44 CLINICAL APPLIED ANATOMY. 



of hair follicles, but is probably due to some anatomical arrange- 

 ment of the vessels of the skin. The well-known area of 

 circum-oral pallor, bounded laterally by the naso-labial folds 

 and below by the point of the chin, corresponds to a definite 

 thickening of the skin around the mouth, the transition from the 

 thin skin of the cheeks to the thick skin of the circum-oral zone 

 taking place at the naso-labial. lines. A more marked thickening of 

 integument is found in the palms and soles, localities where the 

 rash is also wanting. It seems reasonable to believe that the 

 uniform diffuse character of the eruption on the face, in contrast 

 to its punctate appearance elsewhere, has some relation to the more 

 superficial distribution of the free vascular supply to the "flush- 

 area." The arteries of this area are mainly unnamed branches of 

 the posterior aspect of the facial trunk, and lie more superficial 

 than the named facial branches. The scarlatinal rash is most 

 intense in the regions where flexures of the skin naturally 

 occur, such as the axillae, elbows, wrists, groins and knees. In 

 these situations small linear haemorrhages may often be seen. 



On the outer aspects of the upper arms, and on the outer sides 

 of the thighs and legs, the skin normally presents coarse papules; 

 these are brought into prominence by scarlatinal injection, and 

 do not fade so readily as the rash elsewhere. A certain amount 

 of exudation accompanies the fully developed rash, and it is 

 this exudation which lays the foundation of the subsequent 

 desquamation. The peeling roughly follows the order of 

 appearance of the rash, but occurs earlier where the cuticle is 

 very thin, especially in those parts which from their situation 

 are subject to friction. The tongue being exposed to friction 

 and moisture begins to peel at its tip and edges within twenty- 

 four hours, bringing its vascular papillae into greater prominence ; 

 friction of the night-dress determines early peeling about the 

 lower part of the neck and adjacent parts of the chest ; the lobules 

 of the ears and the cheeks coming into contact with the pillow, 

 early show a fine powdering. The thick skin of the palms and 

 soles, and particularly that of the heels, is the last to be shed, 

 and comes off in larger flakes. 



