The pulse becomes more rapid and feeble and the first sound of the heart may be scarcely audible. The tempera ture in the milder forms may gradually fall to normal in the third week, but, in -severe cases, it continues as high as dur ing the second week, presenting, often, marked remissions.
eek.—During this period, as a general rule, convalescence becomes well established and there is a gradual abatement of the symptoms already de scribed. In severe cases the disease may continue throughout the fourth and even the fifth weeks in the same way as in the third, except that the adynamia and emaciation are increased. The urine and faeces may be passed involuntarily. The pulse becomes more rapid and weak, "the running pulse," and death takes place from heart-failure, asthenia, haemorrhage, or perforation. The temperature can be irregular, and may rise from slight causes. Perspirations continue even in the more favorable cases.
The disease may continue through the fifth and sixth weeks.
The Digestive System. — The tongue presents a characteristic appearance. When protruded, tremulousness is ob served; and, in the. latter stages of se vere cases, hesitation; and the patient, apparently from forgetfulness, does not withdraw it. The surface during the first part of the disease is covered with a white fur, thick in the centre and disappear ing toward the tip and edges. It is made up of micro-organisms, degenerated epi thelial cells, and particles of food. At the end of the second and during the third and fourth weeks the surface may become bare, red, and dry. It sometimes presents a glazed appearance, and is more or less cracked, or it may be covered with a brownish-black coating. This may re sult from breathing through the mouth, and is an indication of the severity of the disease. The gums and tongue often bleed, and the accumulation of blood, retained food, and epithelial cells around the teeth and lips form what is known as sorties. When convalescence becomes established the tongue gradually assumes its normal appearance, but the coating returns if there is any rise of temperature or impairment of digestion.
The lips become dry, hard, and cracked, and the mouth often contains a sticky mucus. The chewing of hard substances is often impossible, and even drinking is made difficult.
Anorexia and nausea are, as a rule, present, but occasionally the appetite is maintained throughout the whole course of the disease. The stomach will tolerate
liquid food except in some cases in which there is great gastric irritability, and this is usually more pronounced during the first week. Sometimes this irrita bility continues and the patient suc cumbs for want of sufficient nourish ment. Ulceration of the stomach very rarely occurs in typhoid, and perforation from this cause has been reported.
Thirst is a prominent symptom, and liquids will often be taken with avidity when, owing to the mental condition of the patient, they are not asked for.
More or less diarrhoea in some stages of the disease is the rule, but constipa tion may be present throughout, and this may be the case when extensive ulcera tion of Pet'er's patches is present. Hic cough is sometimes a troublesome symp tom, and is often hard to control.
The number of evacuations in the diarrhceal cases may be from 5 or 6 to 20 or 25 daily. They are copious: liquid, with solid particles (pea-soup character); of a yellow-ochre color, with offensive odor. When allowed to stand, the solid matter settles to the bottom, leaving a clear fluid on top. The former is com posed of undigested food, shreds of mu cous membrane, epithelial cells, mucous corpuscles, and crystals of tribasic phos phate.
The bacillus typhosus is not usually found in the intestinal discharges until after the tenth day. About the com mencement of the third week these or ganisms exist in large numbers, and re cent investigations have demonstrated the fact that the fakes may contain ty phoid bacilli some weeks after convales cence has been established.
Typhoid bacilli are present in the stools in the third week of the disease: from this time they rapidly diminish and soon disappear. If a relapse occurs. there is a reappearance of the organism in the stools. Those cases in which the bacilli are found in the stools long after the disappearance of the fever are cases where the bowel discharges were mixed with urine. In about 25 per cent. of all cases the typhoid bacilli are found in the urine. They rarely appear before the third week of the disease, and sometimes persist long after convalescence is estab lished. Therefore the urine is a much more dangerous excretion for the dis semination of typhoid fever than are the stools. P. H. Smith (Lancet, May 20, '99).