Again, the colour of the rash may vary. It may be very pale, so as to be only discovered by careful examination ; or it may be dusky and pur ple. Often it is more pink than scarlet. Sometimes it is limited to certain parts of the body, such as the sides of the neck, the chest, or abdomen, and cannot be detected upon the limbs. It is usually said to begin about the root and sides of the neck and on the chest ; but if so, these parts precede the rest of the body by a very short interval, and the rash be comes general very quickly. It is at its height on the third or fourth day of the illness. There is then often a good deal of irritation of the skin, and some subcutaneous oedema is present, makes the fingers stiff and clumsy-looking. The•rash may be accompanied by miliaria about the neck and chest ; the skin is often rough from enlargement of the sub cutaneous papillaa (cutis anserina) ; and petechim are not unfrequently present. These small haemorrhag,ic spots do not necessarily indicate any special severity in the attack. Sometimes also vesicles or even papules may be noticed. When the eruption is at its height, a line drawn upon the reddened surface by the finger-nail remains visible as a white streak for about a minute. This sign has been considered to be pathognomonic. The rash begins to fade on or after the fifth day of the illness, and has usually completely disappeared by the tenth.
During the eruptive stage the symptoms of the invasion period increase in intensity. The tongue cleans and becomes deep red with swollen pa pillme, so as to the well-known strawberry appearance. The child is very thirsty, but in the milder cases has a fair appetite. Vomiting is seldom repeated after the first day ; but in exceptional cases this symptom is an obstinate and distressing one, adding greatly to the gravity of the case. If severe, it may reduce the temperature. The soreness of throat usually increases during the eruptive stage ; and examination of the fauces shows a bright redness of the soft palate, uvula, tonsils, pillars of the fauces, and often of the back of the pharynx. Sometimes these parts are also swollen from oedema, so that the uvula is broad and the tonsils nearly meet in the middle line. There is also in most cases excess of ton sillitic secretion, and yellow pulpy matter may be seen collected at the mouths of the follicular recesses, or 'even coating the surface in a uniform layer. If the matter do not escape, it may form an abscess in the tonsil, as in common quinsy. In the more severe cases the tongue loses its moist appearance and the mucous membrane of the mouth, and throat gener ally, looks dry and shining. Unless in the worst cases, ulceration does not occur until the disease is subsiding. Sometimes at an early period the disease is complicated with diphtheria. If the throat affection is severe, there is much pain and tenderness in swallowing ; the voice is nasal iu quality ; and the glands of the neck become enlarged and tender. The inflammation may extend from them into the connective tissue around, and end eventually in suppuration. In an ordinary case the throat improves
as the eruption fades ; but the tonsils and the lymphatic glands may re main enlarged, although painless, for some time after the inflammation has subsided.
The degree of pyrexia as a rule is moderate. The temperature seldom rises above 105°, although in exceptional cases it may reach a higher ele vation. Unless it be maintained by the presence of a febrile complication, the temperature tends to Subside when the rash begins to fade ; and a crisis then usually occurs, the heat of the body being normal for twenty four hours. Should this crisis not occur, the pyrexia may be prolonged for several days. Even in a mild uncomplicated case I have known the tem perature to remain elevated two degrees above the normal level for twelve days. As long as the fever continues, the pulse is as frequent as at the beginning, and slackens when the temperature falls. It often reaches 160, and this frequency is not to be taken as a sign of danger. So, too, deli rium may be present, and if slight and occurring only at night, is not of serious import. The child often complains of headache and of aching pain about the limbs.
The urine is scanty and high coloured. It may contain excess of bile pi.- ment, and there is often a sediment of lithates or of free uric acid. Ac cording to Dr. Gee, the chlorides are sensibly reduced in quantity, and the phosphoric acid undergoes a decided reduction. The urea is not neces sarily increased.
The desquamative stage begins a few days after the rash has faded. The exact period at which it can be first noticed is very variable. The first sign of peeling may be seen while the skin is still tinted with the re mains of the eruption and before the pyrexia has subsided ; or it may be delayed for some days or even weeks after the rash has disappeared. It usually occurs early in proportion to the intensity of the eruption, and if miliaria has been present, is often early and profuse. In the slighter cases it may be long delayed, and Dr. Page states that after a mild attack he has known desquamation to be postponed for five weeks. The epithelium at first looks dry and may be finely wrinkled. Then, on the neck, upper part of the chest, and front of the shoulders, the skin begins to fall in fine bran-like scales. Over those parts where the cuticle is thin and deli cate the desquamation is very fine. Where the skin is thicker the parti cles thrown off are larger, and in some places, such as the hands and feet, large areas of epithelium may be cast off unbroken. On close inspection of the peeling surface the cuticle will be seen to be raised in the form of an empty vesicle. The crown of this elevation falls, leaving a minute circle, which gradually extends itself, until its circumference meets other circles widening in the same way. If the crown of the vesicle does not break off, the separation of the epithelium may go on, at the periphery until, by the coalescence of neighbouring centres of desquamation, large tracts of skin are thrown off.