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hemorrhagic infiltration of the lung may cause grave symptoms or even death.

In the abdominal or gastro-intestinal type, vomiting and purging are common, and there may be great pain and tenderness in the epigastrium or over the entire abdomen. Catarrhal jaundice may occur.

In the cerebral or nervous type, the headache is intense; there may be insomnia, photophobia, tinnitus aurium, talkativeness or even mild delirium. There is decided hyperesthesia; there may be restlessness, tremor, muscular twitchings or jactitations.

In the typhoid type, the course of the disease may be protracted, and the temperature may remain continuously elevated. The prostration may be extreme; the mental phenomena may be characterized by depression, There may be epistaxis, pain in the splenic region, special tenderness in the right iliac fossa and considerable diarrhea. There may be anomalous eruptions -papular, herpetic or erythematous. The action of the heart may be exceedingly feeble. Heart-failure is always a threaten

ing danger.

The duration of influenza is as variable as are the symptoms. It may be less than forty-eight hours; it may be several weeks. Commonly, the acute symptoms last from three or four days to a week, but the weakness and depression continue much longer. Convalescence may be tardy, prolonged subnormal temperature and annoying perspiration being notable features.

In addition to the complications mentioned, there may be hemorrhages from various organs, meningitis-cerebral and spinal-multiple neuritis, arthritis and nephritis. Among the sequelae are tuberculosis, paralyses of various kinds, hemicrania and melancholia, and other psychoses. Of itself influenza is not often fatal or directly provocative of serious complications or sequelæ; but it aggravates existing lesions or morbid processes, reawakens latent disease or searches out the weak point in the organism and renders this liable to the action of exciting causes. Hence, the great variability in its clinical course, and hence, too, the high mortality it occasions among the previously sick and debilitated, among infants and the aged.

With what diseases may influenza be confounded?

The diagnosis of influenza may be extremely easy or extremely difficult. According to its type, it may be mistaken for simple catarrhal inflammation of the mucous membrane of the eye, ear, nose, throat, bronchi, stomach or intestines; for measles; for cerebro-spinal meningitis; for acute articular rheumatism; for dengue; for ordinary types of pleurisy or pneumonia; for malarial fever; for acute tuberculosis; for typhoid fever.

Upon what does the discrimination depend?

In times of prevalence of epidemic influenza, or of the analogous epizoöty, the knowledge of that fact will cause one to be on the lookout for the disease, and he may, perhaps, even call other affections by its name. Characteristics upon which stress should be placed are the sudden onset, the great depression, the cutaneous hyperesthesia, the lumbar and muscular pains and the excessive respiratory distress. These serve to distinguish it from indigestion, gastro-intestinal catarrh, bronchitis, coryza and "colds." In contradistinction from typhoid fever or typhus fever, the common occurrence of some form of catarrhal symptoms, the irregularity of the temperature, the shorter duration and the absence of the characteristic symptoms to be described, are additional discriminating points. The differential diagnosis from the other diseases mentioned will be successively developed.

Typhoid Fever-Enteric Fever.

What is typhoid fever?

Typhoid or enteric fever is an acute, infectious disease, belonging to the group of essential, continued fevers, dependent upon a specific microorganism, and presenting constant lesions: inflammation, swelling, softening and ulceration of Peyer's patches, enlargement and softening of the mesenteric glands and tumefaction of the spleen. It runs a course of about twenty-four days, beginning gradually and terminating by lysis. The disease is most common in young adults and in the autumn.

The typhoid-bacillus (Fig. 1) is a plump, motile organism, with

rounded extremities. It is about one-third as long as the diameter of a red blood-corpuscle and one-third as wide as it is long. It presents a characteristic growth upon potatoes and does not liquefy gelatin. It is best stained by means of an alkaline solu

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tion of methylene-blue or by carbol-fuchsin or anilin-water fuchsin. It differs from other organisms found in the stools in not generating indol. The bacillus has been found during life in the blood, in the urine and in the stools, and, after death, in the intestinal wall, in the mesenteric glands and in the spleen. What is the clinical course of typhoid fever?

The period of incubation of enteric fever varies between two and eleven days. The onset is usually insidious, occasionally abrupt, with a chill. The prodromal period is characterized by headache, pains in the back, epistaxis, general malaise, disturbed sleep, loss of appetite and coated tongue. These symptoms become aggravated, while to them are added relaxation of the bowels, abdominal tenderness, especially in the right iliac fossa, intestinal gurgling and elevation of temperature.

The temperature pursues a characteristic course. (Fig. 2.) There is a period of gradual ascent (first week), a period of maintained height (second week and half of third week), and a period of gradual fall (last half of third week and fourth week).

41° C.

40° C.

39° C.

38° C.

37° C.

For from five to seven days the temperature rises two or three degrees each evening, to recede a degree or a degree and a half on the following morning, until it has reached a level of from 102.5° to 104° F. (in grave cases even higher), at which, with

FIG. 2.

[graphic]

Temperature-chart of a case of typhoid fever. (Wünderlich.)

slight evening remissions and morning exacerbations, it lingers for from ten to fourteen days, then to decline inversely pretty much as it rose, until, with the setting in of convalescence, it may fall below the normal.

The pulse is accelerated, but not, as a rule, in proportion to the rise of temperature. It may not exceed 90. It is peculiarly soft and rebounding, giving rise to an apparent duplication known as dicrotism. The tongue is coated in the middle, but red at the margins and tip. The coating is thick and, at first, white. The red, uncoated portion at the tip occupies a characteristic wedge-shaped area. The lips, gums and teeth become covered with sordes. The patient often exhales a characteristic odor. The pupils are dilated. A limited flush colors the cheek.

Toward the end of the first week or early in the second, a varying number of small, slightly elevated, rose-colored spots that disappear upon pressure or upon stretching the skin may be observed upon the trunk-upon the abdomen or chest, anteriorly or posteriorly. These spots appear in successive crops, each of which lasts for several days.

The urine presents a characteristic reaction. If to one part

of a (one-half per cent.) solution of sodium nitrite in distilled water (1:40) and forty parts of a saturated solution of sulphanilic acid in dilute hydrochloric acid (1:20) is added an equal bulk of urine and the whole is rendered alkaline with ammoniawater, a deep-red color is produced.

In classically typical cases, there is diarrhea; but in almost an equal number, however, the bowels are constipated. The diarrheal stools present a characteristic appearance, being thin and yellowish, "ochrey," or like pea-soup; they have a peculiar, fetid odor; sometimes they contain blood, independently of a formal hemorrhage. Tympanites is common. The area of splenic percussion-dulness is increased. In the second week, if not earlier, mental dulness and listlessness are manifest. The patient pays little heed to his surroundings, but usually responds when spoken to. Deafness and visual disturbances are not uncommon, and there is frequently low delirium. In the third week, the first sound of the heart is observed to be feeble; emaciation is decided, and the tongue often becomes dry, fissured and coated with a heavy, brown fur. Intestinal hemorrhage may occur. Perforation of the bowel, with consecutive peritonitis, is among the dangers.

Usually, towards the end of the third or the beginning of the fourth week, progressive improvement is manifested, coincidently with the decline of temperature. The morning remissions exceed the evening rises. Commonly by the twenty-fourth day, but often much later, the temperature has fallen to the norm. Convalescence is slow.

Death may take place in or after the second week, from exhausstion, toxemia, fever or the accidents of the disease.

Other complications and sequela than those mentioned are bedsores, phlebitis, thrombosis, endocarditis, parotiditis, edema, inflammation or ulceration of the larynx, bronchitis, pleuritis, pneumonia, pulmonary tuberculosis, osteomyelitis, meningitis, peripheral neuritis, the formation of abscesses and gangrene.

Sometimes the symptoms are mild, constituting ambulatory or walking typhoid fever. At other times, the attack, while perhaps severe, terminates at the end of a week, or of two weeks, constituting abortive typhoid fever. A few days after convalescence

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