18 CLINICAL OBSERVATIONS 



4. PRODROMATA AND ONSET 



Attention was devoted to the question of the existence of a 

 prodromal stage of typhus fever. On close questioning a large 

 majority described some symptoms, never prostrating but 

 rather to be classed as an ill-defined malaise for from one to 

 three or more days before the onset of severe symptoms. Our 

 findings tend to strengthen the belief that a prodromal stage 

 exists, but that its symptoms, in the absence of known ex- 

 posure or other suspicious circumstances, are too vague to be of 

 diagnostic value. 



The true onset, in contrast, was in nearly all cases sharply 

 defined. On a certain day and even at a certain time on that 

 day the patient realized that he was sick and as a rule had to 

 give in to the disease at once. On admission to our service he 

 often had difficulty in remembering the number of days that 

 had elapsed since this invasion, but its circumstances were 

 ordinarily well described. Patients too delirious on admission 

 to give a history were able to remember the symptoms of 

 invasion when they became convalescent, although the re- 

 mainder of the course of the disease was often a period of 

 oblivion . 



The commonest symptom of onset was headache in 161 

 cases. It was described as very severe and was frontal, oc- 

 ciputal or general. It was often the chief source of discomfort 

 for several days, but had diminished or ceased before the stage 

 of eruption appeared. 



Chill was second to headache in its prominence, occurring in 

 134 cases. In 84 of these cases there were two or more chills in 

 the first day or days of illness. The remaining 50 had only a 

 single chill. 



Pain in the back and limbs was a complaint in 97 cases but 

 was in most of these subordinate to the headache. Vomiting 

 occurred with onset in 53 cases. Constipation was the rule in 

 the early stages of the disease, being present in 157. Diarrhoea 

 was rare, figuring more in the later stages as will be mentioned 

 under progress. Anorexia was an early symptom in but 77, the 



