19 



Pains.— Pain in some form is one of the earliest and one of the 

 most constant symptoms. It is usually marked, but at times, in 

 children, and occasionally in mild cases in adults, it may be slight, 

 and in the former sometimes altogether absent. Frequently marking 

 the onset or, if not, appearing soon after, are headache, pain in the 

 back and limbs. After two or three days, with the decline in the 

 fever, the severity of these usually diminishes. The headache is 

 usually frontal, but it is sometimes temporal or occipital; there is 

 usually associated with it more or less aching of the eyes. The pain 

 in the back is sometimes described as if it had been produced by 

 blows with a rod, on which account the French in the West Indies 

 have called it the coup de iarre; in some instances it is not unlike the 

 lumbar pain of smallpox. The aching in the limbs has its seat in the 

 muscles, and affects more particularly the muscles of the thighs and 

 calves of the legs. 



Fades. — With the onset of the disease the face usually becomes 

 flushed and somewhat swollen. The flushing may be slight or occa- 

 sionally altogether absent, or it may be so marked as to suggest the 

 initial rash of dengue, especially if it extends, as it sometimes does, 

 down the neck to the iipper part of the chest. The amount of swell- • 

 ing varies; it may be inappreciable or it may be sufficient to smooth 

 out somewhat the lines of expression. Coincident with the flushing 

 of the face the eyes become congested and red and sensitive to light. 

 In mild cases the injection of the conjunctiva may be shown only as an 

 abnormally prominent capillary mesh; in the severe cases the con- 

 junctiva may appear as if inflamed, and in rare instances it may become 

 raised around the cornea from infiltration of serum and blood. The 

 flushing of the face and the injection of the eyes usually diminish as 

 the temperature begins to decline. 



In certain grave cases, coincident with the appearance of black 

 vomit, the face becomes pale, the lips cyanosed, the eyes sunken, and 

 the redness of the conjunctivae becomes replaced by a more or less 

 distinct tinge of yellow. 



'8km. — At first the skin is warm to the touch and usually, but by 

 no means always, dry; sometimes, indeed,. it is covered with perspira- 

 tion which may persist throughout the disease. Later, in some 

 cases, with the occurrence of black vomit, the skin becomes cool and 

 clammy. Jaundice occurs in all but some mild cases; it usually 

 appears first about the third day as a slight tinging of the ocular con- 

 junctiva. At almost the same time, or very soon after, it may be 

 noticed that the skin also has acquired a pale yellow tint. Its early 

 detection may be facilitated by pinching up a fold of skin and causing 

 a momentary local ansemia. 



As the case progresses the icteric tint, which at first is faint, grad- 

 ually becomes more pronounced. The depth of color attained varies 



