colon are in a large proportion of cases normal. In a few the membrane
is paler than in health, and in others it is of an ash-gray color. It
is also sometimes injected and softened. The solitary glands are
frequently enlarged and ulcerated, like those of the ileum. In the
former case the mucous membranes of the large intestine throughout its
whole extent, but especially that of the cæcum and of the part of the
colon adjacent to it, is studded with minute elevations about a line
in diameter. When ulceration has occurred the ulcers are generally
round {264} and small, but they may occasionally be oval and of
considerable size. In the latter case their long diameter will
correspond in direction with that of the circular fibres of the
intestine. Murchison has known them to measure fully an inch and a
half in length. The colon is generally found much distended with
flatus.
Enlargement of the mesenteric glands from cellular hyperplasia and
hypertrophy of the connective tissue is constantly associated with the
morbid changes of the intestines just described. This enlargement
varies in different cases. In some the glands are not larger than a
pea or bean; in others they are said to have reached the size of a
hen's egg. It is always more marked in the glands which lie in the
angle between the lower end of the ileum and the cæcum, and usually
bears some proportion to the intensity of the local disease; but it is
not to be regarded merely as a result of the local irritation, as it
has been observed in parts of the mesentery corresponding to perfectly
healthy portions of the intestine, and as the meso-colic glands have
been involved in cases in which the colon was free from disease. It
has, moreover, been observed in cases in which death has occurred very
early in the disease, and there can therefore be little doubt that it
is as much the result of the infective process as the infiltration of
Peyer's patches. In addition to being enlarged, if death has taken
place before the end of the second week the glands are hyperæmic and
of a purplish color. Later than this, when the sloughs become detached
from Peyer's patches, the swelling of the glands diminishes; they lose
their color and become pale, and if convalescence ensues they return
finally to their former healthy condition. Still, Murchison has seen
them shrivelled and pale or bluish for some time after convalescence.
In other cases the substance of the glands softens, with the formation
of a puriform liquid. If the softening only involves a small part of
the glandular structure, restoration to health may take place through
the absorption of this liquid. If it is more extensive, the whole of
the glands may break down into this puriform liquid, which, when the
patient recovers, undergoes caseous and finally calcareous
degeneration. Occasionally, a gland in this condition is the cause of
death from rupture and extravasation of its contents into the cavity
of the peritoneum.
The glands in the fissure of the liver, the gastric, lumbar, inguinal
glands, and indeed all the lymphatic glands in the body, have
occasionally been found swollen and congested, but their enlargement
cannot be classed among the specific lesions of the disease, but is
merely the result of a local irritation. Thus, Jenner says that in the
case of extensive ulceration of the oesophagus which came under his
observation there was marked enlargement of the oesophageal glands.
Liebermeister says that the lymphatic follicles which surround the
glands at the root of the tongue and in the tonsils are often affected
in the same way as the glands. In most cases after a time the swelling
disappears, but sometimes softening and rupture take place.
The spleen is almost invariably found to be increased in volume and to
have undergone changes in consistence and color. The degree of
enlargement and the other changes vary of course with the stage of the
disease at which death has occurred. The enlargement occurs with less
frequency in elderly than in young people, and is most marked at the
height {265} of the disease, the organ being then often twice or three
times its normal size, and in some cases, it is said, even larger.
Later, and especially during convalescence, the enlargement has
generally very much diminished. During the first ten days of the
disease the spleen is generally tense and firm, engorged with blood,
and dark red in color. Between the tenth and thirtieth days its
appearance remains the same, but the organ is found to be soft and
friable. During convalescence it becomes paler and firmer again, and
is often so shrunken in size that its capsule is relaxed and wrinkled.
Hemorrhagic infarctions are often met with. These sometimes soften and
break down into a puriform liquid, which may sometimes cause
peritonitis by rupture into the peritoneal cavity. Rupture of the
spleen is also said to have occurred from mechanical violence. These
changes are due in part to variations in the amount of blood, and in
part to a medullary infiltration of Malpighian corpuscles similar to
that which takes place in Peyer's patches and the glands of the
mesentery.
LESIONS WHICH ARE NOT PECULIAR TO TYPHOID FEVER, BUT ARE OF MORE OR
LESS FREQUENT OCCURRENCE.--The mucous membrane of the pharynx and
oesophagus may present a perfectly healthy appearance, but
occasionally it is congested and the seat of ulcerations which are for
the most part superficial. Sometimes, however, they have been found to
extend to the muscular coat, but they have never been known to
penetrate all the coats of these organs. Jenner refers to one case in
which there was extensive ulceration of the oesophagus, but usually
the number of ulcers is not large. In a few cases the mucous membrane
of the pharynx is coated with diphtheritic false membrane, and the
submucous tissue is infiltrated with serum and pus (Murchison).
The stomach and the upper part of the intestinal tract present no
lesions which are at all peculiar to typhoid fever. In a certain
number of cases congestion, softening, and even superficial
ulceration, of the mucous membrane of the stomach, and less frequently
of that of the duodenum, have been found. The mucous membrane of the
jejunum and of the upper part of the ileum is not usually much
reddened, and may be even paler than in health. In cases which have
been protracted it may be of an ashy-gray or slate color. The contents
of this part of the intestinal tract, which is rarely much distended
by flatus, do not differ materially in appearance or consistence from
the matter which generally composes the typhoid stool. The bowels may,
of course, be found filled with blood in cases in which a recent
hemorrhage has taken place. Invaginations of the small intestines,
unaccompanied by any evidences of inflammation, are occasionally met
with in the bodies of those who have died of typhoid fever. They are
produced, there is good reason to believe, during the death agony, but
are not peculiar to this disease, as they occur in many other
diseases.
Enlargement of the liver has been found in only a few cases after
death from typhoid fever. Softening is more common, but even this is
not a frequent result of the disease, for it was absent in 41 out of
73 cases examined with special reference to this point by Louis,
Jenner, and Murchison. The organ is occasionally hyperæmic, and darker
in color than in health, but it is oftener pale or normal in
appearance. Even, however, where it appears to be perfectly healthy to
the unassisted eye, {266} the microscope shows that its cells are very
granular and filled with oil-globules which often render the nucleus
indistinct or completely conceal it. When death has taken place at an
advanced stage of the disease many of the cells are found to be
completely broken down into a granular detritus. These changes are
usually proportional to the degree of pyrexia which has been present
during life. Rarer lesions of the liver are pyæmic deposits, embolism,
abscess, and emphysema.
The mucous membrane of the gall-bladder has been found to be the seat
of ulcers by Jenner and numerous other observers. It also occasionally
presents the evidences of catarrhal or diphtheritic inflammation. The
gall-bladder usually contains a pale watery liquid of a less density
than bile. When, however, inflammation of its lining membrane has
existed, its contents are mixed with pus and shreds of false membrane.
The mucous membrane of the larynx is sometimes found to have been the
seat of catarrhal or diphtheritic inflammation, and sometimes also of
ulceration. Jenner says that in typhoid fever laryngitis independent
of pharyngitis is extremely rare, but the German writers express a
different opinion. Griesinger estimated that laryngeal ulcers were
present in one-fifth of the fatal cases. Hoffmann found them
twenty-eight times in two hundred and fifty autopsies, and that the
ulcers had extended to and involved the cartilages in twenty-two out
of the twenty-eight cases. They are most commonly found in the
posterior wall of the larynx, and may involve the vocal cords. These
are often discovered after death in cases in which their existence was
not suspected during life. They were formerly supposed to be the
result of typhoid infiltration of the laryngeal glands, but careful
investigation has shown that they are the consequence of diphtheritic
inflammation of the mucous membranes. Inflammation and ulceration of
the trachea are comparatively rare. Hypostatic congestion and
infarction of the lungs are not uncommonly found after death from
typhoid fever, and less frequently the lesions of pneumonia. Evidences
of recent pleurisy are also discovered in a few cases. Acute miliary
tuberculosis of the lungs is more often met with as a sequela than as
a complication.
The changes in the brain and its membranes caused by typhoid fever are
few and unimportant, even in cases attended by severe nervous
symptoms. Those most frequently found are adhesions of the dura mater
to the inner surface of the cranium, injection or oedema of the pia
mater, congestive oedema, and sometimes softening of the brain and
effusion at the base of the brain. The microscopic changes do not
appear to have been carefully studied. Liebermeister says that the
gray substance of the cortical portion of the brain and of the
interior is sometimes of a rather yellowish-brown color, and that he
noticed besides diffuse yellow and blackish-brown spots in different
places, particularly in the corpus striatum and thalamus opticus. In
such places, he says, the microscope shows a diffuse yellow
coloration, a deposit of small brown pigment-granules, and also,
especially in the optic thalamus and corpus striatum, the
ganglion-cells thickly crowded with brownish or blackish
pigment-granules in such numbers as to conceal the outlines of many of
the cells. These changes Hoffmann,[47] who has specially studied them,
is inclined to place by the side of the parenchymatous degeneration of
other organs. {267} The ganglion-cells of the sympathetic ganglia are
said by Virchow also to contain an unusual amount of pigment.
[Footnote 47: Quoted by Murchison.]
The muscles are frequently the seat of marked changes in typhoid
fever. Their macroscopic appearances vary with the stage of the
disease at which they are examined. When death takes place in the
first or second week they are usually dark red or reddish-brown in
color, and very dry. If it is delayed until later, they "present a
peculiar fawn or yellow tint permeating the ordinary red in patches
and veins not unlike the appearance of veined marble." Their
consistence is also so much diminished that the finger may be readily
passed through them. Occasionally, pseudo-abscesses and hemorrhages
into the muscular sheath are found, and Dauvé and B. Ball[48] report
cases in which, in addition to these changes, rupture of muscles had
occurred. Zenker, who was the first to call attention to them, ranged
the changes seen under the microscope under two heads: (1) granular or
fatty degeneration; (2) waxy degeneration. In the first variety the
transverse striæ disappear and the sarcolemma appears filled with
finely granular matter. In the second variety the striated muscles
become, as it were, pervaded by a coagulating material which sets, and
in contracting breaks up the fibres into great numbers of short
waxy-looking lumps, not unlike a certain variety of casts of the
tubuli recti of the kidneys. When recovery takes place the affected
fibre is believed to be regenerated by a cell-growth within the
sarcolemma. These changes occur in most fevers, as typhus, small-pox,
scarlet fever, and are attributed by authors generally to the
hyperpyrexia which is a frequent accompaniment of these diseases.
Hayem, however, asserts that he has found them well marked in cases
not characterized by a high temperature, and that, on the other hand,
they are sometimes absent in cases where this has been present. The
waxy form of degeneration may affect all the striped muscles, but is
oftenest seen in the muscles of the abdominal walls, the adductors of
the thigh, the muscles of the diaphragm, and tongue.
[Footnote 48: _L'Union Médicale_, 1866, quoted by _Biennial Retrospect
of Medicine and Surgery and their Allied Sciences_, for 1865-66.]
The heart, in common with the other muscles of the body, suffers from
both the forms of degeneration above described, but the granular form
appears to be more common than the waxy. In protracted cases it is
usually much softened, and when thrown upon a plate no longer retains
its form. It has usually lost its normal color and acquired the tint
described by the French as feuille morte (faded leaf). Upon minute
examination the degeneration is found to have taken place in patches,
the diseased fibres being found alongside of others which have
scarcely undergone any alteration. These patches are especially common
in the papillary muscles of the mitral valve--a fact which explains
the occasional presence of systolic murmurs in typhoid fever. In
addition to the microscopic appearances of the muscles already
described, Hayem[49] has observed in his examinations of the heart a
cellular infiltration of the connective tissue and a proliferation of
the muscle nuclei. These changes are sufficient in his opinion to
establish the existence of myocarditis. The same observer thinks he
has also found evidences of the frequent occurrence of endoarteritis
in the multiplication of the cellular elements {268} of the internal
coat of the small arteries, which he has discovered under the
microscope.
[Footnote 49: _Leçons cliniques sur les Manifestations cardiaques de
la Fievre typhoide_, Paris, 1875.]
Some discrepancy of opinion exists in regard to the condition of the
blood in typhoid fever. Trousseau, for instance, speaks of it as being
profoundly altered and in a state of dissolution; Liebermeister says
that at the height of the disease the blood is very dark-colored, and
that after coagulation it presents a small and soft clot; and
Murchison, that a dark, liquid condition of the blood is rarer than in
typhus, and that fine white coagula are more common. Harley too has
frequently found firm colorless clots of fibrin in the heart and roots
of the great vessels in subjects dead in the third week of the
disease. Forget concludes from an examination "of one hundred and
twenty-three specimens of blood derived from patients in all stages of
the disease that an appreciable alteration of the blood in the several
periods of enteric fever cannot be accepted as a general fact; that
the blood is rarely altered in the first period; that the alteration
is more marked in proportion as the disease is more advanced; that the
alteration is not always in proportion to the gravity of the
disease."[50] I have myself seen the disorganization of the blood as
complete in severe cases of typhoid fever which have rapidly proved
fatal as in cases of diphtheria or of other malignant diseases. On the
other hand, in protracted cases and during convalescence the blood is
often thin and watery.
[Footnote 50: Quoted by Harley, Reynolds's _System of Medicine_, vol.
i.]
The kidneys are sometimes engorged with blood, sometimes pale and
flabby. Under the microscope the appearances are similar to those just
described as occurring in the liver, and it is therefore unnecessary
to refer to them more fully here. As a rule, the epithelium becomes
granular earlier and to a marked degree in the cortical than in the
tubular portion. The absence of albuminuria must not always be
accepted as proof of a healthy condition of the kidneys, as this
symptom has been wholly wanting in cases in which the organs have been
extensively diseased.
Analogous changes have also been observed in the salivary glands and
pancreas, except that, according to Hoffmann, a cellular proliferation
precedes the degenerative process.
CLINICAL DESCRIPTION.--The invasion of the disease is usually so
gradual that it is often impossible to obtain from patients exact
information as to the time of the beginning of their illness. Among
those who present themselves for treatment at the Pennsylvania
Hospital it is not uncommon to find that many have suffered for
several days, it may be as long as a week, or even longer, before
taking to their beds, from vague feelings of discomfort, from headache
more or less intense, aching pains in the back or limbs, or from
sensations of chilliness alternating with flashes of heat. In other
cases derangements of the digestive system are more prominent, such as
nausea, or even vomiting, diarrhoea, or irritability of the bowels.
Notwithstanding these symptoms, and the indisposition to exertion
engendered by them, they have frequently continued to follow their
usual avocations up to the time of their application at the hospital
for admission. There is generally, however, no difficulty in
recognizing at once the nature of their disease. Upon examination the
pulse is found to be frequent, the respiration accelerated, the tongue
furred, the skin hot and dry, and the abdomen tympanitic.
{269} Among patients whose position in life enables them to pay
greater attention to trifling symptoms than those who are compelled to
seek hospital relief, opportunity is frequently afforded to the
physician to study the disease at a period less remote from its
commencement. The symptoms it presents when seen as early as the
second day are generally of a very indefinite character. There may be
a feeling of malaise, headache with a tendency to giddiness, pain in
the back and limbs, a slightly coated tongue, thirst, and anorexia.
The patient may complain of chilly sensations alternating with flashes
of heat, but it will rarely be found that the attack has commenced
with a decided chill. Diarrhoea may also be present at this time, or
may not supervene until later. Even in cases in which it is absent the
bowels will generally act inordinately after the administration of a
gentle purgative. Occasionally, the attack begins with vomiting, but
this is not, in my experience, a frequent mode of commencement. If the
visit be made in the morning, the febrile symptoms will be little
marked, the pulse being only slightly accelerated and the temperature
being rarely more than from a half to a degree above the normal. In
the evening, however, the thermometer usually indicates a greater
elevation of temperature.
At subsequent visits the same symptoms are presented. It will be
observed, however, that the fever is decidedly remittent in character,
the evening temperature being always from a degree to a degree and a
half higher than that of the morning, while the temperature of each
succeeding day is a little higher than that of the day which preceded
it. The patient is restless and wakeful at night, or sleep, when
obtained, is unrefreshing and disturbed by dreams. He grows dull and
slightly deaf, and although able to answer questions intelligently
when roused, does so with an effort, and soon after lapses into his
former condition. Although obviously growing weaker every day, it is
sometimes difficult to get him to take to his bed. The diarrhoea
continues and increases in severity; the stools become watery in
character and ochrey-yellow in color; they may exceed six, or even
twelve, in the twenty-four hours. Epistaxis either consisting of a few
drops of blood only, or so profuse as to endanger life, may also occur
during the first week. Examination of the abdomen toward the middle or
close of the first week will almost always reveal the existence of
tympany and of tenderness and gurgling in the right iliac fossa, and
very frequently also of slight enlargement of the spleen. The urine at
this stage of the disease is dense, scanty, and of high color. The
tongue too will be observed to be more heavily coated than at first,
and to be dryish, the fur being disposed on the middle of the dorsum
of the organ, while the tip and edges are free from it and abnormally
red in color. Usually, toward the close of the first week, the pulse
will be found to be between 100 and 120 in frequency. It often,
however, does not attain this frequency, and in some cases does not
exceed 50 throughout the whole of the attack. At the same time, the
thermometer generally indicates a temperature of from 102° to 104°,
and in bad cases even one much higher than the latter.
These symptoms are not pathognomonic, but Murchison regards their
existence in a young person as warranting the suspicion that he is
suffering from this disease. About this time, however, or, to speak
more accurately, usually from the seventh to the twelfth day, a new
symptom occurs {270} which is more characteristic. This is an eruption
of isolated rose-colored spots, the tâches roses lenticulaires of
Louis, occurring principally upon the surface of the abdomen, but not
infrequently seen also upon the chest, back, limbs, and even,
according to some authors, upon the face. They are round in shape,
with a well-defined margin, usually about a line in diameter, but
sometimes considerably larger, slightly elevated above the surface,
and disappearing upon pressure, but returning when the pressure is
removed. They can almost always be found at this stage of the disease
if diligently sought for.