Chapter XVI: Part II: , Showing Predominance of Malarial Element . . . . 617 (15)

The fourth stage, or that of cicatrization, usually commences with the beginning of the fourth week. The swelling of the edges of the ulcers gradually diminishes, and they become adherent to the tissues beneath. The floor of the ulcers covers itself with delicate granulations, which in course of time are converted into connective tissue. This is ultimately coated with epithelium, but neither the villi nor the glands of the mucous membrane are ever reproduced. The resulting cicatrices may be recognized by the affected parts of the bowel being thin and more translucent than in health, and may retain these characters after the lapse of several years. They never give rise to contraction of the bowel. The time occupied in the cicatrization of each ulcer is said to be about two weeks. It occasionally happens that while cicatrization is taking place at one end of the ulcer the process of necrosis and ulceration is still going on at the other, so that two or more ulcers may occasionally run together. This form of ulcer may often retard recovery, and may sometimes end in perforation of the bowel, even after convalescence seems to have been established.

The color and consistence of the mucous membrane of the cæcum and colon are in a large proportion of cases normal. In a few the membrane is paler than in health, and in others it is of an ash-gray color. It is also sometimes injected and softened. The solitary glands are frequently enlarged and ulcerated, like those of the ileum. In the former case the mucous membranes of the large intestine throughout its whole extent, but especially that of the cæcum and of the part of the colon adjacent to it, is studded with minute elevations about a line in diameter. When ulceration has occurred the ulcers are generally round {264} and small, but they may occasionally be oval and of considerable size. In the latter case their long diameter will correspond in direction with that of the circular fibres of the intestine. Murchison has known them to measure fully an inch and a half in length. The colon is generally found much distended with flatus.

Enlargement of the mesenteric glands from cellular hyperplasia and hypertrophy of the connective tissue is constantly associated with the morbid changes of the intestines just described. This enlargement varies in different cases. In some the glands are not larger than a pea or bean; in others they are said to have reached the size of a hen's egg. It is always more marked in the glands which lie in the angle between the lower end of the ileum and the cæcum, and usually bears some proportion to the intensity of the local disease; but it is not to be regarded merely as a result of the local irritation, as it has been observed in parts of the mesentery corresponding to perfectly healthy portions of the intestine, and as the meso-colic glands have been involved in cases in which the colon was free from disease. It has, moreover, been observed in cases in which death has occurred very early in the disease, and there can therefore be little doubt that it is as much the result of the infective process as the infiltration of Peyer's patches. In addition to being enlarged, if death has taken place before the end of the second week the glands are hyperæmic and of a purplish color. Later than this, when the sloughs become detached from Peyer's patches, the swelling of the glands diminishes; they lose their color and become pale, and if convalescence ensues they return finally to their former healthy condition. Still, Murchison has seen them shrivelled and pale or bluish for some time after convalescence. In other cases the substance of the glands softens, with the formation of a puriform liquid. If the softening only involves a small part of the glandular structure, restoration to health may take place through the absorption of this liquid. If it is more extensive, the whole of the glands may break down into this puriform liquid, which, when the patient recovers, undergoes caseous and finally calcareous degeneration. Occasionally, a gland in this condition is the cause of death from rupture and extravasation of its contents into the cavity of the peritoneum.

The glands in the fissure of the liver, the gastric, lumbar, inguinal glands, and indeed all the lymphatic glands in the body, have occasionally been found swollen and congested, but their enlargement cannot be classed among the specific lesions of the disease, but is merely the result of a local irritation. Thus, Jenner says that in the case of extensive ulceration of the oesophagus which came under his observation there was marked enlargement of the oesophageal glands. Liebermeister says that the lymphatic follicles which surround the glands at the root of the tongue and in the tonsils are often affected in the same way as the glands. In most cases after a time the swelling disappears, but sometimes softening and rupture take place.

The spleen is almost invariably found to be increased in volume and to have undergone changes in consistence and color. The degree of enlargement and the other changes vary of course with the stage of the disease at which death has occurred. The enlargement occurs with less frequency in elderly than in young people, and is most marked at the height {265} of the disease, the organ being then often twice or three times its normal size, and in some cases, it is said, even larger. Later, and especially during convalescence, the enlargement has generally very much diminished. During the first ten days of the disease the spleen is generally tense and firm, engorged with blood, and dark red in color. Between the tenth and thirtieth days its appearance remains the same, but the organ is found to be soft and friable. During convalescence it becomes paler and firmer again, and is often so shrunken in size that its capsule is relaxed and wrinkled. Hemorrhagic infarctions are often met with. These sometimes soften and break down into a puriform liquid, which may sometimes cause peritonitis by rupture into the peritoneal cavity. Rupture of the spleen is also said to have occurred from mechanical violence. These changes are due in part to variations in the amount of blood, and in part to a medullary infiltration of Malpighian corpuscles similar to that which takes place in Peyer's patches and the glands of the mesentery.

LESIONS WHICH ARE NOT PECULIAR TO TYPHOID FEVER, BUT ARE OF MORE OR LESS FREQUENT OCCURRENCE.--The mucous membrane of the pharynx and oesophagus may present a perfectly healthy appearance, but occasionally it is congested and the seat of ulcerations which are for the most part superficial. Sometimes, however, they have been found to extend to the muscular coat, but they have never been known to penetrate all the coats of these organs. Jenner refers to one case in which there was extensive ulceration of the oesophagus, but usually the number of ulcers is not large. In a few cases the mucous membrane of the pharynx is coated with diphtheritic false membrane, and the submucous tissue is infiltrated with serum and pus (Murchison).

The stomach and the upper part of the intestinal tract present no lesions which are at all peculiar to typhoid fever. In a certain number of cases congestion, softening, and even superficial ulceration, of the mucous membrane of the stomach, and less frequently of that of the duodenum, have been found. The mucous membrane of the jejunum and of the upper part of the ileum is not usually much reddened, and may be even paler than in health. In cases which have been protracted it may be of an ashy-gray or slate color. The contents of this part of the intestinal tract, which is rarely much distended by flatus, do not differ materially in appearance or consistence from the matter which generally composes the typhoid stool. The bowels may, of course, be found filled with blood in cases in which a recent hemorrhage has taken place. Invaginations of the small intestines, unaccompanied by any evidences of inflammation, are occasionally met with in the bodies of those who have died of typhoid fever. They are produced, there is good reason to believe, during the death agony, but are not peculiar to this disease, as they occur in many other diseases.

Enlargement of the liver has been found in only a few cases after death from typhoid fever. Softening is more common, but even this is not a frequent result of the disease, for it was absent in 41 out of 73 cases examined with special reference to this point by Louis, Jenner, and Murchison. The organ is occasionally hyperæmic, and darker in color than in health, but it is oftener pale or normal in appearance. Even, however, where it appears to be perfectly healthy to the unassisted eye, {266} the microscope shows that its cells are very granular and filled with oil-globules which often render the nucleus indistinct or completely conceal it. When death has taken place at an advanced stage of the disease many of the cells are found to be completely broken down into a granular detritus. These changes are usually proportional to the degree of pyrexia which has been present during life. Rarer lesions of the liver are pyæmic deposits, embolism, abscess, and emphysema.

The mucous membrane of the gall-bladder has been found to be the seat of ulcers by Jenner and numerous other observers. It also occasionally presents the evidences of catarrhal or diphtheritic inflammation. The gall-bladder usually contains a pale watery liquid of a less density than bile. When, however, inflammation of its lining membrane has existed, its contents are mixed with pus and shreds of false membrane.

The mucous membrane of the larynx is sometimes found to have been the seat of catarrhal or diphtheritic inflammation, and sometimes also of ulceration. Jenner says that in typhoid fever laryngitis independent of pharyngitis is extremely rare, but the German writers express a different opinion. Griesinger estimated that laryngeal ulcers were present in one-fifth of the fatal cases. Hoffmann found them twenty-eight times in two hundred and fifty autopsies, and that the ulcers had extended to and involved the cartilages in twenty-two out of the twenty-eight cases. They are most commonly found in the posterior wall of the larynx, and may involve the vocal cords. These are often discovered after death in cases in which their existence was not suspected during life. They were formerly supposed to be the result of typhoid infiltration of the laryngeal glands, but careful investigation has shown that they are the consequence of diphtheritic inflammation of the mucous membranes. Inflammation and ulceration of the trachea are comparatively rare. Hypostatic congestion and infarction of the lungs are not uncommonly found after death from typhoid fever, and less frequently the lesions of pneumonia. Evidences of recent pleurisy are also discovered in a few cases. Acute miliary tuberculosis of the lungs is more often met with as a sequela than as a complication.

The changes in the brain and its membranes caused by typhoid fever are few and unimportant, even in cases attended by severe nervous symptoms. Those most frequently found are adhesions of the dura mater to the inner surface of the cranium, injection or oedema of the pia mater, congestive oedema, and sometimes softening of the brain and effusion at the base of the brain. The microscopic changes do not appear to have been carefully studied. Liebermeister says that the gray substance of the cortical portion of the brain and of the interior is sometimes of a rather yellowish-brown color, and that he noticed besides diffuse yellow and blackish-brown spots in different places, particularly in the corpus striatum and thalamus opticus. In such places, he says, the microscope shows a diffuse yellow coloration, a deposit of small brown pigment-granules, and also, especially in the optic thalamus and corpus striatum, the ganglion-cells thickly crowded with brownish or blackish pigment-granules in such numbers as to conceal the outlines of many of the cells. These changes Hoffmann,[47] who has specially studied them, is inclined to place by the side of the parenchymatous degeneration of other organs. {267} The ganglion-cells of the sympathetic ganglia are said by Virchow also to contain an unusual amount of pigment.

[Footnote 47: Quoted by Murchison.]

The muscles are frequently the seat of marked changes in typhoid fever. Their macroscopic appearances vary with the stage of the disease at which they are examined. When death takes place in the first or second week they are usually dark red or reddish-brown in color, and very dry. If it is delayed until later, they "present a peculiar fawn or yellow tint permeating the ordinary red in patches and veins not unlike the appearance of veined marble." Their consistence is also so much diminished that the finger may be readily passed through them. Occasionally, pseudo-abscesses and hemorrhages into the muscular sheath are found, and Dauvé and B. Ball[48] report cases in which, in addition to these changes, rupture of muscles had occurred. Zenker, who was the first to call attention to them, ranged the changes seen under the microscope under two heads: (1) granular or fatty degeneration; (2) waxy degeneration. In the first variety the transverse striæ disappear and the sarcolemma appears filled with finely granular matter. In the second variety the striated muscles become, as it were, pervaded by a coagulating material which sets, and in contracting breaks up the fibres into great numbers of short waxy-looking lumps, not unlike a certain variety of casts of the tubuli recti of the kidneys. When recovery takes place the affected fibre is believed to be regenerated by a cell-growth within the sarcolemma. These changes occur in most fevers, as typhus, small-pox, scarlet fever, and are attributed by authors generally to the hyperpyrexia which is a frequent accompaniment of these diseases. Hayem, however, asserts that he has found them well marked in cases not characterized by a high temperature, and that, on the other hand, they are sometimes absent in cases where this has been present. The waxy form of degeneration may affect all the striped muscles, but is oftenest seen in the muscles of the abdominal walls, the adductors of the thigh, the muscles of the diaphragm, and tongue.

[Footnote 48: _L'Union Médicale_, 1866, quoted by _Biennial Retrospect of Medicine and Surgery and their Allied Sciences_, for 1865-66.]

The heart, in common with the other muscles of the body, suffers from both the forms of degeneration above described, but the granular form appears to be more common than the waxy. In protracted cases it is usually much softened, and when thrown upon a plate no longer retains its form. It has usually lost its normal color and acquired the tint described by the French as feuille morte (faded leaf). Upon minute examination the degeneration is found to have taken place in patches, the diseased fibres being found alongside of others which have scarcely undergone any alteration. These patches are especially common in the papillary muscles of the mitral valve--a fact which explains the occasional presence of systolic murmurs in typhoid fever. In addition to the microscopic appearances of the muscles already described, Hayem[49] has observed in his examinations of the heart a cellular infiltration of the connective tissue and a proliferation of the muscle nuclei. These changes are sufficient in his opinion to establish the existence of myocarditis. The same observer thinks he has also found evidences of the frequent occurrence of endoarteritis in the multiplication of the cellular elements {268} of the internal coat of the small arteries, which he has discovered under the microscope.

[Footnote 49: _Leçons cliniques sur les Manifestations cardiaques de la Fievre typhoide_, Paris, 1875.]

Some discrepancy of opinion exists in regard to the condition of the blood in typhoid fever. Trousseau, for instance, speaks of it as being profoundly altered and in a state of dissolution; Liebermeister says that at the height of the disease the blood is very dark-colored, and that after coagulation it presents a small and soft clot; and Murchison, that a dark, liquid condition of the blood is rarer than in typhus, and that fine white coagula are more common. Harley too has frequently found firm colorless clots of fibrin in the heart and roots of the great vessels in subjects dead in the third week of the disease. Forget concludes from an examination "of one hundred and twenty-three specimens of blood derived from patients in all stages of the disease that an appreciable alteration of the blood in the several periods of enteric fever cannot be accepted as a general fact; that the blood is rarely altered in the first period; that the alteration is more marked in proportion as the disease is more advanced; that the alteration is not always in proportion to the gravity of the disease."[50] I have myself seen the disorganization of the blood as complete in severe cases of typhoid fever which have rapidly proved fatal as in cases of diphtheria or of other malignant diseases. On the other hand, in protracted cases and during convalescence the blood is often thin and watery.

[Footnote 50: Quoted by Harley, Reynolds's _System of Medicine_, vol. i.]

The kidneys are sometimes engorged with blood, sometimes pale and flabby. Under the microscope the appearances are similar to those just described as occurring in the liver, and it is therefore unnecessary to refer to them more fully here. As a rule, the epithelium becomes granular earlier and to a marked degree in the cortical than in the tubular portion. The absence of albuminuria must not always be accepted as proof of a healthy condition of the kidneys, as this symptom has been wholly wanting in cases in which the organs have been extensively diseased.

Analogous changes have also been observed in the salivary glands and pancreas, except that, according to Hoffmann, a cellular proliferation precedes the degenerative process.

CLINICAL DESCRIPTION.--The invasion of the disease is usually so gradual that it is often impossible to obtain from patients exact information as to the time of the beginning of their illness. Among those who present themselves for treatment at the Pennsylvania Hospital it is not uncommon to find that many have suffered for several days, it may be as long as a week, or even longer, before taking to their beds, from vague feelings of discomfort, from headache more or less intense, aching pains in the back or limbs, or from sensations of chilliness alternating with flashes of heat. In other cases derangements of the digestive system are more prominent, such as nausea, or even vomiting, diarrhoea, or irritability of the bowels. Notwithstanding these symptoms, and the indisposition to exertion engendered by them, they have frequently continued to follow their usual avocations up to the time of their application at the hospital for admission. There is generally, however, no difficulty in recognizing at once the nature of their disease. Upon examination the pulse is found to be frequent, the respiration accelerated, the tongue furred, the skin hot and dry, and the abdomen tympanitic.

{269} Among patients whose position in life enables them to pay greater attention to trifling symptoms than those who are compelled to seek hospital relief, opportunity is frequently afforded to the physician to study the disease at a period less remote from its commencement. The symptoms it presents when seen as early as the second day are generally of a very indefinite character. There may be a feeling of malaise, headache with a tendency to giddiness, pain in the back and limbs, a slightly coated tongue, thirst, and anorexia. The patient may complain of chilly sensations alternating with flashes of heat, but it will rarely be found that the attack has commenced with a decided chill. Diarrhoea may also be present at this time, or may not supervene until later. Even in cases in which it is absent the bowels will generally act inordinately after the administration of a gentle purgative. Occasionally, the attack begins with vomiting, but this is not, in my experience, a frequent mode of commencement. If the visit be made in the morning, the febrile symptoms will be little marked, the pulse being only slightly accelerated and the temperature being rarely more than from a half to a degree above the normal. In the evening, however, the thermometer usually indicates a greater elevation of temperature.

At subsequent visits the same symptoms are presented. It will be observed, however, that the fever is decidedly remittent in character, the evening temperature being always from a degree to a degree and a half higher than that of the morning, while the temperature of each succeeding day is a little higher than that of the day which preceded it. The patient is restless and wakeful at night, or sleep, when obtained, is unrefreshing and disturbed by dreams. He grows dull and slightly deaf, and although able to answer questions intelligently when roused, does so with an effort, and soon after lapses into his former condition. Although obviously growing weaker every day, it is sometimes difficult to get him to take to his bed. The diarrhoea continues and increases in severity; the stools become watery in character and ochrey-yellow in color; they may exceed six, or even twelve, in the twenty-four hours. Epistaxis either consisting of a few drops of blood only, or so profuse as to endanger life, may also occur during the first week. Examination of the abdomen toward the middle or close of the first week will almost always reveal the existence of tympany and of tenderness and gurgling in the right iliac fossa, and very frequently also of slight enlargement of the spleen. The urine at this stage of the disease is dense, scanty, and of high color. The tongue too will be observed to be more heavily coated than at first, and to be dryish, the fur being disposed on the middle of the dorsum of the organ, while the tip and edges are free from it and abnormally red in color. Usually, toward the close of the first week, the pulse will be found to be between 100 and 120 in frequency. It often, however, does not attain this frequency, and in some cases does not exceed 50 throughout the whole of the attack. At the same time, the thermometer generally indicates a temperature of from 102° to 104°, and in bad cases even one much higher than the latter.

These symptoms are not pathognomonic, but Murchison regards their existence in a young person as warranting the suspicion that he is suffering from this disease. About this time, however, or, to speak more accurately, usually from the seventh to the twelfth day, a new symptom occurs {270} which is more characteristic. This is an eruption of isolated rose-colored spots, the tâches roses lenticulaires of Louis, occurring principally upon the surface of the abdomen, but not infrequently seen also upon the chest, back, limbs, and even, according to some authors, upon the face. They are round in shape, with a well-defined margin, usually about a line in diameter, but sometimes considerably larger, slightly elevated above the surface, and disappearing upon pressure, but returning when the pressure is removed. They can almost always be found at this stage of the disease if diligently sought for.

If the disease tends to run a severe course, all the symptoms become aggravated toward the end of the second week. The tongue grows dry and brown, the pulse more frequent, feeble, and markedly reduplicated in character, the diarrhoea still more severe, and the fever higher than before, with little or no tendency to remit in the morning. The nervous symptoms also come into prominence. The headache may grow more violent or may be replaced by increased dulness, which may sometimes be so decided as to render it difficult to fully rouse the patient. At other times delirium is a prominent symptom. This may only occur at night, but not infrequently is observed during the daytime as well. It is usually more active in character than that which accompanies typhus. Trembling of the tongue and of the limbs is not uncommon at this time. The urine becomes more abundant, paler, and less dense than before. Even in cases characterized by symptoms as severe as those above detailed some improvement is, however, often observed to take place between the fourteenth and twenty-first days. The morning remission becomes more decided, the evening temperature less high than that of the preceding day; the stools lessen in number, and gradually assume a more healthy appearance; the pulse diminishes in frequency and gains in force; the tongue becomes moist, and shows a tendency to throw off its fur; the trembling grows less marked; the dulness and delirium lessen; and the patient falls into a refreshing sleep. In other cases, in many of which recovery eventually takes place, there is at this time, instead of an improvement, a still further aggravation of the symptoms. The pulse becomes more feeble and frequent; the tongue is not only excessively dry and brown, but shrivelled and fissured; the lips and teeth are encrusted with sordes; the stools contain shreds of membrane, and often blood; the subsultus tendinum increases; carphololgia, or picking at the bed-clothes, occurs. The prostration becomes so extreme that the patient frequently slips down in bed from sheer weakness. The active delirium of the previous stage is replaced by the low muttering form, or the patient lies upon his back with his eyes half closed in a semi-unconscious condition, from which he is with difficulty aroused, and which may deepen into coma. Occasionally, however, the active delirium continues, and is associated with an obstinate wakefulness; the urine and feces are passed involuntarily, or, with an apparent incontinence of the former, there may be retention, which is very apt to be overlooked. If these symptoms continue for any length of time, bed-sores may form not only over the sacrum, but on other parts subject to pressure, and the patient, worn out by long-continued suffering, dies from exhaustion.

Occasionally, in the midst of these symptoms, and sometimes even in cases in which the condition is not so alarming, prostration approaching {271} collapse, without obvious cause, suddenly supervenes. The pulse becomes a mere thread, the surface is bathed in a clammy sweat, and the temperature is found to have fallen from four to seven degrees, and in some cases even more. These symptoms almost always indicate that intestinal hemorrhage has taken place, and are followed by the discharge of blood either in the course of a few hours or not until a day or two subsequently. If the hemorrhage be moderate in amount, and does not recur, reaction usually takes place in a short time; but if, on the other hand, it is profuse or frequently repeated, death may occur, either immediately or later, as the result of the exhaustion it has induced. Very much the same set of symptoms attend the occurrence of perforation of the bowel, an accident which is also liable to happen in the course of typhoid fever, but which may generally be distinguished from intestinal hemorrhage by its being accompanied by a sharp pain in the abdomen, which is frequently so severe as to cause the patient to cry out, by its not being attended with the same reduction of temperature, and by the absence of blood in the discharges. In a day or two all doubt will be set at rest, if the case be one of perforation, by the occurrence of general peritonitis.

A fatal termination is by no means the usual result, even in cases in which the disease has assumed its worst features. Indeed, it may be said that there is no condition in typhoid fever so grave that recovery from it is impossible. Many authors would make perforation of the bowel an exception to this general rule, but there are observations on record which would seem to show that this accident is not invariably fatal. Even in cases in which the patient has lain helplessly on his back in a semi-unconscious or comatose condition, passing his discharges under him, the physician will often be gratified to find at one of his visits some evidence of improvement, trifling as it will probably be. It may be only a slight change of position, an inconsiderable fall of temperature, or a scarcely appreciable moistening of the tongue; but these changes, insignificant as they apparently are, are sufficient to indicate to the practised eye of the observant physician the approach of convalescence. Next day there will be a still further reduction of temperature, a more decided moistening of the tongue, a sensible diminution of the nervous symptoms, and a reduction in the frequency of pulse. In this condition, however, as may be readily imagined, convalescence may be retarded by numerous accidents, and life may hang trembling in the balance for several days, or even weeks, before it is fully established. It is not necessary to recount here the various steps by which a return to health is reached, as they are essentially the same as those which mark the convalescence of the less severe variety of the disease, and have already been fully referred to in the description of that form.

But even after the establishment of convalescence, and after the patient has been free from fever for several days, febrile attacks lasting for a day or two, or even longer, may occur as the consequence of very slight causes, such as undue excitement, or fatigue of any kind, or the immoderate indulgence of the appetite, which in this condition frequently needs to be restrained. These attacks are usually spoken of as recrudescences of fever, and do not differ materially from attacks of irritative fever occurring under other circumstances. They usually subside under appropriate treatment with the removal of their cause, but leave the patient somewhat {272} weaker than they found him. In other cases, it may be a week or ten days after the fall of the temperature to the normal, and frequently at a time when all danger seems to have been passed, a true relapse of the disease occurs. In this, of course, all the symptoms of the primary attack are reproduced, including even the eruption of rose-colored spots. The temperature usually, however, attains the maximum more rapidly, and the duration of the fever is generally shorter, than that of the original attack. A second relapse is also not very uncommon, and even a third may occur. Various complications and sequelæ also occur in the course of typhoid fever, which will be referred to fully hereafter.

Another form of the disease, which it may be well to allude to briefly here before closing the general description of the disease, is the abortive form. In this variety the attack begins and runs its course up to a certain point, including often even the occurrence of the eruption, as it does in the majority of cases; but at a period which varies between the seventh and fourteenth day the symptoms suddenly subside and the patient rapidly convalesces. In some cases it may be difficult to distinguish this form from an attack of simple continued fever, and, in fact, in cases in which the eruption is absent it will be impossible, unless other cases of typhoid fever have occurred in the same house or family, or unless the patient has been unmistakably exposed to the influences under which the disease arises.

In a few cases the disease begins abruptly with a chill, intense headache, or with gastro-intestinal symptoms, which have in rare instances been so violent as to have suggested to the mind of the attending physician the possibility of corrosive poisoning. This, according to Chomel, is the most frequent mode of commencement, but his experience on this point is opposed to that of the great majority of observers.

* * * * *

I shall now proceed to describe in detail some of the most important of the symptoms presented by the disease.

Even in the beginning of an attack of typhoid fever the face has a listless and languid expression, although the eyes are usually bright and the pupils dilated. In mild cases no further alteration of the physiognomy than this may be noticeable throughout the whole course of the disease, but in bad cases, when the typhoid condition is fully developed, the expression becomes dull and heavy. There is, however, never the general suffusion of the face seen in typhus. On the contrary, the face is often pallid, or there is at most a circumscribed flush on one or both cheeks, which is most marked during the exacerbations of fever or after the administration of food and stimulants. During convalescence the effects of the long illness are fully visible in the face.

Prostration, or loss of muscular strength, is present from the beginning in a large number of cases of typhoid fever, but is generally not so marked in the early stages as in typhus fever. It is usually most intense in grave cases, but to this rule there are numerous exceptions. It is not rare to find patients, in whom the other symptoms are severe, able to sit up in bed, and even to rise to stool, throughout the attack. Bartlett records a case in which the patient did not confine herself to bed until the occurrence of perforation, and I have had under my care a man who, supposing he was suffering only from a slight diarrhoea, performed the duties {273} of a nurse in a military hospital until two days before his death, although the autopsy showed very extensive ulceration of the intestine. Several cases have come under my care in the second week in which patients have walked a considerable distance to make application for admission to a hospital. Generally, however, the prostration becomes extreme in the third and fourth weeks of bad cases, the patient lying helplessly on his back, and frequently slipping down in bed from sheer weakness.

Epistaxis may occur at any stage of typhoid fever, but is most common in the forming stage. Observers differ in opinion in regard to its frequency. Murchison noted it in only 15 of 58 cases, and gives it as his belief that it is more common in France than in England or this country. Flint found that it had occurred in 21 only of 73 cases, and Jenner in 5 of 15 fatal cases. On the other hand, Bartlett says that it is quite a common symptom, and Wood and Gerhard, from the frequency with which they had met with it in the beginning of the disease, were accustomed to regard its presence as of importance in a diagnostic point of view. Part of this divergence of opinion is probably due to the fact that it is usually small in amount, and therefore very apt to be overlooked. I have in many cases, after having been told there had been no epistaxis, found the evidence of it upon the fingers or bed-clothes of the patient. It may, however, be so profuse as to endanger life and render necessary the use of the tampon. Except in the latter case it is without influence upon the course of the disease.

The skin may be almost constantly dry as well as warm throughout the whole course of the fever in a small proportion of severe cases. But, on the whole, perspiration occurs with greater frequency in typhoid fever than in any other acute disease, unless it be rheumatism. It takes place most commonly at night after the evening exacerbation, or in the morning when the patient awakes from sleep, but it is not very rare to find the skin clammy at other times. The sweating is usually general, but in a few cases it is local only. When colliquative, it is frequently exhausting, and is then a grave symptom. It is sometimes prolonged into convalescence, when it is not only annoying, but in consequence of the prostration it induces may sometimes retard the restoration to health.

I have never been able to satisfy myself that any peculiar odor is given off by the skin in typhoid fever, and most observers make a similar statement. Chomel, however, asserted that the perspiration has a strong acid odor, and Bartlett agreed with Nathan Smith in thinking that typhoid fever patients exhale a peculiar odor, not pungent and ammoniacal, like that of typhus, but "of a semi-cadaverous and musty character," which is especially noticeable during the later stages of severe and fatal cases.

The eruption is one of the most characteristic symptoms of the disease. Indeed, in many cases, without it the diagnosis would be impossible. It is rarely absent in a well-developed case. Murchison says that it was noted in 4606 cases only out of 5988 admitted into the London Fever Hospital in twenty-three years, but admits that it would probably have been found in some of the others if it had been properly looked for. Wood says that he has seldom met with cases in which it was absent. It is oftener absent in children than adults--a circumstance which makes the diagnosis of the disease in the former often a matter of great difficulty. It consists of isolated rose-colored spots, slightly elevated above {274} the surface, circular in form or nearly so, having well-defined margins, usually about a line in diameter, but sometimes varying from half a line to two and even three lines in diameter, and disappearing on pressure, to return when the pressure is removed. They are generally first observed some time between the seventh and fourteenth days, but cases are on record, especially in children, in which they are said to have appeared much earlier, and others in which they could not be discovered until the twentieth day. In the latter cases, however, it is not improbable they had really been present at an earlier period, but had escaped detection. The eruption occurs in crops at intervals of three or four days, each spot lasting from three to five days, and the whole duration of the eruption being usually from ten to twenty, and varying of course with the severity of the attack. It may continue to appear as late as the twentieth day, and in cases of relapses very much later. Spots are sometimes seen on the abdomen or elsewhere after the subsidence of fever, and whenever seen indicate that the diseased process is not at an end. They are usually scattered over the lower part of the front of the chest and the abdomen, but are also not infrequently met with upon the back, and if they are not found upon the abdomen, the patient should be gently turned upon his side and this part of his body carefully examined. When very abundant they are often also seen upon the extremities, and occasionally even upon the face. Wood has seen them abundant on the upper and inner part of the thigh, and confined to that place. When tardy in making their appearance, they may often be brought out by application of a mustard plaster or by that of heat in any form; and it is probably, therefore, owing in large measure to the warmth of the bed that they are often so fully developed upon the back. In number they may vary from two or three to several hundred. In one case Murchison counted one thousand, and in three cases which came under my care in the winter of 1881-82 the body was so thickly covered by spots of an unusually large size that when I first saw the patients I directed them to be isolated under the fear that the disease would prove to be typhus fever. When very numerous the edges of two or three of the spots may run together, giving the eruption an irregular character. No relation between the copiousness of the eruption and the severity of the disease has ever been proved to exist. While the prevailing impression, therefore, that cases in which the eruption is freely developed are apt to be of a mild character, is true in many instances, it is by no means so in all. The three cases above referred to all ran a severe course, and one of them proved fatal. The spots disappear after death, and are rarely converted into petechiæ, but in bad cases I have seen purpura spots, and even vibices, developed independently of them. Sometimes the appearance of the eruption is preceded for a day or two by a delicate scarlet rash, which Tweedie says resembles roseola and has been mistaken for scarlet fever.

Sudamina, so called from their resemblance to sweat-drops, also occur not infrequently in this disease. They are minute vesicles, often not larger than a pin's head, but sometimes two lines in diameter, and occasionally, in cases in which two or three have coalesced, much larger. They usually contain at first a clear serum, which may, however, subsequently become turbid, and when very minute must, in consequence of {275} their transparency, be viewed obliquely to be seen. Frequently, when they cannot be distinguished by the eye, they are readily detected by the touch. They rarely occur before the twelfth day, and often not before the close of the third week. Their most usual seat is the neck, the folds of the axillæ, and the groin, but there is no part of the body except the face in which they may not occur. They are most frequently seen in those cases attended by profuse sweating, and are by no means peculiar to typhoid fever, but are met with in other diseases--as, for instance, acute rheumatism--which are attended by this symptom. They are generally followed by branny desquamation of the cuticle in the position they have occupied.

Spots of a delicate blue tint--the "tâches bleuâtres" of French writers--are sometimes observed on the skin in cases of enteric fever. They must be of infrequent occurrence in this country, for, although I have looked carefully for them in every case that has come under my care, I have rarely been able to detect them. According to Murchison, "they are of an irregularly rounded form and from three to eight lines in diameter. They are not in the least elevated above the skin, nor affected by pressure, even at their first appearance. They have a uniform tint throughout their extent, and they never pass through the successive stages observed in the spots of typhus. Two or three of them are sometimes confluent. They are most common on the abdomen, back, and thighs." They are said in some cases to be distributed along the course of the small cutaneous veins, and to occur most frequently in cases which are mild. They are met with in other diseases, and usually precede in appearance the characteristic eruption of typhoid fever.

The hair is very apt to fall out after an attack of typhoid fever. The nails suffer in their nutrition in common with other parts of the body--a fact which may be recognized by the peculiar markings which are found upon them after recovery, and to which attention has been particularly drawn by Morris Longstreth in a paper in the _Transactions_ of the College of Physicians of Philadelphia, vol. iii., 3d Series.

The circulation is usually accelerated from the beginning of an attack of typhoid fever. The degree of acceleration is commonly proportioned to the severity of the other symptoms, and especially to the elevation of the temperature, and is generally more marked in the evening than in the morning. It is subject, however, to numerous variations, not only in different cases, but even in the same case from day to day, and even from hour to hour. Murchison refers to a case in which the pulse sank to 37, and never exceeded 56 during the fever, although it rose to 66 during the convalescence. I have never had the opportunity myself of observing such an infrequent pulse in the febrile period of the disease, but have had cases under my care in which the pulse often fell below 60, and in which it never exceeded 80 until after the commencement of convalescence. A comparatively infrequent pulse may coexist with a high temperature. Thus, for example, a pulse of 80 was noted in one of my cases at the same time that the thermometer showed that the temperature was 105°, and on another occasion in the same case the pulse was 82 and the temperature 104-1/2°. As a rule, the pulse is more frequent in cases which terminate fatally than in those which end in recovery; but to this rule there are numerous exceptions. In eight of Louis's cases it never {276} went above 90, and in some of my own it did not reach 100 on more than one or two occasions. On the other hand, in mild cases the pulse may be exceedingly frequent, reaching, and even exceeding in many cases, 120. When the disease is prolonged and the prostration is extreme, a pulse of from 140 to 150 is not uncommon. In the majority of cases which have come under my care the pulse has varied in frequency from 80 to 120. In some cases the range has been between these two figures, in others it has been very much less.

During convalescence the pulse usually gradually diminishes in frequency, and may sometimes fall below the normal standard. I have known it in a few instances to fall to 38, and have often met with pulses ranging between 40 and 60 at this period. In other cases, on the contrary, the pulse continues frequent during convalescence, or readily becomes so after a slight exertion or excitement of any kind. A slow pulse during convalescence has been in my experience most frequent in men whose health previous to the attack was good, and a frequent pulse in women and delicate men. If the convalescence is retarded by a complication, the pulse will maintain its frequency until this is removed.

The pulse will of course present other changes than those above referred to. It is in the beginning firm and full, but after the first week becomes small and compressible, and acquires the peculiarity known as reduplication. Sometimes, when this is not well developed, it will be rendered quite distinct by elevating the patient's arm. Irregularity or intermission of the pulse, although not commonly observed in this disease, occasionally occurs. The heart's action will also be observed to grow feeble in the course of severe cases, and its first sound indistinct, but neither of these changes is as marked in typhoid as in typhus fever. Hayem asserts that in a certain number of cases a systolic bellows murmur, with its point of greatest intensity at the apex, is heard during the course or at the close of the second week. This murmur is sometimes soft in the beginning, but becomes harsh and intense later, or may have these characters from the start to such a degree as to give the impression that endocarditis exists. During convalescence an anæmic murmur is not infrequently present.

The respiratory movements are accelerated in typhoid fever, as they are in all febrile conditions, independently of any disease of the lungs, and their frequency is generally proportional to that of the pulse. In looking over my records of cases I find that the former are less liable to fluctuate from day to day than the pulse, and that when the latter becomes abnormally infrequent they do not sink below the standard of health. In several cases of which I have notes the respiration was from 20 to 28, while the pulse was below 60, and in a case referred to by Murchison the pulse was 42 at the same time that the respirations, although no pulmonary lesion could be discovered, were 48. The respiration is often, as in the case just alluded to, very much accelerated when the most careful examination of the chest will not lead to the detection of any disease there. This is sometimes the consequence of very great tympanites, which, by interfering with the descent of the diaphragm, gives rise to dyspnoea, but it may also occur as a purely nervous phenomenon. The air expired by patients has been examined, and has {277} been found sometimes, in the later stages of the disease, to contain ammonia.

Bronchitis is so common an accompaniment of typhoid fever that auscultation rarely fails to reveal its presence in some form or other. In some cases there may be only slight harshness of the respiratory murmur at the base of the chest, but in a large number of cases the auscultatory signs will be sonorous, sibilant, and mucous râles. The last named may be so numerous that I have known the disease in the beginning mistaken for acute bronchitis, and even acute phthisis, by accomplished diagnosticians.

Headache is one of the most constant symptoms of typhoid fever. Bartlett says that it is rarely absent, Louis found it in all but 7 of 133 cases, and Jackson noted it in nearly all his cases. It is often the first symptom of which the patient complains, and, when not present at the beginning of the attack, makes its appearance soon after. It is almost as common, although less severe, in mild cases as in grave ones. It sometimes persists throughout the attack, but oftener subsides at the close of the first week or toward the middle of the second, or the patient may cease to complain of it in consequence of the dulness which is very apt to supervene. It is usually referred to the forehead and temples, but may extend over the whole head. It is usually dull and heavy, but in a few cases is throbbing. It is said by authors rarely to be severe, but I have known it so intense and acute as to cause the disease at its commencement to be mistaken for meningitis, and Jackson asserted that it is sometimes so severe that local bloodletting, and even venesection, had to be employed for its relief. It would appear to be as common in children as adults.

The headache is sometimes accompanied by vertigo and dizziness, and even by retraction of the head. Distressing pains in the back and limbs may also occur, and in rare cases even contraction of the hands and feet.

In the beginning of an attack of typhoid fever the patient usually suffers from wakefulness and restlessness at night, and it occasionally happens that the wakefulness becomes a distressing symptom. But in a great many cases, sooner or later in the course of the disease, drowsiness supervenes. In mild cases this symptom is late in making its appearance, and is generally slight and evanescent, but in grave cases it may come on as early as the eighth day, and when once present may gradually become more profound until it deepens at last into unconsciousness. It usually persists until the occurrence of death or of convalescence, but may alternate with periods of delirium, the delirium being more frequent at night and the somnolence by day. It is as frequent in children as in adults. Occasionally, the wakefulness of the earlier stage may reappear at the beginning of the third week, and coexist with muttering delirium, or occasionally with delirium of a more violent character. It then constitutes a most unfavorable symptom, the patient frequently passing several days and nights in incessant agitation, and sinking finally from exhaustion due to want of sleep.