Prognosis 3 and -I included the severe cases, those cases in which either the toxic or infectious symptoms predominate, although they are often seen in combination. The age of the patient also enters into con sideration as a factor in the prognosis. Children between the ages of one and four years are in greater danger than older children.
The severe purely toxic cases arc characterized by an intense erup tion, with eventual occurrence of the double eruption, and conjunctivitis. Symptoms of cardiac weakness arc always present (cyanosis, cold and clammy extremities, (lark red, dirty or bluish-red color of the eruption, and in the most severe cases the eruption is obscured by a general cyano sis). The face is sunken. Sensory symptoms are marked. Restlessness, jactitation, convulsions, toxic frequent and deep respiration are of graver prognostic significance than a mere lethargy or delirium. Persistent vomiting and green, liquid, malodorous stools complete the clinical picture of these severe cases of scarlet fever.
The onset of infectious symptoms (coryza, pharyngeal necrosis, otitis and greater involvement of the lymph-nodes) obscures the prog nosis, because defervescence is postponed. So far as a fatal termination
is concerned, the prognosis depends entirely on the extension and severity of the nasal and pharyngeal involvement and the intensity of the lymphadenitis. An unfavorable prognosis may be made early in such cases in which there appears soon after the onset of the disease an intense swelling of the upper cervical region.
Gangrene of the pharyngeal mucous membrane and the appearance of a ppemia invariably lead to a fatal termination, and, therefore, in such eases, Prognosis 4 is justified.
I wish, again, to call attention to the significance of the temperature curve in scarlet fever. The height to which the temperature may go is not of prognostic significance, but it is of the greatest importance to observe closely the temperature curve. A study of this curve, as in the case of typhoid, will be of considerable assistance in making a prognosis. The appearance of each and every complication or increase in severity of the symptoms is quickly made manifest in a rise in the temperature. Often a slight variation in the temperature curve will direct attention to the onset of a complication; in fact, this may be the first symptom, subjective or objective.