23 
ered, the spots showed distinctl}". I have seen them in a case twenty- 
four days after discharge. 
When convalescence is well advanced desquamation begins and 
extends over the entire body. In very severe cases there may be 
gangrene of the lingers or toes, and still more frequently of the skin 
of the scrotum and penis. The skin is always jaundiced to a greater 
or less degree. This is usuall}^ first noticed in the conjunctiva?, the 
vessels of which are congested from the outset. 
DIGESTIVE SYSTEM. 
The tongue at first has a heavy whitish coat, with red edge and tip; 
later the coat l)ecomes dark brown and the teeth are covered with 
sordes. At first there may be a little nausea, but the appetite is often 
good throughout the first week. In fatal cases nausea becomes more 
persistent during the second week and lasts until the end. Constipa- 
tion is present throughout the course of the attack. Tympanites is 
never excessive; gurgling in right iliac fossa occasionalh". The liver 
is usually moderately enlarged. The spleen is enlarged early and 
mav extend 1 or 2 inches below the costal margin. 
UKINAKY SYSTEM. 
The urine is decreased to about one-half its normal amount for the 
twenty -four hours; small amount of albumin in all cases examined; 
granular, hyaline, and epithelial casts. 
RESPIKATOKY SYSTEM. 
The respiratory rate is always increased, usually varying from 26 
to 40 per minute, in some cases reaching 50 to 60; regular, but often 
shallow. In the second week there is alwavs a slight bronchitis. 
Lobar pneumonia is a frequent complication in fatal cases. Epistaxis 
is usuall}" se^n from the end of the first week. 
NERYOUS SYSTEM. 
Pain in head and back is usually severe during the first week. 
Soreness of the muscles and bones causes the patient to change posi- 
tion often in the endeavor to find a comfortable postui*e. The muscu- 
lar soreness is often veiy severe, even in mild cases, and lasts until 
recovery. The mind is usually clear, even in severe cases, until 
within a few hours of the end. Pupils react normally to light and 
distance; no opisthotomus or other irritative symptoms. 
