Page:A Handbook of the Theory and Practice of Medicine - Volume I - Frederick T. Roberts.djvu/146

130 THEORY AND PRACTICE OF MEDICINE. marked. The expression presents nothing peculiar, and the face is normal in colour, or pale, or a pink circumscribed flush may be noticed on one or both cheeks, varying in depth of tint and not constant. There is pyrexia, the skin being hot and usually dry, but sometimes moist; while the pulse is accelerated to 100 or 120, and somewhat weak and soft; it varies in frequency in the same patient, beings readily quickened, and it is generally more rapid at night. The tongue presents usually a thin whitish or yellowish fur, is moist at first, small and pointed, red at the tip and edges, with enlarged papillæ. In exceptional cases it is large and thickly coated; or red, smooth, and glazed. The lips are parched and dry, and the mouth feels slimy. There is much thirst, with loss of appetite, and often nausea and vomiting.

Abdominal symptoms are prominent as a rule. These are pain and tenderness, especially in the right iliac fossa; more or less tympanitic distension; small gurgling on pressure in the right iliac fossa; and diarrhœa. Physical examination reveals enlargement of the spleen. Sometimes intestinal hǣmorrhage occurs. The diarrhœa varies considerably in severity, the stools numbering from two to twelve, twenty, or more within the twenty-four hours. Usually they range from three to six. At first the fæces present no peculiarities, but after a few days they assume special characters, becoming thin, yellow, pultaceous, and somewhat resembling pea-soup in appearance; very offensive and often ammoniacal; and alkaline in reaction. Uniform throughout when first passed, they separate on standing into an upper watery layer, of a yellowish or brownish colour, containing albumen and salts in solution, the latter including chloride of sodium and carbonate of ammonia; and a lower layer or deposit, consisting of the remains of food, epithelium and mucus corpuscles, blood, small yellow flocculi, shreds of slough, and crystals of triple phosphates.

Head-symptoms are not very marked at this time. Frontal headache persists, with dizziness and buzzing in the ears. Sleep is restless and disturbed, but the mind is clear, though inactive, and there is no delirium even at night. Epistaxis is not an uncommon symptom during this period.

The urine presents well-marked febrile characters; urea and uric acid are in excess; and chloride of sodium is diminished.

Frequently there are slight bronchitic symptoms, dry räles being also heard over the chest.

Eruption.—A specific eruption is present in the great majority of cases of enteric fever, but not invariably. It is not unfrequently absent in very young patients, and in persons over 30. It first appears usually from the 7th to the 12th day, but may in rare instances be seen as early as the 4th, or not until the 20th day. The abdomen, chest, and back are the regions which it generally occupies, but it is occasionally observed on the limbs, or very rarely on the face. It does not appear all at once, but comes out in successive crops, each spot lasting from two to five days, and then fading away completely. The amount of eruption present at one time is never great, the number of spots rarely exceeding from 12 to 20 or 30, and there