Albumen, with or without tube-casts, is not uncommonly found, and traces of sugar have been detected in a few cases. More careful consideration will be given to these under the head of Complications.
The following appearance of the tongue has been repeatedly described, and when present may be regarded as possessing some diagnostic value: The body of the tongue slightly swollen, so as to show the impressions of the teeth, and by the second day the central part of the dorsum covered with a peculiarly white fur, while the edges and a small triangular space at the tip are clean and red. Such a tongue was seen in many cases at the beginning of the Philadelphia epidemic, but later it was present in but a small proportion. We find it specially mentioned in 97 of our recorded cases, or about 50 per cent., the general description being given that it was moist, rather large, with pink, clear edges, and a triangular clear space at the tip, and with heavy white fur in the centre.
Some accurate observers, as Wyss and Bock, did not notice anything peculiar about the tongue, but merely described it as moist and coated with a thick white fur. The tongue often remains moist throughout the case, the coat becoming yellowish, and later brownish. Of course if there is nasal obstruction from epistaxis or catarrh, and the patient breathes through the mouth, the tongue will soon become dry and brown; but in addition, this state of the tongue with sordes on the teeth and lips, appears in a small proportion of cases (3 per cent., Zuelzer; 12 per cent. of our own patients) in conjunction with grave typhoid symptoms.
During the intermissions the tongue clears off quite rapidly, unless marked gastric disturbance persists, but regains its former state as soon as the relapse occurs.
In rare cases the tongue is red and glazed, and Parry and ourselves observed peculiar painful cracks continuing obstinately after the relapse. It is apparent, therefore, that the tongue presents evidences of vitiated secretions, of local catarrh of the buccal mucous membranes, and of the high grade of gastric irritation so constantly attendant on this disease.
As a rule, there is complete anorexia during all of the febrile paroxysm, while in the intermission the appetite soon returns, and is sometimes truly ravenous. We did not, however, observe in any case a voracious appetite during the febrile paroxysms, such as was very often present during the London epidemic of 1843 and the Irish epidemic of 1847, and is particularly mentioned by Murchison.17
17 Op. cit., p. 360.
Thirst is constant and intense, and is excited not only by the high temperature, but by the irritation of the stomach; it may continue through the intermission, when natural appetite and the power of digesting solid food have returned.
Nausea and vomiting are always prominent symptoms, and most especially so in children. In some cases nausea occurs among the prodromes; and occasionally the attack is ushered in by profuse and uncontrollable vomiting instead of by a chill, and the stomach continues entirely non-retentive throughout the paroxysm. Vomiting is not usually so obstinate and severe, however, and with extreme care in feeding and medication it will often be allayed after two or three days. It occasionally recurs profusely immediately before the crisis, as in the case given in full [below], where after a violent attack of vomiting the patient fell asleep, and awakened in a profuse sweat.
This symptom was present in 146 out of 182 of our cases, was usually confined to the febrile stages, and was, as a rule, worse in the initial paroxysm.