TYPHOID FEVER. (54.3 



stances, the infection with typhous poison may give rise to local 

 changes in the intestines, but induce so little alteration in the blood 

 and nutrition as to cause no noticeable functional disturbance. 



While in typhus ambulatorius the constitutional disturbance and 

 fever are so slight as to be scarcely observable, some other cases of 

 typhoid are characterized by unusual intensity of the constitutional 

 disturbance, and especially by the height of the fever. In these cases 

 the disease usually runs a " tumultuous " course. Even in the first 

 week the temperature rises to 106 or more, and the pulse beats 120 

 to 130 per minute. During the day, the patients lie in a state of 

 deep somnolence, and look stupid ; at night they have high delirium, 

 and can scarcely be kept in bed. Subsultus tendinum, picking at the 

 bedclothes, and occasionally convulsive movements, begin early. The 

 ntensity of the local symptoms usually corresponds to that of the gen- 

 eral disease. The tongue becomes dry and crusted early ; even during 

 the first week the bronchitic symptoms, the signs of condensation of 

 the lungs, the meteorism, diarrhoea, and the enlargement of the spleen, 

 attain as high a grade as they usually do by the end of the second 

 week. Toward the end of the first or the beginning of the second 

 week the patient is greatly prostrated, slips down in bed, has a small, 

 irregular pulse, and very rapid superficial respiration. Such patients 

 often die early of paralysis of the heart and oedema of the lungs. In 

 other patients, after a tumultuous course during the first week, the 

 symptoms moderate and show no marked peculiarities during the 

 second or third week. Between typhus of great intensity and tu- 

 multuous course, and typhus of moderate intensity, and between this 

 and typhus ambulatorius, there are numerous intermediate forms, 

 which we shall not fully describe. Many cases, treated for weeks as 

 " gastric " or " mucous " fever, and finally recovering without any affec- 

 tion of the intellect or dryness of the tongue, are mild cases of ty- 

 phoid ; but it is certainly going too far to scratch gastric and mucous 

 fevers entirely out of the list of diseases. As we have shown above, 

 the height of the bodily temperature is more important than the roseola 

 or the enlargement of the spleen in diagnosing between typhoid, that 

 is, an infectious disease, and a genuine intestinal catarrh. 



The appearances are also modified when the typhous intestinal 

 disease is very slight, or, to use the customary expression, when the 

 typhus localizes itself very slightly, if at all, in the intestines, and 

 " runs almost exclusively in the blood." Since, in the first weeks espe- 

 cially, the distinction between abdominal typhus and other acute in- 

 fectious diseases is based chiefly on the intestinal symptoms, an exact 

 diagnosis is entirely impossible in such cases, and we must occasionally 

 content ourselves with a probable diagnosis, by the exclusion of other 



