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An Address ON SOME POINTS OF CLINICAL INTEREST CONNECTED WITH THE EXANTHEMATA.
MAY 27, 1911. first, because scarlet fever is
not intensely infectious like measles and is not often taken from a short exposure to it ; secondly, because cases differ greatly in their infective power, slight cases being apparently the least infectious ON and thirdly, because individuals vary in their infectibility at different times, as is often illustrated by nurses who nurse SOME POINTS OF CLINICAL for months or years in a scarlet fever ward and eventually CONNECTED WITH THE contract it. Is scarlet fever infectious during the desquamation EXANTHEMATA. 7 Whether the peeling epithelium contains the period Delivered before the Harveian Society infecting organism remains to be discovered, but there is abundant evidence of scarlet fever being conveyed by BY SIDNEY clothing, letters. &c., the epithelial scales presumably being F.R.C.P. LOND., the carriers. An interesting case was that of a medical man who asked me to inspect his hands as they were peeling SENIOR PHYSICIAN TO ST. MARY’S HOSPITAL AND TO THE LONDON FEVER HOSPITAL; PHYSICIAN TO THE LOCK HOSPITAL. profusely ; he had had a slight rash some time before. I sent him direct to the Fever Hospital. A week after he left MR. PRESIDENT AND GENTLEMEN,-One feature common home the servant cleaned out the rooms in which he had to all the exanthemata is the rapid diminution in the lodged, and three or four days after that she was attacked mortality they produce in this country. In the year 1850, by scarlet fever. The interval was too long to attribute the when the Registrar-General’s returns commenced, the ex- infection to the first patient, and I can only attribute it to anthemata caused 3233 deaths per million persons living ; in the epithelium left in the bedroom after he left. That 1908 (the latest year in which figures are available) they persistent aural or nasal discharges may convey the infection caused 861 deaths per million living-a fall of 73 per cent. is doubtless true, but this is not evidence that desquamating in 58 years. Of the individual diseases typhus has all but epithelium may not also do so, and though very late desquahave no means of deciding completely disappeared, small-pox only occurs occasionally mation may not be infectious, we when it begins to be so, and it is unsafe to regard peeling as an epidemic, which is trivial in mortality compared with scarlet fever patients as anything but a danger to other those of bygone years. persons. SCARLET FEVER. The amount of peeling is not proportionate to the intensity As to scarlet fever, the mortality has fallen from 890 of the rash. A servant who went into a room where a child ’deaths annually per million persons living in the decade had scarlet fever got the disease with well marked vivid rash. 1861-70 (1861 was the first year in which scarlet fever was A few days later the sick nurse got sore throat, pyrexia, and -classified by the Registrar separately from diphtheria) to 80 symptoms of the fever, but with a rash so slight that I should deaths per million living in 1908-a decrease of 91 per have been very doubtful as to its nature had it not been for - cent. in 48 years. Even in years when an epidemic occurs the circumstances. Both patients went into the surrounding nowadays the mortality is less than in the most favourable of London Fever Hospital; the servant who had the marked years gone by. In my Presidential Address to the Harveian rash hardly peeled at all, while the nurse who had next to no Society in January, 1908, I discussed the question whether rash peeled most profusely. this diminution in the number of deaths arose from lessened Medical men who have decided that a questionable case is prevalence or from lessened virulence (case fatality) of not scarlet fever should still keep an eye on the patient so scarlet fever. And I pointed out that since the Infectious that they may revise their diagnosis if peeling occur. Diseases Notification Act came into force this could be RHEUMATISM IN SCARLET FEVER. ascertained by a comparison of the actual number of cases notified with the number of deaths from the disease in each One of the commonest complications of scarlet fever is year. Even this comparison can only be made for individual rheumatism. When it affects the joints in adults it usually districts, as notification is made to the local authority. gives pain ; but in children the joint affections are often quite In the metropolitan area the cases of scarlet fever notified painless, even more so than in non-scarlatinal rheumatism, have diminished in number from 36,901 in 1893 (the first and often a considerable rise of temperature will be the year in which the Act became generally acted upon) to 17,254 only symptom to call attention to it. Scarlatinal rheumatism in 1909-a reduction of 53 per cent. During the same may affect the fascia or the muscles ; in one case there was a period of 17 years the case mortality fell from 6’ 1 to very acute myositis of the muscles of the lower limbs. 3’55 per cent.-a fall of 59 per cent. These figures apply Scarlet fever (and other exanthems) are usually credited in only to the metropolitan area, but probably similar figures text-books with causing endocarditis and pericarditis, but in apply throughout the country, and it therefore appears that my experience this is very rare even when rheumatism occurs. the rapid diminution of the mortality from scarlet fever is When the heart or the pericardium is affected in scarlet fever blue in part to its lessened prevalence, but in still greater I think rheumatism is the link between them and the scarlet - degree to its lessened virulence in individual cases. This, I fever, and the same is trae of chorea. Nodules sometimes think, will tally with the experience of those who can occur in scarlatinal rheumatism. Purpura may occur in scarlet fever, and is, I think, ’compare their remembrance of scarlet fever as it occurred In the case of a some 30 years ago with the cases as they present themselves generally associated with rheumatism. now, often so devoid of the characteristic symptoms that youth in the Fever Hospital in September, 1907, severe rheumatism followed ten days after scarlet fever with many the diagnosis becomes one of great difficulty. joint effusions, with high temperature, delirium, and serious INFECTIVITY OF SCARLET FEVER. As in one knee-joint fluid remained a long time The questions are often asked, When does scarlet fever symptoms. I introduced into it a needle, thinking it might contain pus, begin and when does it cease to be infectious ?7 A boy was but withdrew pure blood. The case appeared to be one of attacked by scarlet fever at school ; no one else in the school rheumatic purpura, and he got quite well. bad any sign of it. The boy was removed on the morning Rheumatism should always be borne in mind as a possible that his rash appeared. The only other boy who had slept cause of otherwise unexplained rises of temperature during in the room with him before he was removed showed the first convalescence from scarlet fever, and often on careful search scarlet fever three days later, an interval correspond- effusion in some -signtoofthe joint, usually the knee, or some other local incubation period of scarlet fever. I have seen, ing rheumatic affection will be found. where one child got scarlet fever, all the other children RENAL COMPLICATIONS DURING SCARLET FEVER. immediately removed to another house and come back one by one at intervals as each caught the fever from the child last It has been questioned whether the albuminuria so common removed, though in every case the affected chill was taken during scarlet fever convalescence always signifies nephritis. away immediately the rash appeared. One sees cases from But I have seen necropsies after scarlet fever which showed time to time where the only explanation possible is infection evidences of nephritis when there had been no albuminuria, from a ease in its earliest stages, and I cannot doubt that and I know of no cases of scarlatinal albuminuria in which a scarlet fever is infectious directly the rash appears. The necropsy showed absence of nephritis, and scarlatinal illogical reply that persons in contact with scarlet fever albuminuria should always be treated as being an indication in an early stage may escape the disease has no force : of nephritis. TJ /t’7H x 4578.
An Address
INTEREST
PHILLIPS, M.D. LOND.,
1404 I think the change of type in scarlet fever that has taken in the last few years is shown by the descriptions in the older text-books of scarlatinal nephritis with much these now seldom albuminuria, haematuria, dropsy, &c. ; occur. What one commonly finds is that the urine contains a little cloud of albumin, and in adolescents especially a trace of blood, but the patient has no symptoms whatever except perhaps a little pallor of face or feebleness of pulse. Sometimes there is a little headache, but as a rule the patient complains of nothing whatever, and any symptoms soon pass off with the albuminuria if the patient is kept in bed, but if care is not taken the albuminuria will increase. On the other hand, symptoms pointing to marked defect in the renal functions may occur without any albuminuria. In the gravest form of chronic kidney disease-granular kidney-there may be no albuminuria, and the same may be the case in the acute renal affection of scarlet fever. In some cases there may be very severe headache, with or without vomiting, perhaps oedema, little or much, with free flow of urine without albuminuria ; sometimes later on albuminuria appears. An important class of case is that in which there may arise from failure of recent function persistent vomiting without albuminuria or with the very slightest trace of it and without any other symptom of nephritis. A well-marked example was the case of a girl of 15 under my care at the London Fever Hospital, who was admitted for scarlet fever rash and a temperature of 100° F. on July 10th, 1898. The case was a mild one, but on the 16th vomiting commenced with a very minute trace of albumin in the urine. The vomiting was incessant and she was unable to keep down anything, even hot water, for four days. The daily average of urine was 35 oz. ; she had much pain in the back. On the 22nd the vomiting recommenced and persisted for many days, the patient’s life being in great danger from inanition. There never was dropsy or headache, but throughout there was the trace of albumin in the urine. A girl of 11 got scarlet fever rash on July 21st, 1900, and came into the London Fever Hospital. She went on well till August 10th, when she got diarrhoea and a considerable quantity of albumin was present in the urine. This soon sank to a very minute quantity, but only 10 oz. of urine were passed each day. Directly the quantity of urine lessened, although there was scarcely any albuminuria, violent and uncontrollable vomiting began, and it persisted till Sept. 17th z37 days. During that time she was kept alive entirely by nutrient and hot-water enemata. She became extraordinarily feeble and emaciated and was in grave peril for many days, but during all this time there was no symptom of nephritis except the vomiting and decreased secretion of urine, with a small trace of albuminuria. After Sept. 17th the urine increased in quantity, became free of albumin, and she was convalescent on Oct. 23rd. Similar cases occur in diphtheria, as in a child seen in 1909 with Dr. J. Davidson of Uxbridge, and also in renal cases The vomiting is sometimes unconnected with exanthems. associated with very severe pain in the abdomen -possibly from stretching of the capsule of the kidney when it is greatly engorged. Such cases with vomiting and abdominal pain are likely to be interpreted as some grave intra-abdominal lesion requiring laparotomy. Bradford1 remarks that"the grave error of mistaking ursemia for intestinal obstruction has been made more than once." In one such case my suggestion of ursemia was not adopted, and on other advice laparotomy was actually performed for supposed intestinal obstruction, only for the patient to die from suppression of urine. I have seen other cases in which operation was proposed for ursemia, under the impression that the symptoms resulted from duodenal ulcer, from appendicitis, and from an undiagnosable condition. And I wish to lay stress on the occurrence of vomiting and severe pain in the abdomen as signs of nrasmia even when little or no albuminuria is present. MEASLES. like other Measles, exanthems, is declining in the mortality it produces. The deaths from measles per million living fell from 412 annually in the decade 1851-60, to 362 annually in 1901-05; and though at the present moment measles is very prevalent, there is reason for anticipating that the figures for the five years 1905-10 will show a lesser 1
Clifford Allbutt’s
System
of
Medicine, vol. iv.,
p. 328.
before.
Measles is still, however, the to every 1 from scarlet fever, and to every 2 deaths from diphtheria ; whooping-cough alone approaches it, causing 300 deaths to every 380 from measles. The seriousness of measles is the greater from the debility and the glandular and pulmonary affections which may follow it. It is generally accepted that it predisposes to the onset of pulmonary tuberculosis, and from the very large proportion of cases in which tubercle of the abdomen in children is preceded, by some weeks or months, by measles, there is a strong presumption that measles predisposes also Both measles and abdominal to abdominal tuberculosis. tubercle are commonest in the second and third years of life, and it seems more probable that this is so because measles predisposes to it, than the suggested explanation that it is contracted by swallowing tubercle bacilli from the floor during the crawling age. INFECTIVITY OF MEASLES. The extreme infectiousness of measles was exemplified in 1904 when of 14 students whom I took for five minutes into an isolation room to see a case of measles, the only student who had not previously suffered from measles contracted a severe attack, of which the first symptom occurred nine days less two hours after infection. Small-pox is equally infectious. I was accompanied by eight or ten students to an isolation room to see a case of small-pox. An interview of five minutes’ duration sufficed to infect one of the students, who inaugurated by a faint a slight attack of small-pox, 11 days less two hours after the infection. The different infective activity of measles and scarlet fever is illustrated by a case I saw in February, 1910, with Dr. J. D. Cree-that of a youth who had on him at the time the rashes of both scarlet fever and measles, and who was staying in the home of his sister who had lately been confined. I moved him at once to the London Fever Hospital, where the rash of measles came out more profusely, and he subsequently desquamated freely from the scarlet fever. The infant, with whom he had been in contact before he left home, got measles eight or nine days after, but rejected the oppor. tunity of contracting scarlet fever.
mortality
than
most fatal of
place
I
ever
exanthems, causing 3 deaths
LOBAR COLLAPSE
OF
LUNG
IN
MEASLES.
Lobnlar collapse of lung is not uncommon in children with measles and bronchial and alveolar catarrh, the collapsed lung being small areas disseminated through both lungs and mixed up with other areae of alveolar catarrh and of insnffi’ttion. Such a condition is usually regarded as a But collapse of the whole or result of capillary bronchitis. the greater part of a lobe (usually the lower lobe) may suddenly occur in measles without a trace of bronchitis, which, indeed, even if present, would be quite incapable of producing such sudden collapse of a whole lobe. The onset of the collapse is attended with very distressing and alarming
dyspncea. Twelve years ago I was called in the middle of the night to child who was suffering from measles and who had had such an attack on the previous afternoon. I found the child (aged 4 or 5 years) lying in bed with terrible dyspnoea, gasping for breath, intensely cyanotic, with feeble pulse and dieturbed heart action. The lower half of the left side of the chest was quite dull on percussion, with sucking in of intercostal spaces. The temperature was 1030 F. After artificial respiration, pressure on the abdomen, and strychnine the urgency of the symptoms passed off. She was much better next morning, with normal temperature, when I saw her with her medical attendant. She got gradually well, but the physical signs on the left side have not even now quite cleared up. Such cases also occur in other conditions than measles, but are most common in measles. Successive attacks may occur in each of which there is evidence of lobar collapse; they are liable to be taken for pneumonia or pleurisy or for asthma. They are certainly not due to any mechanical plugging up of bronchial tubes, and I can only attribute them to a sudden paralysis of the muscular fibres of the bronchi. DIAGNOSIS OF MEASLES... The early diagnosis of measles from Rötheln is sometimes quite impossible. The preliminary catarrhal stage of measles a diagnostic difference is not to be relied upon, for there see a
,
as
1405 may be none such observed in measles, and I am quite sure that rötheln rash is not the first symptom of the disease in many cases, there being a precedent two or three days of feeling of illness, and, may be, coryza and often tender lymphatic glands in measles may be glands. Again, the lymphatic enlarged in the neck and over the head as well as in rothein, though in some cases of the latter the enlargement is characteristic. On the whole, the most reliable point in the diagnosis are Koplik’s spots. During the last epidemic of small-pox, measles was, in my experience, more commonly taken for it than anything else, the reasons being the great swelling of the face in bad measles cases and the fact that over the forehead, where there is little underlying soft " tissue, measles papules feel I I shotty. Pityriasis rosea may resemble measles at the onset, beginning with pink mottling on the body with a little pyrexia and malaise. And during the last year or two three cases of pityriasis rosea seen by several medical men were sent into the Fever Hospital for measles. It is well to bear in mind that the actual measles rash may be preceded by two or three days by a pink mottled prodromal rash on the face and neck; this rash disappears two days or so before the measles rash. There is an interval in which the patient is free of rash, which has several times led to the mortifying experience of the practitioner of wrongly condemning his own correct
diagnosis. TYPHOID FEVER.
Typhoid fever, like the other exanthems, has in late years greatly lessened in the mortality it causes. Since typhoid fever was first separated from typhus fever in the Registrar’s returns in 1870 the annual mortality from it has fallen from 390 per million persons living to 75 per million in 1908, a reduction of 80 per cent. Comparing the notifications of the disease with the number of deaths annually since the year 1890, the case fatality has fallen very little, if at all, from 16’9per cent. to about 16 per cent. (it was 16-88 in 1908). It would therefore appear that the lessened number of deaths from typhoid fever is due in far greater degree to its lessened frequency of occurrence than to its lessened danger in individual cases. Perhaps the figures here do not express the facts with exactitude, for mild typhoid fever seems commoner than heretofore, and such mild cases may escape notification while fatal cases do not. And typhoid fever, whether more or less virulent than formerly, is certainly very different in type from the time when it so resembled typhus that the two were regarded as the same disease. One rarely sees now, except in cases imported from the continent, .the copious diarrhoea, muttering delirium, and the typhoid state seen even 20 or 30 years ago. There is a general agreement that milk with barley water Citrate of or other diluent is the best diet in typhoid fever. soda added to milk is of great use in preventing heavy curd formation, but I am doubtful whether it is advisable to continue it throughout a protracted case of typhoid fever. Sir Almroth Wright has shown that it increased the coagulability of the blood if given very long. A patient seen in 1908 with Dr. Hastings Stewart was fed entirely on citrated milk throughout a long-continued typhoid attack ; he then got very extensive thrombosis of the veins of the lower limb. Later on he had a relapse of his typhoid and equally severe thrombosis in the veins of the other lower limb. Whey is often useful where milk cannot be taken, and my experience agrees with Dr. Gee’s that patients thrive well on it. During the last 15 years I have followed the practice of Sir William Broadbent in giving calomel or mercury in typhoid fever. Although mercury does not shorten the course of the disease it certainly appears to exert considerable influence on the toxic symptoms, and lowers the range of temperature. There is no reason to withhold calomel when diarrhoea is present; indeed, it may be controlled by it, and if necessary salicylate of bismuth or Dover’s powder can be given with it. Cold bathing is, no doubt, very efficacious, but a patient seriously ill with typhoid fever cannot be moved from bed frequently to and from a bathroom, and the bringing of a large bath and many cans of water into a bedroom, and cooling a bath down by adding water to the bath when a patient is in it, without a wastepipe, together with the labour and noise entailed in emptying and removing the bath from the room, render it
impracticable as a routine method in private practice. As a rule tepid sponging suffices to keep the temperature within moderate limits and gives great relief. (Cases were related exemplifying the occurrence of very severe nervous disturbance in epididymitis following mumps. 2) PREGNANCY AND LACTATION IN RELATION TO THE EXANTHEMS. The exanthems may occur during pregnancy. In a very severe case of typhoid fever seen with Dr. W. F. Campbell in 1889 in the seventh month of pregnancy, and in a case with the late Dr. W. Barter in 1909 in the eighth month, a healthy child was born in each case at full term. In a case of typhoid fever in the fifth month abortion occurred. This was a very severe case, in which suppuration and sloughing of the parotid gland occurred, but the patient recovered. In many cases of scarlet fever occurring during pregnancy in early and in late months, some of them severe, healthy children were born at full term. I have seen two cases in which lactation was performed during typhoid fever. In one case, seen with Dr. Beaman Hicks in July, 1904, the child was suckled during the first eight days of typhoid fever without apparently suffering, but In another case at the mother afterwards got parotitis. hospital in 1898 the infant, eight weeks old, was suckled for the first 10 days of severe typhoid fever, when the milk dried up. HYPERPYREXIA. Hyperpyrexia is often spoken of as a complication of the exanthemata. In young children a high temperature very readily occurs in the exanthems without grave significance, but I have not seen any case of hyperpyrexia in adults from the exanthemata without some local complication to account for it, nor have I found any instance in the case books for many years past of the London Fever Hospital.I show here numerous charts of temperatures over 106° F. in the exanthems, and in every one there was a local cause:a in typhoid fever pneumonia over and over again, or peritonitis after perforation, and in one case cerebral meningitis, in another abscess and sloughing of the gallbladder, and in another the explanation was found post mortem in a calculus and abscess in the kidney. In scarlet fever, hyperpyrexia is usually due to some rheumatic affection such as, pericarditis or to middle-ear suppuration, relievable by perforation of the tympanic membrane, or to mastoid suppuration with or without intracranial suppuration, or to thrombosis of an intracranial sinus. In diphtheria in adults hyperpyrexia is usually due to septic local lesions, such as broncho-pneumonia. And one should not be satisfied with the diagnosis of hyperpyrexia in fevers without a thorough investigation for some local lesion, possible relievable by treatment.
ASSOCIATION
OF
TWO
OR
MORE EXANTHEMATA.
This is very common, though such cases are often recorded as curiosities. In hospitals for infectious diseases one of the things requiring specially to guard against is that patients admitted for one exanthem shall contract another, and, indeed, they seem peculiarly liable to do so. It is common for children to be sent in with scarlet fever who also develop measles or chicken-pox after admission at a date showing that they had already contracted the disease before admission. It is well known that whooping-cough often follows on measles, and diphtheria on scarlet fever. An instance in which scarlet fever and measles rashes existed Scarlet fever at the same time has already been given. may occur with typhoid fever, both rashes being visible at the same time. Mumps is not uncommon with scarlet fever;9 Ihave now under my care at the Fever Hospital children of a family with both scarlet fever and mumps. In a case seen with Dr. W. Balgarnie of Winchfield in 1898 mumps came on late in the disease with very severe symptoms. Influenza, as is well known, is often in some way associated with typhoid fever. In general, the association of two exanthems at the same time tends to severity of symptoms. In a case of typhoid fever with scarlet fever fatal hsematuria occurred, the necropsy showing the ureters full of blood, which evidently came from the kidneys. 2
These
were
published in THE LANCET
of Jan.
7th, 1911, p. 23.
not intensely infectious like measles and is not often taken from a short exposure to it ; secondly, because cases differ greatly in their infective power, slight cases being apparently the least infectious ON and thirdly, because individuals vary in their infectibility at different times, as is often illustrated by nurses who nurse SOME POINTS OF CLINICAL for months or years in a scarlet fever ward and eventually CONNECTED WITH THE contract it. Is scarlet fever infectious during the desquamation EXANTHEMATA. 7 Whether the peeling epithelium contains the period Delivered before the Harveian Society infecting organism remains to be discovered, but there is abundant evidence of scarlet fever being conveyed by BY SIDNEY clothing, letters. &c., the epithelial scales presumably being F.R.C.P. LOND., the carriers. An interesting case was that of a medical man who asked me to inspect his hands as they were peeling SENIOR PHYSICIAN TO ST. MARY’S HOSPITAL AND TO THE LONDON FEVER HOSPITAL; PHYSICIAN TO THE LOCK HOSPITAL. profusely ; he had had a slight rash some time before. I sent him direct to the Fever Hospital. A week after he left MR. PRESIDENT AND GENTLEMEN,-One feature common home the servant cleaned out the rooms in which he had to all the exanthemata is the rapid diminution in the lodged, and three or four days after that she was attacked mortality they produce in this country. In the year 1850, by scarlet fever. The interval was too long to attribute the when the Registrar-General’s returns commenced, the ex- infection to the first patient, and I can only attribute it to anthemata caused 3233 deaths per million persons living ; in the epithelium left in the bedroom after he left. That 1908 (the latest year in which figures are available) they persistent aural or nasal discharges may convey the infection caused 861 deaths per million living-a fall of 73 per cent. is doubtless true, but this is not evidence that desquamating in 58 years. Of the individual diseases typhus has all but epithelium may not also do so, and though very late desquahave no means of deciding completely disappeared, small-pox only occurs occasionally mation may not be infectious, we when it begins to be so, and it is unsafe to regard peeling as an epidemic, which is trivial in mortality compared with scarlet fever patients as anything but a danger to other those of bygone years. persons. SCARLET FEVER. The amount of peeling is not proportionate to the intensity As to scarlet fever, the mortality has fallen from 890 of the rash. A servant who went into a room where a child ’deaths annually per million persons living in the decade had scarlet fever got the disease with well marked vivid rash. 1861-70 (1861 was the first year in which scarlet fever was A few days later the sick nurse got sore throat, pyrexia, and -classified by the Registrar separately from diphtheria) to 80 symptoms of the fever, but with a rash so slight that I should deaths per million living in 1908-a decrease of 91 per have been very doubtful as to its nature had it not been for - cent. in 48 years. Even in years when an epidemic occurs the circumstances. Both patients went into the surrounding nowadays the mortality is less than in the most favourable of London Fever Hospital; the servant who had the marked years gone by. In my Presidential Address to the Harveian rash hardly peeled at all, while the nurse who had next to no Society in January, 1908, I discussed the question whether rash peeled most profusely. this diminution in the number of deaths arose from lessened Medical men who have decided that a questionable case is prevalence or from lessened virulence (case fatality) of not scarlet fever should still keep an eye on the patient so scarlet fever. And I pointed out that since the Infectious that they may revise their diagnosis if peeling occur. Diseases Notification Act came into force this could be RHEUMATISM IN SCARLET FEVER. ascertained by a comparison of the actual number of cases notified with the number of deaths from the disease in each One of the commonest complications of scarlet fever is year. Even this comparison can only be made for individual rheumatism. When it affects the joints in adults it usually districts, as notification is made to the local authority. gives pain ; but in children the joint affections are often quite In the metropolitan area the cases of scarlet fever notified painless, even more so than in non-scarlatinal rheumatism, have diminished in number from 36,901 in 1893 (the first and often a considerable rise of temperature will be the year in which the Act became generally acted upon) to 17,254 only symptom to call attention to it. Scarlatinal rheumatism in 1909-a reduction of 53 per cent. During the same may affect the fascia or the muscles ; in one case there was a period of 17 years the case mortality fell from 6’ 1 to very acute myositis of the muscles of the lower limbs. 3’55 per cent.-a fall of 59 per cent. These figures apply Scarlet fever (and other exanthems) are usually credited in only to the metropolitan area, but probably similar figures text-books with causing endocarditis and pericarditis, but in apply throughout the country, and it therefore appears that my experience this is very rare even when rheumatism occurs. the rapid diminution of the mortality from scarlet fever is When the heart or the pericardium is affected in scarlet fever blue in part to its lessened prevalence, but in still greater I think rheumatism is the link between them and the scarlet - degree to its lessened virulence in individual cases. This, I fever, and the same is trae of chorea. Nodules sometimes think, will tally with the experience of those who can occur in scarlatinal rheumatism. Purpura may occur in scarlet fever, and is, I think, ’compare their remembrance of scarlet fever as it occurred In the case of a some 30 years ago with the cases as they present themselves generally associated with rheumatism. now, often so devoid of the characteristic symptoms that youth in the Fever Hospital in September, 1907, severe rheumatism followed ten days after scarlet fever with many the diagnosis becomes one of great difficulty. joint effusions, with high temperature, delirium, and serious INFECTIVITY OF SCARLET FEVER. As in one knee-joint fluid remained a long time The questions are often asked, When does scarlet fever symptoms. I introduced into it a needle, thinking it might contain pus, begin and when does it cease to be infectious ?7 A boy was but withdrew pure blood. The case appeared to be one of attacked by scarlet fever at school ; no one else in the school rheumatic purpura, and he got quite well. bad any sign of it. The boy was removed on the morning Rheumatism should always be borne in mind as a possible that his rash appeared. The only other boy who had slept cause of otherwise unexplained rises of temperature during in the room with him before he was removed showed the first convalescence from scarlet fever, and often on careful search scarlet fever three days later, an interval correspond- effusion in some -signtoofthe joint, usually the knee, or some other local incubation period of scarlet fever. I have seen, ing rheumatic affection will be found. where one child got scarlet fever, all the other children RENAL COMPLICATIONS DURING SCARLET FEVER. immediately removed to another house and come back one by one at intervals as each caught the fever from the child last It has been questioned whether the albuminuria so common removed, though in every case the affected chill was taken during scarlet fever convalescence always signifies nephritis. away immediately the rash appeared. One sees cases from But I have seen necropsies after scarlet fever which showed time to time where the only explanation possible is infection evidences of nephritis when there had been no albuminuria, from a ease in its earliest stages, and I cannot doubt that and I know of no cases of scarlatinal albuminuria in which a scarlet fever is infectious directly the rash appears. The necropsy showed absence of nephritis, and scarlatinal illogical reply that persons in contact with scarlet fever albuminuria should always be treated as being an indication in an early stage may escape the disease has no force : of nephritis. TJ /t’7H x 4578.
An Address
INTEREST
PHILLIPS, M.D. LOND.,
1404 I think the change of type in scarlet fever that has taken in the last few years is shown by the descriptions in the older text-books of scarlatinal nephritis with much these now seldom albuminuria, haematuria, dropsy, &c. ; occur. What one commonly finds is that the urine contains a little cloud of albumin, and in adolescents especially a trace of blood, but the patient has no symptoms whatever except perhaps a little pallor of face or feebleness of pulse. Sometimes there is a little headache, but as a rule the patient complains of nothing whatever, and any symptoms soon pass off with the albuminuria if the patient is kept in bed, but if care is not taken the albuminuria will increase. On the other hand, symptoms pointing to marked defect in the renal functions may occur without any albuminuria. In the gravest form of chronic kidney disease-granular kidney-there may be no albuminuria, and the same may be the case in the acute renal affection of scarlet fever. In some cases there may be very severe headache, with or without vomiting, perhaps oedema, little or much, with free flow of urine without albuminuria ; sometimes later on albuminuria appears. An important class of case is that in which there may arise from failure of recent function persistent vomiting without albuminuria or with the very slightest trace of it and without any other symptom of nephritis. A well-marked example was the case of a girl of 15 under my care at the London Fever Hospital, who was admitted for scarlet fever rash and a temperature of 100° F. on July 10th, 1898. The case was a mild one, but on the 16th vomiting commenced with a very minute trace of albumin in the urine. The vomiting was incessant and she was unable to keep down anything, even hot water, for four days. The daily average of urine was 35 oz. ; she had much pain in the back. On the 22nd the vomiting recommenced and persisted for many days, the patient’s life being in great danger from inanition. There never was dropsy or headache, but throughout there was the trace of albumin in the urine. A girl of 11 got scarlet fever rash on July 21st, 1900, and came into the London Fever Hospital. She went on well till August 10th, when she got diarrhoea and a considerable quantity of albumin was present in the urine. This soon sank to a very minute quantity, but only 10 oz. of urine were passed each day. Directly the quantity of urine lessened, although there was scarcely any albuminuria, violent and uncontrollable vomiting began, and it persisted till Sept. 17th z37 days. During that time she was kept alive entirely by nutrient and hot-water enemata. She became extraordinarily feeble and emaciated and was in grave peril for many days, but during all this time there was no symptom of nephritis except the vomiting and decreased secretion of urine, with a small trace of albuminuria. After Sept. 17th the urine increased in quantity, became free of albumin, and she was convalescent on Oct. 23rd. Similar cases occur in diphtheria, as in a child seen in 1909 with Dr. J. Davidson of Uxbridge, and also in renal cases The vomiting is sometimes unconnected with exanthems. associated with very severe pain in the abdomen -possibly from stretching of the capsule of the kidney when it is greatly engorged. Such cases with vomiting and abdominal pain are likely to be interpreted as some grave intra-abdominal lesion requiring laparotomy. Bradford1 remarks that"the grave error of mistaking ursemia for intestinal obstruction has been made more than once." In one such case my suggestion of ursemia was not adopted, and on other advice laparotomy was actually performed for supposed intestinal obstruction, only for the patient to die from suppression of urine. I have seen other cases in which operation was proposed for ursemia, under the impression that the symptoms resulted from duodenal ulcer, from appendicitis, and from an undiagnosable condition. And I wish to lay stress on the occurrence of vomiting and severe pain in the abdomen as signs of nrasmia even when little or no albuminuria is present. MEASLES. like other Measles, exanthems, is declining in the mortality it produces. The deaths from measles per million living fell from 412 annually in the decade 1851-60, to 362 annually in 1901-05; and though at the present moment measles is very prevalent, there is reason for anticipating that the figures for the five years 1905-10 will show a lesser 1
Clifford Allbutt’s
System
of
Medicine, vol. iv.,
p. 328.
before.
Measles is still, however, the to every 1 from scarlet fever, and to every 2 deaths from diphtheria ; whooping-cough alone approaches it, causing 300 deaths to every 380 from measles. The seriousness of measles is the greater from the debility and the glandular and pulmonary affections which may follow it. It is generally accepted that it predisposes to the onset of pulmonary tuberculosis, and from the very large proportion of cases in which tubercle of the abdomen in children is preceded, by some weeks or months, by measles, there is a strong presumption that measles predisposes also Both measles and abdominal to abdominal tuberculosis. tubercle are commonest in the second and third years of life, and it seems more probable that this is so because measles predisposes to it, than the suggested explanation that it is contracted by swallowing tubercle bacilli from the floor during the crawling age. INFECTIVITY OF MEASLES. The extreme infectiousness of measles was exemplified in 1904 when of 14 students whom I took for five minutes into an isolation room to see a case of measles, the only student who had not previously suffered from measles contracted a severe attack, of which the first symptom occurred nine days less two hours after infection. Small-pox is equally infectious. I was accompanied by eight or ten students to an isolation room to see a case of small-pox. An interview of five minutes’ duration sufficed to infect one of the students, who inaugurated by a faint a slight attack of small-pox, 11 days less two hours after the infection. The different infective activity of measles and scarlet fever is illustrated by a case I saw in February, 1910, with Dr. J. D. Cree-that of a youth who had on him at the time the rashes of both scarlet fever and measles, and who was staying in the home of his sister who had lately been confined. I moved him at once to the London Fever Hospital, where the rash of measles came out more profusely, and he subsequently desquamated freely from the scarlet fever. The infant, with whom he had been in contact before he left home, got measles eight or nine days after, but rejected the oppor. tunity of contracting scarlet fever.
mortality
than
most fatal of
place
I
ever
exanthems, causing 3 deaths
LOBAR COLLAPSE
OF
LUNG
IN
MEASLES.
Lobnlar collapse of lung is not uncommon in children with measles and bronchial and alveolar catarrh, the collapsed lung being small areas disseminated through both lungs and mixed up with other areae of alveolar catarrh and of insnffi’ttion. Such a condition is usually regarded as a But collapse of the whole or result of capillary bronchitis. the greater part of a lobe (usually the lower lobe) may suddenly occur in measles without a trace of bronchitis, which, indeed, even if present, would be quite incapable of producing such sudden collapse of a whole lobe. The onset of the collapse is attended with very distressing and alarming
dyspncea. Twelve years ago I was called in the middle of the night to child who was suffering from measles and who had had such an attack on the previous afternoon. I found the child (aged 4 or 5 years) lying in bed with terrible dyspnoea, gasping for breath, intensely cyanotic, with feeble pulse and dieturbed heart action. The lower half of the left side of the chest was quite dull on percussion, with sucking in of intercostal spaces. The temperature was 1030 F. After artificial respiration, pressure on the abdomen, and strychnine the urgency of the symptoms passed off. She was much better next morning, with normal temperature, when I saw her with her medical attendant. She got gradually well, but the physical signs on the left side have not even now quite cleared up. Such cases also occur in other conditions than measles, but are most common in measles. Successive attacks may occur in each of which there is evidence of lobar collapse; they are liable to be taken for pneumonia or pleurisy or for asthma. They are certainly not due to any mechanical plugging up of bronchial tubes, and I can only attribute them to a sudden paralysis of the muscular fibres of the bronchi. DIAGNOSIS OF MEASLES... The early diagnosis of measles from Rötheln is sometimes quite impossible. The preliminary catarrhal stage of measles a diagnostic difference is not to be relied upon, for there see a
,
as
1405 may be none such observed in measles, and I am quite sure that rötheln rash is not the first symptom of the disease in many cases, there being a precedent two or three days of feeling of illness, and, may be, coryza and often tender lymphatic glands in measles may be glands. Again, the lymphatic enlarged in the neck and over the head as well as in rothein, though in some cases of the latter the enlargement is characteristic. On the whole, the most reliable point in the diagnosis are Koplik’s spots. During the last epidemic of small-pox, measles was, in my experience, more commonly taken for it than anything else, the reasons being the great swelling of the face in bad measles cases and the fact that over the forehead, where there is little underlying soft " tissue, measles papules feel I I shotty. Pityriasis rosea may resemble measles at the onset, beginning with pink mottling on the body with a little pyrexia and malaise. And during the last year or two three cases of pityriasis rosea seen by several medical men were sent into the Fever Hospital for measles. It is well to bear in mind that the actual measles rash may be preceded by two or three days by a pink mottled prodromal rash on the face and neck; this rash disappears two days or so before the measles rash. There is an interval in which the patient is free of rash, which has several times led to the mortifying experience of the practitioner of wrongly condemning his own correct
diagnosis. TYPHOID FEVER.
Typhoid fever, like the other exanthems, has in late years greatly lessened in the mortality it causes. Since typhoid fever was first separated from typhus fever in the Registrar’s returns in 1870 the annual mortality from it has fallen from 390 per million persons living to 75 per million in 1908, a reduction of 80 per cent. Comparing the notifications of the disease with the number of deaths annually since the year 1890, the case fatality has fallen very little, if at all, from 16’9per cent. to about 16 per cent. (it was 16-88 in 1908). It would therefore appear that the lessened number of deaths from typhoid fever is due in far greater degree to its lessened frequency of occurrence than to its lessened danger in individual cases. Perhaps the figures here do not express the facts with exactitude, for mild typhoid fever seems commoner than heretofore, and such mild cases may escape notification while fatal cases do not. And typhoid fever, whether more or less virulent than formerly, is certainly very different in type from the time when it so resembled typhus that the two were regarded as the same disease. One rarely sees now, except in cases imported from the continent, .the copious diarrhoea, muttering delirium, and the typhoid state seen even 20 or 30 years ago. There is a general agreement that milk with barley water Citrate of or other diluent is the best diet in typhoid fever. soda added to milk is of great use in preventing heavy curd formation, but I am doubtful whether it is advisable to continue it throughout a protracted case of typhoid fever. Sir Almroth Wright has shown that it increased the coagulability of the blood if given very long. A patient seen in 1908 with Dr. Hastings Stewart was fed entirely on citrated milk throughout a long-continued typhoid attack ; he then got very extensive thrombosis of the veins of the lower limb. Later on he had a relapse of his typhoid and equally severe thrombosis in the veins of the other lower limb. Whey is often useful where milk cannot be taken, and my experience agrees with Dr. Gee’s that patients thrive well on it. During the last 15 years I have followed the practice of Sir William Broadbent in giving calomel or mercury in typhoid fever. Although mercury does not shorten the course of the disease it certainly appears to exert considerable influence on the toxic symptoms, and lowers the range of temperature. There is no reason to withhold calomel when diarrhoea is present; indeed, it may be controlled by it, and if necessary salicylate of bismuth or Dover’s powder can be given with it. Cold bathing is, no doubt, very efficacious, but a patient seriously ill with typhoid fever cannot be moved from bed frequently to and from a bathroom, and the bringing of a large bath and many cans of water into a bedroom, and cooling a bath down by adding water to the bath when a patient is in it, without a wastepipe, together with the labour and noise entailed in emptying and removing the bath from the room, render it
impracticable as a routine method in private practice. As a rule tepid sponging suffices to keep the temperature within moderate limits and gives great relief. (Cases were related exemplifying the occurrence of very severe nervous disturbance in epididymitis following mumps. 2) PREGNANCY AND LACTATION IN RELATION TO THE EXANTHEMS. The exanthems may occur during pregnancy. In a very severe case of typhoid fever seen with Dr. W. F. Campbell in 1889 in the seventh month of pregnancy, and in a case with the late Dr. W. Barter in 1909 in the eighth month, a healthy child was born in each case at full term. In a case of typhoid fever in the fifth month abortion occurred. This was a very severe case, in which suppuration and sloughing of the parotid gland occurred, but the patient recovered. In many cases of scarlet fever occurring during pregnancy in early and in late months, some of them severe, healthy children were born at full term. I have seen two cases in which lactation was performed during typhoid fever. In one case, seen with Dr. Beaman Hicks in July, 1904, the child was suckled during the first eight days of typhoid fever without apparently suffering, but In another case at the mother afterwards got parotitis. hospital in 1898 the infant, eight weeks old, was suckled for the first 10 days of severe typhoid fever, when the milk dried up. HYPERPYREXIA. Hyperpyrexia is often spoken of as a complication of the exanthemata. In young children a high temperature very readily occurs in the exanthems without grave significance, but I have not seen any case of hyperpyrexia in adults from the exanthemata without some local complication to account for it, nor have I found any instance in the case books for many years past of the London Fever Hospital.I show here numerous charts of temperatures over 106° F. in the exanthems, and in every one there was a local cause:a in typhoid fever pneumonia over and over again, or peritonitis after perforation, and in one case cerebral meningitis, in another abscess and sloughing of the gallbladder, and in another the explanation was found post mortem in a calculus and abscess in the kidney. In scarlet fever, hyperpyrexia is usually due to some rheumatic affection such as, pericarditis or to middle-ear suppuration, relievable by perforation of the tympanic membrane, or to mastoid suppuration with or without intracranial suppuration, or to thrombosis of an intracranial sinus. In diphtheria in adults hyperpyrexia is usually due to septic local lesions, such as broncho-pneumonia. And one should not be satisfied with the diagnosis of hyperpyrexia in fevers without a thorough investigation for some local lesion, possible relievable by treatment.
ASSOCIATION
OF
TWO
OR
MORE EXANTHEMATA.
This is very common, though such cases are often recorded as curiosities. In hospitals for infectious diseases one of the things requiring specially to guard against is that patients admitted for one exanthem shall contract another, and, indeed, they seem peculiarly liable to do so. It is common for children to be sent in with scarlet fever who also develop measles or chicken-pox after admission at a date showing that they had already contracted the disease before admission. It is well known that whooping-cough often follows on measles, and diphtheria on scarlet fever. An instance in which scarlet fever and measles rashes existed Scarlet fever at the same time has already been given. may occur with typhoid fever, both rashes being visible at the same time. Mumps is not uncommon with scarlet fever;9 Ihave now under my care at the Fever Hospital children of a family with both scarlet fever and mumps. In a case seen with Dr. W. Balgarnie of Winchfield in 1898 mumps came on late in the disease with very severe symptoms. Influenza, as is well known, is often in some way associated with typhoid fever. In general, the association of two exanthems at the same time tends to severity of symptoms. In a case of typhoid fever with scarlet fever fatal hsematuria occurred, the necropsy showing the ureters full of blood, which evidently came from the kidneys. 2
These
were
published in THE LANCET
of Jan.
7th, 1911, p. 23.