Although in this case there were present hydropericardium and symptoms of heart failure, the patient recovered. Of far more serious import as a complication of nephritis is pneumonia, which may be an additional cause of dyspncea. The fatal termination in such cases is undoubtedly hastened by the damage which the heart has sustained because of the nephritis. In the case of the boy (aged nine years) (cited in Table 14a, Jahrb. f. Kinderheilkunde, I, Folge, Bd. III, 1S59), the nephritis was complicated by embolic gangrene of the lower extremities (thrombosis of iliac vein and artery on both sides).
In the absence of these serious complications, and if death is not caused by the Lumina, the prognosis in these cases of scarlatina] ne phritis is, on the whole, a favorable one.
Even in the most severe cases recovery may take place in two or three weeks; occasional traces of albumin are found in the urine for many weeks afterward. The condition may progress to chronicity even when the patient has keen kept in bed from the very beginning of the scarlet fever, but a nephritis extending over a considerable period of time does not preclude eventual recovery.
Frieda W., five years old. Light attack of scarlet fever. Lymph adenitis on the fifteenth day; albuminuria. Two days later, bloody urine. Maximum albuminuria and hmtnaturia on the thirty-first day (over two per cent.); then gradual decline. No oedema after the forty fourth day. Until the seventieth day traces of albumin, although sub jectively the patient was well. Patient allowed to get up out of bed on the seventy-seventh day. Discharged on the eighty-second day.
The most disastrous results are met with in those obscure, unrecog nized cases of nephritis in which the primary attack of scarlet fever was not diagnosed and the patient has been ambulant for days.
It is impossible to make a prognosis while the symptoms are in the stage of development. Neither the height of the fever nor the degree
of albuminuria, nor the intensity of the oedema, are indicative of the ultimate outcome of the ease. Of these three symptoms, the degree of temperature elevation is of the least prognostic value. I have cited an instance (p. 298) where the temperature was 40.9° (105.5° F.) in a case of nephritis, and resolution occurred within two weeks.
The amount of urine voided during the twenty-four hours gives the best clue as to the progress of the nephritis. The more scanty the amount of urine voided, and the longer the oliguria continues, the more serious is the case. A favorable progress of the nephritis is made evident by an increase in the amount of urine, diminished. cloudiness, lessening hrematuria, and reduction in the amount of albumin. Sometimes im provement is inaugurated by a crisis, as in the case of Robert M. (p. 297), where the urine increased rapidly in amount from 150 c.c. to 2000 c.c., and the body weight diminished with corresponding rapidity.
Recurrences seldom occur after complete healing has taken place.
Worthy of special mention are those cases of albuminuria which go unrecognized until after the patient has been allowed to get out of bed. The amount of albumin in the urine is always very slight, and, as a rule, it is possible to free the urine from albumin solely through rest in bed, reminding one of orthostatic albmninuria. The researches of Jehle, Bruck and Nothmann on albuminuria in convalescents justifies the belief that the direct cause of this condition is a lordosis of the lumbar spine. This lordosis is the result of a weakened musculature, which, in turn, is caused by the primary disease and the rest in bed necessitated by it. As the musculature becomes stronger, this so-called "lordotic convalescent albaininaria" disappears.