OTHER COMPLICATIONS OF PRIMARY SCARLET FEVER A. comparatively harmless complication of primary scarlet fever localizes itself in the joints. In from five to eight per cent. of all cases it makes its appearance at the end of the first or the beginning of the second week.
Such an extension manifests itself rather suddenly as a symmetrical painful swelling, usually of the hand, finger, ankle- and knee-joints. Other joints are involved but seldom. Older children complain of pain in the affected joints; in the ease of younger children attention is directed to this complication by the absence of motion in the affected joints.
The joints the seat of such inflammation are hot to the touch, there is sonic (edema, the skin over the swelling is diffusely or sometimes discretely reddened. Suppuration fortunately never occurs. The inflammation persists for from three to seven days, seldom longer, and is almost without exception accompanied by fever. The characteristic lysis occurring at the end of the first week of scarlet fever is delayed.
For two or three days there is a step-like rise in the temperature and then the temperature falls to normal by lysis.
The etiology of ,searlatittal synoviti. is as yet little understood. It is uncertain whether it is of toxic or infectious origin. It must not be confused with the arthritis of origin mentioned above.
In some cases there is pain only, no swelling, in the affected joints.
Josef, aged seven years. Light attack of scarlet fever. Temper ature falls by lysis from 39° C. on the third day (afternoon) to 37.5° C. on the morning of the sixth day. On the seventh day lysis is inter rupted; step-like rise in temperature, reaching 39.3° on the ninth day. From then on lysis.
Eighth day: Pain in both wrist-joints, without Ninth to eleventh day: Pain continuous.
Twelfth day: Pain in the wrist-joints less severe; slight pain in ankle-joints.
Thirteenth day: Pain disappeared.
The heart shows evidences of involvement early in the disease. The first sign is the increased frequency of the pulse rate. This frequency,
as was shown by Trousseau, is out of all proportion to the elevation of the temperature and the age of the patient. A pulse-beat of 150 to 160 in four-year-olds, 120 to 140 in older children (seven to twelve years), is common with a temperature of 39° to 40° C. (102° to 104° F.). This occurrence is not of prognostic significance.
Widening of the cardiac area of dulness transversely is sometimes noted during the first few days of the disease in severe cases: greater dilatation occurs usually only in foudroyant cases. Anatpinically, there are noted, in addition to degenerative processes, genuine myo cardial changes (Romberg). The weakened heart action is made evident by the lowered pulse tension, but more particularly by the fact that in spite of the high internal temperature, a cool sponge bath will immediately lower the temperature and cause cyanosis of the peripheral parts. As the result of the weak heart action and the disturbed circulation, the eruption takes on a dirty, dark-red, even bluish-red color, the skin in the most severe cases becoming deathly pale in color, and on finger pressure the area of anwmia changes to hyperfemic very slowly. Finally, the eruption may give way to a general cyanosis. As everyone knows, it is in eases such as these that it is stated that the eruption "was driven inward." This change in color of the eruption, the result of a circulatory `ilisturbance, is of prognostic significance.
Pospischill recently called attention to the fact that in many cases of scarlet fever a characteristic early symptom is a scratching sound (pericardial in tone), heard at the base. Berkholz confirmed this state ment. Other systolic sounds are often heard at the height of the disease, and even later in many cases. They are basal in character, the point of maximum intensity being over the pulmonary area. They are not of prognostic significance. It is rather difficult to state why they occur.