Chapter XVII: Part II: , Showing Predominance of Malarial Element . . . . 617 (16)

Some degree of mental hebetude is rarely absent, even in the mildest cases of typhoid fever, and is usually among its earliest symptoms. It may, however, be absent occasionally in cases which run a severe course. It exhibits itself in the beginning in an indisposition to be disturbed, a slight inability to fix the thoughts, or a loss of memory. Generally, the {278} patient will be able at first, by an effort, to rouse himself from this apathy, but the moment he relaxes this effort will lapse into his former condition. As the disease progresses the hebetude becomes more profound and is overcome with greater difficulty. In mild cases it may continue until the occurrence of convalescence, but in grave cases it is soon lost in delirium. This is one of the commonest symptoms of the disease. If I should rely solely upon my own experience, I should say that it was rare for any but the mildest cases to run their course without its occurring at some time or other. Louis found, however, that it was absent in 32 cases, 8 of which were fatal, out of 134 cases, and Murchison in 33 cases, 3 of which ended in death, out of 100 cases. In 8 of these fatal cases death was due to perforation--a fact which would seem to show, as suggested by James C. Wilson, that this symptom is not dependent upon the intensity of the local disease alone. The delirium of course varies with the severity of the other symptoms, and especially with the intensity of the fever. In its mildest form it consists of a slight confusion of ideas, which is readily dissipated by fixing the patient's attention, and is most apt to occur in the night or when he first wakes up from sleep. In other cases it is much more marked; occasionally it is violent and noisy; the patient may talk wildly and incoherently, he may break out into a paroxysm of screaming, or, possessed with a sudden terror, he may leave his bed and attempt to rush from the room or to jump from the window. Later in the course of the disease the active delirium subsides, and low muttering delirium takes its place. The latter may go on until convalescence occurs, or the patient may gradually fall into a comatose condition, which very often ends in death.

The delusions from which the patient suffers are various. I have known in two instances a perfectly pure young girl call loudly for her baby, which she accused her mother and sister of keeping from her. Very frequently patients insist that they are in a strange place, and beg piteously to be taken to their home and friends; occasionally, in grave cases, the patient declares that there is nothing the matter with him. This Louis was accustomed to regard as a bad symptom, having never known recovery to take place after it. Delirium generally first makes its appearance some time in the course of the second week, but occasionally the invasion of the disease is marked by maniacal excitement. I have known delirium to occur on the second or third day. Louis records two cases in which it was present during the first night, and Bristowe[51] one in which it was noted on the fourth night. It is sometimes so prominent a symptom in the beginning of an attack that the patient has at first been supposed to be affected with acute mania. M. Motet[52] indeed refers to a case in which a man was actually admitted into an insane asylum before the true nature of his disease became known. On the other hand, delirium may not occur until much later in the disease--sometimes not before the close of the third or even the fourth week, when it may suddenly make its appearance when least expected. I have known it to be present in a marked degree during a relapse when it had been wholly wanting in the primary attack.

[Footnote 51: _Trans. Path. Soc. Lond._, vol. xiii.]

[Footnote 52: _Archiv. gén. de Méd._, 1868, quoted by Murchison.]

During convalescence, especially in cases in which there has been much {279} mental disturbance during the febrile period, the intellect may be weak, and continues so in some cases even after recovery in other respects is complete; but it is rarely permanently impaired. Insanity may also occur during the convalescence or after recovery, but it is usually under these circumstances amenable to treatment. In some cases the moral sense appears to be weakened after an attack, as in the case reported by Nathan Smith, in which a young man of previously good habits developed thieving propensities after his recovery.

Hyperæsthesia of the skin exists, according to Murchison, in about 5 per cent. of the cases, and may occur at any stage of the disease. It is chiefly observed in the abdomen and lower extremities, and is more frequently met with in women and children than in adult males. In a case which was partially under my care during the past summer the slightest touch made the patient, a boy of fifteen years, cry out with pain, and the administration of an enema gave him excruciating agony. Occasionally, the tenderness over the abdomen is so great that it is sometimes difficult to distinguish it from that due to peritonitis, except by the coexistence of hyperæsthesia in other parts of the body. It is very often associated with spinal tenderness, and sometimes with other spinal symptoms. Murchison does not regard it as a formidable symptom.

Cutaneous anæsthesia may also occur, but it is certainly less common in the earlier stages than hyperæsthesia. Rilliet and Barthez look upon it as of grave diagnostic import when it occurs in children.

Muscular tremor is also a common symptom of typhoid fever. A little tremulousness of the tongue when protruded may often be detected before the close of the first week. A little later the hands will be observed to tremble when held up, and still later twitching of the tendons at the wrist may be appreciable while the pulse is being felt. When muttering delirium supervenes this subsultus tendinum becomes constant, and extends to other parts of the body. The hands of the patient are frequently then in constant motion, either picking at the bed-clothes--a very unfavorable symptom--or moving in an objectless manner through the air. This condition presents many points of resemblance to that often seen in delirium tremens, and is said to come on earlier and to be more marked in those who are addicted to the abuse of alcoholic liquors. Hiccough is occasionally observed toward the close of grave cases, and is justly regarded as a bad symptom.

Spasmodic contraction of various groups of muscles is occasionally observed in severe cases, but is less frequent than muscular tremor, and in my experience is generally met with in the earliest period of the disease. The muscles of the extremities, especially those of the legs, are oftenest affected, but I have known the head as rigidly retracted as in tubercular meningitis, and have seen cases in which strabismus has been an early symptom. Murchison has had patients under his care who have suffered from constriction of the pharynx to such an extent that they could not swallow. He also reports cases in which trismus and spasm of the glottis have been present. General convulsions are not common, but occasionally do occur. Although a very grave symptom, they are not invariably fatal. Recovery took place in one of two cases which came under my own observation, and in four of the six recorded by Murchison. They are not always associated with an albuminous {280} condition of the urine. In neither of my cases was there albuminuria, and in only one of the four of Murchison's cases in which the urine was examined was it present. In one of my cases--the fatal one--the convulsions seemed to have been induced by giving the patient improper food; in the other no cause could be discovered.

Ringing or buzzing noises in the ears are present in the early stage of the disease in a large proportion of the cases, and may sometimes persist until the disease is well advanced. Usually, however, after a few days they subside and give place to deafness. This is a very common symptom, and may either affect both ears or be limited to one. In the former case it is probably generally due to the blunted perceptions of the patient, although in a few instances it may be caused, as suggested by Trousseau, by inflammation of the Eustachian tube. When only one ear is affected the deafness is of more serious import, as it is then dependent upon the presence of local inflammation, which may possibly extend to the meninges. It is, as a rule, most marked in the severest cases. Unless there has been a local inflammation it is not followed by permanent impairment of the hearing. It has even been regarded by some observers as a favorable symptom, but this opinion does not appear to rest upon a more substantial basis than the observation of Louis, that the most profound deafness adds nothing to the gravity of the prognosis.

Imperfect or perverted vision occasionally occurs in the course of typhoid fever. In a case which was recently under my care, and which has already been referred to in another connection, there was double vision associated with strabismus. Sometimes haziness of vision, and sometimes even visual illusions, are observed. Bartlett and Murchison have often known intolerance of light present in cases characterized by active febrile excitement. As a general rule, the pupils are widely dilated and the conjunctiva pearly white--a condition which is in marked contrast with what is seen in typhus fever. When, however, stupor supervenes in bad cases, the pupils are frequently as much contracted and the conjunctivæ as much injected as in the latter disease. In a few cases unequal dilatation of the pupils has been noticed. Trousseau was accustomed in his clinical lectures to call attention to the frequency with which sloughing of the cornea occurred in the condition known as coma vigil, in which the patient lies with his eyes wide open. He attributed this accident to the fact that the eye in this condition is not kept constantly moist by the occasional closure of the eyelids, and hence, as its innervation is also impaired, is especially prone to take on ulcerative inflammation. In other cases there is a free secretion of viscid matter, which often glues the eyelids together.

The sense of taste is often lost or perverted. This is partly due to impaired innervation of the tongue and palate, and partly to the thick deposits which usually cover the mucous membrane of these organs.

Frequent observations of the temperature in typhoid fever not merely give most important information in a diagnostic and prognostic point of view, but also often furnish valuable indications for treatment. From a close study of a large number of cases, Wunderlich and other physicians have discovered that the pyrexia has certain characters which distinguish it from other fevers, and which, being present in a case in which the other symptoms are obscure or ill defined, will often enable us to recognize {281} its true nature. The pyrexia may be divided into three periods, each having its own peculiarities. It is usually said that each period lasts about a week, but in severe cases the second and third periods extend over a longer time than this, and the occurrence of a complication or of any other disturbing influence will have its effect in producing either a prolongation of any one or more of these periods, and especially of the last two, or an unwonted elevation or fall of temperature. During the first period there is a progressive rise of temperature, but the rise is never so abrupt as in typhus or in many of the phlegmasiæ. As there are morning remissions, ranging from a degree to two degrees in extent, corresponding to the morning fall in the daily variations of temperature, the tracing upon the temperature chart will be a zigzag line, each evening temperature being from a degree and a half to two degrees higher than that of the preceding evening, while the same difference will be observed in the morning temperature. The temperature ought, therefore, never in an uncomplicated case to be much over 100° on the first evening or 102° on the second. A temperature of 104° at any time during the first or second day will consequently exclude typhoid fever from the diagnosis. From six to eight days are usually occupied before the maximum is reached. I have seen it attained as early as the fourth day in mild cases, and, on the other hand, not until much later in severe ones. It is usually 104° or 105°, but will of course vary with the gravity of the other symptoms. The temperature rarely rises higher than 106° at this period. On the other hand, I have known cases in which it never exceeded 103° during their whole course. It would therefore be wrong to exclude typhoid fever from the diagnosis, as Wunderlich does, if this temperature is not reached by the sixth, or at latest the eighth, day.

In the next period the temperature usually ceases to rise, but has a tendency to oscillate about the maximum temperature of the previous period as a fixed point, occasionally not quite reaching it, at other times rising a little above it. The morning remissions, too, become less decided. In other words, the fever now becomes continuous. This period, although usually lasting about a week, may extend over more than two weeks, even in the absence of complications, in cases which run a severe course, and when it is prolonged from this cause the temperature may again show a tendency to rise, and may even attain an elevation considerably above that of the preceding period. The prognosis in all such cases in which the temperature rises after the middle of the second week is grave. Temperatures of 108°, and even of 110.3°, have been noted at this time. Death invariably follows such high temperatures as these, but before death actually occurs a considerable fall of temperature very often takes place. Wunderlich has also called attention to the fact that it is not uncommon for a sudden and temporary remission of temperature to take place at this stage, varying from one degree to two degrees and a half, which may last from ten to twelve hours, and which usually has occurred in his experience from the sixteenth to the eighteenth day. Toward the close of the second period the morning remissions will be observed to be more decided, while the evening temperature remains about the same as before. The beginning of the third period is indicated by a diminution of the evening exacerbation, while the morning remissions become still more marked. The diminution is progressive, but slow, the {282} temperature each evening falling short by from half a degree to a degree of the point it reached the preceding evening. The morning remissions, on the other hand, each day become greater, a fall of three and a half degrees being not uncommon. The lysis, therefore, occupies usually a longer time than was required by the pyrexia in reaching its maximum. Toward the close of this period the morning temperatures may be normal, as even subnormal, while an elevation of temperature may continue to take place in the evening. Occasionally, however, an abrupt defervescence takes place. The duration of this period will be very much prolonged if complications are present or if the intestinal ulcers are slow in healing. I have known it to last for more than three weeks. During convalescence the temperature is frequently subnormal even in the evening, but the slightest cause is often sufficient to produce a considerable though temporary elevation of temperature. I have known the temperature in one case to rise from 99° F. to 105.6° in a few hours in consequence of an indiscretion in diet, and in another from 100° to 104° from the suffering and excitement caused by a severe attack of toothache. Indiscretions in diet are a fruitful source of these recrudescences of fever. The fever of the third period has all the characters of an irritative fever, and is probably kept up by the irritation arising from the intestinal ulcers. On the other hand, that of the first two periods is due to the action of the specific poison upon the nervous system and the other tissues of the body, and corresponds exactly with the primary fever of the eruptive diseases.

{283}

The febrile movement, however, rarely follows a perfectly typical course, and I consequently find, in looking over the temperature sheets of a large number of cases, very few which bear, except during the first period, anything more than a general resemblance to the chart which {284} Wunderlich has prepared as typical. A very slight cause will exercise, as has already been said, a disturbing influence upon the course of the fever, and serious complications or accidents will of course produce a still more marked effect. An intestinal hemorrhage, for example, will cause a rapid and decided fall of temperature. I have often known it to fall from 104° to the normal temperature, or even below it. This depression, unless the bleeding continues and the case ends fatally in the course of a few hours, is only temporary, the temperature rising within twenty-four hours to its former height, and sometimes even beyond it. A free epistaxis or a copious diarrhoea will in the same way cause a fall of the temperature, but it is rarely so marked as in the preceding case. The same effect is produced by the administration of large doses of quinia or by the application of cold water either in the form of the bath, the douche, or any other form, to the surface of the body. On the other hand, the occurrence of a complication will cause a rise of temperature, often considerably above the maximum of the first period.

The thermometer should be used at least twice daily. In this country it is generally introduced into the axilla, and less frequently into the mouth, for the purpose of making an observation. In other countries it is not infrequently inserted into the rectum, and even into the vagina. The best hours for making the thermometric observations are eight in the morning and eight in the evening, since it has been ascertained from {285} frequent observations that the daily remissions are more marked between the hours of 6 and 8 A.M., and that the temperature usually reaches its maximum some time between those of 7 and 12 P.M.

Loss of appetite is, except in mild cases, one of the earliest symptoms of the disease, and usually persists as long as the fever lasts. It is sometimes accompanied by positive loathing for food, but generally there is no great difficulty in persuading the patient to take the necessary amount of nourishment. During convalescence the appetite returns, and is occasionally immoderate, so that it is frequently necessary to curb it lest harm should be done by over indulgence.

Thirst, usually proportionate to the degree of fever, is also present in the beginning of the fever. Later, when the patient sinks into a semi-unconscious condition and becomes insensible to the wants of the system, he will cease to call for water, although it is still urgently needed.

Nausea and vomiting sometimes occur at the beginning of the disease, but they have not been such frequent symptoms in my experience as they would appear to have been in that of Murchison, who says that they are of such common occurrence that the patient is often supposed at first to be suffering merely from a bilious attack. He does not regard them, when occurring at this stage, as serious symptoms. Indeed, he expresses the belief that the subsequent course of the disease is sometimes favorably modified by them. They may also occur later in the disease, and are then of grave import, as they are not infrequently the consequence of peritonitis. Louis regarded vomiting as a grave symptom, but it is probable it occurred in the cases from which he makes his deductions late in the course of the disease. It may sometimes occur during convalescence, and may then interfere very materially with the proper nutrition of the patient. The matter vomited usually consists of a greenish bilious fluid, with the food last taken. In some cases blood has been thrown up.

The tongue at the beginning of an attack of typhoid fever is usually moist and coated with a thin white fur, and in mild cases may retain these characters until the close. Even in some cases which terminate fatally in the course of the second week, the tongue, with the exception of being less moist than in health, may present no marked deviation from this appearance. Generally, however, as the disease progresses, and sometimes as early as the tenth day, it becomes dry and brownish, and is protruded with a tremulous motion. Still later it tends to cover itself with a thick brown coating. This coating is disposed principally along the middle of the organ, leaving uncovered the edges and tip, which are very apt to be unnaturally red in color. The bare portion at the tip is often rudely triangular in shape--a point which is regarded as of some importance in the diagnosis of the disease by Da Costa. In bad cases, during the course of the third week the tongue is frequently crossed by cracks and fissures, which are the cause of much discomfort to the patient, and when deep may bleed and leave behind them scars which are recognizable during the remainder of his life. In other cases the tongue is dry, brown, and shrivelled, or covered with a tenacious, viscid secretion which renders it difficult to protrude it.

In favorable cases, as convalescence approaches the tongue regains by degrees its normal appearance. At first the only noticeable change may {286} be that the organ is a little less dry than before. In a few days it will be observed to have become moist and to be gradually throwing off its coating. The process is, however, a slow one, and one, moreover, subject to frequent interruption. Very often, when it seems nearly completed it will be suddenly arrested, and the tongue become dry and brown. Sometimes, instead of cleaning itself gradually, the tongue throws off its coating in large flakes, leaving the mucous membrane red and shining, as if deprived of its papillary structure. Wood was accustomed to teach that if the tongue when thus cleaned remained moist convalescence might be expected, but would always be tedious. This is an observation the correctness of which I have had abundant opportunity to confirm. If anything happens, however, to interfere with the progress of convalescence, it not infrequently becomes dry and coats itself over again. When the restoration to health is retarded by the continuance of diarrhoea or by the occurrence of any intercurrent affection, the tongue will often become pale and flabby and be the seat of superficial ulcerations or of aphthous exudations.

The mucous membrane of the posterior fauces is also often red and dry and covered with a glutinous secretion, which often materially interferes with swallowing. The lips and teeth are in bad cases encrusted with sordes, and the former are dry and cracked, and bleed readily when picked.

Meteorism or tympanites is observed in the greater number of cases of typhoid fever, having been noted by Murchison in 79 out of 100 cases, and by Hale in 130 out of 179 cases, and in only 43 of the remainder of his cases is it expressly stated to have been absent. My own experience leads me to believe that it is present in even a larger proportion of cases; in fact, that it is rarely absent. It is, as a rule, later in making its appearance than the other abdominal symptoms, showing itself usually about the end of the first or the beginning of the second week. It is generally most marked in grave cases, especially those attended by severe diarrhoea, but I have seen it highly developed in cases in which the symptom was not present at all or but little developed. It may vary, moreover, frequently in degree at different times in the same case, but when once present generally persists until convalescence is established or death occurs. When extreme, it may give rise to distressing dyspnoea by preventing the descent of the diaphragm.

The meteorism is usually preceded and accompanied by gurgling and tenderness on pressure in the right iliac fossa. The former of these symptoms is most marked in cases in which diarrhoea exists, and is caused by the presence of liquid and gas in the lower part of the ileum. The tenderness is unquestionably due to the presence of ulcers in the same part of the bowel. There is also occasionally pain in the region of the umbilicus, but this is a much less frequent symptom.

Enlargement of the spleen was noted by Hale as being present in some of the cases which he has described. It is a frequent symptom of the disease, and may be generally demonstrated by percussion in the course of the second week. It has not, however, often happened to me to be able to feel the organ enlarged through the abdominal walls, as Murchison asserts he has been able to do. Indeed, tympanites is usually present in a sufficient degree to render this difficult. The enlargement {287} occurs more frequently in persons under thirty years of age than in those over it.

Diarrhoea is one of the most frequent symptoms of the disease, especially in severe cases, and there are very few mild cases in which it does not occur at some period of their course. Louis noted it in all but three of his fatal cases, Murchison in 93 out of 100, and M. Barth in 96 out of 101. It varies in different cases in severity, in duration, and in the time at which it appears. It may be one of the earliest symptoms, presenting itself frequently on the first day, and often being the only one which occasions uneasiness to the patient or his physician. At other times its appearance may be postponed until the end of the first week, or even until the patient is apparently entering on convalescence. It may be mild in the beginning and become more severe as the disease progresses, or after having been at first acute may cease spontaneously in a few days to occasion any uneasiness. In degree it may vary from two stools to three or four, or even twenty, in the course of the twenty-four hours. It is absent in a few cases, but in many even of these cases the bowels will be found to act inordinately after a very moderate dose of purgative medicine. I have known, for instance, the administration of a single teaspoonful of castor oil to be followed by five or six stools in an adult. Constipation does, however, actually exist in a certain number of cases. Murchison has known the bowels in cases in which a relapse has occurred to be constipated in the primary attack and relaxed in the relapse. There is no relation between the severity of the diarrhoea and the extent of the local lesion. Although oftenest met with in mild cases, constipation has existed in cases in which perforation of the bowel or intestinal hemorrhage has occurred during life, or very extensive lesions been found after death.

The stools are fetid and ammoniacal, and are alkaline in reaction, instead of acid as in health. They are usually liquid and of the color of yellow ochre. Murchison says that they separate, on standing, into two layers--a supernatant fluid and a flaky sediment--but that, occasionally, instead of being watery they are pultaceous, frothy, and fermenting, and so light as to float in water. I have myself often seen the appearance which Bartlett compares to that of new cider. They may contain blood, and when they do, occasionally present the appearance of coffee-grounds. They are not infrequently, in grave cases, passed involuntarily.

Intestinal hemorrhage is fortunately not a frequent symptom of typhoid fever. It may occur as early as the fifth or sixth day, but is more common after the middle of the second week or in the third or fourth week. In 60 cases observed by Murchison in which the hemorrhage exceeded six ounces it began during the second week (mostly toward its close) in 8; during the third week in 28; during the fourth in 17; during the fifth in 1; during the sixth in 3; during the seventh in 1; and during the eighth week in 1; while in one case the date of its occurrence is not noted. In the cases observed by Liebermeister and Griesinger, 113 in all, the bleeding took place in a much larger proportion of cases at an early period of the disease, occurring in as many as 43 in the second week, and in only 27 during the third. In 7 cases in which I had the opportunity of observing it in patients under my own care it occurred on the seventeenth day in 1; on the twenty-third day in 1; during the {288} third week in 2; during the fifth week in 2; and on the fifth day of a relapse in 1. There may be a single hemorrhage, or the bleeding may be repeated one or more times. In 5 of my cases there was a second hemorrhage, and in 2 of them a third; and in several of Murchison's cases it recurred at varying intervals after its first appearance.

When the bleeding occurs early in the disease it is usually insignificant in amount, and is due either to extreme congestion of the mucous membrane of the intestine, giving rise to rupture of the capillaries, or to disintegration of the blood, allowing its ready passage through the walls of the vessels. In the latter case it usually coexists with petechiæ or a hemorrhage from some other part of the body, as, for instance, epistaxis or hematuria. After the middle of the second week the hemorrhage is generally the result of the laying open of a small artery, either by the detachment of a slough from one of the glands of Peyer or by the involvement of its walls in the ulcerative process. It is then often profuse, and may even reach several pints in quantity. Murchison has, however, seen profuse hemorrhage at such an early stage of the disease that it was impossible that ulceration could have taken place. The blood is not always voided immediately after a hemorrhage has taken place; it may be retained for some days. Indeed, if the amount be large the patient may die within a few hours of its occurrence without any appearance of blood externally. This is, however, rare; it is more usual for the hemorrhage to be repeated before death takes place, but the occurrence of the bleeding may be suspected in such cases by the abrupt fall of temperature, sometimes below the normal standard, and by the extreme prostration and pallor which come on suddenly without other assignable cause. The depression of the temperature does not continue long. It generally reaches its former elevation, or even exceeds it, in the course of twenty-four hours.

There would appear to be a slight difference in the frequency with which intestinal hemorrhage occurs in different times and at different places. Murchison noted it in 58 cases of 1564, or 3.77 per cent.; Louis in 8 cases of 134, or 5.9 per cent.; Liebermeister in 127 cases of 1743, or 7.3 per cent.; Griesinger in 32 cases of 600, or 5.3 per cent.; and I have noted it 7 times in 81 cases, or in about 8.5 per cent. Liebermeister makes it twice as frequent in women as in men. It seems to be much less common in children than in adults, for in 252 patients under fifteen years of age observed by Taupin, Rilliet, and Barthez it occurred in 1 only. There is considerable diversity of opinion among observers in regard to the importance of this symptom. Murchison lost 32 of his 60 cases. In 11 of the 32 fatal cases the immediate cause of death was peritonitis; in 14 of the remaining 21 cases the patients died within three days of the bleeding, and in 8 of the 14 within a few hours. Of Liebermeister's 127 cases 49, and of Griesinger's 32 cases 10, terminated fatally; 3 of my own cases ended in death, but none of them until several days had elapsed after the bleeding. In the face of facts such as these there have not been wanting authors to assert that the effect of the hemorrhage was sometimes beneficial. Chief among these are the celebrated Irish physician Graves and his devoted admirer Trousseau. There may occasionally be a slight subsidence of the nervous symptoms upon the occurrence of a hemorrhage, consequent upon the reduction of temperature {289} which usually accompanies it, but this relief is only temporary, and procured at too great expense to be really of service to the patient.

The bleeding is most frequently observed in bad cases. All the cases which were under my care in which it occurred were of great severity from the very start. In 18 of Murchison's 60 cases the antecedent symptoms were mild. In 3 of my cases there was severe diarrhoea. In 2 of the other cases, 1 of which was fatal, the bowels were constipated, and in another one, also fatal, they were slightly loose. In 8 of Murchison's cases, 6 of which were fatal, the bowels had been constipated up to the time of its occurrence. The blood, if voided immediately after its escape into the intestines, is generally fluid and bright red in color. When retained for a day or two it is passed in dark clots, and if retained longer than this it is usually mixed with fecal matter when discharged from the bowels, and gives the stools a tarry appearance and consistence, which is not always recognized by inexperienced attendants as due to blood.

It has been asserted that intestinal hemorrhage has become more frequent since the introduction of the cold-water treatment, but Liebermeister shows this to be an error, for he has found that of 861 cases treated before the introduction of this treatment, 72, or 8.4 per cent., had intestinal hemorrhage, but that of 882 cases treated since its introduction hemorrhage occurred in 55, or in 6.2 per cent. Other methods of treatment have also been charged with inducing a tendency to hemorrhage, but probably not upon more substantial grounds than the above.

The occurrence of perforation may be suspected when the patient is suddenly seized with acute pain in the abdomen, accompanied by symptoms of collapse and occasionally by rigors. The fall of temperature is often considerable. Liebermeister refers to one case in which it was as much as 5-1/2°, or from 104° to 98-1/2°. Very soon the abdomen becomes tender on pressure, and, if it were not so before, hard and tympanitic; the pulse grows frequent, small, and sometimes almost imperceptible; the breathing is thoracic; the physiognomy expresses great suffering; the features are contracted, and the face is bathed in profuse perspiration. Nausea and vomiting come on soon after inflammation has commenced, and rapidly exhaust the patient. The decubitus is dorsal, and the legs are generally drawn up so as to relax the abdominal muscles. Prostration rapidly increases until death puts an end to the patient's sufferings. Occasionally, the symptoms are more obscure. Pain and rigors may both be wanting, and nothing but the extreme prostration, the frequent and feeble pulse, and the distended condition of the abdomen will indicate the gravity of the danger. This is not infrequently the case in delirious patients. Death may take place during the collapse, but this is rare. It more frequently takes place on the second or third day; on the other hand, it may be postponed until much later. Liebermeister and Murchison refer to cases in which there was an interval of two or three weeks between the first symptom of perforation and the fatal result.

Perforation of the intestine was formerly regarded as an inevitably fatal accident, but this view is no longer entertained. I have had under my observation cases in which all the symptoms of this accident were present, and in which recovery took place. In some of these cases there {290} may have been an error of diagnosis, but all of them will not admit of this explanation. Moreover, cases of a similar character have been reported by physicians whose skill in diagnosis is universally recognized. Thus, Murchison reports six such cases, Tweedie two, and Wood one. Liebermeister and Bristowe[53] also both say that recovery is possible. This view is sustained by the results of certain autopsies. In one of these, reported by Buhl,[54] a perforation was found completely closed by adhesions to the mesentery, and in others reported by Murchison partial adhesion had taken place between the edges of the perforation and the abdominal walls or to an adjoining coil of intestine. Occasionally, the inflammation excited by the perforation may be circumscribed and terminate in an abscess, which may permit recovery by discharging itself into the bowel or externally. At other times, however, it ruptures into the peritoneal cavity, when death speedily ensues.

[Footnote 53: _Transactions of the Pathological Society of London_, vol. xi. p. 115.]

[Footnote 54: Cited by Murchison.]

Perforation is, fortunately, not a frequent accident in typhoid fever. It was the cause of death in 20 only of 250 fatal cases collected by Hoffmann. It occurred, according to Liebermeister, in only 26 cases, 3 of which ended in recovery, in more than 2000 cases observed at the hospital at Basle. Murchison observed it 48 times in 1580 cases, Griesinger 14 times in 118 cases, and Flint twice in 73 cases. Murchison found that in a total of 1721 autopsies, the details of which were collected from various sources, it was the cause of death in 196, or 11.38 per cent. It would appear to be rather more common on the continent of Europe than in England or in this country. Perforation is much more frequently met with in men than in women. The patients were men in 15 of 21 of Liebermeister's cases, in 51 of 73 of Murchison's, and in 72 of 106 cases collected by Näcke. It is rarer in children than in adults. Rilliet, Barthez, and Taupin met with it only three times in 232 children under treatment. Murchison has, however, had a fatal case in a child of five years of age. It is also not common after forty years of age, but does occasionally occur, although the contrary has been asserted.

Perforation is most likely to happen during or after the third week of the disease, but it has been met with as early as the eighth day, as in a case reported by Peacock. On the other hand, in three cases cited by Morin[55] it did not occur until the seventy-second, seventy-sixth, and one hundred and tenth day, respectively. Instances are on record in which it has taken place after the patient was supposed to be thoroughly convalescent and had returned to his occupation. When it occurs early it is due to the separation of a slough. After the middle or end of the third week it is probably always the result of the extension of the ulcerative process to the peritoneal coat. In a large proportion of cases the perforation has been preceded by symptoms of great gravity, such as severe diarrhoea, great tympany and tenderness of the abdomen, and intestinal hemorrhage, but in a certain number of instances the cases in which it has occurred have been of a mild character, the patient in many of them not considering himself sick enough to take to his bed or even to abstain from his daily labor. After death the perforating ulcer has been found to be the only one.

[Footnote 55: Quoted by Murchison.]

The most frequent causes of perforation are the irritation arising from {291} indigestible and unsuitable food, distension of the bowels by feces or gas, vomiting, and movements on the part of the patient. Liebermeister calls attention to the frequency with which ascarides are found in the intestines of those who die of perforation, and is inclined to think they may have something to do with causing it. Morin[56] reports a case in which the perforation appeared to be caused by the administration of an enema.

[Footnote 56: Quoted by Murchison.]

For our knowledge of the changes in the composition of the urine we are largely indebted to Parkes and certain German observers. As the disease generally begins insidiously, the condition of the urine before the attack and during the first two or three days has not been ascertained with certainty. During the latter part of the first week the amount of water is greatly diminished, occasionally falling to one-fourth or one-sixth of the usual quantity. In the second and third weeks it increases, and at the end of the fourth week may again be normal. The amount may, however, vary from day to day, but its variations do not stand in close relation to those of the febrile heat; that is, the thermometer may mark one day 104°, and the next day 100°, while the amount of urine remains the same. Still, when the temperature begins to fall permanently it increases at once, or, according to Thierfelder, two or three days after. The specific gravity is usually high in almost all cases in which the urine is scanty, and may be as high 1038. With the establishment of convalescence the specific gravity often diminishes before the water begins to increase. In other words, the lessening of the solids of the urine frequently takes place prior to the increase of the water.

The reaction of the urine is very acid in the beginning, but the acidity is not due to an increased secretion of acid, but simply to concentration. Later it may become alkaline, and even ammoniacal. The color of the urine is darker than in health during the early part of the febrile period. This is due partly to concentration, and partly to increased disintegration of the blood-corpuscles, which is a consequence of the fever.

The quantity of urea is augmented during the fever, and especially during the first week, when the water and chlorides of sodium are most diminished. As a general rule, the higher the temperature the greater the amount of urea. It may, however, be very much diminished during the presence of inflammatory complications. On the other hand, it is not affected by diarrhoea. Uric acid is uniformly increased, the amount of increase being relatively greater than that of the urea; it is often doubled, and sometimes the increase is even more than this. This increase takes place, according to Zimmer, up to the fourteenth day. It diminishes after this, and during convalescence may fall below the normal amount. Copious deposits of urates may occur at any time in the course of the disease. The chloride of sodium is usually diminished in amount. This diminution is partly due to a less amount of this salt being taken with the food, and partly to the fact that large quantities of it pass away with the stools. As the diminution cannot always be fully accounted for in this way, it would appear that it is also stored up in the body during the fever. In cases in which sweating and purging are absent the sulphuric acid is increased in amount. The phosphoric acid is at first slightly diminished, but later undergoes an increase. The hippuric acid is also diminished.

{292} Parkes found albumen in the urine in 7 out of 21 cases. In 5 of these it was temporary, and entirely disappeared before the patients left the hospital. Becquerel found it in 8 out of 38 cases, Andral in only 4 out of 34 cases. Griesinger found it commonly, though it was usually temporary. He met with only four or five cases in which it was never present. Kerchensteiner found albumen in a fourth part of the severe cases. Brattler noticed it in 9 out of 23 cases. I have very frequently found it myself, but it has always been in my cases a temporary phenomenon. Desquamative nephritis may occur occasionally in the course of typhoid fever, and give rise to the appearance of a large amount of albumen in the urine, and also occasionally of blood. Renal epithelia and casts are sometimes seen in cases in which there is albuminuria, but usually soon disappear. Zimmermann asserts that in all but very slight cases casts may be found even when no albumen can be detected. The statement is probably too general, but there is no doubt of the occasional presence of casts under these circumstances. Bladder epithelia and pus-cells are seen in a few cases in small quantities, but decided cystitis is rare, unless it has ensued upon retention of urine. Sugar has not been found except in the urine of diabetic patients, who may have happened to contract typhoid fever. In these patients the sugar diminishes, and is sometimes wholly absent during the continuance of the fever. Leucin and tyrosin have been found by Frerichs, but at present no observations have been made as to the frequency or import of their occurrence.

In many cases, when the prostration is extreme, the urine is passed involuntarily, but in some of these cases the incontinence of the urine is only apparent, and is really the result of over-distension of the bladder. This is a condition which is very apt to be overlooked, and I have known paralysis of the bladder to result in consequence of this neglect, and to continue sometimes after convalescence has been established.

COMPLICATIONS AND SEQUELÆ.--Although cerebral symptoms are among the commonest manifestations of the disturbing effects produced in the economy by the typhoid fever poison, they are almost always independent of inflammation of the brain and its membranes. In a few cases, however, the lesions of meningitis have been found after death. In some of these it has come on without assignable cause, in others it has been the consequence of pyæmia, of tubercles, or of the extension of inflammation from the petrous portion of the temporal bone. Occasionally, during convalescence, some impairment of the intellect is observed. This may consist in simply some loss of memory or childishness of manner. At other times delusions of a mild form are present, or else the patient is liable to attacks of acute mania, sometimes violent, coming on suddenly and without fever. In a few instances the moral sense seems to have been perverted, as in the case reported by Dr. Nathan Smith, already referred to, in which a young man of previously good character developed a propensity to steal after his attack. Recovery with the re-establishment of the physical health almost occurs in these cases. Murchison says he knows of no case in which this condition has been permanent. On the other hand, Dr. C. M. Campbell,[57] who had the opportunity of observing an attack of typhoid fever among some insane patients {293} at the Durham County Asylum, reports that the mental state was in no case injuriously affected by the disease, but, on the contrary, underwent a marked improvement in several of the cases. Indeed, in two of the cases, in which the prognosis had become very unfavorable, mental recovery began during the attack of fever.

[Footnote 57: _The Journal of Mental Science_, July, 1882.]

Paralysis, muscular tremors, and chorea are also occasionally observed after attacks of typhoid fever. According to Murchison, paralysis does not supervene until several weeks after the commencement of convalescence. It may last for several weeks or months, but recovery in the majority of instances eventually takes place. According to Nothnägel,[58] the most common form is paraplegia, but it may also take the form of hemiplegia, strabismus, paralysis of the portio dura, motor paralysis of individual spinal nerves, such as the ulnar or peroneal, or local anæsthesia. On the other hand, neuralgias and disturbances of sensation are not common sequelæ of typhoid fever.

[Footnote 58: Cited by Murchison. See also article by Paget, _St. Bartholomew's Hospital Report_, vol. xii.]

Degeneration of the muscular tissue of the heart is probably present in some degree in every case of typhoid fever, being, of course, most marked in the severest cases. There would seem, however, to be no special tendency to disease of its valves or membranes. Arterial thrombosis or embolism, giving rise to gangrene of the part supplied by the obstructed artery, is of occasional occurrence. Patry,[59] Hayem,[60] Trousseau,[61] and others report or refer to several cases in which gangrene of the leg, hand, or cheek was observed, and among others a case in which sphacelus depending upon obstruction of the carotid artery, the result, as Patry thought, of arteritis, commenced in the left ear, and extended from there to the forehead and cheek.[62] A. Martin[63] reports the case of a woman who expelled from the vagina a fetid-smelling structure of cylindrical form, which proved to be the cervix of the uterus, with the upper part of the vagina, and in whom menstruation was not re-established until after the performance of an operation. Spillmann[64] has also called attention to the occurrence of gangrene of the vagina and vulva in cases of typhoid fever. {294} This complication is generally met with toward the end of the febrile period.

[Footnote 59: _Archives générales de Médicine_, 1863, vol. i. pp. 129-549.]

[Footnote 60: _Loc. cit._]

[Footnote 61: _Clinique médicale_.]

[Footnote 62: Since the above was written Barié has called attention in the _Revue de Médicine_, Jan. and Feb., 1884, to the frequency with which acute inflammation of the arteries occurs as a sequel of typhoid fever. The author, whose investigations were limited to the larger arteries, found that the vessels generally implicated are in the order of their frequency, the posterior tibial, the femoral, and the dorsal artery of the foot. The affection is usually unilateral, appears during convalescence or when the patient leaves his bed, and occurs just as often after light as after severe cases. He distinguishes two varieties: 1, acute obliterating arteritis, and, 2, acute parietal arteritis. The first variety is characterized by embryonal infiltration of all the tissues, by disappearance of the smoothness of the intima, which becomes uneven and granular, and by the formation of a secondary thrombus, and almost invariably terminates in dry gangrene. The second is merely an inflammation without such a clot, and always terminates in recovery without gangrene.

The symptoms of obliterating arteritis are--pain, more or less sudden in its onset, directly over the course of affected vessels, and increased by pressure, by the erect position, and by walking; diminution, and then absence, of pulsation; swelling of the limb, without oedema or redness; and, later, the appearance of bluish mottling of the surface, and, more rarely, of patches of purpura; lowering of the temperature, with or without troubles of sensibility, such as formication, anæsthesia, etc., and the appearance of a hard and painful cord, due to the formation of the thrombus. In the parietal form the diminution of the pulsations is sometimes preceded by a considerable exaggeration of their amplitude, and, while the temperature on the affected side is usually lowered, it may sometimes be increased.]

[Footnote 63: _Centralblatt f. Gynakol_, 1881.]

[Footnote 64: _Archives générale_, Mars, 1881.]

Venous thrombosis, the result of weakness of the heart's action, is more frequently observed. It occurs generally during the convalescence of cases which have run a severe course, and usually affects the veins of the lower extremities. I have seen both the femoral veins obstructed from this cause at the same time. All the cases which have come under my own observation have ended in recovery, and only 2 of 31 collected by Liebermeister terminated fatally. Death occurred in 3 of the 17 cases collected by Murchison, but in none of them was this result attributable to this complication alone. There is, however, always danger of a portion of the thrombus becoming detached and producing embolism of the pulmonary artery.

Pyæmia is said by Murchison and other authors to be an occasional complication, but it is certainly rare in this country. In the milder cases abscesses form during convalescence beneath the skin in different parts of the body. In the more severe cases pus is deposited in the joints or in the internal organs. Albert Robin[65] has reported two cases in which there was suppurative joint affection. In one of these the joints of the fingers and toes, with the sheaths of the corresponding extensor tendons and both knee-joints and one shoulder-joint, were affected. In the other the left knee was filled with pus. In both cases the fever soon assumed an adynamic character.

[Footnote 65: _Gazette de Paris_, 1881.]