23 
ered, the spots showed distinctly. I have seen them in a case twenty- 
four days after discharge. 
When convalescence is well advanced descpiamation 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 usualW first noticed in the conjunctivBe, 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 becomes dark brown and the teeth are covered with 
sordes. At first there ma}’ 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 occasionall 3 ^ The liver 
is usually moderately enlarged. The spleen is enlarged early and 
may extend 1 or 2 inches below the costal margin. 
URINARY 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. 
RESPIRATORY SYSTEM. 
The respiratoiT rate is always increased, usualh^ varying from 26 
to 10 per minute, in some cases reaching 50 to 60; regular, but often 
shallow. In the second week there is always a slight bronchitis. 
Lobar pneumonia is a frequent complication in fatal cases. Epistaxis 
is usualW seen from the end of the first week. 
NERVOUS 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 posture. The muscu- 
lar soreness is often very 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 opisthotonius or other irritative symptoms. 
