CLINICAL COURSE 25 



stages is often replaced as the disease progresses by a stupor 

 which increases to almost complete coma and persists in spite of 

 defervescence until death occurs sometimes many days after 

 the fall of temperature. This syndrome was encountered in 11 

 of our cases. In spite of rather early defervescence the mental 

 and general condition of these patients continued to become 

 progressively worse. Nutrition became increasingly difficult 

 and emaciation became marked except in those previously 

 obese (Fig. 9). The eruptions in these cases persisted without 

 fading in spite of normal temperatures until death. After 

 a week, more or less, of this coma with little or no fever 

 terminal rises of temperature with rapid labored breathing 

 supervened and the patients died with the clinical appearance 

 of terminal bronchopneumonia as in other exhausting diseases. 

 Two cases had convulsions immediately before death. Men- 

 ingismus was more or less marked in the cases of coma. The 

 secretion of urine was not suppressed nor was there other evi- 

 dence of nephritis. 



Gangrene of the skin and underlying structures occurred in 

 6 of our cases (Figs. 10, 11, and 12). Thrombosis of the right 

 iliac artery was present in 1 case. Otitis media occurred 

 in 4 cases. Marked deafness persisting with gradual improve- 

 ment into convalescence without evidence of middle ear in- 

 volvement was present in 5. Erysipelas appeared in 1 case. 

 Phlegmons of the skin in 3 are noted. Parotitis occurred in 7 

 cases and submaxillary gland infection in 3. These infections 

 of salivary glands were all suppurative with 1 exception but 

 were accompanied by less severe general symptoms than are 

 common in suppurative parotitis in other diseases. All recov- 

 ered after incision except 2 in which the gland inflammation 

 appeared only when the patients were already moribund, and 

 in which the adenitis is not believed to have contributed ma- 

 terially to the fatal result. 



Constipation was the rule throughout although diarrhoea 

 was present in 17 cases. 



The clinical course of typhus fever as illustrated by our 

 graphic charts of temperature, pulse, and respiration shows 



