The fact that the difference between typhus and typhoid fevers was first recognized only a few years ago affords sufficient evidence that the symptoms of these diseases must be very similar. In describing typhoid fever it will consequently be sufficient if we cate the leading points in which it fers from typhus. Among the earlier symptoms (although they are sometimes postponed to the end of the first week), the most. characteristic are abdominal pains and diarrhea. These are due to an ulcerated condition of the intestines, which will be presently noticed. The diarrhea is either spontaneous, or con tinues after the operation of a purga tive. The stools are loose and frequent.; and either of a dark color and fetid, or of a yellow, pea-soup-like appearance. The abdomen is found on examination to be unnaturally hard and resisting, tympanitic, and sometimes much dis tended; its shape, as Dr. Jenuer was the. first to remark, "is invariably the same, and somewhat peculiar. Its convexity is front side to side, and not from above downward. The patient is never pot-bel. lied, but tub-shaped; the cause probably being that the flatus occupies the colon, ascending, descending, and transverse." Pressure over the region of the ca:cum frequently excites uneasiness, and usu ally gives rise to a peculiar gurgling movement, which is both audible and palpable, and doubtless arises from the intermixture of liquid and gaseous mat ters in the bowels. This gurgling is a still more common symptom at a more advanced stage of the disease, and is of the greater importance since it is rarely met with in typhus or any other dis order. An eruption usually appears at from the 8th to the 12th day of the dis ease. This typhoid rash is very differ ent from that occurring in typhus; it consists of slightly elevated papule or pimples, with their heads rounded, and their bases gradually passing into the level of the surrounding cuticle. These papillm are circular, and of a bright rose color, which fades insensibly into the bac of the surrounding skin. Through out their whole course they disappear completely on pressure, and reappear when the pressure is removed. Each papula lasts three or four days, and fresh ones make their appearance every day or two after their first eruption. The number present at a time is usually from six to twenty, but their limits may range from 1 to more than 100. Theta average size is a line in diameter, and they chiefly occur on the abdomen, chest, and back. As a general rule no fresh spots occur after the 30th day.
The diarrhea, to which reference has already been made, continues with tha progress of the disease, the r atient often having from three to six evacuations daily, and often unconsciously passing them in bed.
This persistence of the diarrhea is one of the results of ulceration of the bowels. An other result of this ulceration is the occurrence of hemorrhage from the bowels, which is one of the most alarming of the symptoms of typhoid fever. It occurs most frequently during the third and fourth weeks, and varies from a mere stain to a large amount. Sometimes the blood thus poured out by the ulceration of the mesenteric veins is retained in the bowel, and is only discovered after death, the clots being unable to pass through the valve of the cmcum. This hemorrhage is always an extremely bad symp tom, and may either cause immediate by fainting, or may so weaken the ixitient, as to cause him to succumb to the disease.
The ranges of temperature in typhoid and typhus fever differ very considerably, and although the range in a mild case of either of these diseases differs considerably from the range in severe cases, the foregoing diagram, copied by Dr. Aitken from Wunder
lich and Traubeo, shows the typical ranges of temperature in these diseases contrasted throughout their course, from the beginning to the end of the disease. The records indicate morning (M) and evening (E) observations. The dotted lines indicate the typhus range, and the continuous dark lines indicate the range in typhoid. This diagram is so plain as to require no explanatory details. It is worth while, however, to direct the reader's attention to the rapid changes which in typhoid occur on and after the 22d day, and in typhus about the 15th day. With regard to the duration of the two diseases, Dr. Jenner found that the average duration of fatal cases of typhoid was 22 days, and of typhus 14 days; the former disease may terminate favorably during the fourth week, and the latter from the 13th to the 17th day.
In cases of recovery from typhoid, a remarkable fatuity remains for a considerable time; a childishness of mind often remaining for more than a mouth after apparent restoration to health. "The patient," says Dr. Aitken, "generally wakes up, as it were, from the fever, a complete imbecile. The whole man is changed. He seems to have renewed his youth. 'Childhood and infancy return, and the greatest care is necessary to prevent untoward events. No man can be considered as fit for work or for general mili tary sercicefor three or four months after an attack of severe typhoid fever." —The Science and Practice of Medicine, 3d ed., vol. i. p. 3S2.
Typhoid fever is essentially a disease of childhood and adolescence, the average ago at which it occurs being 21f years, and it being very rarely that a person aged more than 50 is attacked; while typhus attacks persons of all ages, from early infancy to extreme old age.
The appearances presented on the examination of the body after death are very dif ferent in these diseases. While in typhus the most common morbid appearances are a fluid condition of the blood; hyperemia of the cerebral membranes, and increase of inter-cranial fluid; bronchial catarrh and pulmonary congestion. especially at the pos terior part of the lungs, which are more or less collapsed; softening of the heart, liver, and spleen, and enlargement of the kidneys; in typhoid, there is one constant and char acteristic lesion, viz., a morbid condition of the agminated glands (or glands of Peyer) and solitary glands of the small intestine, and especially of the former. These morbid changes may be briefly summed up as follows: Thickening, redness, tumefaction, and finally ulceration or sloughing of the glands, the ulceration always occurring in the lower third of the small intestine. On the assumption that the natural office of glands is, as Dr. Carpenter suggests, to separate noxious matters from the blood, and to discharge them into the intestinal canal, Dr. C. J. B. Williams suggests that the ulcera tion so constantly met with in typhoid fever may result from the continued operation of the poison of that disease, thus escaping. When these changes proceed as far as ulcer ation, the case is one of extreme danger, although death does not necessarily ensue, because the scars left by healed ulcers are often seen when patients, who have had typhoid fever, have subsequently died from some other disease. The existence of these ulcers is, however, likely to prolong the illness after the fever itself has ended; to pro tract convalescence, and to hinder recovery; and to endanger life, even in cases of apparent convalescence, by causing hemorrhage or perforation of the bowel. This per foration, which gives rise to intense peritonitis, occurs in about one in five fatal cases, and generally takes place through the ileum near the valve.