It is true that the convulsive stage may be followed by a period which is complicated by sundry disturbances of the central nervous system. The parents arc frightened by disturbanees of the organs of special sense, of which the most frequent probably is temporary blindness, urwmic amblyopia and amaurosis. These may be the only symptoms of urremic intoxication, and may appear without premoni tory symptoms. The ophthalmic examination is negative, and there fore the cause is probably a toxic functional disturbance in the cerebral centres', which disappears again in a few hours or days. Less frequent are posturtemic deafness, aphasia and paralysis restricted to isolated nerve centres; psychoses may also result from the urfernic intoxica tion, but this may just as easily appear independently in the course of scarlet fever.
In some eases these symptoms of acute urtrania may not appear at all; the affection taking a more chronic course. Sometimes it will present itself in the guise of vomiting and diarrInea; sometimes in the form of singultus and asthma. Certain patients suffer from violent itching of the skin; others show nervous symptoms, such as headache, vertigo, sleeplessness; all of these forms are of the greatest importance because they have a decisive influence upon the therapeutic measures which we must employ.
In proportion to the multiplicity of urfemic symptoms we may infer a variety of urannic poisons Muller). lIntemia is certainly connected with the retention of toxins, which are still unknown, but for the secretion of which the kidney has become insufficient. Ascoli connects urannia with the entrance into the organism of small frag ments of renal cells, and with the formation of antibodies, the so-called nephrolysins; but his opinion is absolutely hypothetical.
There are still to be mentioned the inflammatory complications of various organs which appear in connection with nephritis, and which change a fever-free course into a feverish condition, or increase an existing fever. These complications damage not only the organs of respiration (bronchitis, pleuritis, pneumonia), but also the heart, on whose peri and endocardium there are in many cases localized in flammation.
Pathological hannorrhagie character of scarla tinal nephritis is exhibited in its pathological anatomy, in children who die in the earlier stages of the disease. The kidney will be found in a condition of hypertemia; if death results front urannic complications the htemorrhagic changes are more or less marked. The accompanying
illustrations (Plates 56 and 57) distinctly show the characteristic renal alterations. The first shows the kidney of a five-year-old boy who died in the middle of the third week as a result of a most serious nephritis with urannia. The kidney shows an appearance which reminds us of certain many colored marbles; grayish white areas are limited by hientorrhagic zones of a deep red color, microscopically the inflammation corresponds to a hfrinorrhagic glomerulitis, the capsular spaces are filled by hmmorrhages from the hyperirmic capillary loops, just as are the tubuli near the glornertili whose epithelium, together with the blood vessels, hardens into a coagulated mass. The necrosis of the glomeruli is often quite extensive, where the epithelium is pre served it shows damage to its parenchyma, and is filled with larger or smaller fat-drops. While according to Ileuhner the loop portions are only rarely the seat of hannorrhagic infarctions, hiemorrhages be found in the intercalary parts of the renal ducts. The collecting tubes may to a great extent be obstructed by hyaline casts, a condition which leads to the retention of urine in the adjoining parts. The char acter of the nephritis which results from the scarlatinal poi.son, is there fore primarily a disorder of the vessels which is most distinctly in the glomeruli, and has given to the scarlatina] nephritis of glom ertilonephritis. After the affection has lasted a fairly long time. the aspect of the acute inflammation will change, later on, it will show interstitial cell accumulation with increase of the connective tissue, and subsequent contraction.
Diagnosis.--If it is possible to follow the development of the renal inHammation in the course of scarlet fever, its diagnosis may be made with ease and certainty. If the exanthem has not been observed, the peeling which may still be present, may lead to a diagnosis, but even without this the knowledge that persons in close contact with the child have suffered with scarlet fever within a short time, gives us the right to make the diagnosis, the possibility of which should be taken into consideration in every case of hafmorrhagic nephritis beginning acutely. Still, under these circumstances it is hardly possible to estab lish more than a probable diagnosis, since in infancy the nephritis which attends other infections and intoxications, may likewise be htemorrhagic.