Otitis, next to angina, is the most com mon complication, and in its results is one of the most serious, as it is a com mon cause of deaf-mutism. It results from extension of the inflammation from the throat through the Eustachian tubes. The tendency to ear involvement varies in different epidemics, but it is more com mon in young patients. It does not usu ally occur until the second week, and, as a rule, involves both ears. Its pres ence may be indicated by earache and an increase in the fever, but frequently a discharge is the first indication that the ears are involved. The process is prone to be a destructive one and to result in long-continued suppuration. It sometimes leads to a rapidly-fatal menin gitis.
Adenitis and cellulitis are common results of streptococcic invasion of the throat. Not only are the lymphatic glands themselves enlarged, but there is more or less inflammatory (edema of the surrounding tissues. That this is due to secondary infection is shown by the fact that streptococci are found in abun dance in both the nodes and oedematous tissues around them. Enlargement of the nodes may be detected during the first week, but serious cellulitis does not, as a rule, occur until later in the disease. Suppuration, sloughing, or even gan grene may occur.
Joint Lesions.—Although acute articu lar rheumatism sometimes occurs, the joint affection often called scarlatina' rheumatism is, in most instances, a syn ovitis. It is mild, and is frequently con fined to the wrist. It appears early in the second week, continues for three or four days, and disappears, suppuration being rare. It is seldom seen under four years. Pyfemic arthritis occurs in ex tremely rare instances, and affects the larger joints, the lesions being multiple. Marsden has recently offered the follow ing excellent classification of the scar latina' joint lesion: (a) synovitis, (b) acute or chronic pycemia, (c) acute or subacute rheumatism, and (d) scrofulous disease of the joints.
Nephritis.—Albumin may be found in the urine during the acute stage; but it is febrile albuminuria, due to degener ative nephritis, which subsides as the temperature falls. In the grave type kidney lesions may occur, to which the term septic nephritis has been given. The urine contains albumin, but blood and casts are not necessarily present, neither do the rational symptoms of uriemia appear.
The most characteristic and common kidney lesion is post-scarlatinal nephritis, and is a diffuse nephritis. It develops during the third or fourth week, and may follow a severe or mild attack. There may be no interval of apyrexia between the kidney attack and the onset of the nephritis. It may be so mild as to almost escape notice, or it may be so severe as to cause speedy death. Recovery may be complete or incomplete. The first symp tom to be noticed is usually oedema of the face, which is frequently accompanied by feverishness and restlessness. Dropsy and all the characteristic symptoms of acute nephritis rapidly develop. The urine usually shows a small amount of albumin for a few days before the advent of definite symptoms. As the disease develops, the urine becomes scanty and high colored, and may be completely suppressed. It contains a large amount of albumin, and is loaded with blood cells and casts. The first evidence of al bumin after the second week should be a warning of danger, and should receive immediate attention.
Pneumonia, although commonly found at the autopsy in patients who have died with septic symptoms, is frequently not recognized before death. Endocarditis and pericarditis, though uncommon, are sometimes encountered. Murmurs are occasionally heard during the course of the disease, which disappear as the active symptoms subside. Permanent organic lesions sometimes develop in conjunc tion with the late kidney complications. Nervous symptoms are rare. The various serous membranes are occasionally in volved. Peculiar attacks of symmetrical, superficial gangrene have been reported. The disease may be complicated by any of the other infectious diseases.
Study of 13 livers from persons dead of scarlet fever. In scarlet fever it is usually increased in volume, pale, often mottled with red or with violet, and presents white or red areas on its sur face. The lesions are usually situated near the portal space and have a tend ency to surround the lobule. The leuco cytes are abundant, and the hepatic cells tend to degenerate in this region. Fatty metamorphosis is the most frequent form of degeneration found. The amount of fat may be twice or three times as much as normal. The most marked and most extensive degenerations were usually found in subacute cases. Roger and Gamier (Revue de Died., Mar. 10, 1900).