In the course of the next three days small areas of necrosis appeared on the uvula and the soft palate. Healing of these spots from eighth to eleventh day. Recession of redness of follicles. Fall of temperature by lysis typical. Normal temperature on seventh day. No desquamation.
On the other hand, cases are met with in which the expression of all the symptoms is reduced to a minimum, both in duration and inten sity, so that the diagnosis often is not made until characteristic sequelie appear, or for no apparent reason all the symptoms are suddenly mark edly increased in severity, the case terminating fatally inside of twenty four hours. In such foudroyant cases the characteristic clinical picture is in no wise changed by the rapid course of the disease.
The following cases are illustrative of the two extremes: ]lie W., eight years old; taken to the scarlet fever station on a wrong diagnosis, presented on the morning of the twelfth day, without previous elevation of temperature or vomiting, flushing of the cheeks, a pale red, typical scarlatina' eruption of the trunk, especially on the back, more discrete on the extremities. Right side of pharynx very red. Eruption paled on following day; desquamation of face on sixth day; several days later of trunk.
Henry M., four and a half years old, strong, well-nourished boy. At 7.30 in the morning, vomiting, sore throat, eruption, two thin green stools, followed by lassitude; continued vomiting. At 11 a.M. confluent slightly elevated eruption on trunk, conjunctivitis, tongue heavily coated, redness and swelling of pharynx. Tonsils not coated. Pulse 1S0, small, irregular. During the afternoon the patient became soporose; extremities, face and mucous membranes cyanotic and cold; deep and frequent respirations (respirations, 54); pulse bad. Death occurred at 9 P.M. Duration of disease, fourteen hours. (At the necropsy, marked status lymphaticus.) These rapidly fatal cases are exceedingly rare. As a rule, death does not occur, even in the most severe cases, before the third to the fourth day. The symptoms increase in severity progressively. Even in such cases the prodromal symptoms are not of such severity as to excite attention, although the unusually severe course of the disease is apparent. Not until the third or fourth day is the foudroyant nature of the disease fully developed, when the involvement of the nervous system (extreme restlessness, somnolence, anxiety, continuous vomiting) and of the circulation (cold and clammy skin, cyanosis, dark, brownish red exanthem, bad pulse and dilatation of heart) is the most prominent symptom. The pharynx is red and swollen; the tonsils, if involved at
all in the clinical picture, are only coated.
This is a typical so-called toxic case of scarlet fever and death occurs as the result of the toxxinia caused by the exciting cause of the disease.
Anatomically, one finds here, first of all, inflammation of the pharynx. Tonsils swollen, soft, containing much exudate, bluish-red in color; gums soft ; uvula, posterior portion of tongue and pharynx, dark bluish-red. The hyperemia is sharply demarcated (Mrlin, Heubner).
The cervical lymph-nodes are markedly enlarged as the result of an acute, inflammatory infiltration. In fact, the entire lymph system pre sents evidences of more or less involvement. The solitary lymph follicle and Peyer's patches and other lymph structures in the intestine are swollen; the mesenteric lymph-nodes are hyperfemic, swollen and trdema tous.
Changes in the thyroid of extreme degree have also been noted (Roger at Gamier, (le Quervain, Sarbach). They consist of hypenernia, des (intimation of the alveolar epithelium, decrease in the amount of colloid, with increased fluidity. The interstitial connective tissue remains unchanged. Clinically, there does not appear to be any reason for these conditions.
So far as the skin is concerned, the eruption is not visible after death. Schamberg, in his histologic studies of the skin, was able to determine evidences of inflammatory disturbances. Rach confirmed these findings. The most extensive and intense changes occur in the connective tissue surrounding the hair follicles. There is more or less serous and cellular infiltration. Huebler described inflammatory changes in the tissues surrounding the blood vessels. The (edema and pigmentation of the skin, the swelling of the follicles and the sudamina can not he accepted as a reason for the appearance of the eruption. Some observers (Lewkowicz, Pohl. Padiatrie, 1, p. 1) arc of the opinion that the urticaria is the result of a secondary infection.