1334 



TYPHUS 



are red; nausea may be experienced, but vomiting is rare, and the 

 bowels are either constipated or normal. 



The nervous system is early affected, the patient being apathetic, 

 drowsy, with a dull expression. The changes in the blood are of the 

 utmost importance, and should be carefully studied. There is 

 sometimes an increase in the red cells, with a corresponding increase 

 in the haemoglobin, and a leucocytosis, which is usually well marked, 

 being on an average about 24,000 per cubic millimetre, but varying 

 between the extremes of 8,000 and 54,000. The differential leuco- 

 cyte count is also of importance, for in cases uncomplicated with 

 malaria or other protozoal infections the polymorphonuclear increase 

 is a characteristic feature, and may exceed 90 per cent., while the 

 mononuclears and lymphocytes may be reduced, especially if the 

 case is to end fatally, while eosinophiles are often entirely absent — 

 a most characteristic feature in a case in the tropics, Vv^here worm 

 infection is common. The mononuclear decrease is, however, not so 

 evident in cases about to recover, nor is it present in natives in the 

 tropics, who, of course, are liable to previous protozoal infections, 

 and this may lower the relative polynuclear count in these regions 

 to 60 per cent, or less. 



Though there is sometimes an increase in the red and almost 

 always in the white corpuscles, the specific gravity is said to be 

 lower than normal, which is rather extraordinary , and must indicate, 

 if true, considerable alterations in the plasma. As the disease 

 progresses the rapidity of the pulse increases, and may reach 140 per 

 minute, and is usually small and of low tension. The blood pressure, 

 according to Rizzuti and Scordo, shows nothing characteristic. 

 The respirations are always quickened, and there are generally signs 

 of pharyngitis, bronchitis, or broncho-pneumonia, while delirium is 

 not uncommon, especially at night. 



The Rash. — ^Definite preliminary rashes are rare, but there is 

 often very marked flushing of the face, neck, and upper part of the 

 chest, with a cutis marmorata or subcuticular mottling of the skin 

 of the lower part of the chest and abdomen. The true rash appears 

 on fourth to fifth day, in the form of roseolar macules, like those 

 seen in typhoid fever, but often more abundant. They are first, 

 seen upon the abdomen, and later spread to the chest, arms, and legs 

 on the two latter of which, at all events in recent epidemics, they 

 are rare, although, according to the older authors, they first appear 

 and are most abundant in this position. The roseolar spots at first 

 disappear on pressure, and later some of them may slowly fade 

 away, while others, ceasing to disappear on pressure, become 

 petechise, though it is rare for them to develop the dark blue appear- 

 ance of the petechiae of such eruptions as those of purpura. This 

 petechial eruption must not be confused with flea-bites, which are 

 characterized at first by a central hsemorrhagic spot, which is 

 surrounded by a circular hjrpersemic zone, disappearing on pressure 

 and fading in a day or so and leaving a perfectly circular, dark red, 

 not raised petechial spot which does not disappear on pressure. 



