Chapter XVIII: Part II: , Showing Predominance of Malarial Element . . . . 617 (17)

Laryngitis may sometimes occur in the course of typhoid fever, and when it assumes the diphtheritic form and runs on to the formation of ulcers is a very serious complication of typhoid fever, as it is not infrequently accompanied by oedema of the glottis and gives rise to the necessity for tracheotomy. It is fortunately, at least in its worst forms, rare in this country. In Germany, judging from the number of cases collected by Hoffmann and Griesinger, it is of more common occurrence. The ulcers are oftener met with in some epidemics than in others. During the winter of 1860-61, which I passed in Vienna, the frequency with which they occurred was the subject of remark among those who were in attendance upon the various clinics.

I have already called attention to the frequency with which bronchitis in some form or other attends upon typhoid fever. When it invades the smaller bronchial tubes it occasionally gives rise to lobular pneumonia or to collapse of some of the lobules of the lung. Lobar pneumonia may also occur in the course of typhoid fever. It was observed 52 times in 1420 cases of typhoid fever under treatment at the Basle hospital from 1865-68. When it comes on late in the disease, especially if the patient is comatose, or even semi-conscious, it may be entirely overlooked, unless the lungs are carefully examined, as it often does not reveal itself to us by any of the ordinary symptoms. It may, however, occur early, and I have known it so prominent in the beginning of an attack that the existence of typhoid fever was not suspected. It sometimes terminates in abscess or gangrene, but is more usually followed by chronic pneumonia, which may eventually either end in recovery or lay the foundation for phthisis. Pleurisy with effusion is also not an uncommon complication. It was observed, according to Liebermeister, at the hospital at Basle 64 {295} times in 1743 cases of fever. It is also a serious complication, as 21 of the 64 cases terminated fatally. Murchison refers to three cases in which it was followed by empyema. Other morbid conditions of the respiratory organs which may occur as complications of typhoid fever are oedema, infarction, hypostatic congestion of the lungs, emphysema, and pneumothorax. Acute miliary tuberculosis is also an occasional complication, but is oftener met with as a sequel. According to Liebermeister, the tendency to pulmonary complications has diminished since the introduction of the cold-water treatment.

Catarrhal or diphtheritic inflammation of the fauces and pharynx occurs in a large number of cases, and frequently gives rise to a great deal of difficulty in swallowing. Indeed, it has been so frequently observed in some epidemics that a few writers have regarded it as a symptom rather than a complication of the disease. Either of the varieties of inflammation may extend through the Eustachian tube to the middle ear and be the cause of deafness, which usually passes off as the inflammation subsides. Occasionally, however, the affection of the middle ear gives rise to perforation of the tympanum or to caries of the petrous portion of the temporal bone.

Murchison says he has known the symptoms of and lesions of dysentery to coexist with those of typhoid fever in several cases, and Liebermeister asserts that diphtheria of the intestinal mucous membrane is an occasional sequel to severe cases, especially when other mucous membranes are the seat of diphtheritic inflammation. In a few instances which have come under his observation it had given rise to perforation of the bowel or to gangrene of the intestinal mucous membrane.

Jaundice occasionally occurs in the course of the disease. I have never happened to see this complication, and am inclined to think it is rare in this country. Liebermeister, however, met with it 6 times in 1420 cases, and Griesinger 10 times in 600 cases. Hoffmann found it in 10 of 250 fatal cases, and Murchison was able to collect 9 cases, all of which but one terminated in death. Several of Griesinger's cases, however, ended in recovery. In a few cases the jaundice may be attributed to catarrh of the biliary ducts, but this solution of the question will not explain those cases in which the feces remain colored throughout. In fatal cases marked degeneration of the liver has been found, which Liebermeister regards as of similar character to that which occurs in acute yellow atrophy. In two of Murchison's cases the liver was small and its secreting cells loaded with oil. In most cases it does not appear until late in the disease, but it has been observed as early as the fifth day.

Abscess of the liver and diphtheritic inflammation of the mucous membrane of the gall-bladder are among the rarer sequelæ of typhoid fever.

Peritonitis is the most serious of all the complications of typhoid fever. Its most common cause is perforation of the bowel, but it may also be due to the extension of inflammation to the peritoneal membrane without ulceration. Liebermeister believes that it is sometimes the result of the typhoid infiltration so frequent in various tissues of the body taking place in the serous membrane. In other cases it arises from the rupture of softened mesenteric glands, of softened {296} infarctions in the spleen, or of the abscesses which are sometimes the consequence of the circumscribed inflammation by which perforation is occasionally prevented from proving immediately fatal. Less frequent causes of it are rupture of the gall-bladder, with the escape of gall-stones into the cavity of the abdomen, abscesses of the ovary, and abscesses in the walls of the urinary bladder. It is said by Murchison to have been in one case the result of a pseudo-abscess in the sheath of the rectus muscle bursting inward.

Swelling of the parotid gland occasionally occurs in typhoid fever, but is much less common than in typhus. It is most frequently met with in bad cases about the end of the third week or later, and generally involves one side only. The swelling is hard and firm in the beginning, and may terminate in resolution or suppuration. I have seen it three times only, twice in my own practice, and once in that of a medical friend. One of my cases was fatal, the other ended in recovery, as did, I believe, the third case. Murchison saw it in only 6 cases, 5 of which were fatal. According to Hoffmann,[66] 16 cases of suppurative parotitis were found at Basle among about 1600 typhoid fever patients, 7 of the 16 ending fatally. Parotitis without suppuration occurred three times. In 15 cases the attack was confined to one side, 9 times to the right and 6 to the left; in 4 it was double. Trousseau[67] looks upon these swellings as a very grave accident, and says that he has scarcely ever seen a case recover in which it has occurred, either in the course of typhoid fever or any other disease. Chomel, on the other hand, is said to have regarded them as critical and auspicious.

[Footnote 66: Quoted by Liebermeister.]

[Footnote 67: _Clinique médicale de l'Hôtel Dieu_, t. i. 1861.]

Menstruation occasionally occurs during typhoid fever, and may be profuse. Bartels,[68] who has investigated the histories of 172 patients in reference to this point, says that the catamenia always appear if the menstrual period falls within the first five days of the fever, and that they do so in two-thirds of the cases if they are expected between the sixth and fourteenth days. On the other hand, menstruation does not occur if the time for it falls in the third week. He says also that the catamenia generally appears about the time they are expected, or later, and very seldom earlier. Liebermeister, on the contrary, says that they often occur prematurely. Other uterine hemorrhages seldom occur, and never in those who have ceased to menstruate or in whom the function has not been established.

[Footnote 68: _Petersb. Med. Wochenschr._, 1881.]

Suppuration of Bartholini's glands is said by Speilman to have taken place in one case.[69] In the fourth week the patient complained of violent pains in the right nympha, which, upon examination, was found to be swollen. A tumor as large as a nut, which was red and painful on pressure, could also be felt in the vagina.

[Footnote 69: _Arch. générales_, Mars, 1882.]

Pregnancy was formerly thought to confer an entire immunity from typhoid fever, but recent and accurate investigations have shown that if this immunity really exists, it is only relative, not absolute. Gusserow[70] says that the disease is more frequently met with in the first half than in the latter half of pregnancy. Abortion under these circumstances commonly occurs. Gusserow says that it takes place in from 60 {297} to 80 per cent. of the cases. He believes it to be due to the high temperature, which causes the death of the foetus, which is then expelled from the uterus. In a few cases, however, the child is born living. Of Murchison's 14 cases, 10 recovered, and two of the ten patients carried the child, at the fourth and eighth months respectively, throughout the attack. All the others miscarried or aborted, only one of them being delivered of a living child. Out of 18 pregnant women[71] treated in the hospital of Basle for typhoid fever, between the years 1865 and 1868, 15 miscarried or aborted. In the three years following the introduction of the anti-pyretic treatment only five cases of abortion occurred, and but one of these proved fatal. This accident generally happens during the second or third week of the fever. It is always a serious complication, and if it occurs in the first three months of pregnancy it generally gives rise to profuse hemorrhage, which is usually followed by a fall of temperature as marked as that observed in hemorrhage from the intestines. Just as in the latter case, the fall is only temporary, being soon succeeded by a rapid rise of the temperature to its former height, or even beyond it.

[Footnote 70: _Schmidt's Jahrbuch_, Bd. 193, No. 1, 1880, from _Berl. klin. Wochenschr._, 1880.]

[Footnote 71: Liebermeister, _loc. cit._]

The danger of bed-sores occurring in typhoid fever is in consequence of the impaired nutrition of the tissues, the length of time the disease lasts, and the great emaciation which usually attends it--greater than in any other acute disease. They constitute a very serious and troublesome complication, and may occur on any part of the body subjected to pressure, but are most frequent over the sacrum and trochanters. Oedema of the lower extremities from feebleness of the circulation is occasionally observed in the convalescence from protracted attacks. Lendel has published a series of 7 cases observed at Rouen, in which the entire body became very oedematous in the second or third week of the attack or during convalescence. In none of the cases was the urine albuminous. All the patients recovered except one, who died of peritonitis. Similar cases have been reported by other observers. Barthez and Rilliet have seen several cases in children.

Periostitis is an occasional sequel. I have seen it in one case only. Sir James Paget,[72] who appears to have met with it in several cases, says that it never occurs in the continuity of the fever, but always when the patient is apparently convalescent, when his temperature is normal and constant, and he is beginning to move about and to grow stronger and stouter. Its most usual seat is the tibia, but it is also met with in the femur, ulna, and parietal bone. Except in one case, Sir James has never seen it in more than one bone in the same person. It is always circumscribed within a space of from one to three inches in extent, and usually subsides without necrosis or other abiding change of structure; but in some cases the patient has remained for some time subject to repeated attacks of pain and swelling of periosteum. In the few cases, he says, in which the periostitis is followed by necrosis the extent of dead bone has always been less than that of the inflammation over it. Murchison, however, refers to two cases of necrosis of the tibia, to one of the temporal bone, and to two in which extensive necrosis of the lower jaw occurred. Gay[73] also reports a case of extensive necrosis of the thigh-bone in a child three years old, following an attack of typhoid fever.

[Footnote 72: _St. Bartholomew's Hospital Report_, vol. xxi.]

[Footnote 73: _Path. Trans. Lond._, vol. xx., p. 290.]

{298} Very frequently after an attack of typhoid fever the patient evinces a tendency to grow stout, which is either continuous or else is gradually lost after he fully recovers his health. This increase in flesh is not always accompanied by a corresponding gain in physical strength, and he may remain for a long time after convalescence is apparently complete incapacitated for much bodily or mental exertion. Sometimes, on the other hand, the patient, instead of gaining flesh and strength, may continue weak and emaciated, even when he is taking a full amount of nourishment, which he is, however, unable to assimilate. Cases of this kind may terminate in phthisis, but they occasionally prove fatal, without any discoverable lesion after death except an abnormally smooth appearance of the mucous membrane of the ileum and a shrivelled condition of the mesenteric glands.[74]

[Footnote 74: Murchison.]

Patients suffering from typhoid fever may occasionally contract other specific diseases. Murchison has notes of eight cases in which the eruption of this disease coexisted with that of scarlatina, and says that it was not uncommon in the London Fever Hospital for a patient suffering from the former disease to contract the latter. Similar cases are recorded by other observers. Typhoid fever may also be complicated with rubeola, pertussis, diphtheria, variola, and vaccinia. I have repeatedly seen children convalescent from typhoid fever in the hospitals of Paris contract one or other of the eruptive fevers.

VARIETIES.--A great variety of forms of typhoid fever has been described by various authors, but as many of them present few points of difference from the usual form of the disease, it will not be necessary to discuss them at any length. They derive their names from some peculiarity of the mode of seizure, from the prominence of some one symptom or set of symptoms, or from the presence of complications. They are--(1) The adynamic form, in which prostration is marked in the beginning and throughout the attack. (2) The ataxic or nervous form, which is characterized by the predominance of delirium, subsultus tendinum, and other nervous symptoms. (3) The hemorrhagic form, in which there is a special tendency to hemorrhage from the different mucous membranes. (4) The abdominal form, in which the abdominal symptoms, such as diarrhoea and tympanites, are well developed. (5) The thoracic form, so called from the presence of some thoracic complication. (6) The gastric or bilious form, in which the disease is complicated at its commencement by gastro-intestinal catarrh. La forme muqueuse of French authors is probably identical with the above. (7) The acute form, in which the disease begins abruptly and with great violence, and runs a very rapid course, terminating usually in death before the end of the first week or early in the second, before ulceration can have taken place. Delirium is an early and prominent symptom in this form, so that it has sometimes been mistaken for meningitis.

Certain forms of the disease deserve a little fuller consideration. One of the most important of these is the abortive form, in which, as its names implies, the fever is cut short in its course, and in which there is every reason to believe that infiltration of Peyer's glands takes place as usual, but that the subsequent course of the disease is different, the glands undergoing resolution instead of advancing to ulceration. The majority {299} of observers agree that in the beginning there is nothing to distinguish such attacks from those which follow their usual course. Liebermeister and Jaccoud state, however, that their commencement is usually more abrupt than in the ordinary variety, the former asserting that the temperature generally reaches its maximum earlier, and the same opinion is expressed by other authors. They are occasionally characterized by severe symptoms, including a high temperature. In the few cases which have come under my own observation the symptoms have been mild, but they were sufficiently developed to leave no doubt on the mind as to the nature of the disease. In a case which aborted on the twelfth day there were hebetude, diarrhoea, tympany, and rose-colored spots persisting even after the subsidence of the fever. Constipation would appear, however, to be more frequent than diarrhoea in this class of cases. The subsidence of the fever may occur at any time between the seventh and fourteenth days; Griesinger has seen it occur as early as the fifth day. Sometimes the defervescence occurs abruptly, with copious perspiration; at others it is gradual and similar to that which takes place in ordinary attacks. Between the abortive form of typhoid fever and simple continued fever there are, of course, many points of resemblance, but cases of the former may generally be recognized by the presence of this rose-colored eruption and enlargement of the spleen, or, where these are absent, by their occurring in the same house or under the same circumstances as typical cases of the disease.

Liebermeister has called attention in his article on typhoid fever in _Ziemssen's Cyclopædia_ to a class of cases which, he thinks, is also caused by the typhoid infection, and of which the prominent feature is the insignificance of the fever or the entire absence of it which characterizes them. Such cases appear to be of frequent occurrence in Basle. Many of them, he says, never show during their entire course any rise of the temperature, or occasionally a slight elevation only, but an enlargement of the spleen could generally be detected, and occasionally an unmistakable rose-colored eruption. The action of the bowels was usually irregular; sometimes there was diarrhoea, and sometimes, on the other hand, obstinate constipation. The other symptoms were prostration, pains throughout the body, often headache, persistent loss of appetite, with more or less swollen and furred tongue, and markedly diminished frequency of the pulse, which disappears with convalescence, while its quality is not appreciably altered. The long duration of an apparently trifling indisposition he considers as especially characteristic. Cayley also refers to cases, and even epidemics, of typhoid fever in which the temperature has been below the normal throughout the whole course of the attack. Strube[75] had the opportunity of observing such an outbreak during the siege of Paris by the Germans in 1870. "In many of the cases," he says, "the temperature throughout was subnormal, and in others never exceeded the normal point. The roseola was usually profuse; the nerve symptoms were of marked severity, and were in inverse ratio to the temperature, consisting of violent delirium alternating with stupor; the duration of the fever was very short, defervescence usually taking place at the end of a fortnight. Of the 23 fatal cases, in 20 death took place during the first fourteen days. The abdominal {300} symptoms were slight, but the characteristic lesions were found on post-mortem examination. All the cases were characterized by great prostration. These cases presented some features which were probably due to this peculiarity of the temperature; thus, the pulse was but little accelerated, seldom exceeding a hundred; the tongue did not become dry and brown; and the enlargement of the spleen was either absent or much less marked than usual. Strube attributed the peculiar features of this epidemic to the depressed condition of the troops; they had been exposed to great hardships on the way to Paris, over-fatigued by forced marches, and very insufficiently supplied with food."

[Footnote 75: Quoted by Dr. Cayley.]

A mild form of the disease has been described by certain authors, in which the symptoms, although not severe, are characteristic, and in which there is therefore, with due care, little danger of making a mistake in diagnosis. It therefore seems an unnecessary refinement to set apart such cases under a separate head.

The latent form, or the typhus ambulatorius of the Germans, is of more importance from the fact that the symptoms are so mild, or that so many of the ordinary symptoms are wanting or masked by those due to complications, that there is great danger of regarding the attack as of little moment. In many cases there is no symptom present but prostration and fever to indicate that the patient is ill, and these may be so slight that he may positively refuse to go to his bed, and may even insist upon pursuing his ordinary avocation, in the midst of which he is often suddenly seized with alarming symptoms, such as violent delirium, intestinal hemorrhage, or, what is more common, those due to perforation of the bowel. Still, even in these cases a careful examination will often disclose the presence of some symptom which had failed before to attract attention, and which will often reveal to us the true nature of the disease. I was myself the subject of such an attack nearly twenty years ago. Supposing that the excessive prostration from which I was suffering was due to overwork at a large army hospital in the neighborhood of Philadelphia, I determined to seek repose in travel and in change of scene. On the eve of doing so I fortunately sent for a medical friend, who, after a thorough investigation of my symptoms, succeeded in finding a few rose-colored spots upon my abdomen. The attack subsequently ran a mild but well-marked course. Occasionally, the symptoms due to a complication so predominate over those arising from the disease itself that they completely mask it. I have known bronchitis so severe as to divert in this way the attention of a skilful diagnostician from the primary disease. When vomiting, together with other symptoms of hepatic derangement, is especially prominent in the beginning of typhoid fever, the mistake is not infrequently made of attributing these symptoms to a "bilious attack."

TYPHO-MALARIAL FEVER.--Under this name, which was originally suggested by J. J. Woodward, Surgeon U.S.A., early in the summer of 1862, as a designation for a class of cases in which the symptoms of typhoid fever are associated with those of remittent, and which was especially common among the soldiers of the United States Army during the late Civil War, are probably included at least two distinct conditions: 1st, remittent fever, in which the disease, on account of the depressing circumstances surrounding the patient, assumes {301} a typhoid form; and, 2d, typhoid fever, occurring in a patient who has also been exposed to malarial influence. This association of diseases is of course not new, or even undescribed before this name was suggested for it. Woodward thinks that he has found enough in the description of Röderer and Wagler to justify him in concluding that the epidemic which occurred at Göttingen in 1762 was really of this character. There would seem also to be no doubt from the descriptions of Dawson[76] and Davis[77] that the fever which decimated the British army in the Walcheren expedition was typhoid fever, modified by the malarial influence to which the soldiers were subjected. The latter of these authors says that the ileum and jejunum in the bodies of those who died of this disease were frequently found interspersed with tubercles, inflamed and ulcerated in different parts.

[Footnote 76: _Observations on the Walcheren Diseases_, Ipswich, 1810, by G. P. Dawson.]

[Footnote 77: _A Scientific and Popular View of the Fever of Walcheren_, J. B. Davis, London, 1810.]

In our own country the occasional association of these two diseases has also long been recognized. Drake describes it under the name of remitto-typhoid, and Dickson seems to have been perfectly familiar with it, for he says that typhoid lesions will sometimes be found in the bodies of those dead of bilious remittent. Levick recognized the presence of the symptoms of both diseases in some patients who were under his care as early as the spring of 1862, and proposed the name of miasmatic typhoid fever for this class of cases in the following June.[78] Meredith Clymer has also frequently met with cases in which the symptoms of the two diseases were coexistent.[79]

[Footnote 78: _Med. and Surg. Reporter_, June 21, 1862.]

[Footnote 79: _The Science and Practice of Medicine_, by William Aitken, M.D., 3d Amer. ed.; with additions by Meredith Clymer, M.D., Philadelphia, 1872.]

As is indicated by the name given to it, the symptoms in this form of typhoid fever are modified by the presence of malarial poisoning. The cases always manifest a decided tendency to periodicity, the evening exacerbations are more decided than in the ordinary form, the remissions are often ushered in with a profuse sweating, gastric and hepatic derangements are more marked, and headache is more severe. There is frequently less mental hebetude or dulness than in ordinary typhoid fever. In some of the cases observed by Levick[80] the symptoms were those of pernicious congestive remittent fever, such as copious serous discharges, not unlike those of Asiatic cholera, colliquative sweats, and other symptoms of exhaustion.

[Footnote 80: _Amer. Journal of the Med. Sci._, April, 1864.]

TYPHOID FEVER IN CHILDREN.--It was formerly thought that infants and very young children were not often the subjects of typhoid fever, but, so far is this opinion from being correct, it is now known that they are especially liable to suffer from it. The rose-colored eruption is more often wanting in them than in adults, and the fever more apt to assume a distinctly remittent type; and hence, no doubt, the difficulty which is often experienced in diagnosticating this fever from other forms of fever in children. There is no doubt that many cases which have been described by authors under the head of infantile remittent fever are really examples of typhoid fever modified simply by the age of the patient. It may occur in infants not more than six months old, and is not infrequent in {302} children of two or three years of age. Henoch,[81] who has had the opportunity of observing a large number of cases, says that the rise of temperature is commonly more abrupt in children than in adults, and that the disease generally runs its course in a shorter time. The pulse is more frequent, and may be as high as 144 in cases in which the prognosis is not grave. Dicrotism is very rare. Slowness and irregularity of the pulse, like that observed in basillar meningitis, he has never seen. The nervous symptoms are not so pronounced even when the temperature is high, and they bear no relation in severity to the height of the temperature. Diarrhoea in the cases observed by Henoch was often absent during the whole course of the attack, and the stools were often brownish or greenish instead of yellow.

[Footnote 81: _Charité Ann._, 1875.]

TYPHOID FEVER OF AGED PERSONS.--The modifications which the disease undergoes when it occurs in patients advanced in life are precisely those to be expected from the diminished activity of the processes of life in them, as compared with those of younger persons. The febrile movement is generally prolonged, although of low grade, the temperature rarely rising high, and frequently during convalescence sinking below the normal. The diarrhoea is commonly not so severe, the delirium so violent, or the rose-colored eruption so often present. On the other hand, adynamic symptoms, such as excessive prostration, tremors, subsultus tendinum, and the like, are frequently prominent from the beginning of the attack.

Several authors, among whom may be mentioned Arnat,[82] Hornburger,[83] and Greenhow,[84] have described a renal form of typhoid fever. In this form the urine is blood red in color or like dark broth. It often contains albumen during the first week of this disease, usually hyaline or more or less granular casts, and occasionally red blood-discs, white cells, epithelia of kidneys and bladder, and epithelial detritus. The specific gravity is high, and the quantity is usually diminished. The prominent symptoms are pain in the region of the kidneys, oedema of face, tense and frequent pulse, great prostration, profuse epistaxis, violent delirium, and hyperpyrexia. The temperature may be 105.8°. On the other hand, the intestinal symptoms are less marked. In fatal cases the lesions of intestinal nephritis have been found at the autopsy.

[Footnote 82: Thesis, _Sur la Fievre typhoide à forme renale_.]

[Footnote 83: _Berlin klin. Wochenschrift_, 1881.]

[Footnote 84: _Transactions of Clinical Society of London_, 1880.]

RELAPSES.--Much difference of opinion will be found to exist among authors in regard to the frequency with which relapses occur in typhoid fever, and this difference does not appear to be due to any greater frequency of this accident in some countries than in others, since Liebermeister met with them in 8.6 per cent. of the cases treated at the hospital at Basle, while, according to other German observers quoted by him, they occur in 6.3 per cent. (Gerhardt), in 11 per cent. (Bäumler), and in 3.3 per cent. (Biermer). Murchison noted them in 80 of 2591 cases in the London Fever Hospital, or in 3 per cent., and Maclagan in 13 of 128 cases at Dundee, or in 10 per cent. about. Immermann[85] of Basle says that they occur in 15 per cent. of the cases, and that in very unfavorable years the proportion may be as high as 18 or 19 per cent. Prof. Henoch[86] observed relapses in 16 cases out of 96, or 16.6 per cent. In my own {303} practice they have not been very numerous. I find that in 80 cases of which I have full notes they are recorded five times, or in 6.25 per cent., and I believe this ratio correctly represents the frequency with which they have happened in all the other cases which have come under my care. Part of this difference of opinion is unquestionably attributable to the fact that under the term relapse are sometimes included two distinct conditions: (1) Mere recrudescences of fever, which occur during the stage of defervescence or that of convalescence, and which are provoked by errors of diet, mental or bodily fatigue, or some other irritating cause. They usually last a day or two, and are entirely distinct from (2), true relapses, in which all the characteristic symptoms of the primary attack are reproduced, and which commonly occur some time after the disease has apparently run its course. There is occasionally no distinct apyretic interval between the two attacks, but in by far the greater number of instances the relapse occurs in the second or third week, or even later, after the establishment of convalescence. In 20 cases reported by W. M. Ord and Seymour Taylor[87] the relapse occurred in the third week of the disease in 1; in the fourth week in 5; in the sixth week in 3; in the seventh week in 7; in the eighth week in 3; in the ninth week in 1. James Jackson refers to a case in which the date of the relapse is not given, but in which he was able to detect the rose-colored eruption in the sixty-sixth day[88] from the commencement of the disease. In my five cases the relapse occurred on the seventh, eighth, ninth, eleventh, and twentieth day after the apparent establishment of convalescence. In these cases the duration of the relapse was 11, 13, 17, 20, and 13 days respectively. The highest temperature noted in any of the relapses was 105°, which occurred in two cases. In both of these this temperature had also occurred in the original attacks. In one of the others, however, a temperature of over 104° F. was repeatedly observed in the relapse, while in the primary attack it had never risen above 102°.

[Footnote 85: _Schweiz. Corr. Bl._, viii. 1878.]

[Footnote 86: _Charité Ann._, ii. 1875.]

[Footnote 87: _St. Thomas's Hospital Report_, vol. ix., London, 1879.]

[Footnote 88: Since the above was written I have had under my care a case of typhoid fever in which a third relapse occurred nearly four months after the patient, a woman aged thirty years, was first taken ill. The following is a brief abstract of the history of this remarkable case: The original attack began about Sept. 20, 1883, was of moderate severity, and lasted between three and four weeks. Convalescence, which seems to have been nearly complete, as the patient had left her bed, was interrupted on Nov. 1st by a relapse, during which she was admitted into the Pennsylvania Hospital. This relapse was severe, and before it had entirely run its course was itself interrupted, on Nov. 17th, by an intercurrent relapse, which lasted two weeks. During these two relapses extensive bed-sores formed upon the nates, occasioning more or less irritation and consequent febrile reaction. On Jan. 11, 1884, a third relapse occurred. This relapse was accompanied by diarrhoea, rose-colored spots, tympany, dry and brown tongue, and other characteristic symptoms of typhoid fever, the diagnosis being fully concurred in by my colleague, Dr. Morris Longstreth, who saw the case with me. Convalescence was again interrupted on Feb. 13th by fever, which continued for two weeks, but which possessed none of the characters of typhoid fever, and was clearly due to imprudence on the part of the patient. The patient is now (April 25, 1884) entirely well, and will shortly be discharged from the hospital.]

The onset of a relapse is usually much more abrupt than that of the original attack. It is rarely preceded by prodromata. The temperature rises more rapidly and attains its maximum earlier, which may be much greater than in the original attack. In one case under my care it reached 105° on the evening of the first day, and temperatures of 103.5° and 104° on the evening of the second day are not infrequent.

{304} The rose-colored eruption appears earlier. In 38 cases investigated by Murchison with reference to this point, it appeared on the third day in 7; on the fourth in 8; on the fifth in 7; on the sixth in 2; on the seventh in 12; and at a later date in 2. In the case the history of which is given below it was detected on the second day. The delirium also comes on sooner. The relapse is usually less severe, and is of shorter duration, than the primary attack. All my cases terminated in recovery. Occasionally, however, it is much more severe. In one case in which the primary attack was so mild that the patient could scarcely be persuaded to remain in bed, the relapse was so severe that for many days it was uncertain whether the patient would recover. In another intestinal hemorrhages to an alarming extent occurred on two occasions. Moreover, of Murchison's 53 cases, 7 were fatal; in 2 of the cases death was due to perforation; in 2 to peritonitis, induced by infarction of the spleen; and in 1 to abortion; and of Ebstein's 13 cases, 3 were also fatal. Occasionally, a second, and it is said even a third, relapse is noted. In one of Da Costa's cases hemorrhage from the bowels took place during a second relapse.

The following histories and temperature charts illustrate the prominent peculiarities of relapses occurring in typhoid fever:

TYPHOID FEVER (with a relapse).--G---- L----, æt. 20, single, seaman, Italian, admitted March 6, 1878; April 30, 1878, left in ward. Patient is unable to speak English. The following history is obtained through an interpreter: His family history is good, and he is naturally a healthy man, never having had any serious illness--no venereal disease, no cough or rheumatism, no intermittent fever, and he has not been in the habit of drinking to excess. His vessel has been lying off Gloucester Point, and two seamen have recently been similarly affected on another vessel anchored near by. For about two weeks he has had malaise, but not until three days ago was he so ill that he was obliged to give up work. He was then taken with cough, chills followed by fever, diarrhoea, headache, and pain in the abdomen. Has had no epistaxis or vomiting.

Upon admission patient has fever, his face is flushed, his tongue coated with a brown fur in the centre, dry, fissured, and red and glossy at the tip and edges. He has hebetude and some delirium, though not very active; he is deaf. His abdomen is somewhat tense and tympanitic, and covered with very numerous rose-colored spots, which disappear momentarily on pressure; they are also distributed over thighs and chest. There seems to be no tenderness on pressure over abdomen, and there is no gurgling felt. Has moderate diarrhoea, having about three stools daily, which are light yellow in color and are loose and fetid. Urine cloudy orange red, acid, 1021. No albumen.

{305} _3.7_. Ord. Ol. Terebinth. gtt. x; Acid. Muriat. dil. gtt. v every two hours, with Quinine gr. viij daily, and restricted diet.

_3.8_. Tongue not so dry; is better. Whiskey fl. oz. ij.

_3.9_. Temperature elevated. Ord. to be sponged.

_3.10_. Has had four stools in the last twenty-four hours. Some sonorous râles over chest posteriorly. Sponging to be repeated when temperature rises.

_3.11_. There is some subsultus. There are more numerous râles heard over chest posteriorly.

Ord. whiskey fl. oz. v daily; turpentine stupes to chest. His diarrhoea is better; considerable hebetude.

_3.12_. Tongue is not so dry, and is cleaner. The spots over his body are beginning to assume more the appearance of petechiæ. They are found everywhere on his body. Has had but one stool within the last twenty-four hours.

_3.13_. He is brighter; skin feels better; tongue cleaner; pulse but 80. Fewer râles heard in chest. No change in his treatment.

_3.14_. Spots disappearing. Two stools in last twenty-four hours, not so loose in character. Pulse dicrotic.

_3.15_. There is no tympany. Had one natural stool yesterday. Sudaminæ over abdomen.

_3.16_. Doing well. Pulse very slow.

_3.17_. Tongue moist and clean; no diarrhoea.

_3.18_. No diarrhoea; spots are still to be seen, but are fading every day.

_3.20_. Takes a little lemon-juice, as the gums are disposed to be a little spongy.

Stop turpentine and muriatic acid.

_3.25_. Bowels somewhat constipated.

Ord. enema of castor oil.

_3.26_. Stop quinine; give whiskey fl. oz. iij only. Allowed chicken and two eggs daily.

Ord. Tr. Cinch. Co. fl. drachms ij s.t.d.

_4.4_. Slight chill, headache, and pain in side. Temp. 101°.

_4.5_. Temp. normal again; as well as before.

_4.8_. Has been up for a week, and steadily gaining in strength, except the slight attack on the 4th, when to-day, without his having taken any indigestible food, or indeed any reason to which it could be assigned, he was seized with a relapse, his temperature rising to 105°, but being reduced a half degree by sponging.

_4.9_. Spots have again appeared in great numbers, and they are very large. Last evening his temperature reached 104-3/4°, and was reduced to 101° by sponging.

_4.10_. Doing very well; spots are still making their appearance.

_4.12_. Diarrhoea not at all excessive.

_4.15_. Spots are very numerous.

_4.20_. Temperature nearly normal.

_4.25_. Doing perfectly well; up and about.

_4.30_. Left in ward, upon completion of my term of service.

{306}

ABORTIVE ATTACK, FOLLOWED BY TYPICAL ATTACK.--Thomas Rogers, October 15, born in Philadelphia, assistant nurse. Admitted {307} January 25, 1883; discharged March 26, 1883, cured. Father died of hemorrhage from the lungs; mother living and healthy. Two years ago he sustained a compound fracture of the left leg from a bale of cotton falling on him; otherwise he has always enjoyed good health. For the past three months he has been assisting the nurse in the receiving ward of this hospital. Four days before admission, without unusual exposure, he had a slight chill, and felt cold for several hours. This was followed by fever and a feeling of weakness. He also had slight headache and the bowels were constipated; no epistaxis.

Upon admission patient has a good deal of hebetude, face flushed, temperature 102°, pulse 106, tongue slightly coated, moist. Has slight pain in right lumbar region, but no distension of abdomen. Urine negative.

Ord. quinine gr. viij. daily; liq. ammon. acet. fl. drachms ij. q.q.h.

_Jan. 29th_. More hebetude; tongue more coated with brownish fur, red at tip; bowels continue costive; opened by an enema.

_31st_. Is brighter and better. One doubtful rose-colored spot seen on abdomen.

_Feb. 4th_. The morning temperatures for the past two days have been subnormal and the evening rise is very slight. All the symptoms also indicate the approach of convalescence.

_6th_. More fever; pulse weaker; functional murmur heard over heart; sudamina out over abdomen. Ord. whiskey fl. oz. ij.

_8th_. Some fulness of abdomen; had three loose yellowish-colored stools in the last twelve hours.

_9th_. A few doubtful rose spots out over abdomen and back; sudamina still abundant.

_10th_. More tympany; numerous rose-colored spots out over abdomen and back; slight epistaxis and bronchitis.

_11th_. Pulse more feeble; still slight diarrhoea. Increase whiskey to fl. oz. iv.

_15th_. Has a good deal of hebetude, but no headache; fewer spots; pulse weaker; temperature lower. Increase whiskey to fl. oz. vj.

_17th_. Temperature high again; most of the spots have disappeared; slight epistaxis and subsultus; no delirium; bowels not open for two days.

_20th_. Temperature falling; spots disappearing; still fulness of abdomen.

_25th_. Temperature has been subnormal for several days, and he is doing well; tongue cleaning. Has emaciated a good deal, and is weak.

_March 1st_. Is convalescent; tongue has lost its redness.

_8th_. Continues to improve; allowed semi-solid food.

_17th_. Is now quite well; has gained a good deal in flesh, and is stronger.

{308}

The examination of the bodies of those who have died during a relapse reveals the presence of two sets of lesions in the cicatrizing ulcers of the primary attack and the recent ulcerations of the relapse. The latter are usually less extensive, and are found to be situated at a greater distance from the lower end of the small intestine, than the former, for the reason that the Peyer's patches most remote from the ileo-cæcal valve are least apt to be affected in the primary attack.

No satisfactory explanation of these relapses has as yet been discovered. {309} They occur in patients of both sexes and of all ages with about the same frequency. They have been attributed to errors of diet, mental and bodily fatigue, and the like, but, while we know that causes of this character often provoke recrudescences of fever, and can understand that they may act as exciting causes of a relapse in cases in which the predisposition exists, it does not seem possible that they should by themselves be able to bring back all the characteristic symptoms of a specific disease. It has been maintained by some authors that a relapse indicates that a new infection has taken place; but this hypothesis, even if we admit that it accounts for those cases in which the patient is allowed to remain in the place in which he has acquired the disease, does not explain those in which he is removed during the first attack to a hospital where all the sanitary arrangements are presumably perfect. Griesinger has endeavored to explain relapses occurring in hospitals by suggesting that they may possibly be due to a fresh contagion from other patients with typhoid fever in the same ward; but this explanation is rendered improbable by the fact that relapses have occurred when cases have been thoroughly isolated. As I have already said, during a long connection with the Pennsylvania Hospital I have only known a single case of typhoid fever to originate within its walls, although relapses probably occur in its wards with the same frequency as in other hospitals. To adopt Griesinger's explanation, it would therefore be necessary to assume that a patient just recovered from an attack of the disease is more susceptible to the action of its contagion than patients suffering from other disease; which seems improbable, to say the least. It has also been maintained that relapses are due to the inoculation of the previously healthy Peyer's patches by the typhoid poison which is thrown off with the sloughs from those first affected. Maclagan alleges that relapses are more frequently met with in cases in which constipation is present in the primary attack, a condition which he regards as favorable to absorption; but this is opposed to the experience of almost every one who has paid any attention to the subject. In the cases which have come under my own observation it certainly was not the case, diarrhoea having been present in all of them. It is more likely, as suggested by Liebermeister, that part of the poison remains latent somewhere in the body, not developed, destroyed, nor expelled during the first attack, but brought later into activity by some exciting cause. Da Costa adopts this view, and says that relapses of typhoid fever are not unlike the outbreaks of malarial fever which occur after worry or fatigue and when there has been no chance for a fresh infection. Different plans of treatment have at various times been charged with increasing the predisposition to relapses. This is especially true of the cold-water treatment, and the records at the hospital at Basle show that the proportion of relapses and the number of deaths from them are both increased under the use of cold water. Liebermeister thinks, however, that this does not necessarily prove that this treatment favors the occurrence of relapses, since before the introduction of this plan of treatment many more typhoid fever patients died in the first attack of the disease. Employing those cases only for statistical purposes in which the patients have survived the first attack, he finds that the difference at once disappears, there being 9 per cent. of relapses before the use of cold water, and 10.3 per cent. after its use.

{310} Gerhardt[89] asserts that in cases in which relapses occur the enlargement of the spleen does not diminish during the non-febrile period that intervenes between the original attack and the relapse.

[Footnote 89: _Ziemssen's Cyclopædia_, vol. i. p. 193.]

Da Costa[90] has shown that the appearance of the white line and furrow left by the primary attack, to which attention has already been drawn, may sometimes be of service to us in diagnosis when we see the patient for the first time during the relapse. In a case which was recently under my care their appearance certainly rendered the nature of the previous illness from which the patient had suffered much clearer than it would otherwise have been.

[Footnote 90: _Transactions of the College of Physicians of Philadelphia_, 3d S., vol. iii.]

DURATION.--The mode of invasion of typhoid fever is generally so insidious, and the first symptoms so little pronounced, that the patient, even if free from mental hebetude and confusion at the time when he first comes under the care of a physician, is usually unable to fix with certainty the time of the beginning of his illness. This inability is of course most marked in what are known as walking cases, in which, notwithstanding that the disease is far advanced, the patient continues to pursue his ordinary avocations or at least refuses to go to bed. In a few cases, however, either in consequence of the violence of the first symptoms or from some other cause, opportunity is afforded to the physician of observing the disease from its onset. In many others the date of commencement may be approximately ascertained. The average duration of such cases, if uncomplicated, has been found to be between three and four weeks. According to Bartlett, the average duration of 255 cases at the Massachusetts General Hospital between the years 1824 and 1835, inclusive, was twenty-two days. It was a little less than this in patients under twenty-one years of age, and a little more in those over. As these cases occurred before the introduction into use of the clinical thermometer, and as the commencement of convalescence is fixed in them at the time when the patients were able to take a little solid food, it is possible the fever may have continued in them some time after convalescence was supposed to have been established. Of 200 cases which ended in recovery, and in which Murchison was able to ascertain with precision the date of commencement, the duration was 10 to 14 days in 7 cases, 15 to 21 days in 49 cases, 22 to 28 days in 111 cases, and 29 to 35 days in 33 cases. The mean duration of these 200 cases was 24.3 days, while that of 112 fatal cases was 27.67 days. From the same author we learn that the average stay in hospital of 500 cases which recovered was 31.24 days, and of 100 fatal cases was 16.52 days, while the average duration of the illness before admission in the 600 cases was 10.78 days. During the twenty years from Jan. 1, 1862, to Dec. 31, 1881, 621 cases of typhoid fever, 121 of which were fatal, were admitted into the Pennsylvania Hospital. No notes of many of these cases were taken, and of some of the others the notes are incomplete or inaccessible, so that they cannot, unfortunately, be used for the purpose of determining the duration of the disease. The books of the hospital, however, show the length of time each patient remained in the wards. From these we learn that the average stay of the 500 patients who recovered was 43.5 days, while that of the 121 patients who died was only 8.75 days, and that of these a large number (28) died within {311} 48 hours after their admission to the hospital. As a rule, patients are retained at the Pennsylvania Hospital until they are fully able to return to work, while at the English and continental hospitals it is usual to discharge them when they cease to need active treatment. This circumstance probably explains the much greater average duration of the cases admitted to the Pennsylvania Hospital than that of the cases referred to by Murchison. In the abortive form the duration of the disease may not exceed ten days, and there are authors who contend that it may occasionally be very much less.

Death may occur at almost any time in the course of typhoid fever. I have never seen it myself take place before the seventh day. Murchison reports two cases in one of which the disease terminated fatally within twenty-seven hours of its commencement, and in the other on the second day. Instances are more numerous in which death has occurred on the fourth, fifth, or sixth day, but still they are comparatively infrequent, and, as a rule, the fatal termination takes place most frequently during the course of the third week. On the other hand, death may sometimes occur at a very much later period. This is, of course, the case when it occurs during a relapse, but if the fever continues after the third week the patient may sometimes die from exhaustion or from the intercurrence of a complication. Death may also be the result of a sequela long after the disease has run its course.

DIAGNOSIS.--The insidious invasion of typhoid fever, together with the absence of pathognomonic symptoms in the beginning, always renders the diagnosis difficult, and sometimes impossible, during the first week. Still, even at this time the existence of the disease may be suspected if the frequent use of the thermometer reveals from day to day a gradual increase of the fever and the existence of evening exacerbations followed by morning remissions, the temperature rising each evening from a degree to two degrees higher than it had done the preceding evening. If in addition to this character of the pyrexia there are diarrhoea with ochrey-yellow stools or an increased susceptibility to the action of cathartic medicines, epistaxis, enlargement of the spleen, slight fulness of the abdomen, with tenderness and gurgling in the right iliac region, slight hebetude and some confusion of ideas upon awakening, the diagnosis becomes more probable. During the next week the symptoms are usually much more characteristic. The presence of marked abdominal symptoms, together with the eruption of rose-colored spots, will generally render the recognition of the disease at this time an easy matter. There are, however, a few cases in which no rose-colored spots can be found, and in which the abdominal symptoms, if they exist at all, are so little marked that they do not arrest attention. Even in these cases the temperature record, when carefully studied, will often throw a good deal of light upon the nature of the disease. If the febrile movement resembles that usual in typhoid fever, if it has continued for more than a week, if the patient has not been recently exposed to malarial influences, and presents no symptoms of local disease, the diagnosis may still be made with at least an approach to certainty.

The following are the diseases which are most likely to be mistaken for typhoid fever: