ACUTE INFECTIOUS DISEASES. 



crust, which gradually becomes blackish by admixture with blood 

 from small fissures in its mucous membrane. Decomposition of the 

 coating of the tongue and teeth causes a very disagreeable, penetrating 

 odor ; movement of the tongue is much impaired, so that speech be- 

 comes indistinct, chewing of hard substances often impossible, and 

 even drinking difficult. Physical examination of the thorax almost 

 always shows more or less extensive condensation of the dependent 

 portions of the lungs ; on both sides of the spine the percussion-sound 

 is less intense ; on ausculting over the back, we find a weak vesicular 

 or undecided breathing and fine mucous rale, rarely bronchial respira- 

 tion, and at other parts of the chest there are numerous loud rhonchi 

 The belly is usually puffed up by the excessive meteorism of the intes- 

 tines, which has never been explained. Its sensitiveness to pressure 

 continues, as does the ileo-caecal gurgling in many cases. The en- 

 largement of the spleen has increased ; and that organ is pressed still 

 farther backward and upward by the inflated intestines. In some 

 cases the roseola spots have become quite numerous, and have spread 

 from the epigastrium and lower half of the thorax to the back ; suda- 

 mina frequently occur. Among the objective symptoms of fever, the 

 bodily temperature in the evening is usually 104 to 106 ; in the 

 morning there is only a slight remission. The pulse, which is less 

 full, soft, almost always double, is often as high as 110 to 120, or 

 more. In many cases the urine contains traces of albumen. 



In the third week of typhoid fever, the patient becomes excessively 

 weak ; he cannot sit up ; and, if the bed be inclined, he slides down 

 coward the foot of it, as often as he is lifted up. In the relaxed mus- 

 cles we may often see and feel contractions of single fasciculi, the so- 

 called subsultus tendinum. The somnolence and stupor reach the 

 highest grade ; the noisy delirium ceases, and the restlessness gives 

 place to increasing stupor; some patients make automatic motions 

 with the hands, or pick at the bedclothes, and almost always pass 

 their faeces and urine in bed. Occasionally the detrusor urinae is also 

 paralyzed, and the bladder excessively distended. The coating on the 

 tongue and teeth becomes thicker, crusty, and fetid ; the stammering 

 speech grows unintelligible ; drinking is very difficult. The chest and 

 abdominal symptoms, also the frequency of respiration, rhonchi and 

 mucous rales, dulness along the back, diarrhoea, and meteorism, become 

 very decided. The spleen does not enlarge any more, but its swell- 

 ing begins to subside. In the third week the roseola spots also 

 Ixjgin to grow pale, while the sudamina increase, and petechiae some- 

 times appear. In most patients there, is erythema about the sacrum 

 and detachment of the epidermis, and the exposed cutis sloughs. At 

 the commencement of the thi~i week there is also apt to be an ir> 



