The process may be over in ten days or a fortnight, or may be pro longed for weeks. It often lingers long about the fingers and toes. A secondary desquamation is even said to occur in some cases, and the peel ing undergoes a species of relapse. Until the last flake of epithelium has been cast off the patient cannot be said to be completely free from in fection.
In this stage the pulse is at first often slower than natural, and may intermit. The temperature, also, after the cessation of the pyrexia, remains subnormal for some days.
In malignant scarlatina the severity of the disease is shown either by violence of nervous phenomena which prove rapidly fatal ; or by the early appearance and intensity of the throat affection, which causes death in the first or second week of the illness.
In the first form the disease from the beginning may show the utmost violence. The vomiting is repeated and distressing ; the child is agitated and delirious or convulsed ; the temperature rises to 107° or 108° ; the breathing is quick and shallow ; the pulse is rapid. After some hours or days, according to the violence of the symptoms, the patient sinks into a stupefied condition with haggard, dusky face, cold extremities, a feeble, rapid pulse, and a moist skin. He vomits frequently or may be violently purged, and dies comatose or in convulsions. In the worst cases the pa tient seems literally overwhelmed by the intensity of the fever poison, and' dies before the rash appears or the sore throat has assumed any special' prominence. Thus, a child may be found a few hours after his first attack collapsed or unconscious, vomiting incessantly, and passing frequent, thin, watery stools. The throat presents a dusky redness ; the pulse is very rapid and feeble ; and the thermometer in the rectum marks or 103'. In a few hours the temperature rises to or 106° ; convulsions come on, and the child dies. In other cases he lingers longer, and may appear to rally for a time; but the depression continues, the stupor returns, and death occurs by the end of the week.
When the disease assumes a malignant form from exaggeration of the throat affection, the course of the disease for the first few days presents nothing abnormal ; but on the fifth or sixth day the fauces become exces sively tender, and deglutition is very difficult and painful. The lymphatic
glands at the angle of the jaw and the connective tissue around them are inflamed and swollen. On examination of the throat the mucous mem brane is seen to be of a deep red or dark purple colour, and patches of ashy gray exudation matter are dotted over the surface of the soft palate, uvula, and tonsils. In the bad cases ulceration takes place in these spots, and, spreading, causes wide destruction of tissue. The face is often livid and haggard ; the pulse is quick, feeble, and fluttering ; there are sordes on the teeth and lips ; the tongue is dry and brown ; the fetor of the breath is extreme ; and an offensive purulent discharge escapes from the nose. At the same time the neck swells and feels brawny to the touch ; the skin melts away in places ; and thin, purulent matter, with shreds and lumps of sloughy connective tissue, are discharged through the openings. The sloughing of the subcutaneous tissue of the is often accompanied by other serious symptoms. Hmmorrhage may take place from the large vessels ; oedema of the glottis may occur ; the patient may fall into a ty phoid state or die from pymmia. In one way or another such cases usually terminate fatally.
When the throat affection assumes a malignant form the prostration is generally marked, and the patient lies in a drowsy state, although he seems intelligent enough when roused. The temperature is not excessively eleva ted, seldom rising above 103° ; but the pulse is very rapid and feeble. It is important to know that the swelling of the cervical glands is not always in proportion to the severity of the throat complication, and furnishes no ground upon which to establish a prognosis. Deep-seated sloughing and fatal hemorrhage may occur in cases where the external glands are only moderately enlarged. If the throat affection is severe from the first, the appearance of the rash' may be delayed for several days ; and it may come out in a patchy manner, being most marked in parts where the skin is especially thin and delicate, as in the folds of the arm-pits and groins.