i38o THE BNTEROIDEA GROUP OF TROPICAL FEVERS 



being but little marked, and the patient, though feeling wretched 

 and ill, perseveres with his work, and may never consult a doctor 

 until well into the second week of the fever, and in some cases may 

 even advance farther in the illness than this before the complaint is 

 diagnosed. 



With regard to the other atypical onsets, it is well to remember 

 that the disease is a septicaemia, and that, following the account of 

 the pathology given above, any organ or system of the body may 

 be specially attacked. Thus, for example, the nervous system may 

 be specially attacked, with the result that the most urgent symptom 

 is a neuralgia, an earache, a backache, or pains resembling those of 

 pleurisy; or, again, there may be signs as though cerebro-spinal 

 meningitis were coming on, or there may be early delirium. If the 

 respiratory system is specially attacked, the signs will be those of 

 bronchitis, pneumonia, or suggestive of acute tuberculosis. If the 

 alimentary canal is selected, there will be symptoms indicating 

 irritant poisoning or appendicitis; if the renal system is marked out 

 for attack, they will resemble the signs of acute nephritis. The 

 above remarks do not by any means cover all the possibilities of 

 the onset, but enough has been said to indicate the remarkably 

 protean nature of the signs and symptoms of enteric fever, and of 

 the way in which it imitates other diseases. 



The First Week. — The early days of this week are as a rule occu- 

 pied by the onset of the fever, as described above, and often the 

 medical attendant does not see the patient until about the end of 

 the third or fourth day of the illness. In the tropics, however, the 

 attack is at times ushered in by some other fever — as, for example, 

 malaria, by which its symptoms are more or less masked. It is, 

 however, possible, even at this early stage, to observe, associated 

 with the symptoms of the predominant disease, signs and symptoms 

 which arouse suspicion of enteric fever. This suspicion is presently 

 converted into certainty as these signs increase in evidence, while 

 the symptoms of the original ailment decrease and finally dis- 

 appear. The signs and symptoms to which we specially refer are 

 the alteration of the temperature chart from one of remittent or 

 intermittent fever in malaria to one of more continued fever, with 

 more marked headache, slowing the pulse, the appearance of 

 dicrotism, the signs of abdominal distension, the local pains, the 

 tenderness, and perhaps the gurgling in the right iliac region, and 

 the altered condition of the tongue. 



During this first week the facies of the patient becomes at times 

 typical — i.e., the cheeks are flushed and the eyes bright, and there 

 may be some photophobia. The decubitus is almost always dorsal. 

 As the week proceeds, the patient becomes more or less apathetic, 

 listless, and drowsy. Headache, noises in the ears, and pains in 

 various parts of the body are the marked symptoms of this week, 

 while sleeplessness is often another marked symptom. Delirium 

 is, however, rare. The temperature continues high, being usually 

 from 103° to 104° F. in the evening, with a remission of a degree 



