SYMPTOM A TOLOGY^DIA GNOSIS 



1347 



increase in the number of respirations, which may reach from 

 twenty-six to sixty per minute. 



The urine presents the usual febrile character, and often contains 

 a trace of albumen, which occasionally may reach considerable pro- 

 portions, and be accompanied by a few granular casts. More 

 rarely the urine may be scanty or even suppressed. The mind is 

 usually clear, but in severe cases a low muttering delirium may 

 occur. 



Terminations. — ^After the fever has reached its height on the fifth 

 to the twelfth day, the temperature either declines by lysis, and 

 recovery takes place, or it remains high, and, a typhoid state de- 

 veloping, death ensues. If the former event is to take place, the 

 temperature, falling by lysis, reaches normal about the fourteenth 

 to the eighteenth day, the eruption commences to fade, and 

 desquamation begins, which extends all over the body, while the 

 other symptoms gradually abate and the patient becomes convales- 

 cent. If, however, death is to ensue, the temperature remains about 

 104° to 106° F., but sometimes shows a sudden final fall just before 

 the fatal event. 



Convalescence. — Convalescence may take some time, and it is said 

 that the sites of the eruption are clearly visible even twenty-four 

 days after recovery if a warm bath is taken. 



Complications. — Pneumonia is a comparatively frequent com- 

 plication, but gangrene of the fingers, toes, and skin of the scrotum 

 and penis may occur. Nephritis, cardiac weakness, and meningitis 

 are possible complications. 



Diagnosis. — ^The malady may be difficult to differentiate from 

 typhoid fever, typhus, and the Japanese river fever. From typhoid 

 fever it can be distinguished by the more acute onset, the petechial 

 eruption, commencing on the hands and wrists, the absence of 

 marked intestinal symptoms, and the presence of leucocytosis. 

 In doubtful cases all the modern bacteriological methods — serum 

 reaction, search for the Bacillus typhosus in the blood, stools, and 

 urine — ^will have to be used to exclude typhoid. 



The distinction between spotted fever and typhus on clinical 

 grounds seems to us impossible. Though in typhus the disease 

 may end more often by crisis than by lysis, all the other clinical 

 symptoms, and the appearance of the eruption, are practically 

 identical; in fact, Sambon and others believe that the Rocky 

 Mountain spotted fever and typhus are the same entity. Possibly 

 typhus and Rocky Mountain spotted fever are due to two varieties 

 of the same organism, or two very closely allied species, in the same 

 way as African, European, American, and Asian relapsing fevers 

 are due to very closely allied organisms. It has been noted that 

 guinea-pigs are susceptible to inoculation of Rocky Mountain fever 

 virus. Inoculation of blood, especially if taken at the end of the 

 febrile stage, produces pronounced swelling of the scrotum in 

 guinea-pigs, and this has been suggested as a test to differentiate 

 Rocky Mountain fever from typhus. Recent immunological studies 



