Clinical Lecture ON HÆMATURIA AFTER SCARLET FEVER.

APRIL 4, 1857. affords evidence of fluid by succussion. The temperature of the skin is higher than natural; the pulse is small and frequent ; the tongue pale and furred; the chest affords no eviON dence of disturbed function. The urine which has passed since admission is of a dark, blood-red colour, highly albuminous by HÆMATURIA AFTER SCARLET heat; and the sediment, under the microscope, exhibiting abundance of large-sized fibrinous casts, entangling blood-discs, FEVER. and many free corpuscles. The little patient complains of loss of appetite, and urgent aching pains across the thirst, BY W. R. BASHAM, M.D., loins. The lumbar spaces are painful on making deep-seated PHYSICIAN TO THE "WESTMINSTER HOSPITAL, AND LECTURER ON THE pressure. He was ordered to be cupped to six ounces from the PRACTICE OF MEDICINE. loins; to take half a drachm of the compound jalap powder; to have a warm-bath each night; and to have the diaphoretic four hours, the action of which was to be promixture GENTLEMEN,-Hæmaturia after scarlet fever is no uncommon moted byevery the child being clothed in flannel. The little fellow occurrence; it is always associated with more or less of general bore the cupping without flinching or crying; and two days dropsy, with a pasty, spansemic appearance of the surface of the afterwards we find the swelling in the abdomen greatly reand the general anasarca of the surface diminished. body. In the great majority of cases, it is a morbid con- duced, There is less heat of skin; the pulse is fuller and slower; there dition, perfectly manageable, quickly yielding to judicious is no thirst; the tongue is clean; and there is some desire for treatment, and only in exceptional cases either leading to, food. But the urine is still highly charged with blood; and or associated with, permanent and organic mischief of the the pain across the loins remains much about the same. Brisk kidneys. purging with the jalap and cream of tartar was continued; and A question of much pathological interest arises out of the by the end of the week a very manifest improvement became The amount of urine began to augment in quantity, study of these cases-namely, whether the congested or im- apparent. so soon as the action of the purgative ceased; but the hsema.peded state of the circulation in the kidneys is mainly depen- turia continued, although less abundant. He was now drydent on arrested cutaneous function during the desquamation cupped over the loins, and with considerable and immediate ’of the cuticle; or is it evidence of the imperfect elimination of relief, indicated by the abatement of the pain, and the clearer the febrile poison during the eruptive stage, and therefore a and more natural appearance of the urine. Its specific gravity ascertained to be 1’016. The dropsy by the tenth day sequel to the completion thereof through these emunctories- was from admission had nearly disappeared; the abdomen was From whichever we the kidneys. point of view study these natural and free from any indication of fluid; and the only symptoms, the condition of the kidneys is that of inflammatory vestige of the anasarca was some slight puffiness of the eyelids congestion, and the impeded renal function demands the same in the morning. The heart had been examined from time to remedial measures. time, and found free from any murmur. The urine at this Of the many’ cases of hæmaturia and dropsy after scarlet period, under the microscope, showed fibrinous casts, with a cells entangled therein; there were also a few fever that come under treatment, some have had the exan- few epithelial scattered blood discs. The appearance is well illustrated in a thematous fever most favourably, and its characteristic stages drawing made at the time: the casts are all large-sized, very have been well marked, but during convalesence, have granular, and within this mould, as it were, are many epibeen incautiously exposed, and the proper precautions, with thelial cells. Another drawing was made from the examiof the urine, when the child was first admitted, and respect to clothing at that period, have been neglected. In nation these there is some show of probability that arrested cutaneous there the casts are of the same character, with this difference, in these latter only blood discs are visible; none of the grafunction may suffice to explain the sequelæ of dropsy and nular epithelial cells cf the tubes are visible; so that it would bloody urine. But, in the vast majority of cases, this secon- appear that, in the early stage, the microscope reveals a state dary condition must be accepted as evidence of the imperfect of simple haemorrhage, the casts of the tubes being the blood elimination of the febrile poison during the antecedent exan- coagulated within them. Later in the disease an exudation of thematous stage, arising either from the greater intensity of the epithelium of the tubes becomes abundant, and may, if unchecked, lead to setious embarrassment of the renal function, the poison, or the incompleteness of the processes by which it and permanent organic mischief in the kidney. With good is released from or decomposed in the system. management, however, this condition may be averted. The amount and duration of the hæmaturia, as a secondary By the fourteenth day material improvement had been affection after scarlet fever, is very variable. In some cases effected; all traces of dropsy had disappeared. The appetite the renal haemorrhage is abundant, and gives to the urine, for was good; no thirst; amount of urine natural, but it was still some consecutive days, a marked blood-red appearance; in albuminous. There was, however, that peculiar pallid look, others, the presence of blood is scarcely recognised, except by that evidence of an impoverished state of the blood which is so a certain dusky appearance, as if a few grains of soot had been universal in this disease, and which tells so forcibly of the moradded to the urine. Nevertheless, whether the haemorrhage bid agencies that, from the primary exanthematous fever to be trifling or abundant, there is always. at the commencement the secondary febrile state with renal haemorrhage, had been of this supplemental stage evidence of more or less febrile dis- continuously deteriorating this fluid in its most important conturbance, clearly expressing the inflammatory nature of this stituent of red globules, that the propriety and even necessity secondary process. Anasarca of greater or less degree of the for the administration of chalybeate medicines must be appawhole surface of the body, sometimes with, more often without, rent. He first took the citrate of iron; but a week afterwards serous accumulations in the abdominal cavity accompanies, the urine continuing albuminous, and the microscope still exmost frequently precedes, the hæmaturia. The pale, pasty, hibiting blood discs and fibrinous casts, this form was changed spanæmic aspect of the patient is also very expressive of this for the tincture of the sesquichloride, which he took for a fortdisorder. night in ten-minim doses. It cannot but havebeen remarked Such are the chief characteristics of the hsematuria, or by you how rapidly the child improved in appearance; how secondary renal affection following scarlet fever; and the case soon, after taking this most valuable of all the preparations of of John D-, ten years of age, admitted into Burdett iron, his countenance and the surface of the body generally inward, in August, 1855, illustrates, in a marked manner, dicated an improved quality in the circulating fluid. Before he these preliminary remarks. This child had scarlet fever the left the hospital we had the satisfaction of finding that the first week in August, and from the mother’s description, urine was quite free from albumen, and that beyond a few the eruptive stage was passed favourably, there being how- isolated and scattered epithelial cells the urine presented no ever troublesome sore-throat, with external swelling of the morbid state under the microscope. neck. By the 14th of August, however, he appears to have I have only a few words to add respecting the period at been quite well. A few days since, however, his face and eye- which in these cases it is proper to put the patient on steel lids were noticed to be swollen in the morning; and, on ad- medicines. Your best guide is the presence or absence of febrile mission the following symptoms were recorded :-The whole disturbance; so long as there is thirst, anorexia, a quick pulse, surface of the body is anasarcous, more evident in the face and and hot skin, febrifuge medicines and local depletion are clearly hands and wrists, feet and ankles, than on the trunk; the indicated; but with the subsidence of these, no time should be abdomen is distended, dull on percussion at the flanks, and lost before the influence of ferruginous remedies should be tried,

Clinical Lecture

No. 1753.

generally in these cases of renal haemorrhage and albumi- ought not lightly, and without serious motives, to have reurine you will find the sesquichloride the most efficacious course to anæsthesia during pregnancy. We have to say something of chloroform during suckling. and best adapted for this class of disorders. and

nous

This case has illustrated the chief features, both of symptoms and treatment, of the hasmaturia and dropsy after scarlet fever. They may be summed up as follows:—Anasarca of the surface, ascites, scanty urine, renal haemorrhage, albuminous urine, with symptoms of febrile disturbance. The principles of treatment were to alleviate the local congestion and impeded function of the kidney; to lessen the febrile excitement; to promote the action of the skin ; and for a time, while the inflammatory congestion of the kidneys continued, to husband the renal function, and by active hydragogue purges to cleanse the system of the accumulated fluid which the embarrassed kidneys were inadequate to excrete; and lastly, when these results had been favourably accomplished, to supply the functions of assimilation with a constituent all important to the impoverished blood, and which, co-operating with animal food and wellregulated diet, soon carried the little patient to a satisfactory convalescence.

we cause a nurse to inhale chloroform ? What influence the anaesthesia, have upon the infant ? This double question, which it would be so important to resolve by a series of careful observations, has many times presented itself to us, because our treatment of abscess of the breast not being able to be used without causing rather severe pains, we have had recourse to chloroform in a considerable number of cases, both in hospital and in private practice. In none of them have we observed any accident, and the children have not appeared to us to experience any dangerous influence from it; still, in two cases, the infants suckled by women who had inhaled chloroform, were seized with drowsiness and pallor, which lasted several hours. We have thought, then, in establishing, in a general manner, that suckling was not a contra-indication of chloroform, that it was our duty not ta forget in certain cases the child suffers from the aumsthetic,

Can

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influence.

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CHAPTER V.

Clinical

Researches

ON THE MEANS OF AVOIDING THE DANGERS DURING OPERATIONS PERFORMED ON THE BACK PART OF THE MOUTH.

ON

The anaesthetic state during painful operations is for the such a boon, that whenever we can, without exposing them to any danger, use this precious means, it is a duty of humanity and of good surgery to do so. If, on the contrary, it BY M. CHASSAIGNAC, is at the risk of real dangers that we spare the pain, there is an SURGEON TO THE HOPITAL LARIBOISIERE, PROFESSEUR AGREGE AT THE unintelligent application of anaesthetics. It is this consideraFACULTE DE MEDECINE DE PARIS. tion, according to us very cogent, which has caused many respectable practitioners not to use chloroform in certain operations, and particularly in those performed upon the back part des de BENJAMIN Interne BALL, ESQ., Hôpitaux Translated by of the mouth. If it were asked,-Do the operations (accomand JOHN & L.A.C. M.R.C.S.E. Paris; CRAVEN, ESQ., panied by haemorrhage) performed at the back part of the mouth comport with the use of chloroform employed without special CHAPTER IV. precautions ? The answer ought to be, No. Can these same operations admit the employment of chloroform with the preOF CHLOROFORM DURING PREGNANCY AND SUCKLING. cautions that we are about to indicate ? It would be improper to IT was hard to believethat the great derangement caused in decide the question at present. But if after having shown the the economy by the action of chloroform would not have a results of our experience, and the considerations which have directed our researches, we can cause those who look over these deleterious action upon the state of the fœtus in the womb, or remarks to share our convictions, we shall be happy to see upon the state of the infant suckled by a nurse to whom chlo- them deduce an affirmative conclusion. We know what grave roform had been given. Facts of this double character, of objections have been raised by our colleagues, and even by ourwhich we have been witness, although not very numerous, selves, against anxsthesia during operations performed in the by the passage of blood into the bronchi in a permit us, if not to solve the question, at least to put it in a throat : inAsphyxia whom consciousness is enchained-let us say, rather in patient manner to elicit, on the part of accoucheurs, information of a great measure extinguished-by chloroform; copious hxmorgreat importance. We will say at first a few words concerning rhages by involuntary deglutition of liquids during the state of anaesthesia, during pregnancy; we will occupy ourselves after- half sleep and torpor which succeeds to the period of collapse. Such are the first obstacles which present themselves to the wards with aneasthesia during suckling. The first time it happened to us to produce anaesthesia during imagination. Another circumstance-the facility with which the touching of the bottom of the throat removes the anesthesia, pregnancy, was in a patient in the H6pital St. Antoine, since, according to the remark of M. Monod, this is one of the arrived at the nfth month of gestation, and in whom it was best means of awakening consciousness in patients too strongly necessary to destroy enormous vegetations occupying the labia influenced by anaesthetics. This joined to the fact, that we externa. This woman had arrived at the fifth month of are compelled by the nature of the operation itself to diminish pregnancy, three operations were performed at sufficiently by one-half the passage of inhalation, understanding that from short intervals, accompanied by the use of chloroform, and the moment we open the mouth to commence the operation, the air enters it without mixture, and thus prepares the terminafollowed notwithstanding by severe pain. We ought to ask tion of the anxsthesia. All this constitutes an ensemble of ourselves if the attacks of hysteria and uterine pains which contra-indications to the use of chloroform in these operations, happened after the two first operations depended upon the and besides the horizontal position which is directed by pruchloroform, or upon the operation itself. As to the attacks of dence, but which has the inconvenience of rendering more diffithe execution of operations at the back of the throat, adds hysteria which followed nearly immediately the employment cult a new contra-indication to those which we have mentioned. of the chloroform, it appears to us rational to attribute them to Thus we do not seek to palliate any of the motives, which, for this agent. As to the uterine pains, if we carefully note that many dexterous surgeons, tend to remove from the operationsthey did not come on until the third day after the operation, which occupy us, the assistance of anaesthetics. If from generalities we descend to particular applications, we see in that’ we shall understand that we ought to attribute them much rather to the results of the operations, and to the vulvar pains which concerns the removal of the tonsils, there are still numerous motives to abstain. In the first place, for the simultaneous than to the action of the chloroform. The more so as in an- removal there is in this so little pain, and so much operation other case, of which we have to speak, and which had not any and surety in its execution, that in truth we do promptitude painful after symptoms, chloroform did not in any way deter- not see sufficient reasons for exerting oneself in seeking means of using chloroform in such a case. But all these reasons, mine uterine contraction. Because that, in the two cases alluded to, chloroform has not which the practitioner understands, cannot be appreciated by certain patients, whom the mere idea of an operation puts beproduced any dangerous effect upon pregnancy, we would be sides themselves, and who prefer to incur all the consequences far from concluding that this agent can be always employed of their state, sooner than look with sanfroid upon a short with impunity in that state. We think, on the contrary, that transient pain. Meanwhile must we abandon this kind of fasin spite of the freedom from accidents in some cases, we tidious patients to all the consequences of their pusillanimity ?

CHLOROFORM.

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