592 ACUTE INFECTIOUS DISEASES. 



also, are much swollen, and form unsightly hard lumps at the sides of 

 the neck. The patient usually lies with the head thrown back, in a 

 half comatose or perfectly unconscious state ; the pulse, which was 

 previously full, becomes small and beats 140 to 160 times a minute ; the 

 bodily temperature rises to 104 or even higher. In such cases, just 

 as in measles complicated with lobular pneumonia, the fever induced 

 by the scarlatina infection becomes excessive from the accompanying 

 pharyngeal inflammation, and the bodily temperature is elevated to a 

 point where adynamia and paralysis always occur. Laryngitis, com- 

 plicating this form of angina, occasionally hastens the fatal result ; it 

 is characterized by hoarseness and dyspnoea rather than by croupy 

 cough. If the patient lives through the stage of efflorescence, des- 

 quamation often takes place normally ; but, in the most favorable 

 cases it lasts a long time, till the ulcers in the neck have healed, and 

 till the discharge from the nose has ceased. Quite often the inflam- 

 mation extends through the Eustachian tubes to the tympanum, result- 

 ing in otitis interna, which leads to perforation of the drum, and often 

 also to caries of the petrous bone. Hence, after scarlatina, many pa- 

 tients have otorrhcea for years, and suffer from deafness for the remain- 

 der of life. If the diphtheritic process has extended to the mouth and 

 lips, the resulting ulcers, especially those at the angles of the mouth, 

 heal very slowly. During the stage of desquamation and convales- 

 cence, the patients are liable to great danger from inflammatory infil- 

 tration of the lymphatic glands and subcutaneous connective tissue of 

 the neck. These rarely end in resolution ; and even suppuration re- 

 sults slowly, and is accompanied by fever, which wears out the patient. 

 I have seen patients die from suppuration of these enlarged glands, 

 even six or eight weeks after recovery from the scarlatina. Inflam- 

 matory infiltration of the cervical glands may also develop without 

 angina maligna, and in such cases also it induces increase of the fever 

 and consequent " typhoid symptoms." It is more probable that the 

 brain symptoms, are due to the high fever accompanying this infiltra- 

 tion of the glands than that they are caused by pressure on the vessels 

 supplying blood to the brain. Parotitis, which sometimes occurs dur- 

 ing the stage of desquamation, just as it does in the course of typhus 

 and cholera, must not be confounded with the above inflammations 

 and suppuration of the lymphatic glands. It is chiefly in this stage, 

 too, that we see inflammations of the synovial membranes, pleura, and 

 pericardium. 



We have mentioned croupous nephritis as a frequent and im- 

 portant localization of the blood-poisoning in scarlatina. The fact that 

 scarlatina dropsy, which generally depends on this localization, usually 

 makes its appearance during this stage, has given rise to the still preva- 



