Sometimes we find the above two forms of malignant fever combined. The nervous symptoms are in excess, and there is also serious ulceration of the fauces and destruction of tissue. Convulsions occurring from any cause during the eruptive period are of very serious import, and generally end fatally whether the throat symptoms are mild or severe.
Complications and Sequelw.—The intercurrent disorders which are liable to occur during or after an attack of scarlet fever may be looked upon as complications or sequelm, according as to whether or not the disease is considered at an end when the temperature returns to a normal level. Most of them arise during the second week of the illness, although some may occur earlier. They will be described in the order of their occur rence.
During the first week the fever may be complicated by diphtheria, diar rhoea, and coryza. The ulcerative throat affection, which by many writers is considered as a complication, has been described as a phase of the malig nant form of the fever.
Diphtheria may be an early complication of scarlet fever, and may spread to the nose and larynx. It often comes on during the first week of the illness, but may occur later and at a time when the patient is supposed to be rapidly approaching convalescence. It generally proves fatal.
Coryza of a mild character occurring in the course of the first week is not a symptom of unfavourable omen ; but if it persist into the second week, it becomes more serious. In such cases the catarrh may spread along the Eustachian tube into the tympanum and set up otitis. If in any case the nasal discharge becomes fetid, it suggests the presence of diphtheria.
Diarrhoea is sometimes an early complication. • It usually ceases after a day or two, but may prove so severe as to endanger the life of the patient. According to Henoch it is preceded by swelling of the Pyerian and solitary glands. Sometimes as the rash fades the diarrhoea, which had at first appeared of little importance, passes into a true entero-colitis. The tem perature which had fallen rises again ; there is nausea and often vomiting ; the belly is swollen and perhaps tender ; and the child complains much of abdominal pain. The tongue, dry and hot, is furred on the dorsum,.
red at the tip and edges. The bowels are loose, and the stools contain much food partially digested, mixed up with mucus and sometimes with blood. The child looks excessively ill and rapidly loses flesh. He may die from the acute attack, or the complication may pass into a chronic stage.
In the second week bronchitis and pneumonia, rheumatism, and serous inflammations may be seen.
Bronchitis and pneumonia, which are common in measles, are compara tively rare complications of scarlatina. It is much more frequent to find inflammations of the serous membranes, especially of the pleura and peri cardium ; and these are often associated with symptoms indistinguishable from those of rheumatism.
Scarlatinous rheumatism may occur during the second week or beginning of the third, and is often met with as a complication or sequel of the fever. Whether the disease is to be looked upon as a true rheumatism quite independent of the scarlatina, or as an arthritis resulting from septicaemia, or as a further manifestation of the scarlet fever poison which may fasten upon the joints as it may fasten upon the kidneys or the throat, is still a matter of discussion. The attack certainly follows the ordinary course of that disease ; it frequently affects the serous membranes in and around the heart ; and the joint inflammation subsides, as a rule, after a day or two, although in exceptional cases it may end in suppuration. This, may, however, occur in cases where there is no suspicion of scarlet fever. Endocarditis is as common as pericarditis, and heart disease in the child often dates from an attack of scarlatina. Pleurisy and pericarditis some times come on in the third week instead of the second, and may occur in cases where joint pains are not complained of. They may then be a symp tom of Bright's disease ; but pericarditis from this cause is not very common in the child as a sequel of scarlet fever. If pleurisy occur the effusion very rapidly becomes purulent.
In the third week the patient is especially liable to kidney mischief. At this time, too, or shortly afterwards, otitis may occur, and gangrene and abscesses may make their appearance.