Dropsy without albuminuria is occasionally met with, and this not a mere anaemic dropsy. In some of these cases albuminuria has been present, but has disappeared. In others there has been no precedent albuminuria.
Otorrhcea is a not uncommon complication of scarlatina. The discharge is often due to an inflammation of the external meatus, and is then, if at tended to quickly, of little consequence. In many cases, however, it is a result of extension of the catarrh from the pharynx or nasal cavities through the Eustachian tube to the middle ear. It is then a more serious matter, for the tympanum soon becomes distended with its purulent contents. Destruction of the small bones of the tympanum usually follows, and the pus bursting through the tympanic membrane escapes by the external canal. The most serious consequences may arise from this complication, as will be described elsewhere (see Otitis, and its consequences).
Abscesses may occur in the second or third week, or towards the close of the stage of desquamation. These collections of pus often delay con valescence, and if they occur in the neck may be signs of serious import. In the cervical region they are nearly always the result of internal ulcera tion. In every case, therefore, a careful examination of the throat should be made, and active measures are required to prevent any spreading of the destructive process in the pharynx. A not uncommon seat of abscess at this period is the submucous tissue at the back of the pharynx. This subject is elsewhere considered (see Retro-pharyngeal Abscess).
Gangrene in various parts may occur. Cancrum oris occasionally fol lows scarlet fever ; and gangrene of the vulva, the pharynx, the skin of the abdomen, and that over a suppurating gland may also be met with. Some times, as may happen in the case of any fever of a low type which causes rapid reduction of the strength, scarlatina, if severe, is followed by hmmor rhagic purpura, with bleeding from several mucous surfaces. Even death may ensue as a consequence of the loss of blood. Nervous sequelae may be also met with. Infantile spinal paralysis has been known to occur ; and herniplegia from plugging of the midclle cerebral artery is seen in rare in stances.
In addition to the above complications, scarlatina is sometimes confused by the presence of other specific fevers. Diphtheria has been already men tioned. Besides this disease, measles and small-pox have been severally known to attack the scarlatinous patient, and run their course at the same time with it. Typhoid fever and scarlatina have been also met with to gether.
There is a form of scarlatina which has been called latent. In this variety the symptoms are mild and ill-defined, and the rash pale and im perfectly developed, or even quite absent. Indeed, the symptoms gener ally are so little severe that the existence of the fever is often not suspected until desquamation begins. It is then remembered that the child had complained of a passing sore throat, and had seemed languid and heavy for a clay or two, but nothing more. In these mild cases the after-course of the illness is not always in harmony with its beginning. Indeed, in no case of scarlatina, however slight the early symptoms may appear to be, can we venture positively to predict a favourable course to the illness.
It was long doubted if the form of scarlatina which occurs sometimes after surgical operations was a true scarlatina. The cases are usually of an
inoffensive type and the general symptoms trifling. Still, a more severe form of the disease is occasionally met with. The rash appears a few days (two or three in most cases) after the operation, and may be almost the only symptom. There is often, however, high fever, but the soreness of throat is insignificant. Occasionally desquamation is absent. The healing of the wound is greatly retarded by the complication. That the disease is really scarlatina is shown by the fact that it protects the patient from the fever poison in after-life.
Diagnosis.—In a typical case scarlet fever is a disease which can scarcely be mistaken. The initial vomiting and sore throat, with elevation of tem perature and rapid pulse, followed on the second clay by a uniform pink rash dotted thickly over with scarlet puncta, is sufficiently characteristic. Unfortunately, many cases are not typical. The sore throat may be scarcely perceptible ; the rash may be pale, discrete, and partial ; and the tempera ture on the morning of the second day may be little elevated above the nor mal level. A child with chronic enlargement of the tonsils, who is subject to attacks of sore throat, is found to be feverish, to have some pain in deglu tition, and to present a pale, ill-developed discrete rash limited to the neck, chest, abdomen, and thighs. In such a case it is allowable to feel some uncertainty as to the nature of the ailment. The appearance of the throat is, however, here of importance. The redness is not limited to the tonsils, but extends over the soft palate, uvula, arches of the fauces, and often the back of the pharynx. The redness is uniform, but at its margin on the soft palate some punctiform redness may be seen ; or the redness may be punctiform in character on the soft palate, and uniform elsewhere. Such a throat, accompanied by vomiting, a hot skin, a quick pulse, and a white coated tongue, is very suspicious of scarlet fever. Some forms of erythema imitate the rash of scarlatina very closely ; and if there is a history of a recent unwonted indulgence in diet, the illness may be easily attributed to this cause. If such a rash be accompanied by a normal temperature, scar latina may be positively excluded. But it is important to remember that the increase of bodily heat may be very moderate. I have known the morning temperature on the second day to be only 99.5°, or one degree above the normal level, although the disease was a true scarlatina, which afterwards became better developed. A pulse of 140, however mild the other symptoms may be, should make us suspect the existence of the fever very strongly ; and in no case where the temperature reaches 100° or over should we venture positively to exclude the disease. An erythematous rash is seldom so widely diffused as is the eruption of scarlatina ; and in particu lar is usually absent from the neck and limbs. It also spreads very irregu larly. In all cases of doubt we should inquire about pains and stiffness in the articulations, and examine the joints, especially those of the fingers, for signs of swelling. We should also feel for enlarged glands in the neck. Often these symptoms are present early, when the eruption is very partial and incomplete.