ACUTE INFECTIOUS DISEASES. 



infectious diseases. If the intestinal symptoms fail entirely, or if there 

 are only slight indications of them, while the bronchitis is severe and 

 is early complicated with collapse and hypostasis of the lung or with 

 decided pneumonia, we have the disease which, especially in those 

 fatal cases where autopsy has shown medullary infiltration of the 

 bronchial glands, has been called pneumo-typhus or broncho-typhus. It 

 is evident that these cases, where the patients have a very cyanotic 

 look and hastened and painful respiration, belong to the malignant 

 forms. While the severe fever increases the production of carbonic 

 acid, the disease of the bronchi and lungs impedes the excretion of the 

 extensively formed deleterious gases. The formation of typhous ulcers 

 in the larynx is not usually accompanied by any characteristic symp- 

 toms, and modifies the appearance of the disease so little that we are less 

 justified in making " laryngotyphus " a separate class than we should 

 be in so considering broncho- and pneumo-typhus. But while, during 

 the first weeks of the disease, laryngeal ulcer is not usually recognized, 

 and is accidentally found on autopsy, it plays a very important part 

 hi the sequelae of typhus. 



Among the accidents that interrupt the normal course of the dis- 

 ease during the first weeks, the most important are perforation of the 

 bowel, intestinal haemorrhage, and the abundant epistaxis which 

 occasionally occurs during the second or third week. 



The perforations of the intestine, which occur during the first 

 weeks of the disease from the formation of a slough not only in the 

 mucous coat covering the patches, but also in the muscular and serous 

 coats at the affected parts, induce intense peritonitis ; but since, pre- 

 vious to the perforation, there has occasionally been adhesion between 

 different loops of intestine, from inflammation of the peritonaeum, this 

 inflammation is sometimes partial, not total, at first. The first signs of 

 perforation are a severe pain in the abdomen, which usually arouses 

 the patient even from deep stupor, and which becomes excessive on 

 the lightest pressure over the abdomen; the patient collapses sud- 

 denly, the face becomes distorted, the pulse small, the extremities cool, 

 and death usually occurs in from twenty-four to thirty-six hours, with 

 the symptoms that we have described (Vol. I.) as indicative of peri- 

 tonitis from perforation of the bowel. The most certain point in the 

 diagnosis of perforation of the intestine is the escape of air into the 

 peritoneal cavity, which is shown by the liver being pressed away from 

 the abdominal wall and a consequent disappearance of the liver-dul- 

 ness. If this symptom be absent, there is at least a possibility thai 

 the peritonitis is not due to perforation of the intestine. 



Intestinal haemorrhages, occurring in the first weeks of typhus, from 

 erosion of the vessels on the detachment of the slough, or from rupture 



