634 ACUTE INFECTIOUS DISEASES. 



jrhich may be discovered by physical examination even during tbo 

 first week. Among the objective symptoms comes next the changed 

 appearance of the patient. While in bed, the face, especially the 

 the cheeks, appears red ; but, if he has been sitting up for some time, 

 he looks pale and meagre. At first the tongue is rarely thickly coated, 

 moist and broad, showing impressions of the teeth along its sides ; it 

 usually has a thin, whitish, epithelial coating, through which some 

 papillae project as red points ; it is covered with a tough, slimy mucus, 

 and appears narrow and pointed. The thin, epithelial coating usually 

 falls off, gradually leaving, as Vogel aptly describes it, " a moist, red, 

 smooth tongue, that looks as if covered with gold-beater's skin, or else 

 is already inclined to dryness. If there be at first a thick, adherent 

 coating on the tongue, it is usually detached from the point posterior- 

 ly, and from the sides toward the middle, so that the whitish yellow 

 coating appears enclosed in a very red border, which constantly in- 

 creases in width ; but in some cases the detachment begins centrally, 

 so that in the middle of the tongue there is a red stripe, that has a pe- 

 culiar tendency to become dry, and at the sides two whitish-yellow, 

 moist, slimy stripes. The central stripe is often broad anteriorly, and 

 disappears posteriorly, so that on the point of the tongue we see a red 

 triangle, with the apex posteriorly." In spite of this peculiar disturb- 

 ance of nutrition on the surface of the tongue, and of the diminution 

 of secretion in the mouth, on microscopical examination of the coating 

 of the tongue, Vogel could find nothing characteristic. Palpation and 

 percussion do not show any anomaly of the heart or lungs, but on 

 auscultation even at first, and always by the end of the first week, we 

 find a more or less extensive whistling sound (rhonchus sibilans), due 

 to catarrh of the smaller bronchi. Even during the first days the ab- 

 domen is usually somewhat puffed up and tense ; deep pressure over it 

 is generally painful, and this sensitiveness to pressure exists not only in 

 the ileo-ccecal region, but also about the navel and in the epigastrium. 

 On pressure in the right iliac region, particularly if there has already 

 been severe diarrhoea, we notice a gurgling sound, the so-called ileo- 

 coecal gurgling, whose diagnostic importance was formerly much over- 

 estimated. Toward the end of the first week, the enlargement of the 

 spleen is ordinarily marked. The enlarged organ usually has a horizon- 

 tal position ; it rarely projects beyond the ribs, and is pressed upward 

 and backward against the spinal column by the distended intestines. 

 Hence, the typhus spleen is rarely to be reached on palpation, and, 

 even when it can be touched, it is so soft that we are unable to define 

 its outlines. But, if we lay the patient on his right side, with his left 

 hand on his head, on percussing the lower ribs of the left side, we find 

 a dull space, which may be six niches long by four wide, and which. 



