1YPHOID FEVER. 645 



of the overfilled capillaries in the spongy elevations of the mucous 

 membrane over the plaques above described, if abundant, often betray 

 themselves before the appearance of blood in the dejections, by the 

 collapse of the patient, which is accompanied by a sudden fall of his 

 temperature, and occasionally by a clearing of the intellect. The loss 

 of blood is often very considerable, but patients rarely die as a direct 

 result of the haemorrhage; the bleeding usually ceases, the typhus 

 pursues its course, but the strength of the patient does not carry him 

 through, and most patients die, sooner or later, after the haemorrhage, 

 from the exhaustion that is completed by the fever and diarrhoea. 



The abundant haemorrhages from the nose during the second and 

 third weeks are far less dangerous than the intestinal haemorrhages ; 

 they are due to an acute hsemorrhagic diathesis, which frequently 

 occurs from excessive debility. They may be so severe as to require 

 the tampon, they exhaust the patient, and at least retard convalescence. 

 In women there is often haemorrhage from the genitals also, which does 

 not always occur at the menstrual period. Although the loss of blood 

 is not great, those haemorrhages which are greeted by the laity as 

 favorable signs are usually mail ominis. 



If we bear in mind that most typhus patients recover very slowly 

 even when the intestinal ulcers heal, the fever disappears, and the ap- 

 petite returns immediately after the disease has run its course, and do 

 not fully regain their strength for five or six weeks, it is not difficult 

 to understand that retarded healing of the intestinal ulcers, and the 

 continuance of even a moderate fever by the bowel-disease, should in- 

 crease the danger to the patient. In these cases we find the typhus 

 proper followed for weeks by symptoms of an asthenic fever, or of a 

 fever in debilitated and anaemic persons. The intellect remains cloud- 

 ed, although the violent delirium usually disappears ; the patient be- 

 comes weaker, and slips down in bed more frequently than before. 

 The tongue does not again become moist, or else becomes dry again, 

 the bronchitic symptoms disappear, but the hypostases extend; en- 

 largement of the spleen and roseola spots can no longer be found, but 

 the meteorism and diarrhoea continue more or less marked. The bed- 

 sore over the sacrum spreads, increases in depth, and may cause fright- 

 ful destruction. Bed-sores also develop over the trochanters, elbows, 

 and on the knees also, if the patients be laid on the belly. Petechiae 

 and ecchymoses form at different parts of the body, especially where 

 there has been any temporary pressure. Emaciation becomes exces- 

 sive ; the pallid skin is constantly bathed in perspiration. The visible 

 mucous membranes also become pale and bloodless. There is often 

 slight oedema of the lower extremities, or excessive oedema of one leg 

 from thrombosis of the femoral vein. Many patients die in the sixth 



