Typhus Fever does not always commence in the same way. It may happen that for several days before the disease assumes its peculiar and proper aspect, and before the patient is rendered unable to pursue his usual occupations, he is affected with certain morbid symptoms which may be considered premonitory of the fever; so that it is sometimes difficult to mark the precise beginning of the disease. The expression of the patient's countenance alters; he becomes pale, languid and abstracted. Those about him observe that he is looking very ill. He is feeble, and soon tired; reluctant to make any exertion of mind or body; listless, dejected, and apprehensive sometimes of some impending evil. He loses his appetite; his tongue becomes white and inclined to tremble; his bowels are irregular, often confined, rarely affected with diarrhoea; his senses lose their natural delicacy. He has uneasiness or wandering pains in various parts of the body; and occasionally there is some giddiness: drowsiness perhaps during the day, and unsound and unrefreshing sleep at night. To collect all this into one expressive word, the patient evidently droops.

Much more commonly, however, these preliminary movements are altogether wanting: the disease sets in suddenly. Its regular onset is marked, very frequently indeed, by a shivering fit. Another common symptom at the commencement is severe headache; pain or aching across the forehead, rarely in the temples, never at the back of the head. The pain is apt to begin during the night or in the early morning, but this is not constantly the case; nor is the pain a constant symptom. Sometimes there is a sense of heaviness and giddiness rather than headache. The expression of the face is dull and heavy, absent, puzzled; its hue thick and dusky. The patient presents very much the appearance of a person made stupid by drink; and he staggers a little when he attempts to walk. The muscular power is sensibly enfeebled: sometimes he will struggle against this; but in a few hours, or in a day or two at farthest, he takes to his bed.

Many of the symptoms which occur during the first stage of the disorder, that is, during the first week, are such as belong to the sanguiferous system. The pulse becomes more frequent than in health, there is increased heat of the skin, and thirst, headache and throbbing of the temples. The pulse varies considerably in different cases, generally it is quicker, but sometimes it is even slower than natural. The quickening of the pulse is greatest in those constitutions which are the most irritable. In young persons, in females, and in weak and delicate males, it will often rise, soon, to 120: while in stronger adults it does not so early attain its maximum of frequency, and perhaps does not exceed 100 throughout the whole course of the disease. Should the pulse in any instance reach 130 or 140, the disease is severe; and the majority of such cases prove fatal. It is almost always soft, soon becomes weak, and gradually gets weaker. Sir William Jenner affirms that in Typhus fever, running an uncomplicated course, the pulse rises slowly in frequency to a certain point, preserves that rate of frequency for a variable period, and then as slowly falls: while in Typhoid fever it rises and falls in a most irregular manner, to-day 120, to-morrow 90, the next day 120, without appreciable cause or consequence. A sudden and considerable increase in the frequency of the pulse should therefore, in Typhus fever, suggest the probability of some inflammatory complication. The skin, during this period, is generally hot and dry, and it feels hot to a bystander.

In severer cases the temperature may be much higher, even early; even above 106, according to Wunderlich. In fatal cases the temperature often rises just before death.

The thirst in Typhus is often troublesome for the first few days. The tongue becomes clammy or dry; sometimes it is clean and smooth; more often furred; its edges and tip may, perhaps, be red, while a white fur either covers entirely the central part of the tongue, or is divided by a straight brown streak which occupies its middle portion. This brown streak is often the first step to dryness and blackness of the tongue.

Slight and transient tenderness of the abdomen is not uncommon during the same period; and there is frequently difficulty of breathing.

The aspect of the patient is characteristic: the features are fixed and inexpressive; or expressive merely of apathy and indifference. If spoken to briskly he responds; and although his sensibility seems blunted, his answers are, as yet, rational and to the purpose.

Delirium does not come on, in general, till towards the end of first week. The patient lies on his back, motionless; he sleeps but little, waking often; and the short snatches of repose he gets are disturbed, apparently by uneasy dreams; and he fancies and perhaps says that he does not sleep at all; or he lies with his eyes open, evidently awake, but insensible to all that is going on around him. Sometimes, even during the first stage of the disorder, the prostration of strength is so great, or the tendency to stupor and indifference is so marked, that the stools are passed under him as he lies in bed, without any apparent endeavour on his part to prevent it, and without any notice of his wants being made to the nurse. The urine, during the same stage, is scanty, high-coloured and often offensive. It is seldom, except in very malignant forms of Typhus fever, that death takes place during this, its primary stage. Towards the end of the first weekly period, the eruption which is peculiar to Typhus fever commonly begins to show itself, although it is sometimes postponed till the next stage.

During the second week the pulse becomes more frequent, weaker, and softer. The tongue grows drier and browner. More sordes, and of a darker colour, accumulate on the teeth and lips. The patient generally loses his headache. His voluntary movements, however, become very much weakened, and are sometimes exercised irregularly. The posture which the patient in this stage almost always assumes is significant of this weakness; he lies on his back, and he sinks down in the bed, slips towards the foot of the bed. He is unable to make or bear that degree of voluntary exertion which would be necessary to place him upon his side; hence it is a good omen-because it is an indication that the patient still retains some strength-if we find him lying on his side, or even on his back with his knees drawn up. Other proofs of muscular debility, approaching to palsy, are apt to present themselves. The voice becomes feeble; the patient can scarcely utter an audible sound. Perhaps he is unable to swallow. This is a very bad symptom, though it is one that has been recovered from. Sometimes it seems that the power of swallowing is not lost, but the sick man is too listless to try to swallow: or the dry and parched state of his tongue and throat render it difficult and painful for him to attempt to do so. He lies with his mouth open; and breathing thus through the mouth tends to dry the tongue. Often, especially in bad cases, there are little convulsive startings of the tendons, and other irregular actions of the muscles: tremulous movements, especially of the tongue and of the hands: and sometimes he is unable to put out the tongue at all.