1384 THE ENTEROIDEA GROUP OF TROPICAL FEVERS 



of the second week, during the third week, or even during 

 convalescence. 



The hps and tongue at the commencement of the second week 

 are in much the same condition as at the end of the first week, and 

 if the attack is of mild or medium virulence, they may remain in 

 this condition during the whole week ; but if the attack is severe, 

 and if the patient passes into the typhoid state, they alter in appear- 

 ance; for in this condition the patient lies on his back, breathing 

 through the partially open mouth, with the lips and teeth covered 

 with the dark brown scabs, formed from epithelial debris, micro- 

 organisms, and food, which are called ' sordes.' The tongue 

 becomes dry, and is covered with a brown or brownish-black fur 

 or crust, and may have painful cracks; but this condition is largely 

 due to oral sepsis, and is not part of the disease, and may be more 

 or less avoided by careful nursing and oral antisepsis. The pharynx 

 is generally more or less inflamed, and may be ulcerated, as may 

 the tonsils. Gastric disturbance, if present in the first week, is not 



Fig. 659B.— Temperature Chart of a Case of Paratyphoid A Fever. 

 (Chart made by Major Archibald.) 



continued into the second week as a rule, and it is rare to observe 

 vomiting in this week unless there is some complication. There 

 may be constipation or there may be diarrhoea, and the motions are 

 often of a yellowish colour, with alkaline reaction and somewhat 

 offensive odour, and may contain sloughs, which will be recognized 

 as greyish-yellow fragments of tissue about an inch in length. 



Haemorrhage is said to occur in about 10 per cent, of cases, but 

 our experience would indicate that it is more frequent than this. 

 It varies from a mere trace to a serious haemorrhage, and most 

 usually occurs from the end of the second to the end of the third 

 week — that is to say, during the period of separation of the sloughs. 



Often there are little or no signs or symptoms to mark a slight 

 haemorrhage, but a profuse haemorrhage produces serious symptoms. 

 Often a haemorrhage takes place without warning, but as it is known 

 to be possible, the attendants will be on the outlook for signs; and 

 our experience is that there often is warning given by the presence 

 of a trace of blood in the motions, by the slight increase of the pulse- 



