has set in, the temperature may again rise, and the attack be repeated, though curtailed in duration, constituting a relapse. A relapse may likewise interrupt the declining course of the disease. Sometimes, when convalescence is apparently about to set in, the temperature reascends and remains elevated for an uncertain period, constituting a recrudescence.

What is the distinction between a relapse and a recrudescence in typhoid fever?

A typical relapse in typhoid fever includes a redevelopment of the entire group of morbid phenomena of the primary disease, as indicated by a characteristic temperature-curve, splenic enlargement and rose-rash, though the duration may be shortened.

A recrudescence refers only to a reappearance of fever. The temperature of recrudescence does not pursue a typical course; it may fall as suddenly as it rose. A recrudescence may depend upon some complication or some accidental source of irritation, e. g., peritonitis, or constipation or the premature or injudicious taking of food. A relapse indicates renewed activity of the specific cause of the disease.

How is perforation of the bowel in typhoid fever to be recognized?

Perforation of the bowel in the course of typhoid fever may or may not be preceded by intestinal hemorrhage. When it occurs, the patient experiences a sudden and intense pain, localized at one spot in the abdomen, but soon extending. There may also be rigors. Tympanites, if absent, develops; if present, it increases. Vomiting may occur. There is exquisite abdominal tenderness; the patient lies upon his back, with the legs drawn up; the face is pale, pinched and anxious; the pulse is small, hard and rapid; the breathing is shallow and thoracic. Shock and collapse are common. With the fall of temperature, the patient's mind may become clear. Death may take place in a few hours; but more commonly the temperature again rises and the symptoms of peritonitis become predominant, death occurring in the course of a few days.

Fatal perforation may, however, occur without decided symptoms either of shock or of peritonitis; or there may be a sudden fall or a sudden rise of temperature, a sudden increase in the pulse-rate or in the intensity of the prostration, or there may be sudden vomiting; or there may be simply persistent and rebellious tympanites, with comparatively slight abdominal tenderness and, perhaps, marked depression in the general state of the patient. While perforation is usually fatal, recovery has occurred in well-authenticated instances.

How are typhoid fever and pyemia to be differentiated?

Pyemia may be attended with typhoid symptoms, diarrhea and cerebral manifestations. The temperature (Fig. 4), however, pursues a different course from that of typhoid fever; it is irregular and presents wide variations in range, often declining below the normal. The morning temperature may be normal, that of noon several degrees above normal, that of evening lower than that of noon. There may be great and sudden changes from day to day. In addition, there may be recurrent chills and sweats. The rose-rash is wanting. The detection of a primary focus of suppuration and the results of metastasis point to the cause of the equivocal symptoms.

How are typhoid fever and a typhoid condition to be differentiated?

A condition of asthenia and low vitality developing in the course of certain febrile conditions, surgical affections, septicemia and pyemia, possibly attended with diarrhea, is to be dis

tinguished from typhoid fever by the previous history: on the one hand, there are the evidences of some constitutional or local disease; on the other, epistaxis, headache, continuous fever of gradual invasion. The age of the patient may have weight: typhoid fever being infrequent after thirty-five and rare after fifty, while in the aged many diseases, especially pneumonia, commonly assume a typhoid type. A rose-rash is significant of typhoid fever.

How are typhoid fever and yellow fever to be differentiated?

Initial headache and pains in the loins attend both typhoid fever and yellow fever; but, in the latter, epistaxis and diarrhea are wanting, the onset is abrupt and the symptoms remit on the second or third day. The discoloration of the skin that gives its name to yellow fever is wanting in typhoid. Yellow fever is a disease of hot climates; typhoid fever, one rather of temperate climates.

How are typhoid fever and variola to be differentiated?

For several days it may be impossible to distinguish typhoid fever and variola from one another. Both present headache and pains in the back. Epistaxis and diarrhea may be wanting in typhoid fever. The onset of variola, however, is likely to be abrupt; that of typhoid fever insidious and gradual. On the third or fourth day, there appears in variola a characteristic eruption; simultaneously, the temperature declines. The eruption of typhoid fever is unlike that of variola and rarely appears before the fifth day. The subsequent course of the two diseases is sufficiently diverse to remove any possibility of confusion. The presence or absence of vaccine protection and the existence of other cases of one or of the other disease may have some weight in the early diagnosis.

How may one avoid confounding pneumonia with typhoid fever?

While pneumonia may present symptoms of a typhoid character and a temperature-course not unlike that of typhoid fever, the respiratory frequency is out of all proportion to the pulserate, while careful physical examination will reveal the signs of pulmonary consolidation (dulness on percussion, bronchial breathing, crepitant râles, increased vocal fremitus and vocal resonance) and perhaps the friction-sound of an associated pleurisy. Pleurisy, however, is by no means rare early in the course of typhoid fever. The appearance of rusty sputum clinches the diagnosis of pneumonia. It must, however, be borne in mind that pneumonia may occur as a complication of typhoid fever. In such a case, the association must be recognized by the rose-rash, the splenic enlargement, the diarrhea and the protracted course of the disease.

How are typhoid fever and trichiniasis to be differentiated?

Trichiniasis may present many of the manifestations of typhoid fever, but the epistaxis, the severe headache, the enlargement of the spleen, the characteristic stools, the typical temperature-curve and the rose-spots are usually wanting. The knowledge that there is such a condition as trichiniasis, with inquiry as to the food taken and the detection of nodules in the painful muscles, ought to be sufficient to prevent mistake.

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Typhus Fever.

What are the symptoms of typhus fever?

Typhus fever, also called fumine-fever, ship-fever and jail-fever, is an acute, infectious, essential fever, a type of contagious disease. It develops in crowded and unwholesome places, among the poor and wretched, but it may be communicated to any. It has a period of incubation of variable duration-from a few hours to two weeks, during which the patient is comparatively comfortable, or there may be a brief stage of preliminary depression.

With the onset of the disease there are general malaise, headache, perhaps a chill, pains in the back and a heavily coated. tongue, perhaps with nausea. The temperature rises to between 104° and 1060 F.; the pulse is frequent, at first full, but early becoming feeble. Stupor soon develops. The bowels are usually constipated. The expression is dull. The conjunctiva are injected. The pupils are usually contracted. The face appears livid. A musty odor is manifest. The body may be covered by a diffuse, red rash. Between the fourth and the sixth day a coarse, papular eruption appears, usually on the trunk and extremities, exceptionally on the face. Intermingled with this are many petechial spots. For two or three days new papules appear, to recede gradually and disappear.

At the close of the first week or early in the second, low, muttering delirium, or coma-vigil, without great restlessness or with ceaseless tossing, muscular twitching and jactitation, appears; the mental depression is profound. In the cerebral type there is a wild, fighting delirium, with intolerance of light and illusions of sight and hearing. Excitement is soon succeeded by weakness and prostration, perhaps by fatal coma. some cases the respiration is shallow, irregular and noisy, though no change in the lungs can be detected. The heart-sounds are feeble, though the beat may be excited. Often, there develops

In

an endocardial murmur, due to the depraved state of the blood. The tongue is brown and cracked, the teeth and gums covered with sordes. The urine is scanty, high-colored, deficient in chlorides and may contain albumin.