ENTERIC FEJ'ER IN THE TROPICS 217 



Arthritis of joints and abscesses in various parts; sequelae may be 

 found. 



SYMPTOMATOLOGY. 



Incubation three to twenty-three days, average ten days. 



Onset insidious, headache, sometimes epistaxis, increasing weak- 

 ness. 



As the condition is a septiccemia any part may be affected, causing 

 pleurisy, vomiting, or other symptoms tending to obscure the 

 diagnosis. 



The disease is usually ushered in by some other fever, as malaria. 



First Week : — 



The tciuperatiire rises " staircase " manner, going up two degrees 

 in the evening and falling one degree in the morning (not always) up 

 to about 104° F. 



The pulse is slow and often dicrotic. 



The skin. — Cheeks flushed. Skin hot and dry, sometimes inter- 

 mittent sweating. A bluish mottling on abdominal wall. Often 

 yellow coloration of palms and soles. 



The tongue. — White moist fur on dorsinn, tip and edges are red. 

 Mouth dr}', thirst marked. 



The abdomen is distended, tenderness in the right iliac fossa, and 

 spleen is enlarged. Abdominal reflex is diminished or lost. Vague 

 general pains. 



Exhaustion increases, patient becomes apathetic, drowsy, eyes 

 bright; sleeplessness and vomiting are not uncommon. 



The stools. — Diarrluva in 20 per cent, of cases, becomes ochre- 

 yellow (pea-soup) in appearance, but the bowels mav be confined 

 throughout. 



Bacilli may be cultivated from the blood, but specific agglutination 

 is not available. 



Second Week : — 



The symptoms above are aggravated, but headache ma}^ disappear. 



The temperature remains high. Mild delirium is not uncommon. 



Rash appears from seventh to twelfth dav in 70 per cent, of cases 

 on abdomen or chest in crops; arms and legs may also be affected. 

 The isolated maculopapules which disappear on pressure are slightly 

 elevated, rose-red, 4 mm. in diameter, last three to five days, leave 

 a yellow stain. They may continue to end of third week. 



Tendency to hagmorrhage (10 per cent, of cases) is marked, and 

 danger of bowel perforation possible. 



The specific agglutination reaction may now be obtained. 



The diazo-reaction of the urine is now also possible. 



