9 
The most characteristic and constant symptom is the eruption (p. 45), which 
usually appears first on the wrists, ankles, and back, about second to fifth, chiefly 
third day, and spreads rapidly over the rest of the body, lasting about 8 to 21 days, 
or even several months, and after the fever subsides, becoming visible upon exposure 
to cold or after a warm bath or active exercise; these spots are petechial and not 
raised; at first they are rose colored, and disappear momentarily upon pressure, but 
later they become permanent and assume a dark blue or purplish color; they may 
coalesce and give a mottled or marbled appearance to the skin; they may or may not 
be tender to the touch. Desquamation (p. 49) begins about the third week. Jaun- 
dice (p. 50) is more or less marked, first noticed in the conjunctivge. There may be 
cj^anosis (p. 50), or — especially on the scrotum, fingers, or toes — gangrene (p. 50). 
Hyperesthesia (p. 51) is common, and may be intense. The subcutaneous fat (p. 51) 
remains. 
The face (p. 51) frequently shows a congested, bloated, stupid expression. There 
maybe ringing in the ears (p. 51). The eyes (p. 52) are more or less injected. 
Photophobia (p. 52) is common, and may be very marked. Nosebleed (p. 52) is more 
or less frequent. Sore throat (p. 53) is more or less common; breath may be offen- 
sive. The tongue at first shows a heavy white or yellowish coat, with red tip and 
edge, and becomes brownish, dry, and cracked as the fever progresses; the teeth 
may be covered with sordes. 
There may be gurgling and tenderness (p. 55) in the right iliac fossa; tympanites 
may develop. The joints may become swollen. 
Loss of appetite (p. 55 ) is an early symptom , or in some cases the appetite remains 
good. 
Irritability of and pains in the stomach (p. 56) are reported. Nausea (p. 56) is more 
or less common, and vomiting may be present. Constipation (p. 58) is very com- 
mon. The liver (p. 58) may be enlarged to some extent. The gall (p. 60) is fluid. 
Pancreas may be normal in size or enlarged. 
Heart sounds (p. 62) are reported as normal. Pulse (p. 63) is usually full and 
strong at the onset, but gradually becoming more and more rapid, losing in strength 
and volume; in ordinary cases it may be 80 to 130, and has been reported as high 
as 150, or even 186. The blood (p. 63) becomes dark and thick; it shows some 
decrease in the red cells (to 4,100,000 or to 3,558,000) and may show some increase 
(12,000 to 15,600) in the white cells, the most interesting feature, according to 
Anderson, being an increase in the large mononuclears; hemoglobin may fall as 
low as 50 per cent. 
The spleen (p. 67) is uniformly enlarged and tender. 
The initial chill (p. 68) may be absent, slight, or severe; and chills or chilly sen- 
sations may continue more or less throughout the attack. 
The fever develops rapidly, and may register 102° to 104° or 105° F. when the 
patient takes to bed. It gradually reaches its maximum in 2 to 7 days, when it ordi- 
narily registers 103° to 106°. For temperature charts, see Wilson and Chowning, or 
Anderson, or page 111. 
An irritative cough ( p. 71 ) may exist from the first. Respiration ( p. 72 ) is increased, 
usually to 26 to 40 — in some cases 50 to 60. Edema of lungs develops in a number 
of cases. 
There may be great tenderness or soreness of the muscles. 
Some cases are exceedingly nervous, symptoms (p. 74) being so prominent as to 
remind one of cerebrospinal meningitis. Malaise, restlessness, insomnia, hyperes- 
thesia, jactitation, dizziness, headache, pains, “bone ache,” tenderness of neck and 
lumbar region, photophobia, divergent and convergent squint, delirium, coma, con- 
vulsions, and in a few cases opisthotonos have been reported. Autopsy fails to reveal 
any lesions which would justify the diagnosis of cerebrospinal meningitis. Kernig’s 
sign is absent. 
