The ear complications in scarlet fever are of considerable prognostic significance. They often result in a permanent impairment of hearing. Statistics show that scarlet fever is one of the most frequent causes of auditory disturbances.
The cOndition of the patient is a most uncomfortable one. The temperature remains elevated so long as the disturbances in the mouth and throat. are active; there is considerable loss of appetite; the ingestion of food is difficult. Therefore, the patient is made to suffer from the local process, which causes the toxaemia, and the weakness which results from the insufficient amount of food ingested.
It has as yet not been determined whether the systemic infection is the result of the entrance of streptococci into the general circulation, or merely the result of the absorption of their toxins. In most cases it is probably a and not a toxtemia. The death of the tissue probably is caused by the as yet unknown bacterial cause of scarlet fever. The streptococci would in all probability not make their way into the tissues until after necrosis has occurred.
The changes in the lymph-nodes are deserving of special mention at this time. In every case of scarlet fever there is some swelling of the lymph-nodes at the angle of the jaw.
Enlargement of the lymph-nodes elsewhere is as observed in the living only in cases of extrabuccal infection. Such patients as come to the necropsy are found to have swelling of the lymph-nodes in other regions, notably in the deep cervical lymph chains, the mesenteric lymph-nodes and the lymph structures of the intestines.
The degree of enlargement of the lymph-nodes at the angle of the jaw is in no wise dependent on the severity of the pharyngeal inflam mation. The moderate involvement seen in uncomplicated cases of scarlet fever recedes concomitantly with the other symptoms. Some times the nodes do not regain their normal size; they remain permanently enlarged, occasionally becoming even larger or undergoing suppuration. In such cases a smooth convalescence is denied the patient and recovery is protracted.
The lymph-node enlargement which accompanies the severe grades of scarlet fever may recede to normal, without suppuration. On the
other hand, in the worst cases of the infectious type of the disease, the lymph-node involvement may assume alarming proportions. Not only are the nodes themselves involved, but the surrounding tissues are infiltrated and (edematous, thus forming a dense mass without circum scribed pus formation.
Areas of htemorrhagie inflammation are seen, as in plague (plague like form of scarlet fever).
The oedema may extend as far as the sternum. Pressure on the trachea may cause dyspncea. In the case of a child, two and a half years old, we were obliged to do a tracheotomy on the twenty-seventh day. Death ensued shortly afterward, however. Incision of the mass did not give the patient any relief. There was no pus.
When suppuration of these masses does occur, it may extend to the neighboring tissues (vessels, mediastinum).
The prognosis in the severe anginose cases is always grave. At best, resolution is delayed until the third week. Perforations of the anterior pillars may heal. Plate 14, b, represents such a case, but, as a rule, the prognosis in such cases is bad. In t he more rapidly progressing cases death results at the end of the first or the beginning of the second week. Occasionally it does not occur until the third or even the fifth week. The longer a fatal termination is deferred, the more varied are the com plications.
The condition may progress to gangrene. In the case of a child, aged three and three-quarter years, brought to the hospital in a mori bund condition, in the fifth week of the disease, the gangrene had involved the oesophagus as far as the cardia. Isolated patches of mucous mem brane were found in the vicinity of the bifurcation.
Entrance of the streptococci into the general circulation may lead to secondary infections in the pericardium and peritoneum; more rarely a general pyremia results, with the formation of metastatic abscesses in other organs as well as in points. Then, again, death may ensue from a lobular pneumonia, which progresses to suppuration and pleurisy. In these cases the clinical picture of scarlatina is completely overshadowed by the septic complications.