ENTERIC FEVER IN THE TROPICS 219 



]\Ieteorism or tympanitis. 



Thrombosis, usual of femoral vein, embolism possible. 



Xeuritis, bronchitis and pneumonia, 



Earlv tvphoid state or cardiac failure. 



Bed sores and boils. Alopecia. 



Tvphoidal arthritis, typhoidal spondylitis, ascending myelitis. 



Periostitis. Inflammation of thyroid. Iritis, orbital cellulitis. 



Relapses during the third and fourth week after the temperature has 

 been normal are not uncommon. 



Signs of perforation. — Sudden and severe pain, rapid and extreme 

 distension of the abdomen, absence of abdominal respiration, tympanic 

 percussion note, absence of hepatic and splenic dulness. Shock, rapid 

 pulse and respiration, fluid in abdomen. Collapse. 



DIAGNOSIS. 



In typical cases easy. The insidious onset, dicrotic pulse, medium 

 enlargement of spleen, rose rash, leucopenia; if all are present it 

 scarcely permits of mistake. 



In the tropics the course is more often atypical. 



Malarial fever \\ill modify the temperature chart, alter the appear- 

 ance of the rash, and easily throw one off his guard. 



Bacteriological diagnosis is therefore all-important, as seen in : — 



(i) The agglutination test (Widal). Important. See p. 611. 



(2) Hfemocultures. Important. See p. 623. 



(3) The bacilli in the stools and urine. 



(4) Spleen puncture gives good results, but should not be a routine 



procedure. 

 {5) Ophthalmo-reaction and cuti-reaction, similar as for tuber- 

 culosis. 



(6) Subcutaneous inoculation of dead cultures and \^incent's splenic 



diagnosis. 



(7) Complement fixation. 



With regard to the ]]^idal reaction (see p. 611), the three strains of 

 bacilli should each be tried failing agglutination of one of them. 



It is absent during the first week in any case, and may be in excep- 

 tional cases during the whole period. On the contrary, if a positive 

 result is obtained, one must remember that a former attack would give 

 it for months or years after it was over. It may be possible in vac- 

 cinated persons. 



It has been found present in jaundice, Weil's disease, and puerperal 

 fever. 



The rapid differentiation of the bacilli of the typhoid group by 

 means of test papers has been devised by Hollande and Beuverie. 



