Although, in the great majority of cases, the temperature rises gradually, it may reach 102° or 103° on the second day.
It is difficult to fix definitely the actual period of onset. Flint considered the time when the patient took to bed as the commencement of the disease. This is a good rule. In the general description it is necessary to divide the time into periods of weeks.
First Week.—In a moderately-severe case the patient, after complaining for a few days of the symptoms already men tioned, becomes so weak that he finds his bed the most comfortable place, or more frequently he consults a physician, who, suspecting the nature of the disease, sends him to bed.
The patient may suffer from severe headache, pains in the back of the neck, in the small of the back, and in the ex tremities. Wakefulness is sometimes a distressing symptom. As a general rule, delirium is absent during the first week. The patient is usually dull and apathetic, but sometimes the intellect is so clear that the attending physician is thrown off his guard. The skin is hot and dry, and, in some cases, an erythematous rash appears, widely spread over the surface of the body.
Toward the end of the week a few rose colored spots appear, usually over the abdomen, but occasionally on other parts of the body. There are not more than twenty or thirty present in most cases, but occasionally they occur in large num bers over different parts of the body. The patient complains of a slight cough; and, on examination of the chest, a few bronchitic files are found. The tongue becomes coated with a white fur, which does not extend quite to the margin or tip. Nausea and want of appetite are present, but usually the patient takes fluids without repugnance. In some cases there is decided irritability of the stomach. More or less diarrhea is usu ally present, but the opposite condition of constipation may prevail. The spleen becomes enlarged toward the end of the week.
The pulse is increased in frequency, but not in proportion to the temperature. It is soft, compressible, and often di erotic.
The temperature gradually rises a part of a degree each day. The evening tem perature is higher than that of the morn ing. The general rise continues until the end of the week.
Second Week.—During the second week the symptoms already described increase in severity. The patient loses strength from day to day until he is no longer able to help himself. Dullness and apathy increase, and deafness becomes more marked. The countenance is flushed and may become expressionless. The headache gradually disappears and delirium supervenes. In severe cases coma vigil, carphologia, and subsultus tendinum may be present at the end of the second week, and death may follow. Successive crops of spots appear on the chest and abdomen. The tongue con tinues coated, or it may become dry, red, and cracked. The stomach is often less irritable than during the first week. The abdomen becomes tympanitic, and tenderness, with gurgling, is noticed in the right iliac fossa. Diarrhoea, with ochre-colored stools, is present in the majority of cases. Haemorrhage may occur toward the end of the week. The pulse becomes more rapid and the tem perature maintains the elevation of the end of the first week, or may ascend still farther. It presents daily variations. The heart's action becomes more feeble; so that in some eases the first sound is scarcely heard. Symptoms of pulmonary congestion may appear.
Third W eck.—In the severe cases the patient's weakness and emaciation be come intense and the muscular move ments are made with difficulty. Sub sultus tendinum may be quite marked. Delirium continues and that peculiar condition of wakefulness, coma vigil, may be pronounced. The emaciation, flushed condition of the cheeks, and the eyes wide open form a very character istic type of countenance.
Frequent perspirations occur, which are followed by eruption of sudamina. The rose-colored spots continue to appear in successive crops. Diarrhoea is often se vere. Iimmorrhage and perforation may occur during this week.