1386 THE ENTEROIDEA GROUP OF TROPICAL FEVERS 



starvation. In mild cases the patient may show marked improve- 

 ment during this week, and the temperature may decline gradually, 

 and reach normal about the fourteenth day. This, however, is 

 rare, and usually the temperature keeps high during the whole 

 week, and the patient enters the third week with all the signs and 

 symptoms of the fully developed attack. 



The Third Week. — During the third week the temperature may 

 gradually fall to normal about the twenty-first day in typical cases, 

 and with this the various symptoms may subside and convalescence 

 begin. In moderately severe cases all the symptoms described in 

 the second week may continue, but the fever may be less, and may 

 gradually remit towards the end of the week. In the severer cases 

 the fever continues, and the patient passes into a condition com- 

 monly called the ' status typhosus.' This is the week in which 

 there is a great danger of haemorrhage and perforation of the intes- 

 tine. 



i; 13 14 15 1 16' 17 IS 19 20 21 22 23 24 Z 

 MtMtMEMtlMtMEMCMEMEMCMEMtMeM 



6 26 2> 28 

 E M E M E M E 



25 30 3. 3 

 M E M EM e M 



2 33 34 



35 36 37 



3« 39 4 

 M E M C M 



0 41 4 

 EMEU 



2 4:> 144 4 



E M\ElM E M 



5 46 47 4a 49 

 EMEUEMEME 





m 



as 

































Fig. 66o. — Temperature Chart of a Double Infection of Typhoid and 

 Paratyphoid B Fevers, 



In thejsevere cases the temperature remains high; the pulse 

 becomes quick; the tongue, teeth, and lips become covered with 

 sordes; the diarrhoea and abdominal distension become worse; 

 and the toxaemia produces delirium, at first mainly at night, but 

 later more or less continuously; or the patient may develop a quiet 

 state of delirium, lying quietly in the bed with the eyes open and 

 staring, and quite unconscious of the surroundings. The muscles 

 are markedly irritable, and show fibrillar contractions, tremblings, 

 and twitchings, with or without subsultus tendinum. Emaciation 

 now progresses, and the anaemia is more marked. This is the time 

 for the pharyngo-typhoid ulcer to appear, and tympanites develops. 



The great danger of the third week is perforation, which is said 

 to occur in about 3 per cent, of cases. It may take place in the 

 mildest of cases, and we have seen it in one in which only two 

 small ulcers could be found at the post-mortem examination, so 

 that no case can be said to be free from this danger. 



The symptoms are often sudden, severe, stabbing pain in some 

 part of the abdomen, and often referred to the region of the right 

 iliac fossa, but may also be referred to the left iliac fossa. This 



