The usual premonitory symptoms are headache, loss of appetite, a feeling of general depression and aching of limbs. These symptoms may either be mild or may appear at once in very aggravated form; violent headache being usually of an acute dull character, accompanied by throbbing in the temples, giddiness, sleeplessness, palpitation, a feeling of oppression of the chest, even mental delusion may appear on the first day. The look of the patient is anxious, pale and cyanosed. The expression of the face resembles that of a man who has had no sleep for two or three nights but is being overpowered with the fatigue consequent to it. These symptoms are usually ushered in with a rise in the temperature. Well-marked rigor is usually not seen, but a slight shiver or chillness is complained of. Pulse is full, bounding and rapid—130 or more per minute. Respiration is difficult and accelerated even to 40 or 50 per minute. Skin is dry and hot, face puffed, conjunctivÆ congested. Sense of hearing is dull. Speech is thick and faltering. Tongue is dry and coated with greyish white or dark brown heavy fur. Violent thirst is present. Sometimes PatchiÆ appear on the skin. In a few hours, or a few days after the appearance of the first symptoms, a swollen gland appears either in the neck or axilla or groin. The gland most commonly affected is one or some of the femoral chain. An inguinal, axillary or a cervical gland may also be affected. A number of glands may swell at one time or glands in all the above situations may be felt painful and swollen. The glands of the neck are most frequently attacked in children. Pains in the lower part of the abdomen and along the spine indicate affection of internal lymphatic glands. In some cases the first symptom noticed is a swollen and painful gland, but fever soon manifests itself. The glandular enlargement may antedate, coincide with, or follow the rise in temperature. Sometimes only pain in the gland is complained of, but no swelling is observed. The temperature rises gradually and goes up to 104°, 105° or 106° F. In some cases a temperature of 108° was observed. There may be a marked morning fall and an evening exacerbation, which is a favourable sign, or the temperature may remain high persistently. All the above symptoms become soon aggravated when the second stage or stage of acute development of the disease appears. Brain symptoms show themselves. Lowson noticed four distinct type of brain symptoms—(1) comatose, when the patient lies paralysed, mind and body; (2) wildly delirious, when the patient struggles and fights and still retains a fair command of rational speech; (3) apathetic, when he lies perfectly quiet but is drowsy; (4) convulsive, which condition occurs when there is inflammation of the meninges or hÆmorrhage in the brain.

In this stage all symptoms of a pronounced typhoid condition supervene. Tongue becomes parched and black. Sordes cover the teeth. Gradually a somnolent condition and low muttering delirium supervene. In some cases the delirium is violent and furious, while in others it culminates in complete stupor and coma. Picking of the bed-clothes, and subsultus tendinum are common, and the urine and fÆces are passed involuntarily. The pupils are dilated. The skin is bathed with profuse perspiration. The pulse is dichrotic and compressible, and gradually becomes anachrotic and intermittent till it finally fails. The area of cardiac dullness is increased and pain in the cardiac region is complained of. Heart begins to fail rapidly. The usual complications of this stage are—(1) meningites; (2) hÆmorrhages; (3) severe gastric disturbance, such as vomiting, diarrhoea, hiccough. As a rule, constipation is found during the course of an attack, but diarrhoea, even severe, may appear. There may be pain in the abdomen. Bladder may be distended and a catheter may be necessary to evacuate it. Cystitics often develop. Œdema of the lungs, pleurisy and pneumonia may also complicate a case. HÆmaturia, hÆmoptysis and hÆmatemesis may be seen. Bronchitis and hypostatic inflammation may occur. The urine always shows presence of albumen. Death may take place from cardiac failure or from any of the above complications. Death may take place within three or four days, though in some virulent cases the patient dies within twenty-four hours. If the primary collapse is tided over, there is great chance of recovery, still deaths often occur of complications several days after the attack.

In mild cases the second stage is not so severe, and temperature may fall by lysis or crisis—the latter being rare.

The glands in the meantime become swollen and are surrounded by a sero-sanguinous exudation. The surrounding parts are oedematous. The glands usually do not suppurate, but they may do so and slough. The usual course after their enlargement is one of four: (1) resolution; (2) lengthened period of enlargement; (3) suppuration; (4) sloughing. In cases that recover the symptoms gradually take a favourable turn and recovery is as rapid as the attack. The fever slackens, the pulse becomes stronger, the tongue moist and the typhoid symptoms gradually pass away. The buboes either suppurate or subside; symptoms of secondary pyaemic conditions, however, may sometimes develop. Deviations from the typical course are, however, often observed. Some cases take an extremely rapid course, the patient succumbing within from 12 hours to two days. The duration of the disease varies between a few hours and a few weeks, but on an average up to the commencement of the convalescence it seems to last from 6 to 10 days. During convalescence the vitality of the issues are very low. Head symptoms sometimes persist for some time. Temper is irritable. The sloughing glands often take a long time to heal. Convalescence is soon established.