In uncomplicated cases the clinical picture is at its worst stage in from three to five days. The reddening and swelling of the pharynx has increased, and the mucous membrane of the mouth is diffusely reddened and swollen (enanthem analogous to the exanthem); the slimy yellowish coating on the tonsils has spread.
The macular eruption on the body has become more intense and a new crop has made its appearance among the older eruptions, so that in the more intense cases the skin now presents a diffuse redness when viewed from a distance. It is only when one looks more closely that it is seen that the eruption is still macular. The entire skin, especially the skin of the trunk and thighs, appears to be infiltrated, swollen and inflamed. The follicular tiNvellings either remain unchanged or have also become more intense; very often they are converted on the third or fourth day of the disease into small papules filled with a cloudy, purulent fluid. These are the so-called "frieseln " of the Germans, or the type of eruption designated as scarlatina miliaris. The appearance of these papules is regarded as of favorable prognostic value.
Of rather unfavorable prognostic value are to be regarded those forms of the eruption which more nearly resemble the eruption of measles maculopapular eruption—which stands out in sharp contrast to the bright red eruption of the typical case of scarlet fever. This is especially noticeable whim viewed from a distance. It is the so-called double exanthem, the scarlatina variegata.
The scarlet fever eruption disappears on finger pressure early in the disease, but on the lower portion of the trunk, especially the skin of the abdomen, the area of finger pressure anemia is seen to be distinctly ieteric in color. The reason for this discoloration is unknown, although beyond question this is not a typical icterus, because this is only rarely associated with scarlet fever. I have seen two such cases. When the skin is stroked with the finger-nail or with the point of some object, there appears in from one-quarter to one-half a minute a one centimetre wide anemic line on either side of the stroke (Raies blanches of the French), the stroke itself remaining slightly reddened. This symptom is not observed in all
cases; its intensity is extremely variable. In several very intense eases I have observed it as late as the middle of the second week of the disease.
Such portions of the skin surface as are exposed to pressure (axillary folds, elbow crease) often present punctiform ecchymotio spots. This is of no significance other than to indicate that the blood vessel walls have become more friable, of which one can easily convince himself by pick ing up the skin—preferably in the infraclavicular region—between thumb and forefinger and pressing it slightly for about five seconds. Even very slight pressure suffices to cause numerous punctiform haemorrhages.
In the case of children with normal skin greater pressure is neces sary to produce the same effect, although t his finding is obtained in many conditions of the skin, especially in measles, although greater pressure must he exerted and even t hen the is not as intense as in scarlet fever. Therefore, these haemorrhages are not to be regarded as being of diagnostic value. Hecht attempted to measure the intensity of these skin hemorrhages as produced by varying pressures, but his results were so extremely variable as to nullify the finding. These hemorrhages are easily made to appear as late as the end of the first week of the disease.
A genuine purpura is seen but seldom, and then only late in the disease. It is probably caused by sepsis. I have seen only one such case, although several instances are recorded in the literature (Risel). This haenorrhagic diathesis does not stand in relationship whatever to the ordinary haemorrhages.
In the more intense cases the eruption remains at its height until the fourth or fifth day, appearing to be more red in the afternoon and evening than in the morning. From that time on it begins to pale in the same order as it made its appearance, first on the face, then on the trunk and extremities. The infiltration of the skin gradually disappears, the skin becomes dry and shrunken, brownish-yellow in color, and a distinct pigmentation is seen on finger pressure. This pigmentation is more diffuse and less intense than in the case of measles.