SYMPTOM A TOLOGY-^ VA RIETIES—COMPLICA TIONS 1 353 



when the pressure is removed, and do not itch. Between the spots 

 on the trunk and forearms folHcular papules may be noted, but 

 the eruption is not so well marked on the arms and thighs. 



At first the pulse is full, and not very rapid, varying from 80 to 

 100 per minute; later it may become small and quick, and at times 

 dicrotic. The first cardiac sound is often impure, and the trans- 

 verse diameter of the cardiac dulness may be increased. 



In the blood the red cells are found to be diminished, and the 

 haemoglobin proportionately reduced. In mild cases there is often 

 an increase in the large mononuclear leucocytes and lymphocytes, 

 but in severe cases the total number of leucocytes is often diminished, 

 though there may be a relative polymorphonuclear increase. 



The tongue is at first moist and slightly coated, but later it 

 becomes dry, brown in the centre, and glazed at the tip and edges. 

 The gums in some cases are spongy, and bleed, while sordes may 

 collect on the teeth, and a few punctiform spots be noted on the 

 palate. The epigastrium and left hypochondrium are tender; 

 the liver, however, is not as a rule palpable, though the spleen is 

 usually slightly enlarged. 



The nose and throat are normal, but the rate of the respirations 

 is increased, and the breath-sounds are harsh and accompanied by 

 rhonchi, which can be heard all over the chest. Usually there is a 

 certain amount of coughing, but the expectoration is scanty. 



The urine is diminished in quantity, high-coloured, and may 

 contain albumen, and often gives the diazo-reaction. Strangury 

 may occur. 



The conjunctivae are early injected, a feature which becomes 

 more marked as the disease progresses, and is associated with 

 lachrymation. 



From the very first there is a great hypersesthesia all over the 

 body, and there may be delirium at night, and difficulty in 

 hearing. 



About the fourteenth day of the illness the eruption begins to 

 fade and the fever to remit, and in the next five or six days the 

 temperature falls by lysis to normal, and, the general condition 

 rapidly improving, convalescence begins. Recovery is usually 

 quick, and by the twenty-first day from the commencement of 

 the attack the patient is well. 



In bad cases, however, coma and h57perpyrexia may develop in 

 the second week, and cause the death of the patient. In other 

 cases death may be caused by complications, which may arise 

 either in the second week or during convalescence. 



Varieties. — Severe types of the disease end in death about the 

 ninth to the fifteenth day from hyperpyrexia, cardiac failure, 

 pulmonary oedema, or from complications. Mild types, showing 

 only the bite and the enlargement of the lymphatic glands, and 

 associated with but little fever or eruption, quickly end in recovery. 



Complications. — ^The commonest complications are parotitis, 

 melaena, mania, and cardiac failure with pulmonary oedema. 



