1382 THE ENTEROIDEA GROUP OF TROPICAL FEVERS 



of the week ; the enlargement of the spleen ; the possible occurrence 

 of the typical spots ; and the continued fever. 



The Second Week. — The signs and symptoms described in the 

 first week continue to increase, with the exception of the headache 

 and local pains, which usually diminish and disappear by about the 

 middle of the week. The tendency to haemorrhage is, however, 

 more marked, and the danger of perforation of the bowels has now 

 to be considered, while the typical rose-coloured rash should appear 

 to a greater or lesser extent ; the specific agglutinin reaction should 

 be obtainable, as well as the diazo-reaction in the urine, while the 

 specific bacilli are much more difficult to obtain from the circulating 

 blood, but can still be recovered from the spleen, the faeces, the rose 

 spots, and often from the urine. Liver or gall-bladder symptoms 

 and other complications may appear. With this introduction the 

 signs and s3miptoms of the second week may be considered in 

 slightly more detail. 



During this week the patient, who may have been up and about, 

 is generally confined to bed, and may be seen for the first time by 

 the physician. The facies is dull, apathetic, and listless; the 

 reaction time is prolonged for answering questions; the hearing 

 may be diminished; and the patient is drowsy. At night there 

 may be sleeplessness and mild delirium. There may be slight sub- 

 sultus tendinum. The decubitus is dorsal. The temperature con- 

 tinues high, varying from about i02°toi05°F., while the pulse is 

 generally relatively slow (90 to 100 beats per minute), although it 

 may reach to 120. The dicrotism may have disappeared, but the 

 blood-pressure has generally diminished somewhat, and the first 

 sound of the heart is not as appreciable as normal. The circulation 

 is as a rule not good; the extremities are apt to be cool, or even 

 cold; and the hands and feet, or more usually the tips of the fingers 

 and toes, may be of a bluish colour. The nails often show signs of 

 lack of vitality, and transverse ridges may be observed. Philipo- 

 wicz's sign may disappear, or may persist through the week, and 

 even later. The typical rose-red or pink maculo-papules appear in 

 successive crops on the front of the abdomen or chest, beginning 

 about the seventh to twelfth days, though in exceptional cases they 

 may occur as early as the fifth day, or they may be delayed as late 

 as the twentieth day, while they may be entirely absent. Their 

 number and presence depends upon some unknown secondary cause 

 and not upon the severity of the attack, to which they bear no refer- 

 ence. They are pinkish or rose-red, circular, slightly elevated, 

 isolated maculo-papules about 4 millimetres in diameter, usually few 

 in number, which disappear temporarily on pressure, but reappear 

 as soon as the pressure is removed. They usually last three to five 

 days, more rarely as long as ten days, and as a rule undergo no change 

 until they fade and disappear, leaving occasionally a brownish stain. 

 They are not associated with any subcuticular mottling, and are 

 but rarely met with on the face, though they may at times be found 

 on the arms and legs. They continue to appear until the end 



