VARIETIES 



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sharp pain disappears, but is replaced by a more general pain all 

 over the abdomen, which may be persistent or intermittent. At 

 times this general pain may be absent. Sometimes, but by no 

 means always, there is vomiting. Usually there is more or less 

 collapse, as indicated by the pinched features and the quick, small, 

 thready pulse. The temperature generally falls, but quickly rises 

 again; the abdomen becomes distended; the liver dulness is en- 

 croached upon by the tympanites, and the breathing becomes 

 thoracic; while the urine may be suppressed. The prostration 

 increases, and the patient may gradually sink and die. In other cases 

 peritonitis may intervene before death. A small perforation may 

 not present the above typical symptoms, and may be only suspected 

 at first by the fall of temperature and the rise of the pulse-rate. 



The Fourth Week. — In typical cases the temperature has fallen 

 to normal by the commencement of this week, and the tongue has 

 begun to clean and all the symptoms abate and gradually disappear, 

 and convalescence begins. Now comes the danger of a relapse, as 

 towards the end of this week the patient begins to get hungry. 



In severe cases the symptoms may continue unabated, and com- 

 plications may occur. 



In protracted cases the patient lies in the status typhosus with a 

 high temperature, passing urine and faeces involuntarily, and may 

 die from cardiac failure, from perforation, or some other complica- 

 tion. 



The Fifth and Sixth Weeks. — These should be weeks of convales- 

 cence, but at any time a relapse may take place, while complications 

 and sequelae may occur. 



Varieties. — The various types of typhoid fever may be classified 

 in the following sequence: Ambulatory, abortive, mild, typical, 

 severe, and the masked. 



The ambulatory is typically presented by a person who feels ill 

 for some days or weeks, but goes about his usual work, feeling 

 exceedingly wretched, until, perhaps, someone, noticing how ill 

 he looks, may take his temperature, and perhaps find it over 

 104° F. ; thereupon the patient seeks advice for the first time, 

 and may be well into the second or even third week of the disease. 

 More rarely a patient may go through the whole attack without 

 medical assistance. Often, however, the illness may begin with 

 the ambulatory variety and end with an exceedingly severe attack. 



The mild, the typical, and the severe, have been included in our 

 general or typical account given above, and these are estimated 

 to be about two-thirds of all cases of enteric fever. 



The masked type of fever is that in which one special group of 

 symptoms is pronounced, as, for example, the nervous, with the 

 severe headaches, neuralgias, early delirium, and other marked 

 mental symptoms — e.g., mania or the signs of meningitis. Another 

 example is that in which the pulmonary symptoms are speci- 

 ally marked — e.g., the early bronchitis or the pneumonia. Other 

 examples are the severe gastro-intestinal symptoms, imitating 



