The redness and swelling of the pharynx and the eruption on the oral mucous membrane disappear slowly, the coating on the tongue gives way to a dark-red color, first at the tip, then gradually extending backward. It is still somewhat thickened and the papilke are prominent (raspberry, strawberry or cat's tongue).
The lymph-nodes in the angle of the jaw diminish in size, are less tender to touch; the pulse becomes less frequent, the subjective symp toms disappear, the appetite is again keen, and the patient. is more restful at night. Beginning with the third or fifth day, the temperature falls by lysis, the morning remissions go more nearly to normal, and the afternoon rise is less high. By the commencement or middle of the second week the temperature is again normal (Figs. 4S and 49). This decline of the temperature by lysis is so characteristic of scarlet fever that any departure therefrom must be noted carefully and the reasons therefor ascertained.
It is of interest to observe t hat when in the course of this fever curve an afternoon rise occurs, such rise, even in the favorable eases, marks the appearance of a new lysis, and the fall to normal is correspondingly delayed.
A crisis occurs rarely (Fig. 50) and in the severe cases it is hardly to be expected.
In the meantime, changes are taking place in the skin,. A very fine "dusty" desquamation is seen on the face. At about the middle of the second week desquamation begins on the neck, trunk and inner sides of the thighs, flaky in character, and often in large lamellae. The palms of the hands and soles of the feet are the last to be involved in this process. Occasionally the entire epidermis is shed, so as to form a veri table cast of the hand and foot (Plate 15). Here, too, desquamation may be seen to occur as late as the sixth to eighth week. The nails also present evidences of the disease.
The injury done to the nail-bed at the height of the disease is mani fested later by an irregular nail growth. As this portion of the nail is hidden by the nail-wall, the faulty growth is not observed until the nail has pushed it forward into view. This occurs at about the beginning of the sixth week. It is seen best from the seventh to the eighth week, being less marked in young children than in older ones, more so in the severe than in the mild cases, most marked in the thumb-nail. The rapidity of the growth of the nail determines the duration of this finding Heller, Feel.). The nail advances 1 mm. in ten days.
The larynx and lamp do not participate in the clinical picture in uncomplicated cases. The existence of hoarseness and a laryngeal cough is indicative of a mixed infection, usually the bacillus diphtherite.
",carlatina eritat larynyem" was known to the earliest observers.
The spleen. is at most only slightly swollen; a trifling enlargement of the liver is often to be noted.
So far as the blood is concerned, there is present at the height of the disease a high polynuclear leucocytosis. There is also a slight increase of the eosinophiles as well as of the plasma cells, as has been determined by Sluka and myself in as yet unpublished observations. In one fatal case the plasma cells in creased to twenty per cent. of the total percentage of leucoeytes.
Beginning witli the fifth day of the disease, the leucocy tosis slowly recedes, the normal count being reached early in the third week.
reports indicate that the belief is held by many that the blood serum of scarlet fever patients contains a com plement binding substance, and that, t herefore, a typical Wassermann's syphilis reaction may be obtained. Insufficient data are as yet on hand to determine the significance of a positive reaction.
In uncomplicated cases of measles, the clinical course is a fairly definite one. This is not true of scarlet fever. The clinical picture is often an exceedingly variable one. In exceptional cases the cardinal symptom of the disease, the eruption, may fail to appear. There is present only the angina (scarlatina sine exanlhentala). The diagnosis in such cases can be made with certainty only when a typical attack occurs in another member of the family.
]lie G., ten years old, complained of headache in the afternoon, angina in the evening. During the night the temperature rose consider ably; no vomiting. The following morning the. temperature had receded considerably; the angina had increased in severity. No eruption. Record made on second day of disease. Four days previously a younger sister of the patient had developed a typical case of scarlet fever. When first seen, the skin was pale. Severe redness and swelling of the pharynx; uvula cedematous. Restlessness at night; temperature 39.6° C.; pulse 144. Third day: Skin pale. One lymph-node enlarged to the size of a pea, tender to touch, in the angle of the jaw on both sides. Nose not involved; tongue slightly coated; strawberry appearance absent. Pharyngeal mucous membrane very red, swollen and oedematous; uvula oedematous; small yellowish masses on right tonsil. Fourth day: Uvula, tonsils and edges of anterior faucial pillars blood-red in color; small red spots in surrounding areas, especially in vicinity of uvula. Spots on tonsil larger. No skin eruption. Slight swelling and redness of follicles on skin of trunk.