SCARLATINA. 591 



from the severe constitutional disturbance, is often overlooked in such 

 cases, is frequently of diphtheritic nature. If the patient do not die 

 during the prodromal stage, the eruption usually appears slowly and 

 irregularly, is pale or livid, only remains on the skin for a short time, 

 and is often accompanied by petechise, which remain after the disap- 

 pearance of the exanthema. The appearance of the eruption does not 

 generally induce any amelioration of the patient's symptoms ; on the 

 contrary, the high fever continues, the pulse becomes weaker, the pros- 

 tration greater. Diarrhoea and meteorism often occur, and the tongue 

 and gums are covered with dry sordes. Most of the patients die in 

 this stage of the disease, and of the few who reach the stage of des- 

 quamation the greater part die of the sequelae. 



Cases, where angina maligna, infiltration, and suppuration of the 

 lymphatic glands, or other disturbances of nutrition, of themselves dan- 

 gerous, occur, may run just as malignant a course as those where gen- 

 eral paralysis is induced, directly or indirectly, by the excessive fever ; 

 we can only point out the various forms of the disease due to malignant 

 local affections, because any exhaustive description of them would be 

 impossible within the limits proposed for this work. Angina maligna 

 not unfrequently occurs during an apparently benign, or so-called nor- 

 mal scarlatina, and in its first stages is not by any means universally 

 accompanied by dangerous symptoms ; the difficulty of swallowing 

 only attains a high grade when, as happens in many cases, there is at 

 the same time a parenchymatous inflammation of the tonsils, which 

 often renders swallowing impossible. The participation of the nasal 

 cavities in the diphtheritic inflammation of the fauces is so constant 

 that the occurrence of a coryza, with a discharge of secretion which is 

 apparently bland and has no peculiar odor, is a very suspicious and 

 usually threatening symptom. This coryza rarely accompanies the 

 catarrhal form of scarlatinous angina ; hence we should dispel the illu- 

 sions of the parents, who consider this discharge from the nose as 

 favorable, and, when they see it, expect their children to escape any 

 cerebral trouble. The only certain point for the diagnosis of diphthe- 

 ritic angina, in its first stage, is the examination of the fauces, which 

 shows the above-described dirty-white, firmly-adherent plaques on the 

 dark-red mucous membrane. But, even in a few days, the symptoms 

 change, and the disease appears very dangerous ; it is true the exan- 

 thema offers no peculiar symptoms, but in the vicinity of the patient 

 we may perceive a fetid odor, which comes from his mouth and nose. 

 The sloughs, changed to dirty tags, adhere to the fauces, or, after they 

 have been detached, unhealthy-looking ulcers form. A yellowish, 

 badly-smelling secretion flows from the nostrils over the cheeks, and 

 corrodes the skin with which it comes in contact ; the cervical glands, 



