ACUTE INFECTIOUS DISEASES. 



in bed. When the chill begins, there is also more or less headachy 

 oppression of the chest, and hurried respiration ; the latter, and the 

 quivering of the lips, render speech indistinct and interrupted ; there 

 is often vomiting also, especially if the chill comes soon' after eating. 

 Objective examination first shows the altered appearance of the pa- 

 tient ; he looks like a person exposed to severe cold, without sufficient 

 clothing, and who is consequently thoroughly chilled. The size of the 

 body appears diminished ; the face is sunken ; the nose pointed, the 

 rings are too large for the fingers. As the flow of arterial blood to 

 the skin is impeded, the latter appears pale, and, as the blood collects 

 in the veins and capillaries, the lips, ends of the fingers and toes, look 

 blue. The flow of blood to the fingers is often entirely arrested ; they 

 look waxy, have no feeling, and do not bleed if wounded. The skin 

 of the extremities and body has the appearance known as goose-flesh 

 (cutis anserina). The pulse is very frequent, small, and hard ; the se- 

 cretion of urine is usually increased ; the urine passed is limpid, and 

 of low specific gravity. Physical examination generally shows en- 

 largement of the spleen. While the diminished supply of warm blood 

 during the chill causes the periphery of the body to assume more and 

 more the temperature of the surrounding atmosphere, and to actually 

 sink several degrees, the temperature of the blood and internal organs 

 rises rapidly. This rise, which begins even before the chill, reaches 

 two or three degrees, and, in severe cases, still more. The above 

 symptoms are mostly to be ascribed to spasmodic contraction of the 

 muscles of the skin and peripheral arteries during the cold stage. 

 The immediate results of this spasm are the goose-flesh, the small, 

 hard pulse, and the deadness of the fingers. The contraction of the 

 muscles of the skin and peripheral blood-vessels secondarily in- 

 duces the apparent diminution in size, the dryness and pallid ap- 

 pearance of the skin, the collection of blood in the veins, and the 

 fall of temperature on the surface of the body. The chilly feeling 

 of the patient is too decided to be referred exclusively to the fall 

 of temperature of the periphery ; on the other hand, the contin- 

 ued coolness of the surface, even under thick feather-beds (which is 

 peculiarly remarkable, because the body gives off but little heat 

 to the parts around), is certainly due to the fact that, during the 

 chill, there is less warmth supplied to the surface, on account of the 

 diminished supply of blood. Lastly, the disturbance of the peripheral 

 circulation increases the lateral pressure in the vessels of the internal 

 organs. But, as we do not know whether the spasm of the muscles of 

 the vessels is limited to the peripheral arteries, and does not extend to 

 the internal ones, it is doubtful whether the headache, oppression, ac- 

 celerated respiration, vomiting, increased secretion of urine, swelling of 



