Prodromes are rarely noticed. For a period of a few days (1 to 3) there may be malaise, restlessness, chilliness, slight nasal catarrh, sore throat, earache, slight difficulty on swallowing, very exceptionally nausea, vomiting and photophobia.
eruption shows itself first on the face. Isolated, round, slightly raised red spots or pale wheals surrounded by a red border appear on the checks. There may be no further change in the eruption, but more commonly the spots become larger and confluent on the second or third day, while the central portion seems flattened and faded. The cheeks (frequently also the ears) appear intensely infiltrated, engorged, red or bluish-red, resembling erysipelas, with a sharp and jagged line of demar cation. Some patients have the appearance of being intensely overheated. The central portion of the face, the lips, chin and bridge of the nose may remain free from the eruption, or somewhat later—likewise also on the forehead, temples and in the region of the throat and neck—there may be seen small efflorescences with but a slight tendency to become confluent.
Then in 1 to 3 days the eruption is also found on the extremities arranged quite symmetrically, the favorite seat being the extensor sur faces of the forearms and legs, shoulders, hips and buttocks, never on the fingers and toes, rarely on the palms of the hands and soles of the feet (two personal observations). The arrangement of the exant hem on the lower extremities is quite symmetrical. While the eruption in these regions also consists originally of pale red spots resembling measles or rubella, they soon tend to change to circular or crescentic or poly cyclic figures, forming bright red wreaths and map- or net-like figures. They may give a mottled appearance to larger areas of skin, especially as together with the original hyperemic redness the rings in the areas of the first eruption present in their central portion a bluish-red, livid or gray and brownish-red tinge. Thus the erythema maculopapulosum changes to an erythema annulate, gyratum, marginat um, figuratum. The diffuse erysipelas-like redness, which, on closer examination, is found to consist merely of a delicate meshwork, rarely appears on the extensor surfaces of the extremities. While the original hyperxmic spots com
pletely disappear on pressure or stretching of the skin, there remain later in aniemic areas yellowish or brownish spots.
Thirdly, frequently not until the third or fourth day, after the exanthem on the face has already subsided, there may appear on the skin of the trunk, neck, chest, abdomen and back, especially on the buttocks, a macular, annular or roseola-like exanthem. Very frequently the trunk remains free from the eruption.
A peculiar characteristic of the eruption is its evanescence. After 2 or 3 days it may quite suddenly disappear only to return again a few hours or days later. While examining certain areas of the skin which seem free from the eruption, it may appear in a few seconds either spon taneously or as a result of irritation (chemic or thermic). The return of the rash does not attack the various parts of the body in regular succession like the first eruption.
As a rule the eruption subsides without causing desquamation, although at times on the trunk there are small flakes or scales detached. On places where the eruption has been most marked, pigmented spots may remain for a while.
In addition to the eruption which often is the only apparent sign of the disease, some eases may be accompanied by the following variable symptoms: Moderate rise of temperature of short duration. By the time the case comes under the physician's observation it has usually fallen to normal or become subnormal. Once the writer observed for two days a tem perature of 39° C. (102° F.). Tripke has reported cases in which the temper ature rose to -10°---11° C. (104°-105.8° F.). There still remains some doubt, however, as to whether they could properly be classed with this disease.
Slight catarrhal conditions of the mucous membranes arc often pres ent, rhinitis, bronchitis, coated tongue, redness and swelling of the mucous membranes covering the mouth and pharynx, angina with a punctate or streaky lacunar deposit, injected conjunctive.