the number of organs affected by scarlatina, and the severity of the injury inflicted upon them, we shall have no difficulty in explaining why so many patients date the commencement of their complaints from an attack of this disorder. I know no other disease excepting cholera in which the after effects are so severe, or of such lengthened duration.

I have quoted the two following cases at present under my care, to show how long the injury to the digestive organs may endure.

CASE 11.-A lady was attacked by scarlatina in 1863. There was sore throat with but little eruption on the skin. The fever was followed by diarrhoea,

I

which persisted when I was consulted two months afterwards. She was then exceedingly feeble, and unable to take much exertion, either bodily or mental. The tongue was white, and the appetite bad. The descending colon felt large, and was very tender on pressure. In spite of all treatment she remained subject to diarrhoea until the autumn of 1865, when it gradually subsided.

The digestion still, however, continues very feeble, and she has never recovered the strength and flesh she had before the fever.

CASE 12.-A child, five years of age, suffered at the same time as the previous patient from scarlatina. When I saw her she was exceedingly weak and anomic. The tongue was white, and the appetite very bad. She had frequent attacks of vomiting and pain after food, and the epigastrium was very tender upon pressure. The bowels were much confined. These symptoms, although relieved by treatment, frequently returned for twelve months after the fever, and it was only very gradually that she regained her former state of health.

Here were two patients attacked by scarlatina at the same time; in the former the colon seemed chiefly to suffer, and in the latter the stomach; but in both it was long before the injured parts recovered the power of properly performing their functions.

I have shown that, even where there is but little eruption on the skin, there may be considerable inflammation of the mucous membrane, and when this occurs it is often difficult to diagnose the disease.

EFFECTS OF SCARLATINA ON DIGESTION.

115

It is only by taking into consideration all the circumstances of the case that we can arrive at a satisfactory conclusion.

CASE 13.-A young lady, about ten years of age, was affected with sore throat. I saw her on the second or third day after her attack, and found the tonsils much swollen, red and ulcerated, but I could discover no eruption on the skin.

A

In a few days the sore throat disappeared. week afterwards she began to complain of severe rheumatism in the hips and knees, which prevented her moving about. About six weeks after the commencement of her illness I was again requested to visit her. I found that after the cessation of the rheumatism she had been attacked with violent pain in the abdomen. The cæcum and ascending colon, to which parts the pain was referred, were very tender on pressure. The pulse was rapid, the tongue brown and dry, there was intense thirst, and no appetite for food. The urine was high coloured, but contained no albumen. Under the remedies employed the pain and tenderness gradually subsided, and the fever disappeared; but many months elapsed before she regained her former state of health.

In this case the affection of the throat, followed by rheumatism of the joints, induced me to believe the case to be one of scarlatina, an opinion which was strengthened by the circumstance that this disease was at the time prevalent in the neighbourhood. The subsequent affection of the large intestine was an additional confirmation of the truth of the diagnosis.