ACUTE INFECTIOUS DISEASES. 



the ulcers heal, the mesenteric glands return to their normal size, and 

 often shrink to small, firm, slate-gray bodies. Some, also, become case- 

 ous and subsequently calcareous. Typhus ulcers do not always heal 

 up, as above described. Occasionally the healing is delayed, but does 

 finally occur. In other cases there is ulceration at the edges and base 

 of the ulcer, which may cause erosion of vessels and abundant intes- 

 tinal haemorrhage or perforation of the intestine. It is difficult to de- 

 termine whether rupture of the serous coat in these slow ulcers finally 

 results from suppuration of its tissue, from extensive gangrene, or, after 

 destruction of the muscular coat, from simple rupture of the thin wall. 

 The fact, that, not unfrequently, errors of diet and mechanical causes, 

 such as compression of the abdominal contents by vomiting, precede 

 the perforation, seems to show that the perforation of the serous coat 

 is often induced mechanically. When death occurs late in the disease, 

 besides the remains of the typhus processes, we occasionally find the 

 evidences of croupous and diphtheritic inflammation of the mucous 

 membrane of the intestinal canal, especially of the large intestine, and 

 very rarely in the gall-bladder also. Lastly, we must add that more 

 or less extensive nephritis, as well as thrombi in the veins, is among 

 the changes not unfrequently found after the typhus proper has run 

 its course. 



SYMPTOMS AND COURSE. In many cases, the evident commence- 

 ment of the disease is preceded for days or weeks by indefinite pre- 

 monitory symptoms, which do not at the time enable us to determine 

 the nature of the malady, but are of diagnostic importance after the 

 disease has developed, as in doubtful cases they aid us in distinguish- 

 ing typhoid fever from other affections that begin suddenly, without 

 premonitory symptoms. These prodromata are feelings of general 

 illness, mental disquiet, great dulness and relaxation, loss of appetite, 

 indigestion, restless sleep disturbed by dreams, headache, dizziness, 

 wandering pains in the limbs, which are usually considered rheumatic, 

 and repeated epistaxis. These symptoms may last from a few days to 

 several weeks. 



We generally consider that the disease proper begins when 

 the first chill occurs during the premonitory symptoms, or, if there 

 has been no prodromal stage, when a chill notifies the patient of his 

 illness. This chill is rarely so severe and continued as in intermittent 

 fever or pneumonia ; there is usually no shivering or chattering of the 

 teeth. Frequently there is not a single chill, but several, and cases do 

 9ccur without any chill. Hence, especially in inattentive patients, we 

 ?annot always tell whether the disease is at the seventh or eighth, or 

 at the tliirteenth or fourteenth day. 



The pathologico-anatomical changes in the intestines during ty 



