OTHER SEQUEL2E Besides the arthritis, of which an example was given (p. 204), there may occur in rare instances temperature elevations, for no discoverable reason, and endocarditis. I have seen five cases of endocarditis. They all followed a mild attack of scarlet fever and led to the development of organic heart disease. The time of onset was the eighteenth, twentieth, twenty-first, twenty-sixth and twenty-seventh day, respectively.
Herminie K., aged five and a half years (Fig. 57). Mild attack. Highest temperature record, 38.1° C. (100.5° F.). Temperature normal on sixth day, continuing normal until twentieth day. On this and fol lowing day temperature rose to 39.4° C. (103° F.), with h markedly increased heart action. Pulse in evening, 1.'i0; temperature, 39.1° C. (102.5° F.). On the twenty-fifth day the hitherto normally situated apex beat was found in the fifth intercostal space. Heart action undulating. Systolic murmur at apex; long in duration. .Accentuation of second pulmonic sound. Condition remained unchanged for several days; temperature falls by lysis. On the third day patient is dismissed with a typical compensating mitral insufficiency.
In a second case two febrile periods preceded the onset of the endo carditis; the cause for the rise in temperature remained obscured.
Such elevations in temperature, without apparent cause, may occur at any time during the disease. Interesting in this connection are two cases occurring in one family. Both children suffered from a mild attack of scarlet fever, but had temperature elevations on the same (lay (Fig. 59).
These temperature variations are, however, analogous to those accompanying post-scarlatinal conditions. It is simply a case of not being able to discover the part that is affected. Moser is of the opinion that the fever is caused by an inflammation of the mesenteric lymph nodes. Bauer says it is due to absorption of toxins from the intestinal tract. The toxins of the disease paralyze the nerve ganglia of the bowel, peristalsis is diminished and constipation ensues.
I wish now to speak briefly of a number of eruptions which are occasionally met with during the height of the disease. They may
consist of large macules and be fleeting in character (Herminie p. 295), but, as a rule, the eruption is maculopapulous. In one of my cases such an eruption, of a brownish-red color, was present for several days on the extremities. Each macule at first measured 1 mm. in diameter but rapidly reached a size of 3 to 4 mm. with a small central pustule. Gradual drying.
Lambert M., five years old Mild attack of scarlet fever; temper ature normal on seventh day. On the seventeenth day, temperature, 39.5° C.; albuminuria on the eighteenth day. During the succeeding few days moderate fever, with in creasing development of the nephritis.
Twenty-third day: Commencement of inter mittent temperature, be tween 36.9° C. and 41° C. (9S.G° and 105° F.), py Tmic type. General condi tion bad; collapse; mental confusion; chills.
Twenty-fourth day: Eruption of the type described above. Re lapses until the twenty-eighth day.
Twenty-sixth day: Inflammatory exudate in left wrist, right ankle and right knee. Joint swellings continue for an unusually long time. Resolution of the nephritis on the forty-ninth day.
The pywmic character of the disease at the time the eruption appears leads to the supposition that embolic processes in the skin are the cause of the disturbance.
In the case of a child seen by Heubner, which developed a adenitis on the eighteenth day, and suffered from a post-scarlatinal synovitis, there was present a peculiar skin eruption, consisting of ness and swelling first of the right elbow, then elsewhere on the body, accompanied by pain. On the twenty-eighth day the skin over the right elbow became gangrenous. After this skin had been shed, healing took place. Heubner considered these skin changes as a vasomotor gangrene. In the past five years I have seen five similar cases, and I have been able to prove that at the time these eruptions were present these efflor essences could be induced by trauma (scratching, etc.). I have proposed the term erythema post-scarlatinosum for this exanthem.