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months’ time his wife contracted the same disease, and in a few months more his younger brother also had a turn. Tn some of these cases it was quite easy to trace the course of infection, but in the great majority it is quite impossible. (2) Is the diagnosis of typhoid fever in tropical climates as difficult as it is made out to be ? To this question on unhesitating no may be given. Tf the physician carries about in his mind the fixed idea that as at home, every continued fever may be a possible typhoid, he will not make a greater percentage of mis- takes than is made by a good physician at home. Naturally the main difficulty is to diagnose between this disease and malarial fever. Malarial fever can be excluded in all but a minority, and that a very small one, by the immediate use of the _ Microscope. If in the country, films may be prepared and examined on one’s return. If the plasmodium is absent this simplifies the case; if present, then one cannot say that the malaria is the chief affection without further proof. Another positive sign may now be tried, viz., Widal’s test. If this is positive (and in cases seen in the country a vaccine tube can be used to collect the blood which may be tested on return), then the case is cleared up. If negative, then it is not | absolute proof that the affection is not typhoid; but | in this case the severity of the illness, combined with | the knowledge of the day of disease, will give a very | fair clue to the extent on which this failure may be depended upon in the matter of diagnosis. I have | used this test with living cultures of the bacillus, but I have the hope that in due time it will be found quite as satisfactory to work with sealed dead cultures of the bacillus carried in small capillary tubes. Putting aside these positive signs, one has other data which rarely in my experience lead one astray. The ist of these is the slight enlargement of the spleen, which is almost universally found in cases of typhoid fever. It is an early sign and a reliable one. As a seneral rule the spleen is easily made out with the ‘tips of the fingers in the left hypochondrium, and is t tender. In acute maJaria it is not at al) unusual The next sign which is of great use is the condition | of the tongue. I think it is best described as the tongue i gastro-intestinal irritation. In some cases, owing ossibly to the difference in food, you do not get the al tongue, but you always get a heavily furred t, especially in the centre of the lateral masses, and as a rule the tongue becomes skinned, cracked, and in any cases almost raw during the course of the disease. Another sign is the condition of the abdomen. In le native, though slight tympanites is common, you | not get the marked tympanites so frequently seen cool climates and amongst heavy meat-eaters. Slight am over the region of the lower part of the ileum is we uncommon, and that quadrant of the abdomen is m these cases kept more fixed during respiration. | Gurgling over the cecum is not uncommon, but of little use in the diagnosis of the case. are, present in about the same proportion of

THE JOURNAL OF TROPICAL MEDICINE. 189

cases as at home, and are generally readily distin- guished (in my experience) from other spots. But [ should not be willing to make my diagnosis hang on these in a tropical climate. Diarrhoea occurs in typhoid patients in about the same proportion as at home, but is generally slighter in amount, and gives but little trouble to the physician. Constipation, which is not infrequent, is a much more difficult matter with which to deal. The Chinese are not by any means lovers of enemata, and in two cases I have brought on an attack of hemorrhage in this way. Neither of the patients took any permanent harm, but the occurrence caused me considerable anxiety at the time.

Delirium is much rarer amongst native than amongst European patients, and when it does occur is not usually so severe. In like manner the depression of the patient is less marked. Possibly this is due to the quieter and less civilised mode of life, the Chinaman being subjected to but little mental stress.

Bronchial catarrh is not uncommon, and occasionally there is a little streaking of blood in the sputum. This does not seem to be of much importance, and cases which present it seem to make as good recoveries as the others. Owing no doubt to the less highly developed sense of hearing, the slight deafness which often is present in European patients does not seem to be present in the native, at least not to a sufficient extent to make the sign either a help in diagnosis or an inconvenience to the patient.

(3) Do typhoid fever and malarial fever run con-

currently in the same patient? As the result of my investigations I have come to

the following conclusions, which agree in the main with those of most of the authorities on tropical diseases :—

(a) It is possible for the two diseases to run con- currently throughout, but it is very rare and I have only met with one undoubted case.

The patient was one of the pastors of the native Church, and I was called to him towards the end of the second week of his attack. His blood gave Widal’s reaction readily and also contained numbers of estivo- autumnal parasites of malignant tertian type. His illness had begun with high fever and a sharp rigor, followed by a hot stage and imperfect sweating. Since that time he had had continuous fever with rigors at irregular intervals, but never less than one in thirty hours, and occasional attempts at sweating. He was much depressed and nauseated, and very constipated. Heavy doses of quinine and phenacetin checked the malaria, and there were no more rigors; but the typhoid ran a perfectly normal course, the temperature descending in the usual way.

(6) But the usual rule may be stated as follows: If the patient has been in good health and not exposed to adverse influences, and has not had a recent attack of malarial fever, the temperature will rise as it does at home and there will be no manifestation of malarial fever.

If, on the other hand, the patient, who is most pro- bably already infected with the plasmodium, as a vast number of the natives in this region are, is exposed to cold or wet, or has to work under a broiling sun, or is freshly infected during the incubation stage of typhoid,