TYPHUS FEVER. 621 



favorable course, a fact that we should know, to avoid exaggerating 

 the danger. Whether a remission occur on the seventh day or not, 

 the fever always increases in the beginning of the second week. In 

 mild cases, tliis increase only lasts a few days, and is not excessive ; 

 but in severe cases the increase lasts till the end of the second week, 

 or even till the sixteenth or seventeenth day, and the temperature may 

 become very high (108 or more). At this time the heart's action is 

 not only much increased, but it is weakened ; hence the heart-sounds 

 are very imperfectly heard, the pulse is small and indistinct, the cir- 

 culation is so much retarded that, in the extremities, the temperature 

 of the skin approaches that of surrounding objects, and the hands and 

 feet appear cool while the trunk is burning hot. 



The third stage of exanthematic typhus, which authors very cor- 

 rectly call the stadium criticum, almost always begins in the latter part 

 of the second week, or, exceptionally, in very severe cases, at the begin- 

 ning of the third week. Before actually seeing such cases, it is almost 

 impossible to imagine the wonderful change in the symptoms, during a 

 single night, in the stadium criticum. In no other disease is there so 

 rapid a change from an apparently hopeless to a very comfortable 

 state. After a peculiarly marked exacerbation of all the symptoms, 

 the patients fall into a quiet deep sleep for several hours, from which 

 they awake with unclouded mind, but usually without any recollection 

 of what they have passed through for the previous days or weeks. 

 During this critical sleep the temperature often falls four degrees, the 

 pulse twenty or thirty beats ; the calor mordax disappears from the 

 skin, and there is a gentle perspiration ; the roseola spots become 

 pale. In favorable cases defervescence is immediately succeeded by 

 convalescence, which, however, is always slow. The patients sleep a 

 great deal ; on waking, their intellect gradually becomes less clouded, 

 although they retain an idiotic, stupid expression for weeks. The 

 dirty coating is thrown off from the teeth and gums, the tongue again 

 becomes moist, and the appetite returns. Sputa cocta are raised by a 

 loose cough ; the skin, from which the roseola spots have disappeared, 

 begins to peel off, any remaining petechiae fade out, the temperature and 

 pulse fall to the normal standard or below it, and the spleen decreases 

 in size. But, even in the best cases, weeks pass before the patient can 

 leave his bed and move about his room. In most of my cases the 

 mental vigor returned even more slowly than the bodily strength. 



The stadium criticum does not always pass immediately into con- 

 valescence ; the typhus proper is often followed by sequelae, which 

 are apparently caused by the high fever, disturbance of respiration, 

 continued abstinence, absorption of exudation, and other unknown 

 causes. This view of the sequelae of typhus is supported by the fact 



