SYMPTOM A TOLOGY 



or so in the morning ; but in our experience a much greater remission 

 than a degree or so is by no means unusual, and the temperature, 

 as already mentioned, may assume an intermittent character. 

 The pulse is about 80 to 100 beats per minute, often with more 

 or less dicrotism, while the blood-pressure varies, the systolic being 

 about 120 millimetres, and the diastolic about 90 millimetres of 

 mercury. At this stage of the disease there is usually little or no 

 change in the blood, though slight leucopenia may be present. 

 The specific agglutinin reaction is not available, but the bacilli 

 can be cultivated from the blood. In uncomplicated cases the 

 spleen is more or less normal at the commencement, but enlarges 

 distinctly towards the end of the week. The respiratory symptoms 

 may cause the patient much annoyance, especially the dry, hacking 

 cough, and there may be signs of mild tonsillitis, pharyngitis, 

 laryngitis, or bronchitis. Pneumonia must be looked upon rather 

 as a complication than as a symptom of the disease. The gastro- 

 intestinal symptoms present much variability. The mouth is 

 often dry, and the patient may be worried by thirst. The lips and 

 teeth are normal, but the tongue, which is moist, is generally coated 

 by a white fur on the dorsum, while the tip and edges are red. There 

 is little or no desire for food; the stomach is irritable, and vomiting 

 may occur, especially if indiscretions in feeding are allowed. The 

 abdomen is more or less distended, especially in the region of the 

 right iliac fossa, where it is often painful and tender, as, indeed, it 

 may be in other places. There may be constipation or there may be 

 diarrhoea; the motions may be of an ordinary colour, but more 

 typically they are ochre-yellow. It is not often that haemorrhage 

 is seen during this week, and is then generally small in amount; 

 but its presence is, in our opinion, a relatively serious symptom. 

 The urine is generally diminished in quantity, high in specific 

 gravity, dark in colour, with a markedly acid reaction, but there is 

 usually no albumen, no casts, and the diazo-reaction cannot be 

 obtained. 



The skin is hot and dry, with, however, paroxysms of greater or 

 lesser amount of perspiration, followed by the presence of more or 

 less sudamina. The typical rose spots do not as a rule appear 

 before the seventh day, and therefore will not be described under 

 this week. At times a bluish subcuticular mottling is to be observed, 

 especially on the abdominal wall, towards the end of this week of 

 quite a different nature to the bluish spots (taches bleudtres), which 

 are generally assigned to the action of lice. There is often a yel- 

 , lowish coloration of the palms of the hands, the lateral aspects of 

 the fingers, and the soles of the feet, sometimes called ' Philipo- 

 wicz's sign,' which, however, is by no means characteristic of 

 enteric fever. 



The most marked feature of the week is the gradual increase in 

 severity of the disease as marked by the growing apathy and 

 dulness of the patient ; the aggravation of the symptoms, with the 

 exception of the pains, which tend rather to abate towards the end 



