GENERAL SYMPTOMATOLOGY The onset of the disease is usually sudden. It is characterized by vomiting, sore throat, fever and a general feeling of malaise. The child is perfectly well in the morning, goes to school as usual, and is suddenly taken violently ill during the session. One of the resident physicians in our scarlet fever hospital was stricken suddenly while on his rounds, having till then enjoyed the best of health.
To attempt to distinguish a prodromal stage is useless; the first evidences or manifestations of illness should be designated "initial sy mpt o s ' If, perchance, the patient is seen shortly after the appearance of these initial symptoms, it will be noted that besides the elevation of temperature and the lassitude, the face is puffy and red. The con junctiva- and nasal mucous membrane are normal (unlike measles), but the mucous membrane of the cheek and gums is slightly reddened and thick, the dorsum of the tongue is heavily coated and discolored. The depth of color increases from before backward, the palate, hard and soft, and the uvula being blood-red. The tonsils are red and swollen, and even as soon as this lacunar deposits may be seen. The paratonsillar lymph-nodes at the angle of the jaw are enlarged and tender to touch. The heart action is conspicuously increased in frequency.
The further progress of the disease is a rapid one. The temperature rises quickly; a temperature of from 39° to 40° C. (102° to 104° F.) is by no means infrequent. In the course of a few hours the typical scarlet red, miliary eruption of scarlet fever makes its appearance. The lesions are from two to three millimetres in diameter, somewhat circumscribed, not elevated appreciably above the skin surface, forming a mosaic pattern, appearing first on the upper part of the trunk, and then spread ing rapidly over the remainder of the trunk. In a little while it makes its appearance as far down as the groin, with isolated outrunners on the inner side of the thigh. Backward, it extends as far as the hips, ending in a triangular border, the tip of the triangle pointing toward the sacrum.
The cheeks are uniformly red, the eruption being confluent, and spreading over the bridge of the nose, as is seen in erysipelas. In con trast to the eruption of measles, the peri-oral region is free from eruption and presents a pale triangular section of skin, the base downward, presenting a sharp contrast to the otherwise general redness of the face.
Subjectively, the lassitude, angina and headache are the symptoms complained of most. The patient desires to remain in bed, his appetite is lost, but, on the other hand, thirst is complained of bitterly. There is constipation and the urine is diminished in amount, high in specific gravity, but containing no pathologic substances until the appearance of the febrile albuminuria. In the milder cases the diazo-reaction is negative; peptone is increased in amount, although, as was pointed out by Tobeitz, this is not to be regarded as of any prognostic value.
If the disease made its appearance in the morning. the clinical pict ure is one as described above.
It is seldom indeed that the rash is delayed for twenty-four or forty eight hours. If it makes its appearance later than this, one must take into consideration whether it was not possible that the scarlet fever is secondary to an ordinary angina.
The patient has a restless night and is often delirious. In the early morning hours the temperature falls somewhat, but the general condition of the patient remains unchanged; in fact, the angina often becomes more intense, the lymph-nodes at the angle of the jaw are much more sensitive to pressure, the rash now appears on the extremities and is much more extensive or more confluent on the trunk. The shoulder girdle is more or less covered by the eruption, and it is also extending to the upper extremities as far as the lower third of the forearm, even the dorsal surface being involved. Finally, the rash spreads to the hand, the viola mantis is diffusely reddened, the dorsum of the hand, especially the dorsum of the fingers, and the contiguous phalangeal surfaces present a flaky eruption and swollen follicles. The latter are also found on the trunk and extremities. The flexor surfaces of the upper extremities, from the middle of the upper arm to the lower third of the forearm, are usually only slightly involved, the eruption appealing here at a later time. On the lower extremities the eruption first makes its appearance on the inner side of the thighs and then on the remaining parts of the legs. The dorsum of the foot and the extensor surfaces of the toes wise present the swollen follicles which appear on the backs of the hands. Coincident with the increase in severity of the symptoms during the second day, the evening temperature becomes higher and the morning temperature is above normal (Fig. 49).