Usually typical 'pea-soup1 Constipation however may be troublesome. 3. Decline (3rd week) - (a) Mild case -Toxemia abates, gradual fall of temperatur

quickens B P tends to fall. Usually there is diarrhoea (c) Temperature - high, with slight morning remissions. (d) Rash - Rose spots on 7th to 10th, day. Usually scanty. Any part of body may be involved but periumbilical area is most common. Slightly elevated and fading on pressure. Appear in crops. Fade in 2 to 3 days. Not constant. In grave cases diffuse purpuric skin eruptions may appear (e) Stools - Usually typical 'pea-soup1 Constipation however may be troublesome. 3. Decline (3rd week) - (a) Mild case -Toxemia abates, gradual fall of temperature (b) Severe Case - Increased toxemia, intestinal hemorrhage or perforation. In very severe cases patient goes into typhoid state largely due to severe electrolyte imbalance. It is characterised by - marked prostration with tendency to slip to foot of bed, delirium or stupor with half-open eyes (coma vigil), muscular twitchings and picking of bedclothes with incontinence of urine and faeces. Death may result from toxic myocarditis. 4. Convalescence - In atypical uncomplicated case fever subsides in four weeks. Return of appetite. Tongue cleans. General weakness. Pulse faster, easily quickened by exertion. Slight peeling of skin and oedema of feet may occur. Femoral thrombosis chief complication. A persistent infection of the gall bladder or less often of the kidneys results in the carrier state RELAPSE - may occur some 10 days after the primary attack especially in those who develop a feeble. immunity as a result of a mild attack or are inadequately treated with short courses of specific therapy. Complications - 1. Gastro-intestinal - (a) Meteorism - Abdomen distended, tense, tympanitic May be accompanied by diarrhoea. Favours perforation and hemorrhage. (b) Intestinal hemorrhage - Usually at end of 3rd week. Sudden onset with faintness, pallor and symptoms of shock, rapid fall of temperature to subnormal, thready rapid pulse, fall of B. P. Stools - Streaks of blood or frank bright blood or tarry stools (c) Paralytic ileus - Distension of abdomen, constipation and persistent vomiting, from extensive intestinal involvement, endotoxemia and hypokalemia. (d) Perforation - Usually at same stage of disease as hemorrhage. Preceding diarrhoea and distension common. May occur in mild attacks. Pain in abdomen and collapse, rapid pulse and local or general peritonitis. (e) Parotitis - Due to oral sepsis. Suppuration common. Danger of aspiration bronchopneumonia. (f) Acute cholecystitis - May occur at onset but usually not till the 3rd week or later. An important sequel is formation of gallstones. (g) Non-perforative peritonitis -In rare cases peritonitis may occur apart from perforation of intestines or other organs such as the gall­bladder, spleen, or suppurating mesenteric glands. The symptoms do not differ from those of perforative peritonitis. (h) Acute pancreatitis - Abrupt onset of agonising pain across the upper abdomen radiating sometimes to back and shoulders. Vomiting and distension of abdomen, collapse and shock, abdominal rigidity, pallor or cyanosis. Mistaken for perforation. Increased serum amylase diagnostic. (i) Hepatitis -Jaundice may occur, usually due to intrahepatic cholestasis. 2. Respiratory - (i) Typhoid pneumonia in 2nd to 3rd weeks. (ii) ARDS - in pts with extensive pneumonia, septic shock and associated malaria. 3. Genito­urinary - (i) Retention of urine. (ii) Transient hematuria or proteinuria due to immune complex mediated GN (ii) Pyelonephritis and cystitis. 4. Circulatory - (a) Myocarditis - Mild common, rarely severe enough to