TYPHOID FEVER. 635 



jorrespondins: to the eighth, ninth, and tenth ribs, nearly reaches the 

 spinal column posteriorly, and the margin of the ribs anteriorly. An 

 increase or decrease of the spleen-dulness, to the extent of a centime- 

 tre or so, cannot be made out with certainty, in spite of what enthusi- 

 asts in physical diagnosis assert. Even when the dulness has undoubt- 

 edly increased or decreased slightly, we must bear in mind that this 

 may depend not only on diminution or enlargement of the organ, but 

 also on changes of its position. A greatly enlarged spleen may in- 

 duce but little dulness when it is pressed into the hollow of the dia- 

 phragm by the distended intestines, and only a small part of it lies in 

 contact with the thoracic wall. Toward the end of the first week, on 

 careful examination, we often find a few pale-red, roseola spots, about 

 the size of a lentil, on the epigastrium and neighboring portions of the 

 abdomen and breast. Finally, the most important objective symptom 

 is the fever. The temperature rises very regularly, in a manner al- 

 most pathognomonic of abdominal typhus. During the first week, 

 the evening temperature is nearly two degrees higher than that of 

 the morning ; the morning temperature of the next day is about one 

 degree lower than that of the preceding afternoon. For instance, a 

 patient who has a temperature of 104. 6 this evening, will, as a rule, 

 have a temperature of 103. 7 to-morrow morning, and to-morrow even- 

 ing a temperature of 105.5. Toward the end of the first week, oc- 

 casionally there is no increase of evening temperature ; but even then 

 the morning temperature is almost always about one degree lower 

 than that of the evening ( Wunderlich). During the first week, the 

 pulse usually increases to ninety or a hundred, or even higher. Its fre- 

 quence does not by any means always correspond to the temperature 

 of the body, for, besides this, there are other causes, not always evident, 

 that influence the heart's action. Among other things, the pulse is ac- 

 celerated from twenty to thirty beats in the minute, if the patient sits 

 up in bed awhile, strains himself, or becomes excited in any way. 

 Regarding the quality of the pulse, the blood-wave is usually quite 

 large, but the artery remains soft during its diastole, and we often no- 

 tice that the first pulsation is followed by a second, weaker one, that 

 the pulse beats double. The double pulse, which does not occur exclu- 

 sively in abdominal typhus, but is more frequent here than in any 

 other disease, and consequently is not without diagnostic importance, 

 is probably due to deficient activity of the contractile elements of 

 the arterial walls, which are in a sub-paralytic state, as it is called. 

 At least it may be shown that, if the arterial walls possessed no 

 ?on tractile filaments, but only elastic elements, the first pulsation, 

 caused by the blood-wave, would be followed by a second evident 

 pulsation (" Nachscliwingung"). During the first week, in accord 



