aggravated toward the end of the second week. The tongue grows dry and
brown, the pulse more frequent, feeble, and markedly reduplicated in
character, the diarrhoea still more severe, and the fever higher than
before, with little or no tendency to remit in the morning. The
nervous symptoms also come into prominence. The headache may grow more
violent or may be replaced by increased dulness, which may sometimes
be so decided as to render it difficult to fully rouse the patient. At
other times delirium is a prominent symptom. This may only occur at
night, but not infrequently is observed during the daytime as well. It
is usually more active in character than that which accompanies
typhus. Trembling of the tongue and of the limbs is not uncommon at
this time. The urine becomes more abundant, paler, and less dense than
before. Even in cases characterized by symptoms as severe as those
above detailed some improvement is, however, often observed to take
place between the fourteenth and twenty-first days. The morning
remission becomes more decided, the evening temperature less high than
that of the preceding day; the stools lessen in number, and gradually
assume a more healthy appearance; the pulse diminishes in frequency
and gains in force; the tongue becomes moist, and shows a tendency to
throw off its fur; the trembling grows less marked; the dulness and
delirium lessen; and the patient falls into a refreshing sleep. In
other cases, in many of which recovery eventually takes place, there
is at this time, instead of an improvement, a still further
aggravation of the symptoms. The pulse becomes more feeble and
frequent; the tongue is not only excessively dry and brown, but
shrivelled and fissured; the lips and teeth are encrusted with sordes;
the stools contain shreds of membrane, and often blood; the subsultus
tendinum increases; carphololgia, or picking at the bed-clothes,
occurs. The prostration becomes so extreme that the patient frequently
slips down in bed from sheer weakness. The active delirium of the
previous stage is replaced by the low muttering form, or the patient
lies upon his back with his eyes half closed in a semi-unconscious
condition, from which he is with difficulty aroused, and which may
deepen into coma. Occasionally, however, the active delirium
continues, and is associated with an obstinate wakefulness; the urine
and feces are passed involuntarily, or, with an apparent incontinence
of the former, there may be retention, which is very apt to be
overlooked. If these symptoms continue for any length of time,
bed-sores may form not only over the sacrum, but on other parts
subject to pressure, and the patient, worn out by long-continued
suffering, dies from exhaustion.
Occasionally, in the midst of these symptoms, and sometimes even in
cases in which the condition is not so alarming, prostration
approaching {271} collapse, without obvious cause, suddenly
supervenes. The pulse becomes a mere thread, the surface is bathed in
a clammy sweat, and the temperature is found to have fallen from four
to seven degrees, and in some cases even more. These symptoms almost
always indicate that intestinal hemorrhage has taken place, and are
followed by the discharge of blood either in the course of a few hours
or not until a day or two subsequently. If the hemorrhage be moderate
in amount, and does not recur, reaction usually takes place in a short
time; but if, on the other hand, it is profuse or frequently repeated,
death may occur, either immediately or later, as the result of the
exhaustion it has induced. Very much the same set of symptoms attend
the occurrence of perforation of the bowel, an accident which is also
liable to happen in the course of typhoid fever, but which may
generally be distinguished from intestinal hemorrhage by its being
accompanied by a sharp pain in the abdomen, which is frequently so
severe as to cause the patient to cry out, by its not being attended
with the same reduction of temperature, and by the absence of blood in
the discharges. In a day or two all doubt will be set at rest, if the
case be one of perforation, by the occurrence of general peritonitis.
A fatal termination is by no means the usual result, even in cases in
which the disease has assumed its worst features. Indeed, it may be
said that there is no condition in typhoid fever so grave that
recovery from it is impossible. Many authors would make perforation of
the bowel an exception to this general rule, but there are
observations on record which would seem to show that this accident is
not invariably fatal. Even in cases in which the patient has lain
helplessly on his back in a semi-unconscious or comatose condition,
passing his discharges under him, the physician will often be
gratified to find at one of his visits some evidence of improvement,
trifling as it will probably be. It may be only a slight change of
position, an inconsiderable fall of temperature, or a scarcely
appreciable moistening of the tongue; but these changes, insignificant
as they apparently are, are sufficient to indicate to the practised
eye of the observant physician the approach of convalescence. Next day
there will be a still further reduction of temperature, a more decided
moistening of the tongue, a sensible diminution of the nervous
symptoms, and a reduction in the frequency of pulse. In this
condition, however, as may be readily imagined, convalescence may be
retarded by numerous accidents, and life may hang trembling in the
balance for several days, or even weeks, before it is fully
established. It is not necessary to recount here the various steps by
which a return to health is reached, as they are essentially the same
as those which mark the convalescence of the less severe variety of
the disease, and have already been fully referred to in the
description of that form.
But even after the establishment of convalescence, and after the
patient has been free from fever for several days, febrile attacks
lasting for a day or two, or even longer, may occur as the consequence
of very slight causes, such as undue excitement, or fatigue of any
kind, or the immoderate indulgence of the appetite, which in this
condition frequently needs to be restrained. These attacks are usually
spoken of as recrudescences of fever, and do not differ materially
from attacks of irritative fever occurring under other circumstances.
They usually subside under appropriate treatment with the removal of
their cause, but leave the patient somewhat {272} weaker than they
found him. In other cases, it may be a week or ten days after the fall
of the temperature to the normal, and frequently at a time when all
danger seems to have been passed, a true relapse of the disease
occurs. In this, of course, all the symptoms of the primary attack are
reproduced, including even the eruption of rose-colored spots. The
temperature usually, however, attains the maximum more rapidly, and
the duration of the fever is generally shorter, than that of the
original attack. A second relapse is also not very uncommon, and even
a third may occur. Various complications and sequelæ also occur in the
course of typhoid fever, which will be referred to fully hereafter.
Another form of the disease, which it may be well to allude to briefly
here before closing the general description of the disease, is the
abortive form. In this variety the attack begins and runs its course
up to a certain point, including often even the occurrence of the
eruption, as it does in the majority of cases; but at a period which
varies between the seventh and fourteenth day the symptoms suddenly
subside and the patient rapidly convalesces. In some cases it may be
difficult to distinguish this form from an attack of simple continued
fever, and, in fact, in cases in which the eruption is absent it will
be impossible, unless other cases of typhoid fever have occurred in
the same house or family, or unless the patient has been unmistakably
exposed to the influences under which the disease arises.
In a few cases the disease begins abruptly with a chill, intense
headache, or with gastro-intestinal symptoms, which have in rare
instances been so violent as to have suggested to the mind of the
attending physician the possibility of corrosive poisoning. This,
according to Chomel, is the most frequent mode of commencement, but
his experience on this point is opposed to that of the great majority
of observers.
* * * * *
I shall now proceed to describe in detail some of the most important
of the symptoms presented by the disease.
Even in the beginning of an attack of typhoid fever the face has a
listless and languid expression, although the eyes are usually bright
and the pupils dilated. In mild cases no further alteration of the
physiognomy than this may be noticeable throughout the whole course of
the disease, but in bad cases, when the typhoid condition is fully
developed, the expression becomes dull and heavy. There is, however,
never the general suffusion of the face seen in typhus. On the
contrary, the face is often pallid, or there is at most a
circumscribed flush on one or both cheeks, which is most marked during
the exacerbations of fever or after the administration of food and
stimulants. During convalescence the effects of the long illness are
fully visible in the face.
Prostration, or loss of muscular strength, is present from the
beginning in a large number of cases of typhoid fever, but is
generally not so marked in the early stages as in typhus fever. It is
usually most intense in grave cases, but to this rule there are
numerous exceptions. It is not rare to find patients, in whom the
other symptoms are severe, able to sit up in bed, and even to rise to
stool, throughout the attack. Bartlett records a case in which the
patient did not confine herself to bed until the occurrence of
perforation, and I have had under my care a man who, supposing he was
suffering only from a slight diarrhoea, performed the duties {273} of
a nurse in a military hospital until two days before his death,
although the autopsy showed very extensive ulceration of the
intestine. Several cases have come under my care in the second week in
which patients have walked a considerable distance to make application
for admission to a hospital. Generally, however, the prostration
becomes extreme in the third and fourth weeks of bad cases, the
patient lying helplessly on his back, and frequently slipping down in
bed from sheer weakness.
Epistaxis may occur at any stage of typhoid fever, but is most common
in the forming stage. Observers differ in opinion in regard to its
frequency. Murchison noted it in only 15 of 58 cases, and gives it as
his belief that it is more common in France than in England or this
country. Flint found that it had occurred in 21 only of 73 cases, and
Jenner in 5 of 15 fatal cases. On the other hand, Bartlett says that
it is quite a common symptom, and Wood and Gerhard, from the frequency
with which they had met with it in the beginning of the disease, were
accustomed to regard its presence as of importance in a diagnostic
point of view. Part of this divergence of opinion is probably due to
the fact that it is usually small in amount, and therefore very apt to
be overlooked. I have in many cases, after having been told there had
been no epistaxis, found the evidence of it upon the fingers or
bed-clothes of the patient. It may, however, be so profuse as to
endanger life and render necessary the use of the tampon. Except in
the latter case it is without influence upon the course of the
disease.
The skin may be almost constantly dry as well as warm throughout the
whole course of the fever in a small proportion of severe cases. But,
on the whole, perspiration occurs with greater frequency in typhoid
fever than in any other acute disease, unless it be rheumatism. It
takes place most commonly at night after the evening exacerbation, or
in the morning when the patient awakes from sleep, but it is not very
rare to find the skin clammy at other times. The sweating is usually
general, but in a few cases it is local only. When colliquative, it is
frequently exhausting, and is then a grave symptom. It is sometimes
prolonged into convalescence, when it is not only annoying, but in
consequence of the prostration it induces may sometimes retard the
restoration to health.
I have never been able to satisfy myself that any peculiar odor is
given off by the skin in typhoid fever, and most observers make a
similar statement. Chomel, however, asserted that the perspiration has
a strong acid odor, and Bartlett agreed with Nathan Smith in thinking
that typhoid fever patients exhale a peculiar odor, not pungent and
ammoniacal, like that of typhus, but "of a semi-cadaverous and musty
character," which is especially noticeable during the later stages of
severe and fatal cases.
The eruption is one of the most characteristic symptoms of the
disease. Indeed, in many cases, without it the diagnosis would be
impossible. It is rarely absent in a well-developed case. Murchison
says that it was noted in 4606 cases only out of 5988 admitted into
the London Fever Hospital in twenty-three years, but admits that it
would probably have been found in some of the others if it had been
properly looked for. Wood says that he has seldom met with cases in
which it was absent. It is oftener absent in children than adults--a
circumstance which makes the diagnosis of the disease in the former
often a matter of great difficulty. It consists of isolated
rose-colored spots, slightly elevated above {274} the surface,
circular in form or nearly so, having well-defined margins, usually
about a line in diameter, but sometimes varying from half a line to
two and even three lines in diameter, and disappearing on pressure, to
return when the pressure is removed. They are generally first observed
some time between the seventh and fourteenth days, but cases are on
record, especially in children, in which they are said to have
appeared much earlier, and others in which they could not be
discovered until the twentieth day. In the latter cases, however, it
is not improbable they had really been present at an earlier period,
but had escaped detection. The eruption occurs in crops at intervals
of three or four days, each spot lasting from three to five days, and
the whole duration of the eruption being usually from ten to twenty,
and varying of course with the severity of the attack. It may continue
to appear as late as the twentieth day, and in cases of relapses very
much later. Spots are sometimes seen on the abdomen or elsewhere after
the subsidence of fever, and whenever seen indicate that the diseased
process is not at an end. They are usually scattered over the lower
part of the front of the chest and the abdomen, but are also not
infrequently met with upon the back, and if they are not found upon
the abdomen, the patient should be gently turned upon his side and
this part of his body carefully examined. When very abundant they are
often also seen upon the extremities, and occasionally even upon the
face. Wood has seen them abundant on the upper and inner part of the
thigh, and confined to that place. When tardy in making their
appearance, they may often be brought out by application of a mustard
plaster or by that of heat in any form; and it is probably, therefore,
owing in large measure to the warmth of the bed that they are often so
fully developed upon the back. In number they may vary from two or
three to several hundred. In one case Murchison counted one thousand,
and in three cases which came under my care in the winter of 1881-82
the body was so thickly covered by spots of an unusually large size
that when I first saw the patients I directed them to be isolated
under the fear that the disease would prove to be typhus fever. When
very numerous the edges of two or three of the spots may run together,
giving the eruption an irregular character. No relation between the
copiousness of the eruption and the severity of the disease has ever
been proved to exist. While the prevailing impression, therefore, that
cases in which the eruption is freely developed are apt to be of a
mild character, is true in many instances, it is by no means so in
all. The three cases above referred to all ran a severe course, and
one of them proved fatal. The spots disappear after death, and are
rarely converted into petechiæ, but in bad cases I have seen purpura
spots, and even vibices, developed independently of them. Sometimes
the appearance of the eruption is preceded for a day or two by a
delicate scarlet rash, which Tweedie says resembles roseola and has
been mistaken for scarlet fever.
Sudamina, so called from their resemblance to sweat-drops, also occur
not infrequently in this disease. They are minute vesicles, often not
larger than a pin's head, but sometimes two lines in diameter, and
occasionally, in cases in which two or three have coalesced, much
larger. They usually contain at first a clear serum, which may,
however, subsequently become turbid, and when very minute must, in
consequence of {275} their transparency, be viewed obliquely to be
seen. Frequently, when they cannot be distinguished by the eye, they
are readily detected by the touch. They rarely occur before the
twelfth day, and often not before the close of the third week. Their
most usual seat is the neck, the folds of the axillæ, and the groin,
but there is no part of the body except the face in which they may not
occur. They are most frequently seen in those cases attended by
profuse sweating, and are by no means peculiar to typhoid fever, but
are met with in other diseases--as, for instance, acute
rheumatism--which are attended by this symptom. They are generally
followed by branny desquamation of the cuticle in the position they
have occupied.
Spots of a delicate blue tint--the "tâches bleuâtres" of French
writers--are sometimes observed on the skin in cases of enteric fever.
They must be of infrequent occurrence in this country, for, although I
have looked carefully for them in every case that has come under my
care, I have rarely been able to detect them. According to Murchison,
"they are of an irregularly rounded form and from three to eight lines
in diameter. They are not in the least elevated above the skin, nor
affected by pressure, even at their first appearance. They have a
uniform tint throughout their extent, and they never pass through the
successive stages observed in the spots of typhus. Two or three of
them are sometimes confluent. They are most common on the abdomen,
back, and thighs." They are said in some cases to be distributed along
the course of the small cutaneous veins, and to occur most frequently
in cases which are mild. They are met with in other diseases, and
usually precede in appearance the characteristic eruption of typhoid
fever.
The hair is very apt to fall out after an attack of typhoid fever. The
nails suffer in their nutrition in common with other parts of the
body--a fact which may be recognized by the peculiar markings which
are found upon them after recovery, and to which attention has been
particularly drawn by Morris Longstreth in a paper in the
_Transactions_ of the College of Physicians of Philadelphia, vol.
iii., 3d Series.
The circulation is usually accelerated from the beginning of an attack
of typhoid fever. The degree of acceleration is commonly proportioned
to the severity of the other symptoms, and especially to the elevation
of the temperature, and is generally more marked in the evening than
in the morning. It is subject, however, to numerous variations, not
only in different cases, but even in the same case from day to day,
and even from hour to hour. Murchison refers to a case in which the
pulse sank to 37, and never exceeded 56 during the fever, although it
rose to 66 during the convalescence. I have never had the opportunity
myself of observing such an infrequent pulse in the febrile period of
the disease, but have had cases under my care in which the pulse often
fell below 60, and in which it never exceeded 80 until after the
commencement of convalescence. A comparatively infrequent pulse may
coexist with a high temperature. Thus, for example, a pulse of 80 was
noted in one of my cases at the same time that the thermometer showed
that the temperature was 105°, and on another occasion in the same
case the pulse was 82 and the temperature 104-1/2°. As a rule, the
pulse is more frequent in cases which terminate fatally than in those
which end in recovery; but to this rule there are numerous exceptions.
In eight of Louis's cases it never {276} went above 90, and in some of
my own it did not reach 100 on more than one or two occasions. On the
other hand, in mild cases the pulse may be exceedingly frequent,
reaching, and even exceeding in many cases, 120. When the disease is
prolonged and the prostration is extreme, a pulse of from 140 to 150
is not uncommon. In the majority of cases which have come under my
care the pulse has varied in frequency from 80 to 120. In some cases
the range has been between these two figures, in others it has been
very much less.
During convalescence the pulse usually gradually diminishes in
frequency, and may sometimes fall below the normal standard. I have
known it in a few instances to fall to 38, and have often met with
pulses ranging between 40 and 60 at this period. In other cases, on
the contrary, the pulse continues frequent during convalescence, or
readily becomes so after a slight exertion or excitement of any kind.
A slow pulse during convalescence has been in my experience most
frequent in men whose health previous to the attack was good, and a
frequent pulse in women and delicate men. If the convalescence is
retarded by a complication, the pulse will maintain its frequency
until this is removed.
The pulse will of course present other changes than those above
referred to. It is in the beginning firm and full, but after the first
week becomes small and compressible, and acquires the peculiarity
known as reduplication. Sometimes, when this is not well developed, it
will be rendered quite distinct by elevating the patient's arm.
Irregularity or intermission of the pulse, although not commonly
observed in this disease, occasionally occurs. The heart's action will
also be observed to grow feeble in the course of severe cases, and its
first sound indistinct, but neither of these changes is as marked in
typhoid as in typhus fever. Hayem asserts that in a certain number of
cases a systolic bellows murmur, with its point of greatest intensity
at the apex, is heard during the course or at the close of the second
week. This murmur is sometimes soft in the beginning, but becomes
harsh and intense later, or may have these characters from the start
to such a degree as to give the impression that endocarditis exists.
During convalescence an anæmic murmur is not infrequently present.
The respiratory movements are accelerated in typhoid fever, as they
are in all febrile conditions, independently of any disease of the
lungs, and their frequency is generally proportional to that of the
pulse. In looking over my records of cases I find that the former are
less liable to fluctuate from day to day than the pulse, and that when
the latter becomes abnormally infrequent they do not sink below the
standard of health. In several cases of which I have notes the
respiration was from 20 to 28, while the pulse was below 60, and in a
case referred to by Murchison the pulse was 42 at the same time that
the respirations, although no pulmonary lesion could be discovered,
were 48. The respiration is often, as in the case just alluded to,
very much accelerated when the most careful examination of the chest
will not lead to the detection of any disease there. This is sometimes
the consequence of very great tympanites, which, by interfering with
the descent of the diaphragm, gives rise to dyspnoea, but it may also
occur as a purely nervous phenomenon. The air expired by patients has
been examined, and has {277} been found sometimes, in the later stages
of the disease, to contain ammonia.
Bronchitis is so common an accompaniment of typhoid fever that
auscultation rarely fails to reveal its presence in some form or
other. In some cases there may be only slight harshness of the
respiratory murmur at the base of the chest, but in a large number of
cases the auscultatory signs will be sonorous, sibilant, and mucous
râles. The last named may be so numerous that I have known the disease
in the beginning mistaken for acute bronchitis, and even acute
phthisis, by accomplished diagnosticians.
Headache is one of the most constant symptoms of typhoid fever.
Bartlett says that it is rarely absent, Louis found it in all but 7 of
133 cases, and Jackson noted it in nearly all his cases. It is often
the first symptom of which the patient complains, and, when not
present at the beginning of the attack, makes its appearance soon
after. It is almost as common, although less severe, in mild cases as
in grave ones. It sometimes persists throughout the attack, but
oftener subsides at the close of the first week or toward the middle
of the second, or the patient may cease to complain of it in
consequence of the dulness which is very apt to supervene. It is
usually referred to the forehead and temples, but may extend over the
whole head. It is usually dull and heavy, but in a few cases is
throbbing. It is said by authors rarely to be severe, but I have known
it so intense and acute as to cause the disease at its commencement to
be mistaken for meningitis, and Jackson asserted that it is sometimes
so severe that local bloodletting, and even venesection, had to be
employed for its relief. It would appear to be as common in children
as adults.
The headache is sometimes accompanied by vertigo and dizziness, and
even by retraction of the head. Distressing pains in the back and
limbs may also occur, and in rare cases even contraction of the hands
and feet.